USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1958 > Part 83
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Painter
(Kind of work done during most of working life)
14 Industry
or Business :
Retirod
15 Social Security No ..
nonn
16 BIRTHPLACE (City)
(State or country)
Russia
17 NAME OF
FATHER
Isaac Zelickman
18 BIRTHPLACE OF
FATHIER (City)
(State or country)
Russia
19 MAIDEN NAME
OF MOTHER
Chava-Cannot be learned
20 BIRTHPLACE OF
MOTHER (City)
(State or country)
Russia
t
21 Sarah Zelickman
Informant
(Address)
400 Shirley St. Winthrop
I HEREBY CERTIFY that a satisfactory standard certificate of death was filed with me BEFORE the burial or transit permit was issued : 1747
(Signature of Agent of Board of Health or other)
.
12 L
1
(Official Designation)
(Date of Issue ol Permit)
X
R-301A 1
CTIONS
ERTIFICATE Iving
F DEATH enter an one or each ) and (c)
s not mean of dying. ort failure. :. It mcans or compli- ich coused
. if any, it rise to (o). ke wader- use last.
a contrib- ath but not he terminal dition given
bapter 137, 54, requires to print or cause or death 00 locates.
No.
Beth Israel Hospital
CERTIFICATE OF DEATH
Registered No.
f(If death occurred in a hospital or institution,
St. [give its NAME instead of street and number)
PHYSICIAN - IMPORTANT
(Was deceased a
U. S. War Veteran,
No
if so specify WAR)
(write the word )
8 yrs
PARENTS
18
RECEIVED
ii
٤٠
6
DEC 2 91359 AM
A TOT CON KTTEST: Charles à mackie City Klubuwar
X
Suffolk
(County)
Boston
(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 Aled for burial permit with Board of Health or Its Agent,
Registered No.
9862
Veterans Administration Hospital
[(If death occurred in a hospital or institution,
St. (give its NAME instead of street and number)
2 FULL NAME
Francis W. H. MEHARG
PHYSICIAN - IMPORTANT
(If deceased is a married, widowed or divorced we'nan, give also maiden name.)
284 Revere Street
St.
Winthrop,
Massachusetts
(If nonresident, give city or town and State)
Length of stay: In place of death
O years Q
months.
.27 days. In place of residence
23 years.
.months.
days.
MEDICAL CERTIFICATE OF DEATH
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
Male
9 COLOR
White
10 SINGLE
(write the word)
Married
MARRIED
WIDOWED
or DIVORCED
4 I HEREBY CERTIFY,
Sept. 24
19
58
That I attended deceased from
October 21
19.
58
10a If married, widowed, or divorced
HUSBAND of
Lena Grace Vance
(or) WIFE of
(Husband's name in full)
11 IF STILLBORN, enter that fact here.
12
69
AGE
Years
4
Months
25
Days
....
... Hours .. .. Minutes
13 Usual
Occupation:
Gas Attendant
(Kind of work done during most of work.r.z life)
14 Industry
or Business:
Service Station
15 Social Security No.
012-18-1307
16 BIRTHPLACE (City)
(State or country)
Ireland
OTHER
SIGNIFICANT
CONDITIONS
Was autopsy performed?
Yes
What test confirmed diagnosis ?_
Autopsy
5 Was disease oninjury in any way related to occupation of deceased ? No
If so, specify/
(Signed)
Joseph H. La Casoe
. M. D.
(Address) VAH- Boston, Magg, Date. Oct ... 21 19 58
Winthrop Cemetery
Place of Burial or Cremation
(City of Town)
Winthrop
DATE OF BURIAL
October 24
1958
7 NAME OF
FUNERAL DIRECTOR
Reynolds Funeral Home
ADDRESS 100 Winthrop St., Winthrop, Ma09.
Received and hled
OCT 24 1358 .19
Charles H. Lno
PARENTS
18 BIRTHPLACE OF
FATHER (City)
(State or country)
Ireland
19 MAIDEN NAME
OF MOTHER
Mary Sheriff
20 BIRTHPLACE OF
MOTHER (City)
(State or country)
Ireland
21 VA Hospital Records, 150 So.
Informant
(Address)
Huntington Ave., Boston, Mass.
I HEREBY CERTIFY that a satisfactory standard certificate of death was filed with me BEFORE the burial or transit permit was issued :
1 (Signature of Agent of Hoard of Ilealth or other)
(Official Designation)
11
(Date of Issue of Permit)
220 020 0 94
CTIONS
ENTIFICATE ving
DEATH enter an one r each and (c)
s sot mcas of dying, art failure, . It means or compli- ich caused
rise to (a). under- last .
s contrib .. th but mot e terminal
apter 137, %, requires to print or csuse or desth OD cstes. 1
er
.
EOM-1-68-921870
3 DATE OF
DEATH
October
21
1958
(Month)
(Day)
VA
(Year)
xxxxxxxxXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX death is said to
have occurred on the date stated above, at
10:20 A
m.
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(2) Laennec's cirrhosis with
hepatio coma,
INTERVAL BETWEEN ONSET AND DEATH
5 yrs
Due THapatoma of the liver.
(b)
months
Generalized arteriosclerosis with (c) arteriosclerotio heart disease,
years
241
PLACE OF DEATH
No ..
(a) Residence. No.
(Usual place of abode)
(Was deceased a
U. S. War Veteran,
if so specify WAR)
WW I
to
(Give maiden name of wife in full)
If under 24 hours
17 NAME OF
FATIIER
Thomas Meharg
R-301A -
5
6
DEC 2 91953 AM
A TRUE COPY ATTEST:
4
Nature of Injury (Signed) If deceased was a U. S. War Veteran, G.L. Chap. 46, Section 10, requires physicians to insert a recital to that effect. DEATH in plain terms, so that it may be properly classified under the International Classification of Causes of Death. See reverse side for extracts from the laws relative to the return of certificates of death. mformation should be carefully supplied. MEDICAL EXAMINERS should state CAUSE AND MANNER OF Manner of
25M. 8.57-920750
-
1958
PLACE OF DEATH
Suffolk (County)
Boston (City or Town)
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 be filed for burial permit with Board of Health or its Agent.
Registered No.
9.900
NoMassachusetts ..... General .... Hospital ....... [{if death occurred in a hospital or institution, St. [ give its NAME instead of street and number)
2 FUI.I. NAME
JAMES.
ANNIS
(If deceased is a married, widowed or divorced woman, give also maiden name.)
(a) Residence. No.
27TaftAvenue, Winthrop
...... St.
(if nonresident, give city r town and State)
....
Length of stay : In place of death ............. years .............. months ............ days. in place of residence .... L.( .... years ........ months ... ........ day.
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
DEATH
....
October
22
1.95.8
(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.)
HUSHAND of
lla If married, widowed, or divalith Gregiry.
(Give maiden name of w 'e in full)
(or) WIFE of
(ilusband's name in 'ull)
12 IF STILLHORN, enter that fact here.
13
50
AGE
Years
11
Months
25
Days
If un 'er 24 hours
ours .......... Minutes
14 Usual
Occupation :
Timekeeper
(Kind of work done during most of working life)
15 Industry
General Electric
or Business:
16 Social Security No.
023-05-4164
Everett
17 BIRTHPLACE (Chy Jass. (State or country )
18 NAME OF FATHER Joseph Annis
19 BIRTHPLACE OF
FATIIER (City)
(State or country)
Unable to obtain
20 MAIDEN NAME
OF MOTHER
Ann E McGork
21 BIRTHPLACE OF
MOTHER (City)
(State or country)
Unable to obtain
7 Winthrop
Winthrop
Place of Burial, or Cremation.
(City or Town)
DATE OF BURIAL
Oct. 25
19.
58
# NAME OF
FUNERAL DIRECTOR
Howard S Reynolds
Winthrop, Lass.
ADDRESS
Received and filed
OCT 24.4058
19
... Markes 4. Imammine. {
9 SEX
Male
10 COLOR OR RACE
White
11 SINGLE
MARRIE )
WIDOWI D
or DIVORCEDMarried
CEREBRAL
HEMORRHAGE
5 Accident, suicide, ur 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 ?
(Specify type of place)
Injury
(How did injury occur?)
While at work ? Was autopsy performed?
6 Was fiscale or Aijury in any way Elated to occupation of deceased ?
if M, So Mikulli trong
M. 1) ..
(Address) Boston
10/22
.. 19.58
PARENTS
22 Edith Annis Informant (Address)27 Taft Ave. Winthrop, -Mas
I HERENY CERTIFY that a satisfactory standard certi icate of death
hled with me BEFORE de burial or transit perout i as issued
nasua
mure forced
(Signature of Agent of Hoard of Health of other)
1150%
12-23-50
(Official Desituation)
( Date of Issue of Permit)
1
R S03
1
PHYSICIAN - IMPORTANT
(Was deceased a
U. S. War Veteran,
il so sperify WAR)
No
(Usual place of abode)
PERSONAL AND STATISTICAL PA TICULARS
(write the word)
331
RECEIVED
TON
OF
-0.
=19 ..
iVin
1.
GLEKK
1
6 5
DEC 311358 AM
A TRUE COTY ATTEST.
EF
C
X
PLACE OF DEATH
Suffolk (County)
Boston
The Commonwealth of Massachusetts EDWARD J. CRONIN SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS STANDARD CERTIFICATE OF DEATH
OUT - OF - TOWN 243
To be filed for burial permit with Board of Health or Its Agent. 98.98
Registered No.
[(If death occurred in a hospital or institution,
St. [give its NAME instead of street and number)
2 FULL NAME
William Law
(If deccased is a married, widowed or divorced woman, give also maiden name.)
(a) Residence.
No.
896A Shirley St.
St.
Winthrop,
Mass.
(If nonresident, give city or town and State)
Length of stay: In place of death.
.- years
months
hospital
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
DEATH
Oct. 22, 1958
(Day)
(Year)
(Month)
4 I HEREBY CERTIFY,
That I attended deceased from
Oct. 20
19
. 19
58
Oct. 22
5
HUSBAND of
(Give maiden name of wife in full)
I last saw himlive on
Oct. 22
. 19 ... 50 death is said to
have occurred on the date stated above, at
8:45 pm
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a)
OVERWHELMING
SEPSIS
INTERVAL
BETWEEN
ONSET AND
DEATH
Due To (b)
Due To (c)
OTII ER
SIGNIFICANT
CONDITIONS
Was autopsy performed?
YES
What test confirmed diagnosis?
5 Was disease or injury in any way related to occupation of deceased? If so, specify
(Signed)
M. D.
(Address)
300 Longwood AVDate 10-23-19 58
Winthrop
(City or Town)
6 Winthrop Place of llurial or Crem: lion 21 ShoAles LAW. DATE OF BURIAL Oct24 196₽ Informant (Address) 896 Shirley St Winthrop
7 NAME OF
FUNERAL DIRECTOR
ADDRESS
Outroy Maurice Kirt 210 Winthrop St. Winthe
Received and filed OCT 2.4 1950 19 Charles H. In a crane
PERSONAL AND STATISTICAL PARTICULARS
8 SEX MALE
9 COLOR
WHITE
10 SINGLE
MARRIED
WIDOWED
or DIVORCED
(write the word)
single
10a If married, widowed, or divorced
(or) WIFE of
(Husband's name in full)
11 IF STILLBORN, enter that fact here.
12
AGE
Years.
27 Days
If under 24 hours
Hours __. Minutes
13 Usual
Occupation :
NONE
(Kind of work done during most of working life)
14 Industry
or Business:
15 Social Security No.
16 BIRTHPLACE (City)
(State or country)
WINTHROP MASS.
17 NAME OF
FATHER
CHARLES LAW
18 BIRTHPLACE OF
FATIIER (City)
ARLINGTON, MASS.
(State or country)
19 MAIDEN NAME
OF MOTHER
FLORENCE GLOCK
20 BIRTIIPLACE OF
MOTIIER (City)
CAMBRIDGE, MASS.
(State or country)
50M-1-58-921876
TIONS R RTIFICATE ving DEATH enter
r each and (c)
of dying. art failure . It means or compli- ih caused 8
rise to (a). mader- last.
, contrib th bu! mot de terminal tion given
apter 137, , requires to print or cause or Ccath on cates.
1
(City or Town)
No.
The Children's Hospital
PHYSICIAN - IMPORTANT
(Was deceased a
U. S. War Veteran,
if so specify WAR)
no
(Usual place of abode)
2
days. In place of residence
........
years
months ........ days.
PARENTS
4 I HEREBY CERTIFY that a satisfactory standard conuficate of death was filed with me BEFORE THE burial y transit permet was issued opname (Signature of Agent of Hoard of Ilealth or other) 10 20.00 11509 (Official Designation) (Date of Issue of lermit)
RECEIVED
TO
6
DEC 2 91C58 AM
A TRUE COPY ATTEST: Charles A. Mickie City Youlive
R-303 A 1
Injury Injury 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 Nature of
25M -8-57-920750
PLACE OF DEATH
Suffolk (County) Wilthogy (City or Town) 85 Winthrop St. No.
The Commonwealth of Massachusetts EDWARD J. CRONIN SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS MEDICAL EXAMINER'S CERTIFICATE OF DEATH
To be filed for burial permit with Board of Health or its Agent.
Registered No.
§(If death occurred in a hospital or institution, St. ¿ give its NAME instead of street and number)
PHYSICIAN - IMPORTANT
2 FULL NAME
Walter B. Keller
(If deceased is a married, widowed or divorced woman, give also maiden name.)
85 Winthrop
St.
Winthrop
(a) Residence. No.
(Usual place of abode)
Length of stay : In place of death& ]
..... years.
.......
... months ...
........
.days. In place of residence.
8
.. years ...
6.months.
.days.
(If nonresidentgive city or town and State)
MEDICAL CERTIFICATE OF DEATH
PERSONAL AND STATISTICAL PARTICULARS
9 SEX
10 COLOR OR RACE
11 SINGLE
(write the word)
Male
White
MARRIED
WIDOWED
or DIVORCED
Widowed
11a If married, widowed, or divorced
Grace
M. Burke
HUSBAND of
(Give maiden name of wife in full)
(or) WIFE of
(Husband's name in full)
12 IF STILLBORN, enter that fact here.
13 66
AGE
Years.
0
Months.
11 Days
If under 24 hours
.......
.. Hours .......... Minutes
14 Usual
Occupation :
Meter maker
(Kind of work done during most of working life)
15 Industry
or Business :
Gas Meters
16 Social Security No.
021-10-6844 A
17 BIRTHPLACE (City) (State or country) Mass
East Boston
18 NAME OF
FATHER
John F. Kelley
19 BIRTHPLACE OF
FATHER (City)
Boston
(State or country)
Wass
20 MAIDEN NAME
OF MOTHER
Catherine Welch
21 BIRTHPLACE OF
MOTHER (City)
Boston
(State or country)
Lasse
22 Informant Mrs. Gracemarie Lappen-day. (Address)5 inthpor St. intheon I HEREBY CERTIFY that a satisfactory standard certificate of death was filed with me BEFORE the burial or transit perinit was issued : Halble 8 Percent D
(Signature of Agony of Board of Health or other)
17/3/58
(Official Designation)
(Date of Issue of Peranit)
X
OF Dec
(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.)
CORONARY THROMBOSIS
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)
(How did injury occur ?)
While at work ?
Was autopsy performed? Mla
6 Was disease or injury in any way related to occuparton of deceased?
(Signed)
man, M. D.
(Address) Boston Date .... 12 /2 1958
Winthrop Cemetery, Winthrop 7
Place of Burial, or Cremation.
(City or Town)
DATE OF BURIAL
December 5th
9 58
8 NAME OF
FUNERAL DIRECTOR
Richard C. Kirby
ADDRESS 917 Bennington St. E. Roston
Received and filed
DEC ..... 5 1958
19
(Registrar)
PARENTS
(Was deceased a
U. S. War Veteran,
if so specify WAR)
VW 1
3 DATE OF
DEATH
1958
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 belicf 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 of officer and the date of his death. , .Gen. Laws, Chap. 46, Scc. 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 nincteen 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.
TOW.
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.
DEC -51958 M 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
May 27.1918
DATE OF DISCHARGE
Sept.12.1919
RANK, RATING ..
Pvt. Ist cl.
ORGANIZATION AND OUTFIT
Co. "K" 30 3d Inf.
SERVICE NUMBER
2723297
PLACE OF DEATH
x Suffolk Winthrop (County) Winthrop (City or Town)
The Commonwealth of Massachusetts EDWARD J. CRONIN SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS STANDARD
CERTIFICATE OF DEATH
Registered No.
245
217 8 hore drive No.
2 FULL NAME Isadore Goldstein
(If deceased is a married, widowed or divorced woman, give also maiden name.)
(a) Residence.
217 Shore Drive
(Usual place of abode)
Length of stay: In place of death
24 years
months ___ days. In place of residence. years. months - days.
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
DEATH
DEC.
4
1958
(Month)
(Day)
(Year)
4 I HEREBY CERTIFY
Feb
1,
1956
to.
DEC. 4
That I attended deceased from
I last saw h/alive on
DEC.
4
-, 195, death is said to
have occurred on the date stated above, at
215 A. m.
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a)
Cancer.
OF
the
Prostate
Due To (b)
Due To (c)
OTHER
SIGNIFICANT
CONDITIONS
disease
NO
Congestive heart
1 yr.
Was autopsy performed?
What test confirmed diagnosis? Surgical & clinical
5 Was disease or injury in any way related to occupation of deceased ? NO If so, specify
(Signed).
Harold miller
, M. D.
109 Wach. ave.
(Address) chelsea max Date
6 anikelly Soc.
Place of Burim or Cremation
melrose
(City or Town) 1958
DATE OF BURIAL alec 4
7 NAME OF
FUNERAL
Doy Funeral Service Donc
ADDRESS
Chelsea
DEC 4 1958
19
(Registrar)
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
male
9 COLOR
White
10 SINGLE (write the word)
MARRIED
WIDOWED
Or DIVORCED
married
10a If married, widowed, or divorced human
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
70
Years
-
Months
Days
If under 24 hours
Hours ..... Minutes
13 Usual
Occupation :
operator
/ (Kind of work done during most of working life)
14 Industry
or Business:
Beach Concession
15 Social Security No .....
none
16 BIRTHPLACE (City)
(State or country)
Poland
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