USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1960 > Part 40
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20 BIRTHPLACE OF
MOTHER (City)
(State or country)
LILLIAN
ロシアアイン
21
Informant
(Address)
48 CLIFF REE WHATHEDE
I HEREBY CERTIFY that a satisfactory standard certificate of death was filed with me BEFORE the burial or transit permit was issued: Mrabril 6 Fireanul. 8-
(Signature of Agent of Board of Health or other)
Healthe Nhicer
8/8/60
(Official Designation) V
(Date of Issue of Permit)
V.B. V
RUCTIONS FOR CERTIFICATE
giving OF DEATH ot enter than one for each (b) and (c)
Does not mean e of dying, heart failure, etc. It means e, or compli- which caused
ms, if any, gave rise to cause (a), the under- cause last.
itions contrib- death but not the terminal indition given
Chapter 137, 954. requires is to print or e cause or of death on tificates, and 48. Acts of uires Physi- print or type er signature.
5.
7 NAME OF
FUNERAL DIRECTOR
MAURICE W. HIRBY
ADDRESS WINTHROP.
Received and filed
AUG 8 1960
19
(Registrar)
5 yrs
(b)
....
l'Arteriosclerosis.
Due To (c)
OTHER
Hypertensive-Arterio
SIGNIFICANT
CONDITIONS
Sclerotic Heart Disease
5 yrs.
Was autopsy performed?
clinica
What test confirmed diagnosis ?
5 Was disease or injury in any way related to occupation of deceased Ve. If so, specify Cleanles
(Signed) Charles Liberman (PRINT OR TYPE SIGNATURE) (Address) Winthrop, Mass Date ..
Liche welleM. D.
8/6/1960
6 HOLYCROSS Place of Burial or Cremation DATE OF BURIAL
MALDIN
{City or Town)
.19 66
....
3 DATE OF
DEATH
August.
6
1980
(Year)
(Month)
(Day)
4 I
HEREBY
CERTIFY, That I attended deceased from
X
1956
August
6
60
I last saw h.J.alive on
August6, 1960
death is said to
have occurred on the date stated above, at
6:0 5 Pm.
DEATH WAS CAUSED BY : IMMEDIATE CAUSE
(a)
Cerebral
Hemorrhage
INTERVAL
BETWEEN
ONSET AND
DEATH
1 day
PARENTS
[(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,
{if so specify WAR)
(a) Residence. No.
(Usual place of abode)
2 FULL NAME
PLACE OF DEATH
[ R-301A 1
-59-925686
Due
· Hypertension and
BOSTON
IPLIAND
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE RANK, RATING
ORGANIZATION AND OUTFIT
SERVICE NUMBER
RULES OF PRACTICE AUG - 21000 Tri
The fulfillment of the purpose of these laws calls for the observance of the following 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 un- related 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 occu- pation, 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 impor- tant, 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. Chil- dren 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.
N of Death. See reverse side for additional information. See also Chap. 38, §§ 6, 20; Chap. 46, §§ 9, 10; Chap. 114, DEATH in plain terms, so that It may be properly classified under the International Classification of Causes information should be carefully supplied. MEDICAL EXAMINERS should state CAUSE AND MANNER OF If deceased was a U. S. War Veteran, G.L. Chap. 46, Section 10, requires physicians to insert a recital to that effect. §§ 44-48. 35M-11-59-926662 N. B .- WRITE PLAINLY, WITH UNFADING BLACK INK-THIS IS A PERMANENT RECORD. Every item of Nature of Injury
PLACE OF DEATH
Suffolk (County)
Winthrop (City or Town)
The Commonwealth of Massachusetts JOSEPH D. WARD 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. 181
[(If death occurred in a hospital or institution, No. 75 Temple Avenue, Winthrop
2 FULL NAME
MAX
CHECKOWAY
(If deceased is a married, widowed or divorced woman, give also maiden name.)
St.
Winthrop, Mass
(If nonresident. ive city or town and State)
Length of stay : In place of death. ... years .... ........ months ... ........ days. In place of residence ... .. .. years ............. months .............. days.
MEDICAL CERTIFICATE OF DEATH
PERSONAL AND STATISTICAL PARTICULARS
3 DATE OF
DEATH
August
8
1960
(Month)
(Day)
(Year)
9 SEX
male
10 COLOR
white
11 SINGLE
MARRIEI)
WIDOWED)
Of DIVORCED
(write the word)
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.) Occlusive coronary arteriosclerosis (or) WIFE of
HUSBAND of
Baderced
(Give maiden name of wife in full)
(Husband's name in full)
12 IF STILLBORN, enter that fact here.
13
4%
2
Months ..
7
Day-
li under 24 hours .Hours . . . .Minutes
5 Accident, suicide, or homicide (specify)
Date and hour of injury
19
IF ACCIDENTAL, was injury causally related to the death ? 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)
Manner of
Injury
(How did injury occur ?)
While at work ?
.. Was autopsy performed ?
Yes
6 Was disease or injury in any way related to occupation of deceased ?
If so,
(Signo Dehall Thongs
M. D.
Michael A, Luongo, M. D.,
(Print or Type Signature)
(Address) Boston, Mass.
Date
8/8
19.60
Place of Burial, or Cremation.
(City or Town)
DATE OF BURIAL
Que 9
19 65
8 NAME OF
FUNERAL DIRECTOR
ADDRESS
121
Received and filed
AUG 8 1960
19
PARENTS
19 BIRTHPLACE OF
FATHER (City)
(State or country )
Rusia
20 MAIDEN NAME
MOTHER Sarah Fahuman
21 BIRTHPLACE OF
MOTHER (City)
(State or country)
Buci
queria
22
Informant
(Address)
75 Temple One with
I HEREBY CERTIFY that a satisfactory standard certificate of death wasfiled with me BEFORE the burial or transit permit was issued :
(Signature of Ageny of Board of Health or other)
Health Care
8:8/60
(Date of Issue of Vermit)
V.B
V
(Official Designation)
(Registrar)
St. ¿ give its NAME instead of street and number)
PHYSICIAN - IMPORTANT
(Was deceased a
U. S. War Veteran,
( if so specify WAR) ....
no
(a) Residence. No.
75 Temple Avenue
(Usual place of abode)
5
AGE.
Years.
14 Usual
Occupation :
(Kind of work done during most i working life)
15 Industry
or Business :
Prudential bus C.
16 Social Security No. ...
018.09. 6445
17 BIRTHPLACE (City)
(State or country )
18 NAME OF
FATHER
frais Chechoway
M R-303 A 1
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE RANK, RATING ORGANIZATION, AND OUTFIT SERVICE NUMBER
RULES OF PRACTICE
The fulfillment of the purpose of these laws calls for the observance of the following rules of practice: 00
(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 poison) thermal, or electrical agents, and deaths following abortion, but also deaths from disease resulting from injury or infection related to occupation, the sudden deaths of persons not disabled by recognized disease, and those of persons found dead.
STATEMENT OF CAUSE OF DEATH
Medical Examiners in certifying to a death will state the cause and manner thereof, and will specify: (1) Under cause the nature of an injury and of its consequences; and (2) under manner the mode of its production together with the circumstances when these are known. For example: "Compound fracture of the femur with ensuing septicemia (gas bacillus) caused by a collision of railroad train and automobile." "Pistol shot wound of the chest with associated hemorrhage, homicidal." "Asphyxiation by suspension, suicidal." "Syncope while under the influence of ether administered as a surgical anaesthetic for (enter name of operation and disease or condition requiring surgery)." "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.)"
RM R-303 A 1
N. B .- WRITE PLAINLY, WITH UNFADING BLACK INK-THIS IS A PERMANENT RECORD. Every item of of Death. See reverse side for additional information. See also Chap. 38, §§ 6, 20; Chap. 46, §§ 9, 10; Chap. 114, DEATH in plain terms, so that it may be properly classified under the International Classification of Causes information should be carefully supplied. MEDICAL EXAMINERS should state CAUSE AND MANNER OF
If deceased was a U. S. War Veteran, G.L. Chap. 46, Section 10, requires physicians to insert a recital to that effect.
35M-11-59-926662
PLACE OF DEATH
SUFFOLK
(County) WINTHROP
(City or Town)
The Commonwealth of Massachusetts JOSEPH D. WARD 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.
185
125 Read St., Winthrop No.
[(If death occurred in a hospital or institution,
St. ¿ give its NAME instead of street and number)
2 FULL NAME
JOHN
MOLOZNIK
PHYSICIAN - IMPORTANT
( Was deceased a
U. S. War Veteran,
(If deceased is a married, widowed or divorced woman, give also maiden name.)
125 Read St.
St
(If nonresident, give city or town and State)
Length of stay: In place of death ........ years ............. months .............. days. In place of residence ...
30 years ...
.......... months ............
.. days.
MEDICAL CERTIFICATE OF DEATH
PERSONAL AND STATISTICAL PARTICULARS
3 DATE OF
DEATH
August 10, 1960
9 SEX
10 COLOR
11 SINGLE
(write the word)
(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, acute
HUSBAND of
ther Louise Eldridge
(Give maiden name of wife in full)
(or) WIFE of
(Husband's name in full)
12 IF STILLBORN, enter that fact here.
13
AGE .... 5.8 Years.
2 Months 10 Days
Hours ..
Minutes
14 Usual
Occupation :
store keeper
( Kind of work done during most of working life)
15 Industry
or Business
Charleston Navy Yard
16 Social Security No. 025-01-2726
Chicago
Manner of
Injury
(How did injury occur?)
Nature of
Injury
While at work?
Was autopsy performed? Yes
6 Was disease or injury in any way related to occupation of deceased?
If so, specify
Wwhall Trongo
(Signed)
M. D.
MichaelA ....... Luongo,M.D ...
(Print or Type Signature)
Boston
Date
8/10,60
7 Woodlawn Cemetery Everett Mass Place of Burial, or Cremation. (City or Town) DATE OF BURIAL
August 22 3960
19
8 NAME OF
FUNERAL DIRECTOR
Cured 13 March
ADDRESS
174 Winthrop St Winthrop
Received and filed
AUG 11 1860
19
(Registrar)
PARENTS
18 NAME OF FATHER Anthony Moloznik
19 BIRTHPLACE OF
FATHER (City)
Chicago
(State or country)
Il1.
20 MAIDEN NAME
OF MOTHER
Eva Kosar
Chicago
21 BIRTHPLACE OF
MOTHER (City)
(State or country)
Ill.
Mrs.
John Moloznik.
22 Informant 125 Read St. Winthrop, Mass.
I HEREBY CERTIFY that a satisfactory standard certificate of death was filled with me BEFORE the burial or transit permu was issued: Malkle 8. Hereanny
Mass
(Signature of Ageny of Board of Health onacher)
health Carech
8/11/60
(Official Designation) (Date of Issue of Permit)/
MARRIED
WIDOWED
or DIVORCED
married
male
white
If under 24 hours
5 Accident, suicide, or homicide (specify)
Date and hour of injury
19
IF ACCIDENTAL, was injury causally related to the death ? 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)
17 BIRTHPLACE (City)
(State or country)
III.
(Address
§§ 44-48.
(a) Residence. No.
(Usual place of abode)
Winthrop,
Mass.
if WVAR)
W.W.2
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
11 December 1942
DATE OF DISCHARGE
26 June 1945
RANK, RATING Motor .machimists .. mate ... First .. Class
ORGANIZATION AND OUTFIT United .. States ... Coast ... Guard
SERVICE NUMBER 3005-160
RULES OF PRACTICE
The fulfillment of the purpose of these laws calls for the observance of the following 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 poison) 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. AUG 3. 1 1930
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 collision of railroad train and automobile." "Pistol shot wound of the chest with associated hemorrhage, homicidal." "Asphyxiation by suspension, suicidal." "Syncope while under the influence of ether administered as a surgical anaesthetic for (enter name of operation and disease or condition requiring surgery) ." "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.)"
PLACE OF DEATH
SUFFOLK (County)
CENSE PETITEALS
The Commonwealth of Massachusetts JOSEPH D. WARD SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS
STANDARD CERTIFICATE OF DEATH
Registered No.
186
A/L(If death occurred in a hospital or institution, BAY VIELL RESTHOME 41 WASHINGTON No:
St. ¿ give its NAME instead of street and number)
PHYSICIAN - IMPORTANT
[(Was deceased a U. S. War Veteran, [if so specify WAR)
NO
(If deceased is a married, widowed or divorced woman, give also maiden name.)
123 BROOKFIELD PD
St.
(If nonresident, give city or town and State)
Length of stay: In place of death .............. years.
2
.months.
days. In place of residencel
.years.
months ..
.days.
MEDICAL CERTIFICATE OF DEATH
PERSONAL AND STATISTICAL PARTICULARS
3 DATE OF
DEATH
AUGUST
10
1960
(Year)
8 SEX
FEMALE
9 COLOR
WHITE
MARRIED
WIDOWED
or DIVORCED
SINGLE
4 I HEREBY
CERTIFY,
That I attended deceased from
AUGUSTI
1960, to ..
AUGUST 10
19 60
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
If under 24 hours
.Hours.
.Minutes
13 Usual
Occupation :
HOME MAKER.
(Kind of work done during most of working life)
14 Industry
or Business :
HOME
15 Social Security No.
EAST BOSTON
MASS
16 BIRTHPLACE (City)
(State or country)
17 NAME OF
FATHER
FLORENCE NOLAN
18 BIRTHPLACE OF
FATHER (City)
(State or country)
IRELAND.
19 MAIDEN NAME
OF MOTHER
HANNAH (UNKNOWN)
20 BIRTHPLACE OF
MOTHER (City)
(State or country)
FRANCIS A NOLAN
122 BROOK FIELD RD WINTHROP
7 NAME OF
MAURICE W KIRBY
FUNERAL DIRECTOR
ADDRESS 210 WINTHROP ST WINTHROP.
Received and filed
AUG 12-1960
19
(Registrar)
PARENTS
(Sig
Dorothy Chenye appleton
M. D.
DOROTHY CHENEY APPLETON
(PRINT OR TYPE SIGNATURE)
(Address) 197 Woodardde Luxe, Date aug. 12 19 20
6
HOLY CROSS
20 MALDEN
(City or Town)
Place of Burial or Cremation
DATE OF BURIAL
AUG 13
19.4.6
21
Informant
(Address)
I HEREBY CERTIFY that A satisfactory standard certificate of death was filed with me BREORE the burial or transit permit was issued: Galky Percance) (Signature of Agent of Board of Health of other) Medaile Chicle 8/12/60
(Official Designation) (Date of Issue of Perinit) L
TRUCTIONS FOR AL CERTIFICATE
n giving E OF DEATH not enter re than one se for each , (b) and (c)
does not mean ode of dying, s heart failure, , etc. It means case, or compli- which caused
itions, if any, gave rise to cause (a), g the under- cause last.
nditions contrib- o death but not to the terminal condition given
. Chapter 137, 1954. requires ans to print or he cause or of death on ertificates, and 48, Acts of quires Physi- print or type oder signature.
5.
1
-11-59-926662
(Month)
(Day)
I last saw hey alive on
AUGUST 9
, 19 60, death is said to
have occurred on the date stated above, at 12:15 Pm.
INTERVAL
BETWEEN
ONSET AND
DEATH
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
CEREBRAL THROMBOSIS WITH
(a)
BILATERAL HEMIPLEGIA
10 DAY.
Due To
(b) ARTERIOSCLEROSIS
TEARS
Due To (c)
OTHER SIGNIFICANT CONDITIONS
Was autopsy performed?
Na
What test confirmed diagnosis ?
5 Was disease or injury in any way related to occupation of deceased? IVA If so, specify
M R-301A 1
(City or Town) NURSING
To be filed for burial permit with Board of Health or its Agent.
2 FULL NAME
HELEN B. NOLAN
(a) Residence.
No.
(Usual place of abode)
30
10 SINGLE
(write the word)
74.
IRELAND.
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE RANK, RATING
ORGANIZATION AND OUTFIT
SERVICE NUMBER
AUG 1 21960 [.
RULES OF PRACTICE
The fulfillment of the purpose of these laws calls for the observance of the following 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 un- related 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 occu- pation, 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 impor- tant, 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. Chil- dren 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.
PLACE OF DEATH
Suffolk (County)
CINS
Winthrop
(City or Town)
The Commonwealth of Massachusetts JOSEPH D. WARD SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS STANDARD CERTIFICATE OF DEATH
To be filed for burial permit with Board of Health or its Agent.
Registered No. 187
[(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, {if so specify WAR) No
(a) Residence. No.
(Usual place of abode)
53 Trident Ave.
St.
Winthrop
(If nonresident, give city or town and State)
Length of stay: In place of death ............ years. months. 1 .days. In place of residence. 3 years .months ............ .. days.
MEDICAL CERTIFICATE OF DEATH
PERSONAL AND STATISTICAL PARTICULARS
3 DATE OF
DEATH
August
19
1960
(Month)
(Day)
(Year)
4 I HEREBY CERTIFY
No
to ..
August 11
1966
I last saw h.l.V.valive on
Ana
1
11/
19 60, death is said to
10a If married, widowed, or divorced
Ethel Ziegler
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 .. 79 ... Years.
Months ..
.Days
If under 24 hours
Hours.
Minutes
13 Usual
Occupation :
Retired
(Kind of work done during most of working life)
14 Industry
or Business :
Poultry business
15 Social Security No.
Russia
16 BIRTHPLACE (City)
(State or country)
17 NAME OF
FATHER
Isaac Palais
18 BIRTHPLACE OF
FATHER (City)
(State or country)
Russia
19 MAIDEN NAME
OF MOTHER
Leah (unknown)
20 BIRTHPLACE OF MOTHER (City) (State or country)
Russia
(Address)
Winthrop
Date ..... 8 .... 1.1.
.1960
6 .
Tifereth Israel of
Everett
Place of Burial or Cremation Winthrop
DATE OF BURIAL
(City or Town) August ...... 1.2.196.0.
7 NAME OF
FUNERAL DIRECTOR
Morris W Brezniak
ADDRESS
470 Harvard St
Brookline
Received and filed
AUG 12 1860
19
(Registrar)
5 grs.
Due To (c)
OTHER
SIGNIFICANT
CONDITIONS
Pneumonia
1 day
Was autopsy performed?
No
What test confirmed diagnosis ?
Clinical
5 Was disease or injury in any way related to occupation of deceased ? If so, specify
PARENTS
21
Informant
(Address)
Mrs ........ Ethel ..... Palais 53 Trident Ave., Winthrop
I HEREBY CERTIFY that a satisfactory standard certificate of death was filled with me BEFORE the burial or transit permit was issued: alle tereanult (Signature of Agent of Board of Health or other) ' Thealth Clicar 8/11/60
(Official Designation)
V
(Date of Issue of Permit)
V.B. V
TRUCTIONS FOR L CERTIFICATE
n giving OF DEATH not enter e than one e for each , (b) and (c)
does not mean de of dying, heart failure, , etc. It means ase, or compli- which caused
tions, if any, gave rise to cause (a), g the under- cause last.
ditions contrib- death but not to the terminal condition given
- Chapter 137, 1954. requires ans to print or ne cause or of death on :rtificates, and 48, Acts of ·quires Physi- print or type ider signature.
11-59-926662
2 FULL NAME
WilliamPalais
(If deceased is a married, widowed or divorced woman, give also maiden name.)
8 SEX
Male
9 COLOR
White
10 SINGLE
(write the word)
MARRIED)
WIDOWED Married
or DIVORCED
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