Town of Winthrop : Record of Deaths 1963, Part 38

Author: Winthrop (Mass.)
Publication date: 1963
Publisher:
Number of Pages: 574


USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1963 > Part 38


Note: The text from this book was generated using artificial intelligence so there may be some errors. The full pages can be found on Archive.org (link on the Part 1 page).


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TOR 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 amy, cave rise to cause (a). the under. cause last.


ditions contrib- death but mot to the terminal condition given


104 141 X72


r Directon use only -CK Ink. F17 1963 5-2-933404


OUT- OF - TOWN SUFFOLK


187


(City or Town making this return)


No .. MASSACHUSETTS GENERAL HOSPITAL .....


......


(Was deceased a U. S. War Veteran, if so specify WAR) no.


(write the word)


PARENTS


......... Withauf Kan:


Y AVTEST. Race.


RECEIVED


OF TOW.


7: 12 1


OFFICE


GLERK


NIIN


65


SS


WINTHROP.


OCT 1 /71963 AM


PLACE OF DEATH


( OUT - OF - TOWN


SUFFOLK


(County)


-


BOSTON


(City or Town)


KEVIN H. WHITE SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS STANDARD CERTIFICATE OF DEATH


188


(City or Town making this return)


Registered No.


08626


f(If death occurred in a hospital or institution, St. ( give its NAME instead of street and number) PHYSICIAN - IMPORTANT


2 FULL NAME


Harry


Blaustein


(If deceased is a married, widowed ot divorced woman, give also maiden name.)


(a) Residence. No.


14h Quincy Avenue


Winthrop 52, Mass.


(Usual place of abode)


Length of stay: In place of death .......... years ....... months. 1 days. In place of residence/ 5 years.


....... months .......... days.


MEDICAL CERTIFICATE OF DEATH


PERSONAL AND STATISTICAL PARTICULARS


8 SEX


MALE


9 COLOR


WHITE


10 SINGLE


MARRIED


WIDOWED


DIVORCED


UNKNOWN


(write the word)


MARRIED


11 If married, widowed, or divorced HUSBAND of GOLDIE


(or) WIFE of


( Husband's name in full)


12


AGE 64 Years Months


.Days


If under 24 hours


Hours ..


.. Minutes


13 Usual


Occupation :


PAINTER-CONTRACTOR ( Kind of work done during most of iworking life)


14 Industry


or Business :.


RETIREd


15 Social Security No 034-14-3368


16 BIRTHPLACE (City) BROOKLYN, NY. (State or country)


17 NAME OF FATHER SAMUEL BLAUSTEIN


18 BIRTHPLACE OF


FATHER (City).


(State or country)


RUSSIA


19 MAIDEN NAME


OF MOTHER


ANNA CNBL


20 BIRTHPLACE OF


MOTHER (City) ..


(State or country)


ROUMANIA


21 Informant


WILLIAM BLAUSTEIN


(Address) 14 CARPENTER Rd, LYNNField


I HEREBY CERTIFY that a satisfactory standard certificate of death was filed with me BEFORE the burial or transit permit was issued: 7.P. Graça 309311


(Signature of Agent of Board of Health or other)


aug.2511963


(Date of Issue of Permit)


T. V.B. /


Xi


ORM R-301


or burial permit rd of Health Agent. RUCTIONS FOR CERTIFICATE


OR TYPE OR CAUSES DEATH


ot enter than one for each (b) and (c)


oes not mean e of dying, heart failure, etc. It means se, or compli- which caused


ons, if any. gave rise to cause (a), the under. cause last.


itions contrib- death but not the terminal ondition given . C.


Was autopsy performed ?


What test confirmed diagnosis ?


5 Was disease or injury in any way related to occupation of deceased ? If so, specify


(Signature)


David W. Eller M. D. DAVID D ULMER M D (Print or Type Name) August241963


PETERSBENT BRIGHAM HOSPITTAS


6 SHARON MED. PARK


SHARON


l'lace of Burial or Cremation


(City or Town)


DATE OF BURIAL


AUGUST 25,


1963


7 NAME OF


FUNERAL DIRECTOR


ARNOLD GOLOV


ADDRESS 1668 BEACON ST. BROOKLINE


Williamf. Kane.


19


AUG 2 7 353


2-933404


MEDICAL EXAMINER DECLINED JURISDICTION


4WeHEREBY CERTIFY , ThatWGattended deceased from August ........ 2.3, 19 ... 6.3 ..... , to.August 24 19 ... 63


I last saw h.h.lalive on August 24 19.6.3, death is said to


have occurred on the date stated above, at


2:40 am.


DEATH WAS CAUSED BY: IMMEDIATE CAUSE


Ventricular fibrillation


INTERVAL BETWEEN ONSET AND DEATH LOmin.


(a)


1)ue To


Myocardial Infarction


(b)


Due To Arteriosclerotic and Hyper- (c) tensive heart disease


7 hrs yrs.


OTHER SIGNIFICANT CONDITIONS


August


24.


19.6.3


(Month)


(Day)


(Year)


(Was deceased a


U. S. War Veteran,


if so specify WAR).


No


(City or town and State)


No.


PETER BENT BRIGHAM HOSPITAL


(Registrar)|| (Official Designation)


A TRUE COPY ATTEST


PARENTS


X70


17 1963


3 DATE OF


DEATH


BONNER


(Give maiden name of wife in full)


A TRUE COPY


TOWA


OF


10.


1110


NIW


CLERK


8


WII


5


6


MASS


OCT 1 71963 AM


1


1


ORM R-301


or burial permit rd of Health Agent. RUCTIONS FOR CERTIFICATE


OR TYPE OR CAUSES DEATH ot enter than one for each (b) and (e)


oes not mean le of dying, heart failure. etc. It means se, or compli- which caused


ons, if any. gove rise 10 cause (a), the under- cause last.


titions contrib. death but not o the terminal endition riven


7 1963 3ª 70


Directen use only CK Ink. .


PLACE OF DEATH


OUT - OF - TOWN SUFFOLK


(County)


I


BOSTON


(City or Town)


The Commonwealth of dassarhuselid KEVIN H. WHITE SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS


STANDARD


CERTIFICATE OF DEATH


Registered No.


[(If death occurred in a hospital or institution, .. St. ¿ give its NAME instead of street and number) PHYSICIAN - IMPORTANT


2 FULL NAME.


(a) Residence. No ..


33.Atlantic


.S ...


Winthrop Masss


(City or town and State)


Length of stay: In place of death .years 1 month 14


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)


Married


4 1 HEREBY CERTIFY , That Wwattended deceased from


.July 11


19 63


to ..... August .... 25.


1963


we last saw


IfLalive on


August 25


1953., death is said to


have occurred on the date stated above, at


10:15am.


DEATH WAS CAUSED BY: IMMEDIATE CAUSE


Ruptured Aneurysm R Anterior


(a) ....


Cerebral Artery


INTERVAL BETWEEN ONSET AND DEATH 6 Wks


Due To


Essential.Hypertension


Unknown


Due To (c)


OTHER


SIGNIFICANT Pneumonia., ..... B .... P.yocyaneus.


CONDITIONS


4 WIss


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


(Signature)


M. D.


(Print or Type Name) (Address) Ase'A Diny Moser Gen' Hosp, Dat August 25. 63


New Calvary Cemetery Boston


6


Place of Burial or Cremation


(City or Town)


DATE OF BURIAL


August ..... 28 ..


19.6.3


7 NAME OF


FUNERAL DIRECTOR


Arthur J. O'Maley


ADDRESS Winthrop Mass


thanh KaceG. 231 A. M (Lease


(Signature of Agent of Board of Health or other)


17552


8-26-63


(Date of Issue of Permit)


- +


A TRUE COPY ATTEST:


11 If married, widowed, or divorced


HUSBAND of


(Give maiden name of wife in full)


Leo W. Pelletier


(or) WIFE of.


( Husband's name in full)


12


AGE. 57 .. Years.


Months.


Days


13 Usual


Sail maker


Occupation :


(Kind of work done during most of iworking life)


14 Industry


or Business :


Sails


15 Social Security No ....


030-03-1090


Jamaica Plain


16 BIRTHPLACE (City)


(State or country)


Mass.


17 NAME OF FATHER Andrew J. O' Connell


PARENTS


18 BIRTHPLACE OF


FATHER (City).


(State or country)


Ireland


19 MAIDEN NAME


OF MOTHER


Bridget Green


20 BIRTHPLACE OF


MOTHER (City).


(State or country)


Ireland®


21 Informant


Leo W. Pelletier


(Address)


....


33 Atlantic ..... St., ..... Winthrop


I HEREBY CERTIFY that a satisfactory standard certifcate of death Kas filed with me BEFORE the burial or transit permit was issued:


(Registrar) || (Official Designation)


1.89


(City or Town making this return)


08697


No. MASSACHUSETTS. GENERAL HOSPITAL .. Mary M. Pelletier Mary . Bolletier (If deceased is a married, widowed or divorced woman, give also maiden name.)


(Was deceased a


U. S. War Veteran,


if so specify WAR)


No


(Usual place of abode)


3 DATE OF


DEATH


August 25.


(Month)


(Day)


(Year)


63


If under 24 hours


Hours ........ Minutes


- (b)


62-933404 .


TOW


OF


11.12


OFF


GLERK


5


THROR.


OCT 1 71963 AM


A TRUE COPY MEN


..


1


Boston


(City or Town)


The Commonwealth of Massachusetts KEVIN H. WHITE SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS


190


(City or Town making this return)


STANDARD


CERTIFICATE OF DEATH


Registered No.


[(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.)


158 Circuit Road


Winthrop, Massachusetts


St


(City or town and State)


Length of stay: In place of death ......... years .......... months.26.days. In place of residence.C ..... years ......... months .......... days.


MEDICAL CERTIFICATE OF DEATH


PERSONAL AND STATISTICAL PARTICULARS


8 SEX


male


9 COLOR


white


10 SINGLE


(write the word)


MARRIED


WIDOWED


DIVORCED Married


UNKNOWN


11 If married, widowed, or divorced


skdie Nicciche


HUSBAND of


(or) WIFE of.


(Husband's name in full)


12


AGE ..


6.9.ears. . 6


Months. 1.1 Days


If under 24 hours


Hours ........ Minutes


13 Usual


Occupation :...


Printer


(Kind of work done during most of ;working life)


14 Industry


or Business:


Printing ..


15 Social Security No.0.10-05-6892


16 BIRTHPLACE (City)


(State or country)


Italy


17 NAME OF


FATHER


Charles Emma


PARENTS


18 BIRTHPLACE OF


FATHER (City)


(State or country)


Italy


19 MAIDEN NAME


OF MOTHER


Lillian Locigno


20 BIRTHPLACE OF


MOTHER (City)


(State or country)


Italy


21 Informant


V. Sadie Emma


158 Circuit Rd., winthrop


(Address)


I HEREBY CERTIFY that a satisfactory standard certificate of death was filed with pre BEFORE the burial or transit permit was issued : Formex


(Signature of Agent of Board of Health or other)


175-99 8/29/69


(Date of Issue of Permit)


V.B.


A TRUE C


COPY ATTEPece


wwf. Kace"


INTERVAL BETWEEN ONSET AND DEATH /wk.


(a)


(b) Biliary & Portal destruction.


(c) Due Frassive Kictostases-Carein of rectum


OTHER


Diffuse Arteriosclerosis. several


CONDITIONS


years


Was autopsy performed ?


Yes-


What test confirmed diagnosis V ...


S Was disease or injury in any way related to occupation of deceased ? If so, specify


(Signature Porph T. Detrole M. D. Joseph T. Ostroski


...........


(Print or Type Name)


(Address) NEDA Date. 8/27 1963


St. Michael Cemetery, Boston 6 Place of Burial or Cremation (City or Town)


DATE OF BURIAL AUS. 30 63


19.


7 NAME OF


FUNERAL DIRECTOR


Ernest P. Caggiano


147 Winthrop St., Winthrop


ADDRESS


Received LAUG-3-0-1963 ....... 19


62-933404


PLACE OF DEATH


ORM R-301


for burial permit ard of Health to Agent. RUCTIONS FOR . CERTIFICATE


· OR TYPE OR CAUSES DEATH not enter : than one e for each (b) and (c)


does mat mean de of dying. heart failure. etc. It means ase, or compli- which caused


ions, if any, gave rise ta cause (a), the under. cause last.


ditions contrib- death but nat to the terminal condition given


54 48 x7/ 17 1963


OUT - OF - TOWN Suffolk


(County)


No.


New England Deaconess Hospital


Mr. Philip Emma


(Was deceased a


U. S. War Veteran,


(if so specify WAR) ..


no


(a) Residence. No ..


(Usual place of abode)


3 DATE OF


DEATH


August


26.


1.95.3


(Month)


(Day)


(Year)


4 I HEREBY CERTIFY, That I attended deceased from


July 31


19.


63


to.


August


26


19.63


I last saw himalive on


August ... 26.


19 ... 63death is said to


have occurred on the date stated above, at .7 .: 25 .... p.m.


(Give maiden name of wife in full)


DEATH WAS CAUSED BY: IMMEDIATE CAUSE Hepatic failure


Tur.


(Registrar) || (Official Designation)


A TRUE COPY ATTIST!


1 porce.


OF TO


71 12


OFFICE


10.


ERK


W


6


MASS


THROF


OCT 1 71963 AM


you


PLACE OF DEATH


- OF - TOWN Suffolk


(County)


Boston (City or Town)


The Commonwealth of Massachusetts KEVIN H. WHITE SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS


.44.


191


(City or Town making this return)


Registered No.


En Route East Boston Roligt No.


(If death occurred in a hospital or institution,


( give its NAME instead of street and number)


2 FULL NAME


agnes.


(First


(Middle Name)


Ford ( Good)


PHYSICIAN - IMPORTANT


( Was deceased a


U. S. War Veteran,


No


(if so specify WAR)


(If deceased is a married, widowed or divorced woman, give also maiden name.)


435 Winthrop St,


Winthrop


St


(If nonresident, give city or town and State)


25


PERSONAL AND STATISTICAL PARTICULARS


3 DATE OF


DEATH


Sept


1


1963


(Month)


(Day)


(Year)


4I 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.) Arterioscleratic Heart


5 Accident, suicide, or homicide (specify)


Date and hour of injury


19


IF ACCIDENTAL, was injury causally refated to the death? Where did Injury occur ? ..... (City or town and State)


Did injury occur in or about home, on farm, in industrial place, or public place ?


.....


......


.....


.


6 Was disease or injury in any way related to occupation of doceased?


., M. D. George Wockyfis


Typ Name) Santi 1963


Winthrop


(City or Town)


63 19


8 NAME OF FUNERAL DIRECTOR Ernest P Caggiano


147 Winthrop St. Winthrop


ADDRESS


Received and filed velicaned Icauc


A TRUE COPY ATTEST:


(Registrar) Tar)


PARENTS


18 NAME OF FATHER Mitchell Goodine


19 BIRTHPLACE OF


FATHER (City)


....


Frederikson


(State or country)


Maine


20 MAIDEN NAME.


OF MOTHER


Margaret Chesie.


21 BIRTHPLACE OF


MOTHER (City)


Frederickson


-


(State or country)


Maine.


John Goodine


22 Informant (Address) 23 Catherine RdBryantville


I HEREBY CERTIFY that a satisfactory standard certificate of death was filed with me BEFORE the burialor transit permit was issued: German


(Signature of Agent of Boardof Health or other)


77670 4-6-63


(Official Designation)


(Date of Issue of Permit)108


Widowed


12 If married, widowed, or divorced HUSBAND of


(Gi. ..... )'", name of wife in full)


(or) WIFE of


John J. Ford


Ausband's name in full)


13


AGE. 65 Years


Months .... .. Days


Laundress


14 Usual


Occupation:


(Kind of work done during most of working life)


Domestic


15 Industry Business :


.......


....


025-26-9538


Social Security No.


17 BIRTHPLACE (City)


....


Vanceboro


(State of country ) gaine.


9 SEX


Female


IO COLOR


White


MARRIED


WIDOWED


DIVORCED)


UNKNOWN


Length of stay: In place of death. ....... .. years .............. months. days. In place of residence. .years ....... months .............. davs.


(a) Residence. No. (Usual place of abode) MEDICAL CERTIFICATE OF DEATH Disease Manner of (Specify type of place) Injury Nature of (How did injury occur ?) Injury If so, specify (Signed) (Address) 784 Mass ...... Date winthro Cemetery 7 Place of Burial or Cremation. Sept 5 DEATH in plain terms, so that it may be properly classified under the International Classification of Causes information should be carefully supplied. MEDICAL EXAMINERS should state CAUSE AND MANNER OF of Death. See reverse side for additional information. See also Chap. 38, §§ 6, 20; Chap. 46, §§ 9, 10; Chap. 114, If deceased was a U. S. War Veteran, G.L. Chap. 46, Section 10, requires physicians to insert a recital to that effect. ff 44-48. DATE OF BURIAL 100M - 3-62-932695 N. B .- WRITE PLAINLY, WITH UNFADING BLACK INK-THIS IS A PERMANENT RECORD. Every item of While at work ? Was autopsy performed!


420 171600 to


R-303 1


or burial permit rd of Health · Agent.


MEDICAL EXAMINER'S CERTIFICATE OF DEATH


(Last Name)


II SINGLE


(write the word)


If under 24 hours Hours .... .. Minutes


RECEIVED


A TRUE C TY ATTEST:


Wirauf Kan C.


1: 12 OFFICE City Registrar W OF TOW


CLERK


6


MASS.


OCT 1 21963 AM 4


1


A


X


RM R-301


or burial permit rd of Health s Agent. UCTIONS FOR CERTIFICATE OF - TOWN


OR TYPE R CAUSES EATH ot enter than one for each (b) and (e)


es mat mean of dying. heart failure. esc. It means e, or campli. which caused


ms, if amy. ave rise ta cause (a), the under. cause last.


itions contrib. death but not the terminal ndition given


583 10%


30 1963


Directen use only CK Ink.


2-933404


OUT - OF - TOWN


SUFFOLK


(County)


Ī


BOSTON


(City of Town)


The Commonwealth of Massachusetts KEVIN H. WHITE SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS STANDARD CERTIFICATE OF DEATH


200010 192


(City or Town making this return)


Registered No.


09173


No .. MASSACHUSETTS GENERAL HOSPITAL


f(If death occurred in a hospital or institution, St. ( give its NAME instead of street and number) PHYSICIAN - IMPORTANT


2 FULL NAME Martha Ingraham


( Lungren )


( If deceased is a married, widowed or divorced woman, give also maiden name.)


Shirley


1197 A Sherry Street


Winthrop, Mass.


(a) Residence. No.


(Usual place of abode)


Length of stay: In place of death .......... years .......... months.


......... days. In place of residence


years.


months .......... days.


PERSONAL AND STATISTICAL PARTICULARS


8 SEX


Female


9 COLOR


White


10 SINGLE


(write the word)


DEATH


(Month)


(Day)


(Year)


4 I HEREBY CERTIFY,


September 19


63


September


9


That Iwallended deceased from


19


63


we last saw h .... . alive on


er


September


9


62death Is said to


19


have occurred on the date stated above, at


11:173 m.


DEATH WAS CAUSED BY: IMMEDIATE CAUSE


(a) HEMORRHAGE .... INTO .... UPPER


INTERVAL BETWEEN ONSET AND DEATH


Due To


G. I. TRACT


( b ) .


... HEPATITIS


? DAYS


13 Usual


Occupation :


Nurse


( Kind of work done during most of working life)


14 Industry or Business:


15 Social Security No ...


030-14-5607


16 BIRTHPLACE (City)


(State or country )


Hartford, Conn.


17 NAME OF


FATHER


C.B.L


18 BIRTHPLACE OF


FATHER (City)


C.B.L.


(State or country )


19 MAIDEN NAME


OF MOTHER


C.B.L.


20 BIRTHPLACE OF


MOTHER (City) ..


(State or country)


C.B. L.


21 Informant


George Ingraham


497A Shirley St. Winthrop


I HEREBY CERTIFY that a satisfactory standard certificate of death was filled with me BEFORE the burial or transit permit was issued: Sampania Bo 9652


(Signature of Ment of Board of Healty or other)


(Date of Love of Permite) 9/10/63


(Official Designation)


T. V. B. 2


A TRUE COPY ATTESTI


11 If married, widowed, or divorced


HUSBAND of


(Give maiden name of wife in full)


George .... Ingraham


(or) WIFE of.


12


63


7


Months ...


Days


If under 24 hours


...


.. Hours ........ Minutes


Due To (c)


OTHER


SIGNIFICANT


CONDITIONS


Was autopsy performed ?


Yes


What test confirmed diagnosis ? ..


Autopsy


5 W'as disease or injury in any way related to occupation of deceased ?


If so, specify ..


CO.Clay


M. D.


Charter Ly Clox, M. D.


(Pfint or Type Name)


PARENTS


Sept. 910 63


(Address) A Dler, Masa Can't, Hos .Date.


Mt. Auburn


Cambridge


6


Place of Ilurial or Cremation


(City or Town)


DATE OF BURIAL


Sept. 11


63


7 NAME OF


FUNERAL DIRECTOR


Vincent J. Mazzarella


ADDRESS


971 Saratoga St. East Boston


Received and filed William& Jant SEP & b (Registrar)|


19.


St.


(Was deceased a


U. S. War Veteran,


if so specify WAR)


No


(City or town and State)


MEDICAL CERTIFICATE OF DEATH


3 DATE OF


September


9


1963


MARRIED,


WIDOWEDMarried


DIVORCED


UNKNOWN


( Husband's name in full)


3 HRS


Years


(Signature)


PLACE OF DEATH-


A TRUE COPY ATTEST:


1


1


1.2.


PERE VED


OF


TOW


OFFICE


KLERK


ت


W


2.


5


MAS


NTHRO


OCT 3 01963 AM


1


X


PLACE OF DEATH


Suffolk


(County)


1


Boston


(City of Town)


The Commonwealth of Massachusetts KEVIN H. WHITE SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS STANDARD CERTIFICATE OF DEATH


193


(City or Town making this return)


Registered No.


09329


f(If death occurred in a hospital or institution, St. | give its NAME instead of street and number) PHYSICIAN - IMPORTANT


2 FULL NAME.


William LEVIN


(If deceased is a married, widowed or divorced woman, give also maiden name. )


62 Shore Drive


St.


Winthrop,


Mass .


(a) Residence. No.


(Usual place of abode)


Length of stay : In place of death .......... years


1 months. 17


.days. In place of residence .......... years .....


.months ..... .... days.


MEDICAL CERTIFICATE OF DEATH


PERSONAL AND STATISTICAL PARTICULARS


8 SEX


Male


9 COLOR


White


10 SINGLE


(write the word)


MARRIED


WIDOWE Married


DIVORCETM


UNKNOWN


11 If married, widowed, or divorced


HUSBAND of


Pauline .... Kramer


(or) WIFE of


(Husband's name in full)


12


AGE72


Years.


7


Months 11


Days


If under 24 hours


Hours


Minutes


13 l'sual


Occupation


Retired accountant


( Kind of work done during most of working life)


14 Industrv or Business.


15 Social Security No


16 BIRTHPLACE (City)


(State or country }


Massachusetts


17 NAME OF


FATHER


Simon


Levin


18 BIRTHPLACE OF


FATHER (City)


(State or country)


Russia


19 MAIDEN NAME


OF MOTHIER


Minna Bernstein


20 BIRTHPLACE OF


MOTHER (City).


(State or country )


Russia


Fuller St Cem. Everett, Mass.


6


Place of Burial or Cremation,


(City or Town)


DATE OF BURIAL


Sept 17 1963


19.


7 NAME OF


FUNERAL DIRECTOR


Levine Funeral


Home


(Address)


Boston, Mass.


I HEREBY CERTITY that satisfactory standard certificate of death was filled with me DEPOLE the burial or transit permit was issued:


1


hoxerson


Received and filed


SEP 1 9 1963


19


Williamf. Kane


1785


(Singatan of Agent of Board of Health or other> 9/6/63


(Date of Issue of Vermit)


, VB


A TRUE COPY ATTEST:


RM R-301


or burial permit rd of Health s Agent. UCTIONS FOR CERTIFICATE


.


OR TYPE R CAUSES EATH t enter than one for esch b) und (c)


es not mean of dying, heart failure. etc. It means e, or compli- which caused


ms,' if any. ave rise ta cause (a). the under. cause last.


tians tontrib. death but not the terminal adition given nc .


53.8 47 X7/ 30 1963


5 Was disease or injury in any way related to occupation of deceased? If so, specify


(Signature )


M. D.


KEVIN .... D .... O'BRIEN, M.D.


VA Hospital, Boston


Sept. 16.63


(Address)


.Date


PARENTS


VA Hospital Records


21 Informant


150 So. Huntington Ave.


470 Harvard St. Brookline, Mass.


ADDRESS


September


15


1963


(Month)


(Day) VA


(Year)


4 IHEREBY CERTIFY,


July 29


1963


. 10


September 15.


63


That


attended deceased from


XXXXXXXXXXXXXXXXXXXXXXXXXxxxxxx death is said to have occurred on the date stated above, at 11:45P .. m.


DEATH WAS CAUSED BY: IMMEDIATE CAUSE


(a) Metastatic carcinoma


Due To


of colon


(b)


Due To (c)


OTHER


SIGNIFICANT


CONDITIONS


Was autopsy performed ?


No


Clinical & Lab. findings


What test confirmed diagnosis


INTERVAL BETWEEN ONSET AND DEATH


years


(('ity or town and State)


Veterans Administration Hospital


No.


62-934553


(Registrar )| (Official Designation)


Boston


(Give maiden name of wife in full)


3 DATE OF


DEATH


(Was deceased a


U. S. War Veteran,


Cif so specify WARI.


WW L


A TRUE COPY ATTEST:


1


1


1


City Registrar


RECE VED


OF TOWN


1440


i !!


CLERK


WII


6


THROP.


OCT 3 01963 AM


X OUT - OF - TOWN


SUFFOLK


(County)


BOSTON


(City or Town)


The Commonwealth of Massachusetts KEVIN H. WHITE SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS STANDARD CERTIFICATE OF DEATH


94


BOSTON


(City or Town making this retu.


09443


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


Emerald Emery.


(If deceased is a married, 'widowed or divorced woman, give also maiden name.)


61 Ihrshall Strect


Winthrop, lass.


St


10


Length of stay: In place of death ......... years .. ...... months .......


35


days. In place of residence- years months days.


MEDICAL CERTIFICATE OF DEATH


3 DATE OF


September


18


1963


DEATH


(Month)


(Day)


(Year)


+ IHEREBY CERTIFY , That wettended deceased from


September 8 19 63


Septover


218 . 19 63


f last saw h


alive on


12:05a


.m.


have occurred on the date stated above, at


INTERVAL BETWEEN ONSET ANO DEATH


DEATH WAS CAUSED BY: IMMEDIATE CAUSE


(a) Bronchopneumonia


Due To


(b) Aspiration Pneumonia


6 Days


Due To


(c)


Left Cerebral Infarct


OTHER


SIGNIFICANT


CONDITIONS


Coronary Heart Disease


Severe


Vrg


W'as autopsy performed ?


Yes


What test confirmed diagnosis?


Autopsy


5 Was disease or injury in any way related to occupation of deceased ? If so, specify


(Signature)


M. D.


Charles L. Clay, M.D. (Print or Type Name) (Address) Aus't. Dir., Mass. Can't. Hosp. Date Sept. 18 63


1.


6 Place of Ilurial or Cremation


(City of Town)


DATE OF BURIAL


19.


7 NAME OF


FUNERAL DIRECTOR


2


ADDRESS


Received and hled


SEP 2 3-1963


19


William f. Kane


PERSONAL AND STATISTICAL PARTICULARS


8 SEX


9 COLOR


its.


10 SINGLE


MARRIED


WIDOWED


DIVORCED ..


UNKNOWN


(write the word)


ido .. .. d'


11 If married, widowed, or divorced HUSBAND of


(Give maiden name of wife in full)


(or) WIFE of


(Husband's name in full)


4


Days


.Years.


Months.


24


Days


If under 24 hours


Hours


Minutes


13 L'sual


Occupation :


(Kind of work done during most of iworking life)


14 Industry


of Business:


Social Security No. 020-24-2007


16 BIRTHPLACE (City )For ( State of country)


17 NAME OF


FATHER


18 BIRTHPLACE OF


FATHER (City)


(State or country)


19 MAIDEN NAME


OF MOTHER


J


20 BIRTHPLACE OF MOTHIER (City). (State or country )


10


21 Informant


.4.


(Address)


I HEREBY CERTIFY that y surisfactory standard certificate of death was Aled with me BEFORE one burial or transit permit was issued:


Sispaty got Agent of sound of Health of other )


17899


8 9/63


( Registrari|| (Official Designation)


(Date of Kove of Permit)


- V.B.A


1


burial permit of Health Agent.


CTIONS R ERTIFICATE


R TYPE CAUSES .ATH enter an one or each ) and (e)


of dying. art failure. c. It means or compli- ich caused


. if any. ve rise to use (a). he under. use last. - ons contrib- ath but not he terminal dition given


20, 8/ 570 30 1963 Director s. only :: Ink.


933404


PLACE OF DEATH


No. MASSACHUSETTS GENERAL HOSPITAL


(Was deceased a


U. S. War Veteran. ......


(if so specify WAR) ..


(a) Residence. No ..


(Usual place of abode)


(City of town and State)


September


18 63


death is said to


10 Days


AGE 2


17


PARENTS


...


A TRUE COPY ATTEST:


RM R-301


A TRUE COPY ATTEST:


1


-


Chy Registrar


RECE VED


TOW:


OF


32 1


E


BLEKK


140


6 5


THROR MA


OCT 3 01963 AM


1


1


ORM R-301


for burial permit ard of Health ts Agent. RUCTIONS FOR CERTIFICATE


OR TYPE OR CAUSES DEATH not enter than one for each (b) and (c)


aes Rat man le af dying. heart failure. etc. It means se, or campli- which caused H.C ions, if any, gave rise ta cause (a). the under- cause last.




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