USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1963 > Part 37
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ORM R-301
1
Sipt 50
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE
RANK, RATING
ORGANIZATION AND OUTFIT
SERVICE NUMBER
.
1
RULES OF PRACTICE SEP 3 01963 /M
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.
ORM R-301
for burial permit ard of Health ts Agent. RUCTIONS FOR CERTIFICATE
OR TYPE OR CAUSES DEATH ot enter than one for each (b) and (c)
oes mat mean le af dying, heart failure, etc. It means se, or campli- which caused
ons, if any, gave rise to cause (a), the under- cause last.
litians contrib- death but nat o the terminal ondition given
PLACE OF DEATH
Suffolk
(County)
1
Winthrop
(City or Town)
Winthrop Community Hospital No.
§(If death occurred in a hospital or institution,
St. ¿ give its NAME instead of street and number)
2 FULL NAME.
Ferrara, Baby Boy
(If deceased is a married, widowed or divorced woman, give also maiden name.)
225 Endicott Ave
.St
Revere
(a)
Residence. No.
(Usual place of abode)
Length of stay: In place of death .......... years .......... months .......... days. In place of residence .......... years ......... months .........
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
9
DEATH
(Month)
(Day)
(Year)
4 I HEREBY CERTIFY , That I attended deceased, from
SEPT
27. 19.63
63
to SEPT 27
I last saw himlive on
SEPT 27
19.6.3 death is said to
have occurred on the date stated above, at 110Am.
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
HYALINE MEMBRANE DIS
Due To
(b)
PREMATURITY
Imo.
Due To (c)
OTHER
SIGNIFICANT
CONDITIONS
NONE
Was autopsy performed?
No
What test confirmed diagnosis? CLINICAL & X-RAY
5 Was disease or injury in any way related to occupation of deceased ... If so, specify
(Signature) myron r Kung M. D. MYRONN. KING MD
(Address)
WINTHE
6
woodlawn
Everett Loss
Place of Burial or Cremation (City or Town)
DATE OF BURIAL
19 .... 65.7
7 NAME OF
FUNERAL DIRECTOR
Ernest P Caggiano
ADDRESS 14 ISt intur Of
Received and filed
SEP 30 1963
19
( Registrar )
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
9 COLOR
White
10 SINGLE
MARRIED
WIDOWED
DIVORCED
UNKNOWN
Single
11 If married, widowed, or divorced HUSBAND of
(Give maiden name of wife in full)
INTERVAL BETWEEN ONSET AND DEATH (or) WIFE of 12 1 day AGE .......... Years .. ....... Months ......... ... Days
(Husband's name in full)
If under 24 hours
A .. Hours ........ Minutes
13 Usual
Occupation :
(Kind of work done during most working life)
14 Industry
or Business :
NONE
15 Social Security No .....
16 BIRTHPLACE (City)
(State or country )
17 NAME OF
FATHER
John Ferrara Jr.
18 BIRTHPLACE OF
FATHER (City)
(State or country)
Doston
19 MAIDEN NAME
OF MOTHER
1
Joen Nolan
20 BIRTHPLACE OF MOTHER (City). (State or country)
Revere
21 Informant
John Ferrara ....
(Address)
225 Tudicott Ave everc
I HEREBY CERTIFY that a satisfactory standard certificate of death was filed with me BEFORE the burial or transit permit was issued: Capl
(Signature of Agent of Board of Health or other) Herethe officer 9/28/63
(Official Designation) 6
(Date of Issue of Permit)
X
62-932382
A TRUE COPY ATTEST:
TEVERE 10: 3-63
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.
1.83
PHYSICIAN - IMPORTANT
(Was deceased a
U. S. War Veteran,
if so specify WAR).
(write the word)
Male
......
(If nonresident, give city or town and State) days.
27
1963
(a)
NOIVO
winthe
PARENTS
(Print or Type Name> LIZPLEASANT Date.
€ 9/28 19 63
Sept 28
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, 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.
RM R-301
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
Registered No.
184
11 TRIDENT Ave
§(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 Veteranl,
if so specify WAR).
NO
(a) Residence. No ...
Il TRIDENT
Ave
.St
WINTHROP
(If nonresident, give city or town and State)
Length of stay: In place of death .......... years .......... months .......... days. In place of residence.A ..... years ..
....... months .......... days.
MEDICAL CERTIFICATE OF DEATH
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
M
9 COLOR
White
10 SINGLE
MARRIED
WIDOWED
DIVORCED
UNKNOWN
(write the word)
MARRIED
11 If married, widowed HUSBAND of
or divorced Sophie
HOFFMAN
"(Give maiden name of wife in full)
(or) WIFE of
(Husband's name in lul1)
Months ...
.. Days
13 Usual
Occupation :
CABINET MAKERS
(Kind of work done during most working life)
14 Industry
or Business:
FURNITURE MFG
15 Social Security No ...
16 BIRTHPLACE (City)
(State or country )
Russia
PARENTS
17 NAME OF
FATHER
NATHAN BRAVERMAN
18 BIRTHPLACE OF
FATHER (City)
(State or country)
Russia
19 MAIDEN NAME
OF MOTHER
SARAH
CBC
20 BIRTHPLACE OF
MOTHER (City)
(State or country)
Russia
21 Informant
HAROLD BRAVERMAN
(Address)
11 TRIDENT Ave Winthrop
I HEREBY CERTIFY that a satisfactory standard certificate of death was filed with me BEFORE the burial or transit permit was issued:
1
(Signature of Agent of Board of Health or other)
1/29/63
(Date of Issue of Permit)
6
TX
A TRUE COPY ATTEST:
1963
(Year)
4 IHEREBY CERTIFY , That I attended deceased from
Feb
19 63
to.
Sept. 28
, 1963
I last saw hiwalive on
sept.
27, 163, death is said to
have occurred on the date stated above, at
9:00A.m.
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a) Emphysema
Due To
(b)
Due To (c)
OTHER
Arteriosclerotic Heart
CONDITIONS
Disease
8mos
NO
Was autopsy performed?
What test confirmed diagnosis ?
Clinical.
5 Was disease or injury in any way related to occupation of deceased ? Va If so, specify
(Signature)
Charles Liberman
M. 1).
CHARLES
LIBERMAN
(Address)
(Print or Type Name)
WINTHROP, MASS Da
9/28/1963
6
STARO CONSTANTINO
W. Roxbury
Place of Burial or Cremation
(City or Town)
DATE OF BURIAL
Sept 29
63
7 NAME OF
FUNERAL DIRECTOR
TORE Funeral Service In
151 Washington ave Chelsea
ADDRESS
Received and filed
SEP 30 1963
19
(City or Town making this return)
ISADORE BRAVERMAN
(If deceased is a married, widowed or divorced woman, give also maiden name.)
2 FULL NAME ..
for burial permit rd of Health s Agent. UCTIONS FOR CERTIFICATE
OR TYPE OR CAUSES DEATH ot enter than one for each (b) and (c)
oes not meon e of dying, heart foilure, etc. It meons se, or compli- which coused
A
ons, if any, gave rise to couse (o), the under- cause lost.
itions contrib- death but not the terminal ondition given C
52-932382
3 DATE OF
September 28
DEATH
(Month)
(Day)
(Usual place of abode)
No.
( Registrar )| (Official Designation)
If under 24 hours
Hours .......
.Minutes
INTERVAL BETWEEN ONSET AND 12 DEATH yours AGE. 72
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE -
RANK, RATING
ORGANIZATION AND OUTFIT
SERVICE NUMBER
1
RULES OF PRACTICE
The fulfillment of the purpose of these laws calls for the observance of the following rules of practice : SEP 3 01563 AM
(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.
RM R-301
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
Registered No. 185
[(If death occurred in a hospital or institution, St. ¿ give its NAME instead of street and number)
PHYSICIAN - IMPORTANT
2 FULL NAME.
(If deceased is a married, widowed or divorced woman, give also maiden name.)
(a) Residence. No ..
16 Lincoln St.
St
Winthrop ,Mass
(If nonresident, give city or town and State)
Length of stay: In place of death. .years .... months ......... days. In place of residence 35 2 ... years. ....... months .......... days.
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
DEATH
September
30,
1963
(Month)
(Day)
(Year)
4 IHEREBY CERTIFY, That I attended deceased from
1:1 cup
19 60,
Sept. 30
1963
I last saw hetalive on Sept. 30, 1963 death is said to have occurred on the date stated above, at 2:50 Am.
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a) Coronary
Thrombosis
INTERVAL BETWEEN ONSET AND DEATH 1/2 kr
(b)
arteriosclerosis-qua
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)
prepar Aregone, M. D.
Joseph GREGORIE
(Print or Type Name)
(Address).
194 Washington ale
9/30 63 19
6 Winthrop
Winthrop
Place of Burial or Cremation
(City or Town)
DATE OF BURIAL
oct. 2
63 19.
7 NAME OF
FUNERAL DIRECTOR
Howard & Foynolds
ADDRESS
.inthron, Las :.
Received and filed OCT 1 1963 19
(Registrar)|
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
9 COLOR
(write the word)
Female
Thite
11 If married, widowed, or divorced HUSBAND of
(Give maiden name of wife in full)
Clifford !. hall
(or) WIFE of
(Husband's name in full)
12
.72
9
1
If under 24 hours
Hours
Minutes
13 Usual
digion clerk
Occupation'
(Kind of work done during most working life)
14 Industry
or Business :
Hospit-1
15 Social Security No.
013-28-5498
16 BIRTHPLACE (City)
(State or country )
Cifloride
17 NAME OF
FATHER
Charles Cole
18 BIRTHPLACE OF
FATHER (City).
(State or country)
Lass
19 MAIDEN NAME
OF MOTHER
Leurs . CLey Land
20 BIRTHPLACE OF MOTHER (City) (State or country)
Carmel
laine
21 Informant
Mildred Car bine
(Address) 16 Lincoln St. Mithrop, Menc.
I HEREBY CERTIFY that a satisfactory standard certificate of death was filed with pre BEFORE the burial or transit permit was issued:
(Signature of Agent of Board of Health or other)
Let 11763
(Official Designation) (Date of Issue of Permit)
A TRUE COPY ATTEST:
62- 2382
r burial permit d of Health Agent. CTIONS OR ERTIFICATE
R TYPE CAUSES CATH tenter han one or each ) and (c)
s not mean of dying, part failure, c. It means or compli- ich caused
s, if any, vve rise to use (a), le under- use last.
ions contrib- uth but not The terminal o ition given
(City or Town making this return) ....
WinthropCommunity Hospital No ....
Marion Hall
(Cole)
(Was deceased a
U. S. War Veteran,
if so specify WAR)
(Usual place of abode)
2 hour
10 SINGLE
MARRIED
WIDOWED
DIVORCED
UNKNOWN widow
AGE
Years.
Months
Days
PARENTS
Boston
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE
RANK, RATING
ORGANIZATION AND OUTFIT
SERVICE NUMBER.
RULES OF PRACTICE
The fulfillment of the purpose of these laws calls for the observance of the following rules of practice : (1) Attending physicians will certify to such deaths only as those of persons to whom they have given bedside care during a last illness from disease 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 6 occupation by the appropriate terms, as housekeeper-private family, cook hotel, etc. For a person who had no occupation whatever write none. HROP.
. . 1
OCT 1 1963 AM
M R-303
ed for burial permit Board of Health r its Agent.
Injury (Address) Death. See reverse side for additional information. See also Chap. 38, §5 6, 20; Chap. 46, §§ 9, 10; Chap. 114, DEATH in plain ternis, so that it may be properly classified under the International Classification of Causes Largased was a U. S. War Veteran, G.L. Chap. 46, Section 10, requires physicians to insert a recital to that effect. ............. information should be carefully supplied. MEDICAL EXAMINERS should state CAUSE AND MANNER OF -WRITE PLAINLY, WITH UNFADING BLACK INK-THIS IS A PERMANENT RECORD. Every item of Nature of Injury
1-3)62-932695
PLACE OF DEATH
SUFFOLK
1
(County)
BOSTON
(City or Town)
Che Commonwealth of Alassachusetts KEVIN H. WHITE SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS
186 OUT - OF - TOWN
(City or Town making this return)
Registered No.
07806
215 Charles St., Boston
[(If death occurred in a hospital or institution,
St. ? give its NAME instead of street and number)
PHYSICIAN - IMPORTANT
2 FULL NAME
JOHN
J
GORMAN
(First Name)
(Middle Name)
(Last Name)
(If deceased is a married, widowed or divorced woman, give also maiden name.)
(a) Residence. No.
(Usual piace of abode)
Length of stay: In place of death.
............ years .............. months ..............
days. In place of residence 5 years.
.. months ..
davs.
MEDICAL CERTIFICATE OF DEATH
PERSONAL AND STATISTICAL PARTICULARS
11 SINGLE
(write the word)
MARRIED
WIDOWEDMarried
DIVORCED
UNKNOWN
12 If married, widowed, or divorced
HUSBAND of
Catherine ..... Boland
(or) WIFE of
(Husband's name in full)
46 13 AGE Years.
.Months ..
If under 24 hours
Hours ............ Minutes
14 Usual
Occupation :
Medical Doctor (Kind of work done during most of working life)
15 Industry on Business : ....... Pediatrician
K Social Security No. 039-10-8125 ...
17 BIRTHPLACE (City)
....
Central Falls ...
(State of country )
Rhode Island
18 NAME OF FATHER James H. Gorman
19 BIRTHPLACE OF
FATHER (City)
(State or country)
England
20 MAIDEN NAME
OF MOTHER
Margaret Dalton
21 BIRTHPLACE OF MOTHER (City) (State or country)
Ireland
7 .M.t ....... S.t ...... Mary ..!. s. ....... Pawtucket , ...... R .I .....
I'lace of Burial or Cremation.
(City or Town)
DATE OF BURIAL .....
August ...... 1
1963
8 NAME OF
FUNERAL DIRECTOR
Arthur J. O'Maley
ADDRESS Winthrop Mass
AUG 2 1963
Received and fried ".
Withany Kane.
(Registrar)
PARENTS
Sono, M. D.
(Suned), Michael A. Luongo, Vel
Boston ( Print or Rype Kame)
Date
7/30
63
19.
Catherine ..... Gorman
22 Informant (Address) 240 Pleasant St., Winthrop
I HEREBY CERTIFY that a satisfactory standard certificate of death was fiol with me BEFORE the burial or transit permit was issued: Argerator
(Signature o) Agent of Board of Health or other)
18906
7/31/63
(Official Designation)
(Date of Issue of Permit)
.......
240 Pleasant Street
St Winthrop, Massachusetts
(If nonresident, give city or town and State)
3 DATE OF
DEATH
July
29,
1963
(Month)
(Day)
(Year)
4 I HEREBY CERTIFY that I have investigated the death of the person above-named and that the CAUSE AND MANNER thereof are as follows : (If an injury was involved, state fully.) Asphyxia, due to hanging.
5 Accident, suicide, or homicide (specify)
Suicide.
Date and hour of injury
July 29,
19.
.63
IF ACCIDENTAL, was injury causally related to the death ?
Injury occur ?
Where did
Boston, Massachusetts
(City or town and State)
Did injury occur in or about home, on farm, in industrial place, or
public place ?
Cell-door of Jail
(Specify type of place)
Manner of
Suspension by undershirt.
(How did injury occur ?)
While at work ?
Was autopsy performed? ...
Yes.
6 Wardisease or injury in any way related to odeupavon of deceased ?
......
X
IN DEATH CERTIFICATES.
63
A TRUE COPY ATTEST:
9 SEX
Male
10 COLOR
White
(Give maiden name of wife in full)
No.
MEDICAL EXAMINER'S CERTIFICATE OF DEATH
[(Was deceased a
U. S. War Veteran,
[if so specify WAR) ..
A TRUE COPY ATTEST:
Williamf Kane 7 1
RECEIVED
IF
TOW 11.12 1
KLERK
10.
4 (MIN)
8
W
THRO
OCT 3 1963 PM
...
7
PLACE OF DEATH
(County)
-
BOSTON
(City or Town)
The Commonwealth of Massachusetts KEVIN H. WHITE SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS
STANDARD CERTIFICATE OF DEATH
Registered No.
08188
[(If death occurred in a hospital or institution. St. ( give its NAME instead of street and number) PHYSICIAN - IMPORTANT
2 FULL NAME ..
Eva Hambro
(If deceased is a married, widowed or divorced woman, give also maiden name.)
(a) Residence. No .....
15.5 .... River .... Road.
(Usual place of abode)
St.Winthrop, Massachusetts
......
(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
DIVORCED
UNKNOWN
widowd
11 If married, widowed, or divorced HUSBAND of
(or) WIFE of.
Morris Hambro
(Husband's name in full)
12
AGE.90
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 :
15 Social Security No ..
16 BIRTHPLACE (City)
(State or country)
Germany
17 NAME OF
FATHER
Abraham Mayer
18 BIRTHPLACE OF
FATHER (City)
(State or country)
Germany
19 MAIDEN NAME
OF MOTHER
Caroline (unknown)
20 BIRTHPLACE OF MOTHER (City) .. (State or country)
Germany
21 Informant
Mrs.Harold Rosen
38 Embassy Road, Brighton, Mass.
(Address)
I HEREBY CERTIFY that a satisfactory standard certificate of death was filed with me BEFOREThe burial or transit permit was issued: ( W) and kg
(Signature of Agent of Board of Health or other)
AUG 1 2 1983 218565
8-9-63
(Registrar)|| (Official Designation) (Date of Issue of Permit)
1 X
A TRUE COPY ATTEST:
MEDICAL EXAMINER TO COUNTERSIGN
Due To (b)
Due To (c)
OTHER SIGNIFICANT CONDITIONS
Was autopsy performed? no.
What test confirmed diagnosis ?
clinical
5 Was disease or injury in any way related to occupation of deceased ?
If so, specify
@@@low
(Signature)
M. D.
Charles L. Clay, M.D.
(Print or Type Name) (Address) Ass's .. Din, Mass. Gon'I, Hosp ...... Date. Aug ....... 8 .19 63
¿Hand in Hand.
West Roxbury
.....
Place of Burial or Cremation
(City or Town)
DATE OF BURIAL
August 9, 10 63
7 NAME OF
FUNERAL DIRECTOR
Benjamin F. Solomon
ADDRESS
420 Harvard Street Brookline
Received and filed 19
......
..........
............
3 DATE OF
DEATH
August
8
19.6.3
(Month)
(Day)
(Year)
4 IHEREBY CERTIFY , That Iwattended deceased from
19
.63.
August .... ] ...... , 19 .....
63 ... ..... August .... 8.
we last saw h .. Ellive on
August .... 8
19 ... 6.3 death is said to
have occurred on the date stated above, at
.6:15 ... p .... m.
(Giye maiden name of wife in full)
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a) Fracture of right hip
INTERVAL BETWEEN ONSET AND DEATH
1 week
X
ORM R-301
for burial permit ard of Health its Agent. TRUCTIONS FOR L CERTIFICATE
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