USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1963 > Part 39
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ditions contrib- death but not o the terminal condition giver
93.9 1 5
X71
30 1963
162-934553
PLACE OF DEATH
OUT - OF - TOWN X Suffolk
The Commonwealth of Massachusetts KEVIN H. WHITE SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS
BOSTON95
(City or Town making this return) 09445
Registered No.
S(If death occurred in a hospital or institution, St. { give its NAME instead of street and number) PHYSICIAN - IMPORTANT
WILLIAM F. FURNISS
2 FULL NAME
(If deceased is a married, widowed or divorced woman, give also maiden name.)
(Was deceased a U. S. War Veteran, WW2
if so specify WAR)
Winthrop, Mass.
St
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
Male
9 COLOR
White
10 SINGLE
(write the word)
MARRIEMarried
WIDOWEY
DIVORCED
UNKNOWN
11 If married, widowed, or, divorced
HUSBAND of
Mary G. Donovan
(Give maiden name of wife in full)
(or) WIFE of.
( Husband's name in full)
12
AGF53 .. Years .. 7
Months.
10 Days
If under 24 hours
Hours .....
Minutes
13 L'sual
Occupation
Office Manager
(Kind of work done during most of working life)
14 Industry or Business ..
15 Social Security No .. 012-03-0083
16 BIRTHPLACE (City) (State or country ) Massachusetts
17 NAME OF FATHER Edward
PARENTS
18 BIRTHPLACE OF
FATHER (City)
Worcester
(State or country)
Massachusetts
19 MAIDEN NAME
OF MOTHER
Katherine
20 BIRTHPLACE OF
MOTHER (City)
(State or country)
Boston
Massachusetts
Winthrop Com. Winthrop, Mass'. 6
l'lace of Burial or Cremation
(City or Town)
DATE OF BURIAL
Sept .21 1963
19
7 NAME OF
O' Malley Funeral Home
ADDRESS
79 Atlantic St., Winthrop, Mass.
SEP 2 3 1963
19
....
A TRUE COPY ATTEST:
I HEREBY CE TIEK that a satisfactory standard certificate of death was filed wal me BEFORE the burial ga transit permit was issued:
1
-
.
(Sknature of Agent of Board of Health as other)
17904
9/19/63
(Date of Issue of Permit)
VIBL
I
Boston
STANDARD
CERTIFICATE OF DEATH
(City or Town)
Veterans Administration Hospital
No.
(a) Residence. No.
366 Pleasant
(Usual place of abode)
(City or town and State)
Length of stay: In place of death ......... .years. 2 .months.20.days. In place of residenceiffars.
.months
days.
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
September
18
1963
DEATH
(Month)
(Day)
(Year)
4 I HEREBY CERTIFY.
ThaVA attended deceased, from
June 23
1963 . September 18
19.63
XXXXXX ., death is said to
7:10 Pm.
have occurred on the date stated above, at INTERVAL BETWEEN DEATH WAS CAUSED BY: IMMEDIATE CAUSE Glioblastoma multiform of ONSET AND DEATH 8
(a)
temporal parietal regional
Due To
(b)
Due To (c)
OTHER
SIGNIFICANT
CONDITIONS
Was autopsy performed ?
No
What test confirined diagnosis ?
Clinical º: Laboratory
5 Was disease or injury in any way related tooccupation of deceased ?
If so, specify
John C. Malio
(Signature)
John C. Daloo M.D.
M. D. VAH Bost8H" Mas's." Sept.19 63
(Address)
Date
19
21 Informant
VA Hospital Records, 150 So. Huntington Ave. ,Boston, Mass.
(Address)
FUNERAL DIRECTOR
Received and filed
Williams. Rauer
(Registrar )|| (Official Designation)
(County)
A TRUC COPY ATTAST: 1 William y Kane. City Registrar
REDE VED
TOWA
OF
1.36.1
OFF
CLERK
5
6
VII
THROP MASS
OCT 301963 AM
RM R-301
r burial permit d of Health Agent. ICTIONS OR CERTIFICATE
OR TYPE R CAUSES EATH t enter han one for each b) and (c)
es not mean of dying, least voiture. tc. It means , or compli- which caused
A
PLACE OF DEATH
X OUT- OF - TOWN SUFFOLK (County) - BOSTON (City of Town)
The Commonwealth of Massachusetts KEVIN H. WHITE SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS
STANDARD CERTIFICATE OF DEATH
196 BOSTON
(City or Town making this return.) 09490
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.)
185 GROVERS
Ave
St
WINTHROP
(City or town and State)
Length of stay : In place of death .......... years .......... months
days. In place of residence. years.
months. .days.
PERSONAL AND STATISTICAL PARTICULARS
8 SEX male
9 COLOR
white
10 SINGLE
(wrile the word)
MARRIED
WIDOWED)
DIVORCED married
UNKNOWN
11 If married, widowed, or divorced
HUSBAND of
Alice Marcus
(Give maiden name of wife in full)
(or) WIFE of
(Husband's name in lull)
12
Years ... ......
.Months
Days
If under 24 hours
Hours .....
Minutes
13 l'sual
Occupa
Merchant
( Kind of work done during most of working life)
14 Industrv
or Business :.
Fruit
15 Social Security No
16 BIRTHPLACE (City).
(State or country}
Boston,
Mass.
17 NAME OF
FATHER
David Schreiber
PARENTS
18 BIRTHPLACE OF
FATHER (City) ..
(State or country)
Germany
19 MAIDEN NAME
OF MOTHER
Hinda Manheimer
20 BIRTHPLACE OF
MOTHER (City)
(State or country)
Boston,
Mass,
21 Informant
Alice Schreiber
(Address )
185 Grovers Ave. Winthrop, Mass.
I HEREBY CERTIFY that a satisfactory standard certifcate of death was hled with me BEFORE the burial or transit permit was issued: Robert Leon ard
(Signature of Agent of Board of Health or other) 4-21-63
(Official Designation)
(Date of Issue ol Permit)
T VB.
A TRUE COPY ATTEST:
2 days
Due To (c)
OTHER SIGNIFICANT CONDITIONS
Was autopsy performed ?
yes
What test confirmed diagnosis?
5 Was disease or injury in any way related to occupation of deceased ? If so, specify
(Signature)
DAVID
ROSEN MD
(Print or Type Name) 330 ,BROOKLINE ANBate (Address) BOSTON Chevra Kadusha. (Montvale) Wobørn 6
Place of Burial or Cremation
(City or Town)
DATE OF BURIAL
September 22. ... 1, 63
7 NAME OF
Benjamin F. Solomon
FUNERAL DIRECTOR
ADDRESS 420 Harvard Street, Brookline.'
Received and fled
SEP 2 5 1963
19
William& Kaver
1 1963
(Month)
(Year)
+IHEREBY CERTIFY , That I attended deceased from
63.
19.
63
10
SEAT
19
SEPT .... 17
19
I last saw horalive on
SEPT
17
19
6?
death is said to
have occurred on the date stated above, at
6:21P.m.
DEATH WAS CAUSED BY: IMMEDIATE CAUSE SALUTE AND CHRONIC PLEIONEPHRITIS (a)
INTERVAL BETWEEN ONSET AND DEATH
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
DEATH
SEPT.
19
(Day)
Beth
ISRAEL HOSPITAL
No.
BENJAMIN F.
SCHREIBER
(Was deceased a
U. S. War Veteran,
(if so specify WARI
no
(a) Residence. No.
(Usual place of abode)
2-933404
as, if any, ave rise to omse (a). the under. ause last.
lions contrib. eath but not the terminal adition given . c 100 110
30 1963
David Rosen M. D.
Sept 14063
Due To CREIER LITHIASIS, LEFT (b)
A TRUE GARY ATTEST:
1
-
Chy Registrar
RECE VED
OF TOW
ERK
5º
6
ROT
OCT 301963 AM
1
I R-301
urial permit f Health ent. ONS IFICATE
TYPE AUSES TH iter one each nd (c)
ot mean dying, . failure, It means compli- caused
if any, rise to (a), under- last.
contrib- but not terminal on given
Was autopsy performed 20.
Charles Lieberman hunt
What test confirmed diagnosis ?
5 Was disease or injury in any way related to occupation of deceased A If so, specify ......
No
(Signature)
Charles Libe way M. D. CHARLES LIBERMAN
(Print or Type Name)
(Addre
WINTHROP, MASS Date 10/9/1963
Winthrop .... : Winthrop ==
I'dte of Burial of Cremation
(City or Town)
DATE OF BURIAL
October 5, ,63
7 NAME OF
FUNERAL DIRECTOR
Arthur J. O'Maley
ADDRESS Winthrop Mass
Received and filed John a. Clark
A TRUE COPY ATTEST:
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
Male
9 COLOR
White
10 SINGLE
MARRIED
WIDOWED Married
DIVORCED
UNKNOWN
Mahoney
(Give maiden name of wife in full)
(or) WIFE
(Husband's name in full)
12
AGI67
Years
Months.
Days
If under 24 hours
Hours.
Minutes
13 Usual
Occupation :
Clerk
(Kind of work done during most working life)
14 Industry
or Business: U.S. District Court
15 Social Security No ..
012-32-3695
16 BIRTHPLACE (City)
(State or country)
Mass
East Boston
17 NAME OF
FATHER
Patrick Canavan
PARENTS
18 BIRTHPLACE OF
FATHER (City)
(State or country)
Ireland
19 MAIDEN NAME
OF MOTHER
Emma Dubberley
20 BIRTHPLACE OF
MOTHER (City).
(State or country)
Nova Scotia
21 Informant
Ellen V Canavan
( Address)
212 Cottage Park Rd., Winthrop
I HEREBY CERTIFY that a satisfactory standard certificate of death was filed with me BEFORE the burial or transit permit was issued: Kaiph & Jejeanne(i)
(Signature of Agent of Board of Health or other)
Health officer
Cet 4 19615
(Date of Issue of Permit)
I
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.
197
S(If death occurred in a hospital or institution, St. { give its NAME instead of street and number)
PHYSICIAN ~ IMPORTANT
2 FULL NAME
John A. Canavan
(If deceased is a married, widowed or divorced woman, give also maiden name.)
(Was deceased a
U. S. War Veteran,
(if so specify WAR).
WW 1
(a) Residence. No ..
212 Cottage Park Road
(Usual place of abode)
(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
3 DATE OF
October 2
1963
DEATH
(Month)
(Day)
(Year)
4 I HEREBY CERTIFY , That I attended deceased from
19
to.
19
I last saw h ...... alive on 19 ., death is said to
have occurred on the date stated above, at
51 40Pm
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a) Death presumably que
(b)
Due To
to natural causes,
INTERVAL
BETWEEN
ONSET AND
DEATH
(c)
probably acute coronary
occlusion based on SIGNIFICANT history. Winthrop Board of Health
PLACE OF DEATH
Suffolk
WINTHROP
(City or Town making this return)
(County)
212 Cottage Park Road No ..
001 4 1963 19
(Registrar)|| (Official Designation),
2382
(write the word)
1 If married
HUSBAND of
.St
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE 8.6-18
DATE OF DISCHARGE
9-30-21
RANK, RATING
Seaman 2nd cl
ORGANIZATION AND OUTFIT U.S .Navy
SERVICE NUMBER
1.20-30.82
1.12 1
C
ERK
1:11
6
INTI
IR
P.
OCT - 41963 PM
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 fromn 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.
×
PLACE OF DEATH
SUFFOLKY (County) WINTHROP (City or Town)
No. 20 SHIRLEY ST
The Commonwealth of Massachusetts KEVIN H. WHITE SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS STANDARD CERTIFICATE OF DEATH
(City or Town making this returt.,
Registered No. 1.98
S(If death occurred in a hospital or institution, St. { give its NAME instead of street and number) PHYSICIAN - IMPORTANT
2 FULL NAME
OSCAR I SUNDBERG
(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
(a)
Residence. No.
20 SHIRLEY ST.
(Usual place of abode)
WINTHROP St
Length of stay: In place of death.
25
... months .......
... days. In place of residence 20 years.
nonth ... .. days.
MEDICAL CERTIFICATE OF DEATH
PERSONAL AND STATISTICAL PARTICULARS
3 DATE OF
DEATH
October
.5.
19.6.3
(Month)
(Day)
(Year)
4 IHEREBY CERTIFY, That I attended deceased from
March ..... 8., 19 .... 6.2.
.. , to.
Oct ...
19 .... 6.3 ...
I last saw h ..... alive on
1m
Oct . 4
16.3, death is said to
have occurred on the date stated above, at 3:20p .m.
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
acute bronchial pneumonia right
4 days
13 Usual
COMPOSITOR
(Kind of work done during most of iworking life)
14 Industry
or Business:
NEWSPAPERS.
OTHER SIGNIFICANT CONDITIONSLOSiS
Old healed .... tubercu-
12 yrs 16 BIRTHPLACE (City)
STOCKHOLM
(State or country ) SWEEDEN
Was autopsy performed?
no
What test confirmed diagnosis ? Clinical & laboratory
5 Was disease or injury in any way related to occupation of deceased ?NO If so, specify
(Signature)
4. Traunstein
M. D. M ....... Traunstein .... Jr .. ...... M ......... (Print or Type Name) 73 Bartlett Rd Oct .7 163
WINTHROP 0
WINTHROP
Place of Burial or Cremation
(City or Town)
DATE OF BURIAL
OCT 2
1943
7 NAME OF
FUNERAL DIRECTOR MAURICE W KIRBY
ADDRESS WINTHROP
Received and filed
OCT 7 1963
.19
( Registrar )
A TRUE COPY ATTEST:
PARENTSK
17 NAME OF FATHER OSCAR, SUNDBERG
18 BIRTHPLACE OF
FATHER (City)
(State or country)
SWEDEN
19 MAIDEN NAME
OF MOTHER
BABARA (UNKNOWN)
20 BIRTHPLACE OF MOTHER (City) ... (State or country) SWEDEN
21 Informant MPS CATHERINE SUNDBERG
(Adress) 20 SHIRLEY ST WINTHROP,
I HEREBY CERTIFY that a satisfactory standard certificate of death was filed with me BEFORE the burial or transit permit was issued: Kaiph & Serianni (3) (Signature of Agent of Board of Health or other) 1
Health officer Cletiber 7-63
(Official Designation) (Date of Issue of Permit)
T V.B V
8 SEX
9 COLOR
(write the word)
MALE
-
WHITE
10 SINGLE
MARRIED
WIDOWED
DIVORCED
UNKNOWN
MARRIED
SULLIVAN
(Give maiden name of wife in full)
INTERVAL BETWEEN ONSET AND DEATH 12
(or) WIFE of.
(Husband's name in full)
AGE 73 Years Months
Days
If under 24 hours Hours Minutes
Due To (b) Carcinoma of the urinary15 yrs
bladder
Due To
(c)
15 Social Security No. 011-05-5159
(Address)
1
burial permit of Health Agent. CTIONS R ERTIFICATE
R TYPE CAUSES ATH enter an one or each ) and (c)
not mean of dying, art failure, c. It means or compli- ich caused
s, if any, ve rise to use (a), he under- use last.
ons contrib- ath but not he terminal dition given
933404
(a)
Occupation :.
11 If married, widowed, or divorced HUSBAND of CATHERINE
(City or town and State)
RM R-301
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE
RANK, RATING
ORGANIZATION AND OUTFIT
SERVICE NUMBER
.
7
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.
X
PLACE OF DEATH
Suffolk (County)
Winthrop (City or Town)
No 20 silestone nd.
[(If death occurred in a hospital or institution, St. ( give its NAME instead of street and number) PHYSICIAN - IMPORTANT
2 FULL NAME
Harold E. Williams
(If deceased is a married, widowed or divorced woman, give also maiden name.)
(a)
Residence. No ..
20 Tilestone Rd.
St
Winthrop, Mass.
(City or town and State)
Length of stay: In place of death ..
4years
.. months .......... days. In place of residence.
.4.Qars.
.. months.
.days.
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
October - 5-
1963
DEATH
(Month)
(Day)
(Year)
4 IHEREBY CERTIFY, That I attended deceased from
19
to.
19
I last saw h ...... alive on
19 ........ , death is said to
have occurred on the date stated above, at
7:20 pm
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
Coronary Thrombosis
(a)
INTERVAL BETWEEN ONSET AND DEATH 4 Hrs
Due To
(b)
Due To (c)
WINTHROP
OTHER
SIGNIFICANT
CONDITIONS
BOARD OF HEALTH
Was autopsy performed ?
No
What test confirmed diagnosis ?
History + Clinical Course
5 Was disease or injury in any way related to occupation of deceased ? If so, specify
(Signature)
John F. Collins MD
M. D.
(Print or Type Name)
(Address)
Revere
Mass
Date
6 Oct
1963
Winthrop Cem, Winthrop, Mass.
6
Place of Burial or Cremanon
(City or Town)
DATE OF BURIAL
Oct. 8, 1963
19
7 NAME OF
Richard C. Kirby Inc
FUNERAL DIRECTOR
917 Bennington St., E. Bos
ADDRESS
Received and filed
OCT-7 -1963
19
(Registrar )
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
M
9 COLOR
W
10 SINGLE
MARRIED
WIDOWED Married
DIVORCED
UNKNOWN
11 If married, widowed, or divorced
Katherine J. Schwarz
HUSBAND of
(or) WIFE of
(Husband's name in full)
12
AGE.
68.
Years
Months ..
22
.Days
If under 24 hours
.Hours .. .... Minutes
13 Usual
Occupation :
Manager
(Kind of work done during most of ;working life)
14 Industry
or Business :
Steel Forgery
15 Social Security No ....
010-03-4152
16 BIRTHPLACE (City) .. .
(State or country)
East Boston
17 NAME OF
FATHER
William Williams
PARENTS
21 Informant
Mrs. Katherine Williams
(Address)
20 Tilestone Rd. Winthrop
I HEREBY CERTIFY that a satisfactory standard certificate of death was filed with me BEFORE the burial. or transit permit was issued: Ruspho A Verranno (1) (Signature of Agent of Board of Health or other) Health Officer Cant 7.1963
(Official Designation ) (Date of Issue of Permit)
T V. I.V
RM R-301
: burial permit of Health Agent. CTIONS R ERTIFICATE
R TYPE CAUSES CATH enter an one or each ) and (c)
s not mean of dying, cart failure, c. It means .or compli- ich caused
s, if any, ve rise to use (a), he under- use last.
ions contrib- ath but not the terminal dition given
by Kugrow King mts
Patient pronounced dead
-933404
A TRUE COPY ATTEST:
The Commonwealth of Massachusetts KEVIN H. WHITE SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS STANDARD CERTIFICATE OF DEATH
WINTHROP
(City or Town making this return)
1
Registered No.
(Was deceased a U. S. War Veteran, if so specify WAR) W.W.1
(write the word)
18 BIRTHPLACE OF
FATHER (City).
(State or country)
Vermont
19 MAIDEN NAME
OF MOTHER
Mable Young
20 BIRTHPLACE OF
MOTHER (City).
(State or country)
Boston
(Give maiden name of wife in full)
(Usual place of abode)
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE July 15 1918
DATE OF DISCHARGE
Dec. 23, 198
RANK, RATING
Pri. Est. Class
ORGANIZATION AND OUTFIT
4th Co. Army
SERVICE NUMBER
2798439
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.
1
6
OCT - 71963 AM
X
PLACE OF DEATH
Suffolk Winthrop
(County)
(City, or Town)
No. 297 Revere
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. 200
S(If death occurred in a hospital or institution, St. ¿ give its NAME instead of street and number)
2 FULL NAME
Ernest F. Nicolas
(If deceased is a married, widowed or divorced woman, give also maiden name.)
277 297 Revere
Winthrop
St.
(If nonresident, give city or town and State)
Length of stay: In place of death .............. years .............. months.
.........
days. In place of residence
.......... months.
.......
.. days.
MEDICAL CERTIFICATE OF DEATH
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
Male
9 COLOR
White
10 SINGLE
(write the word)
DEATH
(Month)
(Day)
(Year)
4 I HEREBY CERTIFY,
That I attended deceased from
196.
NOV. 24
1961, to OCT 7
I last saw hi Malive on
10/
-
., death is said to
have occurred on the date stated above, at
525 Pm.
INTERVAL
BETWEEN
ONSET AND
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a)
CORONARY OCCLUSION
DEATH
6 HRS.
10a If married, widomed, 5divorcecorbett
HUSBAND of
(Give maiden name of wife in full)
(or) WIFE of
(Husband's name in full)
11 IF STILLBORN, enter that fact here.
12
67
5-21-1896
4
Days
If under 24 hours
Hours ..........
Minutes
13 Usual
Occupation :
Retired-Compositor
(Kind of work done during most of working life)
14 Industry
or Business :
Newspaper
15 Social Security No.
011-09-5981
Revere
16 BIRTHPLACE (City)
(State or country)
Mass.
17 NAME OF
FATHER
Henri Nicolas
18 BIRTHPLACE OF
FATHER (City)
(State or country)
Holland
19 MAIDEN NAME
OF MOTHER
Louise Simon
20 BIRTHPLACE OF
MOTHER (City)
(State or country)
Cambridge
Mass.
21 Mrs .Joan DePalma
Informant
(Address) 697 Revere St., Winthrop
I HEREBY CERTIFY that a satisfactory standard certificate of death was filed with me BEFORE the burial or transit permit was issued: Ralph É Sirianne (8)
(Signature of Agent of Board of Health or other)
Hearthe Office
October 8 1963
(Official Designation) (
(Date of Issue of Permit)
TVB.V
TIONS R RTIFICATE
ving DEATH enter an one r each and (c)
not mean of dying, urt failure, . It means or compli- ch caused
, if any, e rise to use (a), e under- se last.
ns contrib- th but not he terminal ition given
apter 137, 4. requires to print or cause or death on icates, and . Acts of res Physi- int or type signature.
6 Winthrop Winthron
Place of Burial or Cremation
Oct. 9 .1963
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