Town of Winthrop : Record of Deaths 1961, Part 36

Author: Winthrop (Mass.)
Publication date: 1961
Publisher:
Number of Pages: 542


USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1961 > Part 36


Note: The text from this book was generated using artificial intelligence so there may be some errors. The full pages can be found on Archive.org (link on the Part 1 page).


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BRALI


Chelsea


(If nonresident, give city or town and State)


months ..


.days.


MEDICAL CERTIFICATE OF DEATH


3 DATE OF


DEATH


SEPT


29


1961


(Year)


(Month)


(Day)


4 I


HEREBY CERTIFY,


That I attended deceased from


JULY 1958, to. SEPT 29 61


I last saw himalive on


91


29


19 6/


death is said to


have occurred on the date stated above, at


... m.


DEATH WAS CAUSED BY: IMMEDIATE CAUSE


NEPHRO SCLEROSIS AND


(a)


ARTERIO-SCLEROTIC HEART


DIS


Due To


GENERAL ARTERIOSCLEROSIS


(b)


3YRS.


Due To (c)


OTHER


SIGNIFICANT


CONDITIONS


Congestive HEART FAILURE 2 DAYS.


Was autopsy performed? No


What test confirmed diagnosis ?


CLINICAL


5 Was disease or injury in any way related to occupation of deceased. 0 If so, specify


PARENTS


(Signed)


Myron b. King


M. D.


OF MOTHER


CATHRINE Lewis


MYRON N.KING MODO (PRINT OR TYPE SIGNATURE) (Address) 222 PLEASANT ST WITHROBate. 9/29


WoodLAWN CEMETERY EVERETT?


(City_or Town) Place of Burial or 'Crematen DATE OF BURIAL ..... OCT, 2,1961 19


7 NAME OF


FUNERAL, DIRECTOR


W. R. CARAFA


Received and filed OCT 2 19


(Registrar)


PERSONAL AND STATISTICAL PARTICULARS


8 SEX


MALe White


10 SINGLE


MARRIED


WIDOWEDfugle


or DIVOREEHC


(write the word)


%


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


AG


82


......


2Months 29 Days


If under 24 hours


Hours.


.. Minutes


13 Usual


Occupation :


Laboral


Rst, BET


(Kind of work done during most of working life)


14 Industry


or Business :


Industry


15 Social Security No.


16 BIRTHPLACE (City)


Shelbourne


(State or country)


NOVIA SCOTIA


17 NAME OF


FATHER


Concernanty Sulan


18 BIRTHPLACE OF


NALES


FATHER (City)


(State or country)


ENGLAND


19 MAIDEN NAME


20 BIRTHPLACE OF


NOVA SCOTIA .


19 61 MOTHER (City) (State or country)


Msp Bessie Suvana


Informant


(Address) 84 BreenDy Weymouth


I HEREBY CERTIFY that a satisfactory standard certificate of death was filed with me BEFORE the burial or transit permit was issued:


(Signature of Agent of Board of Health or other) Health Kirche 10/2/6/


(Official Designationy


(Date of Issue of Permit)


X


R-301A 1


4


Fakt SL


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.


ions contrib- eath but not the terminal dition given


Chapter 137, 54. requires s to print or cause


or death on ificates, and 8, Acts of ires Physi- rint or type er signature.


59-925686


No. PLACE OF DEATH So FOLK (County) WINTHROP (City of Town)


To be filed for burial permit with Board of Health or its Agent.


PHYSICIAN - IMPORTANT [(Was deceased a U. S. War Veteran, [if so specify WAR)


(a) Residence. No. (Usual place of abode)


Length of stay: In place of death. 3 years. . months days. In place of residence :/ 0 years


9 COLOR


1000p INTERVAL BETWEEN ONSET ANO DEATH


3 YRS:


ADDRESS 389 WASHINGTONANE ChelsEn hacer Eferianne


SPACE FOR ADDITIONAL INFORMATION


DATE OF ENTERING MILITARY SERVICE


DATE OF DISCHARGE


RANK, RATING


ORGANIZATION AND OUTFIT


SERVICE NUMBER


..


OFFICE


WERK


8


5


6


C ..


THỊ


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.


OCT #21961 AM


Caraffa


X PLACE OF DEATH


Suffolk (County)


Winthrop


(City or Town)


The Commonwealth of Massachusetts JOSEPH D. WARD SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS


STANDARD 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


Rhoda


E (Woodward)


Kimberly


(First Name)


( Middle Name)


(Last Name)


(If deceased is a married, widowed or divorced woman, give also maiden name.)


198 Somerset Avenue


St. Winthrop 52, Massachusetts


(If nonresident, give city or town and State)


Length of stay: In place of death.


.. years ..


$ 2


month 25


days. In place of residence 45


.years


months.


days.


MEDICAL CERTIFICATE OF DEATH


PERSONAL AND STATISTICAL PARTICULARS


8 SEX


Female


9 COLOR


White


10 SINGLE


(write the word)


MARRIED


WIDOWERMarried


or DIVORCED


10a If married, widowed, or divorced


HUSBAND of


Gilead


(Give maiden name of wife in full)


Kimberly


(Husband's name in full)


DEATH WAS CAUSED BY: IMMEDIATE CAUSE


(a)


Acute myocardial infarction


INTERVAL BETWEEN ONSET AND DEATH 12 wks


Due To


(b)


Coronary sclerosis


5 yrs.


Due To Arteriosclerotic & hypertensive


(c)


heart disease


8 yrs


OTHER


Generalized arteriosclerosis


SIGNIFICANT


CONDITIONS & hypertrophic arthritis


Was autopsy performed?


no


What test confirmed diagnosis?


Clinical & laboratory


5 Was disease or injury in any way related to occupation of deceased? N.O. If so, specify


(Signed)


M: Traunstein


M. D


M. Traunstein, Jr., M./D.


(PRINT OR TYPE SIGNATURE)


(Address)


73 Bartlett Rd.


Date


Sept.


302.19


61


Winthrop 52, Mass.


Winthrop


0


Winthrop


Place of Burial or Cremation


(City or Town)


DATE OF BURIAL


Oct. 3


61


19


7 NAME OF


FUNERAL DIRECTOR


Howard S Reynolds


ADDRESS


Winthrop


Mass


Received and filed


OCT 2- 1961


.. 19.


(Registrar)


PARENTS


18 BIRTHPLACE OF


FATHER (City)


(State or country)


England


19 MAIDEN NAME


OF MOTHER


Tyers


20 BIRTHPLACE OF


MOTHER (City)


(State or country)


England


21


Informant


Gilead Kimberly


(Address) 198 Somerset Ave Winthrop


I HEREBY CERTIFY that a satisfactory standard certificate of death filed with me BEFORE the burial. or transit permit was issued: Ralph C Sirianni 8 (Signature of Agent of Board of Health or other) Health Alice 10/3/61


(Official Designation)


(Date of Issue of Permit)


5928145


R-301A 1


UCTIONS FOR CERTIFICATE


giving OF DEATH


t enter than one for each b) and (c)


es not mean of dying, heart failure, etc. It means ,. or compli- Which caused


ns, if any, ave rise to cause (a), the under- ause last.


'ions contrib- eath but not the terminal sdition given , C .


Chapter 137, 954. requires ns to print or e


cause or of death on "tificates, and 48, Acts of quires Physi- print or type ler signature.


PHYSICIAN - IMPORTANT


[(Was deceased a


U. S. War Veteran,


lif so specify WAR)


(a) Residence. No. (Usual place of abode)


3 DATE OF


DEATH


September 30, 1961


(Month)


(Day)


(Year)


4 I HEREBY


CERTIFY,


That I attended deceased from


April 27,


19


to ..


55


Sept. 30,


19


I last saw Her .. alive on


Sept.


13.0.


19.Q.1 ... , death is said to


have occurred on the date stated above, at


11:50 am.


11 IF STILLBORN, enter that fact here.


12


81


11


25


If under 24 hours


Hours.


.. Minutes


AGE


Years.


Months.


Days


13 Usual


Occupation :


Housewife


(Kind of work done during most of working life)


14 Industry


or Business :


Own Home


15 Social Security No.


019-28-6107


16 BIRTHPLACE (City)


(State or country)


Eng Land


17 NAME OF


FATHER


Robert Woodawrd


des


To be filed for burial permit with Board of Health or its Agent.


Winthrop Community Hospital


No.


CINSEPETI


61


(or) WIFE of


10yrs


SPACE FOR ADDITIONAL INFORMATION


DATE OF ENTERING MILITARY SERVICE


DATE OF DISCHARGE.


RANK, RATING


ORGANIZATION AND OUTFIT


SERVICE NUMBER.


OF


OFEM


BIN


CA !


BERK


·


3


RULES OF PRACTICE OCT 21961 PM


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.


+


RM R-302


1


PLACE OF DEATH


San Diego (County )


San Diego,California (City or Town)


The Commonwealth of Massachusetts JOSEPH D. WARD SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS COPY OF CERTIFICATE OF DEATH


WINTHROP.


(City or Town making this return)


481


MISSION VALLEY INN, Room 323


S (If death occurred in a hospital or institution, give its NAME instead of street and number)


2 FULL NAME ERNEST CLARENCE DAVIS JR


( If deceased is a married, widowed or divorced woman, give also maiden name.)


9.2 ... Upland Road


St


(If nonresident, give city or town and State)


Length of stay:


In place of death .......... years .......... months.


.. 1 .. days. In place of residence .......... years ........


.. months .......... days.


MEDICAL CERTIFICATE OF DEATH


PERSONAL AND STATISTICAL PARTICULARS


3 DATE OF


DEATH


.... June


( Month)


(Day)


( Year)


8 SEX


Male


9 COLOR


White


10 SINGLE


MARRIED


WIDOWED


or DIVORCED


Married


4 I HEREBY CERTIFY, That I attended deceased from 100_1€


11-088041


CERTIFICATE OF DEATH STATE OF CHINOANIA - DEPARTMENT OF PLALIC HEALTH


LOCAL REGISTRATINM


DISTRICT AND 8009


322


LA NAVE OF DECEASED SIST WANT TO


Ernest


MIDDLE NAME


Clarence


LAST NAUT


DAVIS


Jr.


June 10, 1961


11:20 Am


33×8


SEX


Male


4 COLOR OR RACE 5 BIRTHPLACE . : p


Cauc.


New York


6 DATE DE MIRTH


May 31, 1217


7 AGE ..... .....


44


YEARS


B NAME AND BIRTHPLACE OF FATHER


Ernest. C. Davis Sr. N. Y.


00


. MAIDEN NAME AND BIRINPLACE OF MOTHER


Unknown Unknown, New York


ID CITIZEN OF WHAT COUNTRY


U.S.A.


11 SOCIAL SECURITY NUMBER


009-03-7128


12 LAST OCCUPATION 19 ------


10


14 NAME OF LAST EMPLOYING COMPANY OF FIRE OF THE Northeast Airlines


15 KIND OF INDUSTRY OR BUSINESS


Airlines


PLACE OF DEATH 221308


1% CITY OR TOWN


San Diego


190 COUNTY


San Diego


19€ LENGTH OF STAY IN


COUNTY OF DEATH


1 Day yVAM


19F LENGTH OF STAY IN


CALIFORNIA


1 Day


LAST USUAL RESIDENCE


20& LAST USUAL RESIDENCE STREET ADDRESS .A.M .PT: 20% If 10SIM CITY


X


-------------


92 Urland Road


QUES 01 EAT· CORPORATE LNITY


21. NAME OF INFORMANT IN OTHER THAN SPOUSE!


Kirby Funeral Homo


LYTTON 120 CITY OR TOWN


20, STATE


72c Mass.


PHYSICIAN 89


3.


Coroner 4 By & Benjamin T. Willary C.D. M.D. .


27. CORONLA ..... .... .... . . .... ...... ..


Autopsy


220 ADDRESS 3322 Congress Street


22. DATE SIGHED


6/10/61


23 .. .....


FUNERAL DIRECTOR AND LOCAL REGISTRAR


Burial-7em.


24 DATE


June 12, 1361


25 NAME OF CEMETERY OR CREMATORY Local Fas5.


Irk-"F "inth Mintlifor


20 0 ..... . . ..... .. . .. .. ..


29 LOCAL REGISTRO SIGMA


JUN 1 2 1961


3D CAUSE O' DEATH


PART 1 DEATH WAS CAUSED BY MEDIATE CAUSE I A+


Occlusion of left anterior descending coronary artery


APPROXIMATE


INTERVAL


... .....


DUE TO ...


Thrombosis


ONSET AND


DEATH


Atherosclerosis.


DUE TO ICI


PANT # OTHER SIGNIFIC ANT CONDITIONS CONTINOUTING TO DEATH BUT NOT RELATED TO THE TERMINAL DISEASE CONDITION GIVEN IN PART LIAI


( Registrar of City or Town where death occurred )


DATE FILED


19. TX


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


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.)


50M-9-59-926111


Received and filed


FOR PUBLIC HEALTH PROGRAM & STATISTICAL PURPOSES ONLY


-


-


-


NON RESIDENT ALLOCATIONS


& STA


HN RESIDENT ALLOCATICHS FOR PUBLIC HEALTH PROGRAM & STATISTICAL PURPOSES CHL


DECEDENT PERSONAL DATA 518 195-1


DAVIS CC 879-61


Turbine Planning:


16 .... .. .... ... .. ..... .. ..... . Unknown


17


Married


18. NAME OF PRESENT SPOUSE


Dorothy Davis


18. PRESENT OR LAST OCCUPATION OF SPOUSE


Homemaker


19A PLACE OF DEATH- SAMT OF HOSPITAL


Mission Valley Inn, Room 323


19. STREET ADDRESS -· Give StatET 00 QueAL ADORES OR LOCATION DO MỘT VIT PO MI MUNCII


875 W. Camino Del Rio


215 ADDRESS OF INFORMANT --------- Winthrop, Mas achusetts


TITTD STUDENT NETOM


YY Winthrop


1 PHYSICIAN S OR CORONER S CERTIFICATION


SEMMALMER SIGNATURE HO BOT COLLISION LICENCE NUMBER


hlen' 3275


12.0.1


4201


CAUSE OF DEATH


HEALTH DATA


10-13-61


19


(Registrar of City or Town where deceased resided )


urs Minutes


life)


-


PCA P


ZA DATE OF DLAIN-MONTO TAI


VIAe 20 HOUA


( write the word)


(a) Residence. No. ( Usual place of abode)


10


1961


--------


200 COUNTY Suffolk


27 NAME OF FUNERAL DIRECTOR IFYOUIN MIN Johnson-Sau & Knotel Mort.


DETWEEN


c )


Registered No.


( Was deceased a


U. S. War Veteran,


(if so specify WAR,


SPACE FOR ADDITIONAL INFORMATION DATE OF ENTERING MILITARY SERVICE DATE OF DISCHARGE RANK, RATING ORGANIZATION AND OUTFIT SERVICE NUMBER


X


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


OUT - OF - TOWN To be filed for burial permit with Board of Ifeaich or its Agen :. 182


06021


2 FULL NAME


Jennie C. Bowers


( Butler)


( First Name) ( Middle Name) ( Last Name) (If deceased is a married, widowed or divorced woman, give also maiden name. )


(a) Residence. No. 779 Shirley


( U'sual place of abode)


St.


Winthrop, Massachusetts


( If nonresident, give city or lown and State)


year -.. .... .. . months. .


.. days.


MEDICAL CERTIFICATE OF DEATH


3 DATE OF


DEATH


June


23,


1961


(Month)


(1)ay)


(Year)


8 SEX


female


9 COLOR


white


10 SINGLE


MARRIED


WIDOWED


of DIVORCEDWidowed


(write the word)


10a If married, widowed, or divorced


HUSBAND of


(Give maiden name of wife in full)


(or) WIFE of


George Fred Bowers


(Husband's name in full)


11 IF STILLBORN, enter that fact here.


DEATH


3days


AGE


Years ..


12


39


10


Months.


5


If under 24 hours


Days


Ilours. .Minutes


3day 3 13 Usual


Occupation :


Housewife


(Kind of work done during most of working life)


14 Industry


or Business :


at home


15 Social Security No.


16 BIRTIIPLACE (City)


(State or country)


South Thomaston


17 NAME OF


FATHER


William R. Butler


18 BIRTHPLACE OF


South Thomaston


FATHER (City)


(State or country)


Maine


19 MAIDEN NAME


OF MOTHER


Julia A. Sartelle


20 BIRTHPLACE OF


Camden


MOTHER (City) (State or country) Laine


21 Informant (Address) 779 Shirley St., Winthrop


J HEREBY CERTIFY that a satisfactory standard certificate of death was filed with me BEFORE the burial or transit permit was issued:


(Signature of Agent of Board of Health or other)


(Official Designation)


(Date of Issue of Permit)


UCTIGNS OR CERTIFICATE


iving F DEATH t enter han one for each ) and (c)


s not mean of dying, art failure, c. It means or compli- ich caused


, if any, e rise to use (a), e under- use last.


ns contrib- th but not he terminal ition given 0


A


5 Was disease or injury in any way related to occupation of deceased? If so, specify


(Signed)


Charles L. Clay, M. D.


( PRINT OR TYPE SIGNATURE)


(Address) Aus't. Dir., Muss. Gon'l. Hosp. Date.


6-23-1 61


South Thomaston Cem., S. Thomaston 6


/ Place of Burial or Cremation


Mainown)


DATE OF BURIAL June 26,


61


19


/7 NAME OF


FUNERAL


DIRECTOR


Alfred B. Marsh


ADDRESS 174 Winthrop St., Winthrop


... JUN 26 1961 5 ..... 19


INTERVAL BETWEEN ONSET AND


Due_1 (b) Intertrochanteric fracture Due To of right hip (c)


OTHER SIGNIFICANT CONDITIONS


Was autopsy performed?


No


What test confirmed diagnosis?


Clinical


70 ue


Chapter 1370 54. require: to print or cause death on ficates, and 8. Acts o fres Physi. int or type r signature 2.5. 196E. cton


only nk. 904


$145


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) no


Length of stay: In place of death years . months 3 days. In place of residence


PERSONAL AND STATISTICAL PARTICULARS


4 I HEREBY


une 20,


190


61


CERTIFLine 23,


to


That's attended deceased 4"


wq last saw e.Malive on


June 23,


1961


death is said to


have occurred on the date stated above, at ... ] : 05AM .. m.


DEATH WAS CAUSED BY: IMMEDIATE CAUSE


(a) Myocardial infarction


M. D


O PARENTS


Aya MacDonald


v.B.


R-301A -


No. Massachusetts General Hospital


BAKER MEMORIAL


Registered No.


Charles A. Mackie


City Registrar


== CENIEO


TOWA


12.


CLERK


-


3


×


1


PROC


THROP


OCT 2 51961 AM


PLACE OF DEATH


Suffolk (County)


Boston


(City or Town)


Children's Hospital Medical Center


The Commonwealth of Massachusetts JOSEPH D. WARD SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS STANDARD CERTIFICATE OF DEATH


OUT OF - TOWN To be filed for burial permit with Board of Health 33- or its Agent 06298


Registered No.


S(If death occurred in a hospital or institution,


St. } give its NAME instead of street and number) PHYSICIAN - IMPORTANT


2 FULL NAME Pivnick


( First Name)


( Middle Name)


(Last Name)


( If deceased is a prarried, widowed or divorced woman, give also maiden name.)


38 Forrest


Winthrop


.St.


14


6 (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.


1


MEDICAL CERTIFICATE OF DEATH


3 DATE OF


July 3, 1961


DEATH


(Month)


(Day)


(Year)


MALE


9 COLOR


WHITE


10 SINGLE


MAINHED


WHYWEDSINGLE


or-HVHRCED)


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


ACE 14


.Years.


Months ...


.. Days


If under 24 hours


Hours.


.. Minutes


13 Usual


Occupation :


STUDENT


(Kind of work done during most of working life)


14 Industry


or Business :


PUBLIC SCHOOLS WILTROP


15 Social Security No.


.


NONE


16 BIRTHPLACE (City)


(State or country)


WALTHAM MASS


17 NAME OF


FATHER


DAVID PINNICK


18 BIRTHPLACE OF


FATIIER (City)


CHELSEA


(Signed)


Beak Hi Ong


M. D


(State or country)


MASS.


Beale ... H. .. Ong.


(Address)


300 Longwood


(PRINT OR TYPE SIGNATCHEL 3-61


Date 19


LINAS HATZEDEK


EVERETT


6


Place of Burial or Cremation


(City or Town)


DATE OF BURIAL


July 4


1961


7 NAME OF


FUNERAL DIRECTOR


TORF FUNK AM SCRIVI


CHELSEA


ADDRESS


JUL 6 1961


Before the Les 21 macker (Registrar)


PARENTS


19 MAIDEN NAME


OF MOTHER


SYLVIA WOLKON


20 BIRTHPLACE OF


MOTHER (City)


(State or country)


11 ASS.


DAVID PIENICK


21


Informant


(Address)


38 FORREST ST. W.HANY


I HEREBY CERTIFY that a satisfactory standard certificate of death was filed with me BEFORE the burial or transit permit was issued: m samura


(Signature of Agent of Board of Health or other) 7-3-61


2754


(Official Designation)


(Date of Issue of Permit)


X


228145


X


R-301A 1


ICTIONS OR CERTIFICATE


iving F DEATH t enter han one for each b) and (c)


s not mean of dying, eart failure , tc. It means .or compli- hich


cause o Anemia Hemoglobin deficiency. 3


s, if any, ve rise to ause (a), he under- ause last.


ions contrib- cath but not the terminal dition given


Chapter 1374 954. requires ns to print ord e cause or @ of death of tificates, and+ 48. Acts of quires Physi- print or type ler signature


Note : Classifi


25 1964


8 SEX


(write the word)


4 I HEREBY


7-1


CERTIFY


61


19


Im


7-3


I last saw h.


... alive on


39.


death is said to


1:152 m


have occurred on the date stated above, at


INTERVAL


BETWEEN


ONSET AND


DEATH


DEATH WAS CAUSED BY: IMMEDIATE CAUSE


(a)


Sepsis


Due To


(b)


Agammaglobulinemia


Due To


(c)


OTHER


SIGNIFICANT


CONDITIONS


Was autopsy performed?


Yes


(Serving)


What test confirmed diagnosis?


Garna Globulin Level


5 Was disease or injury in any way related to occupation of deceased?


If so, specify


No.


Gerald


[( Was deceased a ₹ U. S. War Veteran. (if so specify WAR)


NO


(a) Residence. No. ( L'sual place of abode)


2


19


7 -Bat I attended deceased fregi]


61


PERSONAL AND STATISTICAL PARTICULARS


CHRISEM


Charles À Maiku City Registrar


==== 150


TO


ILLIK


7


3


-


..


HROP


OCT 2 51961 AM


X


PLACE OF DEATH


SUFFOLK (County) BOSTON (City or Town) MASS.


The Commonwealth of Massachusetts UT - OF - TOWN 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. 84 06:375


Registered No.


[(If death occurred in a hospital or institution, St. ? give its NAME instead of street and number)


PHYSICIAN - IMPORTANT


2 FULL NAME


RICHARD


( First Name)


( Middle Name)


( Last Name)


TRODERMAN


(If deceased is a married, widowed or divorced woman, give also maiden name )


85 BEACH ROAD


(a) Residence. No. ( L'sual place of abode)


Length of stay :


In place of death.


. years . .


.. months


29 HRS.


day's.


In place of residence


. ...


25


years ....... . . months


.days.


MEDICAL CERTIFICATE OF DEATH


3 DATE OF


DEATH


JULY


5


1961


(Month)


(Day)


(Year)


HEREBY CERTIFY.


That I attended deceased from


JULY 4, 1961, 10.


JULY 5


19 .... 61


I last saw h.tMilive on


JULY


5, 19 61, death is said to


have occurred on the date stated above, at


Co P.m.


INTERVAL


(or) WIFE of


(Husband's name in full)


11 IF STILLBORN, enter that fact here.


12


63


AGE


Years .


Months .........


Days


If under 24 hours


Hours.


Minutes


13 Usual


Occupation :


millimary


(Kind of work dond during most of working life)


14 Industry


or Business :


Owner,


15 Social Security No.


CNb1


16 BIRTHPLACE (City)


(State or country)


Russia


17 NAME OF


FATHER


Samuel Tradesmen


Russia


19 MAIDEN NAME


OF MOTHER


Rose Michaels


20 BIRTHPLACE OF


MOTIIER (City)


(State or country)


Russia


Seymour SaleTT Son-in-law-


I HEREBY CERTIFY that a satisfactory standard certificate of death was filed with me BEFORE the burlal or transit permit was issued: 1 ( Signature of Agent of Board of Health or otber)


11/1/1


(Official Designation)


(Date of Issue of Permit)'


1VB


TIONS R ERTIFICATE


ving DEATH enter an one r each )and (c)


not mean of dying, art failure. . It means or compli- ch caused


, if'any, e rise to use (a). e under- use last.


ns contrib- th but not he terminal ition given


Chapter 137. 54. requires s to print or cause or death on ificates, and 8. Acts of ires Physi- rint or type r signature.


25 1961


:8145


JUL 121901 Charles H bracka


PERSONAL AND STATISTICAL PARTICULARS


8 SEX


M


9 COLOR


w


MARRIED


WIDOWED


Of DIVORCED


10 SINGLE


(write the word)


MARRIED


10a If married, widowed, or divisi trude (Speck)


HUSBAND of


(Give maiden name of wife inffull)


DEATH WAS CAUSED BY : IMMEDIATE CAUSE


(a)


BETWEEN ONSET AND DEATH


Due To


(b)


Due To (c)


OTHER


SIGNIFICANT


CONDITIONS


PEPTIC ULCER


Was autopsy performed?


No


What test confirmed diagnosis?


NONE


5 Was disease or injury in any way related to occupation of deceased? If so, specify


No


(Signed)


Paul C. Barran




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