USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1962 > Part 34
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(Middle Name)
(a) Residence. No.
( Usual place of abode)
months ..........
.days.
15,
1962
19
.
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE.
DATE OF DISCHARGE
RANK, RATING
ORGANIZATION AND OUTFIT
SERVICE NUMBER.
RULES OF PRACTICE SEP 1 81962 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.
DRM R-301
d'or burial permit Bird of Health [& Agent. ISIUCTIONS FOR A CERTIFICATE
L'OR TYPE ER CAUSES F)EATH
o ot enter 31 than one u. for each )(b) and (c)
pes not mean we of dying, u heart failure, in etc. It means stie, or compli- which caused
dions, if any, Agave rise to e cause (a), n the under- g cause last.
miitions contrib- t death but not the terminal Condition given
PLACE OF DEATH
X Suffolk (County) Minitrop (City or Town) -
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.
169
(If death occurred in a hospital or institution, St. ( give its NAME instead of street and number)
Rebecca Liberman (widowed)
(If deceased is a married, widowed or divorced woman, give also maiden name.)
Rebecca Schneider.
238 SHORE DRIVE (a) Residence. No. (Usual place of abode)
Length of stay: In place of death- years months ... " days. In place of residence.
(If nonresident, give city or town and State) 4 8 years - months ......... days.
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
DEATH
Sepot.
23
1962
(Month)
(Day)
(Year)
4 IHEREBY CERTIFY, That I attended deceased from
DEC
19
to ..
35
sept
19
62
23
I last saw hex.alive on
Sept.
2.3
19.62, death is said to
have occurred on the date stated above, at 12; y0 P.m.
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
Arterioscleratic Heart Disease
(a)
INTERVAL BETWEEN ONSET AND DEATH 5 yrs.
Due To (b)
Due To (c)
OTHER
SIGNIFICANT
CONDITIONS
·None
Was autopsy performed ?
٧٥٠
What test confirmed diagnosis ?
Clinical
5 Was disease or injury in any way related to occupation of deceased If so, specify ....
(Signature)
Charles Liteman
M. D.
CHARLES
LIBERMAN
(Print or Type Name) (Address) WINTHROP, MASS Date. 9/23/1962
Jeferet Israel AWinthrop Evered
Place of Purial or Crematiog
212/24
DATE OF BURIAL
(City or Town)
7 NAME OF
FUNERAL DIRECTOR.
Voy Funeral Der truc
ADDRESS
Cheleca
Received and filed
SEP24-1962
19
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
Female
9 COLOR
White
10 SINGLE
(write the word)
MARRIED
WIDOWED
DIVORCED
UNKNOWN
Widowed
11 If married, widowed, or divorced
HUSBAND of
max Liberman
(Gire maiden name of wife in full)
(or) WIFE of
(Husband's name in full)
12
.87
.Years
Months.
Days
If under 24 hours
Hours
.Minutes
13 Usual
Occupation
Houveurte
(Kind of work dorfe during most working life)
14 Industry
or Business :
our home
15 Social Security No ...
none
16 BIRTHPLACE (City)
(State or country )
17 NAME OF
FATHER
Oscar Schneider
18 BIRTHPLACE OF
FATHER (City).
(State or country)
Russia
19 MAIDEN NAME
OF MOTHER
(e.3.2.)
20 BIRTHPLACE OF
MOTHER (City)
(State or country)
Ruxvia
Dr. Charles Liberman
21 Informant
(Address)
238 Ahore Derive Wiratirop.
I HEREBY CERTIFY that a satisfactory standard certificate of death was filed with me BEFORE the burial or transit permit was issued: Takhle ( Tariant
(Signature of Agent of Board of Health of other)
Healde Officer
(Date of Issue of Permity 7/24/62
(Registrarmi (Official Designation)
2.2-932382
!
(Was deceased a
U. S. War Veteran,
if so specify WAR)
No
St.
PHYSICIAN - IMPORTANT
2 FULL NA
Vinitrop Com. Hospital No
.........
PARENTS
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE ...
00990971
0
DATE OF DISCHARGE
3V19 4 390HZ SEE
RANK, RATING 87
ORGANIZATION AND OUTFIT
SERVICE NUMBER
SIPI
DEG.
70
06: 21
SEP 2 41962 AM
The fulfillment of the purpose of these laws calls for the deservance of the cat . A following rules of practice: ZYNC (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.
1
Statement of Occupation .- Precise statement of occupation is veryimportant tant, so that the relative healthfulness of various pursuits can be known Make c,AND some entry in this section for every person aged 10 years or over. If the decupa- / 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 Sit THI W dren not gainfully employed may be returned as at school of 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.
ROP
RULES OF PRACTICE
FRM R-301
dor burial permit Bird of Health s Agent. STUCTIONS OR NCERTIFICATE
TOR TYPE R CAUSES HEATH not enter nthan one is for each ), b) and (c)
es not mean 0 of dying, s heart failure, a,etc. It means e, or compli- which caused
uns, if any, have rise to e cause (a), the under- cause last.
ntions contrib- oleath but not the terminal ndition given
X I PLACE OF DEATH
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
(City or Town making this return)
Registered No. 170
[(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 .......
538 Shirley St
(Usual place of abode)
Winthron Mass. St.
(If nonresident, give city or town and State)
Length of stay: In place of death .......... years .......... months ...
.L ... days. In place of residence ....... years .......... months ....... ... days.
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
male
9 COLOR
white
10 SINGLE
MARRIED
WIDOWED
DIVORCED
UNKNOWN
(write the word) Single
11 If married, widowed, or divorced HUSBAND of (or) WIFE of.
(Give maiden name of wife in full)
(Husband's name in full)
12
AGE
Years.
Months ..
1
.Days
If under 24 hours
Hours .. ..
.. Minutes
13 Usual
Occupation :
(Kind of work done during most working life)
14 Industry
or Business:
15 Social Security No .. Winthrop
16 BIRTHPLACE (City)
(State or country)
mark
17 NAME OF
FATHER
John Rush
18 BIRTHPLACE OF
FATHER (City).
(State or country)
Boston
Macs
19 MAIDEN NAME
OF MOTHER
Jacqueline Reilly
20 BIRTHPLACE OU
MOTHER (City) ..
(State or country)
Boston
mars
62 John Ruch
2I Informant
(Address)
538 Shirley 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 Effects
9/24/62
(Date of Issue of Permit)
1
(Print or Type Name)
(Address)
190 g /issoud SI l'inthrop Date 9/24/649
6 Winthrop
Winthrop
Place of Turial or Cremation Seht 25
(City or Town)
DATE OF BURIAL
19.
7 NAME OF Ernest Pleaggiano 147 Winther St Winthrop ADDRESS
Received and filed SEP 24 1962- 19.
......
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
DEATH
Sart.
23
135?
(Month)
(Day)
(Year)
4 I HEREBY CERTIFY, That I attended deceased from
Sept 22
19 62
1962
to .....
Sept 23
I last saw hlmalive on
Sent 23
196oh, death is said to
have occurred on the date stated above, at
6 51 pm.
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a) Prematurity
2 days
Due To (b)
Due To (c)
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
(Signature)
William Glazier
M. D.
PARENTS
2 FULL NAME Michael
Rush
(If deceased is a married, widowed or divorced woman, give also maiden name.)
No ..
Winthrop Community Hospital
2.2-932382
(Registrar)|| (Official Designation)
INTERVAL BETWEEN ONSET AND DEATH
-
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE RANK, RATING
ORGANIZATION AND OUTFIT
SERVICE NUMBER
RULES OF PRACTICE
6
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 dalt 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.
PLACE OF DEATH
Suffolk (County)
INSE PETIT
Winthrop
(City or Town)
No. 2.65 River Road
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.
Registered No. §(If death occurred in a hospital or institution, St. ¿ give its NAME instead of street and number)
PHYSICIAN - IMPORTANT
2 FULL NAME
Joseph F .Rebello
(First Name)
( Middle Name)
(Last Name)
( If deceased is a married, widowed or divorced woman, give also maiden name.)
(a) Residence. No. 265 River Road
(Usual place of abode)
Length of stay:
In place of death.
1
.years ..
.months.
.. days. In place of residence.
40
years.
.months.
.. days.
MEDICAL CERTIFICATE OF DEATH
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
Male
9 COLOR
White
10 SINGLE
MARRIED
WIDOWED
or DIVORCEDNed
10a If married, widowed, or divorced
HUSBAND of
Marion V.
DeCosta
(Give maiden name of wife in full)
(or) WIFE of
(Husband's name in full)
11 IF STILLBORN, enter that fact here.
12
AGE.
75 Years.
Months ...
.. Days
If under 24 hours
Hours.
.. Minutes
13 Usual
Occupation :
Retired Telephone Worker
(Kind of work done during most of working life)
14 Industry
or Business :
N.F. Tel & Tel Co.
15 Social Security No.
011-07-2057
16 BIRTHPLACE (City)
Boston
(State or country) Mass
17 NAME OF
FATHER
Manuel Rebello
18 BIRTHPLACE OF
FATHER (City)
(State or country)
Azores
19 MAIDEN NAME
OF MOTHER
Mary Pimentel
20 BIRTHPLACE OF MOTHER (City) (State or country)
Azores
21 Marion Lynch
Informant
(Address)
265 River Road 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) Hedlite Officer
9/28/65
(Official Designation)
(Date of Issue of Permit)
¿ 928145
MR-301A 1
TI CTIONS IR L ERTIFICATE
Diving
F DEATH r .: enter e lan one eor each ) and (c)
ds not mean d of dying, Heart failure, c. It means a.or compli- Nich caused
is, if any, ve rise to tuse (a), The under- use last. :
dons contrib- ath but not the terminal Cidition given C.
Chapter 137, f 954. requires ns to print or 1: cause or of death on c tificates, and e 48, Acts of ruires Physi- t print or type uler signature.
PARENTS
6
Winthrop Cemetery
Winthrop
Place of Burial or Cremation
(City or Town)
DATE OF BURIAL
September 29
19 62
7 NAME OF
FUNERAL DIRECTOR
Arthur .T.O'Maley
Winthrop, Mass.
ADDRESS
Received and filed
SEP 28 1962
19
(Registrar)
(Day)
(Year)
4 I HEREBY CERTIFY
AUG10,
1962 to
SEAT26,
62
I last saw hfMalive on
SEPT.
26
19.62, death is said to
have occurred on the date stated above, at 2-0 m.
DEATH WAS CAUSED BY : IMMEDIATE CAUSE
(a) CARDIAC FAILURES
INTERVAL
BETWEEN
ONSET AND
DEATH
IMO.
Due To
(b)
CHRONIC MYOCARDITIS
IMG
Due To (c)
OTHER
CARCINOMA OF LUNG
2MO
SIGNIFICANT
CONDITIONS
INANITION+PROSTATECTOMY
Was autopsy performed?
NO
What test confirmed diagnosis?
5 Was disease or injury in any way related to occupation of deceased?
If so, specify
NO
(Signed)
-am. CAPLAN
M. D
(PRINT OR TYPE SIGNATURE) 186 PRINCETONST FAST BOSTON SEPT. 26. 1962
( Address)
3 DATE OF
September 26. 1962
DEATH
(Month)
That I attended deceased from
(Was deceased a ₹ U. S. War Veteran, {if so specify WAR) Vo
St.
(If nonresident, give city or town and State)
(write the word)
171
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, of 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.
PLACE OF DEATH
Suffolk (County) WinThrop (City or Town) mounts Nursing Home No.
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.
172
Registered No.
S(If death occurred in a hospital or institution,
St. { give its NAME instead of street and number)
PHYSICIAN - IMPORTANT
2 FULL NAME
Charles
( First Name)
(Middle Name)
BELL
(Last Name)
[if so specify WAR)
(If deceased is a married, widowed or divorced woman, give also maiden name.)
279 Chestnut
.. St.
Chelsea
(a) Residence. No.
(Usual place of abode)
Length of stay: In place of death.
.years
.months.
31
.days. In place of residence.
years.
months ..
.days.
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
lla If married, widowed, or divorced HUSBAND of
(or) WIFE of
(Give maiden name of wife in full)
Jennie (( BZ)
(Husband's name in full)
12 DATE OF BIRTH
13
AGE 18
Years.
-
Months ............
Days
If under 24 hours
Hours ..........
Minutes
14 Usual
Occupation :
Dealer
(Kind of work done during most of working life)
15 Industry
or Business :
Retail Alve
16 Social Security No.
22.915-18-7987
Was autopsy performed?
110
17 BIRTHPLACE (City)
(State or country)
Russia
5 Was disease or injury in any way related to occupation of deceased?
If so, specify
NO
(Signed)
MORRIS CLAYMANIhus
M. D.
(Address)
(Print or Type Name) CHELSEA DIAS5. 198CHESTNUTSTI Date CEPT, 26 1962
agudas Sholom Avere 6 Place of Burial or Cremation (City or Town) Sixt 21 1962 DATE OF BURIAL
7 NAME OF
FUNERAL DIRECTOR
Joy Juncal dur Ine
ADDRESS
Received and filed SEP 27 1962 19
(Registrar)
PARENTS
18 NAME OF
FATHER
nathan Beel
19 BIRTHPLACE OF
FATHER (City)
Russia
(State or country)
20 MAIDEN NAME OF MOTHER
C.B.L.
21 BIRTHPLACE OF MOTHER (City) (State or country)
Russia
22 Informant
nas Celia Silver
(Address) 130 Chauff ST Chelka
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 Afew
(Official Designation)
(Date of Issue of Permit)
31-930213
RI R-301 1
1-6- 3519 ed 8-25-
STUCTIONS FOR AICERTIFICATE
Ingiving EOF DEATH Jot enter nthan one as for each ) b) and (c)
es not mean 10 of dying, s heart failure, a,etc. It means ep, or compli- which caused
ins, if any, have rise to e cause (a). mathe under- ause last.
n'ions contrib- o'cath but not the terminal ndition given
t - Chapter 137, 1954 requires s ans to print or he cause or e of death on hertificates, and p .- 48, Acts of ,equires Physi- s5 print or type ender signature.
A TRUE COPY ATTEST:
3 DATE OF
DEATH
Self, 26
1962
(Month))
(Day)
(Year)
4 I HEREBY CERTIFY
JAN. T
19 ...
62 to
Sept.26
That I attended deceased from
I last saw himalive on
Septi the
1962
death is said to
have occurred on the date stated above, at
55
.. m.
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
CUCINOMIT COLON
(a)
Due To
(b)
CARCINOMATOSIS
Due To (c)
OTHER
SIGNIFICANT
CONDITIONS
HOHE
What test confirmed diagnosis?
INTERVAL BETWEEN ONSET ANO DEATH
1hr
19 ..
[ (Was deceased a
U. S. War Veteran,
(If nonresident, give city or town and State)
Chelsea
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE
RANK, RATING
ORGANIZATION AND OUTFIT
SERVICE NUMBER
TO !.
RULES OF PRACTICE ,
4 .. .
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 ffronf disease un. related to any form of injury.
(2) Board of Health physicians will certify to such deaths only a's 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 de the supportably due to injury. These include not only deaths caused directly or mhdirectly 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
Middlesex
(County)
1
Medford
(City or Town)
No. 220 Forest
The Commonwealth of Massachusetts KEVIN H. WHITE SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS COPY OF CERTIFICATE OF DEATH
Medford
(City or Town making this return)
Registered No.
123
[(If death occurred in a hospital or institution, St. ¿ give its NAME instead of street and number)
2 FULL NAME
(If deceased is a married, widowed or divorced woman, give also maiden name.)
{if so specify WAR
no
(a) Residence. No ..
144 Circuit Rd.
(Usual place of abode)
St
Winthrop
(If nonresident, give city or town and State)
Length of stay: In place of death ..
2
r$6.
.. months.
days. In place of residence.
1 years 1
.months .......... days.
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
DEATH
September
27
1962
(Month)
(Day)
(Year)
4 I HEREBY CERTIFY,
That I attended deceased from
Jan
19
50
Ato.
Sept
27
19
62
19
... , death is said to
have occurred on the date stated above, at
3 .. 3.0P
INTERVAL BETWEEN ONSET AND DEATH
hrs
Due To Gen. Arteriosclerosis (b)
yrs
Due To (c)
OTHER
SIGNIFICANT
Senility
CONDITIONS
Parkinson's Sundrome
vrs
Was autopsy performed?
no
What test confirmed diagnosis ?
none
5 Was disease or injury in any way related to occupation of deceased ? no. If so, specify
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