USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1961 > Part 1
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Part 1 | Part 2 | Part 3 | Part 4 | Part 5 | Part 6 | Part 7 | Part 8 | Part 9 | Part 10 | Part 11 | Part 12 | Part 13 | Part 14 | Part 15 | Part 16 | Part 17 | Part 18 | Part 19 | Part 20 | Part 21 | Part 22 | Part 23 | Part 24 | Part 25 | Part 26 | Part 27 | Part 28 | Part 29 | Part 30 | Part 31 | Part 32 | Part 33 | Part 34 | Part 35 | Part 36 | Part 37 | Part 38 | Part 39 | Part 40 | Part 41 | Part 42 | Part 43 | Part 44 | Part 45 | Part 46 | Part 47 | Part 48 | Part 49 | Part 50 | Part 51
THOMAS GROOM & CO.INC. STATIONERS. AND ACCOUNT BOOK MANUFACTURERS 105 State Street. BOSTON.
To duplicate this Book send number 5-23573
Digitized by the Internet Archive in 2016 with funding from Boston Public Library
https://archive.org/details/townofwinthropre 1961wint
X SUFFOLK (County)
The Commonwealth of Massachusetts JOSEPH D. WARD SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS STANDARD
To be filed for burial permit with Board of Health or its Agent.
Registered No.
[(If death occurred in a hospital or institution, { give its NAME instead of street and number)
PHYSICIAN - IMPORTANT
[(Was deceased a U. S. War Veteran, (if so specify WAR)
(If deceased is a married, widowed or divorced woman/ give also maiden name.) 164 SOMERSET AVE WINTHROPST.
(a) Residence.
(Usual place of abode)
Length of stay: In place of death. ...... .. years .... ......... months.
5 days. In place of residence .............. years ....... ... months ........... .days.
PERSONAL AND STATISTICAL PARTICULARS
3 DATE OF
DEATH
JAI 2 1961 (Year)
(Month)
(Day)
8 SEX
FEMALE
9 COLOR
WHITE
10 SINGLE
(write the word)
MARRIED
WIDOWED WIDOWED
or DIVORCED
4 I
HEREBY
CERTIFY,
That I attended deceased from
JAN
52, 10
.. , to.
JAN 2
6/
I last saw HERlive on
JAN
2
19 61, death is said to
have occurred on the date stated above, at
2SEP
.. m.
INTERVAL
BETWEEN
ONSET AND
DEATH
5DAYS
AGE
LOUIS
' (Give maiden name of wife in full)
KRAMER
(Husband's name in full)
11 IF STILLBORN, enter that fact here.
12 80 Years 4 Months. 4 Days
If under 24 hours
Hours ............ .Minutes
13 Usual
Occupation :
HOUSEWIFE
(Kind of work done during most of working life)
14 Industry
or Business :
OWN
HOME
15 Social Security No. NONE
16 BIRTHPLACE (City)
(State or country)
GERMANY
17 NAME OF
FATHER
HERMAN TEICHMEIER
18 BIRTHPLACE OF
FATHER (City) (State or country)
GERMANY
19 MAIDEN NAME OF MOTHER MARIE HASE
20 BIRTHPLACE OF MOTHER (City) (State or country)
GERMANY
21 Informant ALFRED W. TEICHMEIER (Address) I OAK KNOLL RD. METHUEN
I HEREBY CERTIFY that a satisfactory standard certificate of death was filed with me BEFORE the burial or transit permit was issued:
(Signature of Agent of Board of Health or other)
Health Officina
Jan 2, 1961
.... (Official Designation) (Date of Issue of/Permit)
INSTRUCTIONS FOR EDICAL CERTIFICATE
In giving USE OF DEATH do not enter more than one cause for each f (a), (b) and (c)
This does not mean , mode of dying, h as heart failure, henia, etc. It means , disease, or compli- ions which caused ath.
Conditions, if any, which gave rise to above cause (a), itating the under- lying cause last.
Conditions contrib- ing to death but not ated to the terminal ease condition given (a).
Tote :- Chapter 137. ts of 1954. requires ysicians to print or e the cause or ses of death on Ith certificates, and apter 48, Acts of 9, requires Physi- ns to print or type ne under signature.
50H-11-59-926662
PLACE OF DEATH
FORM R-301A 1 WINTHROP (City or Town) ·LACIÓAM WINTHROP COMMUNITY HOSPTIAL
No.
2 FULL NAME.
FRIEDA (TEICHMEIER) KRAMER
10a If married, widowed, or divorced HUSBAND of
(or) WIFE of
DEATH WAS CAUSED BY: IMME IATE CAUSE
LOBAR PNEUMONIALEFT
(a)
...
Due To (b)
CEREBRAL VASCULAR ACCT
3 DAYS
Due To ARTERIO-SCLEROTIC S HYPER (c)
TENSIVE HEART DIS E CONG
OTHER
FAILURE
SIGNIFICANT
CONDITIONS
CARCINOMA OF UTERUS
Was autopsy performed?
IVO
What test confirmed diagnosis ?
CLINICAL+ Yen
5 Was disease or injury in any way related to occupation of deceased? No. If so, specify
(Signed) MYRON N. KING M.D
M. D.
(PRINT OR TYPE SIGNATURE)
(Address) 222 PLEASANT WINTER
5 Date.
1/2/06/
6 BELLEVUE CEMETERY LAWRENCE Place of Burial or Cremation (City or Town)
DATE OF BURIAL JAN. 5.
1961 19
7 NAME OF FUNERAL DIRECTOR
J. B. EMMERT + SONS
ADDRESS 93 E. HAVERHILL ST. LAWRENCE
Received and filed
(Registrar)
8 YRS.
24RS.
PARENTSS
CERTIFICATE OF DEATH
(If nonresident, give city or town and State)
MEDICAL CERTIFICATE OF DEATH
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE
RANK, RATING
ORGANIZATION AND OUTFIT
SERVICE NUMBER 1
i
6
THROP
RULES OF PRACTICE
The fulfillment of the purpose of these laws calls for the obserata 31961 AM
following rules of practice :
(1) Attending physicians will certify to such deaths only as those of persons to whom they have given bedside care during a last illness from disease un- related to any form of injury.
(2) Board of Health physicians will certify to such deaths only as those of persons who, though disabled by recognized disease unrelated to any form of injury, have died without recent medical attendance or whose physician is absent from home when the certificate of death is needed.
(3) Medical Examiners will investigate and certify to all deaths supposably due to injury. These include not only deaths caused directly or indirectly by traumatism (including resulting septicemia), and by the action of chemical (drugs or poisons) thermal, or electrical agents, and deaths following abortion, but also deaths from disease resulting from injury or infection related to occu- pation, the sudden deaths of persons not disabled by recognized disease, and those of persons found dead.
Statement of Cause of Death .- Physicians: see explanatory instructions on face side of standard certificate of death.
Statement of Occupation .- Precise statement of occupation is very impor - tant, so that the relative healthfulness of various pursuits can be known. Make some entry in this section for every person aged 10 years or over. If the occupa - tion had been given up or changed, or if the deceased had retired from business, report the kind of work done during most of working life even if retired. Chil- dren not gainfully employed may be returned as at school or at home. For a woman whose only occupation was that of home housework, write housework. For a person engaged in domestic service for wages, however, designate the occupation by the appropriate terms, as housekeeper-private family, cook- hotel, etc. For a person who had no occupation whatever write none.
X
Middlesex
Everetty
(City or Town)
Whidden Memorial Hospital
The Commonwealth of Massachusetts JOSEPH D. WARD SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS COPY OF MỸYCH CERTIFICATE OF DEATH
Everett
(City or Town making this return)
2
Registered No. .....
f (If death occurred in a hospital or institution.
.. St. ¿ give its NAME instead of street and number)
Berenice A (Nickerson) Goodwin
( If deceased is a married, widowed or divorced woman, give also maiden name.)
15 Willow Ave.
Winthrop,
Mass.
(If nonresident, give city or town and State)
Length of stay: In place of death.
........ years ....
.months
7
13
days. In place of residence ..
... years.
.. months .......... days.
MEDICAL CERTIFICATE OF DEATH
PERSONAL AND STATISTICAL PARTICULARS
3 DATE OF
January 5, 1961
1051
(Day)
( Year)
ented deceased from
I last saw
her
Jän. 5
19 ........ , death is said to
have occurred on the date stated above, at
8:55 Pm.
INTERVAL
BETWEEN
ONSET AND
DEATH
11 IF STILLBORN, enter that fact here.
12
78
3
18
If under 24 hours
Hours ...
Minutes
13 Usual
Occupation :
Teacher (retired)
( Kind of work done during most of working life)
14 Industry
or Business :
Public School
15 Social Security No. None
16 BIRTHPLACE (City)
(State or country)
17 NAME OF
FATHER
James Nickerson
18 BIRTHPLACE OF
FATHER (City)
Nova Scotia
(State or country )
19 MAIDEN NAME
OF MOTHER
Adelia Garron
Nova Scotia
21 Etta G. English
Informant
( Address)
Winthrop
A TRUE COPY
ATTEST :
(Registrar of City or Town where death occurred) .
DATE FILED
January 10,
19
1
( Registrar of City or Town where deceased resided )
PARENTS
50M-9-59-926111
No ..
2 FULL NAME
(a)
Residence. No ..
( Usual place of abode)
DEATH
(Month)
CE
4
Sept.
19
to ..
(b)
(c)
OTHER
SIGNIFICANT
CONDITIONS
What test confirmed diagnosis ?
( Address)
6
DATE OF BURIAL
Copies of returns of deaths which occurred in your city or town in case the deceased resided in another city or town
No
PLACE OF DEATH
FORM R-302
WRITE PLAINLY WITH UNFADING BLACK INK OR USE APPROVED BLACK TYPEWRITER RIBBON - r
resided as soon as possible. after the close of the month in which the death occurred. (See Chap. 46, Sec. 12. G. L.) at the time of death should be transmitted on Form R-302 to the clerk of the city or town in which the deceased MARGIN RESERVED FOR BINDING THIS IS A PERMANENT RECORD
John F. Williams
( Signed )
Everett
1=6
M. D.
Date. 196.1.
Woodlawn Crematory Everett Place of Burial or CreuJanuary 9, (City or Town)
19
Howard S Reynolds
7 NAME OF FUNERAL DIRECTOR Winthrop, Mass.
ADDRESS
Received and filed FEB 13 1961 19 .....
9 COLOR
8 SEX
Female
White
10 SINGLE
MARRIED
WIDOWED
or DIVORCED
(write the word)
Widow
10a If married. widowed, or divorced
HUSBAND of
( Give maiden name of wife in full)
(or) WIFE of.
Benjamin F. Goodwin
(Husband's name in full)
DEATH WAS CAUSED BY : IMMEDIATE CAUSE
Carcinoma of Pancreas
(a)
Due To
Secondary Carcinoma
of Liver
Due To Acute Dilation Heart
Was autopsy performed ?
Clinical Findings
5 Was disease or injury in any way related to occupation of deceased ? If so, specify
20 BIRTHPLACE OF
MOTHER (City)
(State or country)
.
1
( Was deceased a
U. S. War Veteran.
if so specify WAR,
1
19
AGE
Years.
Months.
.. Days
TOW
F
11 12 1
OLE
OFFIC
10
RH
MIN
*
mmmmm
3
WII
RO
FED 1 31961 MM
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE DATE OF DISCHARGE RANK, RATING ORGANIZATION AND OUTFIT SERVICE NUMBER
X PLACE OF DEATH
PuisTor
7.61
The Commonwealth of Massachusetts JOSEPH D. WARD SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS STANDARD
To be filed for burial permit with Board of Health or its Agent.
3
Registered No.
[(If death occurred in a hospital or institution,
St. { give its NAME instead of street and number)
2 FULL NAME
Mary A. Murray
(If deceased is a married, widowed or divorced woman, give also maiden name.)
25 White St.
St.
(If nonresident, give city or town and State)
Length of stay: In place of death .............. years ...
3
months .............. days. In place of residence.
............. years.
months ....
......
... days.
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
January
6,
1961
DEATH
(Month)
(Day)
(Year)
4 I HEREBY CERTIFY,
That I attended deceased from
une
59
San 6
19.61
I last saw himalive on
Ja
6
19 .... 1., death is said to
have occurred on the date stated above, at
gioi p. m.
DEATH WAS CAUSED BY : IMMEDIATE CAUSE
(a) Cerebro vascular
Hemorrhage
Due To
arteriosclerosis
(b)
generalized
Due To
Senility
(c)
yp
OTHER
SIGNIFICANT
CONDITIONS
Was autopsy performed?
no
What test confirmed diagnosis ?
5 Was disease or injury in any way related to occupation of deceased?
If so, specify
(Signed).
Joseph Gregorie
., M. D.
194 Wash iPRINTOn TARESIGNATURE) 1/7 61
(Address)
Date
19
6 Holy Cross
Malden
Place of Burial or Cremation
Jan.
9
(City or Town)
61
19
7 NAME OF
FUNERAL DIRECTOR
Frederick J. Magrath
ADDRESS
East ..... Boston
Received and filed JAN 10-1961 19
(Registrar) #
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
female
9 COLOR
white
10 SINGLE
(write the word)
(Give maiden name of wife in full)
(or) WIFE of
(Husband's name in full)
11 IF STILLBORN, enter that fact here.
94
12
AGE
Years.
Months.
.Days
If under 24 hours
Hours.
Minutes
13 Usual
Occupation :
housework
"(Kind of work done during most of working life)
14 Industry
or Business :
15 Social Security No.
16 BIRTHPLACE (City)
(State or country)
NovaScotia
17 NAME OF
FATHER
Andrew
Cameron
18 BIRTHPLACE OF
FATHER (City)
(State or country)
Nova Scotia
19 MAIDEN NAME
OF MOTHER
Elizabeth Morrison
20 BIRTHPLACE OF
MOTHER (City)
(State or country)
James K. Murray
"Nova Scotia
21
Informant
(Address)
280 Revere St. Winthrop
I HEREBY CERTIFY that a satisfactory standard certificate of death was filed with me BEFORE the burial or transit permit was issued:
· (Signature of Agent of Board of Health or other)
emma 8, 1461
(Official Designation)
(Date of Issue of Permit)
Y
FORM R-301A 1
3.515
INSTRUCTIONS FOR EDICAL CERTIFICATE
In giving USE OF DEATH do not enter more than one cause for each f (a), (b) and (c)
This does not mean mode of dying, h as heart failure, henia, etc. It means disease, or compli- ions which caused th.
Conditions, if any, which gave rise to bove cause (a), tating the under- lying cause last.
Conditions contrib- ng to death but not ited to the terminal case condition given (a).
ote :- Chapter 137, s of 1954. requires sicians to print or e the cause or ses of death on th certificates, and ipter 48, Acts of 9, requires Physi- has to print or type ne under signature.
50M-11-59-926662
Suffolk
(County)
Winthrop
CERTIFICATE OF DEATH
(City or Town)
Mount's Convalescent Home
No.
PHYSICIAN - IMPORTANT
[(Was deceased a
no
U. S. War Veteran,
(if so specify WAR)
(a) Residence.
No.
(Usual place of abode)
East Boston
MARRIED.
WIDOWEWidowed
or DIVORCED
10a If married, widowed, or divorced
HUSBAND of
James F. Murray
INTERVAL
BETWEEN
ONSET AND
DEATH
1 dag
own home
PARENTS
DATE OF BURIAL
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE
RANK, RATING
ORGANIZATION AND OUTFIT
SERVICE NUMBER
RULES OF PRACTICE
The fulfillment of the purpose of these laws calls for the observance of the following rules of practice : (1) Attending physicians will certify to such deaths only as those of persons to whom they have given bedside care during a last illness from disease un- related to any form of injury.
(2) Board of Health physicians will certify to such deaths only as those of persons who, though disabled by recognized disease unrelated to any form of injury, have died without recent medical attendance or whose physician is absent from home when the certificate of death is needed.
(3) Medical Examiners will investigate and certify to all deaths supposably due to injury. These include not only deaths caused directly or indirectly by traumatism (including resulting septicemia), and by the action of chemical (drugs or, poisons) thermal, or electrical agents, and deaths following abortion, but also deaths from disease resulting from injury or infection related to occu- pation, the sudden deaths of persons not disabled by recognized disease, and those of persons found dead.
Statement of Cause of Death .- Physicians: see explanatory instructions on face side of standard certificate of death.
Statement of Occupation .- Precise statement of occupation is very impor- tant, so that the relative healthfulness of various pursuits can be known. Make some entry in this section for every person aged 10 years or over. If the occupa - tion had been given up or changed, or if the deceased had retired from business, report the kind of work done during most of working life even if retired. Chil- dren not gainfully employed may be returned as at school or at home. For a woman whose only occupation was that of home housework, write housework. For a person engaged in domestic service for wages, however, designate the occupation by the appropriate terms, as housekeeper-private family, cook- hotel, etc. For a person who had no occupation whatever write none.
X PLACE OF DEATH
Suffolk (County)
CONSEDITING
STANDARD
CERTIFICATE OF DEATH
Registered No.
[(If death occurred in a hospital or institution,
St. } give its NAME instead of street and number)
PHYSICIAN - IMPORTANT
[(Was deceased a { U. S. War Veteran, {if so specify WAR)
(If deceased is a married, widowed or divorced woman, give also maiden name.)
46 Washington Ave.
St.
Winthrop
(If nonresident, give city or town and State)
Length of stay : In place of death .. .
... years ............ months
14 days. In place of residence.
.......
.years.
... months
.days.
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
DEATH
an.
7
1961
(Month)
(Day)
(Year)
4ş I
HEREBY
CERTIFY
That I attended deceased from
mar
1950 to Jan, 1
1900
1 last saw h.C.lalive on
Jan
3
19 ..
.. , death is said to
have occurred on the date stated above, at
10-12. P ..
.. m.
INTERVAL
BETWEEN
ONSET AND
DEATH
weeks
Due To Carcinoma
(b) Gall Bladder
Due To
(c)
OTHER
arteriosclerosis
SIGNIFICANT CONDITIONS general
1900
Was autopsy performed?
no
What test confirmed diagnosis ?
operation
5 Was disease or injury in any way related to occupation of deceased ? If so, specify .........
(Signed) popple fre igone M. D. 194 Washurtto ane (PRINT OR TYPE SIGNATURE) Joseph GREGORIA Date 1-9
1960
6 Winthrop Cemetery, Winthrop
(City or Town)
Place of Burial or Cremation
DATE OF BURIAL
Jan. 10
60
19
7 NAME OF
FUNERAL DIRECTOR
ErnestP ...... Caggiano
ADDRESS
147 Winthrop St. Winthrop
Received and filed
JAN 10-1961
19
(Registrar)
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
female
9 COLOR
white
10 SINGLE
(write the word)
MARRIEDwidowed
WIDOWEIN
or DIVORCEI)
10a If married, widowed, or divorced
HUSBAND of
Edgar D." Waterman
(Husband's name in full)
11 1F STILLBORN, enter that fact here.
87
12
AGE
Years.
Months ..
Days
If under 24 hours
Hours.
.......... Minutes
13 Usual
Occupation :
Housewife
(Kind of work done during most of working life)
14 Industry
or Business :
at home
15 Social Security No.
16 BIRTHPLACE (City) (State or country)
Cape Breton
Canada
17 NAME OF
FATHER
Henry Bennett
18 BIRTHPLACE OF
FATHER (City)
(State or country)
Cape Breton
Canada
19 MAIDEN NAME
OF MOTHER
?
Young
20 BIRTHPLACE OF
MOTHER (City)
(State or country)
Canada
Cape Breton
Mrs Doris Gillis
(Address) 330 Selby St. Montreal, Que.
I HEREBY CERTIFY that a satisfactory standard certificate of death was filed with me BEFORE the burial or transit permit was issued: Labitir Serca
(Signature of Agent of Board of Health or other) Jan 7, 1961
(Official Designation)
(Date of Issue of Permit)
NSTRUCTIONS FOR CAL CERTIFICATE
In giving SE OF DEATH lo not enter ore than one use for each a), (b) and (c)
s does not mean mode of dying, as heart failure, ia, etc. It means sease, or compli- which caused
ditions, if any, :h gave rise to le cause (a), ing the under- cause last.
onditions contrib- to death but not to the terminal condition given
: :- Chapter 137, of 1954, requires cians to print or the cause or s of death on certificates, and er 48, Acts of requires Physi- to print or type under signature. Mit ..
6.6600
-
Winthrop (City or
No.
...
46 Washington Ave
The Commonwealth of Massachusetts JOSEPH D WARD SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS
To be filed for burial permit with Board of Health or its Agent.
2 FULL NAME
Selena Waterman (Bennett)
(a) Residence. No. (Usual place of abode)
to ...
DEATH WAS CAUSED BY : IMMEDIATE CAUSE
(a)
Carcinomatosis
( weeks)
(Ging maiden name of wife in full)
(or) WIFE of
PARENTS
(Address)
RM R-301A 1
5.24.60
MIX
31-6-59-925686
21
Informant
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE.
DATE OF DISCHARGE
RANK, RATING
ORGANIZATION AND OUTFIT
SERVICE NUMBER
TO:
RULES OF PRACTICE
The fulfillment of the purpose of these laws calls for the observance of the following rules of practice :
(1) Attending physicians will certify to such deaths only as those of persons to whom they have given bedside care during a last illness from disease un- related to any form of injury.
(2) Board of Health physicians will certify to such deaths only: as those of persons who, though disabled by recognized disease inrelated to any form of injury, have died without recent medical attendance or ( whose physician is absent from home when the certificate of death is needed.
(3) Medical Examiners will investigate and certily to all deaths supposably due to injury. These include not only deaths caused directly or indirectly by traumatism (including resulting septicemia), and by the action of chemical (drugs or poisons) thermal, or electrical agents, and deaths following abortion, but also deaths from disease resulting from injury erinfection Related to occu- pation, the sudden deaths of persons not disabled By recognized disease, and those of persons found dead.
Statement of Cause of Death .- Physicians: see explanatory instructions on face side of standard certificate of death.
Statement of Occupation .- Precise statement of occupation is very impor- tant, so that the relative healthfulness of various pursuits can be known. Make some entry in this section for every person aged 10 years or over. If the occupa- tion had been given up or changed, or if the deceased had retired from business, report the kind of work done during most of working life even if retired. Chil- dren not gainfully employed may be returned as at school or at home. For a woman whose only occupation was that of home housework, write housework. For a person engaged in domestic service for wages, however, designate the occupation by the appropriate terms, as housekeeper-private family, cook- hotel, etc. For a person who had no occupation whatever write none.
ORM R-301A 1
INSTRUCTIONS FOR DICAL CERTIFICATE
In giving JSE OF DEATH do not enter more than one cause for each (a), (b) and (c)
his does not mean mode of dying, as heart failure, nia, etc. It means disease, or compli- ns which caused h.
unditions, if any, sich gave rise to ove cause (a), iting the under- ing cause last.
Conditions contrib- 3 to death but not ed to the terminal se condition given 1)
te :- Chapter 137, of 1954. requires icians to print or the cause or es of death on 1 certificates, and ter 48, Acts of requires Physi- ; to print or type : under signature.
OM-11-59-926662
PLACE OF DEATH
SUFFOLK (County) WINTHROP (City or Town)
The Commonwealth of Massachusetts JOSEPH D. WARD SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS STANDARD
CERTIFICATE OF DEATH
Registered No.
5
WINTHROP COMMUNITY HOSPITAL, {If death occurred in a hospital or institution. No.
St. [ give its NAME instead of street and number)
PHYSICIAN - IMPORTANT
[(Was deceased a
U. S. War Veteran,
[if so specify WAR)
No
(If deceased is a married, widowed or divorced woman, give also maiden name.)
AVENUE
St.
(If nonresident, give city or town and State)
Length of stay: In place of death .............. years ...
months 2 3 days. In place of residence.
22 years.
......
.. months.
......
.days.
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
DEATH
JAN
8
1961
(Month)
(Day)
(Year)
4 I HEREBY
CERTIFY,
JAN
19
51
to
JAN
8
19.6
I last saw h. FRalive on
1/8
19 61, death is said to
have occurred on the date stated above, at
352 pm
INTERVAL
BETWEEN
ONSET AND
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
Cachal vascular accident
(a)
DEATH 3 who
3 YRS.
Due To
general arteriosclerosis
(c)
AURICULAR FIBRILLATION -MYOCARDIAL.
OTHER
SIGNIFICANT
POST LEFT Thigh amputation"
CONDITIONS
DIABETES MELLITUS MILD
LYRS.
iYR.
Was autopsy performed ?
What test confirmed diagnosis ?
CLINICAL.
5 Was disease or injury in any way related to occupation of deceased? No If so, specify
(Signed)
MYRON
Dr. KING MD
(PRINT OR TYPE SIGNATURE) (Address) wwwPleasantST ... Date ... 1/8 /06/
ANSHA SFARD'
Place of Burial or Cremator
DATE OF BURIAL JAN 9
7. NAME OF
FUNERAL DIRECTORS
Louie Hymaning
ADDRESS
Received and filed ItaClark
(Registrar)
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
9 COLOR
FEMALE WHITE
10 SINGLE
(write the word)
MARRIED
WIDOWED
or DIVORCED LL iDOWD.
10a If married, widowed, or divorced HUSBAND of
(or) WIFE of
JOSEPH
(Give maiden name of wife in full)
B: COHEN
(Husband's name in full)
11 IF STILLBORN, enter that fact here.
12
AGE
74 years.
2
Months.
16 Days
If under 24 hours
Hours.
.Minutes
13 Usual
Occupation :
HOUSEWIFE
(Kind of work done during most of working life)'
14 Industry
or Business :
AT HOME
15 Social Security No. NINE
16 BIRTHPLACE (City)
(State or country)
RUSSIA
17 NAME OF
FATHER
KiVA BRENNER
18 BIRTHPLACE OF
FATHER (City)
(State or country)
RUSSIA
19 MAIDEN NAME
M. D.
OF MOTHER
EVA COHEN
20 BIRTHPLACE OF
MOTHER (City)
(State or country)
Russin
21 Informant
(Address) A PARKVIEW BLVD. GRANSTIX ROL
I HEREBY CERTIFY that a satisfactory standard certificate of death was filed with me BEFORE The burial 6r transit permit was issued: 1
(Signature of Agent of Board of Health or other)
De.O. Jan 9, 1961
(Official Designation)
(Date of Issue of Permit)
To be filed for burial permit with Board of Health or its Agent.
FANNIE (BRENNER) COHEN 2 FULL NAME
(a) Residence. No.
200 WOODSIDE
(Usual place of abode)
That I attended deceased from
67
Due
(b)
Hypertensive q artenco valentes
Heart ois à congesture future
5YRS.
No
6
DANVERS
(City or Town)
1961
19
PARENTS
William ECHEN SEN
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
DATE OF. DISCHARGE
RANK, RATING
ORGANIZATION AND OUTFIT
SERVICE NUMBER
TOWA
RULES OF PRACTICE
JE OF
ERIT
The fulfillment of the purpose of these laws calls for the observance ofthe following rules of practice : L'O
(1) Attending physicians will certify to such deaths only as those of persons to whom they have given bedside care during a last illness from (disease un- related to any form of injury. - Those of 5 MASS
(2) Board of Health physicians will certify to such deaths only as persons who, though disabled by recognized disease unrelated to an injury, have died without recent medical attendance or whose soy yo absent from home when the certificate of death is needed.
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