Town of Winthrop : Record of Deaths 1963, Part 39

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


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



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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