USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1947 > Part 72
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5. Color or
4. Sex
m
race
w
that I last saw h.
__ alive on
, or ounty)
U. S. GOVERNMENT PRINTING OFFICE 16-13403 NOV 2 5 1947
-
P.202
Sate Board of Health Bureau of Vital Statistics
PLACE OF DEATH:
a County manatee
District Nos
1) Precinct
Precinct No.
(c) City or Town
Winthrop
(If outside city or toy'ff limits, write RURAL)
(d) Street No.
(E rural, give location)
(e) Citizen of Foreign country ?.
no
20
If yes, name country
making return) 214
1 or institution, et and number)
en and State)
mos.
days.
(Year)
ded deceased from
19 ...
death is said to
m.
Duration
Physician
Underline the cause to which death should be charged sta- tistically.
of deceased ?
(a) (Probably) Accident, suicide, homicide (specify)
(b) Date of occurrence.
M. D.
(c) Where did injury occur?
(City or town)
(County) (State)
(d) Did injury occur in or about home, on farm, in industrial place,
Pin public placez (Specify type of place)
While at workz yot injury_
Amature
M. D.
(a) Address
Date Signed
ATTEST :
(Registrar of city or town where death occurred)
19
Received and filed .. NOV 251947
19
DATE FILED
20. Date of Death: Month march Day 28
Year 1947 Hour Minute
40 P.M.
make
5. Color or race white
I. Single, married, widowed or divorced manuel 6 (a) If married, widowed or divorced, husband of (or) Wife of mary Brinley 75
6 (b) Age of husband or wife, if allve. years
7 Birth date of deceased.
3 1872
(month)
(day)
(year)
& Age: Years
Months
Days
If less than one day
74
4
25
hrs
min.
1. Birthplace Boston
marc
(City, town or county> > (State or foreign country)
10. Usual occupation Salt. Alandan Co.
Il. Industry or business
12. Name
13. Birthplace
Barton man
14. Maiden name Catherine Slum
E 15. Birthplace Borta
1. Informant's Signature zur g. w. That (a) Address Withlos Mars.
7 Burial, cremation or removal? 7 (a) Date: 3/30/47 17 (b) Place Wind 1
1. Funeral Director's Signature. ER Shona
1 (2) Address: Ready To Ale.
2. USUAL RESIDENCE OF DECEASED
(a) State.
mark.
(b) County
(Write name, pot number)
City or Town Bradenton
down' No
Name of hospital or institution Bradesiden jemand (If not in hospital or institution, write street number or jocation) el Length of stay: In hospital or institution
3 month
At place of death (Specify whether years, months or days)
1 FULL NAME OF DECEASED John w. Her but
3 (a) If veteran,
3 (b) Social Security
name war
No home
MEDICAL CERTIFICATION
21. I hereby certify that I attended the deceased from Muy 28 1947 January 38 1842; that I last saw halive on Musel 3 8 1.47; and
Duration
that death occurred on the date and hour stated above. Imanediate cause of death
3 hours
Due to
Due to
Other conditions
(Include pregnancy within 3 months of death)
Major findings: of operations
(Give date of operation)
of autopsy
Underline the cause to which death should be charged sta- tistically.
22. Lf death was due to external causes, fill in the following:
19
(City or Town) .19
Local Registrar
In Blake
CERTIFI NON RESIDENT
State File NOL
6294
Registrar's No.
73
FLORIDA
The Commonwealth of Massachusetts
109
ty or 30 5
yes or no
(Registrar of City or Town where deceased resided)
R-302
1
PLACE OF DEATH
(County)
(City or Town)
The Commonmuralth of Massachusetts OFFICE OF THE SECRETARY DIVISION OF VITAL STATISTICS COPY OF CERTIFICATE OF DEATH
(City or town making return)
Registered No.
215
(If death occurred in a hospital or institution, give its NAME instead of street and number)
2 FULL NAME
JOHN VINCENT O'DONNELL
(If deceased is a married, widowed or divorced woman, give also maiden name.)
(a) Residence. No.
(Usual
DO NOT WRITE IN SPACES
PLACE OF DEATH
Registrar's No ..
S.
mos.
days.
(E
PLACE
County Chatting
State
Coupty __
PERSO
3 SEX
4 4444
City or Borough, Name of Hospital or Institution. 3 Nicholson
(If set in hospital or institution write atreet number or location)
Length of Stay In this Community
yTs.
mos. 2 days
brs.
foreign country ?. country
Kindly Type or Print
FULL NAME
(Surname last, first name here)
IF VETERAN, NAME WAR ..
SOCIAL SECURITY 20-05-664 NO ....
RESIDENCE
SEX
COLOR OR RACE
Single, Married, Widowed or Divorced (write the word)
I HEREBY CERTIFY, That A attended the deceased from
May 11
1347
7 IF STILLBORN,
If married, widowed or divorced HUSBAND OF
Age, If Ilving
8
DATE
AGE Years
BIRTH DATE OF DECEASED (Month, day sod year)
AGE
Months
Daye"
If Leve Hra.
Baumatic valisites tech Dug to.I. Bureau, aortic & mural
many
Industry 10 or Business :
CAUSE
11 Social Security
USUAL OCCUPATION. Industry or business
Other conditions. (Include pregnancy within 3 months of death)
PHYSICIAN -
12 BIRTHPLACE ( (State or country
NAME
13 NAME OF FATHER
CONT. CAUSE
BIRTHPLACE (City of town) (State of country)
MAIDEN NAME
BIRTHPLACE (CIU or two) Cercle · (State or country)
If death were due to external causes, All in the following: Accident, suicide, er homlake (specify)
Date of occurrence
Where did Injury encur?
-
15 MAIDEN NAM OF MOTHER
PLACE OF BURIAL
DATE
(Spydle ipe of place)
While at work ?.
Means ofpory
Dste
19
16 BIRTHPLACE MOTHER (Ci (State or cour
FUNERAL DIRECTOR (Aåren)
17 Informant ( Address)
RECEIVED
26. 20.47
Address!
129 Hunmich ave. Fremmich, .. " Đạio thịand
(City or Town) 19
22 NAME OF FUNERAL DIRECTOR ADDRESS
Reoelved and filed
NOV 25-1947
19
(Registrar of City or Town where deceased resided)
50m (e)-1-41-4667
A TRUE COPY. ATTEST : (Registrar of city or town where death occurred)
DATE FILED 19
Physician
Major findings: Of operations.
of autopsy
which death shouldbe charged tte.
Underline the cause to which death should be charged sta- tistically.
PARENTS
14 BIRTHPLACE FATHER (Ci (State or cou
SIGNATURE OF INFORMANT
PLACE OF ACCIDENT
MOTHER FATHER
BIRTHPLACE (City of town). (State or country)
Due to.
to May 22 May It , 19/ / and that
that i Ist saw himlDalive on
death occurred on the date stated above, at.
(Cine full maldon name) (Or) WIFE OF
Imnydiate cause Carline Failure
Usual 9 Occupation :
Than-
One Day Min.
ttended deceased from
19
19 death is sald to
m.
Duration
6 Age of husband
City or Borough _. (Il gutaide city er Locough Noche, namy soyabip) Street No. 10 C Ce RET
1947
Citizen of (If rural give location) If so, neme
(Year)
Sa If married, wid HUSBAND of
(or) WIFE of
DATE OF DEATH
town and State)
NEW JERSEY DEPARTMENT OF HEALTH-BUREAU OF VITAL STATISTICS
Length of stay: In
DELOW
FORMER OR USUAL RESIDENCE
Township
ATH
.... nicu m ouvir or owns the tin of death should be made forthwith and transmitted on Form R-802 to the clerk of the city or town in which the deceased resided. (See Chap. 46, Sec. 12, G. L.)
No.
St.
(If U. S. War Veteran, specify WAR)
. .. ...
atlon of deoessed ?.
(City ar tương) Did Injury cocur Is or sbout home, en farm, in industrial plast, la pebble piace?
M. D.
12
MEDICAL CERTIFICATION
R-302
Essex
(County)
Lynn
(City or Town)
No. 94 Franklin
St.
S (If death occurred in a hospital or institution, give its NAME instead of street and number)
2 FULL NAME
Martha W Berry (Kendall)
(If deceased is a married, widowed or divorced woman, give also maiden name.)
(if U. S.
War Veteran,
speolfy WAR)
(a) Residenoe. No.
96 Bartlett Rd.
St.
Winthrop, Mass
(Usual place of abode)
(If nonresident, give city or town and State)
Length of stay : In hospital or Institution.
(Before death)
(Specify whether)
years
months
days.
In this community
5Grs.
mos.
days.
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
4 COLOR OR RACE
5 SINGLE
(write the word)
Female
White
MARRIED
WIDOWED
or DIVORCED Married
5a If married, widowed, or divoroed HUSBAND of
(or) WIFE of
Joseph W
Berry
(Give maiden name of wife in full)
(Husband's name in full)
85
6 Age of husband or wife if alive years
7 IF STILLBORN, enter that fact here.
AGE 77 Years 5 Months 13 Days
If less than 1 day
Hours ..........
Minutes
Usuai
9 Occupation :
Housewife
Industry
10 or Business :
own home
11 Soolal Security No ..
none
Boston
12 BIRTHPLACE (City)
(State or country)
Mass.
13 NAME OF
FATHER
George Kendall
PARENTS
14 BIRTHPLACE OF
FATHER (City)
London
(State or country)
England
15 MAIDEN NAME
OF MOTHER
Mary A. Riley
16 BIRTHPLACE OF
MOTHER (City)
(State or country)
England
17 Joseph S. Perry
informant.
obstation, if any
( Address) 38 Lowell Rd., Winthrop
A TRUE COPY.
ATTEST :
(Registrar of city or town where death 'occurred)
DATE FILED
19
Sept. 17.
47
18 DATE OF
DEATH
August 15, 1947
(Month)
(Day)
(Year)
19 | HEREBY CERTIFY,
11/30
19 ... 4.6.
to
8/1.5.
19
47
I last saw h ............. allve on
8/15
19.4 .. 7, death Is sald to
have occurred on the date stated above, at
8:45 Dom
Duration
Immediate cause of death.
Chr. deg. myocarditis
10yrs.
& decomp.
Due to.
Gen, arteriosclerosis
15yrs.
Due to.
Other conditions.
Paralysis agitans
(Include pregnancy within 3 months of death)
Major findings :
Of operations
Date of.
12yrs. Physician
Underline the cause to which death should be charged sta- tistically.
Of autopsy
What test confirmed diagnosis?
20 Was disease or Injury In any way related to oooupation of deceased ?.
If so, speolfy
(Signed).
EdmundA ........ Jannino
M. D.
(Address)
181 N. Common St. Date 8/15 19 47
21 PLACE OF BURIAL,
CREMATION OR REMOVALWinthrop.
Winthrop
(Cemetery }
(City or Town)
DATE OF BURIAL
August 18
19.47
22 NAME OF
FUNERAL DIRECTOR
Howard S. Reynolds
ADDRESS
Winthrop, Mass.
Reoelved and filed
DEC 2 1941
19
(Registrar of City or Town where deceased resided)
of the city or town in which the deceased realded. (See Chap. 46, Sec. 12, G. L.)
50m (e)-1-41-4667
PLACE OF DEATH
The Commontoralth of Massachusetts OFFICE OF THE SECRETARY DIVISION OF VITAL STATISTICS COPY OF CERTIFICATE OF DEATH
Lynn
(City or town making return)
Registered No.
86.216
1
MEDICAL CERTIFICATE OF DEATH
That I attended deceased from
R-302
Essex
(County)
Lynn
(City or Town)
No.
Lynn Hospital
The Commonlocalth of Massachusetts OFFICE OF THE SECRETARY DIVISION OF VITAL STATISTICS COPY OF CERTIFICATE OF DEATH
Lynn
(City or town making return)
Registered No.
909 217
- ( If death occurred in a hospital or institution, St. 3 give its NAME instead of street and number)
2 FULL NAME
Chester E. Donaghy
(If deceased is a married, widowed or divorced woman, give also maiden name.)
(a) Residence. No.
45 Pleasant
St.
Winthrop
(If nonresident, give city or town and State)
Length of stay: In hospital or Institution ..
hosp.
years
months
1
days.
In this community
yrs.
mos.
1 days.
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
4 COLOR OR RACE
5 SINGLE
(write the word)
MARRIED
WIDOWED
or DIVORCED
Widowed
5a If married, widowed, or divorced
HUSBAND of
à Nichols
(or) WIFE of
(Husband's name in full)
6 Age of husband or wife if allve
years
7 IF STILLBORN, enter that fact here.
8
AGE.
Years
53
5
.Months
28 Days
If less than 1 day Hours. .. Minutes
Usual
9 Ocoupatlon :
Auditor
Industry
10 or Business :
S.O.C.O., N. Y.
11 Social Security No.
087-09-2472
12 BIRTHPLACE (City)
(State or country)
13 NAME OF
FATHER
Elijah Donaghy
PARENTS
14 BIRTHPLACE OF
FATHER (City)
(State or country)
Canada
15 MAIDEN NAME
OF MOTHER
Annie Briggs
16 BIRTHPLACE OF
MOTHER (City)
(State or country)
Canada
17 Fthel F. Allen
Relation if any
Informant
( Address)
16 Springvale Ave. , Lynn
A TRUE COPY.
ATTEST:
(Registrar of city or town where death occurred)
DATE FILED
Sept ....... 17,
19
47
MEDICAL CERTIFICATE OF DEATH
18 DATE OF
DEATH
Aug. 30,
1947
(Month)
(Day)
(Year)
19 | HEREBY CERTIFY, That I attended deceased from
AUG.
29
.....
...
1947
to.
Aug
30
19 ..... 4.7
I last saw h.
im .... allve on
Aug
30
1947
death Is sald to
have occurred on the date stated above, at
10:30a
m.
Duration
Immediate cause of death.
Circulatory failure
1day
Due to
Infection (organism
unknown )
Due to
Other conditions.
Arteriosclerosis
unknown Physician
(Include pregnancy within 3 months of death)
Major findings :
Of operations
Date of
charged sta·
What test confirmed diagnosis ?.
White blood count.
20 Was disease or Injury In any way related to occupation of deceased ?.
If so, speolfy
(Signed)
William M.
Leyton
M. D.
.
(Address)
381 Broadway
Date.
9/1 1947
21 "PLACE OF BURIAL,
Waterside Com.
CREMATION OR REMOVAL .
(Cemetery)
Faccio behead
DATE OF BURIAL
.S.e.p.t ..
.. 3.,
19
47
22 NAME OF
FUNERAL DIRECTOR
.. W/m ....... C ....... Good.ri.cb
ADDRESS
128 Washington St ..
ynn
Reoelved and filed
DEC 2 1947
19
(Registrar of Clty or Town where deceased realded)
50m (e)-1-41-4667
icasuru m another city or town at the time of death should be made forthwith and transmitted on Form R-302 to the clerk of the city or town in which the deceased resided. (See Chap. 46, Sec. 12, G. L.)
1
PLACE OF DEATH
(If U. S.
War Veteran,
speolfy WAR)
no
(Usual place of abode)
(Before death)
(Specify whether)
Male White
(Give maiden name of wife in full)
Underline the cause to which death should be
Of autopsy
Visceral congestion of
brood .
tistically.
+
DEPARTMENT OF COMMERCE
BUREAU OF THE CENSUS
STANDARD CERTIFICATE OF DEATH
FORM APPROVED Budget Bureau No. 41-R132-42
State File No.
Registrar's No.
218
State of New .. Hampshire
1. PLACE OF DEATH:
2. USUAL RESIDENCE OF DECEASED:
(a) State
Mass
(b) County
Suffork
(b) City or town
Bartlett
(If outside city or town limita, write RURAL)
(c) Name of hospital or institution:
Bartlett Village
(If outside city or town limita, write RURAL)
(d) Street No.
39 Coral Avenue
(If not in hospital or institution, write street number or location)
(If rural, give location)
(d) Length of stay: In hospital or institution
In this community
3 weeks
(Specify whether
If foreign born, how long in U. S. A .?
years.
3. (a) FULL NAME Michael J. Connelly
20. Date of death: Month
Sept.
day
5
year
1947
hour
12
minute
30
A.M
21. I hereby certify that I attended the deceased from
6. (a)Single, widowed, married,
Aug 28,
19_
470
Sept. 5,
1947
4. Sex __ Male
race
white
divorced Widoved
6. (b) Name of husband or wife
MargaretE, Driscoll
alive
6. (c) Age of husband or wife if
and that death occurred on the date and hour stated above.
Immediate cause of death
Cardiac Failure
Code 200A
8. AGE: Years 80
Months
If less than one day
hr.
min
9. Birthplace
Boston,
Mass
(City, town.,or county) (State or foreign country)
10. Usual occupation
Rigger
11. Industry or business
12. Name
John Connelly
13. Birthplace
Ireland
(City. town, or county)
(State or foreign country)
14. Maiden name
Margaret
15. Birthplace
fraland
(City, town, or county) (State or foreign country)
16. (a) Informant's own signature Frank H. Connelly
(b) Address _. 39Coral Ave, Winthrop Lass.
22. If death was due to external causes, fill in the following:
fa) Accident, suicide, or homicide (specify)
(b) Date of occurrence
(c) Where did injury occur?
(City or town) (County) (State)
(d) Did injury occur in or about home, on farm, in industrial place, in public
place?
(Specify type of place)
While at work? (e) Means of injury
423 Signature
John i. Twaddle MD
(M. D. or other)
Address
Glen, N. H.
Date signed _9/5/
47
DER
1047 DEC
194 k
3. (b) If veteran,
name war
3. (c) Social Security No.
5. Color or
(Month)
(Day)
(Year)
Due to
Due to
Other conditions.
HInolude pregnancy within 3 months of death)
PHYSICIAN
Major findings: Of operations
autopsy
Underline the cause to which death should be charged sta- tistically.
17. (a)
Burial
(b) Date thereof __ 9/8/47
(Month) (Day) (Year)
(c) Place; burial or cremation
(Burial, cremation, or removal) Talden, Mass. Toly Cross Cemetery
18. (a) Signature of funeral director Arthur H. Furber
(6) Address
North Conway ....... H.
19. (a) 9/8/47 (b) .Frad L. Garland
(Date received local registrar) (Registrar's signature)
8-6917 8
U. S. GOVERNMENT PRINTING OFFICE 16-13493-1
that Nast saw him
__ alive on
Sept. 4,
19 __ 47
Duration
years
7. Birth date of deceased
Sept. 16, 1866
11
Days 19
MOTHER FATHER
years, months or days)
MEDICAL CERTIFICATION
(a) County
Carroll
(c) City or town
Winthrop
DEC->>
A R-302
1
PLACE OF DEATH
SUFFOLK LEGION
The Commonwealth of Massachusetts OFFICE OF THE SECRETARY DIVISION OF VITAL STATISTICS COPY OF CERTIFICATE OF DEATH
JUSTON
(City or town making return)
Registered No.
$$19
No. Boston Psychopathic Hoso
(If death occurred in a hospital or institution,
St.
give its NAME instead of street and number)
Alfonzo Sanden
(If deceased is a married, widowed or divorced woman, give also maiden name.)
20 Crescent
St.
Winthrop
(If nonresident, give city or town and State)
Length of stay: In hospital or Institution
(Before death)
(Specify whether)
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
3 SEX
M
4 COLOR OR RACE|
Col.
5 SINGLE
(write the word)
MARRIED
WIDOWED
or DIVORCED ingle
(Month)
(Day)
(Year)
19 | HEREBY CERTIFY,
9/11/47
19
to ..
10/11/47
19
I last saw h ...... 1.m ....
17/11/47
19
death Is sald to
(or) WIFE of
( Husband's name in full)
6 Age of husband or wlfs If allve years
7 IF STILLBORN, enter that fact here.
AGE Years ... 1.O .... Months 4 Days
If less than 1 day Hours .Minutes
Usual
9 Ocoupation :
Cleanser
Industry
Pullman Co
10 or Business:
11 Soolal Security No ..
unknown
12 BIRTHPLACE (City)
(State or country )
Charleston SC
Other conditions
(Include pregnancy within 3 months of death)
Physician
Major findings:bilateral prefrontal
Of operations
lobotomy
Date
of
9/22/47
Of autopsy
10/11/47
What test confirmed diagnosis ?.
20 Was disease or Injury In any way related to occupation of deceased ?
If so, speolfy
(Signed)
HJ De Shon
M. D.
(Address) 7L Fenwood Ra
Date 7/11/197
21 PLACE OF BURIALMIT Hope - Boston
CREMATION OR REMOVAL
(Cemetery )
27/14/47
19
DATE OF BURIAL
(City or Town)
22 NAME OF
FUNERAL DIRECTOR
N G Davis
ADDRESS
Boston
Received and filed
19
NOV 121917
(Registrar of City' or Town where deceased resided)
50m-(b) -6-44-14607
resided in another city or town at the time of death should be made forthwith and transmitted on Form R-302 to the clerk
of the city or town in which the deceased resided. (See Chap. 46, Sec. 12, G. L.)
PARENTS
14 BIRTHPLACE OF
FATHER (City)
S.C
(State or country )
15 MAIDEN NAME
OF MOTHER
Perolee Logan
16 BIRTHPLACE OF
MOTHER (City)
(State or country)
Relation, if any
InfoMED Records (Address)
A TRUE COPY.
ATTEST :
(Registrar of city ort 10/15/47 19
death occurred)
DATE FILED
have ooourred on ths date stated above, at
9 452
m.
Duration
Immediate cause of death. cerebral infarct-right
3 wks
terminal cardine failure
3 da ...
Due to.
Due to.
13 NAME OF
FATHER
John A Sanden
18 DATE OF
DEATH
Oct 11/47
(If U. S.
War Veteran,
speolfy WAR)
.no
(a) Residence. No.
(Usual place of abode)
hoso
7
months
days.
years
In this community
yrs.
mos.
30days.
5a If married, widowsd, or divorced
HUSBAND of
(Give maiden name of wife in full)
That I attendsd deceased from
Underline the cause to which death should he charged sta- tIstically.
J
2 FULL NAME
(City or Town)
RM R-305
PLACE OF DEATH
SUFFOLK 1 BOSTON
(City or Town)
No.
818 Harrison Ave
The Commonwealth of Massachusetts OFFICE OF THE SECRETARY COPY OF MEDICAL EXAMINER'S CERTIFICATE OF DEATH
BOSTON
(City or town making return)
Registered No.
9053220
(If death occurred in a hospital or institution, St. give its NAME instead of street and number)
(If deceased is a married, widowed or divorced woman, give also maiden name.)
7 Wave Way Ave.
St.
(If nonresident, give city or town and State)
months
days.
In this community
mos.1
days.
MEDICAL CERTIFICATE OF DEATH
18 DATE OF
DEATH
Oct/17/47
(Month)
(Day)
(Year)
19 | HEREBY CERTIFY that f heve Investigated the death of the person above-named and that the CAUSE AND MANNER thereof are as follows: (If an injury was involved, state fully.) Coronary sclerosis
treated .... therefor.
20 Acoldent, sulolde, or homlolde (specify)
Date of ooourrence.
19
Where did Injury ooour ?
(City or town and State)
Did Injury ooour In or ebout the home, on ferm, In Industrial place, or In
publlo pleoe?
(Specify type of place)
Collapsed at place of business
Manner of
Injury
Neture of Injury
While et work ?.
Was there an autopsy ?
No
21 Was diseese or Injury In any way related to oooupation of decessed ?.
If so, speolfy
(Signed)
Timothy Leary
(Address)
Date. 10-1719 4
22
Pultusker Cem-West Rox.
Place of Burial, Cremation or Removal.
(City or Town)
DATE OF BURIAL
Oct ..... 19/47
19
23 NAME OF
FUNERAL DIRECTOR
L Levine
ADDRESS
Brookline
ass.
Received and filed NOV 1 2 19 17
19
(Registrar of City or Town where deceased resided)
25m-(d) .6-43-12056
17
Informant.
(Address)
Dr ... Jagob Walla &glatlog dyrDy In-Law
A TRUE COPY
ATTEST :
(Registrar of clty or town where death occurred)
DATE FILED
Qct .. 2.1/47.
19
(write the word)
Married
widowed, or divo Regina Mochedlover
years
If lese than 1 day Hours .Minutes
2 FULL NAME.
Abraham Klier
(a) Residence. No.
(Usual place of abode)
Length of stay: In hospital or Institution.
(Before death)
(Specify whether)
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
M
4 COLOR OR RACE
W
5 SINGLE
MARRIED
WIDOWED
or DIVORCED
50 If married,
HUSBAND of
(Give maiden name of wife in full)
(or) WIFE of
(Husband's name in full)
6 Age of husband or wife If allve
60
7 IF STILLBORN, enter thet faot here.
8
AGE
60
Years
Months
Deys
Usual
9 Oocupation :
Leather Worker
10 or Business :
11 Soolal Seourlty No.
12 BIRTHPLACE (City)
Russia
(State or country)
13 NAME OF
FATHER
Rubin Klier
14 BIRTHPLACE OF
Russia
FATHER (City)
(State or country)
15 MAIDEN NAME
OF MOTHER
Zlateh
-
PARENTS
16 BIRTHPLACE OF
Russia
MOTHER (City)
(State or country)
of the city or town in which the deceased resided as soon as possible after the close of the month in which the death
occurred. {See Chap. 46, Sec. 12, G. L.)
resided in another city or town at the time of death should he made forthwith and transmitted on Form R-805 to the clerk
Copies of returns of deaths recorded during the previous month which occurred in your city or town in case the deceased
Industry
Repairer of Notions
years
(If U. S.
War Veteran,
speolfy WAR)
Winthrop Mass.
1
M.
M R-302
Suffolk
(County)
Boston
(City or Town)
No.
Jewish Memorial .... Cospt
The Commonwealth of Massachusetts OFFICE OF THE SECRETARY DIVISION OF VITAL STATISTICS COPY OF CERTIFICATE OF DEATH
Boston
(City or town making return)
9251
- (If death occurred in a hospital or institution, St. give its NAME instead of street and number)
2 FULL NAME
(If deceased is a married, widowed or divorced woman, give also maiden name.)
10 Wave Way Ave.
Winthrop
Mass.
(a) Residence. No.
(Usual place of abode)
St.
(If nonresident, give city or town and State)
Length of stay : In hospital or Institution.
(Before death)
(Specify whether)
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
3 SEX
M
4 COLOR OR RACE
W
5 SINGLE
(write the word)
Married
1
5a If married, widowed, or divorce Rose Lurensky
HUSBAND of
( Give maiden name of wife in full)
(or) WIFE of
(Husband's name in full)
6 Age of husband or wife If allve
60
years
7 IF STILLBORN, enter that faot here.
8 AGE. 64 Years Months Days
If less than 1 day
.. Hours.
Minutes
Usual
9 Ocoupation :
Tailor
Industry
Z & C Clothing Co.
10 or Business:
11 Soolal Security No ... .
Cannot .... be ... learned
12 BIRTHPLACE (City)
(State or country)
Russia
13 NAME OF
FATHER
Samuel Boiarsky
PARENTS
14 BIRTHPLACE OF
FATHER (City)
(State or country)
Russia
15 MAIDEN NAME
OF MOTHER
Cannot be learned
16 BIRTHPLACE OF
MOTHER (City)
(State or country)
Russia
17
Informant
(Address)
Dr Samuel H, Boajon if any
Correct Namo "Son
A TRUE COPY.
ATTEST!
I Manning
(Registrar of city or town wherg death occurred) Oct.21/47 19
Received and filed.
19
DATE FILED
18 DATE OF
DEATH
(Month)
(Day)
(Year)
19 I HEREBY CERIAFY.
Sept .30
19
That I, attended deceased from
19
47
ot/18
.. Y.
I last saw h.
im allve on.
ct/18/47
19.
.. , death Is said to
have ooourred on the date stated above, at
5,45AM
m.
Duration
Immediate cause of death.
Broncho Pneumonia
Epidermoid carcinoma
1 ..... Yr.
Due to.
of the larynx
Due to.
Other conditions
(Include pregnancy within 3 months of death)
Physician
Major findings:
Total laryngectomy
Of operations
June 1946
Date of
Underline the cause to which death should be charged sta- tistically.
Of autopsy
Clinical
What test confirmed diagnosis?
20 Was disease or injury in any way related to oooupation of deceased ?
If so, spoolfy
(Signed)
RM Phillips
M. D.
(Address)
Boston .. Mass
Date
10-18 9 47
21 PLACE OF BURIAL,
CREMATION OR REMO
Kenesseth
-srael-Woburn Mass.
(Cemetery)
(City or Town)
DATE OF BURIAL
Oct.
19/47
19
22 NAME OF
FUNERAL DIRECTOR
B ... Birnbach
ADDRESS
Dorchester Mass.
NOV 13 1947
( Registrar of City or Town where deceased residled)
50m- (b).6.44-14607
resided in another city or town at the time of death should be made forthwith and transmitted on Form R-802 to the clerk of the city or town in which the deceased resided. (See Chap. 16, Sec. 12, G. L.)
1
PLACE OF DEATH
Benjamin Boiarsky
(If U. S.
War Veteran,
spoolfy WAR)
Oct. 18/47
MARRIED
WIDOWED
or DIVORCED
months
18 days.
In this community
yrs.
.18
days.
years
Registered No.
.. 6-Mos.
A R-302 7
Suffolk
(County)
Boston
(City or, Town) ass.
General Hospital
The Commonwealth of Massachusetts OFFICE OF THE SECRETARY DIVISION OF VITAL STATISTICS COPY OF CERTIFICATE OF DEATH
Boston
(City or town making return)
Registered No.
9417 222
St. (If death occurred in a hospital or institution, give ite NAME instead of etreet and number)
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