USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1958 > Part 61
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If under 24 hours
..._ Ilours ..... Minutes
13 Usual
Occupation :
House-wife
(Kind of work done during most of working life)
14 Industry
or Business :
At home
IS Social Security No.
Boston
17 NAME OF
FATHER
Jemos Bernard Smarkowetz
18 BIRTIIPLACE OF
FATIIER (City)
Russia
(State or country)
19 MAIDEN NAME
OF MOTIIF.R
Esther (unknown)
20 BIRTHPLACE OF
MOTHIER (City)
(State or country)
England
21 Mrs. Harry Lurraine
Informant
(Address)
15 Violante St., Mattapan
7 NAME OF FUNERAL DIRECTOR Paul_R. Levino
ADDRESS
470 Harvard St., Brookline
JUN 1,3 1958"
Received and Charles H. Ina (Registrar)
No PARENTS
Ashkonaz
Everett
Place ol Burial or Cremation
(City or Town)
DATE OF BURIAL
Juno 11 1958
BOM-5-57-620345
-301A
IONS .
TIFICATE
DEATH nier
each and (c)
I dring. & failure.
r compli.
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a)
Chronic Pyelonephritis
Due To
(b) .
Arterial and Arteriolar
Nephrosclerosis, Advanced
Due To (c)
OTIIER
SIGNIFICANT
CONDITIONS
Was autopsy performed?
Yes
What test confirmed diagnosis'
Autopsy
S Was disease or injury in any way related to occupation of deceased ?- . If so, specify
Victoria Cass
(Signed)
, M. D.
(Address) P. Bent Brigham Hosp Date
June 10 19 58
& SF.X
Female
9 COLOR
White
10 SINGLE
(write the word)
MARRIED
WIDOWED
of DIVORCED
Widowed
, death is said to
m.
have occurred on the date stated above, at 3:52 A
INTERVAL
BETWEEN
ONSET AND
12 68
DEATH
App 10
Years
Months ....
. Days
1
I HEREBY CERTIFY that a satisfactory standard certificate of death was filled with me BEFORE the burial or transit permit was josyedin C. Mancano D 23287 (Signature of Agent of Board of Health or other) June 10,58
(Official Designation)
(Date of Issue of Permit)
PEV
if any. rise to (.). under . 446 centri bur . net terminal
pter 137, requirea a print ar cause ar den1b .n cales.
8
2 FULL NAME .-
(Usual place of abode)
Registered No.
16 BIRTIIPLACE (City)
(State or country)
A TRUE COPY ATTEST: Charles it Mackie City Registrar
SEP 1 91933 48
SUFFOLK
(County)
BOSTON
(City or Town)
The Commonwealth of Massarquarta OF - TOWN EDWARD J. CRONIN SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS STANDARD
To be filed for burial permit with Board of Health or Its Agent.
166
CERTIFICATE OF DEATH Registered No. MEMORIAL f(If death occurred in a hospital or institution,
BAKER MASSACHUSETTS GENERAL HOSPITAL No. - -- Boatrice
2 FULL NAME
Marion. Holt
(Rowe)
(If deceased is a married, widowed or divorced woman, give also maiden name.)
U. S. War Veteran,
(if so specify WAR)
80 SagameRE AVE
(a) Residence.
.586 Shirley
St.,
St ..
Winthrop, Mass.
(If nonresident, give city or town and State)
Length of stay: In piace of death
years.
months
6 days. In place of residence
20years
. months
days.
MEDICAL CERTIFICATE OF DEATHI
J DATE OF
DEATH
June
11
1958
(Month)
(1)a y)
(Year)
4IHEREBY CERTIFY, ThatD attended deceased from
june
5
19.58, to June
11
, 1958
Wi last saw HONlive on - June ___ 11 _._ , 19 .58 death is said to
have occurred on the date stated above, at _11:00pm
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a) Coronary artery disease
Doe To (b) - .
Due To (c)
OTHER
SIGNIFICAN Pulmonary_ fibrosis
CONDITIONS
Pulmonary emphysema
Was autopsy performed?
no
What test confirmed diagnosis'.
clinical
I Was disease or injury In any way related to occupation of deceased?
If so, specify
(Signed)
@h@low
M. D.
(Address) Asat. Dir. Mass. Gen'l Hoop. Date 6 12
1958
6 Bellville Cemetery, Newburyport, Mass. Place of Burial or Cremation (City or Town) DATE OF HURIAL Juno 13.1958
7 NAME OF
FUNERAL DIRECTOR
Gefreut B. Marche
ADDRESS. 174-Winthrop St Winthrop, Ma88.
RoDedihd hled
JUN 18. 1958 19
Charles H Inockie
(Registrar)
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
9 COLOR
10 SINGI,E,
(write the word)
MARRIED
divorced
female
white
WIDOWED
or DIVORCED
10a If married, widowed, or divorced HUSBAND of (Give maiden name of wife in full)
(or) WIFE. of
- Horace Holt
nshand's name in full)
11 IF STILLBORN, enter that fact here.
12
AGE. 70 Years
8 Months 24 Days
If under 24 hours
Hloura ... Minutes
Occupation :
13 Usual
Telephone soligitor
(Kind of work done during most of working life)
14 Industry
or Business :
retailsales
15 Social Security No ..
nono
16 BIRTIIPLACE (City)
(State or country)
Cambridge
17 NAME OF
FATHER
Ernest Houghton Rowe
18 BIRTIIPLACE OF
FATIIFR (City)
Newburyport
(State or country)
Mas8.
19 MAIDEN NAME
OF MOTHER
Charlotte Elisabeth Curr
30 BIRTIIPLACE OF
MOTHIER (City)- Newburyport
(State or country)
Mass
21 InformaMiss. Charlotte S. Holt (Address) 738 Keystone-Avo. RivorForos I HEREBY CERTIFY that a satisfactory standard didid no Jah was filed with me BEFORE the highlpr transit permit was issued : I meader (Signature of Agent of Board of Health or other)
8142
6-13-08
(Official Designation) (Date of Issue of Permit)
59
PLACE OF DEATH
R-301A -
mg PREC. 4
CTIONS OR ERTIFICATE Iving
F DEATH tenter an one er each ) and (c)
ich caused 0 . i ... vive to (a).
last.
ath but mot the terminal dition sites
bepler 137, 4, requires to print er cause of death on Acales.
PARENTS
St. [give Ita NAME Instead of street and number)
nee
PHYSICIAN - IMPORTANT
-
(Was deceased a
NO.
(U'smal place of abode)
INTERVAL BETWEEN ONSET AND DEATH 6 mos
-
1
of dying. art failure.
A TRUE COPY ATTEST: Charles H. mackie City Registrar
SEP 2 91050 AU
:
PLACE OF DEATH
SUFFOLK
(County)
BOSTON
(City or Town)
The Commonwealth of flansachartta. OF - TOWN EDWARD J. CRONIN SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS STANDARD CERTIFICATE OF DEATH
To be filed for burial permtt with Board of Heatth or Ita Agent.
05749
MASSACHUSETTS GENERAL HOSPITAL f(If death occurred in a hospital or institution, St. (give ita NAME instead of street and number) No.
2 FULL NAME- John McDonald
(If deceased is a married, widowed or divorced woman, give also maiden name.)
(a) Realdence. No ..
25 Taylor St.
(Usual place of abode)
St Winthrop, Mass
(If nonresident, give city or town and State)
Length of stay : In place of death ........ yeara months 2 2days. In place of residence 50 years. ... months .... days.
MEDICAL CERTIFICATE OF DEATH
PERSONAL AND STATISTICAL PARTICULARS
3 DATE OF
DEATH
June
11,
1958
(Month) (Day)
(Year)
8 SEX
Male
9 COLOR
Thite
10 SINGLE
(write the word)
MARRIED
WIDOWED
of DIVORCEISingle
4 I HEREBY CERTIFY, That attended deceased from May 20, 158 ,
1958
to
June 11
"Piast saw himalive on June 11,
. death is said to
have occurred on the date stated above, at
6:55Am.
INTERVAL BETWEEN ONSET AND
DEATH 10yrs.
20 YRS.
Due To (c)
OTHER
SIGNIFICANT
CONDITIONS
CHRONIC PANCREATITIS
20YRS
Was autopsy performed?
YES-
What test confirmed diagnosis'
AUTOPSY.
S Was disease or injury in any way related to occupation of deccased ?. If so. specify
(Signed)
(Address)
M. D. Aaat. Dir. Maas. Gen'l Hoap.
Vate June11 , 58
6 Winthrop
Winthrop (City or Town)
Place of Burial or Cremation
DATE OF BURIAL
June 13, 1958
7 NAME OF FUNERAL DIRECTOR Arthur J. O'Maley Winthrop, Mass
ADDRESS
JUN 16 1558' 19
Recommend and filed Charles H. Mackie
(Registrar)
PARENTS
18 BIRTIIPLACE OF
FATIIER (City) (State or country ) Prince Edwaras Island
19 MAIDEN NAME
OF MOTHER
Isabelle McDougall
20 BIRTHPLACE OF MOTHER (City) (State or country) Prince Edwards Island
2t Mary Flannery
Informant
(Address)
25 Taylor St,,Winthrop
I HEREBY CERTIFY that a satisfactory standard certificate of death was filed with me BEFORE the burial or transit permit was issued :
of meade (Signature of Agent of Board of llealth or other)
8/18
6-12-08
(Official Designation) (Date of laque of Permit)
SOM-9-57-020343
301A 1
ONS
TIFICATE
DEATH nter
each nd (e)
dying. failure,
compli- . raused
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a) LAENNEC'S CIRRHOSIS
(b) -
Due To CHRONIC ALCOHOLISM.
13 L'suai
Occupation :
Chauffeur
(Kind of work done during most of working life)
14 Industry
or Business :
WinthropSewer Dopt
15 Social Security No.
16 BIRTHPLACE (City
(State or country)
Prince Edwards Island
Charlottetown
17 NAME OF
FATIIF.R
Allan McDonald
.. y, rise (.), last.
..... i. but not terminal
pter 137. requires print ar .... .. eath .. ates.
Registered No.
PHYSICIAN - IMPORTANT
(Was deccascd a
U. S. War Veteran,
No
if so specify WAR)
10a If married, widowed, or divorced
HUSBAND of
(Give maiden name of wife in fuli) .
(or) WIFE of
(Husband'a name in full)
11 IF STILLBORN, enter that fact here.
12
AGE
60
Years
Months
Dayı
If under 24 hours
........ llours ... . Minutes
5 i/
A TRUE COPY ATTEST: Charles H Mackie City Registrar
SEP 1 71958 AM
-303
PLACE OF DEATH
X Suffolti County) 1 Barton .. Dity or Town) Mars. General Hospital.
The Commonwealth of Massachusetts EDWARD J. CRONIN SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS MEDICAL EXAMINER'S CERTIFICATE OF DEATH
OUT - OF - TOWN
To he filed for burial permit with Board of Health or its Agent. 68
Registered No.
[(If death occurred in a hospital or institution, St. { give its NAME instead of street and number) No. Nancy
2 FULL NAME
(If deceased is a married, yflowed or divorced yourh, give also maiden name.)
(a) Residence. No. L (U'sual place of abode)
.......
Ocean
View
St. Winthrop
If nonresident, give city
town and State)
Length of stay: In place of death. .... years .. months ............. days. In place of residence. ............ year ............. months ......... .. days.
MEDICAL CERTIFICATE OF DEATH
PERSONAL AND STATISTICAL PARTICULARS
(write the word)
B SINGER.E
MARRIED
WIDOWED
DIVORCE
Single
lla If married, widowed, or divorced
HUSBAND of
(Give maiden name of wife in full)
(or) WIFE of
(Hushand's name in full)
12 IF STILLBORN, enter that fact here.
13 8
0
29
AGE
Years
Months
Days
If under 24 hours Hours .......... Minutes
14 Usual
Occupation :
( Kind of work done during most of working life)
15 Industry
or Business:
School
16 Social Security No.
None
17 BIRTHPLACE (City)
(State or country )
ass
18 NAME OF FATHER Herbert N Ingersoll
19 BIRTHPLACE OF
FATHER (City)
(State or country) Laine
Addison
20 MAIDEN NAME
OF MOTHER
Jessie M Witherell
23 BIRTIIPLACE OF
MOTHIER (City)
(State or country)
Melrose
7 Winthrop
Winthrop
Place of Burial; or Cremation.
(City or Town)
June
28
,58
DATE OF BURIAL
Howand S Reynolds
ADDRESS
JUN 30 Bud0.
Received Charles 4
(Registra?)
PARENTS
25 M . 8-57.930750
DEATH in plain terme, so that it may be properly classified under the International Classification of Causes Uf deceased was a U. S. War Veteran, G.L. Chap. 16, Secttym0, requires physicians to insert a recital to that effect.
830 of Death. See reverse ude for extracts from the laws relative to the return of certificates of death. Injury
5 Accident, suicide, or homicide (specify Claridad.
Date and hour of injury
6/251758
Where did
Injury occur ?
Winthro
2
(City or town and State)
Did injury occur
in or aber. home, on farm, in industrial place, or in
public place?
Sidewalk near
Manner of
(Specify type of place)
Injury
( Ingalid injury ne?)
Natur of
Struck by motor car
While at work ? .. Was autopsy performed? to
6 l'as disease or injury in any way related to becuration of deceased?
(Signed)
(Address) Boston
M. D). Die' 6/251258.
A NAME OF
FUNERAL DIRECTOR
Winthrop
Va88
22 Herbert N Ingersoll Informant (Address) 23 Ocean View St. Winthrop I HEREBY CERTIFY that a satisfactory standard certificate of death was filed with me BEFORE the burial of transit permit was issued : Mauricio Harria
(Signature of Agent of Board of Health or other) D 08333 ......
6.27.55
(Official Designation)
(Date of Issue of Fermit)
X
J DATE OF DEATH ..
Jun (Month)
ne 25 1958 (Year)
( Day)
4| HERFIY CERTIFY that I have investigated the death of the perfny above- named and that the CAUSE AND MANNER thereof are as follows: (If an injury was involved, state full".) CRUSHING INJURY OF CHEST WITH RUPTURE OF BRONCHUS
9 SEX
emale
30 COLOR OR RACE
White
ingersoll
PHYSICIAN - IMPORTANT
(Was deceased a U. S. War Veteran, so specify WAR)
Student
Winthrop.
A TRUE COPY ATTEST: Charles it Mackie City Registrar
SEP _ S1352 AM
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
25.M . 8. 57.430750
(a) Residence. No.
(Usual place of abode)
3 DATE OF
DEATII
4I HEREBY CERTIS
Where durl
Injury occur ?
public place ?
Manner of
(Specify type of place)
Nature of
Injury ..
(Signed)
Lf deceased was a U. S. War Veteran, G.L. Chap. 46, Section 10, requires physicians to insert a recital to that effect.
Injury
(llow did injury occur?)
July
1
1958
(Day)
(Year)
that I have investigated the death ol the person above named and that the CAUSE AND MANNER thereof are as follows: (If an injury was involved, state fully.)
CORONARY OCCLUSION
PERSONAL AND STATISTICAL PARTICULARS
9 SEX
male
10 COLOR OR RACE
white
11 SINGLE
MARRIED
WIDOWED
of DIVORCEMarried
(write the word)
lla If married, widowed, or divorced
HUSBAND of ....
Gertrude Whi to
(Give maiden name of wife in full)
(or) WIFE of
(Husband's name in full)
12 IF STILLHORN, enter that fact here.
13
RGE.64
Years
Months
Days
If under 24 hour«
Hours .. ....... Minutes
14 Usnal
Occupation :
Prop
(Kind of work done during most of working life)
15 Industry
or Business :
News Stand
16 Social Security No.
Russia
17 BIRTHPLACE (City)
(State or country)
"Aaron Hoffman
18 NAME OF
FATHER
Russia
19 MIRTIIPLACE OF
FATIIER (City)
(State or country)
Bessie Chatnoff
20 MAIDEN NAME
OF MOTHER
Russia
21 DIRTIIPLACE OF
MOTHER (City)
(State or country)
Russia
....
22 Informant Gertrude Hoffman (Address)4] Cutler St Winthrop MAS I HEREBY CERTIFY that a satisfactory standard certificate of death was iyed with me BEFORE the burial or transit perinit was issued: 1 miade
(Signature of Agent of lloard of Health or other)
8407
7-2-8
(Official Designation) (Date of Issue of Permit) VIV
( Registrar)
PARENTS
.. M. D. 1258
(ArleIress) Die 7/1
Hebrew Volin Cem Baker St W Rox 7
Place of Burial, or Cremation. (City or Town)
DATE OF BURIAL
July 3rd
158
A NAME OF
FUNERAL, DIRECTOR
Henry Levina
ADDRESS4 70 Harvard St Brookline MasB.
JUL 7 1958
Received Charles H Mache
OUT - OF - TOWN
To he filed lor burial permit with Board of Health or Its Agent.
Che Commonwealth of Massachusetts EDWARD J. CRONIN SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS MEDICAL EXAMINER'S CERTIFICATE OF DEATH Registered No. En route to Mass. Grand Hospital, S'IL death occurred in a hospital or institution.
St. [ give its NAME instead of street and number)
HARRY HOFFMAN
2 FULL NAME
PHYSICIAN -- IMPORTANT
(Was deceased a
U. S. War Veteran,
if so specify WAR)
(If deceased is a married, widowed or divorced woman, give also maiden name.)
41 LUTLER St., Winthrop
S
(If nonresident, give city or town and State)
Length of stay : In place of death ......... year .......... .months ....... ... days. In place of residence .......... years ............ months ............ days.
VEDICAL, CERTIFICATE OF DEATHI
5 Accident, suicide, or homicide (specify)
Date and hour of injury
19
(City or town and State)
Did injury occur in or about home, on farm, in industrial place, or in
While at work ?
Was autopsy performed?
200
6 Was disease in injury in any way related in occupation of deceased?
/2011
PLACE OF DEATH
X Suffolk ........ Tounty) Boston (City or Town)
-303 A 1
A TRUE COPY ATTEST: Charles it. Mackie City Registrar
X
ITH AND WELFARE
CERTIFICATE OF DEATH
STATE FILE NO.
170
1.
PLACE OF DEATH
COUNTY
Kennebec
2. USUAL RESIDENCE Where deceased lived. If institution residence before admission
a.
STATE
Massachusetts COUNTY Suffolk
CITY, TOWN, OR LOCATION.
Gardiner, Maine
c. LENGTH OF STAY IN 1b
2 hours
c. CITY, TOWN, OR LOCATION
Winthrop
d. NAME OF
(if not in hospital, give street address)
HOSPITAL OR
INSTITUTION Gardiner General Hosp
d. STREET ADDRESS
52 Beach Road
..
IS PLACE OF DEATH IN RURAL AREA?
NO.OF
..
IS RESIDENCE IN RURAL AREA? f.
YES 0
NO DX
IS RESIDENCE ON A FARN?
YES :]
NO 0:
Ja. NAME OF DECEASED-First Name! 3b.
Carl
Middle Name
Ieo
3c. Last Name
Boot
4.
DATE
OF
DEATH
7-6 - 1258
5.
SEX
6.
COLOR OR RACE
White
7. Married
Widowed
Divorced
L
DATE OF BIRTH
April 26, 1887
PAGE (in yearsof under 1 year) is under 24 hrs lost birthday! Days Min MOL
100. USUAL OCCUPATION Give kind of 10b. KIND OF BUSINESS OR 11. BIRTHPLACE (State or foreign country)
work dops most of working life, even if retred)
Expeditor
Expedition
YBUSTRY
Boston
Mass.
12 CITIZEN OF WHAT
U.S.A.
13. FATHER'S NAME
John Reinolds Root
14. MOTHER'S MAIDEN NAME
Alice I. Earle
15. NAME OF SPOUSE (If Married)
Mary G. Connolly Rool
Address
(Tes NO, OF UNK. )
no
(It yes, give wor or date of service)
17. SOC.SECURITY NO. 18. INFORMANT
sidow
52 Besel Boad Winthrop, Las
19. CAUSE OF DEATH (Enter only one cause per line for, (a), (b), and (c).)
PART 1. DEATH WAS CAUSED BY:
IMMEDIATE CAUSE (a).
thrombosis
INTERVAL BETWEEN
ONSET AND DEATH
4.201
Condition, if any,
which gave rise to
above causa (a)
whating the under-
lying couse last
DUE TO (c)
SUICIDE
3
Hour
Month, Day, Year
p.m.
21b. DESCRIBE HOW INJURY OCCURRED. (Enter nature of injury in Fort I or Part 11 of Ham ID)
TH ETO NAL VCE
CAN'S ICAL . HER'S
220. MEDICUL SANNER: I hereby corrity that death occurred of the lime
and from the reuses stated above, and that I hold on (investigation; (autopay)
on the remains of the deceased as required by law.
Death cu curro3
22b. PHYSICIAN I hereby certify that I attended the deceased from 7/ 5 /2 }
7/6/50
and low see him alive on
.A.m. on the date and from the causes noted above
23b. ADDRESS
23c. DATE SIGNED 7/6/8
DATE
24 NAME OF CEMETERY ORATORY
24d. LOCATION KONYI town, o. county
(State)
KOR
ADDRESS 36. FUNERAL DIRECTÓN 26. DATE, RECO, BY LOCAL NG Bragden-Members Honmouth JE, DAL1958
27.
R
RE A TRUE COPY, ATTEST.
58
=
(Kegistrar)
(Official Designation)
(Date of Issue of Permit)
1
AND im NCE
INT
MAME
SE
TH
INT .
PART II. OTHER SIGNIFICANT CONDITIONS contributing to death but not related to the terminal disease condition given in Part (e)
20.
WAS AUTOPSY
PERFORMED?
YES " NO"
21a. ACCIDENT
HOMICIDE
C
216
TIME OF
INJURY
ZTZ. TOJURY OCCURRED
WHRE AT. . HOT WHILE
WORK DAY WORK
21. PLACE OF INJURY log in or about home.
Form factory, street, office bloky., etc.)
211. CITY, TOWN, OR LOCATION
COUNTY
STATE
(Degres or title)
DUE TO (b)
Month
Dcy
Year
-
COUNTRY ?
18. WAS DECEASED EVER IN U S. ARMED FORCES?
Never Married
(Ii rural give location)
A TRUE COPY ATTEST: Charles it mackie City Registrar
SEP _ C1933 7H
R-302 1
at the time of death should be transmitted on Form R-302 to the clerk of the city or town in which the deceased Copies of returns of deaths which occurred in your city or town in case the deceased resided in another city or town resided as soon as possible, after the close of the month in which the death occurred. (See Chap. 46, Sec. 12, G. L.)
PLACE OF DEATH
QUEENS
(County) St. Albans, N. Y.
(City or Town)
The Commonwealth of Massachusetts EDWARD J. CRONIN SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS COPY OF CERTIFICATE OF DEATH
(City or Town making this return)
Registered No. 172
S(If death occurred in a hospital or institution, St. { give its NAME instead of street and number)
2 FULL NAME. GEORGE E ..... EASON
(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 .... 41 Marshall .. St., Winthrop St
(Usual place of abode)
(If nonresident, give city or town and State)
Townth of stav. In place of deathyears ...
... months. days. In place of residence ........... years .. months ........ .. days.
ITH (Rev. 9/54) 141
Certificate of Drath
SP-5 -. 53014
Boro Pesth
FILED
Certificate No ....
1. NAME OF DECEASED
George
JASON
Institution
(Prins or Typewrite)
First Name
Middle Name Last Name
PERSONAL PARTICULARS (To be filled in by Funeral Diector)
MEDICAL CERTIFICATE OF DEATH (To be filed in by the Physician)
8
(c) Post Office and Zone ......
WINTHROP
Area-Dist.
41 MARSHALL
(d) No. ..
(If in rural area, give location) (e) Length of residence or may in City of New York immediately prior to death Non resident
16 DATE AND HOUR OF DEATH
(Month)
(Day)
(Year)
(Hour)
M.
July
13 1958
11:07AM
17 SEX
IS COLOR OR RACE
119 Approximate Ago
Nativ. Det.
4 DATE OF BIRTH OF DECEDENT
(Month) DECEMBER
(Day) 29,
1910
$ AGE
If imder I year
If LESS than I day. bra, or
Cause 1
47
L Usual Occupation (Kind of work done during most of working life, even if retired)
MILITARY
Comme 3
b. Kind of Business er Industry in which this work wie done U. S. NAVY
7 SOCIAL SECURITY NO.
Operation
& BIRTHPLACE (State or Foreign Country)
KANSAS
, OF WHAT COUNTRY WAS DECEASED A CITIZEN AT TIME OF DEATH?
U.S.A.
100. WAS DECEASED EVER IN UNITED STATES ARMED FORCES? Yes
1936 to Present-Active Witness my hand this 3/day of
July 1958
II NAME OF FATHER OF DECEDENT
GEORGE W. EASON
Signature
11 MAIDEN NAME OF MOTHER OF DECEDENT
MYRTLE JANE HANDS
11 NAME OF INFORMANT RELATIONSHIP TO DECEASED | ADDRESS
RECORDS - U.S.NAVAL BOBPITAD. ST.ALBANS, L.I. N.Y.
14h. Locados (City, Town er County and State)
ARLINGTON, VA
[ 14c. Date of Burial or Cremation 7/18/58
21 FUNERAL DIRECTOR RIVERSIDE MEMORIAA INC
310 CONEY
ISLAND AND Boy
BUREAU OF RECORDS AND STATISTICS
DEPARTMENT OF HEALTH
THE CITY OF NEW YORK
ICAL PARTICULARS
10 SINGLE MARRIED WIDOWED or DIVORCED
(write the word)
name of wife in full)
d's name in full)
ere.
If under 24 hours Hours ........ Minutes
e during most of working life)
(Year) Vale
Caucasian
20 I HEREBY CERTIFY that (I attended the deceased). (a staff physician of this institution attended the deceased)"
from.I April
168 to.13 July 1958
and last saw h.i.m. alive ath.l.
on 13 July .1958
I further certify that death + Was ... caused, directly or indirectly by accident, homicide, suicide, acute or chronic poisoning, or in any suspicious or unusual manner, and that it was due to NATURAL CAUSES more fully described in the confidential medical report filed with the Department of Health.
· Cross out words that do not apply. t See frit instruction on reverse of cortifeste.
25M-8-56-916227
THIS CERTIFICATE NOT VALID UNLESS FILED IN THE HEALTH DEPARTMENT DO NOT WRITE IN THIS SPACE, MARGIN RESERVED FOR CODING AND BINDING
Doro-Resid
2 USUAL RESIDENCE: (s) State ..
MASSACHUSETTS
15 PLACE OF DEATHI
(a) NEW YORK CITY : (b) Borough ..... Unng
(c) Name of Hospital or Institution
NAVHosp. St. Albans NY
(If not in hospital or institution, give street and number.)
(d) If in hospital, give Ward No. 1-3
20/3/1
3 SINGLE, MARRIED, WIDOWED, OR DIVORCED (write the word)
MARRIED
1
002
6 Occupation
10h. IF YES, Give war ar dates of service
Address U.S. H.
140, Meme of Comstary er Crematory ARLINGTON NATIONAL CEM
ADDRESS
.....
wn where death occurred)
19
X
dayı
No.
X
Suffolk
(County)
Boston
(City or T
OSTON CITY HOSPITAL
The Commonwealth of Massachusetts EDWARD J. CRONIN SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS STANDARD CERTIFICATE OF DEATH
OUT - OF - TOWN
1
To be filed for burial permit. with Board of Health or Its Agent 6919
Registered No.
f(If death occurred in a hospital or institution, St. (give its NAME instead of street and number) - PHYSICIAN - IMPORTANT
2 FULL NAME-
Thomas Ippolito David
IPPOLITO
(If deceased i, a married, widowed or diyorced woman, give a so maiden name.)
Mayflower Nursing Home
39 Groves Avenue
(a) Residence. No. (Usual place of ahode)
Wint hrop Mass
(If nonresident, give city or town and State)
20
Length of stay: In piace of death ...... years _....... months
3
days. In place of residence
years
6
months
. days.
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
DEATH
July 15, 1958
(Month)
(Day)
Hos a Battent
4IHEREBY CERTIFY.
July 12, .1958
to
July 15
58
7. death is said to
have occurred on the date stated above, at 7 : 20 A .m.
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
Pulmonary Congestion and
(a) ..
Edema.
INTERVAL
BETWEEN
ONSET AND
DEATH
hours
Due To
Arteriosclerotic Heart
(b) .
Disease.
Due To (c)
OTHER
SIGNIFICANT
CONDITIONS
.yes
Was autopsy performe !?
What test confirmed diagnosis ?..
autopsy
S Was disease or injury in any way related to occupation of deceased? If so. specify
(Signed)
M. D. (Ad.BOSTON CITY HOSPITAL
Date 7-15-58
St. Michaels
Place of Burial or Cremation
(City or Town)
DATE OF BURIAL
July
18,
19
58
7 NAME OF
FUNERAL DIRECTOR
Rose Scaramella
147 Winthrop St., Winthrop
ADDRE
Received and fled
JUL 1 8 195819 Charles H. maan
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
male
Maria Frischetti
10a If married.
HUSBAND of
(Give maiden name of wife In full)
(or) WIFE of
(Husband's name in full)
11 IF STILLBORN, enter that fact here.
12
90
AGE
Years
Months
Days
If under 24 hours
...... flours ...... Minutes
Laborer
13 Usual
Occupation :
(Kind of work done during most of working life)
14 Industry
or Business:
Construction
15 Social Security No.
GHb
16 BIRTIIPLACE (City)
(State or country)
Italy
17 NAME OF
FATHER Information unavailable
PARENTS
18 BIRTHPLACE OF
FATHER (City)
(State or country)
Italy
19 MAIDEN NAME OF MOTHER Information unavailable
20 BIRTHPLACE OF
MOTHER (City)
(State or country)
Italy
Informant
21
Mrs. Maria Ippolito
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