USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1963 > Part 43
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(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.
TOWN
OFFICE OF
ERK
WINTHROE
5
6
OCT 2 81963 PM
M R-304 X
PLACE OF DELIVERY No.
SUFFOLK (County ) WINTHROP (City or Town)
FNS
The Commonwealth of Massachusetts KEVIN H. WHITE SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS CERTIFICATE OF FETAL DEATH ( STILLBIRTH)
To be filed for burial perant with Board of Health or its Agent.
Registered No.
215
-
(If death occurred in a hospital or institution,
give its NAME instead of street and number)
3 DATE OF
DELIVERY 10
1
28/ 63
(Year)
4 SEX
Male .... Female ...... Undetermined.
5 COLOR (if
determined). Wh
6 THIS BIRTH (Check one)
Single X Twin
Triplet
7 IF MULTIPLE BIRTH, BORN :
1st .. . ... 2nd .....
.3rd
FATHER
MOTHER
PRESENT NAME
15
72 Wordsworth St.
RESIDENCE, NO.
CITY OR TOWN
E. Boston
STATE
STREET
Mass.
10 COLOR OR
RACE
wh
11 AGE AT TIME OF
THIS DELIVERY
29 (Years)
16 COLOR OR
RACE.
wh
17 AGE AT TIME OF
THIS DELIVERY
25
(Years)
12 PLACE OF
BIRTH
Annapolis
(City or Town)
Maryland
(State or country)
18 PLACE OF
BIRTH
Boston
Mass.
(City or Town)
(State or country)
13
OCCUPATION
shipwright
19 INFORMANT
Harry T. Ford
20 PREVIOUS DELIVERIES TO MOTHER
(Do not include this fetus)
2
(a) How many children are
now living?
2
(b) How many children were
born alive
dead?
0
but are now
(c) How many previous fetal deaths of ANY gestation age ? 0
21 LENGTH OF
PREGNANCY
completed weeks
28
22 Weight /Lb.
OF FETUS
(or
Oz.
Grams)
23 WHEN DID FETUS DIE?
Before
Labor
During Labor or Delivery Unknown
24 AUTOPSY Yes
No
25 FETAL DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a) Mitranterne.
Death
Due To (b)
Due To (c)
OTHER SIGNIFICANT
CONDITIONS
26
Woodlawn Cemetery Everett Mars Place of Burial or Cremation (City or Town) , 1963 October 29 DATE OF BURIAL "Transp Janne Home use 2 Jenning ADDRESS 726 Saratoga
Received and filed
E. Boston 10-29 1963
( Registrar )
A TRUE COPY ATTEST :
I HEREBY CERTIFY that this delivery occurred on the date stated above at 7-p .m., and product of conception was not a live birth.
Signature of Altending Physician or Medical Examiner :
M. D.
G. Guy GRANDE LOW (PRINT OR TYPE NAME) 20 SARATOGA 55 Date 10/29/19 63 Address
EAST BOSTON MASS
I HEREBY CERTIFY that a satisfactory certificate of fetal death was filed with me BEFORE the burial or transit permit was issued:
Ralph SE Sinanna (18) (Signature of Agent of Board of Health or other ) Hearth Officer ( Official Thsignation )
October 29,1963 X
-
(Date of Issue of Permit )
giving USE OF L DEATH not enter than one e for each (a), (b) nd (c)
or maternal ion causing death (do use such as stillbirth maturity.) and/or ma- conditions, , which gave to above (a), stating nderlying last.
tions of fetus other which ave contrib- to fetal , but, in so is known, not related use given ).
10M-6-62-933404
1
WINTHROP COMMUNITY HOSPITAL
St.
2 NAME OF FETUS
(if given)
Ford, Baby Boy
8
FULL
NAME
Harry T. Ford
14
MAIDEN NAME
Marilyn A. Marcella
Marilyn A. Ford
RESIDENCE, NO/2 Wordsworth Street STREET
CITY OR TOWN
E. Boston
STATE. Mass.
(Month )
(Day)'
27 NAME OF
FETAL DEATH
EXTRACTS OF CERTAIN SECTIONS OF CHAPTER 46 AS AMENDED OR ADDED BY CHAPTER 48, ACTS OF 1960.
Section 2A. "Examination of records and returns of illegitimate births, or abnormal sex births, or fetal deaths, ... shall not be permitted except ... ".
Section 9A. When a child is born dead, after a period of gestation of not less than twenty weeks, and in the fetus there is no attempt at respiration, no action of heart and no movement of voluntary muscle, the physician or officer attending at the birth of such child shall forthwith furnish for registration, at the request of an undertaker or other authorized person or of any member of the family of the deceased, a certificate of fetal death on a form which shall be prepared by the secretary of state as required by section sixteen. Town clerks shall record certificates of fetal death in the town register of deaths in the same manner as a death certificate, but they shall not be required to record such certificates in the town register of births.
Section 12. ". No birth record of a child born out of; wedlock or of a child of abnormal sex, and no record of fetal, death shall so ber, transmitted to any other city or town."
THROP
Section 24. In any statement of births, deaths and fetal deaths printed by a town the name of an illegitimate child or of its parents or of the parents of a child born dead shall not be printed, but the word "illegitimate" or "fetal death" shall be used in place thereof. A town violating this section shall forfeit to the mother of such child not more than one hundred dollars.
--
RM R-302
THIS IS A PERMANENT RECORD
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)
Chelsea
(City or Town)
The Commonwealth of Massachusetts KEVIN H. WHITE SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS COPY OF CERTIFICATE OF DEATH
211
Chelsea
(City or Town making this return)
527
216
[(If death occurred in a hospital or institution,
St. ( give its NAME instead of street and number)
2 FULL NAME
Clarence Hernandez
(If deceased is a married, widowed or divorced woman, give also maiden name.)
if so specify WAR)
91 Winthrop
Winthrop, Mass.
(City or town and State)
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
DEATH
Sept.11. 1963
(Month)
(Day)
(Year)
4 I HEREBY CERTIFY, That I attended deceased from
Cept.69 63, to Copt. 1]
19.
63
I last saw h ... Lalive on ....... Sept.1}
19 .. 6.3death is said to
have occurred on the date stated above, at ................ 4 5m,
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
INTERVAL BETWEEN ONSET AND DEATH
12
AGE 7Sears 6 Months - Days
If under 24 hours
Hours . . ...
Minutes
13 Usual
Occupation :
U.S. Army (SEC)
(Kind of work done during most of working life)
disease+ Industry
U.C.Army
OTHER
SIGNIFICANT
Pneumonia
CONDITIONS
Was autopsy performed?
... y.o.s.
What test confirmed diagnosis ?
5 Was disease or injury in any way related to occupation of deceased ? If so, specify
(Signature)
John J. Tobin, Jr.
M. D.
(Address)
USNA, Chelsea ....... Dag /11/68.19.
6
linthrop Cem. Winthrop Mass
Place of Burial or Cremation
(City or Town)
DATE OF BURIAL
Sept. 13, 1963
19
7 NAME OF
Reynolds Fun. Tome
FUNERAL DIRECTOR
ADDRESS
180 Winthrop St. ,Winthrop,
Received and filed
-NOV 18 1963
19
(Registrar of City or Town where deceased resided)
8 SEX
9 COLOR
10 SINGLE
MARRIED
WIDOWED
DIVORCED
(write the word)
Malo
White
Married
11 If married, widowed, or divorced
HUSBAND of
Vivian Pendue
(Give maiden name of wife in full)
(or) WIFE of
(Husband's name in full)
(a)
Congestive heart failure
1)ue To
(b)
Due To
Arteriosclerotic heart
(c)
or Business :
15 Social Security No .....
010-22-8477
16 BIRTHPLACE (City)
(State or country )
Fort Hamilton, N. Y.
17 NAME OF
FATHER
Joseph A . Hernan dez
PARENTS
18 BIRTHPLACE OF
FATHER (City)
(State or country)
Boston, Mass.
19 MAIDEN NAME
OF MOTHER
dary Salvo
20 BIRTHPLACE OF
MOTHER (City)
(State or country)
South Carolina
21 Informant
Irs.Vivian Hernandez (wife)
(Address)
91 .... Winthrop.St., Winthrop
LA IRT. COPY Graph a Tyrrell
ATTEST:
DATE FILED
(Registrar of City or Town where death occurred) Sept. 12,1963 .... 19 ...
T V.B.V
SOM-6-62-933404
X
1
No ............. U .S.Naval .... Hospital
Registered No.
(Was deceased a
U. S. War Veteran,
WWI
(a) Residence. No ..
St
(Usual place of abode)
Length of stay: In place of death.
wears ....... @months ....... Adays. In place of residence ..... 5years .......... Months .......... daws.
PERSONAL AND STATISTICAL PARTICULARS
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE June 1903
DATE OF DISCHARGE
Dec. 1929
RANK, RATING
SFC
ORGANIZATION AND OUTFIT
U. S.Army
SERVICE NUMBER R718714
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.
RECEIVED
NMOL
2
CLER Statement of Occupation .- Precise statement of occupation is very impor- tant, so that the relative healthfulness of various pursuits can be known. Make some cutty 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.
OF
.For Lperson engaged in domestic service for wages, however, designate the occupation by the appropriate terms, as housekeeper-private family, cook- hotel, etc. . For had no occupation whatever write none.
C
OFFI WINT
orson & D'AON
217
OUT - OF - TOWN
(City or Town making this rett .:
09667
Registered No. f(ff death occurred in a hospital or Institution, .St. ( give its NAME instead of street and number) PHYSICIAN - IMPORTANT
2 FULL NAME.
Frank St .George
(If deceased is a married, widowed or divorced woman, give also maiden name.)
(Was deceased a
U. S. War Veteran,
NO
(if so specify WAR)
36 Sagamore Avenue
St
Winthrop, Mass.
(a) Residence. No
(Usual place of abode)
(C'ity or town and State)
Length of stay: In place of death .......... years .......... months,2. .days. In place of residence.L.O.years ......... months .......... days.
MEDICAL CERTIFICATE OF DEATH
3 DATE OF September
22
1963
DEATH
(Month)
(Day)
(Year)
4 IHEREBY CERTIFY, That I attended deceased
September 17, 63
September
22
We last saw h ...... alive on
September
22
63
19.
... , death is said to
have occurred on the date stated above, at 9:45p.
.. m.
INTERVAL BETWEEN ONSET AND DEATH
12
6 monthIGE 77Years
MonthsDays
If under 24 hours
Hours ........ Minutes
13 Usual
Retired Longshoreman
Occupation :
(Kind of work done during most of iworking life)
14 Industry
or Business:
Shipping
15 Social Security No ...
030-01-4640
BIRTHPLACE (City).Zast .... Doston
(State or country)
Mass
17 NAME OF
FATHER
John St. George
PARENTS
18 BIRTHPLACE OF
FATHER (City)
East .... Boston
(State or country)
19 MAIDEN NAME
OF MOTHER
Rose Maguire
20 BIRTHPLACE OF
MOTHER (City).
(State or country) Hass.
East Boston
21 Informant
Edward St. George
( Address)
6 Revere St., Winthrop
I HEREBY CERTIFY that a satisfactory standard certificate of death shled with me BEFORE the burial or transit perioit was issued: Jacqueline ssante (Spelature of Agent of Board of Health or other) #B18018. 9/25/63
(Date of laave of Permit)
T Y.
A TRUE COPY ATTEST:
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
ale
9 COLOR
White
10 SINGLE
MARRIED
WIDOWED
DIVORCED
UNKNOWN
(write the word)
Widowed
11 If married, widowed,
Affn't evond Tuckley
HUSBAND of
(Give maiden name of wife In full)
DEATH WAS CAUSED BYI IMMEDIATE CAUSE
(a) Carcinoma of Lung
Due To (b)
Due To (c)
OTHER
SIGNIFICANT
CONDITIONS
Carcinoma ..... o.f ..... C.o.l.o.n
Was autopsy performed?
les
What test confirmed diagnosis ?
Autopsy
5 Was disease or injury in any way related to occupation of deceased? If so, specify
(Signature)
M. D.
.Charles Lo Print or Type Name)
(Address) Assit. Die, Mass. Con'l, Heap. Date ...
Sept. 22 63
Winthrop Cemetery Hinthrop
Place of Burial or Cremation
(City or Town)
DATE OF BURIAL
Sept. 26.
19 .... 6.3
7 NAME OF
FUNERAL DIRECTOR
Ernest P. Caggiano
ADDRESS
147 Winthrop St., Winthrop
Received and fled
Willand. KauSEP 30 19796
2-933404
PLACE OF DEATH
SUFFOLK
(County)
-
BOSTON
(City of Town)
.
No .. MASSACHUSETTS GENERAL ·· HOSPITAL. ...........
The Commonwealth of Massachusetts KEVIN H. WHITE SECRETARY OF THE COMMONWEALTH. DIVISION OF VITAL STATISTICS STANDARD CERTIFICATE OF DEATH
RM R-301
or burial permit rd of Health Agent. UCTIONS FOR CERTIFICATE
OR TYPE R CAUSES EATH ot enter than one for each (b) and (c)
I mat mean of dying, Asort failure. etc. / msIns ", or compli. which caused .
was, if any.
causa (a). the under. COMse last.
Itions contrib- death but not ths terminal mitlen rivan M.C.
3 50
201963 Director vee caly CK Ink.
(Registrar) || (Official Designation)
(Husband's name in full)
(or) WIFE of
19
Em
Month's
A TRUE COPY ATTEST:
Williaml. Kane. City Registrar
OF TO
11.12
1.10
C.
1
3
KERK
1
HROP MI
NOV 2 01963 AM
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
.
Chelsea
(City or Town making this return)
1
PLACE OF DEATH
Suffolk (County)
The Commonwealth of Massachusetts KEVIN H. WHITE SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS COPY OF VIỆTEM
CERTIFICATE OF DEATH
Registered No.
534
218
§(If death occurred in a hospital or institution, ... St. ¿ give its NAME instead of street and number)
2 FULL NAME.
Marie Bornstein
(If deceased is a married, widowed or divorced woman, give also maiden name.)
(Was deceased a
U. S. War Veteran,
if so specify WAR
(a)
Residence. No ..
Mounts Rest Home , 104 Highland Ave Winthrop, Mass.
(Usual place of abode)
(If nonresident, give city or town and State)
Length of stay: In place of death ..... year .....
... months ..... days. In place of residence .....?.. years ......_ months ..... . days.
MEDICAL CERTIFICATE OF DEATH
PERSONAL AND STATISTICAL PARTICULARS
3 DATE OF
DEATH
(Month)
Sept.23,1963
(Year)
8 SEX
9 COLOR
Female
White
10 SINGLE
MARRIED
WIDOWED
DIVORCED
UNKNOWN
Widowed
4 I HEREBY CERTIFY, That I attended deceased from
Sept.23 1.63 ... .. Sept.23
163
I last saw heralive on .......
Sept .23
19 ... 6/ death is said to
have occurred on the date stated above, at .6. 45 -.. m.
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
INTERVAL BETWEEN ONSET ANO DEATH
12
AGE7.7
.. Years.
.Months
.... Days
If under 24 hours Hours ........ Minutes
(a) Cerebral vascular
(b)
2 hrs.
13 Usual
Occupation :
Housewife
(Kind of work done during most working life)
Due To
(c)
?Esophageal ..... veins
14 Industry
or Business:
at ..... home
OTHER
SIGNIFICANT
G.I.Bleeding
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
(Signed) Benjamin .... I.Cassin M. D.
(Address) 117 Wash. Ave. ... Sent.23 19 63 Chelsea ,Mass
20 BIRTHPLACE OF
MOTHER (City)
(State or country)
Russia
a Cherra Torah, Tvorett, Mass
Place of Burial or Cremation
(City or Town)
DATE OF BURIAL
Sept.25,1963
19
7 NAME OF
FUNERAL DIRECTOR
Torf Fun . Service
ADDRESS Washington Ave. , Chelsea, Mass FRUE COPY
Received and hled NOV 18 1963 19
ATTEST:
(Registrar of City or Town where death occurred)
DATE FILED
(Registrar of City or Town where deceased resided)
at the time of death should be transmitted on Form R-302 to the clerk of the city or town in which the deceased
resided as soon as possible, after the close of the month in which the death occurred. (See Chap. 46, Sec. 12, G. L.)
50M - 10-61- 931673
.
X
THIS IS A PERMANENT RECORD
PARENTS
18 BIRTHPLACE OF
FATHER (City).
(State or country )
Russia
19 MAIDEN NAME
OF MOTHER
Paula(cannot be learned)
Mrs.Maurice Greenfield
21 Informant
( Address)
79 Garland St.Chelsea, Mass
Sept.24,1963 19 ... TX
(write the word)
11 If married, widowed, or divorced
HUSBAND of
(Give maiden name of wife in full)
(or) WIFE of.
Harris Bernstein
(Husband's name in full)
Due To
accident
15 Social Security No .... NO.110
BIRTHPLACE (City).
(State or country)
Paris, France
17 NAME OF
FATHER
Isaac Salacechik
Chelsea (City or Town)
No.
Chelsea ... Memorial ... Hospital
SPACE FOR ADDITIONAL INFORMATION DATE OF ENTERING MILITARY SERVICE DATE OF DISCHARGE RANK, RATING ORGANIZATION AND OUTFIT SERVICE NUMBER
RECEIVED
OWN CLERK 10.
1.1. 3
OF
(MIN
SSVNC
3
0 00
1110
WINTH
HV 89618 M'AON
OUT - OF - TOWN
To be filed for burial pernuit trith Board of Health or un Agent. Registered No.
j(If death occurred in a hospital or institution. 1 give its NAME instead .f street and number)
PHYSICIAN - IMPORTANT
SWas deceased a U. S. War Veteran, if so specify WAR) No
283 Court Road
St .. Ward, .Wirthrop, I 'senchusetts.
(If nonresident, give city or town and State)
Length of residence in city or town where death occurred
63 yrs.
mos.
days. How long in U S., if of foreign birth? yr3.
mos. ] days.
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
18 DATE OF
DEATH
(Mont)
(Day)
(Year)
19 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, stare fully.)
Arteriosclerotic Heart Disease
20 IN WHAT C'TY OR TOWN WAS INJURY SUSTAINED? (Signed) 5-2
M. D.
(Ad reº7)
Curtis, M.D.
Winthrop
CKA LATION OK REMOVAL Winthrop.
(Cen. . cry)
(City of town)
DATE OP BURIAL Sept. 28, 19.63
22 NAME OF UNDERTAKER Richard C. Kirby Inc. ADDOr. 3 ?'7 Hennin :ton St. E.Boston
R-
X
: R-03 B
3 SEX (or) WIFE of Us:ai 1 PARENTS If deceased was a U. S. Wer Ve . a CI. Chap. 4, & chips, 10, regione; ; 's an to in ert a recital to that ele t 10 or Husiness:
5M-9-53 -- 2216,
17
in .ant' Mary R. Nichol: > (5) 233 Court Rd. With
Rela: 3. if any
2
I HEREBY CERTIFY ti it a satisfactory st n tard ce fcate of death was file I with the BEFORE the bur 7 or transit peito si ira Jacqueline rechszent of Board of fish os 8180421 -23-63 . .
(Date of Issue of } ut)
5 SINGLE
(write the word)
MARRIED WIDOWED or DIVORCED
Married
4 't married. widomed .. 85 divorced. AUSNA) D of . 4AW. Menis McDonald (Give maiden name of wife in full)
(Ilusband's hame in full)
6 Age of husband or wife if alive .
years
" 'R ST"".LBORN. enter that fact here:
y AGE F,3 Years Months 18 Days
If less than 1 day I ours Minutes
9
Occupation:
Appraiser
Industry
Estates
11
Social Security No. ..
021-07-9194
Winthrop ...... Mass.
BIRTHPLACE (City) (Stite or country) 13 NAME OF FATHER Walter E. Nichols
14
BIRTHPLACE OP
FATHER (City)
East Boston.
(State or country) Mass.
15 MAIDEN NAME
OP MOTHER Amanda P. Harrington
16 BIRTHPLACE OF MOTHER (City) East Boston (State or country) MUSS.
0 1963
... asta fis . the laws relative to the return of . civica."> of cash.
Ge& Pevar .o s: le -
DEATH in p!
of heat".
nu
PLACE OF ! . TH
COUNTY (County)
1
CUPFOLK (City or Town) Deter Beat Brigham Hosp No. Paul Nichols
Thr Commmesiff of . mon-thusatts EDWARD J. CRONIN SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS MEDICAL EXAMINER'S CERTIFICATE OF DEATH
7 FULL NAME ..
(If deceased is a married, widowed or divorced woman, give also maiden name.)
(a) Residence. No. (Usual place of abode) .
4 COLOR
White
25
1
21
1
(Offi 1 Deugnation)
/11 .4
Litern
A TRUC COPY ATTEST!
Wichand. Kane. City Registrar
IF TON;
12.
CLERK
6"
195
HROP.
NOV 2 01963 AM
X
PLACE OF DEATH
Suffolk
(County)
I
Chelsea
(City or Town)
No.
Soldiers' Home
The Commonwealth of Massachusetts KEVIN H. WHITE SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS COPY OF QVILTEM CERTIFICATE OF DEATH LIDERTATE
Chelsea
(City or Town making this return)
541
220
Registered No.
S(If death occurred in a hospital or institution, St. ( give its NAME instead of street and number)
Joseph Edward Amerena
2 FULL NAME.
(If deceased is a married, widowed or divorced woman, give also maiden name.)
(a)
Residence. No ...
37 Floyd
Winthrop, Mass.
St
(If nonresident, give city or town and State)
Length of stay: In place of death ...... years.
... months ..
147ys. In place of residence.
·ears .......... months .......... days.
MEDICAL CERTIFICATE OF DEATH
Sept.26,1963
(Month)
(Day)
(Year)
4 I HEREBY CERTIFY
Sept. 9
63
That I attended deceased from
I last saw
Emlive on
Sept .. 26
19.63 death is said to
have occurred on the date stated above, at 2.2.3.5p.m.
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
INTERVAL
BETWEEN
ONSET AND
DEATH
(a) Arteriosclerotic heart
disease
yrs.
mo s.
OTHER
heart failure
hrs.
Was autopsy performed?
yes
What test confirmed diagnosis ? autopsy
5 Was disease or injury in any way related to occupation of deceased? If so, specify
(Signed)
Richard F.McCarthy
M. D.
(Addre Soldiers !. Home
Date Sept. 27/63
Holy Cross, Malden , Mass. 6
I'lace of Burial or Cremation
(City or Town)
Sept .29,1963
19
7 NAME OF
FUNERAL DIRECTOR
Di Pietro and Fazza Fun.
ADDRESS 11 Henry St., E.Boston, Mass
Received and hled
NOV 18 1963
19
8 SEX
Male
9 COLOR
White
10 SINGLE
MARRIED
WIDOWED
DIVORCESingle
UNKNOWN
(write the word)
JI If married, widowed, or divorced HUSBAND of
(Give maiden name of wife in full)
(or) WIFE of.
(Husband's name in full)
12
AGE56 ... Years.
7 .... Months 2.0
.Days
If under 24 hours
Hours .......
.Minutes
13 Usual
Occupation :
(Kind of work done during most working life)
14 Industry
or Business:
Retail Liquor Store
15 Social Security No 021-01-3666
16 BIRTHPLACE (City)
(State or country)
"Salem, Mass .
17 NAME OF
FATHER
Joseph Amerena
18 BIRTHPLACE OF FATHER (City) (State or country) Boston, Mass .
19 MAIDEN NAME OF MOTHER Mary Lee
20 BIRTHPLACE OF
MOTHER (City)
(State or country)
Salem, Mass.
21 Informant Ospital Records
(Addre
Soldiers' Home, Chelsea, Mass.
A TRUE COPY
Brech ó Terrell
ATTEST:
(Registrar of City or Town where death occurred)
DATE FILED
Sept.27,1963 ... 19 ....
TX
THIS IS A PERMANENT RECORD
4Copies 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.) .....
M R-302
3 DATE OF
DEATH
Due To
(b)
Due To
(c)
at the time of death should be transmitted on Form R-302 to the clerk of the city or town in which the deceased
SIGNIFICANT
CONDITIONS
SOM - 10-61-931673
(Registrar of Chy or Town where deceased resided)
PERSONAL AND STATISTICAL PARTICULARS
WWII
(Was deceased a
U. S. War Veteran,
(if so specify WAR,
(Usual place of abode)
hospital
to ...
Sept.26
63
Coronary artery
insufficiency .Congestive
Manager-retired
PARENTS
DATE OF BURIAL
-
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE. 10./3/42
DATE OF DISCHARGE. 10/19/45
RANK, RATING T4 272 Ord.Main.Co.AAArmy
ORGANIZATION AND OUTFIT
U. S.Army
SERVICE NUMBER.
31208234
RECEIVED
TOWA
CLERK
12
MIN
S
? MASS
1+10
19
n
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