USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1962 > Part 32
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DEATH WAS CAUSED BY: IMMEDIATE CAUSE (a) myocardial Heart Disease
INTERVAL BETWEEN ONSET AND DEATH
Due
(b)
Iarteriosclerosis-gener
Due To (c)
OTHER
Diabetes Mellitus
SIGNIFICANT
CONDITIONS Gangrene -KliB, qTé2
Was autopsy performed? What test confirmed diagnosis ?
5 W'as disease or injury in any way related to occupation of deceased ? If so, specify
(Signature)
JOSEPH GREGORIE M.A
(Print or Type Name)
(Address) 19 Washingtowing 8-26 19 62
M. D. PARENTS
6 Cambridre Cem Cambridge Place of Turial or Cremation (City or Town)
DATE OF BURIAL August 29 19 62 (Address)
7 NAME OF FUNERAL DIRECTOR .A. Long & Son Inc.
ADDRESS 1979
Mass, Ave., Cambridge
Received and filed AUG-27 1962 19
(Registrar)
62-932382
(City or Town making this return)
yr.
1
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 on Aufthe 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.
asthose6 962 PM
(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.
FI R-301 1
S UCTIONS FOR A CERTIFICATE
Lgiving EDF DEATH Not enter rthan one for each b) and (c)
es not mean of dying, sheart failure, B,etc. It means e, or compli- hich caused
sins, if any, ave rise to ause (a), the under- ause last.
N'ions contrib- o'cath but not I the terminal ndition given
DI :- Chapter 137, ฿ 1954 requires sians to print or :he cause or BE of death on th ertificates, and Ipr 48, Acts of 1, equires Physi- Iso print or type sender signature.
71 020012
PLACE OF DEATH
X SUFFOLK (County)
WINTHROP (City or Town)
55 BUCHANAN ST.
The Commonwealth of Massachusetts KEVIN H. WHITE 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.
Registered No. 159
[(If death occurred in a hospital or institution, St. Į give its NAME instead of street and number)
PHYSICIAN - IMPORTANT
TYLER MCEACHERN [(Was deceased a
(If deceased is a married, widowed or divorced woman, give also maiden name.)
(a) Residence. No.
(Usual place of abode)
Length of stay: In place of death 50 years - months. - .. days. In place of residence.
years
~ monthsdays.
MEDICAL CERTIFICATE OF DEATH
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
Male
9 COLOR
White
10 CITIZEN
OF U.S.
YES
NO
11 SINGLE
MARRIED
WIDOWED
DIVORCED
UNKNOWN
I last saw h.l./ ... alive on
AUG 21
196 2 death is said to
have occurred on the date stated above, at
805 pm.
DEATH WAS CAUSED BY : IMMEDIATE CAUSE
(a)
GENERAL CARCINOMATOSIS
INTERVAL
BETWEEN
ONSET AND
DEATH
EMC.
2/4 YRS
Due To (c)
OTHER
SIGNIFICANT
CONDITIONS
HYPERTROPHY OF PROSTATE
6400
16 Social Security No.
not known
17 BIRTHPLACE (City)
.....
(State or country)
NOVA SCOTIA
18 NAME OF
FATHER
JOHN MCEACHERN
19 BIRTHPLACE OF
FATHER (City)
(State or country)
NOVA SCOTIA
20 MAIDEN NAME
OF MOTHER
NOT KNOWN
21 BIRTHPLACE OF
MOTHER (City)
(State or country)
AGNEN J. TYLER
22
Informant
(Address)
58 BUCHANAN ST. Winthech
I HEREBY CERTIFY that a satisfactory standard certificate of death was filed with me BEFORE the burial or transit permit was issued: Ralph E. Sirianni
(Signature of Agent of Board of Health or other)
Hatk Officer
8/28/62
(Date of Issue of Permit)
(Official Designation)
Pant;
( Registrar)
PARENTS
WINTHROP CEM. WINTHROP
(City or Town)
DATE OF BURIAL
7 NAME OF
FUNERAL DIRECTOR
Maurice H. Kirby
ADDRESS
210
WINTHROP ST. WINTHROP
Received and filed
AUG 28-1962
19
lla If married, widowed, or divorced
HUSBAND of
AGNES
ROCK
(Give maiden name of wife in full)
(or) WIFE of
(Husband's name in full)
12 DATE OF BIRTH
DEC. 7 1884
13
AGE ...
78 Years -
.Months .............. Days
If under 24 hours Hours. Minutes
14 Usual
Occupation :
WATER DEPT - WINTHROP
(Kind of work done during most of working life)
15 Industry Tow WINTHROP WATER DEPT or Business :
. . .
Was autopsy performed?
What test confirmed diagnosis?
CLINICAL + Operation
5 Was disease or injury in any way related to occupation of deceased? NO If so, specify
(Signed) Kupon b. King M. D. MYRON IN. KING UM.D (Print or Type Name) (Address) ILLPLEASANT ST WINTIENEn Date.
AUG 28 60
6
Place of Burial or Cremation
AUG. 29
1962
26
1962
(Year)
(Month)
(Day)
4 LHEREBY CERTIFY,
That I attended deceased from
1962
O
apr 20 19
to ...
QUE 26
¿ U. S. War Veteran,
if so specify WAR) no
No. JAMES (First Name) (Middle Name) (Last Name)
2 FULL NAME
58 BUCHANANST. WINTHROPSt.
(If nonresident, give city or town and State)
NOVA SCOTIA
3 DATE OF
DEATH
AUG
Due To
(b)
CARCINOMA OF RECTUM
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 :'r'
(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 Yecent 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.
ORM R-301
e for burial permit Eard of Health Pts Agent. ØRUCTIONS FOR CERTIFICATE
V OR TYPE EOR CAUSES FDEATH
a ot enter o: than one u for each (b) and (c)
oes not mean me of dying, & heart failure, is etc. It means sse, or compli- which caused
dons, if any, cigave rise to De cause (a), In the under- Ficause last.
o itions contrib- t death but not the terminal condition given 1
PLACE OF DEATH
Suffolk (County)
Winthrop (City of 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. 160
[(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
... days.
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
August
26
1962
DEATH
(M'onth)
(Day)
(Year)
4 I HEREBY CERTIFY, That I attended deceased from
April
19 S.L.
...
to ......
August26
19 ...
I last saw hi .. Malive on
19 4, death is said to
have occurred on the date stated above, at 1:4.5 P. m.
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a) myocardial infarction
INTERVAL BETWEEN ONSET AND DEATH
Tyr's.
Du
(c)
Congestive heart failure
OTHER SIGNIFICANT CONDITIONS
diabetes mellitus
W'as autopsy performed?
NO
What test confirmed diagnosis ?
X- Rays
5 Was disease or injury in any way related to occupation of deceased ? If so, specify
(Signature)
AB. Ducukat
M. D. H.B LitenHield
+47 Shi (Print or Type Name) (Address) winthrop yRas Date aug 2b 1962
6 .Winthrop Cemetery Winthrop
Place of Turial of Cremation
(City or Town)
DATE OF BURIAL
Aug. 29,
62
19.
7 NAME OF
FUNERAL DIRECTOR
Ernest P. Caggiano
147 Winthrop St., Winthrop
ADDRESS
Received and filed
AUG 28 1982
19
(Registrar)
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
9 COLOR
(write the word)
male white
11 If married, widowed, or divorced
HUSBAND of
Amy Johnson
(Give maiden name of wife in full)
(or) WIFE of.
(Husband's name in full)
12
AGE. 7.2. Years.
.Months.
Days
If under 24 hours
Hours.
Minutes
13 Usual
Occupation :
Retired Police Officer
(Kind of work done during most working life)
14 Industry
or Business :.
Town .... of Winthrop
15 Social Security No ....
16 BIRTHPLACE (City)
(State or country)
Rhode Island
17 NAME OF
FATHER
Theadore Northrop
18 BIRTHPLACE OF
FATHER (City).
(State or country)
Rhode Island
19 MAIDEN NAME
OF MOTHER
Frances ?
20 BIRTHPLACE OF
MOTHER (City)
(State or country)
Rhode Island
21 Informant
Charles ... Northrop
(Address)
34 Sunnyside Ave. Winthrop
I HEREBY CERTIFY that a satisfactory standard certificate of death was filed with me BEFORE the burial or transit permit was issued: Ralph
(Signature of Agent of Board of Health or other)
Health Office
5/28/62
(Date of Issue of Permit)
(Official Designation)
2,2-932382
1
2 FULL NAMETheadore Mortimer Northrop
(Ii deceased is a married, widowed or divorced woman, give also maiden name.)
(a)
Residence. No 69 Eirch Rd.
(Usual place of abode)
St
(If nonresident, give city or town and State)
Length of stay: In place of death .......... years .......... months
.8.
.days. In place of residence.
15
10 SINGLE MARRIED WIDOWED DIVORCED UNKNOWN Widowed
Wickford
PARENTS
Due
arteriosclerotic heart disease
(b)
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 last illness from disease un- related to any form of injury. AUG
(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.
X PLACE OF DEATH Suffolk NÉV
4 EN
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.
161
St. \ give its NAME instead of street and number) winthrop Contrat) ,ty fest! (If death occurred in a hospital or institution. No. JOHN POLINO
2 FULL NAME
(If deceased is a married, widowed or divorced woman, give also maiden name.)
922 NORTH SHORE RD.
-St.
REVERE
MASS
(If nonresident, give city or town and State)
Length of stay: In place of death ........... years. months. days. In place of residence .............. years ......... .. months .............. days.
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
August
27
196.2
DEATH
(Month)
(Day)
(Year)
4 I HEREBY
CERTIFY,
July 18
1962
I last saw h.//halive on
August 26, 1962, de
is said
have occurred on the date stated above, at
4:15 11 m.
INTERVAL BETWEEN ONSET AND DEATH
11 IF STILLBORN, enter that fact here.
12
67
1 1/2 YRS AGE
Years ....
Months
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.
010-10-3361
16 BIRTHPLACE (City)
(State or country)
Italy
17 NAME OF
FATHER
Angelo Polino
18 BIRTHPLACE OF
FATHER (City)
(State or country)
Italy
19 MAIDEN NAME OF MOTHER Catherine (unknown)
20 BIRTHPLACE OF
MOTHER (City)
(State or country)
Italy
21 Mary Polino (daughter)
Informant
(Addres 922 No. Shore Rd, Revere, Mass.
I HEREBY CERTIFY that a satisfactory standard certificate of death was filed with me BEFORE the burial or transit permit was issued: Tripp 6. Sirianni ......
(Signature of Agent of Board of Health or other)
Heriti Officer
8/28/62
(Date of Issue of Permit)
(Official Designation)
(Registrar)
PARENTS
(Signed) .
John F. Pagar M. I).
John 7. Pepi, M.D.
PE SIGNATURE) 821 Saratoga St. E. B. Date Freq. 27, 1962
6
St. Michael Cemetery
Place of Burial or Cremation
DATE OF BURIAL
August 29,
19
(City or Town) 62
7 NAME OF
FUNERAL DIRECTOR
Vincent Kapino
ADDRESS 9 Chelsea St., East Boston, Mass
Received and filed AUG-2-8-1982 19
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
male
9 COLOR
white
10 SINGLE
MARRIED
WIDOWED
or DIVORCED
(write the word)
widowed
10a If married, widowed, or divorced HUSBAND of
Antonette Arciero.
(Give maiden name of wife in full)
(or) WIFE of
(Husband's name in full)
DEATH WAS CAUSED BY : IMMEDIATE CAUSE
(a)
CARCINOMA OF PROSTATE
WITH Generalized Metastasis
Due To (b)
Due To (c)
OTHER
Diabetes MELLITUS
SIGNIFICANT
CONDITIONS
Was autopsy performed?
NO
What test confirmed diagnosis ?
Surgery
1 /2 yrs ago
5 Was disease or injury in any way related to occupation of deceased? If so, specify
1 YR
INTRUCTIONS FOR ICL CERTIFICATE
1 giving § OF DEATH d not enter me than one a'e for each (1, (b) and (c)
ndoes not mean 1de of dying, heart failure, n! etc. It means diase, or compli- which caused
n'ions, if any, gave rise to cause (a), the under- cause last.
ditions contrib- death but not eto the terminal sicondition given 2
t - Chapter 137, r 1954, requires sians to print or he cause or e of death on bertificates, and ot, 48, Acts of quires Physi- s
print or type e lider signature.
5 -11-59-926662
MM R-301A 1
(County) winthrop (City or Town)
Registered No.
PHYSICIAN - IMPORTANTR I [(Was deceased a
U. S. War Veteran,
[if so specify WAR)
YES
(a) Residence. No. (Usual place of abode)
40
That I attended deceased from
,62
to.
August 20
19.
Boston
Retired
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE April 26, 1918
DATE OF DISCHARGE
July 7, 1919
RANK, RATING
Private
ORGANIZATION AND OUTFIT U.S. Army, Co. L 339th Inf.
SERVICE NUMBER. 204.3.5.75
RULES OF PRACTICE
The fulfillinent 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 ferent tedicht atendance or whose physician is absent from home when the certificate of Hell 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.
-
ORM R-301
for burial permit Dard of Health its Agent. 'RUCTIONS FOR . CERTIFICATE
· OR TYPE OR CAUSES DEATH
not enter e than one e for each , (b) and (c)
does not mean de of dying, heart failure. etc. It means ase, or compli- which caused
tions, if any, gave rise to cause (a). In the under- cause last.
Ciditions contrib- Lo death but not I'd the terminal I condition given
204.1 58 X7/
F 5-1962
-62-932382
PLACE OF DEATH
SUFFOLK
SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS
STANDARD
CERTIFICATE OF DEATH
[(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, (il so specily WAR)
No
(a) Residence. No ....
16.Johnson Ave
Winthrop, Mass
(Usual place of abode)
Length of stay: In place of death ......... years ......... months.23.days. In place of residence .. 3.9.years.
.... months ..
.. days.
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
DEATH
August
7
19.62
(Month)
(Day)
(Year)
4 WHEREBY CERTIFY , That "Attended deceased from
July 15. 1.62
to ...
.Aug.
7.
19.62
WAlast saw h .. i mive on
Aug ......? ,
19.
death is said to
· have occurred on the date stated above, at
7:57 A.m.
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
Myelogenous Leukemia with
INTERVAL BETWEEN ONSET AND DEATH
(a)
Due To
leukemic Infiltrate to
(b)
Liver and Bpleen
Due To
Pyonephrosis
(c)
OTHER
SIGNIFICANT
CONDITIONS
Bronchopneumonia
Was autopsy performed? What test confirmed diagnosis ?
5 Was disease or injury in any way related to occupation of deceased? If so, specify
(Signature)
A.D. froderas
M. D.
DR. PHILAP SNODGRASS (Print or Type Name)
.8/7 ,62
PEPER BENT BRIGHAM-HOSP ......... Date
Winthrop Cemetery Winthrop
6
Place of Burial or Cremation
(City or Town)
DATE OF BURIAL August9, 19.62
7 NAME OF
FUNERAL DIRECTORRichard C. Kirby Inc.
ADDRESS
917 Bennington St.E.Boston
AUG 10 1962
19
Received and filed
Charles & mackie
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
M
9 COLOR
White
10 SINGLE
MARRIED
(write the word)
WIDOWED Married
DIVORCED
UNKNOWN
11 If married, widowed, or divorced
HUSBAND of
Mary A Shaughnessy
(or) WIFE of.
(Husband's name in full)
12
AGI
82
Years
Months ..
.1)ays
Il under 24 hours
Hours ........ Minutes
13 Usual
Occupation :
Contractor
( Kind of work done during most working life)
14 Industry
or Business:
Painting and Decorating
15 Social Security No ..
16 BIRTHPLACE (City) (State or country) East Boston
17 NAME OF
FATHER
Charles McDonald
18 BIRTHPLACE OF
FATHER (City)
(State or country)
Nova Scotia
19 MAIDEN NAME
OF MOTHER
Hanna Sullivan
20 BIRTHPLACE OF
MOTHER (City)
(State or country)
Nova .... Scotia.
21 Inlormant
Mr.s ........ Mar.y ..... A ...... McDonald
(Address)
16 Johnson Ave. Winthrop, Mass.
I HEREBY CERTIFY that a satisfactory standard certificate of death was filed with pe BEFORE the burial or transit permit waa issued:
Signature of Apint of Board of Health or other)
12418
8/8/62
(Date of Ilsue of Permit)
(Registrar)|| (Official Desighation)
162
The Commonwealth of Massachusetts KEVIN H. WHITE
OUT - OF - TOWN
(City or Town making this return)
1
(County) BOSTON, MASS
(City or Town)
PETER BENT BRIGHAM HOSPITAL No ...
2 FULL NAME Matthew Mc Donald
(If deceased is a married, widowed or divorced woman, give also maiden name.)
.........
(If nonresident, give city or town and State)
(Give maiden name of wife in full)
PARENTS
Registered No.
TRUE COPY ATTEST: nurles id Mackie City Registrar
OCT -51962 AM
ORM R-301
le for burial permit bard of Health a te Agent. IN RUCTIONS FOR IC. CERTIFICATE
I?' OR TYPE SIOR CAUSES O DEATH
d not enter w: than one a e for each (1. (b) and (c)
isdoes not mean ide of dying, heart failure. etc. It means linse, or compli- u which caused .
ions, if any, i gave rise to M cause (a), h! the under- camse last.
Cditions contrib- death but not to the terminal condition given
393 109
₮ 5-1962
-62-932382
PLACE OF DEATH
Suffolk
(County)
STANDARD
CERTIFICATE OF DEATH
Registered No.
07821 -
[(If death occurred in a hospital or institution, St. ¿ give its NAME instead of street and number)
2 FULL NAME
Louis Yavner
(If deceased is a married, widowed or divorced woman, give also maiden name.)
29 Pico Ave., Winthrop, Mass.
St
(If nonresident, give city or town and State)
Length of stay : In place of death .......... years .......... months ...
.. 3.3lays. In place of residence. 8
.. years.
MEDICAL CERTIFICATE OF DEATH
PERSONAL AND STATISTICAL, PARTICULARS
8 SEX
Male
9 COLOR
White
10 SINGLE
MARRIED
WIDOWED
DIVORCED
UNKNOWN
(write the word)
Married
11 If married, widowed, or divorced
HUSBAND of
Sarah Chick
(or) WIFE of.
(Husband's name in full)
12
AGE76.Years ..
Months ....
Days
If under 24 hours
Hours ........ Minutes
13 Usual
Occupation :
Cutter
(Kind of work done during most working life)
[4 Industry
or Business :
men's clothing
15 Social Security No ......
011-05-8123
16 BIRTHPLACE (City)
(State or country)
Russia
17 NAME OF
FATHER
Joshua Yavner
18 BIRTHPLACE OF
FATHER (City)
(State or country)
Russia
19 MAIDEN NAME
OF MOTHER
(unknown)
20 BIRTHPLACE OF
MOTHER (City).
(State or country)
Russia
CENTER HOSPITAL
6 .Dor ...... Hebrew Helping ..... Hand ..... Everett Place of Burial or Cremation (City of Town)
DATE OF BURIAL
August ......... 1.0 .1962
7 NAME OF
FUNERAL DIRECTOR
Henry ..... Levine
ADDRESS
470 Harvard St. Brookline
AUG 1 3 1962.
Received and filed
Charles & Mackie
19.
(Registrar)
PARENTS
21 Informant
Mrs ...... Sarah .... Yavner.
(Address)
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