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