USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1951 > Part 104
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12 IF STILLBORN, enter that fact here.
13
63
AGE
Years
Months.
Days
If under 24 hours
Hours .....
Minutes
14 Usual
Occupation: Retired .... Custodian
(Kind of work done during most of working life)
15 Industry
or Business:
Buildings
16 Social Security No ...
17 BIRTHPLACE (City)
(State or country)
England
18 NAME OF
FATHER
Cannot be learned
PARENTS
19 BIRTHPLACE OF
FATHER (City).
(State or country)
England
20 MAIDEN NAME
OF MOTHER
Beauregard
Paris
21 BIRTHPLACE OF
MOTHER (City)
(State or country)
France
22
Ruth Salemmi
Informant.
(Address)
Washburn Ave Revere
I HEREBY CERTIFY that a satisfactory standard certificate of death was .... filed with me BEFORE the burial or transit permit was issued: Walter & Kapers (Signature gf Agent of Board of Health or other)
health Check 12.28 51
(Official Designation)
(Date of Issue of Permit)
(a) Residence.
No. ...
(Usual place of abode)
Length of stay: In place of death ..
3 DATE OF
DEATH
(Month)
Fracture!
Where did
(Specify type of place)
Manner of
Injury
accident
(How did injury occur?)
Fracture
While at work?
(Signa)
7
Brookdale
Place of Burial, or Cremation.
DATE OF BURIAL
If deceased was a U. S. War Veteran, G.L. Chap. 46, Section 10, requires physicians to insert a recital to that effect.
place?
M.T.A.
Statu
whar 28. 195 (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.)
Malnutrition and chopne ponea follow
5 Accident, suicide, or homicide (specify) Goidel
Date and hour of injury.
Oct 16 951
Injury occur?
Boston Man
(City or town and State)
Did injury occur in or about home, on farm, in industrial place, or in public
Was topay performed?
110
esor injury in any way related to occupation of deceased ?.
Mongo M. D. (Address) 25 Chattench Sor Bate 13/281951
Dedham
(City of Town)
De ember 317 1951.
8 NAME OF
FUNERAL DIRECTOR
...
Winthrop Mass
ADDRESS
Received and filed
JAN 2 1952
.19
(Registrar)
Phill
(If dezased is a married widowed or divorced woman, give also maiden name.)
142
(City or Town) Please
2 FULL NAME.
78 Washburn Clues.
MEDICAL CERTIFICATE OF DEATH
(County)
fall
Manchester
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 th of a person whom he has attended during his last illness, at the request an undertaker or other authorized person or of any member of the family of deceased, furnish for registration a standard certificate of death, stating to the t of his knowledge and belief the name of the deceased, his supposed age, the ease of which he died, defined as required by section one, where same was tracted, the duration of his last illness, when last seen alive by the physician 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 ceding scction or by section forty-five of chapter one hundred and four- n, shall, if the deceased, to the best of his knowledge and belief, served in the ny, navy or marine corps of the United States in any war in which it has been gaged, insert in the certificate a recital to that effect, specifying the war, and 11 also certify in such certificate both the primary and the secondary or imme- te cause of death as nearly as he can state the same. For neglect to comply h any provision of this section, such physician or officer, shall forfeit ten dollars. r the purposes of this section and of sections forty-five, forty-six and forty-seven said chapter one hundred and fourteen, the word "war" shall include the China ief expedition and the Philippine insurrection, which shall, for said purposes, be med to have taken place between February fourteenth, eighteen hundred and ety-eight and July fourth, nineteen hundred and two, and the Mexican border vice of nineteen hundred and sixteen and nineteen hundred and seventeen. L. Chap. 46, Sec. 10.
No undertaker or other person shall bury or otherwise dispose of a human body a town, or remove therefrom a human body which has not been buried, until he s received a permit from the board of health, or its agent appointed to issue :h permits, or if there is no such board, from the clerk of the town where the "son died; and no undertaker or other person shall exhume a human body and nove it from a town, from one cemetery to another, or from one grave or tomb er than the receiving tomb to another in the same cemetery, until he has eived a permit from the board of health or its agent aforesaid or from the clerk the town where the body is buried. No such permit shall be issued until there all have been delivered to such board, agent or clerk, as the case may be, satisfactory written statement containing the facts required by law to be urned and recorded, which shall be accompanied, in case of an original inter- nt, by a satisfactory certificate of the attending physician, if any, as required by v, or in lieu thereof a certificate as hereinafter provided. If there is no attending ysician, or if, for sufficient reasons, his certificate cannot be obtained early ough for the purpose, or is insufficient, a physician who is a member of the board health, or employed by it or by the selectmen for the purpose, shall upon plication make the certificate required of the attending physician. If death is used by violence, the medical examiner shall make such certificate. If such a mit for the removal of a human body, not previously interred, from one town another within the commonwealth cannot be obtained early enough for the rpose, the certificate of death made as above provided and in the possession of undertaker desiring to make such removal shall constitute a permit for such noval; provided, that such body shall be returned to the town from which it was moved within thirty-six hours after such removal, unless a permit in the usual 'm 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.)"
PACE FOR ADDITIONAL INFORMATION
ATE OF ENTERING MILITARY SERVICE
ATE OF DISCHARGE
ANK, RATING.
RGANIZATION AND OUTFIT
ERVICE NUMBER
·
4
7
Josto
EU52
The Commonwealth of Massachusetts EDWARD J. CRONIN SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS
STANDARD CERTIFICATE OF DEATH
Registered No. 295
(If death occurred in a hospital or institution, give its NAME instead of street and number)
2 FULL NAME ..
(If deceased is a married, widowed or divorced woman, give also maiden name.)
(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
3 DATE OF
DEATH
Dee.
(Month)
2.9 (Day)
1451
(Year)
4 LHEREBY CERTIFY.
That I attended deceased from
De 24
19 51
to
Du 24
197
I last saw h BY ... alive on ..
24
19.57, death is said to
11:25P. have occurred on the date stated above. at m. INTERVAL BE- TWEEN DNSET AND DEATH
DISEASE OR CONDITION
DIRECTLY LEADING
TO DEATH (a)
promotenty.
ANTE Due To CEDENT (b) CAUSES
Due To (c) ..
OTHER SIGNIFICANT CONDITIONS
Major findings: Of operations.
Date of operation. Was autopsy performed?
What test confirmed diagnosis?
5 Was disease or injury in any way related to occupation of deceased? If so, specify ... (Signed)
M. D.
(Address)
6
Place of Burial or Cremation
Biostar (City of Town)
DATE OF BURIAL
1957
7 NAME OF FUNERAL DIRECTOR
ADDRESS 4/ Haverhill to Bestor
Received and filed.
JAN 2 JAN 2
1952 19
" -. 7 (Registrar)
temale
9 COLOR OR RACE Huta
10 SINGLE MARRIED WIDOWED or DIVORCED
(write the word)
10a If married, widowed, or divorced HUSBAND of .. (Give maiden name of wife in full)
(or) WIFE of
(Husband's name In fully alive
11 IF STILLBORN, enter that fact here.
12
AGE
Years
Months
Days
If under 24 hours Hours55 Minutes
13 Usual Occupation: (Kind of work done during most of working life)
14 Industry or Business:
15 Social Security No.
16 BIRTHPLACE (City) ..
(State or country)
17 NAME OF FATHER
alfred Valente
18 BIRTHPLACE OF FATHER (City) (State or country)
Boston
19 MAIDEN NAME 2 OF MOTHER
Guerra
20 BIRTHPLACE OF MOTHER (City) (State or country)
alfred Valente 9 At
21 Informant (Address)
I HEREBY CERTIFY that a satisfactory standard certificate of death was filed with me BEFORE the burial or Hansit permy was issued: Waltergr Raker (Signatur of Alot of Board of Health or other)
tto (Official Designation)
Dec 31/5/
(1)ate of Issue of Permnt)
RUCTIONS FOR CERTIFICATE
giving OF DEATH ot enter than one for each (b) and (c)
does not mean of dying, such ilure. asthenia .. ans the disease. cations which th.
id conditions. ing rise to the se (a) stating rlying cause
tions contrib- e death but not the disease or causing death.
50m-(b)-11-49-970.569
PLACE OF DEATH
(County) Cinturones (City or, Town)
Il .... tour : 12 Community forpetali No.
Valenti
PHYSICIAN - IMPORTANT (Was deceased a U. S. War Veteran,
if so specify WAR)
East Braton
St.
7, 8 SEX
PERSONAL AND STATISTICAL PARTICULARS
PARENTS
D. Cxinman Klaffer 21 Breed HA E100
michael is.
Date de. 30 1951
Bastano
To be filed for burial permit with Board of Health or its Agent.
A R-301A 1
Stillto
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 ath of a person whom he has attended during his last illness, at the request an undertaker or other authorized person or of any member of the family of e deceased, furnish for registration a standard certificate of death, stating to the st of his knowledge and belief the name of the deceased, his supposed age, the sease of which he died, defined as required by section one, where same was ntracted, the duration of his last illness, when last seen alive by the physician 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 eceding section or by section forty-five of chapter one hundred and four- en, shall, if the deceased, to the best of his knowledge and belief, served in the mny, navy or marine corps of the United States in any war in which it has been gaged, insert in the certificate a recital to that effect, specifying the war, and all also certify in such certificate both the primary and the secondary or imme- ate cause of death as nearly as he can state the same. For neglect to comply th any provision of this section, such physician or officer, shall forfeit ten dollars. or the purposes of this section and of sections forty-five, forty-six and forty-seven said chapter one hundred and fourteen, the word "war" shall include the China lief expedition and the Philippine insurrection, which Shall, for said purposes, be emed to have taken place between February fourteenth, eighteen hundred and nety-eight and July fourth, nineteen hundred and two, and the Mexican border rvice of nineteen hundred and sixteen and nineteen hundred and seventeen. L. Chap. 46, Sec. 10.
No undertaker or other person shall bury or otherwise dispose of a human body a town, or remove therefrom a human body which has not been buried, until he s received a permit from the board of health, or its agent appointed to issue ch permits, or if there is no such board, from the clerk of the town where the rson died; and no undertaker or other person shall exhume a human body and move it from a town, from one cemetery to another, or from one grave or tomb her than the receiving tomb to another in the same cemetery, until he has ceived a permit from the board of health or its agent aforesaid or from the clerk the town where the body is buried. No such permit shall be issued until there all have been delivered to such board, agent or clerk, as the case may be, satisfactory written statement containing the facts required by law to be turned and recorded, which shall be accompanied, in case of an original inter- ent, by a satisfactory certificate of the attending physician, if any, as required by w, or in lieu thereof a certificate as hereinafter provided. If there is no attending ysician, or if, for sufficient reasons, his certificate cannot be obtained early ough for the purpose, or is insufficient, a physician who is a member of the board health, or employed by it or by the selectmen for the purpose, shall upon plication make the certificate required of the attending physician. If death is used by violence, the medical examiner shall make such certificate. If such a rmit for the removal of a human body, not previously interred, from one town another within the commonwealth cannot be obtained early enough for the irpose, the certificate of death made as above provided and in the possession of e undertaker desiring to make such removal shall constitute a permit for such moval; provided, that such body shall be returned to the town from which it was moved within thirty-six hours after such removal, unless a permit in the usual rm 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., (Tercentenary Edition).
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.
No undertaker or other persons 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., (Tercentenary Edition).
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 deathsonly 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 .- Physicians: see explanatory instructions on face side of standard certificate of death.
Statement of Occupation .- Precise statement of occupation is very import- ant, 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. Children 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.
PACE FOR ADDITIONAL INFORMATION
ATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE
ANK, RATING ORGANIZATION AND OUTFIT
ERVICE NUMBER
R-305 1
PLACE OF DEATH
I SUREOLK BOSTON (City or Town) 2 Medford Ct.
The Commonwealth of Massachusetts EDWARD J. CRONIN SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS COPY OF MEDICAL EXAMINER'S CERTIFICATE OF DEATH
BOSTON
(City or town making return)
11168
Registered No.
296
f(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.) 69 Cottage Park Road St.
(Was deceased a
U. S. War Veteran,
if so specify WAR)
Winthrop
Mass.
(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
9 SEX
F
10 COLOR OR RACE
11 SINGLE
MARRIED
WIDOWED Divorced
or DIVORCED
11a If married, widowed, or divorced
HUSBAND of.
(Give maiden name of wife in full)
(or) WIFE of
Joseph F Whalen
(Husband's name in full)
12 IF STILLBORN, enter that fact here.
13
AG 55
Year2
5
Days
If under 24 hours
Hours .....
Minutes
14 Usual
Occupation:
Counter Girl
(Kind of work done during most of working life)
15 Industry
or Business:
Greyhound Bus Terminal
16 Social Security No.
034-14-3757
17 BIRTHPLACE (City).
(State or country)
Hedgeport ... N.S.
18 NAME OF FATHER Robert Porter
19 BIRTHPLACE OF FATHER (City) (State or country)
Wedgeport N.S.
20 MAIDEN NAME
OF MOTHER
Nathalie Surette
21 BIRTHPLACE OF
MOTHER (City)
Wedgeport N.S.
(State or country)
Dr Edward JJ Whalen Son
22 Informant (Address)
A TRUE COPY. Charles it Inacki
ATTEST:
(Registrar of City or Town where death occurred)
DATE FILED
.19
(Registrar of City or Town where deceased resided)
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
after the close of the month in which the death occurred. (See Chap. 46, Sec. 12, G. L.)
25m-(c)-11-49-900.475
6 Was disease or injury in any way related to occupation of deceased ?.
If so, specify
(Signed)
Richard Ford
M. D.
Date .... 12-18 1 5
(Address) Winthrop Com Winthrop Mass.
7 Place of Burial, or Cremation. (City or Town)
Dec.20/51
DATE OF BURIAL 19
8 NAME OP
R C Kirby
FUNERAL DIRECTOR Bostontaus"
ADDRESS
Received and filed.
JAN 1-4 1932
19
Dec.17/51
3 DATE OF
DEATH
(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 -? a Bilateral broncho
5 Accident, suicide, or homicide (specify)
Date and hour of injury 19
Where did Injury occur?
(City or town and State)
Did injury occur in or about home, on farm, in industrial place, or in public place?
Manner of
(Specify type of place)
Injury
(How did injury occur?)
Nature of
Injury
While at work?
Was autopsy performedautopsy
PARENTS
No.
Irene M Whalen
(a) Residence. No. (Usual place of abode)
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 the word)
RECEIVED
11
11 12
OFFIS
10.
8
7
6
JAN 1 Z AM
M 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 after the close of the month in which the death occurred. (See Chap. 46, Ser 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
SUFFOLK (County)
BOSTON
(City or Town)
The Commonwealth of Massachusetts EDWARD J. CRONIN SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS COPY OF CERTIFICATE OF DEATH
BOSTON
(City or town making return)
Registered No.
11558
297
f(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.)
25 STURGIS
St.
WINTHROP
(If nonresident, give city or town and State)
Length of stay: In place of death .........
.years.
Hose
.months. 1
days. In place of residence ............ years ....
.. months .........
...... days.
MEDICAL CERTIFICATE OF DEATH
PERSONAL AND STATISTICAL PARTICULARS
3 DATE OF
DEATH
D.E.C .... 30 ..... 1.9.5.1
(Month)
(Day)
(Year)
4 I HEREBY CERTIFY,
That I attended deceased from
DEC 30
1951
DEC 29
19 .. 51
to
I last saw h
ER
alive on
DEC
30
1951
death is said to
have occurred on the date stated above, at
INTERVAL BE- TWEEN ONSET AND DEATH 29YRS
11 IF STILLBORN, enter that fact here.
12
AGE
Years
......
Months.
I ... Days
If under 24 hours
Hours ....
Minutes
ANTE
CEDENT (b)
CAUSES
Due To
ANOXIA AT BIRTH
(SEPARATED PLACENTA )
Due To (c)
OTHER
SIGNIFICANT
CONDITIONS
Major findings: Of operations
Date of operation.
Was autopsy performed ?... NO
What test confirmed diagnosis?
CLINICAL FINDINGS
5 Was disease or injury in any way related to occupation of deceased ?.. N.O. If so, specify
(Signed)
E A MORTIMER JR
M. D.
(Address)
CH.
Date ..
12/30
19 ... 511
6 .P.RIDE. OF ... BOSTON. C.EM.
Place of Burial or Cremation
WOBURN MASS (City or Town)
DATE OF BURIAL
DEC 31 .195 1
19
7 NAME OF
FUNERAL DIRECTOR
A GOLOV
ADDRESS DORCHESTER
Received and filed. 19
JAN 2 1 1952
(Registrar of City or Town where deceased resided)
PARENTS
18 BIRTHPLACE OF
BOSTON
FATHER (City)
(State or country)
MASS
19 MAIDEN NAME
OF MOTHER
RAY GERTE
20 BIRTHPLACE OF
MOTHER (City)
(State or country)
MASS
21 Informant (Address)
HARRIS KING
A TRUE COPY Charles H."
ATTESTE
(Registrar of City or Town where death occurred)
DATE FILED
JAN 2 1952
.19
(write the word)
8 SEX
FEMALE
9 COLOR OR RACE
WHITE
10 SINGLE
MARRIED
WIDOWED SINGLE
or DIVORCED
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) ENCEPHALOPATHY
13 Usual
Occupation:
(Kind of work done during most of working life)
14 Industry or Business:
15 Social Security No.
16 BIRTHPLACE (City).
(State or country)
MASS
BOSTON
17 NAME OF
FATHER
MYRON N KING
25M (E ).6.50.902253
No.
CHILDREN'S HOSP
BABY GIRL KING
(Was deceased a
U. S. War Veteran,
NO
if so specify WAR)
(a) Residence. No. (Usual place of abode)
WRITE PLAINLY, WITH ONFADING BLACK INK - THIS IS A PERMANENT RECORD
DORCHESTER
1
BIRTH NO.
STATE OF
STATE FILE NO.
102974
1. PLACE OF DEATH
a. COUNTY
CHESTER
2. USUAL RESIDENCE (Where deceased lived. If institution: residence before
Mars.
a. STATE
b. COUNTY
Suffolk
b. CITY (If outside corporate limits, write RURAL and give
OR
TOWN
Calu Pmb.
township)
c.
LENGTH OF
STAY (in this place)
1/400.
c. CITY (If outside corporste limits, write RURAL and give townshjo)
OR
TOWN
Winteroto
d. FULL NAME OF (If not in hospital of institution, give street address or location)
HOSPITAL OR
INSTITUTION
Veterans adminet Heraf
b. (Michiley
d. STREET
ADDRESS
247 Shirley
3. NAME OF
DECEASED
( Type of Print )
a. (First)
Eduard
c. (Last)
crous
4. DATE
OF
DEATH
(Month)
De 25 1951
5. SEX m
6. COLOR OR RACE
W.
7. MARRIED, NEVER MARRIED,
WIDOWED, DIVORCED (Specify)
Man.
8. DATE OF BIRTH
Mary 6
1898
9. AGE (In years
last birthday)
53
Months | Days
IF UNDER 24 HRS. Hours Min.
10a. USUAL OCCUPATION (Give kind of work done duping most of working life, even if retired) Sine Mau
10b. KIND OF BUSINESS OR IN-
Tele.
DUSTRY
11. BIRTHPLACE (State or foreign country)
mare.
12. CITIZEN OF WHAT
COUNTRY?
usa.
13. FATHER'S NAME Michael G. Crows
14. MOTHER'S MAIDEN NAME
alice Carol
15. WAS DECEASED EVER IN U.S. ARMED FORCES? !
(Yes, no, or unknown)
16. SOCIAL SECURITY NO.
Custodian & Recordara
17. INFORMANT
86 Llewellyna Registrar Coalesnelle
18. CAUSE OF DEATH Enter only one cause per line for (a), (b), and (c)
1. DISEASE OR CONDITION
DIRECTLY LEADING TO DEATH*(a)
Hemorrhage, Gastro Subestival 2 hrs.
ANTECEDENT CAUSES
Carcinomatoria Sutra- 62oo.
11. OTHER SIGNIFICANT CONDITIONS Conditions contributing to the death but not related to the disease or condition causing death.
15-3 X
11 chro 20. AUTOPSY?
YES
NO (STATE)
21a. ACCIDENT
SUICIDE
HOMICIDE
(Specify)
21b. PLACE OF INJURY (e.g., in or about home. farm, factory, street, office bldg., etc.)
21d. TIME
OF
INJURY
(Month)
(Day) (Year)
(Hour) m.
21e. INJURY OCCURRED WHILE AT WORK NOT WHILE AT WORK
21f. HOW DID INJURY OCCUR?
22. I hereby certify that I attended the deceased from 4-3
alive on
,19
, and that death occurred at 8:15 /m., from the causes and on the date stated above.
23a. SIGNATURE
a. G. Hacker
(Degree or title)
23b. ADDRESS
Va.r. Coaterriel .
23c. DATE SIGNED
12-25-51
(State)
24a. BURIAL. CREMA- TION REMOVAL (Specify)
24b. DATE
Mensal 12/26/51
24c. NAME OF CEMETERY OR'CREMATORY
Calvaut" Cemetery
24d. LOCATION (City, town, or county)
Boston Mark
DATE REC'D BY LOCAL 12-26-51
REG.
REGISTRAR'S SIGNATURE
25. FUNERAL DIRECTOR
Florence M Vander archive & Maclean Concerto
ADDRESS
PHS-798(VS) REV. 4-48 FEDERAL SECURITY AGENCY PUBLIC HEALTH SERVICE
U. S. GOVERNMENT PRINTING OFFICE 16-53457-2
INTERVAL BETWEEN ONSET AND DEATH
*This does not mean the mode of dying, such as heart failure, asthenia, etc. It means the dis- ease, injury, or complica- tion which caused death.
Morbid conditions, if any, giving DUE TO (b)
rise to the above cause (a) stating
the underlying cause last.
abdorzumal.
Primary Rite Colon
DUE TO (c)
19a. DATE OF OPERA- TION
19b. MAJOR FINDINGS OF OPERATION
General Parecia cerebral Tiffe.
21c. (CITY, TOWN, OR TOWNSHIP)
(COUNTY)
NONRESIDENT
(1949 Revision of Standard Certificate) CERTIFICATE OF DEATH PENNSYLVANIA
298
Form approved. Budget Bureau No. 68-R375.
ad nicion).
(If rural, give location)
IF UNDER 1 YEAR
(Day)
(Year)
(If yes, give war or date= o service) WriedF
MEDICAL CERTIFICATION
, 1949 to 12-25, 1951, that I last saw the deceased
RE: - 199
03
6
1952 MAY-9
4
299
8430
REGISTRATION DISTRICT NO.
1901
NUMBER REGISTRAR'S 21566
CERTIFICATE OF DEATH
FILE NO.
1A. NAME OF DECEASED-FIRST NAME 1B. MIDDLE NAME
1c. LAST NAME
2A. DATE OF DEATH - MONTH. DAY. YEAR
Ro
3. SEX
4. COLOR OR RACE
5. MARRIED NEVER MARRIED, WIDOWED. DIVORCEBY
6. DATE OF BIRTH Unknown
7. AGE (LAST BIRTHDAY)
IF UNDER 1 YEAR IF UNDER 24 HOURS DATS HOURS
MINUTES
8A. USUAL OCCUPATION (GIVE KIND OF DURING MOET OF WORKING LIFE EVEN IF WORK PONE KETINEDI
8s. KIND OF BUSINESS OR INDUSTRY
19. BIRTHPLACE ¿SUNTFOR FOREIGN
Poland
10. CITIZEN OF WHAT COUNTRY? United States
11. NAME AND BIRTHPLACE OF FATHER
12. MAIDEN NAME AND BIRTHPLACE OF MOTHER
Unknown)White (Unknown)
(Unknown) (Unknown)
14. WAS DECEASED EVER IN U. S. ARMED FORCES? SPECIFY YES. NO. UNKNOWN No
IF YES. GIVE WAR OR DATES OF SERVICE
Unknown
176. LENGTH OF STAY (IN THIS PLACE)
Los Angeles
2 Months
17D. FULL NAME AND ADDRESS OF HOSPITAL OR INSTITUTION - (IF NOT IN HOSPITAL OR INSTITUTION. GIVE STREET ADDRESS OR LOCATION) Cedars of Lebanon Hospital, 4833 Fountain Ave.Los Angeles
18A. STREET ADDRESS (IF RURAL GIVE LOCATION)
18. CITY OR TOWN LO.9YTANS SAME OF NEAREST TOWNI
18c. COUNTY
18D. STATE
140 Shirley Street
Winthrop
Suffolk
416
THIS DOES NOT MEAN THE MODE OF DYING SUCH AS HEART FAILURE. ASTHENIA. ETC. IT MEANS THE DISEASE. INJURY OR COMPLICATIONS WHICH CAUSED DEATH.
19.1. DISEASE OR CONDITION DIRECTLY LEADING TO DEATH
(A) Congestive heart failure
2 Days
INTERVAL
ANTECEDENT CAUSES
MORBID CONDITIONS. IF ANY, GIVING DUE TO (8)
Rheumatic hea
BETWEEN
RISE TO THE ABOVE CAUSE (A) STATING
THE UNDERLYING CAUSE LAST.
DUE TO (C)
19-IL' OTHER SIGNIFICANT CONDITIONS CONDITIONS CONTRIBUTING TO THE DEATH BUT NOT RELATED TO THE DISEASE OR CONDITION CAUBINL REATH.
20A. DATE OF OPERATION
20m. MAJOR FINDINGS OF OPERATION
21. AUTOPSY YES
NO
22A. ACCIDENT
(SPECIFY)
22 .. PLACE OF INJURY 158,N.91 FASH. FACTORY, STREET. OFFICE BUILDING
22c. LOCATION
CITY OR TOWN
COUNTY
STATE
DEATH DUE TO EXTERNAL VIOLENCE
220. TIME
OF INJURY
MONTH DAY YEAR HOUR
22E INJURY OCCURRED
WHILE
NOT WHILE
M
AT WORK AY WORK
238 PHYSICIAN"S: 1 HEREBY CERTIFY THAT I ATTENDED THE DECEASED FROM ... 12/28/51
12/29/51
-19 .; THAT ) LAST SAW THE DECEASED ALIVE ON.
AND THAT OFATH OCCURRED FROM THE CAUSES AND AT THE HOUR AND DATE STATED ABOVE.
23E DATE SIGNED
23c. SIGNATURE
DEGREE OR TITLE
230. ADDRESS 4833 Tountat A
1/1/52
24A CURIAL
24m. DATE
24c. CEMETERY OR CREMATORY Local Jewish Com. Dorchester Masnc
Archer 1692
27. DATE RECEIVED BY LOCAL REGISTRAR 28. SIGNATURE OPLOCAL REGISTRAR
26 FUNERAL DIRECTOR
1-1-52
Glasband Mortuary , Los Angeles, Calif.
STATE OF CALIFORNIA
ay
DEPARTMENT OF PUBLIC HEALTH
NON-RESIDENT REALLOCATION FOR STATISTICAL PURPOSES ONLY
This is to certify that this is a true court of the document
DECEDENT. PERSONAL DATA (TYPE OR PRINT NANE)
Tenal
W ov
Abt 65 YEARS
MONTHS
28. HOUR 10:45
50/2
2021 PLACE OF DEATH 9888 USUAL RESIDENCE (WHERE DECEASED LIVED) ( IF INSTITUTION. RESI- DENCE BEFORE ADMISSION
CAUSE OF DEATH CENTER ONLY ONE CAUSE PER LINE FOR (A). (8) AND (C))
ONSET AND
DEATH
OPERATIONS
SUICIDE
HOMICIDE
22F. HOW DID INJURY OCCUR?
JAUTOPSY. INQUEST. OR
23A. CORONER'S: I HEREBY CERTIFY THAT I HAVE HELD AN O INVESTIGATION ON THE REMAINS OF THE DECEASED AND FIND THAT THE DECEASED CANE TO DEATH AT THE HOUR AND DATE STATED ABOVE. C
12/29/51
PHYSICIAN'S OR CORONER'S CERTIFICATION
alles S. Shector M.D.
25. SIGNATURE OF EMBALMER
LICENSE NUMBER
CREMATION REMOVAL 1/1/52
FUNERAL DIRECTOR AND REGISTRAR
APPROXIMATE
17A. PLACE OF DEATH - CITY OR TOWN LIG.SYTTIDE CORESAATE LIMITS WRITE
15. SOCIAL SECURITY NUMBER
16. INFORMANT Roso Applebaur
13. NAME OF SPOUSE (IF MARRIED)
17c. COUNTY Los Angeles
TE YMITO WRITE
STATE 51-103508
December 30, 1951
-
140
44
国青年年中 年业部集集
+44
午编
4444 44407
1イニ4444
南出版出品 中車业业事
山南号
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