USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1949 > Part 23
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(Give maiden name of wife in full)
(or) WIFE of
TWEEN ONSET AND DEATH
DISEASE OR CONDITION DIRECTLY LEADING TO DEATH (a). Uremia
Due Carcinoma of colon
1} yrs
(Kind of work done during most of working life)
Major findings:
Left anterolateral cordotomy
Of operations. upper cervical cord.
.Was autopsy performed ?.
What test confirmed diagnosis?
Autopsy.
5 Was disease or injury in any way related to occupation of deceased?
No
If so, specify,
F Haase Jr
(Address) ..
Asst Dir MGH
Date.
5/21 19 49
M. J.D
Winthrop
21
Informant
(Address)
Nora L Brennan (wife)
50m-(e)-10-48-24658
(Month)
ANTE
CEDENT
CAUSES
Due To
(c)
OTHER
SIGNIFICANT
CONDITIONS
(Signed)
Copies of returns of deaths which occurred in your city or town in case the deceased resided in another city or town at the time
after the close of the month in which the death occurred. (See Chap. 46, Sec. 12, G. L.)
of death should be transmitted on Form R-302 to the clerk of the city or town in which the deceased resided as soon as possible
Date of operation
572/49
(a) Residence. No. (Usual place of abode)
(Was deceased a U. S. War Veteran, { if so specify WAR)
None
(write the word)
I last saw h
im alive on
May 20, 19 49
6:35 P
.m.
10 das
.Mass ... Gen HospBaker Memorial No.
WRITE PLAINLY, WITH UNFADING BLACK INK - THIS IS A PERMANENT RECORD
1
בי
Copies of returns of deaths which occurred in your city or town in case the deceased resided in another city or town at the time after the close of the month in which the death occurred. (See Chap. 46, Sec. 12, G. L.) of death should be transmitted on Form R-302 to the clerk of the city or town in which the deceased resided as soon as possible
PLACE OF DEATH
Md sx .
(County)
(City or Town)
The Commonwealth of Massachusetts OFFICE OF THE SECRETARY DIVISION OF VITAL STATISTICS
COPY OF CERTIFICATE OF DEATH
Registered No.
5771
No. St ...... Joseph's Hospital Thomas J. Boyd
[(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.)
33 Bayview Ave.
St.
Winthrop .....
Mass.
(a) Residence. No. (Usual place of abode)
(If nonresident, give city or town and State)
Length of stay: In place of death
.. years.
.. months.
days. In place of residence.
... ... years.
months
days.
MEDICAL CERTIFICATE OF DEATH
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
Male
9 COLOR OR RACE
White
(write the word)
10 SINGLE
MARRIED
WIDOWED
or DIVORCED
Single
4 I HEREBY CERTIFY,
That I attended deceased from
19 ... 23.,
to.
May ..... 26,
19 ..
49
I last saw h
imalive on.
May 26,, 19 49, death is said to
10a If married, widowed, or divorced
HUSBAND of
(Give maiden name of wife in full)
(or) WIFE of
(Husband's name in full)
DISEASE OR CONDITION
DIRECTLY LEADING
TO DEATH (a)
Hypertensive
cardiovascular disease
TWEEN ONSET AND DEATH
11 IF STILLBORN, enter that fact here.
12
AGE.
58
Years
Months.
Days
If under 24 hours
Hours ... ... Minutes
13 Usual
Occupation :
Mechanic
-
(Kind of work done during most of working life)
14 Industry
or Business:
Auto
15 Social Security No ....
16 BIRTHPLACE (City).
(State or country)
Malone, N. Y.
17 NAME OF
FATHER
John Boyd
Major findings:
Of operations.
Date of operation.
Was autopsy performed?
no
What test confirmed diagnosis ?.
PE
5 Was disease or injury in any way related to occupation of deceased? IVO
If so, specify.
(Signed)
Anthony Reppucci
M. D.
(Address) 310 Merrimack
Date
5/27/
.. 49
6
Edson Cemetery
Lowell .... Ma.s.s ..
Place of Burial or Cremation
(City or Town)
DATE OF BURIAL.
May 28,
19
Informant
(Address)
215 Broadway
Lowell, Mass .:
7 NAME OF
FUNERAL DIRECTOR
John J. Savage
ADDRESS
Lowell Mass.
Received and filed 19
JUN 10.1949 Udedecken resided)
PARENTS
18 BIRTHPLACE OF
FATHER (City)
(State or country)
Ireland
19 MAIDEN NAME
OF MOTHER
Delia Seymour
20 BIRTHPLACE OF
MOTHER (City)
(State or country)
Mrs. Isabelle Brown
49 21
A TRUE COPY.
"ulsam iz quil'.
ATTEST:
(Registrar of City or Town where death occurred) 5/28/49
DATE FILED
.19
....
1
(Registrar of City or Town where
3 DATE OF
DEATH
May 26, 1949
(Month)
(Day)
(Year)
have occurred on the date stated above, at.
10:25Pm.
INTERVAL BE-
2 yrs
ANTE
Due To
Generalized arteriof
CEDENT (b)
CAUSES
sclerosis
Due To (c)
OTHER
SIGNIFICANT
CONDITIONS
50m-(e)-10-48-24658
M R-302 1
WRITE PLAINLY, WITH UNFADING BLACK INK - THIS IS A PERMANENT RECORD
Malone, N. V.
(City or town making return)
(Was deceased a
U. S. War Veteran,
if so specify WAR)
1
M R-305 1
No.
3 DATE OF
DEATH
Injury
If so, specify
7
8 NAME OF
Copies of returns of deaths which occurred in your city or town in case the deceased resided in another city or town at the time
after the close of the month in which the death occurred. (See Chap. 46, Sec. 12, G. L.)
of death should be transmitted on Form R-305 to the clerk of the city or town in which the deceased resided as soon as possible
Injury
over
May
30
1949
(Month) (Day)
(Year)
4 I HEREBY CERTIFY that I have 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.)
11a If married, widowed, or divorced
HUSBAND of
(Give maiden name of wife in full)
(or) WIFE of.
Richard Metcalf
(Husband's name in full)
12 IF STILLBORN, enter that fact here.
13
AGE
52 Years 4
Months.
9 Days
If under 24 hours
Hours .. ... Minutes
14 Usual
Occupation1.
Bookeeper
(Kind of work done during most of working life)
15 Industry
or Business:
Newspaper
16 Social Security No.
031-22-3738
Winthrop
17 BIRTHPLACE (City)
(State or country)
MASS"
18 NAME OF
FATHER
George L'Stevenson
19 BIRTHPLACE OF
Charlestown
FATHER (City).
(State or country)
Mass
20 MAIDEN NAME
OF MOTHER
Emma Abbott
21 BIRTHPLACE OF
MOTHER (City)
(State or country)
Medford, Mass.
Winthrop Cmtry Winthrop, Mass.
Place of Burial, or Cremation.
(City or Town)
19.49
DATE OF BURIAL June 1
FUNERAL DIRECTOR
Howard S Reynolds
ADDRESS
180 Winthrop St., Winthrop Massa
Received and filed
JUN 1.5 .1949
19
(Registrar of City or Town where deceased resided)
PERSONAL AND STATISTICAL PARTICULARS
9 SEX
Female
10 COLOR OR RACE
White
11 SINGLE
MARRIED
WIDOWED
or DIVORCED
(write the word)
Widowed
multiple injuries (over)
5 Accident, suicide, or homicide (specify).
Accident
Date and hour of injury.
5/30/49
19 2+A.M.
Where did
Injury occur?
Gorham St., East Chelmsford
(City or town and State)
Did injury occur in or about home, on farm, in industrial place, or in public
place?
Highway
(Specify type of place)
Manner of
Car ran out of control, hit tree
Nature of
(How did injury occur?)
While at work?
No
.Was autopsy performed?
Yes
6 Was disease or injury in any way related to occupation of deceased?
....
(Signed)
Marshall L Alling
M. D.
(Address)
Lowell Mass.
Date.
May 39049
No
PARENTS
25m-(h)-10-48-24658
PLACE OF DEATH
Middlesex (County) Chelms ford
(City or Town)
The Commonwealth of Massachusetts OFFICE OF THE SECRETARY DIVISION OF VITAL STATISTICS COPY OF MEDICAL EXAMINER'S CERTIFICATE OF DEATH
Chelmsford (City or town making return)
Registered No.
175
J(If death occurred in a hospital or institution, St. ¿ give its NAME instead of street and number)
2 FULL NAME.
Ethel s Metcalf
(If deceased is a married, widowed or divorced woman, give also maiden name.)
131 Lowell Ave.
Winthrop, Mass.
(a) Residence. No. (Usual place of abode)
St.
(If nonresident, give city or town and State)
Length of stay: In place of death.
.. years ..
.months.
days. In place of residence.
52
.years
4
.9 ..
.months.
.days.
MEDICAL CERTIFICATE OF DEATH
WRITE PLAINLY, WITH UNFADING BLACK INK - THIS IS A PERMANENT RECORD
M
A TRUE COPY.
ATTEST:
(Registrar of City or Town where death occurred)
DATE FILED
Nay
31,
......
.19
49
22 Lester E Stevenson
Informant.
(Address)
12 Pico Ave. Winthrop Mass.
Gorham
(Was deceased a
U. S. War Veteran.
if so specify WAR)
Compound comminuted fracture lower jaw at chin - Fracture 1-5 left ribs, - 1-7 right rit fracture in middle of sternum - Laceration of liver & Lungs and right adrenal - Hemorrha in both plura 7 puncture retro-peritoneal - Hemorrhage separating layers of wall of aort complete severance of trachea and left common caroted artery. M.L.Alling
-
PLACE OF DEATH
Sullek (County)
(City or Town] 125 Cliff Care No. Juan King 2 FULL NAME.
The Commonwealth of Massachusetts OFFICE OF THE SECRETARY DIVISION OF VITAL STATISTICS MEDICAL EXAMINER'S CERTIFICATE OF DEATH
To be filed for burial permit with Board of Health or ite Agent.
Registered No.
J(If death occurred in a hospital of 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 married, widowed or divorced woman, give also maiden name.)
125 Cliff are Northrop St.
(If nonresident, give city or town and State)
Length of stay: In place of death. .. years .. 4 months days. In place of residence 2 years .months. days. .
(a) Residence. No. (Usual place of abode) MEDICAL CERTIFICATE OF DEATH 3 DATE OF DEATH June- (Month) (Day) 5 Accident, suicide, or homicide (specify). Where did Injury occur? (etry or town and State) (How did injury occur?) Nature of Injury Jan-1949 If so, specify4. (A dress) . Boutin DATE OF BURIAL of Death. See reverse side for extracts from the laws relative to the return of certificates of death. DEATH in plain terms, so that it may be properly classified under the International Classification of Causes If deceased was a U. S. War Veteran, G.L. Chap. 46, Section 10, requires physicians to insert a recital to that effect. information should be carefully supplied. MEDICAL EXAMINERS should state CAUSE AND MANNER OF 50m-(g)-10-48-24658 N. B. - WRITE PLAINLY, WITH UNFADING BLACK INK -THIS IS A PERMANENT RECORD. Every item of While at work? .Was autopsy performed?
3- 1949
(Year )
4 I HEREBY CERTIFY that I have investigated the death of the person above-named and that the CAUSE AND MANNER thereof are as follows: (If an injury was involved, state fally.) Semilch : Cilerio clerotic
Heart Disease: purlaneous Cerebral Hemorragia Recent Fracture St. Denis
12 IF STILLBORN, enter that fact here.
13
AGE
80
Years
Months
Days
If under 24 hours
Hours .... Minutes
14 Usual
Occupation:
at Home
(Kind of work done during most of working life)
15 Industry
or Business:
housework
16 Social Security No.
Bertin
17 BIRTHPLACE (City)
(State or country)
man
18 NAME OF
FATHER
Joseph Hing
PARENTS
19 BIRTHPLACE OF
FATHER (City)
(State or country)
Germany
20 MAIDEN NAME
OF MOTHER
Ellen Flappene
21 BIRTHPLACE OF
MOTHER (City)
(State or country)
Cheland
22
Informant
Ellen Hung
(Address) 19 Sammelt Cute Monthsich
I HEREBY CERTIFY that a satisfactory standard certificate of death was filed with me BEFORE the burial or transit permit was issued:
die(Signature of Agent of Board of Health or other)
(Official Designation) 1949
. (Date of Issue of Permit)
BOSTON HEALTH DEPT.
6/21/40
PERSONAL AND STATISTICAL PARTICULARS
9 SEX
Female 1
10 COLOR OR RACE
White
11 SINGLE
MARRIED
WIDOWED
or DIVORCEDmale
Ala If married, widowed, or divorced HUSBAND of. (Give maiden name of wife in full)
(or) WIFE of.
(Husband's name in full)
Date and hour of injury ..
Jan-1 19499
Did injury occur in or about home, on farm, in industrial place, or in public place?
(Specify type ofplace)
Injury
Fell accidentally other form
6 Was disease or injury in any way related to occupation of deceased?
M. D.
(Signed)
force-3 - 1049
ToMalden
7 Place of Burial, or Cremation (City or Town)
Sime 6
1949
8 NAME OF
FUNERAL DIRECTOR albert a. Duncan
ADDRESS 18 Hathor At Somerville
JUN 7-1918
Received and filed ..
948
M R-303 A 1
JUN 2 1 1949
(write the word)
1
EXTRACTS FROM THE LAWS OF THE COMMONWEALTH OF MASSACHUSETTS GOVERNING THE
RETURN OF CERTIFICATES OF DEATH
A physician or registered hospital medical officer shall forthwith, after the death of a person whom he has attended during his last illness, at the request of an undertaker or other authorized person or of any member of the family of the deceased, furnish for registration a standard certificate of death, stating to the best of his knowledge and belief the name of the deceased, his supposed age, the disease of which he died, defined as required by section one, where same was contracted, the duration of his last illness, when last seen alive by the physician or officer and the date of his death. . . Gen. Laws, Chap. 46, Sec. 9.
A physician or officer furnishing a certificate of death. as required by the preceding section or by section forty-five of chapter one hundred and four- teen, shall, if the deceased, to the best of his knowledge and belief, served in the army, navy or marine corps of the United States in any war in which it has been engaged, insert in the certificate a recital to that effect, specifying the war, and shall also certify in such certificate both the primary and the secondary or imme- diate cause of death as nearly as he can state the same. For neglect to comply with any provision of this section, such physician or officer, shall forfeit ten dollars. For the purposes of this section and of sections forty-five, forty-six and forty-seven of said chapter one hundred and fourteen, the word "war" shall include the China relief expedition and the Philippine insurrection, which Shall, for said purposes, be deemed to have taken place between February fourteenth, eighteen hundred and ninety-eight and July fourth, nineteen hundred and two, and the Mexican border service of nineteen hundred and sixteen and nineteen hundred and seventeen. G. L. Chap. 46, Sec. 10.
No undertaker or other person shall bury or otherwise dispose of a human body in a town, or remove therefrom a human body which has not been buried, until he has received a permit from the board of health, or its agent appointed to issue such permits, or if there is no such board, from the clerk of the town where the person died; and no undertaker or other person shall exhume a human body and remove it from a town, from one cemetery to another, or from one grave or tomb other than the receiving tomb to another in the same cemetery, until he has received a permit from the board of health or its agent aforesaid or from the clerk of the town where the body is buried. No such permit shall be issued until there shall have been delivered to such board, agent or clerk, as the case may be, a satisfactory written statement containing the facts required by law to be returned and recorded, which shall be accompanied, in case of an original inter- ment. by a satisfactory certificate of the attending physician, if any, as required by law. or in lieu thereof a certificate as hereinafter provided. If there is no attending physician, or if, for sufficient reasons, his certificate cannot be obtained early enough for the purpose, or is insufficient, a physician who is a member of the board of health, or employed by it or by the selectmen for the purpose, shall upon application make the certificate required of the attending physician. If death is caused by violence, the medical examiner shall make such certificate. If such a permit for the removal of a human body, not previously interred, from one town to another within the commonwealth cannot be obtained early enough for the purpose, the certificate of death made as above provided and in the possession of the undertaker desiring to make such removal shall constitute a permit for such removal; provided, that such body shall be returned to the town from which it was removed within thirty-six hours after such removal, unless a permit in the usual form for the removal of such body has been sooner obtained hereunder. If the
death certificate contains a recital, as required by section ten of chapter forty-six, that the deceased served in the army. navy or marine corps of the United States in any war in which it has been engaged, such recital shall appear upon the permit. The board of health, or its agent, upon receipt of such statement and certificate. shall forthwith countersign it and transmit it to the clerk of the town for registra- tion. The person to whom the permit is so given and the physician certifying the cause of death shall thereafter furnish for registration any other necessary information which can be obtained as to the deceased, or as to the manner or cause of the death, which the clerk or registrar may require .- Chap. 114, Sec. 45, G. L. as amended by Chap. 48, Acts of 1927 and Chap. 414, Acts of 1931. No undertaker or other person shall bury a human body or the ashes thereof which have been brought into the commonwealth until he has received a permit so to do from the board of health or its agent appointed to issue such permits, or if there is no such board, from the clerk of the town where the body is to be buried or the funeral is to be held, or from a person appointed to have the care of the cemetery or burial ground in which the interment is made ......... Chap. 114, Sec. 46, G. L., as amended.
Medical examiners shall make examination upon the view of the dead bodies of persons as are supposed to have died by violence, or by the action of chemical, thermal or electrical agents or following abortion, or from diseases resulting from injury or infection relating to occupation, or suddenly when not disabled by recognizable disease, or when any person is found dead ....... - General Laws, Chap. 38, Sec. 6., as amended by Chap. 632, Sec. 4, Acts of 1945,
.. The medical examiner certifies the cause and manner of death to the best of his knowledge and belief.
RULES OF PRACTICE
The fulfillment of the purpose of these laws calls for the observance of the follow- ing 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 unrelated 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 occupation, the sudden deaths of persons not disabled by recognized disease, and those of persons found dead
STATEMENT OF CAUSE OF DEATH
Medical Examiners in certifying to a death will state the cause and manner thereof, and will specify: (1) Under cause the nature of an injury and of its consequences; and (2) under manner the mode of its production together with the circumstances when these are known. For example: "Compound fracture of the femur with ensuing septicemia (gas bacillus) caused by a steam railway accident.""Pistol shot wound of the chest with associated hemorrhage, hom- icidal." "Asphyxiation by suspension, suicidal." "Syncope while under the influence of ether administered as a surgical anaesthetic." "Fracture of the skull with associated internal injury sustained under circumstances unknown."
If disease or injury was related to occupation, specify. If investigation shows the death to have been due to disease, specify: (1)Under cause its known or presumable nature; and (2) under manner, indicate the circumstances leading to medico-legal inquiry. For example: "Hemorrhage spontaneous of the brain (basal ganglia) (found dead in bed)." "Heart disease, presumably coronary sclerosis. (Sudden death.)''
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE. RANK, RATING ORGANIZATION AND OUTFIT
SERVICE NUMBER
RM R-302 1
WRITE PLAINLY, WITH UNFADING BLACK INK - THIS IS A PERMANENT RECORD
(Usual place of abode)
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
DEATH
June 7/49
(Month)
(Day)
(Year)
June 7
19 ..
.49.
to
June .... 7 19.49
have occurred on the date stated above, at
9 PM. ... m.
DISEASE OR CONDITION
DIRECTLY LEADING
TO DEATH
(a) Myocardial infarction.
ANTE
1945
CEDENT (b) .
CAUSES
disease
Due To
Rheumatic heart
Due To
(c)
Major findings:
None
Of operations
Date of operation
Was autopsy performed?
What test confirmed diagnosis?
Clinical
5 Was disease or injury in any way related to occupation of deceased ?.
If so, specify
(AddressP Bent Brigham HOSte 6-7
19.49
(Signed)
N A Wilhelm
M. R.
6
Winthrop
Winthrop
(City or Town)
Place of Burial or Cremation
DATE OF BURIAL
June 10
19
50m-(e)-10-48-24658
after the close of the month in which the death occurred. (See Chap. 46, Sec. 12. G. L.)
of death should be transmitted on Form R-302 to the clerk of the city or town in which the deceased resided as soon as possible
Copies of returns of deaths which occurred in your city or town in case the deceased resided in another city or town at the time
OTHER
Renal tract infection 1949
SIGNIFICANT
CONDITIONScerebral embolus 4/19 49
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
F
9 COLOR OR RACE
W
10 SINGLE
(write the word)
MARRIED
WIDOWED
DIVOR
Divorced
4 I HEREBY CERTIFY,
That ]
attended deceased from
I last saw h. er . alive on
June 7 19 49 death is said to
INTERVAL BE-
TWEEN ONSET
AND DEATH
1 day
10a If married, widowed, or divorced
HUSBAND of
(Give maiden name of wife in full)
(or) WIFE of
George Milan
(Husband's name in full)
11 IF STILLBORN, enter that fact here.
12
AGE64 Years.
9
.Months
14 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.
None
16 BIRTHPLACE (City)Winthrop
(State or country)
Mass
17 NAME OF
FATHER
Cyrus J Belcher
18 BIRTHPLACE OF
FATHER (City) Winthrop Mass
(State or country)
19 MAIDEN NAME
OF MOTHER
Emma Spooner
20 BIRTHPLACE OF
MOTHER (City)
(State or country)
21
Informant
MissE Belcher
cousin
(Address)
A TRUE Conhal 6 .
ATTEST:
(Registar of City or Town where death occurred)
Received and filed.
JUN 2 4 1949
June .... 13.
1949
(Registrar of City or Town where deceased resided)
PARENTS
49
HOSTON
(City or town making return)
Registered No.
5065 MY
No. - 1. Peter Bent Brigham Hosp Buanite m.
alip. 39
1
[(If death occurred in a hospital or institution,
St. [ give its NAME instead of street and number)
2 FULL NAME. May J. Belcher (If deceased is a married, widowed or divorced woman, give also maiden name.)
(Was deceased a
U. S. War Veteran.
if so specify WAR)
(a) Residence. No.
339 Winthrop St
B
St
Winthrop Mass
(If nonresident, give city or town and State)
Length of stay: In place of death
years.
.months ..
1. days. In place of residence
15
years
months.
days.
PLACE OF DEATH
SUFFOLK BOSTON
(City or Town)
The Commonwealth of Massachusetts OFFICE OF THE SECRETARY DIVISION OF VITAL STATISTICS COPY OF CERTIFICATE OF DEATH
7 NAME OF
FUNERAL DIRECTOR
H S Reynolds
ADDRESS
Winthrop ....... Mass
DATE FILED
6/13/49
.. 19 ..
RM R-302 1
Copies of returns of deaths which occurred in your city or town in case the deceased resided in another city or town at the time WRITE PLAINLY, WITH UNFADING BLACK INK - THIS IS A PERMANENT RECORD
50m-(e)-10-48-24658 after the close of the month in which the death occurred. (See Chap. 46, Sec. 12, G. L.) of death should be transmitted on Form R-302 to the clerk of the city or town in which the deceased resided as soon as possible (c)
PLACE OF DEATH
SUPTOLK (County)'
(City or Town)
The Commonwealth of Massachusetts OFFICE OF THE SECRETARY DIVISION OF VITAL STATISTICS COPY OF CERTIFICATE OF DEATH
(City or town making return)
Registered No.
5067
73
Palmer Memorial ( NEDH No.
[(If death occurred in a hospital or institution.
St. [ give its NAME instead of street and number)
2 FULL NAME .. Philip Covitz
(If deceased is a married, widowed or divorced woman, give also maiden name.)
30 A Mermaid Ave
St.
Winthrop Mass
(If nonresident, give city or town and State)
Length of stay: In place of death
.years.
months
2
.days.
In place of residence
2
.. years
6
months.
days.
MEDICAL CERTIFICATE OF DEATH
PERSONAL AND STATISTICAL PARTICULARS
3 DATE OF
DEATH
June 9/49
(Month)
(Day)
(Year)
8 SEX
M
9 COLOR OR RACE
W
10 SINGLE
(write the word)
MARRIED
WIDOWED
or DIVORCEDWidowed
4 I HEREBY CERTIFY,
June . 7.
19.
4.9.,
to.
June .... 9.
19
4.9
I last saw h. 1m .... alive on
June ... 9 .... 19 49 death is said to
(or) WIFE of
(Husband's name in full)
TWEEN OKSET
AND DEATH
11 IF STILLBORN. enter that fact here.
12
64
AGE
Years.
Months
Days
If under 24 hours
Hours . Minutes
13 Usual
Occupation:
Brush maker (retired
(Kind of work done during most of working life)
14 Industry
or Business:
Brush Mfgring
15 Social Security No.
16 BIRTHPLACE (City).
(State or country)
Russia
17 NAME OF
FATHER
Joseph Covitz
Major findings:
Of operations.
No Operation
Date of operation.
Was autopsy performed ?..... No.
What test confirmed diagnosi
PE & tests of blood
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