USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1962 > Part 31
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X PLACE OF DEATH I
Suffolk
(County)
Winthrop
(City or Town)
The Commonwealth of Massachusetts KEVIN H. WHITE SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS STANDARD CERTIFICATE OF DEATH
A
(City or Town making this return)
Registered No.
154
S(If death occurred in a hospital or institution, .St. { give its NAME instead of street and number)
Celia Markell Rubin
(If deceased is a married, widowed or divorced woman, give also maiden name.)
19 Nevada St
(a) Residence. No.
(Usual place of abode)
Length of stay: In place of dear - years months
.days. In place of residence ... years.
.... months. .days.
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
Female
9 COLOR
White
10 SINGLE MARRIED WIDOWED DIVORCED UNKNOWN
(write the word) HARRied
11 If married, widowed, or divorced HUSBAND of
(Give maiden name of wife in full)
(or) WIFE of.
DR. MAURICE
5.
Rubin
(Husband's name in full)
12
AGE 70 Years.
Months.
Days
If under 24 hours
Hours ...
.. Minutes
13 Usual
House wÖRk
Occupation :
(Kind of work done during most working life)
14 Industry
or Business :
At home
15 Social Security No.
RUSSIA
16 BIRTHPLACE (City)
(State or country)
17 NAME OF FATHER ISRAEL MARKELL
18 BIRTHPLACE OF
FATHER (City)
Russin
(State or country)
19 MAIDEN NAME
OF MOTHER
C. b.I.
20 BIRTHPLACE OF
MOTHER (City).
Russia
(State or country)
Solomon Rubin
21 Informant
(Address)
118 BAINbridge St
MAIDEN
I HEREBY CERTIFY that a satisfactory standard certificate of death was filed with me BEFORE the burial or transit permit was issued: -Talet 6. firma (Mis)
(Signature of Agent of Board of Health or other)
Health Ofiert 8/03/62-
(Date of Issue of Permit)/ >
lı for burial permit >ard of Health o its Agent. N RUCTIONS FOR C. CERTIFICATE
N' OR TYPE SIOR CAUSES ). DEATH do not enter Ic: than one ale for each a (b) and (c)
istaes nat mean nie af dying, heart failure, etc. It means lisse, or campli- s which caused
nions, if any, ic gave rise ta cause (a), the under- cause last.
Ciditians contrib- death but nat do the terminal secanditian given )
(Signature) H. B. Green field M. D. +60€
+478kg
Mass Date Guy 29
1962
6 OhEl Jacob
WobuAN
Place of Turial or Cremation (City or Town)
DATE OF BURIAL
August 23 19.62
7 NAME OF
FUNERAL DIRECTOR
ARNold Golor
ADDRESS 1665 BEACON St BrooklinNE
Received and filed August 23 19 6-2
St
Winthrop
(If nonresident, give city or town and State)
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
DEATH
August 22 1962
(Month)
(Day)
(Year)
4 I HEREBY CERTIFY, That I attended deceased from
act 195.00 to. Avq
I last saw h. Yalive on
aug
19 ...? , death is said to
have occurred on the date stated above, at
11:30 P .. m.
INTERVAL BETWEEN ONSET AND DEATH
1 hour
Due To
(b)
arteriosclerotic heart disease
Due To (c)
OTHER SIGNIFICANT CONDITIONS
Congestive heart failure
Was autopsy performed?
What test confirmed diagnosis ?
5 Was disease or injury in any way related to occupation of deceased ? If so, specify NO
(Address)
(Print of Type Wame)
PARENTS
PHYSICIAN - IMPORTANT
2 FULL NAME
(Was deceased a U. S. War Veteran, if so specify WAR)
10
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
myocardial infarction
19
(a)
ORM R-301
62-932382
(Registrar) (Official Designation)
Winthrop Community Hospital No.
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE RANK, RATING
ORGANIZATION AND OUTFIT
SERVICE NUMBER
RULES OF PRACTICE
RECEIVED
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) Medieal 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.
J
THROR
Statement of Cause of Death .- Physicians: see explanatory instructions on face side of standard certificate of death.
AUG 2 31962 PM . 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.
TOW,
BLEKK #
NI !!
X
PLACE OF DEATH
Suffolk
(County)
1
Winthrop
(City or Town)
No
Winthrop Community Hospital
The Commonwealth of Massachusetts KEVIN H. WHITE SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS STANDARD CERTIFICATE OF DEATH
(City or Town making this return)
Registered No. 155
[(If death occurred in a hospital or institution, St. ¿ give its NAME instead of street and number)
PHYSICIAN - IMPORTANT
2 FULL NAME
(If deceased is a married, widowed or divorced woman, give also maiden name.)
38 Forrest St
(a) Residence. No.
(Usual place of abode)
Length of stay: In place of death .......... years .......... months ...
20
.days. In place of residence .......... years .......... months .......... days.
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
DEATH
(Month)
(Day)
(Year)
4 I HEREBY CERTIFY, That I attended deceased from Feb 19 61 to .. Aug. 25 1962
I last saw hExalive on Aug. 25, 196 7, death is said to have occurred on the date stated above, at 16:30Am.
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a) glomerulo- hephrits.
15 yrs.
Due To (b) ...
Due To (c)
UREMIA
OTHER
SIGNIFICANT
CONDITIONS
Anemia
Hypertension
1 1/2yrs 1 2yrs. 1/2 yrs
Was autopsy performed?
No
What test confirmed diagnosis ?
Clinical
5 Was disease or injury in any way related to occupation of deceased ? If so, specify ......
(Signature)
M. D. CHARLES LIBERMAN
(Print or Type Name)
(Address)
WINTHROP, HLAS Date 8/25/1962
SHAKA TFILO Both El (Lebanon) West Roxbury 6
Place of l'urial or Cremation (City or Town) August 26. 19 62
DATE OF BURIAL
7 NAME OF
FUNERAL DIRECTOR
Benjamin F. Solomon
ADDRESS 420 Harvard Street, Brookline.
Received and filed
AUG 27 1962
19
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
nemale
9 COLOR
white
10 SINGLE MARRIED WIDOWED DIVORCED married UNKNOWN
11 If married, widowed, or divorced HUSBAND of
(or) WIFE of
"orris Freedman
(Husband's name in full)
12
42
AGE
Years
Months.
Days
13 Usual
Housewife
Occupation :
(Kind of work done during most working life)
14 Industry or Business :
15 Social Security No .. worcester
16 BIRTHPLACE (City)
(State or country )
Mass.
17 NAME OF
FATHER
Is-ael Xinkin
18 BIRTHPLACE OF
FATHER (City)
Cinciffati,
(State or country)
Ohio
19 MAIDEN NAME
OF MOTHER
Ann
(unknown)
20 BIRTHPLACE OF MOTHER (City). (State or country) russia
2I Informant
(Address)
Norris Freedman
38 Forest Street, Winthrop, Mass
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) 1.0. 11000
(Registrar) (Official Designation)
(Date of Issue of Permit)
1-62-932382
FORM R-301
ill for burial permit 1 oard of Health cits Agent. II TRUCTIONS FOR IL CERTIFICATE
UIT OR TYPE S OR CAUSES O DEATH dinot enter ne than one a,e for each (1, (b) and (c)
i. does not mean de of dying, heart failure, etc. It means diase, or compli- n. which caused
ntions, if any, i gave rise to 0' cause (a), tg the under- n cause last.
Coditions contrib- to death but not esto the terminal si condition given
PARENTS
St.
(Was deceased a
U. S. War Veteran,
(if so specify WAR)
no
Winthrop, Mass.
(If nonresident, give city or town and State)
(write the word).
(Give maiden name of wife in full)
If under 24 hours
Hours ......
Minutes
INTERVAL BETWEEN ONSET AND DEATH
8 25 1962
Sylvia Minkin Freedman
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE.
DATE OF DISCHARGE
RANK, RATING
ORGANIZATION AND OUTFIT
SERVICE NUMBER
AUG 2 171962 PH
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.
DRM R-301
lı for burial permit ward of Health o ;. ts Agent. N! RUCTIONS FOR CI CERTIFICATE
NOR TYPE EOR CAUSES IDEATH
Iciot enter o than one u: for each a (b) and (c)
s oes not mean mle of dying, a heart failure, i etc. It means isse, or compli- s which caused
dions, if any, ci gave rise to vi; cause (a), in the under- g cause last.
Colitions contrib- I death but not d ) the terminal e ondition given
11.C.
PLACE OF DEATH
Suffolk (County)
1
Winthrop
(City or Town)
No
the Washington Ave.
The Commonwealth of Massachusetts KEVIN H. WHITE SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS
STANDARD CERTIFICATE OF DEATH
Registered No.
150
§(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 ...
20 Cora St.
(Usual place of abode)
Length of stay: In place of death ... years 4 months.
.. days. In place of residence. .years ... .... months ........ ... days.
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
Male
9 COLOR
White
10 SINGLE
MARRIED,
WIDOWEDVidowed
DIVORCED
UNKNOWN
11 If married, widowed,
HUSBAND of
Ellen Boyle
(or) WIFE of.
(Husband's name in full)
12
AGE95
Years
Months.
Days
If under 24 hours
Hours .....
Minutes
13 Usual
Occupation :
Consultant
(Kind of work done during most working life)
14 Industry
or Business :
Winthrop Sewer Dep't
15 Social Security No ...
Boston
16 BIRTHPLACE (City)
(State or country)
Pass.
17 NAME OF FATHER John Kennedy
PARENTS
18 BIRTHPLACE OF FATHER (City) (State or country) Ireland
19 MAIDEN NAME
OF MOTHER
Mary ----
20 BIRTHPLACE OF MOTHER (City) (State or country) Ireland
Helen Franklin
21 Informant
(Address)
20 Cora St. Winthrop
I HEREBY CERTIFY that a satisfactory standard certificate of death
was filed with me BEFORE the burial or transit permit was issued:
Palpat
Sirian
..
6
(Signature of Agent of . Board of Health or other)
(N13)
Health Officer
8/27/6.2
(Date of Issue of Permit)
(Official Designation)
(Registrar)
St
(If nonresident, give city or town and State)
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
DEATH
Aug.
25
1962
(Month)
(Day)
(Year)
4 IHEREBY
CERTIFY, That I
June
19410
Aug.
to.
25,
have occurred on the date stated above, at
7:15 P.m.
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
INTERVAL BETWEEN ONSET AND DEATH yrs.
A (a) Myocardial heart disease
Due To arteriosclerosis, generalized (b)
yrs.
Due To (c)
OTHER
SIGNIFICANT
CONDITIONS
Senility
yrs
Was autopsy performed?
What test confirmed diagnosis ?
5 Was disease or injury in any way related to occupation of deceased?
If so, specify
(Signature)
M. D. Joseph Gregorie, M.D.
(Print or Type Name) (Address) 194 Washington Ave. Date.
8/26/ 9.62
6
Winthrop Cemetery
Winthrop
(City or Town)
DATE OF BURIAL
Aug.
28
1962
7 NAME OF
FUNERAL DIRECTOR
Arthur J. O'Maley
ADDRESS
Winthrop, Mass.
Received and filed
AUG .2.7 1962
JohnClark
19
WINTHROP (City or Town making this return)
2 FULL NAME.
John J. Kennedy
(If deceased is a married, widowed or divorced woman, give also maiden name.)
60
attended deceased from
,52
I last saw
AMalive on
August 25,
,62
death is said to
(Give maiden name of wife in full)
(write the word)
52-932382
Place of Burial or Cremation
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 obseryance 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 of2 Pii 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.
X
OM R-303
le for burial permit lard of Health o ts Agent.
N. B .- WRITE PLAINLY, WITH UNFADING BLACK INK-THIS IS A PERMANENT RECORD. Every item of of Death. See reverse side for additional information. See aiso Chap. 38, §§ 6, 20; Chap. 46, §§ 9, 10; Chap. 114, DEATH in piain 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
im C.
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
(City or Town making this return)
Registered No.
1.57
Winthrop Community Hospital No.
S(If death occurred in a hospital or institution,
St. ¿ give its NAME instead of street and number)
PHYSICIAN - IMPORTANT
2 FULL NAME
LESLIE M. BROWN
(First Name)
( Middle Name)
(Last Name)
[ ( 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.)
26 30 Nevada St., Winthrop, lasst.
(a)
Length of stay: In place of death.
years ...
.. months.
days.
In place of residence. ...... .years ............ months .. .......... days.
PERSONAL AND STATISTICAL PARTICULARS
August 26. 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.)
12 If married, widowed, or divorced
Rose Gross
HUSBAND of
(Give maiden name of wife in full)
(or) WIFE of
(Husband's name in full)
·13 DATE OF BIRTH
14 AGE 67
Years .....
Monthe ...........
If under 24 hours Hours ........... .Minutes
15 Usual
Occupation
(Kind & work done during most of working life)
16 Industry or Business .... .....
17 Social Security No.
18 BIRTHPLACE (City)
(State or country)
Mass.
19 NAME OF
FATHER
William Brown
Boston,
20 BIRTHPLACE OF
FATHER (City)
(State or country)
Mass.
21 MAIDEN NAME
OF MOTHER
Annie {Peyser)
22 BIRTHPLACE OF
MOTHER (City)
Boston
(State or country)
Mass.
23 Edmund Brown
Informant
(Address)
29 Myrtle Avenue, Winthron
I HEREBY CERTIFY that a satisfactory standard certificate of death was filed with me BEFORE the burial or transit permit was issued: ,
8 NAME OF FUNERAL DIRECTOR Benjamin F. Solomon
ADDRESS 420 Harvard Street, Brookline
Received and filed
AUG 22136 Clark
.19
9 SEX
male
10 COLOR
white
11 SINGLE
( write the word )
MARRIED
WIDOWED
DIVORCED
UNKNOWN
married
Hypertensive ..... cardiovascular disease; occlusive coronary artery iosclerosis; acute pulmonary adema
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 ?
Did injury occur in or about home, on farm, in industrial place, or
public place ?
Collapsed while operating.
Yes
6 Was disease or injury in any way related to o cupation ofdeces sed ?
50 M. D.
Michael A. Lubrigo, M.D. (Print or Type Name)
8/26. .19.62
David Vicur Choulim (Lebanon)W. Roxbury Place of Burial, or Cremation. (City or Town) August 27. 19 62 DATE OF BURIAL
PARENTS
50M-9-61-931348
1
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.
(Usual place of abode) MEDICAL CERTIFICATE OF DEATH 3 DATE OF DEATH (Month) (Day) (City or town and State) Manner of motorecifcgyps of place) Injury (How did injury occur ?) Nature of Injury If : (Signed) (Address) Boston, Mads. Date An mynt mit ARNICE AD ARTICLE OF DEATH AN NEXTU CERTIFICATES While at work ? . Was autopsy performed ?
(If nonresident, give city or town and State)
(Signature of Agent of Board of Health or other)
00719
(Official Designation)
(Date of Issue of Permit)
Laundry
Boston
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 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 attendancefor 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.)" .
ORM R-301
ifi for burial permit board of Health o.ts Agent. IN RUCTIONS FOR IC. CERTIFICATE
IN' OR TYPE SI OR CAUSES O. DEATH d not enter c: than one ale for each (= (b) and (c)
Isdoes not mean nde of dying, heart failure, ms etc. It means liise, or compli- s which caused
mions, if any, ic gave rise to m cause (a), ti the under- ny cause last.
Ciditions contrib- death but not do the terminal secondition given
1.0.
PLACE OF DEATH
Suffolk (County)
The Commonwealth of Massachusetts KEVIN H. WHITE SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS
STANDARD CERTIFICATE OF DEATH
Registered No.
158
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
(a) Residence. No 9 Grovers Ave, Winthrop (Usual place of abode)
Length of stay: In place of death ..... years .......... months .......
1
.days. In place of residence 4 years months days.
PERSONAL AND STATISTICAL PARTICULARS
8 SEX Female
9 COLOR
White
10 SINGLE MARRIED WIDOWED DIVORCED UNKNOWN
(write the word)
Married
11 If married, widowed, or divorced HUSBAND of (Give maiden name of wife in full)
(or) WIFE ofWilliam.A ....... MacFarlane
(Husband's name in full)
12
AGE. 7.8Years .... 2 .. .. Months .. .. 7 ...... Days
If under 24 hours
Hours .......
Minutes
13 Usual Occupation :. House.w.i.f.e. ( Kind of work done during most working life)
14 Industry or Business :
15 Social Security No .... none
16 BIRTHPLACE (City) ..
Prince Ed. Island
(State or country )
17 NAME OF FATHER Alexander Gillis
1
18 BIRTHPLACE OF
FATHER (City)
cannot be learned
(State or country)
19 MAIDEN NAME
OF MOTHER
cannot be learned
Kath Rine. Macleod
20 BIRTHPLACE OF
MOTHER (City).
cannot be learned
2
(State or country)
21 InformantIn.s ....... ira.c.e ..... Milne
9 Grovers Ave. Winthrop
I HEREBY CERTIFY that a satisfactory standard certificate of death was filed with me BEFORE the burial or transit permit was issued: Dulph Sirianni
(Signature of Agent of Board of Health or other) Halte (fficer 8/09/12
(Official Designation)
(Date of Issue of Permit) 1/
1
Winthrop (City or Town)
N .... inthrop Community .... Hospital Jessie mac FARLANE 2 FULL NAME
(If deceased is a married, widowed or divorced woman, give also maiden name.)
. St (If nonresident, give city or town and State)
MEDICAL CERTIFICATE OF DEATH
3 DATE OF DEATH Glug 26 196 2
(Months
(Day)
(Year)
4 I HEREBY CERTIFY , That I attended deceased from July 26, 19 62 to Chce 26 1962
I last saw heralive on
aug. 261
19 67 death is said to
have occurred on the date stated above, at 1.40P .. m.
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