USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1957 > Part 84
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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., (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, fromh, the.clerli of the town where the body is to be buried or the funeral is to be held, of 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 deaths only as those of persons who, though disabled by recognized disease unrelated to any form of injury, have died without retent medical aftendance or whose physician is absent from home when the cer ffeate of death is needed.
(3) Medical Examiner's 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.
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE RANK, RATING
ORGANIZATION AND OUTFIT
SERVICE NUMBER .. .....
X
PLACE OF DEATH
SUF FOLK (Cnunty) BOSTON (City nr Town)
Nn. BETH
The Commonwealth of Massachusetts EDWARD J. CRONIN SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS STANDARD
OUTUCE OFQWOW To be filed for bariat permit with Board of Health or Its Agent
CERTIFICATE OF DEATH
Registered Na.
Jeff death occurred in a hospital or institution, St. (give ita NAME. instead of street and number)
PHYSICIAN
IMPORTANT
( Was deceased a
S War Veteran,
un specify WARD
(a) Residence. Nn.
9
GROVERS AVE
WINTHROP.
(If nonresident, give city nt town and State)
(Usual place of about)
Length of stay: In place ni death
years
13/4.
4months
days. In place of residence40 years
months
days.
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
DEATH
SEPT
fMonth)
(Day)
30
1957
(Year)
4 I HEREBY CERTIFY.
That I attended deceased from
Aug. 8
1957
.
. 19
57, in SEPT.
30
I last saw her alive nn
SEPT. 30
. 19
, death is said to
have occurred on the date stated above, al
9
a.
m
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a)
HEMORRHAGE
Due To
CARCINO MATOSIS (OVARIES)
- (b)
Due To
(c)
142
OTHER
SIGNIFICANT
CONDITIONS
Was autopay performed'
YES
What test confirmed diagnosis?
5 Was disease or injury in any way related to occupation of deceased?
If an, specify
No
(Signed)
1. Chaundof
. M
(Address)
330 Brookline Avelar Sept 30
1057
6 Tare of fariali
DATE OF BURIAL
October 3,1957
19
7 NAME OF
HI'NERAL DIRECTORAlfred B. Marsh
ADDRESS 174 Winthrop St. Winthrop,
OCT 8
Received and Hed
Charles H. Mack
8 SEX F
9 COLOR
W
10 SINGLE. (write the word)
MARRIED
WIDOWED WIDOWED.
of DIVORCED
30a If married, widowed, or divorced
HE'SHAND of
ffiive maiden name of wife in full)
(or) WIFE
John Malcolm Milne, Sr.
(Husband's name in full)
HI IPSTILLHORN, enter that fact here.
INTERVAL
BETWEEN
ONSET AND
DEATH
1 HOUR
12
Mit69 Years
8 Months
13)ay.
If under 24 hours
Hours
Minutes
13 l'anal
Occupation:
HouseWE UP fone during most of working file)
14 Industry
nr Business:
Own Home
15 Social Security No.
nono
16 HARTIIPLACF (City)
(State of country }
Scotland
17 NAME OF
FATHER
Robert Smith
PARENTS
18 MIRTIPLACE OF
FATHER (C'ity)
1
(State of country)
Scotland
19 MAIDEN NAME
OF MOTHER
Elizabeth Moir
MHIORTHPLACE OF
MOTHER (City )
(State of country )
Scotland
Winthrop Cemetery Winthrop ...
Ma88.
21
Informant
John Malcolm Milne, Jr.
( Address)
9 Grovere Aye. Winthrop
I HEREBY CERTIFY that a satisfactory standand cellficate of death
why me BEFORE the Mial of transit primit was issued
was hled
Mass.
Jacques
Une Comey'
Kent of Board of Health or other)
2- 3967
(D)fhcral Designation )
10 - 2 (5-7)
(Date nl Issue of Permil)
ERTIFICATE
ving
F DEATH enler an one or each ) and (c)
of dying. art failure.
or comple.
. op rite to (.). last.
ar contrib .. eth but not he terminal
bapter In, 4, requires to print or cause of death en Acales.
R-301A -
CTIONS
ISRAEL HOSP.
KATHERINE MILNE 2 FI'L.L. NAME
(If deceased is a married, widowed or divorced woman, give also maiden name )
St.
PERSONAL AND STATISTICAL PARTICULARS
2 years.
--
Glasgow
A TRUE COPY ATTEST: Charles it mackie City Registrar
JAN 1 31150 14
MI-301A -
PLACE OF DEATH
Suffolk (County)
1
Boston 1
(City or Town)
The Commonwealth of Massachusetts EDWARD J. CRONIN SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS STANDARD CERTIFICATE OF DEATH
OUT -OF- TOWN To be filed for burial permit with Board of Health of its Agent
69250
The Boston Floating Hospital No.
j{If death occurred in a hospital or institution,
St. (give its NAME instead of street and number)
PHYSICIAN -IMPORTANT
( W'as deceased a
no
IT S. War Veteran, if so specify WAR)
Winthrop,
Nass.
(If nonresident, give city or town and State)
Length of atay: In place of death
years
months
days. In place of residence
years
months
days.
MEDICAL CERTIFICATE OF DEATH
PERSONAL AND STATISTICAL PARTICULARS
& SEX
female
9 COLOR
white
10 SINGLE (write the word)
MARRIED
WIDOWED
single
of DIVORCED
10a If married, widowed, or divorced
HUSBAND of
(Give maiden name of wife in full)
(or) WIFE. of
(Husband'a name in full)
11 IF STILLBORN. enter that fact here.
12
AC.F.
Years
Months
2
Days
If under 24 honra
I[ours
Minutes
13 l'sual
Occupation :
(Kind of work done during most of working life)
14 Industry
or Business:
15 Social Security No ..
16 BIRTHPLACE (City)
(State of country)
Boston, Mass.
17 NAME OF
FATHER
Aldo V. Belmonte
18 BIRTHPLACE OF
FATHER (City)
East Boston,
(State or country)
Mass.
19 MAIDEN NAME OF MOTHER Anna Karie Visco
20 BIRTHPLACE OF
MOTHIER (City)
(State or country)
East Boston
1888.
21 Aldo V .. Belmonte (father)
Informant
(Address) 6 Elmwood Ct., Winthrop, Mas8.
I HEREBY CERTIFY that a satisfactory standard seglificate of death was hed with me BEFORE the bunny of transit wiffit was toour quelanal a a.
e (SignatuPol Agent of luard of Health w others -4080
10/18/57
t(fhcial Designation)
(Date of Issue of l'esmit)
X
3 DATE OF
DEATHI
October
(Month)
(Day)
4,
1957
(Year)
4 I HEREBY CERTIFY.
That I attended deceased from
October 3,
19 57
October 4,
. 19
I last saw h alive on
October 4,
. 19 57, death is said to
have occurred on the date stated above, at 7:25 a. m.
INTERVAL BETWEEN ONSET AND DEATH
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
Irreversible shock
( a)
Due To (b)
282.9
Due To (c)
OTHER
SIGNIFICANT
ilcal atresia, volvulus, with
CONDITIONSInfarction, perforation and
Was autopsy perlormed?
Yes
(peritonitis
What test confirmed diagnosis?
Operation
5 M'as disease or injury in any way related to occupation of deceased? If so, specify
(Signed)
. M. D).
(Address) 20 Adli Street
Date
10-4
-1952
Holy Cross Cemetery kalden
Place of lurial or Cremat'October , 10 DATE OF BURIAL 19
(City of Town) 57
7 NAME OF
Q Anthony P. Rapino
FUNERAL DIRECTOR
9 Chelsea St., East Boston, Ma88.
ADDRESS
Received
OCT 1 4 1957 Charles H. Mackie
( Registrar)
BELMONTE, Doreen (If deceased is a married, widowed or divorced woman, give also maiden name.)
2 FULL NAME.
R TIONS 11 IRTIFICATE
C DEATH center t.a one reach (I and (c)
de mot mran e of dying. Art failure.
sem compli-
car lot
del but not 1. terminal
C' pter 137, 199 requires asi print or . .... .. of eath on rtl ates.
PARENTS
Registered No.
6 Elmwood Ct. (a) Residence. No. (Usual place of abode)
10 hrs., 15 min.
St.
19
57
6
A TRUE COPY ATTEST: Charles it Mackie City Registrar
JAN 1 31058 AM
X
Suffolk (foanty )
West Roxbury
1City or Town)
CERTIFICATE OF DEATH
Registered Na
S(If death occurred in a hospital or institution.
St. \ Rive its NAME instead of street and number)
IMPORTANT
PHYSICIAN t Was deceased a U. S. War Veteran, WWI if an specify WAR)
Winthrop
( If nonresident, Rive city of town and State)
Years months days.
MEDICAL CERTIFICATE OF DEATHI
PERSONAL. AND STATISTICAL. PARTICULARS
A SEX M
9 COLOR
W
10 SINGLE
( write the word)
MARRIED Married
WIDOWED
or DIVORCED
10a If married, widowed, or divorced
HUSBAND of
Mildred Jacobs
(Give maiden name of wife in full)
(or) WIFE of
(Husband's name in full)
11 IF STILLHORN, enter that fact here.
12
AGE
68years
9
Months
13Days
Hours ....... Minutes
I.t \'sual
Occupation :
( Kind of work done during most of working life)
14 Industry
or Business:
self-employed Machine Tools
15 Social Security No.
015 28 6794
16 MIRTHPLACE (City).
( State or country )
164661/1666
Russia
17 NAME OF
FATHER
Morris Beal
PARENTS
18 MIRTIPLACE OF FATHER (C'it1) ( State of country )
Russia
19 MAIDEN NAME OF MOTHER Sophie Rose
20 BIRTHPLACE OF MOTHER (City) (State of country)
Russia
I'Ince of Itarsal or Cremation (t'ity ni Town) 21 Informant Mrs. Mildred Beal
DATE OF BURIAL 19 57
7 NAMF. OF
FUNERAL DIRECTOR
Solomon funeral Home
BrooklineMasse
ADDRESS
OCT TI 1957 Charles H. Mackil
...
.... (Registrar)
INTERVAL BETWEEN ONSET ARO DEATH
Due To
(b) ....
Arteriosclerotic heart
disease
Due To (c)
4/20
OTHER SIGNIFICANT CONDITIONS
Was autopsy performed? yes What test confirmed diagnosis?
I Was disease or injury in any way related to occupation of deceased? no
1.Signed)
C. E. Forkner, Jr.
. M. D.
(Address). VAH, West Roxbury, Ma'ss. 10/8/2 57 Hand-in-Hand Cemetery. W. Roxbury. MABB 6
October 9
The Commonwealth of MassachusettsUT - OF - TOWN EDWARD J. CRONIN SECRETARY OF THE COMMONWEALTH Is be filed for burial permits with Hadid of Health DIVISION OF VITAL STATISTICA STANDARD
Veterans Administration Hospital
No. .
2 FU'L.I. NAME
DAVID BEAL
( If deceased is a married, widowed or divorced woman, give also maiden name.)
7 Amelia Ave.
(a) Residence. No.
( I'sual place of almale)
Length of stay: In plare of death 0 yeni. O
months 9 days In plare of trsiden
3 DATE OF
October 8, 1957
DEATII
( Month)
(Day)
(Year )
9/29/
57
10/8/
4 I HEREBY CERTIFY,
That I attended deceased from
19
(o
19
57
19 57 death is said to
I last saw himalive on
10/8/
have occurred on the date stated alive, at
7:30 A.
m.
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a)
Coronary thrombosis
PLACE OF DEATH
R-301A -
CTIONS OR CERTIFICATE giving OF DEATH t enter ban one for each b) and (c)
ces not mean of dying. eart failure. tc. It mean! ,.or campli. which caused
as, if any, are rise ta ause (a). the under. ONse last. -
ions contrib. cath but mot the terminal adition given
Chapter 117. D'A, requires . to print or cause of I death on tifcates.
( Address) 7 Amalia Ave., Winthrop, Mass. I HEREBY CORTIS that a tuttefactory standard estimate of death wydal with me BEFORE the burialge transit prinny seemed: Jacqueline lacey At Agent of Board of Health or other)
10 -4051 10-9-50
fOfficial Designation ) flate of lesue of Permit)
V.B. V
If under 24 hours
Merchant
10 days
St
A TRUE COPY ATTEST: Charles it. mackie City Registrar
JAN 1 81950 :
73488 06107 MR-301A -
PLACE OF DEATH
Suffolk (County)
Boston (City or Town)
Veterans Administration Hospital No.
f(If death occurred in a hospital or institution, St. \Rive its NAME. instead of street and number)
PHYSICIAN IMPORTANT (Was deceased a U. S. War Veteran, if so specify WAR)
WW II
« Winthrop, Mass.
( If nonresident, give city of town and State)
(I'qual place of ahade)
Length of stay : In place of death years
months 12 days. In place of residence years
months
days.
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
DEATH
October
8
1957
(Year)
(Manth)
(Dav)
4I HERERY CERTIFY.
That I attended deceased from
Sept. 26
. 12 57 . 1 October 8
. 19
57
, death is said to
have occurred on the date stated above, at
11:55 Pm.
DEATH WAS CAUSED BY : IMMEDIATE CAUSE
(a) Glioblastoma, multiforme
Due To Arteriosclerotic heart (b)
disease
Due To (c)
OTHER SIGNIFICANT CONDITIONS
Was autopsy performed ?
Yes
What test confirmed diagnosis?
Autopsy
5 Was disease or injury in any way related to occupation of deceased > No If so, specily
(Signed)
Charles E. Marton
, M. D.
6
Winthrop Cemetery, Winthrop, Mass. Place of Burial or Cremation October 14, 1957
DATE OF BURIAL 19
7 NAME OF
FUNERAL DIRECTOR
Howard Reynolds
ADDRESS
Winthrop St., Winthrop, Mass.
OCT 14 1857
19
Received Charles H. Mackie
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
9 COLOR
10 SINGLE (write the wurd)
MARRIED
Malo White
or DIVORCED
Married
Lifil'an Brems
HUSBAND of
(Give maiden name of wife in full)
(or) WIFE of
(llusband's name in full)
11 IF STILLBORN, enter that fact here.
12
8
AGE 71 Years 8
Months 8 Days
If under 24 hour»
Hours
Minutes
13 ['sua!
Lieutenant - BFD
Occupation :
(Kind of work done during most of working life)
14 Industry
or Business:
Boston Fire Department
15 Social Security No.
555-74-3643
16 BIRTHPLACE (City)
(State or country )
Massachusetts
17 NAME OF
FATHER
Thomas Dunbar
18 RIRTIIPLACE OF
Rye
FATHER tCity)
(State or country )
New Hampshire
19 MAIDEN NAME
OF MOTHER
Hattie Chick
20 BIRTHPLACE OF
MOTHER (City)
(State of country )
Tama New Hampshire
Informant
Hospital records, VA Hospital
( Address)
150 S. Huntington Ave., Boston
I FLEREHY CERTIFY that a satisfactory standard certificate of death bled with me BEFORE by linsal or transypermit was issued. Jacqueline Casey (State of Agent of Board of Health of other) (
2-4075
10-10.59
( Date of Issue of l'ermit)
(Official Designation)
11
RUCTIONS FOR CERTIFICATE
giving OF DEATH
not enter than one for each (b) and (c)
dort ant mren le of dying. heart failure. str. It meant tr. or compli which caused
ows. if any.
(a). the
under- last
finnı contrib. death but not o the terminal omdition 2114.
Chapter 1.37. 1954, requires Ins to print or be cause of of death on ertlocates.
SOM-5-57-020345
EDWARD J. CRON N SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS
OUT - OF- TOWN To be fed for burial permit with Board of Health
STANDARD CERTIFICATE OF DEATH
Registered Nn.
.
2 FULL NAME FRANK B. DUNBAR
( If deceased is a married, widowed or divorced wnman, give also maiden name.)
(a) Residence. No. 10 Eleanor Court
INTERVAL BETWEEN ONSET AND DEATH Month
Years
2/20
(Address) VAH Boston, Mass. Date Oct. 9 1º 57
PARENTS
Boston
.
A TRUE COPY ATTEST: Charles it Mackie City Registrar
DECE'Y
JAN 1 81059 14
2.302 1
PLACE OF DEATH
Suffolk
(County)
Boston
The Commonwealth of Massachusetts EDWARD J. CRONIN SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS VILTEM COPY OF
Boston ......
(City or Town making this return)
9215
Registered No.
$ (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.)
LO Elmwood Avenue
St
Winthrop,
Mass
(a) Residence. No ... (Usual place of abode)
2
12
(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
October
8
1957
(Month)
(Day)
(Year)
4 I HEREBY CERTIFY,
8/8
57
10/8
19
I last saw h.Qualive on
19
8/8
19 ...
2.7death is said to
have occurred on the date stated above, at
11:30 a
m.
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
Septicemia.
(a)
INTERVAL
BETWEEN
ONSET AND
DEATH
?
Due To
Osteomyelitis
4 wks
(b)
Due To
R hip fracture
(c)
OTHER
Diabetes
SIGNIFICANT
CONDITIONS
ASHD
Was autopsy performed?
no
What test confirmed diagnosis?
5 Was disease or injury in any way related to occupation of deceased ?..... 11Q If so, specify.
(Signed)
Gordon Kooth
M. D.
(Address)
330 Brookline Ave
Date
10/8
5'
19
Tifereth Israel of Winthrop 6
Place of Burial or Cremationverett, Nass Town)
DATE OF BURIAL. 10/9 19
57
7 NAME OF
Henry Letine
FUNERAL DIRECTOR
ADDRESS 470 Harvard St Brookline
Oct 11 57
Received and filed.
7-13-58
19
(Registrar of City or Town where deceased resided)
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
Fem
9 COLOR
White
10 SINGLE
(write the word)
MARRIED
WIDOWED
or DIVORCED
Widowed
10a If married, widowed, or divorced
HUSBAND of
(Give maiden name of wife in full)
Bernard Tratt
(or) WIFE of
(Husband's name in full)
11 IF STILLBORN, enter that fact here.
12
69
AGE
Years.
.Months ............ Days
If under 24 hours
Hours ........ Minutes
13 Usual
Occupation :
(Kind of work done during most of working life)
14 Industry
At home
or Business:
15 Social Security No ._.
none
16 BIRTHPLACE (City)
(State or country)
Riga
Latvia
17 NAME OF
FATHER
Samuel Wolfson
PARENTS
18 BIRTHPLACE OF Riga
FATHER (City).
(State or country)
Latvia
19 MAIDEN NAME
OF MOTHER
20 BIRTHPLACE OF
MOTHER (City).
(State or country)
Estelle Weiner
21
Informant.
(Address)
40 Elmwood Ave Winthrop
A TREE Charles H. Mackie
ATTEST:
(Registrar of City or Town where death occurred)
DATE FILED OCT. 11, 1957
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 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, after the close of the month in which the death occurred. (See Chap. 46, Sec. 12, G. L.)
SOM.11.55.916:45
(City or Town)
CERTIFICATE OF DEATH
Beth Israel Hospital
No
Rose Tratt
(Was deceased a
U. S. War Veteran,
if so specify WAR)
None
That I attended deceased
from
57
Housewife
8 wks
Riga
Latvia
1
JAN 1 91258 /*
R- 301A 1
UCTIONS FOR CERTIFICATE giving OF DEATH t enter
for each ৳) and (c)
oes set mr .. of dytag. Acest failure. fc. It mrest . or compli- Aich caused
ve rise fa (.). the under. last.
ratk bat not the terminal
Chapter 137, 954, requires as to print er cause er f death on tiscates.
COM-5-57-920345
PLACE OF DEATH
SUFFOLK (County) ROXBURY (City or Town)
The Commonwealth of Massachusetts EDWARD J. CRONIN
SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS
OUT - OF - TOWN To be filed for burial permit w11h Rozid of Health of Its Agent
STANDARD
CERTIFICATE OF DEATH
Registered No.
f(If death occurred in a hospital or institution.
St. \Rive 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. 35 Sea View Ave
St.
Winthrop
( If nonresident, sve city or town and State)
Length of stay: In place of death
years 3
months 5
days. In place of residence
/
years
months
days.
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
DEATH
OCTOBER (Month)
14,
Day)
1957 (Year)
4I HEREBY CERTIFY, That I attended deceased from
JULY
1
. 1957 in
OCTOBER
14
. 19 57
Mive on
I last saw h
OCTOBER 14, 19 57, death is said to
have occurred on the date stated above, at 2:40 P.m.
INTERVAL
BETWEEN
ONSET ANO
>
DEATH
YRS
10a If married. widowed, or divorced
HUSBAND of
(Give maiden name of wife in full)
(or) WIFF. of
(Husband's name in full)
11 IF STILLBORN, enter that fact here.
78
12
AGE
Years
Months
- Days
If under 24 hours
Hours
Minutes
13 \'sual
Occupation :
Housework
(Kind of work done during most of working life)
14 Industry
or Bustor ..
At Home
15 Social Security No.
None
16 BIRTHPLACE (City)
(State or country )
Russia
17 NAME OF
FATHER
Hyman Libber
18 BIRTHPLACE OF
FATHER (City)
(State or country )
Russia
19 MAIDEN NAME
OF MOTHER
Zelda Portnoy
20 BIRTHPLACE OF
MOTHER (City)
(State ur country)
Edward Kurland
of (som)
I HEREBY CERTIFY that a satisfactory standard certificate of death
u Med with ine IF.Fr)RF. the
Massa
(Signature of Agent of Hoard in Health or other)
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