Town of Winthrop : Record of Deaths 1961, Part 45

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


USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1961 > Part 45


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Winthrop Community Hospital No.


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


2 FULL NAME


Mary Jacobson


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


162 Endicott Ave., Revere, Mass.


St.


Length of stay: In place of death


.years.


0


months.


3


.days.


10


In place of residence.


.years.


months .. .


.days.


MEDICAL CERTIFICATE OF DEATH


PERSONAL AND STATISTICAL PARTICULARS


3 DATE OF


November, 19, 1961


DEATH


(Month)


(Day)


(Year)


8 SEX


Female


9 COLOR


White


10 SINGLE


(write the word)


MARRIED Married


WIDOWED


or DIVORCED


4 1


HEREBY CERTIFY, That I attended deceased from


Nov. 17 , 19 61, toNov.19,


61.


I last saw er ... alive on


Nov ....... 19


19.61.


death is said to


have occurred on the date stated above, at


16.00 A.M.


(or) WIFE of


Bernard Jacobson


(Husband's name in full)


DEATH WAS CAUSED BY : IMMEDIATE CAUSE


(a) ...... Myocardial Infarction


Due To


(b)


Coronary .... Occlusion


3 Days


(Kind of work done during most of working life)


14 Industry


or Business :


At Home


15 Social Security No. None


SIGNIFICANT


Diabetes ..... Mellitus


Few Years


CONDITIONS


Was autopsy performed?


No


What test confirmed diagnosis ?


Electrocardiogram


No


19 MAIDEN NAME


(Signed)


Votre 7. Calleria Va


M. D.


OF MOTHER


Bluma Levine


John F. Collins . ... M. D.


(PRINT OR TYPE SIGNATURE)


(Address) Revere , ... Mass.


Date .... Nov. 19,1961


6 Boylston Lodge Mem, Park Baker St Place of Burial of Cremation (City or Town)


DATE OF BURIAL W. Rox.


Nov. 20 1961


7 NAME OF FUNERAL DIRESTChlossberg Fun. Ser. ADDRESS 1257 Blue Hill Ave- Matt: 19


Received and filed


NOV 20 1961


(Registrar)


PARENTS


20 BIRTHPLACE OF


MOTHER (City)


(State or country)


Russia


· 21


Bernard Jacobson Reve:


Informant (Address) 162 Endicott Ave. Beachmont I HEREBY CERTIFY that a satisfactory standard certificate of death was/filed with me BEFORE the burial. or transit permit was issued: Teacher . Fireands / ( Signature of Agent of Board of Health or other)


L'atte


11/20/61


(Date of Issue of Permit)


(Official Designation)


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


STANDARD CERTIFICATE OF DEATH


Registered No.


PHYSICIAN - IMPORTANT


f(Was deceased a


U. S. War Veteran,


ivo


{if so specify WAR)


(a) Residence. No.


(Usual place of abode)


0


(If nonresident, give city or town and State)


10a If married, widowed, or divorced


HUSBAND of


(Give maiden name of wife in full)


INTERVAL


BETWEEN


ONSET AND


DEATH


3 Days12


AGE


.70 Years.


Months.


.. Days


11 IF STILLBORN, enter that fact here.


If under 24 hours


Hours ...........


.Minutes


13 Usual


Occupation :


Housewife


OTHER


nary Artery Disease


2 Years


16 BIRTHPLACE (City)


(State or country)


Russia


17 NAME OF


FATHER


Ephram Winer


18 BIRTHPLACE OF


FATHER (City)


(State or country)


Russia


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


Due To (c) Coro


REVERE. 12-7-61


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


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:


(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.


NOV 2 01961 /M


X


PLACE OF DEATH


Suffolk (County)


Winthrop (City or Town)


Winthrop Community Hospital


Jason


Edward Heath


2 FULL NAME


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


xxxxxxxxxxxxxxxx 32 Marshall


St.


Winthrop


(If nonresident, give city or town and State)


Length of stay: In place of death ..


.. years.


months


16 days. In place of residence ..


3.0.years.


.months ..


days.


MEDICAL CERTIFICATE OF DEATH


PERSONAL AND STATISTICAL PARTICULARS


3 DATE OF


DEATH


November


23


1961


8 SEX


9 COLOR


(Month)


(Day)


(Year)


male


white


HEREBY CERTIFY


nov. 7, 1961, o.


That I attended deceased from


23


61


19.


10a If married, widowed, or divorced


HUSBAND of


Edna Augusta May Leonard


have occurred on the date stated above, at


8:12 Am


(or) WIFE of


(Husband's name in full)


DEATH WAS CAUSED BY : IMMEDIATE CAUSE


(a)


myocardial


Heart


Disease


INTERVAL BETWEEN DNSET AND DEATH


11 IF STILLBORN, enter that fact here.


12


AGE.81


Years.


11


Months.


.8.


Days


If under 24 hours


Hours .............. Minutes


13 L'sual


Occupation :


salesman


(Kind of work done during most of working life)


14 Industry


or Business :


retail Oil Co.


15 Social Security No.


025-01-0439


16 BIRTHPLACE (City)


(State or country)


Quebec


17 NAME OF


FATHER


Jason Heath


18 BIRTHPLACE OF


FATHER (City)


Quebec


(State or country)


Thurzah LeClair


19 MAIDEN NAME


Paris. Fr.


20 BIRTHPLACE OF


MOTHER (City)


Mrs .Edward J Heath


(State or country)


32 Marshall St. Winthr


6 Winthrop Cemetery Winthrop, Mass . Informant (Address)


Place of Burial or Cremation (City or Town) DATE OF BURIAL November 25 ,1961 Cuped B. March


7 NAME OF


FUNERAL DIRECTOR


ADDRESS


174 Winthrop St. Winthrop,


Novembre 24 1961


(Registrar)


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


Mass.


(Signature of Agent of Board of Health or other)


11/241-1


(Official Designation) (Date of Issue of Permit)


F


io, if any, te rise to forse (a), e under- Lise last.


duins contrib- dth but not ale terminal cmition given


apter 137, 151. requires anto print or he cause or of death on rt cates, and Acts of qies Physi- pnt or type de signature.


Asseple


(Signed)


Joseph GREGORIE


...


M. D.


OF MOTHER


Quebec


(PRINT OR TYPE SIGNATURE) are /24 1961


(Address) 194 Washington Date


3 weeks


CONDITIONS Where- post of,


Was autopsy performed?


What test confirmed diagnosis ?


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


PARENTS


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


230


Registered No.


[(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.


(U'sual place of abode)


10 SINGLE


(write the word)


MARRIED married


WIDOWED


or DIVORCED


I last saw h ...... alive on


nov. 22 196 death is said to


(Give maiden name of wife in full)


Due To


arteriosclerosis


(b)


....


generalized


Due to Senility


(c)


OTHER


Perforated papper


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


R-301A 1


TICTIONS R L ERTIFICATE


ving IF DEATH enter can one elor each . ) and (c)


de not mean de of dying, art failure, . It means Ipor compli- ach caused


-6 1-925686


Received and filed


CERTIFICATE OF DEATH


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 :


(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 Mass


(City or Town)


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


CERTIFICATE OF DEATH


Registered No.


231


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


PHYSICIAN - IMPORTANT


2 FULL NAME


Annie


(Phillips).


Goldman


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


(a) Residence. No.


14. Trident Ave., Winthrop Mass


St.


(Usual place of abode)


(If nonresident, give city or town and State)


Length of stay : In place of death ........ .. years ....


months


23 days. In place of residence.


............ years ..


months


.days.


MEDICAL CERTIFICATE OF DEATH


PERSONAL AND STATISTICAL PARTICULARS


3 DATE OF


DEATH


November


28


1961


(Month)


(Day)


(Year)


8 SEX


FEM


9 COLOR


WHITE


10 SINGLE


(write the word)


MARRIED


WIDOWED WIDOWED


or DIVORCED


4 I HEREBY


Now.


1946


CERTIFY


That I attended deceased from


1961


to ...


NOV. 28


10a If married, widowed, or divorced


HUSBAND of


(or) WIFE of


MAX GOLDMAN


(Husband's name in full)


11 IF STILLBORN, enter that fact here.


80


12


AGE ..


Years.


Months ...


.Days


If under 24 hours


Hours.


Minutes


13 Usual


Occupation :


CAT


HOME 1


(Kind of work done during most of working life)


14 Industry


or Business :


HOUSE WIFE


15 Social Security No.


None


16 BIRTHPLACE (City)


(State or country)


Russia


17 NAME OF


FATHER


ABRAHAM PHILIPS


18 BIRTHPLACE OF


FATHER (City)


(State or country)


Russia


19 MAIDEN NAME


OF MOTHER


Rose PALAIS


20 BIRTHPLACE OF


MOTHER (City)


Russia


(State or country)


MORRIS


SANDLER Brillan


21


Informant


(Address)


: S NEPTUN


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)


(Official Designation) V


(Date of Issue of Permit)


1X


ACTIONS R CERTIFICATE


ving F DEATH Di enter an one obor each () and (c)


do not mean de of dying, ut failure, t. It means 1st or compli- @ch caused


io if any, Sie rise to Bise (a), under- Cse last.


ditns contrib- dth but not o le terminal os tion given


-Capter 137, 19 . requires nro print or he cause or of death on rt cates, and Acts of ques Physi- pit or type de'signature.


(Signed)


Glucides Libo Jau, M. D.


CHARLES LIBERMAN


(PRINT OR TYPE SIGNATURE)


(Address) Winthrop, lass Date 11/28/1961


0


Place of Burial or Cremation


(City or Town)


DATE OF BURIAL


Nov 29


1961


7 NAME OF


FUNERAL DIRECTOR


TORF funeralService die


ADDRESS


151 Washington Ave Chelsea


Received and filed


... 19


(Registrar)


25 yrs.


(c) Duodenal Ulcer bleeding


3wks.


OTHER


SIGNIFICANT Arteriosclerotic Heart


CONDITIONS


Disease


5yrs.


Was autopsy performed?


NO


What test confirmed diagnosis ?


Clinical


5 Was disease or injury in any way related to occupation of deceased? No. If so, specify


PARENTS


(Give maiden name of wife in full)


I last saw hey ... alive on


19 61, death is said to


Nov. 28


have occurred on the date stated above, at


8:10 A.m.


INTERVAL


BETWEEN


ONSET AND


DEATH .


24 hrs.


DEATH WAS CAUSED BY : IMMEDIATE CAUSE


(a) gastro Intestinal Hemorrhage


Du (b)


I Duodenal Ulcer, Chronic


-69-925686


MR-301A 1


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


No.


Winthrop Community Hospital


[(Was deceased a


{ U. S. War Veteran,


{if so specify WAR) No


BELE'LED


TOW; OF


SPACE FOR ADDITIONAL INFORMATION


DATE OF ENTERING MILITARY SERVICE


DATE OF DISCHARGE


RANK, RATING


6


ROP.


ORGANIZATION AND OUTFIT


SERVICE NUMBER NOV.2.81961 .. AM


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.


X PLACE OF DEATH 1


REVERZ


The Commonwealth of Massachusetts EDWARD J. CRONIN 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.


232


Mount's Convalescent Home


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


Highland Avenue John A Chase -


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


6 Garfield Avenue


St ... Revere Mass


(If nonresident, give city or town and State)


months.


days.


MEDICAL CERTIFICATE OF DEATH


3 DATE OF


DEATH


November 29 1961


(Month)


(Day)


(Year)


4 I HEREBY CERTIFY,


That I attended deceased from


NOV. 20, 19 61, to NOV.30


61


19


I last saw h.L.KCalive on


Nov. 29, 1961, death is said to


have occurred on the date stated above, at


58


.m.


DEATH WAS CAUSED BY: IMMEDIATE CAUSE


(a) Coronary


Occlusion


Due To


(b) -.


Aveviosclusis


1


Due To


(c)


C.A.


OTHER


SIGNIFICANT


CONDITIONS


Was autopsy performed?


What test confirmed diagnosis?


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


(Signed) 2000


(Address) 67 Calcul A


M. D.


Date 31/11 1961


6


Woodlawn Cemetery


Everett Mass


Place of Burial or CrematiDecember_ ] (City or Town)


DATE OF BURIAL.November of


19


67


7 NAME OF


FUNERAL DIRECTOR William J .Killion


ADDRESS 1 Sprague St. Revere Mass


Received and filed


19


(Registrar)


PERSONAL AND STATISTICAL PARTICULARS


8 SEX


male


9 COLOR


white


10 SINGLE


(write the word)


MARRIED


WIDOWED


or DIVORCEHarried


10a If married, widowed, ondiyesed Stone


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


86Years.


7


Months


12Days


If under 24 hours


Hours ...... Minutes


AGE


conductor


13 Usual


Occupation :


(Kind of work done during most of working life)


14 Industry


or Business: Rail road


15 Social Security No ..


023-07-1615


16 BIRTHPLACE (City)


(State or country)


Lynn, Mass.


|17 NAME OF


FATHER


Eaward F. Chase


18 BIRTHPLACE OF


FATHER (City).


(State or country)


Lynn, Mass.


19 MAIDEN NAME


OF MOTHER


Ann Clifford


20 BIRTHPLACE OF


MOTHER (City)


(State or country)


Nova Scotia


21


Informant !.


Mrs John Chase


(Address) 6 Garfield Ave, Revere


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


(Signature of Agent of Board of Health or other) Dixite Cilicie


1/04/61


(Official Designation) (Date of Issue of Permit)


1


iis does not mean tode of dying, his heart failure, hea, etc. It means sease, or compli- io which caused et


Colitions, if any, oh! gave rise to be


cause (a), taig the under- cause last. yı


Tc :- Chapter 137, ts f 1954, requires y¡ dans to print or Je the


cause or is of death on it certificates. :E:HAP. 46, §§ 9 & ., HAP. 114 $$ 45, 16 CHAP. 38 $ 6.)


1MM.10.58-923886


Suffolk (County)


Winthrop (City or Town)


No.


2 FULL NAME


PHYSICIAN - IMPORTANT (Was deceased a


U. S. War Veteran,


if so specify WAR)


No


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


Length of stay: In place of death ......... years months 3 days. In place of residence. 40 years.


INTERVAL BETWEEN ONSET AND DEATH


siddi


PARENTS


Registered No.


FRM R-301A


.B .- THIS IS A FIANENT RECORD. Use only 1TE APPROVED b:k ink or black Nyewriter ribbon.


ISTRUCTIONS FOR ELCAL CERTIFICATE


In giving TE OF DEATH o not enter are than one lise for each f .), (b) and (c)


(iditions contrib- - nio death but not at to the terminal ea condition given


SPACE FOR ADDITIONAL INFORMATION


DATE OF ENTERING MILITARY SERVICE


DATE OF DISCHARGE


RECEIVED


RANK, RATING


TOWA


OF


11.12.


ORGANIZATION AND OUTFIT


SERVICE NUMBER


CHI f


QUERK


-


6


C.


THI


RULES OF PRACTICE The fulfillment of the purpose of these laws voron seblinde of the follow- ing rules of practice:


(1) Attending physicians will certify to such deaths only as those of persons to whom they have given bedside care during a last illness from disease unrelated to any form of injury.


(2) Board of Health physicians will certify to such deaths only as those of persons who, though disabled by recognized disease unrelated to any form of injury, have died without recent medical attendance or whose physician is absent from home when the certificate of death is needed.


(3) Medical Examiners will investigate and certify to all deaths supposably due to injury. These include not only deaths caused directly or indirectly by traumatism (including resulting septicemia), and by the action of chemical (drugs or poisons) thermal, or electrical agents, and deaths following abortion, but also deaths from disease resulting from injury or infection related to occupation, the sudden deaths of persons not disabled by recognized disease, and those of persons found dead.


Statement of Cause of Death .- Physicians: see explanatory instructions on face side of standard certificate of death.


Statement of Occupation .- Precise statement of occupation is very import- ant, so that the relative healthfulness of various pursuits can be known. Make some entry in this section for every person aged 10 years or over. If the occupa- tion had been given up or changed, or if the deceased had retired from business, report the kind of work done during most of working life even if retired. Children not gainfully employed may be returned as at school or at home. For a woman whose only occupation was that of home housework, write housework. For a person engaged in domestic service for wages, however, designate the occupation by the appropriate terms, as housekeeper-private family, cook-hotel, etc. For a person who had no occupation whatever write none.


X PLACE OF DEATH


fuck (County)


(City or Toyn) 457 Skwley AT


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.


[(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)


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


4.51 Shirley


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


2.8.


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


Female


9 COLOR


10€SINGLE


(write the word)


MARRIED


WTPETTED


or DIVORCED


Masved


10a If married, widowed, or divorced


HUSBAND of


(or) WIFE of/ ...


(Husband's name in full)


11 IF STILLBORN, enter that fact here.


12


70


AGE


Years ....


.......... Months.


Days


If under 24 hours


Hours ............


.Minutes


13 Usual


Occupation :


Horizonte


(Kind of work done during most of working life)


14 Industry


or Business :


Ceun homme


15 Social Security


16 BIRTHPLACE (City)


(State or country)


Rusia


17 NAME OF


FATHER


18 BIRTHPLACE OF


FATHER (City)


(State or country)


Ricerca


19 MAIDEN NAME


OF MOTHER


Lilly E.BIS


20 BIRTHPLACE OF


MOTHER (City)


(State or country)


Russia


21 Jouph & Ahapin


Informant


DATE OF BURIAL


7 NAME OF


Jot Funeral Despre Pour


FUNERAL DIRECTOR& ADDRESS Lexivia


Received and filed


.......... 19


(Registrar)


15 years


Due To (c)


OTHER SIGNIFICANT CONDITIONS


Was autopsy performed ?


NO


What test confirmed diagnosis ?


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


PARENTS


(Signed) H. B. Greenfield (PRINT OR TYPE SIGNATURE)


M. D.


4+75hs Date ..... 11.30 1961


10


Place of Barial or Cremation Dex 1


(City or Town)


(Address) +57 Anuliny St 7


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


(Signature of Agent of Board of Health-or other)


(Official Designation)


(Date of Issue of Permit)


ITRUCTIONS FOR IL CERTIFICATE


1 giving !: OF DEATH i not enter e than one te for each :, (b) and (c)


.does not mean Ide of dying, heart failure, 1 etc. It means lase, or compli- which caused


ions, if any, gave rise to cause (a), the under- cause last.


ditions contrib- death but not 'o 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 ider signature.


-6-59-925686


No. Lena.


2 FULL NAME


Shapiro


St.


50


(If nonresident, give city or town and State)


3 DATE OF


DEATH


November 30


1961 (Year)


(Month)


(Day)


4 I HEREBY CERTIFY,


19.20


to ..


nov


I last saw H&R.M.alive on 11- 29 19 .. death is said to (6)


have occurred on the date stated above, at


58


... m.


INTERVAL


BETWEEN


ONSET AND


DEATH


DEATH WAS CAUSED BY: IMMEDIATE CAUSE


(a) ...


Congestive heart


Due To


(b)


Rheumati heart disease


from 19 ....


That I attended deceased


30


Registered No.


M R-301A 1


SPACE FOR ADDITIONAL INFORMATION


DATE OF ENTERING MILITARY SERVICE


RECEIVED


DATE OF DISCHARGE


OF TO !!!:


1 0 7:


RANK, RATING


ORGANIZATION AND OUTFIT


SERVICE NUMBER




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