USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1963 > Part 11
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SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE. RANK, RATING
ORGANIZATION AND OUTFIT
SERVICE NUMBER
PLACE OF DEATH
Suffolk
(County) Winthrop
(City or Town)
No.
55 Bellevue Ave.
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. 51
[(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.)
V.I .. 239 Ilensan.T ST. '55 Bellevue Ave. (a) Residence. No. (Usual place of abode)
St.
30 (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
PERSONAL AND STATISTICAL PARTICULARS
3 DATE OF
DEATH
MARCH
10
1963
(Year)
8 SEX
Female
9 COLOR
White
widow
10 SINGLE
(write the word)
MARRIED
WIDOWED
or DIVORCED)
4 1
HEREBY CERTIFY, That I attended deceased from
NOVEMBER 20, 1952, to MARCH 10
1963
I last saw h. .... alive on
MARCH 9
19.
63, death is said to
have occurred on the date stated above, at 10:00 A
... m.
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a) ACUTE MYOCARDIAL INSUFFIENCY
INTERVAL
BETWEEN
ONSET AND
DEATH
10a If married, widowed, or divorced
HUSBAND of
Albert W Abbott
(Give maiden name of wife in full)
(or) WIFE of
(Husband's name in full)
11 IF STILLBORN, enter that fact here.
85 2
21
If under 24 hours
Hours ............ Minutes
13 Usual
Occupation :
Housewife
14 Industry
or Business :
At Home
15 Social Security No.
002-03-1027
birmingham
16 BIRTHPLACE (City)
(State or country)
England
17 NAME OF
FATHER
Francis Davis
18 BIRTHPLACE OF FATHER (City) (State or country) England
19 MAIDEN NAME
Elizabeth
20 BIRTHPLACE OF MOTHER (City) (State or country) Lnclend
21 Informant
Albert L Abbott
(Address) 4 Bald Rock au. Cochituate, 1.05.
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)
Pugnale 17, 1963
(Date of Issue of Permity
1 V.F. V
RUCTIONS FOR . CERTIFICATE
giving OF DEATH not enter : than one e for each (b) and (c)
does not mean de of dying, heart failure, etc. It means se, or compli- which caused
ions, if any, gave rise to cause (a), · the under- cause last.
ditions contrib- death but not o the terminal condition given
n -.
. Chapter 137, 1954, requires ns to print or ne cause or of death on ertificates, and 48, Acts of quires Physi- print or type der signature.
. .. inthrop
.inthrop
6
....
Place of Burial or Cremation
March
(City or Town) 19
7 NAME OF
FUNERAL, DIRECTOR
Howard J Reynolds
.. ... ..
ADDRESS
Received and filed
MAR 12 1963 19
(Registrar)
PARENTS
(Signed)
Dorothy Cheney appleton
M. D.
OF MOTHER
DOROTHY Cheney APPLETON
(PRINT OR TYPE SIGNATURE)
(Address) 197 Woodside WINTERASE
Date MARCH 11 1963
5 YRS
Due To
(c)
HYPERTENSION
10YRS
OTHER SIGNIFICANT CONDITIONS
Was autopsy performed?
No
What test confirmed diagnosis ?
5 Was disease or injury in any way related to occupation of deceased? NO If so, specify
IDAY
12
AGE
Years.
Months.
.. Days
(Kind of work done during most of working life)
Due To
(b)
HYPERTENSIVE HEART DISEASE
(Month) (Day)
liinnie G (Davis) Abbott
PHYSICIAN - IMPORTANT [(Was deceased a { U. S. War Veteran, [if so specify WAR)
14
MI R-301A 1
-6-59-925686
(Official Designation)
DATE OF BURIAL
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE.
RANK, RATING
ORGANIZATION AND OUTFIT
SERVICE NUMBER
-
11 12 1.
OFFICE
NiW
GEERK
65
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.
MAR 1 21963 AM
RECEIVED
OF.TOWR
ORM R-301
for burial permit bard of Health its Agent. TRUCTIONS FOR L CERTIFICATE
FOR 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
ions, if any, gave rise to cause (a), the under- cause last.
ditions contrib- death but not to the terminal condition given
1.0.
PLACE OF DEATH
Suffolk (County)
1
Winthrop (City or Town)
The Commonwealth of Massachusetts KEVIN H. WHITE SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS
STANDARD CERTIFICATE OF DEATH
Registered No.
.......
52
[(If death occurred in a hospital or institution, St. ¿ give its NAME instead of street and number)
Ida Saran Tick Doodlesack
(If deceased is a married, widowed or divorced woman, give also maiden name.)
(a) Residence. No.
17 Cutler St.
(Usual place of abode)
Length of stay: In place of death,2.
.years ......... months ......... days. In place of residence >
.years.
.months .......... days.
MEDICAL CERTIFICATE OF DEATH
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
Female
9 COLOR
White
10 SINGLE
MARRIED
WIDOWED
DIVORCED
UNKNOWN
(write the word)
Widowed
11 If married, widowed, or divorced
HUSBAND of
(Give maiden name of wife in full)
(or) WIFE of.
Hyman Doodlesack
(Husband's name in full)
12
AGE 77 Years
Months ..
Days
If under 24 hours
Hours ....
Minutes
13 Usual
Occupation :
House-wife
(Kind of work done during most working life)
14 Industry
or Business:
At home
15 Social Security No ..
none
16 BIRTHPLACE (City)
(State or country)
Poland
17 NAME OF
FATHER
William Blotnick
PARENTS
18 BIRTHPLACE OF
FATHER (City)
Po.Land
(State or country)
19 MAIDEN NAME
OF MOTHER
Esther (unknown)
20 BIRTHPLACE OF
MOTHER (City)
(State or country)
Poland
21 Informant
William Tick
( Address)
40 Court St., Boston
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),
Pilarch. 11,196.3
(Official Designation)
(Date of Issue of Permit)
A TRUE COPY ATTEST:
(Registrar) ||
........
PHYSICIAN -- IMPORTANT
(Was deceased a
U. S. War Veteran,
(if so specify WAR).
No
Winthrop
St
(If nonresident, give city or town and State)
3 DATE OF
DEATH
MARCH
10
1963
(Month)
(Day)
(Year)
4 I HEREBY CERTIFY,
That, I attended deceased from
July
19 52
MARCH 10
19
63
......
to ....
I last saw h&M.falive on
MARCH 10
1963
death is said to
have occurred on the date stated above, at
7:00Pm.
INTERVAL BETWEEN ONSET AND DEATH
3yrs.
Due To
(b)
Due To (c)
OTHER
SIGNIFICANT
NONE
CONDITIONS
No
Was autopsy performed?
What test confirmed diagnosis? Clinical
1
5 Was disease or injury in any way related to occupation of deceased ? If so, specify .......
(Signature)
Oleartes Liberman
. D.
CHARLES LIBERMAN
(Address WINTHROP, MASS Date.
3/10/1963
Isaac Elchonon
Everett
Place of Burial or Cremation
(City or Town)
DATE OF BURIAL
March
12
19 63
7 NAME OF
FUNERAL DIRECTOR
Paul R. Levine
ADDRESS
470 Harvard St.,
Brookline
Received and filed
MAR 11 1963
19
.......
62-932382
X
No ...... 17 Cutler St.
(City or Town making this return)
2 FULL NAME
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a) Hypertensive-Coronary Artery
Heart Disease
(Print or Type Name)
6
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 uhs .. . related to any form of injury.
3 75
(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.
MR-301A
1
PLACE OF DEATH
Suffolk (County) Winthrop
(City or Town)
The Commonwealth of Massachusetts EDWARD J. CRONIN SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS
STANDARD CERTIFICATE OF DEATH
Registered No. 53
[(If death occurred in a hospital or institution,
St. [give its NAME instead of street and number)
MORRIS BARD
2 FULL NAME
(If deceased is a married, widowed or divorced woman, give also maiden name.)
21 Pearl Avenue
St.
Winthrop Mass.
(a) Residence. No.
(Usual place of abode)
(If nonresident, give city or town and State)
3
Length of stay: In place of death
3
.. years.
months
_. days. In place of residence
years.
months.
days.
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
DEATH
MARCH
12
1963
(Month)
(Day)
(Year)
4 I HEREBY CERTIFY,
That I attended deceased from
JULY
28
50
to.
1963
MAR. 12
I last saw h//h alive on
MAR 12 1963,
death is said to
have occurred on the date stated above, at
845 A
m.
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a)
ACUTE CORONARY INFARCTION
Due To CHRONIC MYOCARDIAL DIS (b)
+ ARTERIO-SCLEROTIC HEART DIS
Due To (c)
OTHER
SIGNIFICANT
CONDITIONS
NONE
Was autopsy performed?
Nu
What test confirmed diagnosis? ....
CLINICAL
5 Was disease or injury in any way related to occupation of deceased NO If so, specify
(Signed Japon b. King MN M. D. 22/2 PLEASANTOST MAR 12 1963 (Address) INFIERAR AINSI Date.
Beth El. Cem 6
Baker St W Rox.
Place of Burial or Cremation
(City or Town)
DATE OF BURIAL
March 13th
63
7 NAME OF
FUNERAL DIRECTOR
Philip Briss
ADDRESS+70. Harvard St Brookline
Received and filed MAR 13 1963 19
(Registrar)
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
male
9 COLOR
white
10 SINGLE
(write the word)
MARRIED
WIDOWED married
or DIVORCED
10a If married, widowed, or divorced
HUSBAND of
Dora Shapiro.
(or) WIFE of.
(Husband's name in full)
11 IF STILLBORN, enter that fact here.
70
12
AGE
Years.
Months
.. Days
If under 24 hours
Hours ...... Minutes
13 Usual
Occupation :
self employed
or Business:
15 Social Security No ..
UNKNOWN
16 BIRTHPLACE (City) ..... Israel
(State or country)
17 NAME OF
FATHER
Isaaih Bard
18 BIRTHPLACE OF
FATHER (City)
(State or country)
Israel
19 MAIDEN NAME
OF MOTHER
Gittel (unknown)
20 BIRTHPLACE OF
MOTHER (City)
(State or country)
Israel
21 Dora Bard
Informant
(Address)
21 Peerl Ave. Winthrop Mass
I HEREBY CERTIFY that a satisfactory standard certificate of death was filed with me BEFORE the burial or transit permit was issued : Ralph E . fireanni (3) (Signature of Agent of Board of Health or other)
Health Care
(Official Designation))
(Date of Issue of l'ermit)
Draud 13 19613
TV.KV
.- THIS IS A NENT RECORD. Ise only E APPROVED ink or black writer ribbon.
TRUCTIONS FOR L CERTIFICATE n giving OF 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
ions, if any, gave rise to cause (a), the under- cause last.
itions contrib -- > death but not to the terminal condition given n. c. . Chapter 137, 1954, requires ans to print or he cause of of death on ertlicates. HAP. 46, 55 9 & AP. 114 $$ 45, CHAP. 38 $ 6.)
. 10.58-923600
DI.A
No.
21 Pearl Avenue, Winthrop
To be filed for burlal permit with Board of Health or its Agent.
PHYSICIAN - IMPORTANT
(Was deceased a
U. S. War Veteran,
NO
if so specify WAR)
(Give maiden name of wife in funl)
INTERVAL
BETWEEN
ONSET AND
DEATH
15MIN
14YRS.
(Kind of work done during most of working life)
14 Industry
Merchant
PARENTS
SPACE FOR ADDITIONAL INFORMATION. TOWA
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE
OFF
Mi !!!
RANK, RATING
B
6
ORGANIZATION AND OUTFIT
NTHROR
SERVICE NUMBER
LERK
MAR 1 31983 AM
RULES OF PRACTICE
The fulfillment of the purpose of these laws calls for the observance of the follow- ing rules of practice:
(1) Attending physicians will certi y to such deaths only as those of persons to whom they have given bedside care during a last illness from disease unrelated to any form of injury.
(2) Board of Health physicians will certify to such deaths only as those of persons who, though disabled by recognized disease unrelated to any form of injury, have died without recent medical attendance or whose physician is absent from home when the certificate of death is needed.
(3) Medical Examiners will investigate and certify to all deaths supposably due to injury. These include not only deaths caused directly or indirectly by traumatism (including resulting septicemia), and by the action of chemical (drugs or poisons) 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 disat led 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 import- ant, 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. Children not gainfully employed may be returned as at school or at home. For a woman whose only occupation was that of hore housework, write housework. For a person engaged in domestic service for wages, however, designate the occupation by the appropriate terms, as housekeepe. - private family, cook-hotel, etc. For a person who had no occupation whatev 'r write none.
The Commonwealth of Massachusetts KEVIN H. WHITE SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS (City or Town making this return;
STANDARD
CERTIFICATE OF DEATH
Registered No. 541
f(If death occurred in a hospital or institution, St. ¿ give its NAME instead of street and number) PHYSICIAN - IMPORTANT
2 FULL NAME. KATHARINE
(If deceased is a married, widowed or divorced woman, give also maiden name.)
73 WOODSIDE
AUF
St WINTHROP MASS,
(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
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
FEMALE
9 COLOR
WHITE
10 SINGLE
MARRIED
WIDOWED
(write the word)
SINGLE
UNKNOWN
11 If married, widowed, or divorced HUSBAND of (Give maiden name of wife in full)
(or) WIFE of.
(Husband's name in full)
12
AGE 95 Years - Months."
Days
13 Usual
Occupation :
MAID
(Kind of work done during most of iworking life)
14 Industry
or Business :.
HOUSE WORK
15 Social Security No.
025-26-5848
16 BIRTHPLACE (City). (State or country ) NOVA SCOTIA
17 NAME OF
FATHER
HUGH MCISAAC
18 BIRTHPLACE OF
FATHER (City)
(State or country)
NOVA SCOTIA
19 MAIDEN NAME
OF MOTHER
NOT KNOWN
20 BIRTHPLACE OF
MOTHER (City).
(State or country)
NOVA SCOTIA
21 Informant
MRS. EDWARD HANNAFORD
(Address)
75 WOODSIDE AVE, WINTHROP
I HEREBY CERTIFY that a satisfactory standard certificate of death was filed with me BEFORE the burial or transit permit was issued: Kniph E. Aireanni (3) (Signature of Agent of Board of Health or other) Health Officer
mendla 19196-3
(Date of Issue of Permit)
-62-933404
2622
FORM R-301
d for burial permit Board of Health its Agent. STRUCTIONS FOR AL CERTIFICATE
IT OR TYPE OR CAUSES F DEATH
not enter re than one se for each ), (b) and (c)
does not mean sode af dying, s heart failure, a, etc. It means ease, or campli- which caused
litions, if any, h gave rise to e cause (a), ng the under- cause last.
nditians contrib- to death but nat to the terminal condition given
WINTHROP CEM.
WINTHROP
(City or Town)
6
Place of Burial or Cremation
DATE OF BURIAL
MARCH
19
, 1963
7 NAME OF
FUNERAL DIRECTOR
MAURICE W. KIRBY
ADDRESS 210 WINTHROP, MASS.
Received and filed MAR 19 1963. 19
A TRUE COPY ATTEST:
PLACE OF DEATH
SUFFOLK (County) WINTHROP (City or Town)
LINSE PETITEPU
WINTHROP
CONV. HOME
MC ISAAC
(Was deceased a
U. S. War Veteran,
(if so specify WAR)
no
(a) Residence. No ..
(Usual place of abode)
MARCH
16
1963
(Month)
(Day)
(Year)
4 I HEREBY CERTIFY
6-19-
1959, to
3-16-63
19
I last saw haftlive on 3-16-63, 19 ., death is said to
have occurred on the date stated above, at
1030 Pm.
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
UREMIA.
INTERVAL BETWEEN ONSET AND DEATH
WWEEK
Due To ARTERIOSCLEROSIS
(b)
Due To CHRONIC NEPHRITIS
(c)
OTHER SIGNIFICANT CONDITIONS
W'as autopsy performed?
What test confirmed diagnosis ?
5 Was disease or injury in any way related to occupation of deceased ?
If so, specify
NO
(Signatury a.M. Caplan A. M.CAPLAN MD (Print or Type Name) (Address 186PRINCETON STEB Date: 3 -18 1963
M. D.
PARENTS
(Official Designation) ( Registrar )
1
No ..
3 DATE OF
DEATH
That I attended deceased from
(a)
If under 24 hours
Hours ...... . Minutes
1 YEAR
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE
RANK, RATING
TOW. .OF
ORGANIZATION AND OUTFIT
SERVICE NUMBER
6
ROR.
RULES OF PRACTICE
The fulfillment of the purpose of these laws calls for following rules of practice :
MARselv 91983h&M
(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.
ORM R-304
PLACE OF DELIVERY No.
Suffolk (County )
Winthrop (City or Town)
Winthrop Community Hospital
The Commonwealth of Massachusetts JOSEPH D. WARD SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS CERTIFICATE OF FETAL DEATH (STILLBIRTH)
To be filed for burial permit with Board of Health or its Agent.
Registered No. 55
(If death occurred in a hospital or institution, give its NAME instead of street and number)
3 DATE OF
DELIVERY
March 18, 1963 ( Month )
( Day)
(Year )
4 SEX
Male. X.Female .....
Undetermined.
5 COLOR (if
determined)
W
6 THIS BIRTH (Check one)
Single. X
Twin
Triplet
7 IF MULTIPLE BIRTH, BORN :
1st .. . ... 2nd
.3rd
FATHER
MOTHER
14
MAIDEN NAME
PRESENT NAME
Doris Larle
Doris Imbrici
9 RESIDENCE, NO. 0
16 Paris Street
.. STAT
STREET
Mass
15
RESIDENCE, NO.
CITY OR TOWN
16 Paris
STREET
E. Boston,
STATE.
Mass.
10 COLOR OR RACE White
11 AGE AT TIME OF
THIS DELIVERY
49 .(Years)
16 COLOR OR
RACE ..
W
18 PLACE OF
BIRTH
(City or Town
Maine (State or country )
(Cu:
13 OCCUPATION Retired
20 PREVIOUS DELIVERIES TO MOTHER (Do not include this fetus) TWO
(a) How many children are
now living ?
3
(b) How many children were born alive but are now dead? 0
(c) How many previous fetal deaths of ANY gestation age ? 0
21 LENGTH OF PREGNANCY 40 .completed weeks
22 WEIGHT OF FETUS 8 Lb. 15 Grams )
Oz.
23 WHEN DID FETUS DIE Y Before Labor
24 AUTOPSY
Yes
No
25 FETAL DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a) Prolapse of Cord
Due To (b) Due To (c)
OTHER SIGNIFICANT
CONDITIONS
None
26
Holy Cross Cemetery Malden
Place of Burial or Cremation
March
22
(City or Town) .63
19
27 NAME OF FUNERAL DIRECTOR
Vincent Rapino
ADDRES 9 Chelsea t., East Boston, Mass.
Received and filed
MAR 21 1963 19
Registrar )
I HEREBY CERTIFY that this delivery occurred on the date stated above at7 : 20A . m., and product of conception was not a live birth.
Signature of Attending Physician or Medical Examiner :
1
M.D.
Maurice Traunstein, Jr., M.D. (PRINT OR TYPE SIGNATURE)
Address 73 Bartlett Road
Date
3/18
1963
I HEREBY CERTIFY that a satisfactory certificate of fetal death was filed with me BEFORE the burial or transit permit was issued :
Parph
(Signature of Agent of Board of Health or other ) . Health Officer (Official Designation )
march 21,1963"
(Date of Issue of Permit )
In giving CAUSE OF ETAL DEATH
do not enter more than one cause for each of (a), (b) and (c)
·tal or maternal ndition causing tal death (do 't use such ·ms as stillbirth prematurity.) ·tal and/or ma- ·nal conditions, any, which gave se to above use (a), stating e underlying use last.
nditions of fetus mother which hy have contrib- ed to fetal ath, but, in so . as is known. re not related | cause given (a).
5M-6-60-928241
1
2 NAME OF FETUS (if given)
Baby Boy Imbrici.
A TRUE COPY ATTEST.
19 INFORMANT
Ralph Imbrici (father)
During Labor or Delivery
Unknown
17 AGE AT TIME OF
THIS DELIVERY 38
.(Years)
12 PLACE O
BIRTH
Italy
4
DATE OF BURIAL
(or
CITY OR TOWN
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