Town of Winthrop : Record of Deaths 1963, Part 41

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


USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1963 > Part 41


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


Part 1 | Part 2 | Part 3 | Part 4 | Part 5 | Part 6 | Part 7 | Part 8 | Part 9 | Part 10 | Part 11 | Part 12 | Part 13 | Part 14 | Part 15 | Part 16 | Part 17 | Part 18 | Part 19 | Part 20 | Part 21 | Part 22 | Part 23 | Part 24 | Part 25 | Part 26 | Part 27 | Part 28 | Part 29 | Part 30 | Part 31 | Part 32 | Part 33 | Part 34 | Part 35 | Part 36 | Part 37 | Part 38 | Part 39 | Part 40 | Part 41 | Part 42 | Part 43 | Part 44 | Part 45 | Part 46 | Part 47 | Part 48 | Part 49 | Part 50 | Part 51 | Part 52 | Part 53 | Part 54


-


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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