USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1963 > Part 7
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(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.
RM R-301
or burial permit rd of Health s Agent. UCTIONS FOR CERTIFICATE
OR TYPE R CAUSES EATH t enter than one for each b) and (c)
es nat mean af dying, heart failure, etc. It means ,or campli- which caused
ns, if any, ave rise ta cause (a), the under- ause last.
tians contrib- leath but nat the terminal nditian given C.
2-932382
A TRUE COPY ATTEST:
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
9 COLOR
white
10 SINGLE
(write the word)
single
MARRIED
WIDOWED
DIVORCED
UNKNOWN
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.8.5. Years ......... Months .... 2.4 Days
If under 24 hours
.Hours ... .... Minutes
13 Usual
retired Bldg.Supt.
Occupation :
(Kind of work done during most working life)
14 Industry or Businessommercialapartments
15 Social Security No .......
010-03-1223 1793
16 BIRTHPLACE (City)
(State or country)
England
17 NAME OF
FATHER
Edward Richards
PARENTS
18 BIRTHPLACE OF
FATHER (City)
(State or country)
England
19 MAIDEN NAME
OF MOTHER
Margaret Jones
20 BIRTHPLACE OF
MOTHER (City).
(State or country)
Wales
Alfred O. Richards
Informant
( Address)
24 Quincey Ave, Winthrop
I HEREBY CERTIFY that a satisfactory standard certificate of death was filed with me BEFORE the burial or transit permit was issued: 4
(Signature of Agent of Board of Health or other) (~e)) .
Fel. 19. 1963
(Registrar)|| (Official Designation)
(Date of Issue of Permit)
TV
1
inthrop (City or Town)
No.
Robert Owen Richards
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.
29
S(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.
(a) Residence. No .. 24 Quincey Avenue
S
(If nonresident, give city or town and State)
.months .......... days.
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
DEATH
February
16
1963
(Month)
(Day)
(Year)
4 I HEREBY CERTIFY,
That I attended deceased from
JANUARY 27 1963
to ...
FEBRUARY 16
63
I last saw hagalive on
FEBRUARY 15, 1963, death is said to
have occurred on the date stated above, at 2:45 Am.
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a) ACUTE CEREBRAL HEMORRHAGE
INTERVAL BETWEEN ONSET AND DEATH
8 DAYS
5 YEARS
Due To (c)
OTHER
SIGNIFICANT
CONDITIONS
Was autopsy performed ?
No
What test confirmed diagnosis ?
5 Was disease or injury in any way related to occupation of deceased? No
If so, specify
(Signature)
Dorothy Cheney appleton
M. D.
DOROTHY Cheney APPLETON
(Print or Type Name)
(Address) 197Woodside
ViniTHACO BADE Date 2/18
1963
Winthrop Cemetery, Winthrop
6
Place of Burial or Cremation
(City or Town)
DATE OF BURIAL February 19, 1963
..... 12
7 NAME OF
FUNERAL DIRECTOR
alfred -B. March
ADDRESS
174 Winthrop St
Winthrop
Received and filed
FEB 19 1963
19
PLACE OF DEATH
Suffolk (County)
2 FULL NAME
24 Quincey Avenue
(If deceased is a married, widowed or divorced woman, give also maiden name.)
(Usual place of abode)
Length of stay: In place of death years 2 months days. In place of residence 39
male
Due To
(b)
ARTERIOSCLEROSIS
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 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.
ORM R-301
I
Winthrop
(City or Town)
The Commonwealth of Massachusetts KEVIN H. WHITE SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS
STANDARD
CERTIFICATE OF DEATH
Registered No.
30
S(If death occurred in a hospital or institution, St. ¿ give its NAME instead of street and number)
PHYSICIAN - IMPORTANT
2 FULL NAME. MARY EMMA ( Armstrong) TAYLOR
(If deceased is a married, widowed or divorced woman, give also maiden name.)
10
Surfside Avenue
St
Winthrop
(a) Residence. No ..
(Usual place of abode)
(If nonresident, give city or town and State)
Length of stay: In place of death.
4years ......... months .......... days. In place of residence4.Q.
.. years .......... months .......... days.
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
DEATH
FEBRUARY
16.
1963
(Month)
(Day)
(Year)
4 I HEREBY 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
....
1'30 P.m.
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a)
Death due to natural
Due To
Causes , presumably due
(b)
Due To.
arteriosclerotic heart
OTHER
disease
SIGNIFICANT
CONDITIONS
Winthrop Boardy Healthy
Was autopsy performed?
What test confirmed diagnosis?
5 Was disease or injury in any way related to occupation of deceased? If so, specify
(Signature)
CHARLES
LIBERMAN
(Address)
(Print or Type Name) Winthrop Mass Date
2/17/1963
6
Holy Cross
Malden
Place of Burial or Cremation
(City or Town)
DATE OF BURIAL
February
1.9 ....
1963
7 NAME OF
FUNERAL DIRECTOR
FRANK H. CARR
ADDRESS
79 EIm
St., Charlestown
Received and filed
FEB 18-1963
19
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
F
9 COLOR
White
10 SINGLE
MARRIED
WIDOWED Married
DIVORCED
UNKNOWN
11 If married, widowed, or divorced
HUSBAND of
(Give maiden name of wife in full)
(or) WIFE of
FRANK L. TAYLOR
(Husband's name in full)
12
AGE92
Years
Months.
.Days
13 Usual
Occupation :
(Kind of work done during most working life)
14 Industry
or Business :
At Home
15 Social Security No.
16 BIRTHPLACE (City)
(State or country)
Nova Scotia
17 NAME OF
FATHER
Robert Armstrong
18 BIRTHPLACE OF
FATHER (City)
(State or country)
Nova Scotia
19 MAIDEN NAME
OF MOTHER
unknown
20 BIRTHPLACE OF
MOTHER (City)
(State or country)
Nova Scotia
Mrs. Esther Sanborn
21 Informant
(Address)
32 Francis St., Belmont
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)
7.1.18.1967
(Registrar )|| (Official Designation)
(Date of Issue of Permit)
1 X
A TRUE COPY ATTEST:
62-932382
PLACE OF DEATH
Suffolk (County)
No
10 Surfside Ave., Winthrop
(City or Town making this return)
for burial permit ard of Health ts Agent. RUCTIONS FOR CERTIFICATE
OR TYPE OR CAUSES DEATH not enter than one : for each (b) and (c)
oes not mean le of dying, heart failure, etc. It means se, or compli- which caused
ons, if any, gave rise to cause (a), the under- cause last.
litions contrib- death but not o the terminal ondition given
M. D. PARENTS
(c) ....
INTERVAL
BETWEEN
ONSET AND
DEATH
If under 24 hours
Hours ......
.Minutes
Housewe
Chester
(write the word)
(Was deceased a
U. S. War Veteran,
(if so specify WAR)
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE RANK, RATING
ORGANIZATION AND OUTFIT
SERVICE NUMBER.
RULES OF PRACTICE FEB 1 81963 AM of the
The fulfillment of the purpose of these laws calls for the observance 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.
1
ORM R-301
for burial permit ard of Health ts Agent. TRUCTIONS FOR CERTIFICATE
OR TYPE OR CAUSES DEATH not enter e than one e for each (b) and (c)
does not mean de of dying, heart failure, etc. It means ase, or compli- which caused
ions, if any, gave rise to cause (a), the under- cause last.
ditions contrib- death but not to the terminal condition given
PLACE OF DEATH
JUFFOLK (County) WINTHROP (City or Town)
The Commonwealth of Massachusetts KEVIN H. WHITE SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS
STANDARD
CERTIFICATE OF DEATH
Registered No.
31
No MAY FLOWER NURSING HOME 39 GROVERS ALE ( If death occurred in a hospital or institution.
St. ( give its NAME instead of street and number) PHYSICIAN - IMPORTANT
2 FULL NAME ... S
JULIA J (BARRY) SULLIVAN
(If deceased is a married, widowed or divorced woman, give also maiden name.)
(Was deceased a
U. S. War Veteran,
if so specify WAR).
NO
(a)
Residence. No. 47 SUNNYSIDE AVE
(Usual place of abode)
St
WINTHROP.
(City or town and State)
Length of stay: In place of death .......... years .......... months.
days. In place of residence 40 years.
months.
.days.
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
DEATH
(Month)
(Day)
(Year)
4 IHEREBY CERTIFY , That I attended deceased from
Nov.
19 62 to Fele
17
63
I last saw hetalive on
Feb 15, 1969, death is said to
have occurred on the date stated above, at 7110An
INTERVAL
BETWEEN
ONSET AND
DEATH
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a) Myocardial Heart
Disease
Due To
(b) arteriosclerosis
Due To
(c)
OTHER
SIGNIFICANT
CONDITIONS
Diabetes Mellitus
6 hours
Was autopsy performed ?
What test confirmed diagnosis ?
5 Was disease or injury in any way related to occupation of deceased VO
If so, speerfy
ature spe regar M. D.
Joseph GREGORIE
(Print of Type Name) (Address) 9+ Washinghaare Date ?.
2/18 63 19
6 WINTHROP
WINTHROP.
Place of Burial or Cremation
(City or Town)
DATE OF BURIAL
FEB
20
1963
7 NAME OF
FUNERAL DIRECTOR
MAURICE W KIRBY
ADDRESS
WINTHROP
Received and filed
FEB 19 1963
19
( Registrar )|
8 SEX
9 COLOR
10 SINGLE
(write the word)
MARRIED
WIDOWED
DIVORCED
UNKNOWN KLIDUMED
FEMALE
WHITE
11 If married, widowed, or divorced HUSBAND of
(or) WIFE of
(Give maiden name of wife in full)
CORNELIUS SULLIVAN
(Husband's name in full)
12
AGE. 77 Years.
.. Months.
Days
If under 24 hours
.. Hours ........ Minutes
13 Usual
HOME MAKTER
(Kind of work done during most of 1working life)
14 Industry
or Business :.
HUME
15 Social Security No. NONE
16 BIRTHPLACE (City)
(State or country )
17 NAME OF
FATHER
JOHN SULLIVAN BURRY
18 BIRTHPLACE OF
FATHER (City)
(State or country)
IRELAND
0
PARENTS
21 Informant
JOSEPH F SULLIVAIL
( Address)
47 SUNNYSIDE AVE 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) .......
Health Officer
Feb . 19, 1963
(Official Designation)
(Date of Issue of Permit)
62-933404
A TRUE COPY ATTEST:
17
1963
PERSONAL AND STATISTICAL PARTICULARS
Occupation:
IRELAND
19 MAIDEN NAME
OF MOTHER
UNKNOWN )
20 BIRTHPLACE OF
MOTHER (City)
(State or country)
IRELAND
(City or Town making this return)
1
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 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.
ORM R-301
1
PLACE OF DEATH
Suffolk (County)
Winthrop
(City or Town)
The Commonwealth of Massachusetts KEVIN H. WHITE SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS
STANDARD
CERTIFICATE OF DEATH
Registered No.
32
[(If death occurred in a hospital or institution, St. ¿ give its NAME instead of street and number)
2 FULL NAME Elizabeth (If deceased is a married, widowed or divorced woman, give also maiden name.)
Mccluskey (Dunnigan)
(a)
Residence. No.
18 James Ave.,
(Usual place of abode)
Length of stay: In place of death .......... years ......... months ... 16days. In place of residence ..
years .......... months .......... days.
MEDICAL CERTIFICATE OF DEATH
PERSONAL AND STATISTICAL PARTICULARS
3 DATE OF
DEATH
February
18
1963
(Month)
(Day)
(Year)
4 IHEREBY CERTIFY, That I attended deceased from
Jan,
1962, to
Feb 15
63
I last saw hexalive on
Feb. 18
., 19 63 death is said to
have occurred on the date stated above, at.
10:10 Pm.
INTERVAL BETWEEN ONSET AND DEATH
(a) Hypertensive and Arlexion
3yrs.
(b)
Due To (c)
OTHER
SIGNIFICANT
CONDITIONS
Was autopsy performed ?
No
What test confirmed diagnosis? Clinical
5 Was disease or injury in any way related to occupation of deceased ? No If so, specify .............
(Signature)
M. D. CHARLES LIBERMAN
(Print of Type Name)
(Addre
Winthrop, Mass Date 2/18/1963
6
St. Patrick's
Lowell
Place es Dutral of cremation
(City or l'own)
DATE OF BURIAL
Feb. 21
, 53
7 NAME OF
FUNERAL DIRECTOR
Maurice W. Kirby
ADDRESS
Winthrop
Received and filed
FEB 19 1963
19
(Registrar)
8 SEX
9 COLOR
White
MARRIED
WIDOWED Widowed
DIVORCED
UNKNOWN
11 If married, widowed, or divorced
HUSBAND of
(Give maiden name of wife in full)
(or) WIFE of
Frank A. Mccluskey
(Husoand's name in full)
12
AGE,8 1
.Years
Months.
Days
If under 24 hours
Hours .......
Minutes
13 Usual
Occupation :
Domestic
( Kind of work done during most working life)
14 Industry
or Business :
15 Social Security No.
027-29-4881
16 BIRTHPLACE (City)
(State or country )
Mass.
17 NAME OF
FATHER
Francis Dunnigan
PARENTS
18 BIRTHPLACE OF
FATHER (City)
(State or country)
Treland
19 MAIDEN NAME
OF MOTHER
Mary McArdle
20 BIRTHPLACE OF
MOTHER (City)
(State or country)
Ireland
21 Informant
Mary Mccluskey
( Address)
18 James Ave., Winthrop
I HEREBY CERTIFY that a satisfactory standard certificate of death was filed with me BEFORE the burial or transit permit was issued: Maich VerLa (Signature of Agent of Board of Health or other) ( NO)
Health Office
Feb. 19 1963
(Official Designation) (Date of Issue of Permit)
TV
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 se, 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
62-932382
A TRUE COPY ATTEST:
PHYSICIAN - IMPORTANT
(Was deceased a U. S. War Veteran, if so specify WAR) no
Winthrop Mass
St
(If nonresident, give city or town and State)
38
10 SINGLE
(write the word)
Female
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
Due Selerotic Heart Disease
House 1
North Chelmsford
No.
Winthrop Community Hospital
(City or Town making this return)
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE. July 15, 1942
DATE OF DISCHARGE Feb. 24, 1945
RANK, RATING MOLM Second Class
ORGANIZATION AND OUTFIT
US Navy
SERVICE NUMBER.
140-40-83
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.
FED 250003 AN
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 se, 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 C.
PLACE OF DEATH
Suffolk (County) Winthrop
The Commonwealth of Massachusetts KEVIN H. WHITE SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS
STANDARD CERTIFICATE OF DEATH
Registered No. 34
[(If death occurred in a hospital or institution, St. { give its NAME instead of street and number)
PHYSICIAN - IMPORTANT
2 FULL NAME
(If deceased is a married, widowed or divorced woman, give also maiden name.)
47 Washington Avenue
... St ..
(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
3 DATE OF
DEATH
Feb.
22
1963
(Month)
(Day)
(Year)
4 I HEREBY 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
........
5 ..... m.
INTERVAL BETWEEN ONSET AND DEATH
(a)
Due Tonatural causes, probably (b)
acute coronary occlusion on
Due
(c)
Basis of history
OTHER SIGNIFICANT CONDITIONS
Winthrop Boarding Health
Was autopsy performed?
What test confirmed diagnosis ?
5 Was disease or injury in any way related to occupation of deceased ? If so, specify
(Signature)
Charles
CHARLES
LIBERMAN
(Address)
(Print of Type, Name) WINTHROP MASS Date:
e: 2/22/1963
6
Forest Hills Crematory.,
Poston
Place of Burial or Cremation
(City or Town)
February 25, 1963
DATE OF BURIAL
7 NAME OF
FUNERAL DIRECTOR
Benjamin F. Solomon
ADDRESS
420 Horvard Street, Brookline
Received and filed
FEB 25 1963
19
(Registrar)
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
female
9 COLOR
white
10 SINGLE
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