USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1962 > Part 7
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[(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.)
(a) Residence. No.
88 Crescent Ave
(Usual place of abode)
Revere
(If nonresident, give city or town and State)
Length of stay: In place of death .. ...
years ..
months.
2.2 days.
In place of residence.
.years
8
.months
days.
MEDICAL CERTIFICATE OF DEATH
PERSONAL AND STATISTICAL PARTICULARS
3 DATE OF
DEATH
February 24,
1962
(Month)
(Day)
(Year)
4 I. HEREBY CERTIFY
That I attended deceased from
Feb. 2 1962 to.
Feb. 24
62
...
I last saw h. ... alive on
Fel.
2 4
, 1962, death is said to
have occurred on the date stated above, at 1110 pm.
INTERVAL
BETWEEN
ONSET AND
DEATH
Carcino
inomatosis
weeks
10a If married, widowed, or divorced
HUSBAND of
Edward
(Give maiden name of wife in full)
Green
(Husband's name in full)
11 IF STILLBORN, enter that fact here.
12
38
AGE
Years
9
Months ...
1
Days
If under 24 hours
Hours.
.Minutes
13 Usual
Occupation :
(Kind of work done during most of working life)
14 Industry
or Business :
Laxz
15 Social Security No. 371-14-8608
16 BIRTHPLACE (City)
(State or country)
17 NAME OF FATHER Unknown) Fittte.
18 BIRTHPLACE OF
Cannot be learned
FATHER (City) (State or country)
19 MAIDEN NAME OF MOTHER
Cannot be learned Алессией
20 BIRTHPLACE OF MOTHER (City) (State or country)
Charles Doty
21 Informant (Address) 88 Crescent Are, Revere
I HEREBY CERTIFY that a satisfactory standard certificate of death was filed with me BEFORE the burial or transit permit was issued:
/ , (Signature of Agent of Board of Health or other)
(Official Designation)
(Date of Issue of Permit)
5 /26/62 Y
: RUCTIONS FOR CERTIFICATE
1 giving JOF DEATH
· ot enter os than one u: for each a) (b) and (c)
bes not mean me of dying, s heart failure, ia etc. It means see, or compli- bhich caused
dans, if any, chave rise to ' cause (a), nuthe under- g cause last.
ontions contrib- to'eath but not the terminal adition given
te Chapter 137, @:1954. requires siens to print or e cause or es of death on h ctificates, and pte 48, Acts of , ¿quires Physi- stprint or type e uler signature.
6-6928145
1
Registered No.
2 FULL NAME
Lee
(First Name)
(Middle Name)
(Last Name)
Green (Little)
9 COLOR
White
10 SINGLE
MARRIED
WIDOWED
or DIVORCED Married
DEATH WAS CAUSED BY : IMMEDIATE CAUSE
(a)
Due
(b)
Carcinoma of Ovary
Due To (c)
(bilateral)
OTHER
SIGNIFICANT
CONDITIONS
Was autopsy performed?
NO
What test confirmed diagnosis?
Biopsy
5 Was disease or injury in any way related to occupation of deceased? (20 If so, specify
(Signed)
ed) Dasple Frezarel M. D
Joseph Gregorie
(PRINT OR TYPE SIGNATURE)
(Address)
19-Washington W Date
2/25 67
6 .
Woodlawn
Everett
Place of Burial or Cremation Feb, 28, 1962
(City or Town)
DATE OF BURIAL
7 NAME OF FUNERAL DIRECTOR Arthur S. Porcella
ADDRESS 876 Winthrop Awe, Revere
Received and filed MAR 5 1962 19
(Registrar)
PARENTS
Cannot be learned
1
(write the word)
8 SEX
Female
(or) WIFE of
months
EI R-301A 1
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE.
TO !!
RANK, RATING
1_
ORGANIZATION AND OUTFIT
8
SERVICE NUMBER
6
RULES OF PRACTICE MAR =51962 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 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.
1
DRM R-302
Suffolk ( County )
1 Revere
(City or Town )
The Commonwealth of Massachusetts JOSEPH D. WARD SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS COPY OF CERTIFICATE OF DEATH
Revere
(City or Town making this return)
Registered No.
S (If death occurred in a hospital or institution, ¿ give its NAME instead of street and number)
2 FULL NAME
Margaret .... P.lacco ..... (Buckley)
( If deceased is a married, widowed or divorced woman, give also maiden name.)
(a) Residence. No. 21 .... Nevada ( Usual place of abode)
(If nonresident, give city or town and State)
Length of stay:
In place of death
.years ...
3 .. months.2/4 days. In place of residenceb.Q.
... years.
......... months .......... days.
MEDICAL CERTIFICATE OF DEATH
PERSONAL AND STATISTICAL PARTICULARS
3 DATE OF
DEATH
February
(Month)
24,
1962
(Day)
(Year)
& SEX
Female
9 COLOR
White
10 SINGLE
( write the word)
MARRIED
WIDOWED Widowed
or DIVORCED
4 I HEREBY CERTIFY.
That I attended deceased from
N.o.v ...........
19
55
to ....... Feb ....
24
19 .. 62.
I last saw h ... elve on
Feb ....... 24
19.62
death is said to
( Give maiden name of wife in full)
(or) WIFE of
Joseph Placco
(Husband's name in full)
DEATH WAS CAUSED BY : IMMEDIATE CAUSE
(a) Uremia
3days
87
12
AGE
Years.
Months ........
.. Days
If under 24 hours
Hours.
... Minutes
13 Usual
Occupation:
Housewife
( Kind of work done during most of working life)
14 Industry
or Business :
Own Home
15 Social Security No.
16 BIRTHPLACE (City)
(State or country )
Ireland
17 NAME OF
FATHER
Michael Buckley
PARENTS
18 BIRTHPLACE OF
FATHER (City)
(State or country )
Ireland
19 MAIDEN NAME
OF MOTHER
Ellen Sweeney
(Signed )
James F. Burns
M. D. <
( Address )
Everett
Date
2/25/
62-
19
20 BIRTHPLACE OF
MOTHER (City)
( State or country )
Ireland
Winthrop Cemetery
Winthrop
Place of Burial or Cremation
(City or Town)
62
Helen Wyke
21 Informant ( Address) 21 Nevada St., Winthrop
A TRUE COPY
ATTEST :
Received and filed 3-5-62 19
DATE FILED
( Registrar of City or Town where death occurred )
February 26,
19
62
ALWRITER KIDDUN -
THIS IS A PERMANENT RECORD
6 resided as soon as possible, after the close of the month in which the death occurred. (See Chap. 46. Sec. 12. G. L.) at the time of death should be transmitted on Form R-302 to the clerk of the city or town in which the deceased Copies of returns of deaths which occurred in your city or town in case the deceased resided in another city or town Due To
50M-9-59-926111
ADDRESS
7 NAME OF
FUNERAL DIRECTOR
Winthrop, Mass.
Arthur J. O'Maley
( Registrar of City or Town where deceased resided )
INTERVAL BETWEEN DNSET AND DEATH
11 IF STILLBORN, enter that fact here.
Due To
(b)
.Myocarditis
(c) Chronic Nephritis
2yrs.
OTHER
SIGNIFICANT
CONDITIONS
Was autopsy performed ?
NO
What test confirmed diagnosis ?
Clinical Signs
5 Was disease or injury in any way related to occupation of deceased ? If so, specify
No
DATE OF BURIAL February 27,
14
6mo.
10a If married, widowed, or divorced HUSBAND of
have occurred on the date stated above, at 11: 30A.
X PLACE OF DEATH
No .... Grover Manor Hospital
( Was deceased a
U. S. War Veteran.
if so specify WAR,.
No
St
Winthrop ....... Mas.s.
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE DATE OF DISCHARGE RANK, RATING ORGANIZATION AND OUTFIT SERVICE NUMBER
X
PLACE OF DEATH
Suttak (County) Boston (City or Town) Beth Israel Hospital No.
JOSEFA D. WARD ¿CCRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS STANDARD
CERTIFICATE OF DEATH
To be filed for burial permit with Board of llealth or its Agent.
31 :0316
[(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.)
(a) Residence. No. ( l'sual place of abode)
85 Sagamore Avenue
.. St.
Winthis
(If nonresident, give city or town and State)
Length of stay: In place of death ..
.years.
.. months. day- In place of residence.
5
.years
.months.
.days.
MEDICAL CERTIFICATE OF DEATH
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
FEMALE
9 COLOR
White
10 SINGLE
(write the word)
MARRIED SiNg/c
WIDOWED
or DIVORCED
10a If married, widowed, or divorced
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 125 Years 3 Months.
14 Days
If under 24 hours
.Hours.
......
.Minutes
13 Usual
Occupation :
Clerk.
(Kind of work done during most of working hie)
14 Industry
or Business :
BOSTON HAY + GRAIN.
15 Social Security No. ....
023-16-0964
AJOSTON
16 BIRTHPLACE (City)
(State or country)
MASS
17 NAME OF
FATHER
Moses LouRiE
18 BIRTHPLACE OF
FATHER (City)
Russia
(State or country)
19 MAIDEN NAME
OF MOTHER
LENA BAND
20 BIRTHPLACE OF
MOTHER (City)
(State or country)
RUSSIA.
21 MORRIS SegAN
(Address) - SAGEMORE BURUNDIBOD
I HETEDY CERTIFY that a satisfactory standard certificate of death was only with me BEFORE the burial or transit permit was issued: Durata
(Signature of Agent of Board of Health or other)
5346, 1-11-6 2
I (Official Designation)
(Date of Issue of Permit)
TIL
.
Er mot mean of dying. art failure. . It means da or compli- ich caused
tus. if any. the rise in use (a). The under- muse last.
1
Due To
Due To (c)
OTHER
SIGNIFICANT
CONDITIONS
Was autopsy performed?
110
What test confirmed diagnosis?
5 Was disease or injury in any way related to occupation of deceased? I ..... If so, specify
(Signed)
Elaine Liberatain
(PRINT OR TYPE SIGN. TURE)
(Address)
330 Bradiline Albare
119
1962
WINTHROP COM. EUBRETT
6
Place of Burial or Cremation
(City or Town)
DATE OF BURIAL
JANUARY 1/3
1959
7 NAME OF
FUNERAL DIRECTOR
ARNOLD Golor
ADDRESS: 1668 BEACONST. Brookline
Received and filed. JAN 20 1967 0
19
(Registrar)
62
(Month)
(Day)
(Year)
4 1 HEREBY
CERTIFY.
,62
1/9
I last saw h .... alive on
119
to.
That I attended deceased from
119
1962
death is said to
have occurred on the date stated above, at
......... m.
... .....
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a)
acute myocardial infarction
FEAT .:
2 hrs
1 R-301A 1
RICTIONS
CERTIFICATE
niving IF DEATH
tt enter Than one se or each ) and (c)
dons contrib- with but not to the terminal coition given
20.1
Chapter 137 54. requires clas to print or cause or death on ce ficates, and cf 8, Acts of re ires Physi- to rint or type un r signature. R16 1962 evner x.ved
50- 8145
1
Registered No.
2 FULL NAME
Matida (First Name) (Middle Name) (Last Name)
Lourie
1/2 hour
M. D
PARENTS
3 DATE OF
DEATH
LUE COPY AT
C
MAR 1 61962 AM
15.3.
CERTIFICATE OF DEATH
32
STATE OF MAINE DEPARTMENT OF HEALTH AND WELFARE
1. PLACE OF DEATH
o. COUNTY
Kennebec
2. USUAL RESIDENCE Where deceased lived. If institution, residence before adm is an
o.
STATE
Lass.
b. COUNTY Suffolk
b. CITY, TOWN, OR LOCATION
Gardiner
c. LENGTH OF STAY IN 1b
45 minutes
c. CITY, TOWN, OR LOCATION
Winthrop
d. NAME OF
frenteip's greatest address
HOSPITAL OR :
INSTITUTION Gardiner Paper will
d. STREET ADDRESS
93 Cliff Ave.
e. IS RESIDENCE ON A FARM?
1
YES
NO %
30. NAME OF DECEASED-First Name! 3b. Middle Nome
Laffava
o
3 c.
Lost Nome
Miller
Month
Doy
4.
DATE
OF
DEATH
Jan. 11. 1962
Year
5. SEX
Tale
6. COLOR OR RACE
1.nite
7. Nomed 2. Never Worried
Widawed
D.varced
8. DATE OF BIRTH
June 26, 1907
9.AGE (In years| f under 1 year If under 24 hrs
Mas
Days
Hrs.
Min.
10a. USUAL OCCUPATION Give and at
10b.
KIND OF BUSINESS OR
INDUSTRY
11. BIRTHPLACE (State ar foreign country)
Hampden, Maine
12 CITIZEN OF WHAT
UCA
COUNTRY ?
13. FATHER'S NAME
Leslie =. Miller
14. MOTHER'S MAIDEN NAME
Jou Stell_ Taylor
15. NAME OF SPOUSE (if
harrted)
Adelo Lurver
ller
C.USE OF DATH
LE ,E TYPE OPRINT
PART II. OTHER SIGNIFICANT CONDITIONS contributing to death but not related to the terminal disease condition given in Part ! a
20. NO .. WAS AUTOPSY PERFORMED? YES
210. ACCIDENT
C
SUICIDE
HOMICIDE
21b. DESCRIBE HOW INJURY OCCURRED. (Enter nature of injury in Part i or Part II of item 19,
CATH DE TO KERNAL K.ENCE 85- 196/24
2 1 c .
TIME OF
INJURY
Hour
o m.
p m.
Month, Doy. Yeor
21d. INJURY OCCURRED WHILE AT r
NOT WHILE AT WORK. 2
21e. PLACE OF INJURY (eg, in or about home, farm, factory, street, affice bldg , etc )
21f. CITY, TOWN, OR LOCATION
COUNTY
STATE
YSCIAN'S ADICAL MINER'S IFCATION
UMRAL RECTOR AID GITRAR
24a. BURIAL, CREMATION, REMOVAL (Specify) Burial
24b. DATE 1/14/62
24c. NAME OF CEMETERY OR CREMATORY Locust Grove Toomb
24d. LOCATION (City, .pwn, or county)
Hampden, Mey
25. FUNERAL DIRECTOR: Brookings & Smith
ADDRESS
26. DATE RECD. BY LOCAL REG. Bangor, Me. 1 - 11-12
22b. PHYSICIAN: I hereby certify that I attended the decease 1 tr n
and last saw him alive an
10 0
m. on the date ond from the . . s state i
230. SIGNATURE
(Degree ar title)
23b.
ADDRESS
21
-
23c. DATE SIGNED
(State)
27. REGISTRAR'S SIGNATURE
NVI FOISIZO 1966
CEDENT SONAL ATA
PE OR RT NAME
16. WAS DECEASED EVER IN US ARMED FORCES?
17. SOC.SECURITY NO. 18. INFORMANT
003-03-2640
Adele L. Miller
93 Cliff
Winthrop.
·TH
INTERVAL BETWEEN ONSET AND DEATH 1
19. CAUSE OF DEATH (Enter anly one couso per line for (o), (b), and (c).) .
PART 1. DEATH WAS CAUSED BY:
IMMEDIATE CAUSE (o)
4200
Conditions, if any,
which gave rise to
obave cause (o)
stoting the under-
lying couse lost.
DUE TO (b)
DUE TO (c).
(Yesno. or unx.) NŐ
ill yes, give was or dates of service,
last birthday)
54
ACE OF TH AND SUAL IDENCE
STATE FILE NO
22a. MEDICAL EXAMINER: I hereby certify that death occurred at the time and tram the causes stated above, and that I held an (investigation) (aulapsy) on the remains of the deceased as required by law.
6
RECEIVED
OF TOWN
7 :
10.
UFF
3
CLERK
B
WI
.
HELP
APR -51962 PM
X
Suffolk
(County ) Chelsea
(City or Town)
Chelsea Memorial Hospital
The Commonwealth of Massachusetts JOSEPH D. WARD SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS COPY OF CERTIFICATE OF DEATH
Chelsea
( City or Town making thị - " rn)
15
33
(If death occurred in a hospital or institution,
.St. } give its NAME instead of street and number)
(If deceased is a married, widowed or divorced woman, give also maiden name.)
10 Prospect Ave.
1
Winthrop, Mass.
(If nonresident, give city or town and State)
Length of stay: In place of death .......... years.
-
...... months.
2
days. In place of residence.
15
ears
months .......... days.
MEDICAL CERTIFICATE OF DEATH
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
9 COLOR
10 SINGLE
MARRIED
( write the word)
WIDOWED
or DIVORCEWidowed
10a If married, widowed, or divorced
HUSBAND of
(Give maiden name of wife in full)
(or) WIFE of
John J.Dunn
Date of birth June 3" 1981
11 IF STILLBORN. enter that fact here.
12 80 7
9
If under 24 hours
.. Hours ......
.. Minutes
13 Usual
Occupation :
Housewife
( Kind of work done during most of working life)
14 Industry
or Business :
at home
15 Social Security No. .. none
16 BIRTHPLACE {City)
(State or country)
Ireland
FATHER
John Coughlin
18 BIRTHPLACE OF
FATHER
(State or country }
Ireland
19 MAIDEN NAMary Hallisey OF MOTHER
20 BIRTHPLACE OF
MOTHER (City)
(State or country )
Ireland
St. Josephs Cem. , W.Roxbury 6
Place of Burial or Cremation (City or Town)
Jan.15,1962
19
7 NAME OF
FUNERAL
Richard C.Kirby, Inc.
917 Bennington St.F. Boston
ADDRESS
Received and filed MAR 13-1962. 19
( Registrar of City or Town where deceased resided )
A TRUE COPY Jorgele a. Tyrrell
ATTEST :
( Registrar of City or Town where death occurred)
DATE FILED
.Jan .12,1962
19
TX
VIVALA MIDDUN -
THIS IS A PERMANENT RECORD
WPITHALATNY VERIFYINTVISTA
No
2 FULL NAME
Helen M. Dunn
(a)
Residence.
No.
( Usual place of abode)
3 DATE OF
DEATH
Jan . 12. 1962
( Month)
(Day)
4 I HEREBY CERTIFY,
Jan.11
19 ...
62
to ...
Jan.12
have occurred on the date stated above,
OTHER
SIGNIFICANT
CONDITIONS
Was autopsy performed ?
none
(Signed )
Salvatore A.DeLuca
( Address)
DATE OF BURIAL
resided as soon as possible, after the close of the month in which the death occurred. (See Chap. 46, Sec. 12, G. L.)
What test confirmed diagnosis ?
clinical
That I
attended deceased from
19.62
I last saw
R.L.alive on
Jan.12
196.2, death is said to
10:05Am.
INTERVAL
BETWEEN
ONSET AND
DEATH
DEATH WAS CAUSED BY : IMMEDIATE CAUSE
(a) Congestive heart failure
Due To
Myocardial infarction
5 Was disease or injury in any way related to occupation of deceased ? If so, specify
PARENTS
50M-9-59-926111
1
PLACE OF DEATH
DRM R-302
(b) at the time of death should be transmitted on Form R-302 to the clerk of the city or town in which the deceased Copies of returns of deaths which occurred in your city or town in case the deceased resided in another city or town Due To (c)
M. D.
550 Park Ave. Revere. 1/12/62
21 Mrs. Rita Cullinane-dau.
Informant
( Address)
"10 Prospect Ave . , Winthrop
Registered No.
( Was deceased a
U. S. War Veteran.
if so specify WAR
( Year)
Female
White
AGE.
Years.
Months
Days
........
6
SPACE FOR ADDITIONAL INFORMATION
MAR 1 31962 FM
DATE OF ENTERING MILITARY SERVICE DATE OF DISCHARGE RANK, RATING ORGANIZATION AND OUTFIT SERVICE NUMBER
R-301 1
ACTIONS
PLACE OF DEATH
SUFFOLK (County)
ROXBURY (City or Town)
No. JEWISH MEMORIAL
The Commonwealth of Cansarhusetta KEVIN H. WHITE SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS STANDARD CERTIFICATE OF DEATH
OUT - OF - TOWN To be filed for burial permis with Board of Health or its Agent. .. ₹01618
34
Registered No. [(If death occurred in a hospital or institution,
HOSPITAL St. } give its NAME instead of street and number)
2 FU'1.1. NAME SAMUEL MACHOTT
( First Name} ( Middle Name) (1.ast Name) (If deceased is a married, widowed or divorced woman, xive alsn maiden name.)
{ a} Residence. No. 215, COURT
( L'sual place of abode)
R.D., WINTHROP Si.
(If nonresident, give city or town and State)
Length of stay: In place of death.
... years.
months 1.7 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 1
NO C
II SINGLE MARRIED WIDOWED DIVORCED UNKNOWN
lla If married, widowed, or divorced Many Hirshovitz
HUSBAND of
(Give maiden name of wife in full)
(or) WIFE of
(Husband's name in full)
12 DATE OF BIRTH
March 24,1890
13
77
AGE ....
Years.
2 ... Months ..
27
... Days
If under 24 hours ..... .Hours ........... Minutes
14 Usual
Occupation :
Hardware Dealer
(Kind of work done during most of working life)
15 Industry
or Business :
Retired
16 Social Security No. 014-12-9919
17 BIRTHPLACE (City)
(State or country)
New York
18 NAME OF
FATHER
Hyman MacHott
19 BIRTHPLACE OF
FATHER (City)
(State or country)
Russia
20 MAIDEN NAME
OF MOTHER
Bessie C BL
21 BIRTHPLACE OF
MOTHER (City)
(State or country)
Russia
22 Informant (Address)
Hyman MacHott 215 Court Ra-Winthrop
I HEREBY CERTIFY that a satisfactory standard certificate of death was bled with me BEFORE the burial or transit permit was issued:
(Signature of Agent of Board of Health or other
22738 1/21/62
I (Official Designation)
(Date of Issue of Permit)
A TRUE COPY ATTEST:
(Registrar)
PARENTS
Sharon Memorial Park Sharon
6 Place of Burial or Cremation January 21 62 19.
DATE OF BURIAL
7 NAME OF
FUNERAL
DIRECTOR
Arnold Golov
1668 Beacon St Brookline
ADDRESS
Receivety and filed .
JAN-23 1962
19
MONTHS
Was autopsy performed?
YES
What test confirmed diagnosis? CLINICAL, AUTOPSY
S Was disease or injury in any way related to occupation of deceased? If so, specify
(Signed)
ALBERT SHETITOB
M. D.
(Print or Type Name) JEWISH MEMORIAL
(Address) HOSPETT Date JANUARY 201962
Due To (c)
OTHER BRONCHOGENIC CARCINOMA SIGNIFICANT CONDITIONS WITH METASTASIS
(Month) (Day) (Year)
41 HEREBY CERTIFY. That I attended deceased from
DECEMBER 5. 1961, 10 JANUARY
20
. 19.62 I last saw h& Malive on JANUARY 20, 1962, death is said to have occurred on the date stated above, at 1: 50 Am IWILLVAL DETWEEN DEATH WAS CAUSED BY: IMMEDIATE CAUSE (a) BRONCHOPNEUMONIA C:SET ANO DEATH DAYS
Due To (b)
ving « DEATH enter an one ebor each 1) and (e)
de nat mean de af dying, Jut failure. €. It means se or compli- with caused
ion if amy. go rise to Ese (a). .dt under- case lass.
lists contrib- deh but not oto terminal onion given
: hapter 137, [ 1:4 requires iar to print or the cause or o death on cerncates, and r . Acts of req res Physi. to Ent or type indisignature.
416 1962
51-9 213
PHYSICIAN - IMPORTANT
[( Was deceased a U. S. War Veteran. No
(if so specify WAR)
1
3 DATE OF DEATH JANUARY 20 1969
(City or Town)
ERTIFICATE
Charles it Mackie City, Registrar
! ! : "
6
MAR 1 61962 AM
R-301A -
PLACE OF DEATH
Suffolk (County)
Boston
(City or Town)
The Commonwealth of Massachusetts JOSEPH D. WARD SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS STANDARD CERTIFICATE OF DEATH
OUT - OF - TOWN To be filed lor burial permit with Board ol Heal ::. or its Agent. 35 01080.
Registered No.
f(If death occurred in a hospital or institution,
St. { give its NAME instead of street and number)
PHYSICIAN - IMPORTANT
2 FULL NAME Tanger Samuel ( l'irst Name) (Middle Name) (Last Name)
( if dereased is a married, widowed or divorced woman, give also maiden name.)
(a) Residence. No.
17 Cottage Ave., Winthrop, Mass.
(L'sual place of abode)
Length of stay :
In place of death
years ..
2
months.
12
.days.
In place of residence.
10 years
months ...
......
.. days.
MEDICAL CERTIFICATE OF DEATH
PERSONAL AND STATISTICAL PARTICULARS
3 DATE OF
DEATH
January
31
1962
(Month)
(Day)
(Year)
4 I HEREBY CERTIFY,
That I attended deceased from
62
19
10a Il married, widowed, or divorced
HUSBAND of
Celia .... Liebman
(Give maiden name of wife in full)
(or) WIFE of
(Husband's name in full)
11 IF STILLBORN, enter that fact here.
12
AGE .... 7.1.Years
........
Months .............. Days
Il under 24 hours
Hours ...........
... Minutes
Due To
METASTATIC
(0) CARCINOMA OF RECTUM
Due To (c)
OTHER
SIGNIFICANT
CONDITIONS
Was autopsy performed?
NO
What test confirmed diagnosis?
BIOPSY
S Was disease or injury in any way related to occupation of deceased? NO If so, specify
(Signed)
DOLLARO HIRSE GARDNER
(PRINT OR TYPE SIGNATURE)
(Address) NECH Date .. 1/3/1962
6
Sharon Memorial park
Sharon
Pisce of Burial or Cremation
(City of Town)
DATE OF BURIAL
February
1
162
7 NAME OF
FUNERAL DIRECTOR
Arnold .... Golov
ADDRESS16.6.8 .... Beacon .... S.t ....... Brookline
Received?and filed 0 FEB -2 1962 Charcos & Machu
19
(Registrar)
PARENTS
18 BIRTHPLACE OF
FATHER (City)
(Siate or country)
Russia
19 MAIDEN NAME
OF MOTHER
Tobe Cohen
20 BIRTHPLACE OF
MOTHER (City)
(State or country)
Russia
21
Informant
(Address)
118-Bainbridge St. Malden
I HEREBY CERTIFY that a satisfactory standard certificate of death was filed with me BEFORE the burial or transit permit was issued: brugessin 20
(Signature of Agent of Board of Health or other) 175657
(Oficial Designation)
(Date of Issue of Permit)
phs
1
V.B.V
TICTIONS OR ML:ERTIFICATE
niving P DEATH Rt enter ennan one se or each ) and (c)
dir mot mean od of dying, art failure. Ur. It means 4 or compli- sich caused
rge, if any, D'e rise to use (a), De under- lise last.
di. ms contrib- n dtk but not 10 10 terminal caltion given
-4
:- hspter ¥37. f 34. requires cis to print or th esuse or # t desth on cesficates, and :er B. Acts of recires Physi- to Int or type une· signature.
>R5- 1962
60-$1145
[(Was deceased a
{U. S. War Veteran.
lil so specily WAR)
no
Winthrop Mass.
.. St.
9 COLOR
White
10 SINGLE
(write the word)
MARRIED
WIDOWEDM
or DIVORCED
Married
November 20 19 61
to ..
January 31
I last saw h .. imalive on ... January ........ 31 ........ , 19.62 .... , death is said to have occurred on the date stated above, at 7:35 A. m. INTERVAL BETWEEN ONSET AND DEATH
DEATH WAS CAUSED BY : IMMEDIATE CAUSE
(2) CARDIA RESPIRATORY FAILURE
WANT 13 Usual
Occupation :
Manufacturer
(Kind of work done during most of working lile)
14 Industry
or Business :
Retired
15 Social Security No.
025 18 4818
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