Town of Winthrop : Record of Deaths 1963, Part 49

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


USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1963 > Part 49


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).


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U. S. War Veteran, WWI


(if so specify WAR)


(Usual place of abode)


.........


(Registrar)!| (Onthaal Designation)


(Give maiden name of wife in full)


RECEIVED


TOWA


OF


A TRUE CUNY ATTEST:


Wichauf. Kane


1340 Li


CLERK


6


WIN


RO


City Registrar


JAN 1 01964 AM


X


PLACE OF DEATH


WORCESTER


GRAFTON


The Commonwealth of Massachusetts KEVIN H. WHITE SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS COPY OF MEDICAL EXAMINER'S CERTIFICATE OF DEATH


GRAFTON (City or Town making this return) 251182


Registered No.


[(If death occurred in a hospital or institution,


St. ¿ give its NAME instead of street and number)


2 FULL NAME


Louis C. Sanderson


(If deceased is a married, widowed or divorced woman, give also maiden name.)


(a) Residence. No.


240 Pleasant Street


St


Winthrop, Mass.


(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


9 SEX


Male


10 COLOR


White


11 SINGLE


MARRIED


WIDOWED


DIVORCED


UNKNOWN


(write the word)


Single


12 If married, widowed, or divorced


HUSBAND of


(Give maiden name of wife in full)


(or) WIFE of


(Husband's name in full)


13


AGE .. 6.8.


Years.


9


„Months ..


.. 12 Days


If under 24 hours


.Hours


.. Minutes


5 Accident, suicide, or homicide (specify)


Date and hour of injury


19


IF ACCIDENTAL, was injury causally related to the death ?


15 Industry


or Business :


None


16 Social Security No.


None


17 BIRTHPLACE (City)


(State or country)


Boston, Mass


18 NAME OF


FATHER


Charles W. Sanderson


19 BIRTHPLACE OF


FATHER (City)


(State or country)


Mass.


Bos.t.on., ..


20 MAIDEN NAME


OF MOTHER


Carrie S. Peterson


21 BIRTHPLACE OF


MOTHER (City)


(State or country)


Boston,


Mass .


22 Grafton, State Hosp. Records


Informant


(Address)


North Grafton, "ass.


A TRUE COPY


ATTEST:


Registrar of City or Town where death occurred)


DATE FILED


December 3,


63


19


(Registrar of Clty or Town where deceased resided )


PARENTS


(Signed) Walter F. Mahoney, M. D. M. D.


(Address) Westboro, Mass. Date


Nov.23 1.63


Hillcrest Cemetery, N. Grafton 7


Place of Burial or Cremation. November 29,


19


DATE OF BURIAL


8 NAME OF


Misiaszek Funeral Home


FUNERAL DIRECTOR


250 Main St., S. Grafton,


ADDRESS


Received and filed


DEC 11 1963


19


SOM-3-62-932695


ORM R-305 1


Copies of returns of deaths which occurred in your city or town in case the deceased resided in another city or town at THIS IS A PERMANENT RECORD


(City or Town)


No.


(Usual place of abode)


45


8


3 DATE OF


DEATH


(Month)


(Day)


public place ?


Manner of


(Specify type of place)


Injury


(How did injury occur ?)


Nature of


Injury


While at work?


No


as soon as possible after the close of the month in which the death occurred. (See Chap. 46, Sec. 12, G. L.)


the time of death should be transmitted on Form R-305 to the clerk of the city or town in which the deceased resided


Where did


Injury occur ?


(City or town and State)


November 23, 1963


(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.)


Sudden Death, Presumably Coronary Thrombosis.


Did injury occur in or about home, on farm, in industrial place, or in


No


Was autopsy performed ?


No


6 Was disease or injury in any way related to occupation of deceased ?


If so, specify


None


14 Usual


Occupation :


(Kind of work done during most of working life)


Not


Learned


((Was deceased a


U. S. War Veteran,


No


(if so specify WAR)


8


(City or Town) 63


Grafton State Hospital


SPACE FOR ADDITIONAL INFORMATION


DATE OF ENTERING MILITARY SERVICE


DATE OF DISCHARGE


RANK, RATING


E TOW;


ORGANIZATION AND OUTFIT12.1


SERVICE NUMBER


5


......


HROP.


DEC 1 11963 AM


X


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. 252


[(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)


(a)


Residence. No ......


1.5 .... Pleasant ..... Park ..... Road


St


(If nonresident, give city or town and State)


Length of stay: In place of death 50 ears. ....... months .......... days. In place of residence .......... years .......... months .......... days.


MEDICAL CERTIFICATE OF DEATH


3 DATE OF


December 2 .1963


DEATH


(Month)


(Day)


(Year)


4 I HEREBY CERTIFY , That I attended deceased from


.


October 1963


to ...


1962


I last saw h ..... ,alive on


Dec


1963


have occurred on the date stated above, at 4: 19 hm.


death is said to


DEATH WAS CAUSED BY: IMMEDIATE CAUSE


(a) Cerebro Vascular Occlusion)


INTERVAL BETWEEN ONSET AND DEATH 6 mes


Due


(b)


Cerebral Arteriosclerosis


Due To (c)


OTHER


SIGNIFICANT


CONDITIONS


None


Was autopsy performed?


NO


What test confirmed diagnosis ?


clinical


5 Was disease or injury in any way related to occupation of deceased 10 If so, specify. ......


(Signature)


Elcarlos Libe quan


M. D.


CHARLES LIBERMAN


(Print or Type Name)


(Address) WINTHROP CLASS


12/2/ 1963


Holyhood Brookline Mass


6


Place of Burial or Cremation


(City or Town)


DATE OF BURIAL


December 5


19.63


7 NAME OF


FUNERAL DIRECTOR


Arthur J. O'Maley


ADDRESS


Winthrop Mass.


Received and filed


DEC 4 - 1963


19.


(Registrar)


A TRUE COPY ATTEST:


PERSONAL AND STATISTICAL PARTICULARS


8 SEX


Male


9 COLOR


White


10 SINGLE


(write the word)


MARRIED


WIDOWEH dowed


DIVORCED


UNKNOWN


11 If marrie


Allider RorcedHoward


HUSBAND of


(Give maiden name of wife in full)


(or) WIFE of.


(Husband's name in full)


12


AGE 86 .. Years ..


.. Months.


Days


If under 24 hours


Hours ........ Minutes


13 Usual


Occupation :


Retired


(Kind of work done during most working life)


14 Industry


or Business :


Comercial Artist


15 Social Security No ...


16 BIRTHPLACE (City)


(State or country )


Germany


PARENTS


18 BIRTHPLACE OF


FATHER (City)


(State or country)


Germany


19 MAIDEN NAME


OF MOTHER


Anna Loefler


20 BIRTHPLACE OF


MOTHER (City)


(State or country )


Germany


21 Informant


Veronica Preg ....


( Address)


15 Pleasant Park Road


I HEREBY CERTIFY that a satisfactory standard certificate of death was filed with me BEFORE the burial or transit permit was issued: Ruxph 16.


(Signature of Agent of Board of Health or other)


Health officer


Diamber + 1963


(Official Designation) 6


(Date of Issue of Permit)


T V.B.


1


Winthrop (City or Town)


No ...........


15 Pleasant Park Road


Joseph F. Preg


2 FULL NAME


(If deceased is a married, widowed or divorced woman, give also maiden name.)


2-932382


ORM R-301


for burial permit ard of Health ts Agent. RUCTIONS FOR CERTIFICATE


OR TYPE OR CAUSES DEATH ot enter than one for each (b) and (c)


oes not mean e of dying, heart failure, etc. It means e, or compli- which caused


ons, if any, gave rise to cause (a), the under- cause last.


itions contrib- death but not the terminal ondition given


(Usual place of abode)


(City or Town making this return)


17 NAME OF


FATHER


Joseph Preg


TOW 11.22


73


SPACE FOR ADDITIONAL INFORMATION


DATE OF ENTERING MILITARY SERVICE.


6


HROP.


DATE OF DISCHARGE.


RANK, RATING


DEC. . A1963.AM


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 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.


)


PLACE OF DEATH


Suffolk


(County)


Winthrop


(City or Town)


No.


67 Atlantic Strect


The Commonwealth of Massachusetts JOSEPH D WARD SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS


STANDARD CERTIFICATE OF DEATH


Registered No.


253


f(If death occurred in a hospital or institution, St. } give its NAME instead of street and number)


2 FULL NAME.


Grace (Peters) Tibbetts


(If deceased is a married, widowed or divorced woman, give also maiden name.)


(a) Residence.


No.


( Usual place of abode)


67 Atlantic Street


St.


(If nonresident, give city or town and State)


Length of stay: In place of death


50


ars.


months ... ... days. In place of residence years.


months


days.


MEDICAL CERTIFICATE OF DEATH


3 DATE OF


December 6, 7763


DEATH


(Month)


(Day)


(Year)


4 I HEREBY CERTIFY,


-


That I attended deceased from


ec.


1963


to.


Tec. 6,


1963


19


I last saw h.@lalive on


December 6.


1953


death is said to


have occurred on the date stated above, at 8:45 F.Im.


INTERVAL


BETWEEN


ONSET AND


DEATH


DEATH WAS CAUSED BY : IMMEDIATE CAUSE


(a)


Cerebral Thrombosis


(b) Due ToArter'orclerosis


5 yrs


Due To (c)


OTHER


SIGNIFICANT


CONDITIONS


none


Was autopsy performed?


no.


What test confirmed diagnosis ?


Minimal Findings


5 Was disease or injury in any way related to occupation of deceased ? ...... If so, specify " Solar 7. Collins net (Signed) M. D. Gen F. - lin3, ID (PRINT OR TYPE SIGNATURE)


(Address) 27 Tarrington Ct, Date Dec. C, 1963


6


vijutimon oninthron


Place of Burial or Cremation


(City or Town)


DATE OF BURIAL


Dec. 10


19


7 NAME OF


FUNERAL DIRECTOR . Howard ~ Reynold:


ADDRESS A.A intimo2 12:


Received and filed


DEC 9- 1963


19


(Registrar)


PERSONAL AND STATISTICAL PARTICULARS


8 SEX


Female


9 COLOR


White


10 SINGLE


(write the word)


MARRIED


WIDOWED


or DIVORCED'


iloned


10a If married, widowed, or divorced


HUSBAND of


(Give maiden name of wife in full)


Wesley Tibbetts


(or) WIFE of


(Husband's name in full)


11 IF STILLBORN, enter that fact here.


12


98


6


5


Months.


Days


If under 24 hours


Hours.


.Minutes


13 Usual


Occupation :


Houselife


(Kind of work done during most of working life)


14 Industry


or Business :


Own Home


15 Social Security No.


Westport


16 BIRTHPLACE (City)


(State or country)


Nova Scotia


17 NAME OF


FATHER


Alfred Peters


PARENTS


18 BIRTHPLACE OF


FATHER (City)


(State or country)


Nova Scotia


19 MAIDEN NAME


OF MOTHER


Adelaide Cann


20 BIRTHPLACE OF


MOTHER (City)


(State or country)


Nova Scoti-


21 El.iur Tilbetts


Informant


(Address)


57 Atlantic St. nuithop, Mis


I HEREBY CERTIFY that a satisfactory standard certificate of death was filed with me BEFORE the burial or transit permit was issued: Devanna (P)


(Signature of Agent of Board of Health or other)


Health Officer


Decevalor y 1963 5


(Official Designation)


(Date of Issue of Permit)


-301A 1


IONS


TIFICATE


ng. DEATH nter n one each and (c)


not mean f dying, t failure, It means r compli- caused


if any, rise to e (a), under- e last.


s contrib- h but not terminal ion given


pter 137, requires print or ause or leath on ates, and Acts of s Physi- t or type ignature.


925686


To be filed for burial permit with Board of Health or its Agent.


PHYSICIAN - IMPORTANT f(Was deceased a {U. S. War Veteran, (if so specify WAR)


52


TAGE


Years.


None


SPACE FOR ADDITIONAL INFORMATION


DATE OF ENTERING MILITARY SERVICE


DATE OF DISCHARGE RANK, RATING


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.


LERK


OF


MIN


NTHRO


G.


OFFIC


WINTI


89/16 030


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 prison engaged in domestic service for wages, however, designate the occupation by the appropriate terms, as housekeeper-private family, cook- Hotel Cc. For a person who had no occupation whatever write none.


...


X PLACE OF DEATH


suffolk (County)


Winthrop (City or Town)


The Commonwealth of Massachusetts JOSEPH D. WARD SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS


STANDARD CERTIFICATE OF DEATH


To he filed for buriaf permit with Board of Health or its Agent.


254


(If death occurred in a hospital or institution, St. } give its NAME instead of street and number)


2 FULL NAME


imie F. vir (Fox)


(If deceased is a married, widowed or divorced woman, give also maiden name.)


(a) Residence. No. 165 Bowdoin It.


St.


(If nonresident, give city or town and State)


Length of stay : In place of death .......... ... years.


months .


2


days. In place of residence.


years


months .. ...


.days.


29


MEDICAL CERTIFICATE OF DEATH


PERSONAL AND STATISTICAL PARTICULARS


8 SEX


female


9 COLOR


white


10 SINGLE


(write the word)


MARRIED)


WIDOWEDWidowed


or DIVORCED


10a If married, widowed, or divorced HUSBAND of


(or) WIFE of


Lockhart L.


(Give maiden name of wife in full) muir


(Husband's name in full)


11 IF STILLBORN, enter that fact here.


12


53


Years.


Months.


24Da


Days


If under 24 hours


Hours ...........


Minutes


13 Usual


Occupation :


comemaler


(Kind of work done during most of working life)


14 Industry


or Business :


at home


15 Social Security No.


16 BIRTHPLACE (City)


(State or country)


17 NAME OF


FATHER


George H. Fox


18 BIRTHPLACE OF


Dewsbury


FATHER (City)


(State or country)


Onels_id


19 MAIDEN NAME OF MOTHER Louisa Downes


20 BIRTHPLACE OF MOTHER (City) (State or country)


Uland


(Address WINTHROP MASS Date.


Dec / 1963


6


int non Cemeter, introp


Place of Burial or Cremation (City or Town) DATE OF BURIAL .De.c ........ 10., 19


1


7 NAME OF FUNERAL DIRECTOR ornest r. Copieno


ADDRESS 147 i trop st., wit ron


Received and filed


DEC 10 1963


19


(Registrar)


PARENTS


21 Informant (Address) 16 Lowdoin Et


1 11EREBY CERTIFY that a satisfactory standard certificate of death Agas filed with me BEFORE the burial or transit permit was issued:


(Signature, of Agent of Board of Health or other) Harett, officer


(Official Designation)


(Date of Issue of Permit)


925686


-301A 1


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 e (a), under- e last.


-


Due To (c)


0


OTHER


SIGNIFICANT


CONDITIONS


Jueumonía


2 days


Was autopsy performed?


What test confirmed diagnosis ? .


@ linien/


5 Was disease or injury in any way related to occupation of deceased? /h If so, specify


(Signed)


6 Cealles


.. , M D. CHARLES LIBER MAN (PRINT OR TYPE SIGNATURE)


(Month)


(Day)


(Year)


4 I HEREBY CERTIFY,


12/5/


1963


to ....


121


That I attended deceased from


1963


7/


I last saw h& Yalive on


17/7/


1


6.3


19.


death is said to


have occurred on the date stated above, at 6:00 P.m.


INTERVAL


BETWEEN


ONSET AND


DEATH


DEATH WAS CAUSED BY: IMMEDIATE CAUSE


(a)


Cerebral Hemorrhage


Due To (b)


3 DATE OF


DEATH


Dec. 7, 1263


PHYSICIAN - IMPORTANT


[(Was deceased a { U. S. War Veteran, no


[if so specify WAR)


(Usual place of abode)


Registered No.


No. Bay View Nursing Home


pter 137, requires print or cause or death on ates, and Acts of es Physi- t or type ignature.


s contrib- h but not terminal ion given


SPACE FOR ADDITIONAL INFORMATION


DATE OF ENTERING MILITARY SERVICE


DATE OF DISCHARGE


RANK, RATING


RECEIVED ORGANIZATION AND OUTFIT


SERVICE NUMBER.


11


LERK


MINS


6


LAS


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.


DEC 1 01963 . .


RULES OF PRACTICE


5


PLACE OF DEATH


Suffolk (County)


Boston 7-7-64


The Commonwealth of Massachusetts JOSEPH D WARD SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS


STANDARD


CERTIFICATE OF DEATH


Registered No.


[(If death occurred in a hospital or institution,


St. ? give its NAME instead of street and number)


PHYSICIAN - IMPORTANT


f(Was deceased a


U. S. War Veteran,


[if so specify WAR)


No


(If deceased is a married, widowed or divorced woman, give also maiden name.)


129 Stanwood


St.


Roxbury


(If nonresident, give city or town and State)


Length of stay: In place of death ....


.. years


1


months .


days. In place of residence.


.years.


months ..


.days.


31


MEDICAL CERTIFICATE OF DEATH


3 DATE OF


DEATH


December


11, 1963


(Month)


(Day)


(Year)


4 I HEREBY CERTIFY


That I attended deceased from


Nov


.- 3


63, 1


to


Dec


11


1963


I last saw himalive on


10, 19 63, death is said to


have occurred on the date stated above, at


9:15Am.


INTERVAL


BETWEEN


ONSET AND


DEATH


DEATH WAS CAUSED BY : IMMEDIATE CAUSE


(a) Arterios clerctic Heart Disease


Due Topperalized Arteriosclerosis


3yrs


Due To (c)


OTHER


SIGNIFICANT


CONDITIONS


None


Was autopsy performed?


What test confirmed diagnosis? Clinical


5 Was disease or injury in any way related to occupation of deceased Ve .. If so, specify


(Signed)


Liberman


M D.


CHARLES LIBERMAN (PRINT OR TYPE SIGNATURE) (Address) WINTHROP MASS Date 12/11/1963


Roxbury Lodge, West Roxbury 6


Place of Burial or Cremation


(City or Town)


DATE OF BURIAL


December 12,


63


7 NAME OF


Benjamin Birnbach


FUNERAL DIRECTOR


ADDRESS


10 Washington St. Dorch.


Received and filed


DEC 12 1963


19


(Registrar)


PERSONAL AND STATISTICAL PARTICULARS


8 SEX


Male


9 COLOR


White


Bertha Novick


10 SINGLE


(write the word)


MARRIED


WIDOWED


DIVORCE


Married


10a If married, wi


HUSBAND of


(Give maiden name of wife in full)


(or) WIFE of


(Husband's name in full)


11 IF STILLBORN, enter that fact here.


12


82


1yr


Years.


Months.


Days


If under 24 hours


Hours .............. Minutes


13 Usual


Coal Dealer


Occupation :


(Kind of work done during most of working life)


14 Industry


or Business :


Retired


15 Social Security No.


016-12-4878


16 BIRTHPLACE (City)


(State or country)


Poland


17 NAME OF


FATHER


Louis Lefkofsky


18 BIRTHPLACE OF


FATHER (City)


(State or country)


Poland


19 MAIDEN NAME


OF MOTHER


Rachael (CBL)


20 BIRTHPLACE OF


MOTHER (City)


(State or country)


Poland


21 Jimmy Lewis


Informant


(Address)


129 Stanwood St. Roxbury


] HEREBY CERTIFY that a satisfactory standard certificate of death


was filed with me BEFORE the burial , or transit permit was issued:


Falph


Dirianne


(Signature of Agent of Board of Health or other)


1 3


Health Milicer


Dec.1.1963


5


(Official Desiggation)


(Date of Issue of Permit)


X


TIONS


RTIFICATE


ing DEATH enter n one each and (c)


not mean of dying, rt failure, It means or compli- h caused


if any, rise to se (a), under- se last.


as contrib- th but not e terminal tion given


apter 137, . requires o print or cause or death on cates, and Acts of es Physi- nt or type signature.


-925686


X


1


-301A


1


Winthrop (City or Town)


No.


Bayview Nursing Home


To be filed for burial permit with Board of Health or its Agent.


255


PARENTS


2 FULL NAME


Solomon Lefkofsky


(a) Residence. No.


(Usual place of abode)


SPACE FOR ADDITIONAL INFORMATION


DATE OF ENTERING MILITARY SERVICE


DATE OF DISCHARGE RANK, RATING


ORGANIZATION AND OUTFIT


SERVICE NUMBER


RECEIVED


TOW


IF


11.12 1


6


DEC 1 21963 PM


RULES OF PRACTICE


The fulfillment of the purpose of these laws calls for the observance of the following rules of practice :


(1) Attending physicians will certify to such deaths only as those of persons to whom they have given bedside care during a last illness from disease un- related to any form of injury.


(2) Board of Health physicians will certify to such deaths only as those of persons who, though disabled by recognized disease unrelated to any form of injury, have died without recent medical attendance or whose physician is absent from home when the certificate of death is needed.


(3) Medical Examiners will investigate and certify to all deaths supposably due to injury. These include not only deaths caused directly or indirectly by traumatism (including resulting septicemia), and by the action of chemical (drugs or poisons) thermal, or electrical agents, and deaths following abortion, but also deaths 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.




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