USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1962 > Part 12
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AND PLEURAL EFFUSION
(Month)
(Day)
2 FULL NAME
Grace (Ferrara Caggiano
To be filed for burial permit with Board of Health or its Agent.
OM R-301A 1
Messina
Italy
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE
RECEIVED
RANK, RATING
TOM
ORGANIZATION AND OUTFIT
SERVICE NUMBER.
ir FE
n.
100
.....
8
6
19
RULES OF PRACTICE
The fulfillment of the purpose of these laws calls following rules of practice :
fAPR .Berv1962:AM
(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.
INTE
DR. GREGORYES CARE - I AM COVERING FOR HIM
ISTRUCTIONS FOR O AL CERTIFICATE
In giving JE OF DEATH not enter ure than one c se for each ), (b) and (c)
h does not mean ode of dying, s heart failure, ez, etc. It means Lease, or compli- which caused h
mitions, if any, hi gave rise to ' cause (a), ag the under- in cause last.
(nditions contrib- go death but not" e to the terminal as condition given
Pte :- Chapter 137, L. c of 1954 requires h icians to print or 1 the cause or Il:s of death on certificates, and hiter 48, Acts of- N requires Physi- 13 to print or type a : under signature
THIS PAT. HAS BEEN ONDE
PLACE OF DEATH
Suffolk (County)
Winthrop (City or ffown)
Thornton 27 Ihrenton
The Commonwealth of Massachusetts KEVIN H. WHITE SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS
STANDARD CERTIFICATE OF DEATH
Winthrop
S(If death occurred in a hospital or institution, St. ¿ give its NAME instead of street and number)
PHYSICIAN - IMPORTANT
((Was deceased a
{if so specify WAR) no
(If deceased is a married, widowed or divorced woman, give also maiden name.) St. Thornton Kon ST
27
(a) Residence. No. (Usual place of abode)
Length of stay: In place of death 14 .years
- .months.
.days. In place of residence 14 years.
........... months ............ days.
MEDICAL CERTIFICATE OF DEATH
PERSONAL AND STATISTICAL PARTICULARS
8 SEX F
9 COLOR
W
10 CITIZEN
OF U.S.
YES NO
11 SINGLE
MARRIED
WIDOWED
DIVORCED
UNKNOWN
lla If married, widowed, or divorced HUSBAND of
(Give maiden name of wife in full)
(or) WIFE of
Albert C Knox
(Husband's name in full)
12 DATE OF BIRTH
hot Known 128-1947
13
AGE 64 Years
.....
.. Months .............. Days
If under 24 hours Hours ........... Minutes
14 Usual
Occupation :
> Home
(Kind of work done during most of working life)
15 Industry
or Business:
SHouse wifer
16 Social Security No. none
East Boston
17 BIRTHPLACE (City)
(State or country)
Mass,
18 NAME OF
FATHER
Richard Frasier
19 BIRTHPLACE OF
FATHER (City)
Un Known
M. D.
(State or country)
unknown
20 MAIDEN NAME
OF MOTHER
Margaret Green
21 BIRTHPLACE OF
MOTHER (City)
(State or country)
un Known
22 Albert C. KNAX
Informant
(Address)
27 Thornton ST. Winthrop
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 Effect
4/7/12
(Official Designation)
(Date of Issue of Permit)
1
V.B.V
A TRUE COPY ATTEST:
(Registrar)
PARENTS
Winthrop
Winthrop
6 Place of Burial or Cremation (City or Town)
DATE OF BURIAL April 3, 1962
7 NAME OF
FUNERAL DIRECTOR
Maurice W. Kirby
ADDRESS 210 WinthropST, Winthrop
Received and filed APR 2 - 1962 19
62
(Month)
(Day)
(Year)
4 I HEREBY, CERTIFY
MAR 31
1962
to .....
MAR 31
That I attended deceased from 62
I last saw hellalive on
MAR 31 1962 death is said to
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a)
...
GENERAL CARCINOMAJOSIS
Due To (b) CARCINOMA OF BLADDER 1YR
Due To (c)
OTHER SIGNIFICANT CONDITIONS
Nove.
Was autopsy performed? No
What test confirmed diagnosis?
CLINICAL
No
5 Was disease or injury in any way related to occupation of deceased? If so, specify
(Signed)
Myron n. Kus
MYRONO N. KINGMYD 222 8 (print or Tyger Name) 51
(Address) WINTEROD .. Date. 4/2067
V
IRM R-301 1
58
Registered No.
To be filed for burial permit with Board of Health or its Agent.
2 FULL NAME
No. Margaret (First Name) (Middle Name) (Last Name)
M Knox (Frasier)
(If nonresident, give city or town and State)
NT-
13-61-930213
3 DATE OF
DEATH
March
have occurred on the date stated above, at 12:25 Pm INTERVAL BETWEEN ONSET ANO DEATH IMO
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE
F TO!
RANK, RATING
ORGANIZATION AND OUTFIT
1-2
1
SERVICE NUMBER
6
RULES OF PRACTICE APR 2 1962 AM
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 froin 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.
1961
RM R-303 Lost
DE THERETIEF OR CATISES OF DEATH ON DRATH CERTIFIGAINS
(L'sual place of abode) MEDICAL CERTIFICATE OF DEATH 3 DATE OF DEATH (Month) (Day) public place ? (Specify type of place) Manner of Injury Nature of (How did injury occur ?) Injury (Signed) (Print or Type Name) 7 Winthrop Place of Burial, or Cremation. of Death. See reverse side for additional information. See also Chap. 38, §§ 6, 20; Chap. 46, §§ 9, 10; Chap. 114, DEATH in plain terms, so that it may be properly classified under the International Classification of Causes information should be carefully supplied. MEDICAL EXAMINERS should state CAUSE AND MANNER OF If deceased was a U. S. War Veteran, G.L. Chap. 46, Section 10, requires physicians to insert a recital to that effect. §§ 44-48. DATE OF BURIAL C 50M- 3-61-930213 N. B .- WRITE PLAINLY, WITH UNFADING BLACK INK-THIS IS A PERMANENT RECORD. Every item of While at work ? Was autopsy performed
PLACE OF DEATH
SUFFOLK
(County)
WINTHROP
(City or Town)
The Commonwealth of Massachusetts KEVIN H. WHITE SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS MEDICAL EXAMINER'S CERTIFICATE OF DEATH
To be filed for burial permit with Board of Health or its Agent.
Registered No.
59.
180 PORTLETT RE: 130 GROVERS -
AVE.
S(If death occurred in a hospital or institution, St. ¿ give its NAME instead of street and number)
PHYSICIAN - IMPORTANT
2 FULL NAME
GERARD
(First Name)
( Middle Name)
(Last Name)
(If deceased is a married, widowed or divorced woman, give also maiden name.)
(a) Residence. No.
130
GROVERS
AVE
St.
WINTHROP
Length of stay :
In place of death.
years ............ months.
7
.days. In place of residence
40
years.
.. months .........
days.
MARCH 31 1962
(Year)
4 I HEREBY CERTIFY that I have investigated the death of the person above-named and that the CAUSE AND MANNER thereof are as follows: (If an injury was involved, state fully.) ACUTE ALCOHOLISM
9 SEX
MALE
10 COLOR
WHITE
11 CITIZEN
OF U.S.
YES NO
12 SINGLE MARRIED WIDOWED DIVORCED UNKNOWN
12a If married, widowed, or divorced
Marion Ho lett
HUSBAND of
(or) WIFE of
(Husband's name in full)
13 DATE OF BIRTH Apr. 2
1372
14 AGE 79 Years ..
13
22
Months ............. Days
If under 24 hours Hours Minutes
15 Usual Occupatio
.Brosser
(Kind w work done during most of working life)
16 Industry
Coffee
17 Social Security No.
021-26-5387
18 IRTHPLACE (City)
(State or country)
Italy
19 NAME OF
FATHER
Anthony LaCentra
20 BIRTHPLACE OF FATHER (City) (State or country) Italy
21 MAIDEN NAME
OF MOTHER
Erminia Brienza
22 BIRTHPLACE OF MOTHER (City) (State or country) Italy
23 Informant Ruth Mossman
(Address)95 Johnson Ave. Winthrop, Lass
April
3
19 52
8 NAME OF
FUNERAL DIRECTOR
Howard 3 Reynolds
ADDRESS Winthrop Lass
Received and filed
APR 2- 1962
19.
A TRUE COPY ATTEST: (Registrar)
I HEREBY CERTIFY that a satisfactory standard certificate of death was filed with me BEFORE the burial or transit permit was issued: Talkles tereanne (Signature of Agent of Board of Health or other) Realthe Office 4/2/62 (Date of Issue of Permit) (Official Designation) V.B. V
NOT Bund LES -
-
5 Accident, suicide, or homicide (specify) Date and hour of injury 19
IF ACCIDENTAL, was injury causally related to the death ? Where did Injury occur ? (City or town and State) Did injury occur in or about home, on farm, in industrial place, or in
6 Was disease or injury in any way related to occupation of deceased ? If so, specify
PARENTS
M. D.
DEONAND ATKINS M.D
(Address) 25 SHATTUCK ST. Date APRIL 1 19 62
Winthrop
(City or Town)
-
1
LaCentra
LA CENTRE
f (Was deceased a
U. S. War Veteran,
lif so specify WAR)
(If nonresident, give city or town and State)
PERSONAL AND STATISTICAL PARTICULARS
(Give maiden name of wife in full)
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE
:
RANK, RATING
ORGANIZATION AND OUTFIT
SERVICE NUMBER
THROP.
RULES OF PRACTICE
APR 2 1962 AM
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 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 poison) , 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
Medical Examiners in certifying to a death will state the cause and manner thereof, and will specify: (1) Under cause the nature of an injury and of its consequences; and (2) under manner the mode of its production together with the circumstances when these are known. For example: "Compound fracture of the femur with ensuing septicemia (gas bacillus) caused by a collision of railroad train and automobile." "Pistol shot wound of the chest with associated hemorrhage, homicidal." "Asphyxiation by suspension, suicidal." "Syncope while under the influence of ether administered as a surgical anaesthetic for (enter name of operation and disease or condition requiring surgery) ." "Fracture of the skull with associated internal injury sustained under circumstances unknown."
If disease or injury was related to occupation, specify. If investigation shows the death to have been due to disease, specify: (1) Under cause its known or presumable nature; and (2) under manner, indicate the circumstances leading to medico-legal inquiry. For example: "Hemorrhage spontaneous of the brain (basal ganglia) (found dead in bed)." "Heart disease, presumably coronary sclerosis. (Sudden death.)"
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.
60
[(If death occurred in a hospital or institution, . St. } give its NAME instead of street and number)
PHYSICIAN - IMPORTANT
2 FULL NAME Elsa R .Shea (First Name) (Middle Name) (Last Name)
f (Was deceased a U. S. War Veteran, (if so specify WAR)
No
(1f deceased is a married, widowed or divorced woman, give also maiden name.)
53 Ingleside Avenue
.St.
(1f nonresident, give city or town and State)
Length of stay: In place of death ..
years ..
1 months 2.5 days.
In place of residence. 40
·ears.
months.
.. days.
MEDICAL CERTIFICATE OF DEATH
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
Female
White
9 COLOR
10 SINGLE
MARRIED
WIDOWED
or DIVORCEDOwed
10a If married, widowed, or divorced
HUSBAND of
(Give maiden name of wife in full)
(or) WIFE of
John P. Shea
(Husband's name in full)
11 IF STILLBORN, enter that fact here.
12
AGE
6.8 Years.
Months.
.Days
If under 24 hours
Hours ...........
Minutes
13 Usual
Occupation :
Practical Nurse
(Kind of work done during most of working life)
14 Industry
or Business :
Home ..... Nursing.
15 Social Security No.
Waterbury
16 BIRTHPLACE (City)
(State or country)
Conn
17 NAME OF
FATHER
Hermon Gartz
18 BIRTHPLACE OF
FATHER (City)
(State or country)
Austria
19 MAIDEN NAME
OF MOTHER Mary Gramelspacka
20 BIRTHPLACE OF MOTHER (City) (State or country) Austria
21
Elsa Verdy
Informant
(Address)
53 Ingleside Ave Winthroo
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) Realel Afferr
4/2/62
(Date of Issue of Permit)
(Official Designation)
PARENTS
6 Winthrop
Winthrop
Place of Burial or Cremation
(City or Town)
DATE OF BURIAL Anr.i.l ..... 3. 19.6.2.
7 NAME OF
FUNERAL DIRECTOR
Arthur J. O'Maley
ADDRESS
Winthrop Mass
Received and filed APR 2 - 1962 19
(Registrar )
INTERVAL BETWEEN ONSET AND DEATH 7 mos.
Due To (b)
Due To (c)
OTHER
SIGNIFICANT
CONDITIONS
Was autopsy performed?
no
What test confirmed diagnosis? clinical & laboratory
5 Was disease or injury in any way related to occupation of deceased? If so, specify
no
(Signed)
M. Traunstein M. D M. Traunstein, Jr. , M.D.
(PRINT OR TYPE SIGNATURE)
(Address) 73 Bartlett Rd.
Date 3-31 62
19
3 DATE OF
DEATH
(Month)
March 31, 1962
(Day)
(Year)
4 I HEREBY
Sept. 8
1.61
Mar. 31
CERTIFY,
That I attended deceased from
to
19.
62
I last saw h.e.Talive on
March 31
19.62
death is said to
have occurred on the date stated above, at
3:45 am.
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
Carcinoma of left lung with
(a) massive pleural effusion
OM R-301A 1
:TRUCTIONS FOR DIAL CERTIFICATE
In giving JE OF DEATH
i not enter 'e than one ase for each (), (b) and (c)
ki' does not mean ode of dying, $ heart failure, en!, etc. It means dease, or compli- n which caused h
mitions, if any, his gave rise to a cause (a), ag the under- cause last.
Unditions contrib- g'o death but not e to the terminal Is condition given a
Ne :- Chapter 137, 1 of 1954. requires yicians to print or p the cause or us of death on a certificates, and iter 48. Acts of 5 requires Physi- a to print or type under signature.
M-60-928145
To be filed for burial permite with Board of Health. or its Agent.
No. ........
Winthrop Community Hospital ..
(a) Residence. No. (Usual place of abode)
(write the word)
SPACE FOR ADDITIONAL INFORMATION
RECENTES
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE.
TOMA OF
RANK, RATING
ORGANIZATION AND OUTFIT
SERVICE NUMBER
6
APR 2 1962 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.
-
MIN
:
AI R-301A 1
Suffolk ....... (County) BRIGHTON .... PLACE OF DEATH OUT HOF - TOWN
The Commonwealth of Massachusetts JOSEPH D. WARD SECRETARY O. THE COMMONWEALTH DIVISION OF VITAL STATISTICS
61
To be filed for burial permit with Board of Health or its Agent. 02116
STANDARD
CERTIFICATE OF DEATH
Registered No.
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
(Last Name)
(If deceased is a married, widowed of divorced woman, give also maiden name.)
St. Winthrop
(If nonresident, gule city or town and State)
Length of stay: In place of death. .years .... .. months ..
8
.days. In place of residence.
years ..
.. months ..
.. days.
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
DEATH
Feb.
27
1962
(Month)
(Day)
(Year)
4 I HEREBY CERTIFY,
That I attended deceased from
......
2-17
19
62
to
2-37
1962
I last saw h.Malive on
2-27, 1962, death is said to
have occurred on the date stated above, at
4:45Am.
(or) WIFE of
(Husband's name in full)
11 IF STILLBORN, enter that fact here.
12
AGE ....
Years ............
Months 8 Days
If under 24 hours
.Hours .............. Minutes
13 Usual
Occupation :
(Kind of work done during most of working life)
14 Industry
or Business :
15 Social Security No.
16 BIRTHPLACE (City)
(State or country)
Brighton
17 NAME OF
FATHER
DONALD H. COLPAK
18 BIRTHPLACE OF
FATHER (City)
....
Winthrop
(State or country)
19 MAIDEN NAME
OF MOTHER
Claire MARIe WARsh
20 BIRTHPLACE OF
MOTHER (City)
(State or country)
Medford
St. Elizabeth's Hospital
7 NAME OF FUNERAL DIRECTOR ....
ADDRESS
310 Market St. Bughia
.19
artes A.
( Registrar)
PARENTS
... f.
1Mt Benedict CEineteRy West Roxbury 0
Place of Burial or Cremation
(City or Town)
DATE OF BURIAL
MARCH 2
19
INTERVAL BETWEEN ONSET AND DEATH
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
RITTER'S DISEASE
(a)
....
Due To (b)
Due To (c)
OTHER SIGNIFICANT CONDITIONS
NO
Was autopsy performed?
...
What test confirmed diagnosis?
OBSERVATION
5 Was disease or Injury in any way related to occupation of deceased? If so, specify .......
(Signed)
Charts at. Brennan, M. D
CHARLES G. EXENISAN
(Address)
(PRINT OR TYPE SIGNATURE) St. Elizabern's
. Date .. 2.2.7
1962
21
Informant
(Address)
Brigata
I HEREBY CERTIFY that a satisfactory standard certificate of death was fred with me BEFORE the burial or transit permit was issued: W Vm- amada (Signature of Agent of Board of Health or other)
6071 3-1-62
(Official Designation)
(Da (Date of Issue of Per Permit)
IN'RUCTIONS FOR ICL CERTIFICATE
1 giving 'S OF DEATH d not enter ne than one a.e for each (1, (b) and (c)
i does not mean ode of dying, heart failure. n, etc. It means Lase, or compli- which caused
ations, if any, gave rise to cause (a). er the under- cause last.
sditions contrib- , death but not to the terminal condition given
66
;Chapter 137, 1954. requires cians to print or the cause or s of death on certificates, and ter 48, Acts of requires Physi- to print or type under signature.
AY 8 - 1962
(City or Town) ST. Elizabeth's Hospital No.
2 FULL NAME
Baby Boy COLPAK (First NameY (Middle Name)
(a) Residence. No. (Usual place of abode)
150 Locust
1 SEX
Male
9 COLOR
White
10 SINGLE
MARRIED
WIDOWED
or DIVORCED Ouml
10a If married, widowed, or divorced
HUSBAND of
(Give maiden name of wife in full)
(write the word)
......
PERSONAL AND STATISTICAL PARTICULARS
A TRUE COPY ATTEST:
Charles it. Mackie City Registrar
8 .
6
THROP
MAY - 81962 AM
Su SS . PUT - OF -ST
The Commonwealth of Massachusetts JOSEPH D. WARD SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS STANDARD
62
To be filed for burial permit with Board of Health or its Agent. 02118
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)
NO
(If deceased is a married, widowed or divorced woman, give also maiden name.)
2.8 Pearl Street AVE
St. Winthrop, Mass.
(a) Residence. No.
(L'sual place of abode)
Length of stay: In place of death.
.years ..
months.
In place of residence.
.years.
months.
.. days.
MEDICAL CERTIFICATE OF DEATH
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
9 COLOR
FEMALE WHITE
10 SINGLE
MARRIED
WIDOWED
or DIVORCED
PosSICK
WIDOWED
10a If married, widowed, or divora QR V
HUSBAND of
(Give maiden name of wife in full)
(or) WIFE of
(Husband's name in full)
11 IF STILLBORN, enter that fact here.
12
AGE 84
Years .......
Months ....... Days
If under 24 hours
............ Hours ............ Minutes
13 Usual
Occupation :
HOUSE WIFE
(Kind of work done during most of working life)
14 Industry
or Business :
OWN
NOME
15 Social Security No.
NONE
16 BIRTHPLACE (City)
(State or country)
RUSSIA
17 NAME OF
FATHER
AARON SHLILLER
18 BIRTHPLACE OF
FATHER (City)
(State or country)
RUSSIA
19 MAIDEN NAME
OF MOTHER
C. BL.
20 BIRTHPLACE OF
MOTHER (City)
(State or country)
RUSSIA
ROSEPALMER
21
Informant
(Address)
28 PEARL QUE WINTHEJA
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)
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