Higgins, Francis JThe Commonweaub of fM!5!5a0U5ettg
(INSTRUCTIONS ON REVERSE SIDE) STANDARD CERTIFICATE OF DEATH
FOR USE BY
REGISTRY OF VITAL RECORDS AND STATISTICS
PHYSICIANS AND 9_9 I REGISTERED NUMBER STATE USE ONLY
MEDICAL EXAMINERS DECEDENT -NAME FIRST MIDDLE LAST SEX DATE OF DEATH (Mo., Day, Yr.)
STATE USE
ONLY
4c Hosp
5 Type
6 Hisp Race
10 Age
15 Resid
15 Out-State
23 Disp
]Zp
35c Work Inj
35f Place
36-37 Cert
40a Pron
Pronouncement of Death
Form (R-302) on File: ?
PERMANENT
BLACK INK ONLY
R-301-08
1 Francis J. Higgins 2Male 3 March 4, 2011
PLACE OF DEATH (City7Town): COUNTY OF DEATH HOSPITAL OR OTHER INSTITUTION - Name (if not in either, give street and number)
4a Danvers 4b Essex 4c Kaplan Family Hospice House
PLACE OF DEATH (Check only one):
i SOCIAL SECURITY NUMBER IF U
WAR TERAN
ce
HOSPITAL: OTHER Hosp SPE
[]Inpatient?ER/ Outpalient []DOA []Nursing Home Residence Erther(Specify) House 06-28-0886 7
a
5 7
WAS DECEDENT OF HISPANIC ORIGIN? RACE (e.g. White, Black, American Indian, etc.) DECEDENTS EDUCATION (Highest Grade Completed,
(If yes, Specify Puerto Rican, Dominican, Cuban, etc.) (Specify) Elements Sec 0-12 College 1-4 5+
NO MYES White 11
S eci : Bb 9
AGE - Last Birthday UNDER I YEAR UNDER 1 DAY DATE OF BIRTH (Mo., Day, Yr) BIRTHPLACE (City and State or F oreign Country)
(yrs.)
75 MOS. I DAYS HOURS I MINS
Nov. 5, 1935
Newton, Massachusetts
10a b c 10d 11
MARRIED, NEVER MARRIED LAST SPOUSE (If wile. give maiden name) USUAL OCCUPATION KIND OF BUSINESS OR INDUSTRY
WIDOWED OR DIVORCED
Divorced
Mary Reagan (Prior- If Retired)
Repairman
Appliances
72 13 14a 4b
RESIDENCE - NO. 8 ST., CITY/TOWN, COUNTY, STATE/COUNTRY
28488 Highway 19N, Lot 134, Clearwater, Pinelass County, Florida ZIP CODE
33761
1
15x 5b
FATHER - FULL NAME STATE OF BIRTH (It not in US, MOTHER. NAME (GIVEN) (MAIDEN) STATE OF BIRTH (If not in the US,
Thomas Higgins
1 ?
RNTAry)husetts Sadie McGarry namecurf Ada
6 17 18 19
INFORMANTS NAME - MAILING ADDRESS - NO. 8 ST., CITY/TOWN, STATE, ZIP CODE RELATIONSHIP
Mary McMenemy 32 Barbour Road, Hampton, NH 03842 Daughter
20
1 21 2
23 METHOD OF IMMEDIATE DISPOSITION FUNERAL SERVICE LICENSEE OR OTHER DESIGNEE LICENSE If
BURIAL ? CREMATION
ENTOMBMENT ?REMOVALFROM.STATE
Clarence R. Lyons 50054
DONATION ? OTH. SPEC. 24 25
PLACE OF DISPOSITION (Name of Cemete Crematory or other)
Walnut Grove G7emetery. LOCAT N (City7Town, State)
'boners, Massachusetts
26a 26b
DATE OF DISPOSITION
(Mo.,Day,M,ftr. 8, 2011 * E AND ADDRESS OF FACILITY OR OTHER DESIGNEE
. R. Lyons & Sons, Inc., 28 Elm St., Danvers, MA 01923
F
27 b
2
29 PART I - Enter the diseases, injuries, or complications that caused the death. Do not use only the mode of dying, such as cardiac or respiratory arrest, shock or heart failure Approximate Interval
List only one cause on each line (a through d) PRINT OR TYPE LEGIBLY.
IMMEDIATE CAUSE (Final Between Onset an Death
disease or condition resulting a. "?'??JJ
in death) / DUE TO fOR AS A CONSEQUENCE OF)
Sequentially list conditions, if b,
any, leading to immediate DUE TO (OR AS A CONSEQUENCE OF)
cause. Enter UNDERLYING
CAUSE (disease or injury that c.
initiated events resulting in DUE TO (OR AS A CONSEQUENCE OF)
death) LAST
tl.
PART II - Other significant conditions contributing to death but not resulting in underlying cause given in Part I. WAS AUTOPSY WERE AUTOPSY FINDINGS
PERFORMED? AVAILABLE PRIOR TO
(Yes or No) COMPLETION OF CAUSE
. OF DEATH? (Yes or No)
NOTIFIED? NATURAL ? HOMICIDE ? COULD NOT BE DETERMINED (Mo., Day, Yr.) (Yes or No)
(Yes or No)
[]
?
[]
1
33 ACCIDENT
SUICIDE
P ENDING INVESTIGATION 35a 35b M 35c
DESCR IBE HOW INJ URY OCCURRED PLACE OF INJURY (At home, LOCATION (No. 8 St., City7Town, Stale)
tam, street, factory, office bldg.,
etc.,) Specify
35d 35e 35i
< 36a To e be of my knowledge. de th ccurred at the tim
th e, date, an lace and due to the 37a On the basis of examination andior investigation in my opinion death occurred at the time
a
m
cau
se(
aid
wit' ,
aw
n date, and place and due to the cause(s) stated.
m (Signatur
and Tit a 3 (Signature
a and 711e)
E Z DATE SIGNED ( `Day r
O
??A
?? II HOUR OF DEATH Ew Z DATE SIGNED (Mo., Day, Yr.)
OJ HOUR OF DEATH
ZD
r
U i 36b ( n
36. - V
19 M ()
m U 37b
37c M
a F NAME OF ATTENDING PHYSICIAN IF NOT CERTIFIER c w PRONOUNCED DEAD (Mo., Day, Yr.) PRONOUNCED DEAD (Hr)
~ ~
U 36d 37d 37e M
AND ADDRESS OF CERTIFYING PHYSICIAN OR MEDICAL
N
A
MME EXAMINER (Type or Print) LICENSE NO. OF CERTIFI
R
`
?_
{
) /? I
l?l E
WAS THERE A IF YES, DATE IF YES, TIME
J
j2a AME OF PRONOUNC tFt TITLE
PRONOUNCE ENT FORM?
(Yes or N S P ONOUNCED PRONOUNCED
4
?
`
J R
N
? P
A
? N
P
40, J O l
4
40 M
` w
_?
I
-
.
.
.
.
.
DATE BURT 4 PERMIT 1 SUED
! RECEIVED IN THE CITY/TOWN OF DpATE OF RECORD
C
OF
SIGNATUR -BD.
HEALTH AGENT /g CLERK'S
SIGNATURE ?(/+' 1"? r 7 /1 D
V
INSTRUCTIONS
USE ONLY PERMANENT BLACK INK
DATE ENTERED MILITARY SERVICE: _ Jan. 20, 1954 DISCHARGE DATE: Dec. 31 1956
SERVICE NUMBER: 21266237 RATING: Unknown
ORGANIZATION/OUTFIT: U. S. Army
CERTIFIER: Complete the following items. DO NOT COMPLETE ITEMS 1 TO 28 ON THE FRONT SIDE.
DECEDENT- NAME FIRST MIDDLE LAST SEIX? A ,, J DATE OF DEATH
1
ram C_ 1 [4
1 Y1$ 2 1 "t ??l 3 ((?
U
PLACE OF DEATH (City/Town) COUNTY OF DEATH WS'ATAL OR OTHER INSTITUTION - Name (if not in either, give street and number)
4- ? 4b Cass 4 j= ? I t? 2 ? d +?..L1Y?a't..
PLACE OF DEATH (Check only one)
HOSPITAL: OTHER:
[ ) Inpatient [ I ER/Outpatient [ I DOA [ l Nursing Home [ I Residence Other (Specify)'ii)__rt -Q le Q?
5 Y
CERTIFYING PHYSICIAN: Complete only items 29-36 and 38-40 on reverse side AND information above.
MEDICAL EXAMINER: Complete only items 29-35 and 37-40 on reverse side AND information above.
FUNERAL DIRECTOR: 1. Complete items 1-28 and item 40 if not completed by certifier.
2. File completed certificate with Board of Health or its authorized agent for the city or town where
the death occurred (item 4a).
BOARD OF HEALTH AGENT: 1. Examine for accuracy and completeness.
2. Sign and date item 41 only after the certificate is satisfactory and the permit issued.
Strikeovers, erasures, liquid erasure, use of correction tape on correcting typewriters are not OermLd.
REFERRAL TO THE OFFICE OF THE CHIEF MEDICAL EXAMINER (OCME)• ""q >" tl"
Deat
hs requiring referral to the OCME, M.G.L. C 38, §3 include those deaths: (1) where criminal violence may have t r_lace; y accident or unin-
tentional injury; (3) suicide; (4) under suspicious or unusual circumstances; (5) following an unlawful abortion; (6) rela ?occual illness or injury;
(7) in custody, in any jail or correctional facility or in any mental health or mental retardation institution; (8) where s pWn of e of a child, family
or household member, elder person or disabled person exists; (9) due to poison or acute or chronic use of drugs or a
4 (10) o keletal remains; (11)
associated with diagnostic or therapeutic procedures; (12) suddenly when the decedent was in apparent good healt 1within 24 ours of admission
to a hospital or nursing home; (14) in any public or private conveyance; (15) fetal death, reportable under C 111, §202 ?e,,[e the riod of gestation has
been 20 weeks or more, or where fetal weight is 350 grams or more; (16) all children under the age of eighteen year (. any R n found dead; (18)
in any emergency treatment facility, medical walk-in center, day care center, or under foster care; or (19) occurring ccircu ces as defined by
regulations. All deaths listed above must be referred to the OCME regardless of the time interval between the ind nMnd d'? and regardless of
whether such incident appears to have been the immediate cause of death, or a contributory factor thereto. $ '0 If a death requiring referral to the OCME has not been referred, any physician, police officer, hospital administrator, ?d nu?A, or licensed funeral
director with knowledge of such an unreported death is required to make the referral. Failure to notify the OCME may Ul,in a fine up to $500 and may
also include notification to an applicable board of registration.
PHYSICIAN RESPONSIBILITY TO COMPLETE A DEATH CERTIFICATE:
Under M.G.L. C 38, §13, if the OCME waives jurisdiction in the cases listed above and in all deaths not requiring referral to OCME, physicians are respons-
ible for preparation of a death certificate in the following order of priority: the attending physician or his covering physician; the licensed physician declar-
ing such person dead; or, if the death occurred in a hospital, a duly appointed registered hospital medical officer.
f
April 11, 2011
Pinellas County
Bureau of Vital Statistics
4175 East Bay
Suite 160
Clearwater, FL 33764
To whom it may concern:
We received the enclosed copy of Certificate of Death for Francis J. Higgins in
our office. It came from Town Hall, Office of Administrative Services in
Danvers, NIA 01923. I'm forwarding this document to your office.
If you have any questions, please give me a call at 727-562-4093.
Sincerely,
Judith LaCosse
Staff Assistant
Official Records & Legislative Services
Enclosure(s)