Town of Winthrop : Record of Deaths 1963, Part 43

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


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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