The Death and Burial of Bolesław Dominik Izbicki – 1937

Bolesław Dominik Izbicki, son of Dominik Izbicki and Józefata Marianna Bizewska, husband of Wiktoria Kruczyńska, died on 10 March 1937 in Worcester, Worcester County, Massachusetts, USA and was buried on 12 March 1937 in Notre Dame Cemetery, Worcester, Worcester County, Massachusetts, USA.

The Death and Burial Record of Bolesław Dominik Izbicki - 1937

The Death and Burial Record of Bolesław Dominik Izbicki – 1937

SOURCE:  Worcester, Massachusetts, Death Records 1937, vol. 95: 363, Boleslaw D Izbicki, Massachusetts Registry of Vital Records and Statistics, Dorchester.

Click on the link for a PDF copy of the death and burial record of Bolesław Dominik Izbicki.  The record states:

The Commonwealth of Massachusetts
OFFICE OF THE SECRETARY
DIVISION OF VITAL STATISTICS
MEDICAL EXAMINER’S
CERTIFICATE OF DEATH
WORCESTER (City or town making return)  363
Registered No. 685

1  PLACE OF DEATH  WORCESTER (County) WORCESTER (City or Town)
No. 9 Esther St.,      Ward
{(If death occurred in a hospital or institution, give its NAME instead of street and number)

2  FULL NAME Boleslaw D Izbicki (If deceased is a married, widowed or divorced woman, give also maiden name.)
{(If U. S. War Veteran, specify WAR)
(a) Residence.  No. 9 Esther St.,      Ward, (If nonresident, give city or town and state)
Length of residence in city or town where death occurred 30 yrs.     Mos.     Days.
How long in U. S. if of foreign birth?  30 yrs.     Mos.     Days.

PERSONAL AND STATISTICAL PARTICULARS
3   SEX  male
4   COLOR OR RACE  white
5   SINGLE MARRIED WIDOWED or DIVORCED (write the word)  married
5a  If married, widowed, or divorced HUSBAND of Victoria Kruczynska (Give maiden name of wife in full) or WIFE of      (Husband’s name in full)
6   IF STILLBORN, enter that fact here.
7   AGE  57 Years – Months – Days
If less than 1 day     Hours     Minutes
OCCUPATION
8   Trade, profession, or particular kind of work done, as spinner, sawyer, bookkeeper, etc  Laborer in 7871
9   Industry or business in which work was done, as silk mill, saw mill, bank, etc  Street Department
10  Date deceased last worked at this occupation (month and year)
11  Total time (years spent in this occupation
12  BIRTHPLACE (City)    (State or country)  Poland  20-7
PARENTS
13  NAME OF FATHER  Dominick
14  BIRTHPLACE OF FATHER (City)    (State or country)  Poland  20-7
15  MAIDEN NAME OF MOTHER  Cannot be learned
16  BIRTHPLACE OF MOTHER (City)    (State or country)  Poland  20-7
17  Informant  Mrs. Victoria Izbicki
(Address)  Worcester

I HEREBY CERTIFY that a satisfactory standard certificate of death was filed with me BEFORE the burial or transit permit was issued:
Peter O Shea, M. D.
(Signature of Agent of Board of Health or other)
Director (Official Designation)
March 12, 1937 (Date of Issue of Permit)

MEDICAL CERTIFICATE OF DEATH
18  DATE OF DEATH  March 10, 1937 (Month) (Day) (Year)
19  I HEREBY CERTIFY that I have investigated the death of the person above-named and that the CAUS AND MANNER thereof are as follows:  (If an injury was involved, state fully)
Probably coronary sclerosis
Coronary thrombosis.Unexpected
death. Found dead in bed.
94B  (no autopsy)
(See reverse side for description for unknown person)
20  If death was due to external causes (VIOLENCE) fill in the following:
Accident, Suicide or Homicide?  —
Date of Injury  ___ 19
Where did injury occur?  — (City or town and State)
Manner of Injury  —
Nature of Injury  —
21  Was disease or injury in any way related to occupation of deceased?  No
If so, specify
(Signed) Frederick H Baker,Med.Exam M. D.
(Address)  Worcester  Date  3-10-1937

22  PLACE OF BURIAL, CREMATION OR REMOVAL  Notre Dame (Cemetery), Worcester (City or town)
DATE OF BURIAL  March 12,1937     19
23  NAME OF UNDERTAKER  L Karolkevicz & Son Inc.
ADDRESS  Worcester

Received and filed March 13, 1937     19
[signed] Malcolm C Midgley (Registrar)
A TRUE COPY, ATTEST:

Copyright © 2011 by Stephen J. Danko

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