USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1960 > Part 45
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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.
RM R-302
1
PLACE OF DEATH
Suffolk
(County )
Revere
The Commonwealth of Massachusetts JOSEPH D. WARD SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS TEHT COPY OF CERTIFICATE OF DEATH
Revere
(City or Town making this return)
204
§ (If death occurred in a hospital or institution. St. ¿ give its NAME instead of street and number)
Edward Hurwitz
2 FULL NAME
(If deceased is a married, widowed or divorced woman, give also maiden name.)
9 Cliff Avenue
X
Winthrop
St
( Usual place of abode )
7
(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
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
Male
9 COLOR
White
10 SINGLE
MARRIED
WIDOWED
or DIVORCED
( write the word).
Married
4 I HEREBY NOV . 4
CERTIFY.
57
That I
Sept.
attended deceased
26
19
60
death is said to
have occurred on the date stated above, at .m.
INTERVAL BETWEEN ONSET AND DEATH
9mos
57
12
AGE
Years.
Months
Days
If under 24 hours
Hours ..
Minutes
13 Usual
Occupation :
(Kind of work done during most of working life)
14 Industry
Attorney at law
or Business :
15 Social Security No.
Boston
16 BIRTHPLACE (City)
(State or country)
Samuel Hurwitz
17 NAME OF
FATHER
18 BIRTHPLACE OF
FATHER (City)
(State or country )
Russia
19 MAIDEN NAME Sadie Freedman OF MOTHER
20 BIRTHPLACE OF
MOTHER (City)
Russia
( State or country )
oris Hurwitz
Place of Burial or CrematioSeptemberCity 27rown) 60
19
7 NAME OF
Philip Briss
170 Harvard St., Bkin.,Mass
ADDRESS
Received and filed OCT 4 1960 19
(Registrar of City or Town where deceased resided)
A TRUE COPY
ATTEST :
( Registrar of City or Town where death occurred)
DATE FILED
1
September
27,
60
19
VAV
3 DATE OF
DEATH
(Address)
resided as soon as possible, after the close of the month in which the death occurred. (See Chap. 46, Sec. 12, G. L.)
at the time of death should be transmitted on Form R-302 to the clerk of the city or town in which the deceased
CONDITIONS
September
26,
1960
(Month)
(Day)
(Year)
I last saw h
anve on
5:00P.
10a If married, widowDordivorceFrank
HUSBAND of
(Give maiden name of wife in full)
(or) WIFE of
(Husband's name in full)
DEATH WAS CAUSED BY : IMMEDIATE CAUSE
Metastatic Carcinoma
Due To
Carcinoma of Colon
2yrs
9mos
OTHER
None
SIGNIFICANT
Was autopsy performed ?
Clinical
What test confirmed diagnosis ?
No
5 Was disease or injury in any way related to occupation of deceased ? If so. specify
Benjamin Barton
(Signed)
107 .Ferry .... St.
9/27
a
.Date
19
Sharon Memorial Park
Sharon
50M-9-59-926111
(a) (b) 6 Copies of returns of deaths which occurred in your city or town in case the deceased resided in another city or town Due To (c)
-- ----- --- --- ...
THIS IS A PERMANENT RECORD
PARENTS
(Address )
21
Informant
9 Cliff Ave., Winthrop
DATE OF BURIAL
Grover Manor No
(City or Town)
Registered No.
( Was deceased a
U. S. War Veteran,
No
(a) Residence. No ..
19
to:
im Sept. 26
11 IF STILLBORN, enter that fact here.
Self employed
No
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE DATE OF DISCHARGE RANK, RATING ORGANIZATION AND OUTFIT SERVICE NUMBER
R-301A 1
PLACE OF DEATH
Suffolk County )
Winthrop (City or Town)
No.
24.1. 31 COMSI
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.
205
[(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)
ho
(a) Residence. No. (Usual place of abode)
Length of stay: In place of death. .years ... - .months .. /. .. days. In place of residence. 35
.years .. months- .. davs.
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
DEATH
Sep
28
1960 (Year)
JAN
HEREBY CERTIFY
That I attended deceased from
60
I last saw him alive on
Sep. 27
160
.. , death is said to
have occurred on the date stated above, at
12.30 Am.
DEATH WAS CAUSED BY IMMEDIATE CAUSE
Coronary Heart disease
(
INTERVAL BETWEEN ONSET AND DEATH 1 day
5Yrs
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
(Signedy J.B. TOLTZ B. TGet My (PRINT OR TYPE SIGNATURE) (Address ) 332 Bellingham St Chelsea
M. D.
9/2860
Chaves achen anche Stard Place of Burial or Cremation (City or Town) DATE OF BURIAL Lupt 28 1960
7 NAME OF FUNERAL I Voz 7 unual Serviorne ADDRESS Enelua
Received and filed
SEP-28-1960
19
(Registrar)
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
male
9 COLOR
White
MARRIED
WIDOWED
OF DIVORCED
married
10a If married, widowed, or divorced Bessie Cohen 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.
76
Years.
Months
Days
If under 24 hours
Hours.
Minutes
13 Usual
Occupation :
Stitcher (Retired)
(Kind of work done during most of working life)
14 Industry
or Business :
Waste Materials
15 Social Security No.
16 BIRTHPLACE (City)
(State or country)
Russia
17 NAME OF
FATHER
(CB2)
Shapiro
18 BIRTHPLACE OF
FATHER (City)
(State or country)
Russia
19 MAIDEN NAME
OF MOTHER
(C.B.L.)
20 BIRTHPLACE OF
MOTHER (City)
(State or country)
Russia
21 Informant Minnie Diekman (Address) 20 Buckingham R& Mollaste Mais
I HEREBY CERTIFY that a satisfactory standard certificate of death was filed with me BEFORE the burial 'or transit permit was issued: J'aisu jereanul 7
(Signature of Agent of Board of Health or other)
19128 60
(Official Designation)
(Date of Issue of 'Permit) /
X
UCTIONS FOR CERTIFICATE
giving OF DEATH ot enter than one for each (b) and (c)
es not mean of dying, heart failure, etc. It means , or compli- hich caused
ns, if any, ave rise to cause (a), the under- ause last.
tions contrib- eath but not the terminal dition given
Chapter 137, 54. requires s to print or cause
or death on ificates, and 48, Acts of Hires Physi- print or type er signature.
59-925686
mayflower nursing Home , Shapiro
2 FULL NAME. Benjamin
(If deceased is a married, widowed or divorced woman, give also maiden name.) 52 Chester Cell
Chelsea
St.
(If nonresident, give city or town and State)
10 SINGLE
(write the word)
(Month) (Day)
55
Sep 28
19
Due To
arterio sclerosis
(b)
PARENTS
Registered No.
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 law's 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.
X PLACE OF DEATH
Suffolk (County
Winthrop ((ity or Town)
No.Payview Nursing Home
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.
206
J(If death occurred in a hospital or institution, St. { give its NAME instead of street and number )
PHYSICIAN - IMPORTANT
f(Was deceased a .. { U. S. War Veteran, {if so specify WAR)
no
i If deceased is a married, widowed or divorced woman, give also maiden name.)
(a Residence Nc. 75. Condor
St
East Foston
il'sual place of abode )
Length of stay: In place of death.
years ....._....
months.
2 days. In place of residence
.years. . .. months .. days.
MEDICAL CERTIFICATE OF DEATH
PERSONAL AND STATISTICAL PARTICULARS
3 DATE OSeptember
29,
1960
DEATH
(Month)
(Day)
(Year)
8 SEX
female
9 COLOR
white
MARRIED
wIDONEtowed
or DIVORCED
4 I HEREBY CERTIFY
to ..
143/19
SEPT 29,
That I attended deceased from
1960
I last saw hERalive on
SEPT 29,
196.€
death is said to
have occurred on the date stated above, at
5:30 pm.
INTERVAL
BETWEEN
ONSET AND
DEATH WAS CAUSED BY : IMMEDIATE CAUSE
(a) CEREBRAL HEMORRHAGE
LEFT HEMIPLEGIA
DEATH
DAY
12
AGE 86
Years.
.. Months.
.Days
If under 24 hours Hours ... Minutes
housework
13 Usual
Occupation :
(Kind of work done during most of working life)
14 Industry
or Business :
own home
15 Social Security No.
16 BIRTHPLACE (City) East Boston, Mass.
(State or country)
17 NAME OF
FATHER
William McKenney
18 BIRTHPLACE OF
FATHER (City)
(State or country)
unknown
19 MAIDEN NAME
OF MOTHER
Bridget Melody
20 BIRTHPLACE OF
MOTHER (City)
(State or country)
Emma Kane
Ireland
6
Holy Cross
Malden
Place of Burial or Cremation
DATE OF BURIAL
Oct.
3 (City or Town)
60
19
7 NAME OF
FUNERAL DIRECTOR
Frederick J. Magrath
ADDRESS
East ...... o.s.t.on
Received and filed SEP-30-1960 19
(Registrar)
PARENTS
21
Informantz
(Address)3 Condor St. E. Boston
I HEREBY CERTIFY that a satisfactory standard certificate of death was filed with me BEFORE the burial .or transit permit was issued: Halkle C- Pireannex
(Signature of Agent of Board of Health of other)
Theattle Glicer
9/30/60
(Official Designation)
(Date of Issue of Permit) /
RUCTIONS FOR CERTIFICATE
giving OF DEATH ot enter than one for each (b) and (c)
es not mean ? of dying, heart failure, etc. It means e, or compli- which caused
ns, if any, ave rise to cause (a), the under- cause last.
tions contrib- leath but not the terminal ndition given
Chapter 137, 954. requires is to print or cause or f death on tificates, and 48, Acts of uires Physi- print or type er signature.
1-59-925686
R-301A 1
Due To (c)
OTHER
SIGNIFICANT CARDIAC DECOMPENSATION/YR
CONDITIONS
RIGHT HEMIPLEGIA
16 YRS.
Was autopsy performed ?
NO
What test confirmed diagnosis ?
5 Was disease or injury in any way related to occupation of deceased? NO If so, specify
(Signed)
a.M. Caplan
A. Nathan Caplan
M. D.
(Address)
(PRINT OR TYPE SIGNATURE)
186 Princeton Spate 9/30
19.60
10a If married, widowed, or divorced
HUSBAND of
(Give maiden name of wife in full)
(or) WIFE of
John T. Peterson
(Husband's name in full)
11 IF STILLBORN, enter that fact here.
- (b) Due To ARTERIOSCLEROSIS-
BOSTON 09-1.01
Registered No
2 FULL NAME Emma .... L ....... Peterson
(If nonresident. give city or town and State)
10 SINGLE
(write the word)
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE RANK, RATING
ORGANIZATION AND OUTFIT
SERVICE NUMBER
SEP 3 01950 TH
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 rece.it 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 pur uits 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.
RM R-302
resided as soon as possible. after the close of the month in which the death occurred. (See Chap. 46. Sec. 12, G. L.) 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 THIS IS A PERMANENT RECORD
T 19
BUREAU OF RECORDS AND STATISTICS
DEPARTMENT OF HEALTH
THE CITY OF NEW YORK
ICAL PARTICULARS
10 SINGLE ( write the word) MARRIED WIDOWED or DIVORCED
en name of wife in full)
nd's name in full)
ere.
If under 24 hours Hours ..... Minutes
ne during most of working life)
19. Approximate Age
Notiv. Dac.
4. DATE OF BIRTH OF DECEDENT
7
60
5. AGE
yre.
10
776
., Usual Occupation (Kind of work done during most of working lifa, aven if retired)
NONE
Couso 2
b. Kind of Business or Industry in which this work was done
None
SOCIAL SECURITY NO.
NONE
Operation
8. BIRTHPLACE (State or Foreign Country} U.S.A.
9. OF WHAT COUNTRY WAS DECEASED A CITIZEN AT TIME OF DEATH?
U.S.A.
100, WAS DECEASED EVER IN UNITED STATES ARMED FORCES? NONE
10b. IF YES, Give wer or detes of Survice ALOAre
Cem
11. NAME OF FATHER OF DECEDENT
WALTER
12. MAIDEN NAME OF MOTHER OF DECEDENT
EVELYN
Zory Soland Col' Hosp.
Type Aecid,
13. NAME OF INFORMANT
RELATIONSHIP TO DECEASED
ADDRESS
14a, Name of Cemetery or Crumotory
14b. Location (City, Town or County and Stets)
14c. Dete of Burial or Cremation
Occurrence
21. FUNERAL DIRECTOR
ADDRESS
or Town where death occurred)
........... ........ 19
1
PLACE OF DEATH
Borough, BROOKLYN
The Commonwealth of Massachusetts JOSEPH D. WARD SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS COPY OF
WINTHROP
(City or Town making this return)
207
(If death occurred in a hospital or institution, St. ¿ give its NAME instead of street and number)
Long Island College Hospital No ...
(Baby Boy) - - - - Rikeman
( Was deceased a U. S. War Veteran.
if so specify WAR,
78 Temple Avenue
(If nonresident. give city or town and State)
days. In place of residence .......... years ........ months ......... days.
17H (Rev.7/59) -13
Certificate of Death
.. 189
Boro Dseth
Certificate No.
1. NAME OF BABY
Boy
3, ReMAN
DECEASED. (Print or Typewrite)
Fizet Nomy
Middle Name
Last Name
Institution
PERSONAL PARTICULARS (To be fitled In by Funere! Director)
MEDICAL CERTIFICATE OF DEATH (To be filled in by the Physician)
USUAL RESIDENCE: (n) State_"ASS, 2.
Boro-Rseld.
(b) Com (c) Post ON WINTHROP and Zons.
(d) No. 18 Temple
Ave.
Aree-Dist.
(If Inkural aren, give location)
(d) 1[ In hospital, give Word No.
(Month) (Dey).
NURsery (Yeer) (Hour) 60 60 A
3. SINGLE, MARRIED, WIDOWED, OR DIVORCED (write the word)
SINGLE
MALE WHITE HOUR 30MIN
(Year) 20 I HEREBY CERTIFY that (I attended the deceased)* (a staff physician of this institution attended the deceased)"
from. 7. 6 -19 60 to 7-60 10 60
and last saw h Zalive at. Y'A M on.
4.25 NO Caused I further certify that death 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.
" Croes out worde thet do not apply.
Att .- Autop.
i See firet instruction on reverse of certificate.
Witness my hand this 11 day of July
Signature.
Anthony Bonelli
D.O. . M.D.
THIS CERTIFICATE NOT VALID UNLESS FILED IN THE HEALTH DEPARTMENT DO NOT WRITE' IN THE SPACE. MARGIN RESERVED FOR CODING AND BINDING
15. PLACE OF DEATH:
3.00 K Lyn
(.) NEW YORK CITY:,(b) Borough.
(c) Name of Hospital LONG ISLAND College or Institution .... (If not In hospital or instifution, give street end numbor.)
(s) Length of reeldence or stay in City of New York Immediately prior to death
16. DATE AND HOUR OF DEATH 7. 6
17. SEX 18. COLOR OR RACE
(Month)
If under 1 your
If LESS than I day
Couse 1
days hrs. or min.
IX
6.Occupation
7.60 1960
2 FULL NAME
( If deceased is a married, widowed or divorced woman, give also maiden name.)
(a) Residence. No .. ( Usual place of abode )
NEW YORK CITY, N. Y.
(City or Town)
CERTIFICATE OF DEATH
Registered No.
FILED
months
0
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE DATE OF DISCHARGE RANK, RATING ORGANIZATION AND OUTFIT SERVICE NUMBER
X PLACE OF DEATH -
SUFFOLK BOSTON
(('ity or lown)
The Commonwealth of Massarbusrifs JOSEPH D WARD SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS STANDARD
CERTIFICATE OF DEATH
Registered 117055
MASSACHUSETTS GENERAL HOSPITAL f(If death occurred in a hospital of institution. St { give its NAME instead of street and number ) No.
2 FULL NAME.
Katherine Pitts (Slavin)
( If deceased is a married, widowed of divorced woman, give also maiden name.)
i Residence No.
494 Shirley St
il'smal place of abode )
length of stay : In place of death
.years .............. months
8
.days. In place of residence
8 . years. .. .. months
. .. days.
MEDICAL CERTIFICATE OF DEATH
PERSONAL AND STATISTICAL PARTICULARS
3 DATE OF
DEATH
July
0
1960
(Year)
# SEX
Female
9 COLOR
White
In SINGLE
. {write the word)
·
(Monthy
(Dáy)
4 I HEREBY CERTIFY,
That i attended deceased from
Jul.y.
1
19 .. 60, to .......
July
.9
19 60
wě last saw h.e. lalive on
July
9
19.60, death is said to
(or) WIFE of
Newman Pitts
(Husband's name in full)
DEATH WAS CAUSED BY : IMMEDIATE CAUSE
(a)
Pulmonary embolus
INTERVAL
BETWEEN
DNSET AND
DEATH
hours
71
11 IF STILLBORN, enter that fact here
12
AGE
Years
4
Months.
6
„Days
If under 24 hours
Hours ...........
.. Minutes
13 Usual
Occupation
None
(Kind of work done during most of working life)
14 Industry
or Business :
At Home
15 Social Security No.
001-26-9703
Newport
16 BIRTHPLACE (City)
(State or country)
Rhode Island
17 NAME OF
FATHER
John Slavin
18 BIRTHPLACE OF
FATHER (City)
(State or country)
Unable to Obtain
19 MAIDEN NAME,
OF MOTHER
Mary A Martin
20 BIRTHPLACE OF
MOTHER (City)
...
(State or country)
Unable to Obtain
(Address)
Date ...
19
6 South Cemetery Wilton N.H.
21
O.A.A. Records
Informant
(Address) Winthrop Mass.
7 NAME OF
FUNERAL DIRECTOR
Howard S Reynolds
ADDRESS
Winthrop, Mass.
I HEREBY CERTIFY that a satisfactory standard certificate of death was filed with me BEFORE the burial or transit permit was issued: Mary Cunniff
(Signature of Agent ol Board of Health or other)
7 11 60
(Official Designation)
(Date of Issue of Permit)
1
M R-301A 1
TRUCTIONS FOR CERTIFICATE
RIVINg OF DEATH
not enter e than one e for each (b) and (c)
does not meon de of dying, heart failure, etc. It meons ase, or compli- which caused
2166.
ions, if any, gove rise to cause (a), the under- couse lost.
ditions contrib- death but not to the terminal Condition given 5
Chapter 137. 1954. requires ns to print or e cause or of death on tificates, and 48. Acts of quires Physi- print or type der signature.
(Signed)
..................
M. D.
Ass't CHORIFOR ZIERIGNATURE)
days
Due To
(c)
retroperitoneal Phlegmon
days
OTHER
SIGNIFICANT
CONDITIONS
Was autopsy performed ?
Yes
What test confirmed diagnosis ?
autopsy
5 Was disease or injury in any way related to occupation of deceased ?
Il so, specify
......
PARENTS
Place of Burial or Cremation
(City or Town)
DATE OF BURIAL
.....
July 12
19 .... 60.
8867
(Registrar)
OUT - OF - TOWN
To be filed for burial permit with Board of Health or its Agent. 207.
PHYSICIAN - IMPORTANT [(Was deceased a RU S. War Veteran, (if so specify WAR)
Winthrop Mass
(If nonresident. give city of town and State)
MARRIED
WIDOWED Widow
or DIVORCED
10a If married, widowed, or divorced
HUSBAND of
(Gjvg maiden name of wife in full)
have occurred on the date stated above, at
4:COA .... m.
Thrombosis leftilliac vien
(b) ....
DV 2 1960 eil Director: ce use only ACK Ink. 16-59-925686
A TRUE COPY ATTEST:
Charles it Mackie City Registrar
TOM
OFF
0
LERK
5
THROP
NOV = 21960 AM
PLACE OF DEATH
Suffolk
(County)
Boston
(City or Town)
The Commonwealth of Massachusetts JOSEPH D. WARD SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS STANDARD CERTIFICATE OF DEATH
208
To be filed for burial permit with Board of Health or its Agent.
Registered No.
07127
S(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)
WW I
2 FULL NAME
(If deceased is a married, widowed or divorced woman, give also maiden name.)
100 Upland Road
Xt.
Winthrop, Mass.
(Usual place of abode)
Length of stay : In place of death .............. years ............
months
-1
.days. In place of residence.
life
months .............. days.
MEDICAL CERTIFICATE OF DEATH
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
Female
9 COLOR
White
10 SINGLE (write the word)
MARRIED Widowed
WIDOWEDW
or DIVORCED
4 I HEREBY CERTIFY,
July .... 12 ...
19.60 ..
to ....
July ...
12 ......
XXXX death is said to
have occurred on the date stated above, at
... m.
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a)
1. Aneurysm of ascending
aorta with rupture into
Due To
esophagus and massive
(b)
gastro-intestinal hemorrhage
hours
Due To (c)
OTHER
SIGNIFICANT
CONDITIONS
Was autopsy performed ?
YES
What test confirmed diagnosis?
Autopsy & Clinical
findings
5 Was disease or injury in any way related to occupation of deceased? . NO
If so, specify.
1) Richard 2. Frost .
(Signed)
RICILARD ... G ...... FROST.
(PRINT OR TYPE SIGNATURE) (Address) VAH .... Boston, Mas.s.
Date .. July 12 19 60
Holy Cross Cemetery Malden Mass 6
Place of Burial or Cremation
DATE OF BURIAL
July ........ 15
(City or Town)
19.
60
7 NAME OF
FUNERAL DIRECTOR
Ernest P. Caggiano
ADDRESS 147 Winthrop Sty Winthrop Mass.
Received and filed
A. 19.
1.1 /7
-1
(Registrar)
PARENTS
18 BIRTHPLACE OF
FATHER (City)
(State or country)
Ireland
19 MAIDEN NAME
OF MOTHER
Nora O'Brien
Boston
20 BIRTHPLACE OF
MOTHER (City)
(State or country)
Mass.
VAH Records,150 S.Huntington Ave
21 Informant (Address) Boston, Mass.
I HEREBY CERTIFY that a satisfactory standard certificate of death was foed with me BEFORE we butial or transit permit was issued: Jacqueline Care (Signature of Agent of Board of Healthor other
E108918 Taller 13, 1960
(Oficial Designation) (Date of Love of Permit)
V
ISTRUCTIONS FOR' AL CERTIFICATE
In giving E OF DEATH o not enter ore than one use for each ). (b) and (c)
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