USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1963 > Part 41
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-
X PLACE OF DEATH
Suffolk
(County) inthrop
(City or Town)
No.
Bay View Nursing . Home
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. 205
§(If death occurred in a hospital or institution,
St. } give its NAME instead of street and number)
PHYSICIAN - IMPORTANT
[(Was deceased a
{ U. S. War Veteran, {if so specify WAR)
2 Highland Ave
St.
(If nonresident, give city or town and State)
years ..
months ...
.days.
MEDICAL CERTIFICATE OF DEATH
PERSONAL AND STATISTICAL PARTICULARS
3 DATE OF
DEATH
OCTOBER
13
1963
(Year)
8 SEX
Female
9 COLOR
White
10 SINGLE
MARRIED
WIDOWED
or DIVORCED , idow
4 I HEREBY CERTIFY, That I attended deceased from MARCH 12
1950, to OCTOBER 13
19 63
I last saw hez alive on
11:45 Pm
OCTOBER 13
19 63, death is said to
have occurred on the date stated above, at
... m.
INTERVAL
BETWEEN
ONSET AND
DEATH
DEATH WAS CAUSED BY : IMMEDIATE CAUSE
(a)
HypoSTATio PNEUMONIA
5DAYS
10a If married, widowed, or divorced
HUSBAND of
(or) WIFE of
Alfred T
(Give maiden name of wife in full)
Da gne ss
(Husband's name in full)
11 IF STILLBORN, enter that fact here.
12
AGE 76
Years
23
10
.Months.
.Days
If under 24 hours
Hours ..
Minutes
13 Usual
Occupation :
Housewife
14 Industry
or Business :
at Home
15 Social Security No.
Home
.esbech Samorid chire
16 BIRTHPLACE (City)
(State or country)
England
17 NAME OF
FATHER
George w Baxter
18 BIRTHPLACE OF
FATHER (City)
(State or country)
England
Wesbech Cambridgshire
19 MAIDEN NAME
OF MOTHER
Thry An Boyce
20 BIRTHPLACE OF
MOTHER (City)
(State or country)
1
Howard Bagnoes
21
Informant
(Address)
4 .1 and v., juthrow, icama
7 NAME OF
FUNERAL DIRECTOR
Howard . Reynolds
ADDRESS
.Litarot,
OCT 16 1963 19
Received and filed
(Registrar)
7DAYS
Due TOARTERIOSCLEROTIC HEART
(c)
DISEASE
7 YEARS
OTHER
SIGNIFICANT
CONDITIONS
Was autopsy performed?
No
What test confirmed diagnosis ?
5 Was disease or injury in any way related to occupation of deceased: 10 If so, specify
(Signed)
Dorothy Cherry appleton
M. D.
DOROTHY Cheney APPLETON
(FRINT OR TYPE SIGNATURE)
(Address) 197 Woodside AVE Date OCTOBER 14.63
6
inthrup
Place of Burial or Cremation
DATE OF BURIAL
throp
Oct. 16,
ity or Town)
53
19
PARENTS
HEREBY CERTIFY that a satisfactory standard certificate of death was filed with me BEFORE the burial or transit permit was issued: Ralph E Mireanne (3) (Signature of Agent of Board of Health or other) Health Officer Cet 16,1963
(Official Designation
(Date of Issue of Permit)
* VIV
IONS
TIFICATE
ing DEATH nter n one · each and (c)
not mean of dying, 't failure, It means r compli- h caused
if any, rise to se (a), under- e last.
s contrib- h but not e terminal ion given
pter 137, requires print or cause
or death on ates, and Acts of es Physi- it or type signature.
-925686
-301A I
2 FULL NAME
Louisa Li (Baxter) Bagness
(If deceased is a married, widowed or divorced woman, give also maiden name.)
(a) Residence. No.
( Usual place of abode)
Length of stay: In place of death.
... years
10
months
14 days. In place of residence.
57
(write the word)
(Month) (Day)
(b) TO ACUTE MYOCARDIAL INSUFFICIENCY
(Kind of work done during most of working life)
Terbech Cambrid shire
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE.
DATE OF DISCHARGE
RANK, RATING
ORGANIZATION AND OUTFIT
SERVICE NUMBER
RULES OF PRACTICE
RECEIVED
TOW
OF
OFFICE
1.1
10.
MIN
BLERK
WIN
6
AS
HRAD
OCT 1 61963 PM
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.
5
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.
!
241 WASHINGTON AVE
2 FULL NAME Edward L
Fitzgerald
(If deceased is a married, widowed or divorced woman, give also maiden name.)
Ting Book-19 Pleasant CT. 24, Washington Que.
(a) Residence. No ..
(Usual place of abode)
Length of stay: In place of death 2 years months.
days. In place of residence 50 years months days.
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
October - 13-
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
12.45 Pm.
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
Coronary Thrombosis
(a)
Due To (b)
Due To (c)
OTHER
SIGNIFICANT
CONDITIONS
Was autopsy performed ?
No
What test confirmed diagnosis ?
Medical - History
5 Was disease or injury in any way related to occupation of deceased NO If so, specify
(Signature)
John F. Collins MD
M. D.
(Print or Type Name)
(Address)
Cerere Mass
Date
14Oct 19 63
6
WINTHROP
WINTHROP
Place of Burial or Cremation
(City or Town)
DATE OF BURIAL OCT 16 1963
7 NAME OF
FUNERAL DIRECTOR
MAURICE W KIRBY
ADDRESS
WINTHROP.
Received and filed
OCT 14 1963
19
( Registrar )|
A TRUE COPY ATTEST:
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
MALE
9 COLOR
WHITE
10 SINGLE
MARRIED
WIDOWED
DIVORCED
(write the word)
11 If married, widowed, or divorced HUSBAND of
(Give maiden name of wife in full)
(or) WIFE of
(Husband's name in full)
12
AGE 60 Years.
Months ..
Days
If under 24 hours
Hours. . ... Minutes
13 Usual
LEAD MAN
Occupation :.
(Kind of work done during most of iworking life)
14 Industry
or Business:
MACHINERY CE
15 Social Security No ...
025-03-2424
16 BIRTHPLACE (City) ..
(State or country)
MASS
EAST BOSTON
17 NAME OF
FATHER
MICHAEL M FITZGERALD
18 BIRTHPLACE OF
FATHER (City)
(State or country)
BOSTON
19 MAIDEN NAME
OF MOTHER
ELIZABETH DALEY
20 BIRTHPLACE OF
MOTHER (City).
EAST BOSTON
(State or country)
MASS
21 Informant
WILLIAM FITZGERALD
(Addre
19 PLEASANT COURT WINTHROP
I HEREBY CERTIFY that a satisfactory standard certificate of death was filed with me BEFORE the burial or transit permit was issued: Laeple & Serano (3) (Signature of Agent of Board of Health or other)
Health Officer
Cet 14 1963
(Official Designation)
(Date of Issue of Permit)
T
V.B. V
1
PLACE OF DEATH
X SUFFOLKT. (County)
The Commonwealth of Massachusetts KEVIN H. WHITE SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS STANDARD CERTIFICATE OF DEATH
(City or Town making this return,
Registered No.
206
burial permit of Health Agent. TIONS 1
RTIFICATE
TYPE CAUSES ATH enter in one r each and (c)
nat mean of dying, ut failure, . It means or campli- ch caused
, if any, e rise ta se (a), e under- se last.
ns contrib- th but mat te terminal ition given
Certificate
Hoved Greenfield WAS
sequer ly
Pronounced dead by
933404
WINTHROP (City or Town)
f(If death occurred in a hospital or institution,
St. ¿ give its NAME instead of street and number)
PHYSICIAN - IMPORTANT
(Was deceased a
U. S. War Veteran,
(if so specify WAR)
NO
.... St.
(City or town and State)
DIVORCED
INTERVAL
BETWEEN
ONSET AND
DEATH
12 Hrs
PARENTS
M R-301
RECEIVED
TO !! OF
11 . 12 1
OFF
3
;LERK
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE 6 5
DATE OF DISCHARGE
THROP.
RANK, RATING OCT.1.41963 PM
ORGANIZATION AND OUTFIT
SERVICE NUMBER
RULES OF PRACTICE
The fulfillment of the purpose of these laws calls for the observance of the following rules of practice :
(1) Attending physicians will certify to such deaths only as those of persons to whom they have given bedside care during a last illness from disease un- related to any form of injury.
(2) Board of Health physicians will certify to such deaths only as those of persons who, though disabled by recognized disease unrelated to any form of injury, have died without recent medical attendance or whose physician is absent from home when the certificate of death is needed.
(3) Medical Examiners will investigate and certify to all deaths supposably due to injury. These include not only deaths caused directly or indirectly by traumatism (including resulting septicemia), and by the action of chemical (drugs or poisons), thermal, or electrical agents, and deaths following abortion, but also deaths from disease resulting from injury or infection related to occu- pation, the sudden deaths of persons not disabled by recognized disease, and those of persons found dead.
Statement of Cause of Death .- Physicians: see explanatory instructions on face side of standard certificate of death.
Statement of Occupation .- Precise statement of occupation is very impor- tant, so that the relative healthfulness of various pursuits can be known. Make some entry in this section for every person aged 10 years or over. If the occupa- tion had been given up or changed, or if the deceased had retired from business, report the kind of work done during most of working life even if retired. Chil- dren not gainfully employed may be returned as at school or at home. For a woman whose only occupation was that of home housework, write housework. For a person engaged in domestic service for wages, however, designate the occupation by the appropriate terms, as housekeeper-private family, cook- hotel, etc. For a person who had no occupation whatever write none.
X
SUFFOLK
(County) WINTHROP
(City or Town)
The Commonwealth of Massachusetts KEVIN H. WHITE SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS
(City or Town making this return)
MEDICAL EXAMINER'S CERTIFICATE OF DEATH
Registered No.
207
41 Cutler Street, Winthrop
[(If death occurred in a hospital or institution,
St. ? give its NAME instead of street and number)
2 FULL NAME
(First Name)
(Middle Name)
(Last Name)
U. S. War Veteran,
(if so specify WAR).
no
(If deceased is a married, widowed or divorced woman, give also maiden name.)
41 Cutler Street, Winthrop
(a) Residence. No.
(Usual place of abode'
3
Length of stay : In place of death
years.
............ months .............. days. In place of residence ...
49
.years.
.months.
23 days.
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
DEATH
October
14,
1963
(Month)
(Day)
(Year)
4 I HEREBY CERTIFY that I have investigated the death of the person above-named and that the CAUSE AND MANNER thereof are as follows: (If an injury was involved, state fully.) Cirrhosis of liver; uremia; malnutrition.
12 If married, widowed, or divorced
HUSBAND of
(Give maiden name of wife in full)
Charles D. Smith
(Husband's name in full)
41
13 AGE Years
If under 24 hours Hours Minutes
14 Usual
Occupation:
egreary
(Kind of work done during most of working life)
15 Industry Business :
Office
work
(City or town and State)
Did injury occur in or about home, on farm, in industrial place, or
public place ?
(Specify type of place)
Manner of
Injury
(How did injury occur ?)
Nature of Injury
While at work ? .. Was autopsy performed. .
6 Was disease or injury in any way related to occupation of deceased ?
If so specif.
(Sigped).
M. D.
/Michael A Luongo, M.D.
..........
Bost d'rint or Type Name)
(Address)
Date
10/14 ,63 .19.
7 ....... Winthrop Cemetery, inthron (City or Town) Place of Burial or Cremation.
DATE OF BURIAL Oct. 17, 1963
8 NAME OF
FUNERAL DIRECTOR
Ernest :. Cciano
ADDRESS 147 winthrop st inthron
Received and filed
OCT 15 1963
19
PARENTS
19 BIRTHPLACE OF
FATHER (City)
(State or country)
Mass.
Boston
20 MAIDEN NAME
OF MOTHER
Lillie B. Jacobs
21 BIRTHPLACE OF MOTHER (City) West Newton
(State or country) Lass.
22 Informant (Address) 41 Cutler St., Winthrop
I HEREBY CERTIFY that a satisfactory standard certificate of death was filed with me BEFORE the burial or transit permit was issued:
(Signature of Agent of Board of Health or other) Heaith Officer let 15.1963
(Official Designationy
(Date of Issue of l'ermit)
DEATH in plain terms, so that it may be properly classified under the International Classification of Causes
of Death. See reverse side for additional information. See also Chap. 38, §§ 6, 20; Chap. 46, §§ 9, 10; Chap. 114,
§§ 44-48.
100M - 3-62-932695
1
-303 burial permit of Health Agent.
If deceased was a U. S. War Veteran, G.L. Chap. 46, Section 10, requires physicians to insert a recital to that effect.
5 Accident, suicide, or homicide (specify) Date and hour of injury 19
IF ACCIDENTAL, was injury causally related to the death ? Where did Injury occur ?
PERSONAL AND STATISTICAL PARTICULARS
9 SEX
female
10 COLOR
(write the word)
11 SINGLE
MARRIED
WIDOWED
DIVORCED
UNKNOWN
divorced
white
PHYSICIAN - IMPORTANT
(Was deceased a
No. LILLIAN TI. SMITH
(COX)
St
(If nonresident, give city or town and State)
A TRUE COPY ATTEST: (Registrar)
Securi
No. 020-09-9206
„inthron
17 BIRTHPLACE (City) (state of country)
18 NAME OF FATHER Richard E. Cox
D
No.
(or) WIFE of
Luth Donovan
PLACE OF DEATH
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE
RANK, RATING
‹
ORGANIZATION AND OUTFIT
in:
SERVICE NUMBER
5
6
WINTHROP
RULES OF PRACTICE
The fulfillment of the purpose of these laws calls for the observance of OCT. 1 51963 PM 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 unrelated 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 poison) , thermal, or electrical agents, and deaths following abortion, but also deaths from disease resulting from injury or infection related to occupation, the sudden deaths of persons not disabled by recognized disease, and those of persons found dead.
STATEMENT OF CAUSE OF DEATH
Medical Examiners in certifying to a death will state the cause and manner thereof, and will specify: (1) Under cause the nature of an injury and of its consequences; and (2) under manner the mode of its production together with the circumstances when these are known. For example: "Compound fracture of the femur with ensuing septicemia (gas bacillus) caused by a collision of railroad train and automobile." "Pistol shot wound of the chest with associated hemorrhage, homicidal." "Asphyxiation by suspension, suicidal." "Syncope while under the influence of ether administered as a surgical anaesthetic for (enter name of operation and disease or condition requiring surgery)." "Fracture of the skull with associated internal injury sustained under circumstances unknown."
If disease or injury was related to occupation, specify. If investigation shows the death to have been due to disease, specify: (1) Under cause its known or presumable nature; and (2) under manner, indicate the circumstances leading to medico-legal inquiry. For example: "Hemorrhage spontaneous of the brain (basal ganglia) (found dead in bed)." "Heart disease, presumably coronary sclerosis. (Sudden death.)"
M R-302
Copies of returns of deaths which occurred in your city or town in case the deceased resided in another city or town resided as soon as possible, after the close of the month in which the death occurred. (See Chap. 46, Sec. 12, G. L.) at the time of death should be transmitted on Form R-302 to the clerk of the city or town in which the deceased
PLACE OF DEATH
Suffolk
(County)
Revere
The Commonwealth of Massachusetts KEVIN H. WHITE SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS COPY OF
CERTIFICATE OF DEATH
Registered No.
208
S(If death occurred in a hospital or institution, St. { give its NAME instead of street and number)
Grace K. McCarthy (Harney)
(If deceased is a married, widowed or divorced woman, give also maiden name.)
78 Ingleside Ave.
Winthrop
(a) Residence. No.
(Usual place of abode)
5
30
(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
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
Female
9 COLOR
White
10 SINGLE
MARRIED
WIDOWED
DIVORCED
UNKNOWN
(write the word)
Married
11 If married, widowed, or divorced
HUSBAND of
Williame 90
(Giye maiden Mecaen fyl)
(or) WIFE of
(Husband's name in full)
67
12
AGE
Years.
Months.
.Days
If under 24 hours
Hours ..
.Minutes
13 Usual
Occupation :
(Kind of work done during most working life)
14 Industry
or Business :
Home
15 Social Security No ...
none
Revere
16 BIRTHPLACE (City)
(State or country )
Mass.
17 NAME OF
FATHER
Edward Harney
PARENTS
18 BIRTHPLACE OF
FATHER (City)
(State or country)
Nova Scotia
19 MAIDEN NAME
OF MOTHER
Catherine Corbett
20 BIRTHPLACE OF
MOTHER (City).
(State or country)
Mass.
William S. McCarthy
21 Informant
(Address)
78 Ingleside Ave.,Winthrop
4
A TRUE COPY
ATTEST:
(Registrar of City or Town where death occurred)
DATE FILED
October
17,
63
T V.V
H
That attended deceased frem
-
I last saw h ...... alive on
IA.
have occurred on the date stated above, at
.n.
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
Carcinomatosis
INTERVAL BETWEEN ONSET AND DEATH lyr.
(a)
Due To
Carcinoma Lt. Breast
(b)
Due To (c)
OTHER
Acute Cardiac
SIGNIFICANT
CONDITIONS
Insuf.
1963 - Denied
Was autopsy performed?
X-ray - Parecentesis
What test confirmed diagnosis ?
5 Was disease or injury in any wayrelated to occupation of deceased ?
If so, specify
(Signed)
Harold L. Musgrave
M. D.
620 Beach St.
10/17
63
(Address) Revere Date
19
Winthrop
Winthrop
6
Place of Burial or Cremation
October
( Cit 8,
5 Town)
63 19.
7 NAME OF
FUNERAL DIRECTOR
Maurice W. Kirby
ADDRESS
Winthrop
Received and filed
NOV 6 - 1963
19.
(Registrar of City or Town where deceased resided)
50M - 10-61-931673
I
(City or Town)
No ...
Grover Manor Hospital
Revere
(City or Town making this return)
(Was deceased a
U. S. War Veteran.
(if so specify WAR
3 DATE OF
October
16,
1963
DEATH
(Month)
(Day)
(Year)
19
Oct. 16
63
19
19.
,death is said to
1961
Homemaker
DATE OF BURIAL
Newburyport
.
2 FULL NAME
THIS IS A PERMANENT RECORD
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE.
Oct. 11. 1918
DATE OF DISCHARGE
Oct. 11. 1920
RANK, RATING Yeoman 2/c/ F. Provisional
Navy
ORGANIZATION AND OUTFIT
2000558
SERVICE NUMBER
TO !!
"1330
ERK
6
YROR
NOV - 61963 AM
RM R-301
r burial permit d of Health Agent. CTIONS OR ERTIFICATE
R TYPE CAUSES CATH tenter han one or each ) and (c)
s not mean of dying, cart failure, c. It means of compli- ich caused
s, if any, ve rise to use (a), he under- use last.
ions contrib- ath but not the terminal dition given 1 c .
PLACE OF DEATH
Suffolk (County)
The Commonwealth of Massachusetts KEVIN H. WHITE SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS
STANDARD CERTIFICATE OF DEATH
Registered No.
205
f(If death occurred in a hospital or institution,
No ..
.St. ¿ give its NAME instead of street and number)
PHYSICIAN - IMPORTANT
2 FULL NAME
Charm Samuel
(If deceased is a married, widowed or divorced woman, give also maiden name.)
(a) Residence. No ...
17 Temple Ave.
(Usual place of abode)
St
Winthrop, Masa.
(If nonresident, give city or town and State)
.months. .days. In place of residence. years. months .......... days.
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
DEATH
Oct.
(Month)
(Day)
(Year)
4 I HEREBY CERTIFY
That; I attended deceased from
FED
1958
to ...
Oct.
17.
19
63
I last saw himlalive on
Det, 17,
1963
death is said to
have occurred on the date stated above, at
3:20 A.m.
DEATH WAS CAUSED BY: IMMEDIATE CAUSE Coronary Occlusion, acute (a)
INTERVAL BETWEEN ONSET AND DEATH 2hrs.
Due
(b)
· Arteriosclerotic Heart Disease
5yrs
Due To
myocardial infarction
(c)
OTHER SIGNIFICANT CONDITIONS
Diabetes Mellitus
3 /2 yrs
Was autopsy performed?
What test confirmed diagnosis ?
Clinical
5 Was disease or injury in any way related to occupation of deceased ?" If so, specify .
(Signature)
Charles Liberman
M. D.
CHARLES
LIBERMAN
(Print or Type Name)
(Address) WINTHROP, MASS Date 10/17/1963
Sharon Memorial Park, Sharon 6
Place of Burial or Cremation October 18 {City or Town) 63
DATE OF BURIAL
Levine Chapels Ine !!
For me Chapels
7 NAME OF
FUNERAL HECTOR
Harvard St F
, Brookline
Howard SO Brookline
ADDRESS
Received and filed
OCT 17-1963
19.
(Registrar)
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
Male
9 COLOR
White
10 SINGLE
(write the word)
Married
WIDOWED-
DIVORCED
UNKNOWN
11 If married, widowed, or divorced.
HUSBAND of
Vinetta.Silverman
(Give maiden name of wife in full)
(or) WIFE of
(Husband's name in full)
12
65
AGE
Years
Months.
.Days
If under 24 hours
Hours ... .... Minutes
13 Usual
Occupation :
Retired
(Kia of work done during most working life)
14 Industry
or Business :
Electrician
15 Social Security No.
029-10-5954
16 BIRTHPLACE (City) (State or country ) Russia
17 NAME OF
FATHER
Isaac Charm
18 BIRTHPLACE OF
FATHER (City)
(State or country)
Russia
19 MAIDEN NAME
OF MOTHER
Jennie Blair
20 BIRTHPLACE OF
MOTHER (City).
(State or country)
Russia
Mrs. Vinetta Charm
21 Informant
(Address
17 Temple Ave. , Winthrop
I HEREBY CERTIFY that a satisfactory standard certificate of death was filed with me BEFORE the burial or transit permit was issued : Ralph 10 Serianni (G) (Signature of Agent of Board of Health or other) Herethe Offeren Cletolov, 719613
(Official Designation)
(Date of Issue of Permit)
A TRUE COPY ATTEST:
5
V. B
.
-932382
1
Winthrop (City or Town)
Winthrop Community Hospital
Winthrop
(City or Town making this return)
) (Was deceased a U. S. War Veteran, (if so specify WAR) NO
Length of stay: In place of death
1 Hour
TT
17
1963
3/2 yrs
PARENTS
TOW
OF
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
0
DATE OF DISCHARGE
RANK, RATING WINTHROP 0
5
ORGANIZATION AND OUTFIT
SERVICE NUMBER OCT 1.71963 PM 2
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.
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