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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