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