USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1959 > Part 50
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RULES OF PRACTICE
The fulfillment of the purpose of these laws wald 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- preisify to such deaths only as those of persons who, though disabled by recortiled' disease umelated 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.
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE
RANK, RATING
ORGANIZATION AND OUTFIT
SERVICE NUMBER
K
PLACE OF DEATH
Suffolk
(County)
Chelsea
(City or Town)
The Commonwealth of Massachusetts EDWARD J. CRONIN SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS COPY OF CERTIFICATE OF DEATH
(City of tam bale@ this return)
162
Registered No. 416
§(If death occurred in a hospital or institution, St. { give its NAME instead of street and number)
No ... U.S. Haval Hospital
2 FULL NAME Baby Girl Pa
(If deceased is a married, widowed or divorced woman, give also maiden name.)
(a) Residence. No ...
70 Bowdoin
St. winthrop Muss
(If nonresident, give city or town and State)
(L'sual place of abode)
Length of stay: In place of death ..... years.
.months .. days. In place of residence. years. months days.
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
Female
9 COLOR
Whit
10 SINGLE
MARRIED
WIDOWED
or DIVORCEIgle
10a If married, widowed, or divorced HUSBAND of
(Give maiden name of wife in full)
(or) WIFE of
(Husband's name in full)
11 IF STILLBORN, enter that fact herstillborn
12
AGD
Years .....
Months." Days
If under 24 hours
Hours 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)
Chelsea, Mass.
17 NAME OF
FATHER
Harry J.
18 BIRTHPLACE OF FATHER (City). Trenton, N.J.
(State or country)
19 MAIDEN NAME OF MOTHERElizabeth A. Lestor
20 BIRTHPLACE OF MOTHER (City) (State or country) Trenton , .. . J.
21 lizabeth A. Pae (mother)
Informant
(Address) inthron, f ss.
A TRUE COPY
ATTEST:
Joseph atuvell
(Registrar of City or Town where death occurred)
DATE FILED
Aug. 14, 1959
19
X
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
DEATH
Aug.7,1959
(Month)
(Day)
(Year)
4 I HEREBY CERTIFY,
That I attended deceased from
19 to
19
I last saw h alive on
19 -, death is said to
have occurred on the date stated above, at
m.
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a)
Stillborn.
Due To
(b)
Due To (c)
OTHER SIGNIFICANT CONDITIONS
Was autopsy performed ? What test confirmed diagnosis?
5 Was disease or injury in any way related to occupation of deceased? If so, specify.
(Signed) Fred C. Richardson M. D.
(Address) USNH, Chelsea, Mass. 8/7/599
Woodlawn, Iverett, Lass.
6 Place of Burial or Cremation Aug. 13,1959 (City or Town) DATE OF BURIAL
19
Willwerth run. Home
7 NAME OF FUNERAL DIRECTOR Somerville, Wass.
ADDRESS.
Received and filed. SEP 17 1959 19
(Registrar of City or Town where deceased resided)
PARENTS
25M-2-50-922072
INTERVAL BETWEEN ONSET AND DEATH
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, (. L .. )
R-302 1
(Was deceased a
U. S. War Veteran,
if so specify WAR)
(write the word)
.
.
1
4
..
SEP 1 71953 AM
X
- Barnstable
(County) Barnstable
The Commonwealth of Massachusetts EDWARD J. CRONIN SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS COPY OF
.... Barnstable
(City or Town making this return)
220163
CERTIFICATE OF DEATH
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.)
(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
3 DATE OF
August
22
1959
DEATH
(Month)
(Day)
(Year)
4 1 HEREBY CERTIFY,
That I attended deceased from
-
19. to
19.
I last saw h ........ alive on
19 death is said to
have occurred on the date stated above, at
9:40pm.
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
Prematurity -
(a)
duration-6 mos.
INTERVAL BETWEEN ONSET AND DEATH
Due To (1)
Due To (c)
OTHER SIGNIFICANT CONDITIONS
Was autopsy performed? What test confirmed diagnosis?
5 Was disease or injury in any way related to occupation of deceased? If so, specify.
(Signed)
E. Robert Harned
M. D.
Chatham, Mass. 8-24- 59
(Address) ...
Seaside Cem. Chatham, Mass.
Date ...
19
6 .19 Place of Burial or Cremation Aug. 2(City or Town) 59 DATE OF BURIAL ..
Chatham Memorial Chapel
7 NAME OF FUNERAL DIRECTOROld Harbor Hd. , Chatham ADDRESS SEP 14 1959
Received and filed.
19
(Registrar of City or Town where deceased resided)
PERSONAL AND STATISTICAL PARTICULARS
8 SEX Male
9 COLOR
white
10 SINGLE
MARRIED
WIDOWER ingle
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)
11 IF STILLBORN, enter that fact here.
12
AGE
.. Years.
Months ..
Days
Hours!
15
hours
13 Usual
Occupation :
(Kind of work done during most of working life)
14 Industry or Business :
15 Social Security No ....... (Hyannis) Barnstable
16 BIRTHPLACE (City)
(State or country)
Masy.
17 NAME OF William F. Pumphret FATHER
18 BIRTHPLACE OF Boston, Mass. FATHER (City) (State or country)
19 MAIDEN NAMELeanor C. Burns OF MOTHER
20 BIRTHPLACE OF Boston, Mass. MOTHER (City) ... (State or country)
21 William
Pumphret
Informant 225 Wash, Ave. , Winthrop (Address)
TRUE COPY and w Deave
ATTESTY
(Registrar of City or Town where death occurred)
DATE FILED
Aug. 24
19 59
X
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 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.)
PLACE OF DEATH
(City or Town)
No.
(Hyannis)
Cape Cod Hospital
(Male) Pumphrot
(a) Residence. No ..
(Usual place of abode)
(write the word)
.Minutes
Infant
PARENTS
25M-2-58-922072
SEP 1.41.72
X
Middlesex
(County) Tewksbury, Mass.
(City or Town)
The Commonwealth of Massachusetts EDWARD J. CRONIN SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS COPY OF CERTIFICATE OF DEATH
TEWKSBURY HOSPITAL
(City or Town making this return)
1991.64
S(If death occurred in a hospital or institution, St. { give its NAME instead of street and number)
2 FULL NAME
Audriann ....... Nigrelli
(If cleceased is a married, widowed or clivorced woman, give also maiden name.)
(a) Residence. No .. 123 Locust
Winthrop, Mass
(If nonresident, give city or town and State)
(Usual place of abode)
Length of stay: In place of death
0 ... years. 7 .months ... 9.days. In place of residence. .......... years. months ............ days.
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
DEATH
August 24, 1959
(Month)
(Day)
(Year)
4 I HEREBY CERTIFY,
That I attended deceased from
Jan ....... 15., 19 ..
59
to ... August ..... 24 ..... , 19.5.9.
I last saw h .. enlive on
August ..... 24., 19.5.9, death is said to
have occurred on the date stated above, at 9:30 Pm.
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
Myelomeningocoele
(a)
and Hydrocephalus
Due To (b)
Due To (c)
OTHER SIGNIFICANT CONDITIONS
NO
Was autopsy performed?
What test confirmed diagnosis?
Clinical
5 Was disease or injury in any way related to occupation of deceased ?....... If so, specify
(Signed)
Lois B. Crowell
M. D.
(Address)
Tewksbury Hospital
Date.
8-24- 1959
Winthrop Cemetery, Winthrop, Mass 6 Place of Burial or Cremation ity or Town) August 28 1,59
DATE OF BURIAL
7 NAME OF
FUNERAL
DIRECTOR.
147 Winthrop St., Winthrop
ADDRESS
Received
filed
SEP 16 1959
19
Supr
(Registrar of City or Town where deceased resided)
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
9 COLOR
10 SINGLE
(write the word)
Female
White
10a If married, widowed, or divorced 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
AGEO
Years9
Months 1
Days
If under 24 hours
... Hours ........ Minutes
13 Usual
Occupation :
Infant.
(Kind of work done during most of working life)
14 Industry
or Business:
15 Social Security No .....
16 BIRTHPLACE (City)
(State or country)
Revere
Mass.
17 NAME OF
FATHER
Cosimo Nigrelli
PARENTS
18 BIRTHPLACE OF
Lawrence
FATHER (City).
(State or country)
Mass.
19 MAIDEN NAME
OF MOTHER
Marie Dudley
20 BIRTHPLACE OF
MOTHER (City).
(State or country)
Mass.
21
Informant.
(Address)
Hospital Records
A TRUE COPY
ATTEST:
(Registrar of City or Town where death occurred)
L
August 24
59
DATE FILED
19
×
25M-2-58-922072
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. I .. ) at the time of death should be transmitted on Form R-302 to the clerk of the city or town in which the deceased
PLACE OF DEATH
R-302 1
No.
TEWKSBURY HOSPITAL ..........
Registered No.
(Was deceased a
U. S. War Veteran,
if so specify WAR)
MARRIED
WIDOWED
or DIVORCED
Infant
INTERVAL BETWEEN ONSET AND DEATH since birth
......
Ernest C. Caggiano
Chelsea
SEP 161337
PLACE OF DEATH
Suffolk (County) Winthrop (City or Townl)
The Commonwealth of Massachusetts EDWARD J. CRONIN SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS STANDARD
CERTIFICATE OF DEATH
To be filled for burial permit with Board of Health or its Agent.
winthrop Community Hus Strive its NAME instead of street and number) No. Justin Alexander A. Duncan [(If death occurred in a hospital or institution, PHYSICIAN - IMPORTANT
(If deceased is a married, widowed or divorced woman, give also maiden name.)
52 Lowell
Road
St.
Winthrop-
MASS
(a) Residence. No. (Usual place of abode)
5 1/2
(If nonresident, give city or town and State)
Length of stay: In place of death
years.
months
days. In place of residence.40 years.
months ...
.. days.
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
September - 6 - 1959
DEATH
(Month)
(Day)
(Year)
4 I HEREBY CERTIFY,
That I attended deceased from
31 Aug . 19 59 to
6
Sept
50
I last saw himalive on
5 Sept, 1959, death is said to
have occurred on the date stated above, at
8.30 Am.
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a)
Coronary
Thrombosis
INTERVAL BETWEEN ONSET AND DEATH 5 Days
11 IF STILLBORN, enter that fact here.
12
AGE 82Years ..
10Months 3 Days
If under 24 hours
Hours ....... Minutes
13 Usual
retired banker
Occupation :
(Kind of work done during most of working life)
14 Industry
or Business:
savings bank
15 Social Security No. 013-05-8037
16 BIRTHPLACE (City)
Somerville
(State or country)
Massachusetts
17 NAME OF
FATHER
William Duncan
18 BIRTHPLACE OF
FATHER (City)
Portsmouth
(State or country)
England
19 MAIDEN NAME
OF MOTHER
Mary Ann Whyte
20 BIRTHPLACE OF
MOTHER (City)
Dundee
(State or country)
Scotland
21
Informant
Mrs. Ellen 0. Duncan
(Address) 52 Lowell Road Winthrop
I HEREBY CERTIFY that a satisfactory standard certificate of death
was filed with me BEFORE the burial or transit permit was issued:
lass.
Ralph E. VSerianni
(Signature of Agent of( Board of Health or other)
CHE
Sapr 8-1959
HO
(Official Designation)
(Date of Issue of Permit)
CTIONS OR ERTIFICATE Iving F DEATH enter an one or each ) and (c)
s not mean of dying, art failure. . It means of compli- ich caused
, if any, je rise to use
(a), he under- last.
ns contrib- ath but not the terminal dition given
hapter 137, 54, requires to print or cause or death on ficates.
50M-1-58-921876
6
Winthrop Cemetery Winthron, Mass. Place of Burial or Cremation (City or Town)
DATE OF BURIAL September 9.1959
19
7 NAME OF
FUNERAL DIRECTOR
Cucked 13. March
ADDRESS
174 Winthroo Storwinthrop,
Received and filed
SEP 8 18:00
19
(Registrar)
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
male
9 COLOR
white
10 SINGLE
(write the word)
married
MARRIED
WIDOWED
or DIVORCED
10a If married, wide
Josephine Oliver
19.
HUSBAND of
(Give maiden name of wife in full)
(or) WIFE of.
(Husband's name in full)
Due To Arteriosclerotic
-
(b)
Heart Disease
Du
Arteriosclerosis
(c)
OTHER
Terminal, Brancholoneu
SIGNIFICANT
CONDITIONS
BronchiEctasis
Was autopsy performed ?
Yes
What test confirmed diagnosis ?.
ECG- X RAY
5 Was disease or injury in any way related to occupation of deceased
If so, specify./
(Signed).
John 7 Celui
, M. D.
(Address) Kerene Mass
Date 6 Sept 06
a
PARENTS
5 years
5 years
nienia 1 dias
M.S.
R-301A 1
2 FULL NAME.
Registered No. 165
(Was deceased a
U. S. War Veteran,
if so specify WAR)
EXTRACTS FROM THE LAWS OF THE COMMONWEALTH OF MASSACHUSETTS GOVERNING THE
RETURN OF CERTIFICATES OF DEATH
A physician or registered hospital medical officer shall forthwith, after the death of a person whom he has attended during his last illness, at the request of an undertaker or other authorized person or of any member of the family of the deceased, furnish for registration a standard certificate of death, stating to the best of his knowledge and belief the name of the deceased, his supposed age, the disease of which he died, defined as required by section one, where same was contracted, the duration of his last illness, when last seen alive by the physician or officer and the date of his death. . . Gen. Laws. Chap. 46, Sec. 9.
A physician or officer furnishing a certificate of death as required by the preceding section or by section forty-five of chapter one hundred and four- teen, shall, if the deceased, to the best of his knowledge and belief, served in the army, navy or marine corps of the United States in any war in which it has been engaged. insert in the certificate a recital to that effect, specifying the war, and shall also certify in such certificate both the primary and the secondary or imme- diate cause of death as nearly as he can state the same. For neglect to comply with any provision of this section, such physician or officer, shall forfeit ten dollars. For the purposes of this section and of sections forty-five. forty-six and forty-seven of said chapter one hundred and fourteen, the word "war" shall include the China relief expedition and the Philippine insurrection, which shall, for said purposes, be deemed to have taken place between February fourteenth, eighteen hundred and ninety-eight and July fourth, nineteen hundred and two, and the Mexican border service of nineteen hundred and sixteen and nineteen hundred and seventeen. G. L. Chap. 46. Sec. 10.
No undertaker or other person shall bury or otherwise dispose of a human body in a town. or remove therefrom a human body which has not been buried, until he has received a permit from the board of health, or its agent appointed to issue such permits, or if there is no such board. from the clerk of the town where the person died; and no undertaker or other person shall exhume a human body and remove it from a town, from one cemetery to another, or from one grave or tomb other than the receiving tomb to another in the same cemetery. until he has received a permit from the board of health or its agent aforesaid or from the clerk of the town where the body is buried. No such permit shall be issued until there shall have been delivered to such board, agent or clerk, as the case may be, a satisfactory written statement containing the facts required by law to be returned and recorded, which shall be accompanied, in case of an original inter- ment, by a satisfactory certificate of the attending physician, if any, as required by law, or in lieu thereof a certificate as hereinafter provided. If there is no attending physician, or if, for sufficient reasons, his certificate cannot be obtained early enough for the purpose, or is insufficient, a physician who is a member of the board of health, or employed by it or by the selectmen for the purpose, shall upon application make the certificate required of the attending physician. If death is caused by violence, the medical examiner shall make such certificate. If such a permit for the removal of a human body, not previously interred, from one town to another within the commonwealth cannot be obtained early enough for the purpose. the certificate of death made as above provided and in the possession of the undertaker desiring to make such removal shall constitute a permit for such removal; provided, that such body shall be returned to the town from which it was removed within thirty-six hours after such removal, unless a permit in the usual form for the removal of such body has been sooner obtained hereunder. If the
death certificate contains a recital, as required by section ten of chapter forty-six. that the deceased served in the army, navy or marine corps of the United States in any war in which it has been engaged, such recital shall appear upon the permit. The board of health, or its agent, upon receipt of such statement and certificate, shall forthwith countersign it and transmit it to the clerk of the town for registra- tion. The person to whom the permit is so given and the physician certifying the cause of death shall thereafter furnish for registration any other necessary information which can be obtained as to the deceased, or as to the manner or cause of the death, which the clerk or registrar may require .- Chap. 114, Sec. 45. G. L., (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 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 .- 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
A R-302 1
PLACE OF DEATH
Swansea (City or Town) 936 gardner W. 12dl No.
The Commonwealth of Massachusetts EDWARD J. CRONIN SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS COPY OF CERTIFICATE- OF DEATH
Swansea (City or town making return)
Registered No.
2 2 166
[(If death occurred in a hospital or institution, St. \ give its NAME instead of street and number)
Rebecca Freeman
2 FULL NAME ..
(If deceased is a married, widowed or divorced woman, give also maiden name.)
(a) Residence. No.
15 nevada
(Usual place of abode)
St.
winthrop mars.
(If nonresident, give city or town and State)
Length of stay: In place of death.
......
years ......
months 5 days. In place of residence
.years
months.
.days.
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
DEATH
Sent.
15
1959.
(Year)
(Month)
(Day)
4 I HEREBY CERTIFY,
That I attended deceased from
Dec. 6
19 55,
to
Sept.15
1959
I last saw her alive on
Sept. 1/5, 1959, death is said to
have occurred on the date stated above, at
9:20 p.m.
INTERVAL BE-
TWEEN ONSET AND DEATH
DISEASE OR CONDITION
DIRECTLY LEADING
TO DEATH (a).
CARCINOMA LEFT
OVARY WITH METASTASES TO
ANTE
CEDENT (b)
CAUSES
Due To RIGHT OVARY
Due To
(c)
OTHER
RECURRENT MALIGNANT
SIGNIFICANT
DISEASE TO ABDOMEN
Major findings:
Of operations
NO.
Date of operation.
Was autopsy performed?
What test confirmed diagnosis ?.
Pathological Exam.
NO
5 Was disease or injury in any way related to occupation of deceased?
If so, specify ....
(Signe
Cornelius H. Harves
M. D.
(Address) Fall River, Mas Date Sept. 16 1959
6
The Pride of Jacot West Roxbury mas Place of Burial or Cremation (City or Town)
DATE OF BURIAL
Sept. 17
1959
7 NAME OF
FUNERAL DIRECTOR
Paul Levine
ADDRESS.
470 Harvard St Brookline man
Received and filed
Sept 16
1959
29
(Registrar of City or Town where deceased resided)
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
Female White
10 SINGLE
MARRIED
WIDOWED
or DIVORCED
Single
10a If married, widowed, or divorced
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
AGELO
69
Years ... "
Months ......
Days
If under 24 hours
Hours ........
Minutes
13 Usual
Bookeeper
Occupation:
(Kind of work done during most of working life)
14 Industry
or Business:
15 Social Security No.
16 BIRTHPLACE (City)
(State or country)
Russia
17 NAME OF
FATHER
Jacob Freeman
18 BIRTHPLACE OF
FATHER (City)
(State or country)
Russia
19 MAIDEN NAME
OF MOTHER
anna Metcalf
20 BIRTHPLACE OF
MOTHER (City)
(State or country)
Russia
.
21
Dr. William Freengan
(Address)
936 gard The Rd. Wanea
A TRUE COPY
ATTEST:
albert B. almy
(Registrar of City or Town where death occurred)
DATE FILED
Sept. 16
1×5-9.
......
W.B.
of death should be transmitted on Form R-302 to the clerk of the city or town in which the deceased resided as soon as possible Copies of returns of deaths which occurred in your city or town in case the deceased resided in another city or town at the time after the close of the month in which the death occurred. (See Chap. 46, Sec. 12, G. L.)
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