USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1963 > Part 8
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MARRIED
WIDOWED
DIVORCED
UNKNOWN
(write the word)
married
11 If married, widowed, or divorced HUSBAND of
(or) WIFE of.
(Give maiden name of wife in full)
Abraham Roitman
(Husband's name in full)
12
AGE342
Years
Months ..
.Days
If under 24 hours
Hours
Minutes
13 Usual
Occupation :
Physician (retired)
(Kind of work done during most working life)
14 Industry
or Business :
15 Social Security No ...
16 BIRTHPLACE (City)
(State or country )
Latvia
17 NAME OF
FATHER
Abraham Segal
18 BIRTHPLACE OF FATHER (City) (State or country)
Pussis
19 MAIDEN NAME
OF MOTHER
Treda (unknorm)
20 BIRTHPLACE OF MOTHER (City) (State or country )
21 Informant
br-han Roitman
( Address)
47 Washington Avenue, Winthrop, Mass
I HEREBY CERTIFY that a satisfactory standard certificate of death was filed with me BEFORE the burial or transit permit was issued: 6
(Signature of Agent of Board of Health or other) Hearthe office
(Official Designation)
(Date of Issue of Permit)
TV
A TRUE COPY ATTEST:
2-932382
1
(City or Town)
No.
47 Washington Avenue
(City or Town making this return)
Jennie S. Roitman
(Was deceased a
U. S. War Veteran,
(if so specify WAR).
no
(a)
Residence. No
(Usual place of abode)
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
presumably to
M. D. PARENTS
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE RANK, RATING
ORGANIZATION AND OUTFIT
SERVICE NUMBER
RULES OF PRACTICE FEL DENC3 75
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 fromn 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
or burial permit rd of Health s Agent. UCTIONS FOR CERTIFICATE
OR TYPE R CAUSES DEATH ot enter than one for each (b) and (c)
Des not mean e of dying, heart failure, etc. It means e, or compli- which caused
ms, if any, gave rise to cause (a), the under- cause last.
itions contrib- death but not the terminal ndition given ,C.
2-932382
TRUE COPY ATTEST:
PERSONAL AND STATISTICAL PARTICULARS
8 SEX FEM
9 COLOR
White
10 SINGLE
MARRIED
WIDOWED
DIVORCED
UNKNOWN
(write the word) Widowed
11 1f married, widowed, or divorced HUSBAND of
(or) WIFE of.
BARNEY GLOOBERMAN
(Husband's name in full)
12
AGE 82
Fears
Months.
Days
If under 24 hours
Hours ..
Minutes
13 Usual
House wife
Occupation :
(Kind of work done during most working life)
14 Industry
or Business :
AT Home
15 Social Security No ...
None
16 BIRTHPLACE (City)
(State or country )
Russia
17 NAME OF
FATHER
LABE Sheits
PARENTS
18 BIRTHPLACE OF
FATHER (City)
Russian
(State or country)
19 MAIDEN NAME
OF . MOTHER
CBC
20 BIRTHPLACE OF
MOTHER (City)
(State or country)
Mrs Albert ARONOFSKY
21 Informant
(Address)
106 Summit itve, 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 Oficer
F 1- 27-1963
(Date of Issue of Permit)
1 X
1
PLACE OF DEATH
SUFFOLK
(County) Winthrop
(City or Town)
Wintheen Com, Hosp. No
[(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.)
106 Summit Ave
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
3 DATE OF
DEATH
Feb
26
1963
(Month)
(Day)
(Year)
4 I HEREBY CERTIFY, That I attended deceased from
Det
1950
to ...
Feb. 26
1963
I last saw heV.alive on
Feb , 26
, 1963, death
.. , death is said to
have occurred on the date stated above, at 6:30p. m.
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a) Arteriosclerotic Heart Disease
INTERVAL BETWEEN ONSET AND DEATH 14%.
(b) .
Myocardial Infarction
5 days
Due To (c)
OTHER
SIGNIFICANT
Nine
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 or Type Name)
(Addre WINTHROP, MASS Date 2/26/1963
TiFERETH IS. 01 Winthrop. Eventt
6
Place of Burial or Crematum
(City or Town)
DATE OF BURIAL
Relimany
27
19
63
7 NAME OF
TORF funeral Service Ine
FUNERAL DIRECTOR
ADDRESS
Washington Are Chelsea
Received and filed
FEB 27 1963
19.
The Commonwealth of Massachusetts KEVIN H. WHITE SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS STANDARD
(City or Town making this return)
CERTIFICATE OF DEATH
Registered No.
35
Rebecca
Glooberman
(Was deceased a
U. S. War Veteran,
if so specify WAR)
NO
(a) Residence. No ...
(Usual place of abode)
St
(Registrar) (Official Designation)
(Give maiden name of wife in full)
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.
63 AF
ORM R-301
or burial permit rd of Health s Agent. RUCTIONS FOR CERTIFICATE
OR TYPE OR CAUSES DEATH ot enter than one for each (b) and (c)
oes not meon e of dying, heart failure, etc. It means se, or compli- which caused
ons, if ony, gave rise to couse (o), the under- couse lost.
itions contrib- deoth but not the terminal ondition given
2-933404
A TRUE COPY ATTEST:
8 SEX
MALE
9 COLOR
WHITE
IO SINGLE
MARRIED
WIDOWED
DIVORCED
(write the word)
MARRIED
11 If married, widowed, of divorced MARIE W AMIPAULT HUSBAND of (Give maiden name of wife in full)
(or) WIFE of.
(Husband's name in full)
12
AGE: 53 Years.
Months ..
.. Days
If under 24 hours
Hours. .... Minutes
13 Usual
Occupation :
WELDER.
(Kind of work done during most of iworking life)
14 Industry
or Business :
CONSTRUCTION (BLDG,)
15 Social Security No 349-01-1201
BELVEDERE
16 BIRTHPLACE (City)
(State or country)
ILh.
17 NAME OF
FATHER
WILLIAM STURGES
18 BIRTHPLACE OF
FATHER (City)
(State or country)
ILL.
ELGIN
19 MAIDEN NAME
OF MOTHER
ANNE ACTON
20 BIRTHPLACE OF
MOTHER (City)
(State or country)
ILL.
DECATUR.
6
WINTHROP
WINTHROP
Place of Burial or Cremation (City or Town)
DATE OF BURIAL MARI 1963
7 NAME OF
FUNERAL DIRECTOR
MAURICE W KIRBY
ADDRESS WINTHROP
Received and filed
FEB 28 1963
19
(Registrar )
The Commonwealth of Massachusetts KEVIN H. WHITE SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS STANDARD QVIỆTEM
CERTIFICATE OF DEATH
Registered No.
36
[(If death occurred in a hospital or institution, St. ( give its NAME instead of street and number) PHYSICIAN - IMPORTANT
2 FULL NAME.
WILLIAM A STURGES
(If deceased is a married, widowed or divorced woman, give also maiden name.)
(a)
Residence. No ...
25 TEMINS BURY ST.
... St. .....
(City or town and State)
Length of stay: In place of death / 2 years
months.
days. In place of residence years months
.. days.
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
DEATH
Feb. 26, 1963
(Month)
(Day)
(Year)
4 IHEREBY CERTIFY
May29 1939, 10
Feb. 22
1963
That I attended deceased from
I last saw h.). @live on
Feb. 22.
1963, death is said to
have occurred on the date stated above, at
939 am.
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
Coronary Occlusion
(a)
INTERVAL BETWEEN ONSET AND DEATH
Due To
Arteriosclerofic heart
(b)
Syv;
(c)
Due To
disease
Chronic Asthma
15423
OTHER
Chronic Emygewandloyal
SIGNIFICANT
CONDITIONS Epilepsy JuJUS
Was autopsy perfornfed ?
What test confirmed diagnosis ?
Wil
5 Was disease or injury in any way related to occupation of deceased ?
If so, specify
None
(Signature)
Imple Zawieller
M. D.
Joseph Zambella
"(Print or Type Name)
(Ad 324 SummerStiE
2- -8-63
PARENTS
21 Informant
MARIE W STURGES
(Address).
25 TEWKSBURY ST WINTHROP
I HEREBY CERTIFY that a satisfactory standard certificate of death was filed with me BEFORE the burial or transit permit was issued : Nespole E. fireanni (3) (Signature of Agent of Board of Health or other) Health office Feb . 25 - 16 2
(Official Designation)
(Date of Issue of Permit)
TX
PLACE OF DEATH
X SUFFOLK (County) WINTHROP (City or Town) 1
ATE
25 TEWKSBURY ST. No.
(City or Town making this return)
(Was deceased a U. S. War Veteran, (if so specify WAR) NO
(Usual place of abode)
PERSONAL AND STATISTICAL PARTICULARS
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE
RANK, RATING
ORGANIZATION AND OUTFIT
SERVICE NUMBER
RULES OF PRACTICE FEL 86 63/
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.
M R-301
burial permit of Health Agent. TIONS 1
RTIFICATE
TYPE CAUSES ATH enter in one r each and (c)
not mean of dying, rt failure, . It means or compli- ch caused
if any, : rise to se (a). : under- se last.
ns contrib- th but not e terminal ition given
002
13 1963
PLACE OF DEATH
Suffolk
(County) Boston
(City or Town)
KEVIN H. WHITE SECRETARY OF THE COMMONWE DIVISION OF VITAL STATISTICS
STANDARD CERTIFICATE OF DEATH
Registered No.
183
((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.)
80 Johnson Avenue
St
Winthrop, Mass.
(a) Residence. No.
(Usual place of abode)
Length of stay : In place of death .......... year ........... months
47
.days. In place of residence.
60
ears ...... months .......... days.
MEDICAL CERTIFICATE OF DEATH
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
9 COLOR
White
10 SINGLE
MARRIED
WIDOWED
DIVORCED
UNKNOWN
(write the word)
Married
11 If married, widowed, or divorced
(Give maiden name of wife in full)
(or) WIFE of
(Husband's name in full)
12
AGE ... 8.4 ears 2.
Months.2.1 .. Days
If under 24 hours
Hours ..
.. Minutes
13 Usual
Occupation :
Caretaker ( retired)
( Kind of work done during most working life)
14 Industry
or Business
Real Estate
15 Social Security No ....
none
16 BIRTHPLACE (City)
Boston,Mass.
(State or country )
Was autopsy performed ?
No
What test confirmed diagnosis?
SPUTUM CULTURES & SMEARS
5 Was disease or injury in any way related to occupation of deceased ?
....
If so, specify ....
NO
(Signature)
Stewart Wright
M. D.
STEWART WRIGHT
(Address)
........
Forest Hills Cemetery, Boston
6
Place of Ilurial or Cremation
(City or Town)
7 NAME OF
FUNERAL DIRECTOR
J.S.Waterman & Sons
ADDRESS
495 Commonwealth Ave, Boston
Recorml aff f
JAN 9 1963
Charles H. Mackie
....
(Registrar)
PARENTS Q
17 NAME OF
FATHER
John W.Day
18 BIRTHPLACE OF
FATHER (City)
(State or country)
England
19 MAIDEN NAME
OF MOTHER
Eliza Cox
20 BIRTHPLACE OF
MOTHIER (City) ..
(State or country)
England
21 Informant
Rosanna Day
( Address)
80 Johnson Ave, Winthrop, Mass.
I HEREBY CERTIFY that a satisfactory standard certificate of death was filed with me BEFORE the burial or transit permit was issued:
.. .......................
603844
(Simimare of Agent of Board of Health or other) 1-8-63
(Official Designation) (Date of Issue of Permit)
A TRUE COPY ATTEST:
3 MOS
Due To (b)
Due To (c)
to ..
January 7
19
I last saw AMalive on
January
.7
63
19
death is said to
HUSBAND of
Rosanna .... M.B.e.v.e.lander ...
have occurred on the date stated above, at
2.45 a
„.m.
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
INTERVAL BETWEEN ONSET AND DEATH.
TUBERCULOSIS PULMONARY & ORAL (a)
3 DATE OF
DEATH
(Month)
(Day)
January
7
1963
(Year)
4IHEREBY CERTIFY
November 21
19
62
That I attended deceased som
Male
OUTSOSTODWIT
(City or Town making this return)
1
No ...
......
New England Center Hospital
Mr. George Compton Day
(\'as deceased a
U. S. War Veteran,
if so specify WARI
none
(If nonresident, give city or town and State)
OTHER
SIGNIFICANT
CONDITIONS
NEW ENGLAND"ENTER HERE. 7 JAN 63
DATE OF NURIAL
January 9,1963
19
32382
A TELL COPY ATTEST: Cartes & Mackie City Reoxtar
OF
TOWA
OFFICE
GLERK
00
6 0
THROP M
MAR 1 31963 AM
1
ORM R-301
for burial permit ard of Health ts Agent. TRUCTIONS FOR L CERTIFICATE
·OR TYPE OR CAUSES DEATH not enter than one e for each (b) and (c)
does mot meon de of dying. heart foilure, etc. It means ase, or compli- which caused
ioms, if any, gave rise to cause (0). the under- cause last.
ditions contrib- death but not o the terminal condition given
.c.
634 R 9 1963 1963
Director use only K Ink.
62-932382
PLACE OF DEATH
SUFFOLK
(County )
qu'il TU
STANDARD CERTIFICATE OF DEATH
1047
Registered No.
f(If ileath occurred in a hospital or institution, St. I give its NAME instead of street and number)
2 FULL NAME ..
James. J .... Sharkey
(If deceased is a married, widowed or divorced woman, give also maiden name.)
19 Buchanan Street
Winthrop, Mass.
(If nonresident, give city or town and State)
Length of stay: In place of death ......... years.2 months ... / days. In place of residence. KOyears months days.
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
January
29
1963
DEATII
(Month)
(Đầy)
(Year)
4IHEREBY CERTIFY , That we attemiled deceased from
November 281. 63
19
63
10.
January
29
63
January 29
19
., death is said to
wel last saw h ...... alive on
9:00a.
have occurred on the date stated above, at
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a).
le Cerebral Artery
Thrombosis
(b) .. Due To theesclerosis
vars
Dite To (c)
OTHER
SIGNIFICANT CUSO Tubular Necrosis
CONDITIONS
3
Y ?- S
Was autopsy performed?
Yes
What test confirmed chagnosis ?
Autensy
5 Was disease or injury in any way related to occupation ol deceased ?
If so, specify
(Signature)
Caclay
M. D.
Charles to. Clay, M. D ... (Print or Type Name)
(Address Ase's. Din, Moss, Gon'L Hosp ......... Date ....
Jan. 29.63
6
WINTHROP
WINTHROP
Place ol Burial or Cremation
(City or Town)
DATE OF BURIAL
FEB 1
1) 63.
7 NAME OF
FUNERAL DIRECTOR
MAURICE 1. KIRBY
ADDRESS
19 413 7
Received any hled
Charles it Mackie
8 SEX
9 COLOR
(write the word)
MALE
WHITE
10 SINGLE
MARRIED
WIDOWED
DIVORCED
UNKNOWN
MARRIED
Il If married, widowed, or divorced
HUSBAND of
ELLA V.
THORNTON
(Give maiden name of wife in full)
(or) WIFE of.
(Husband's name in full)
12
AGES Wear.
Month-
Days
If under 24 hours
Hours .. ..... Minutes
13 l'sual
Occupation :
CLERK.
( Kind of work done during most working life)
14 Industry
or Business
LING STORING
15 Social Security No. 0.21-09-6014
16 BIRTHPLACE (City). LAST Desicil (State or country )
17 NAME OF
FATHER
JAMES P SHLARNEY
18 BIRTHPLACE OF
FATHIER (City)
(State or country)
BOSTON
19 MAIDEN NAME
OF MOTHER
MARY & MACEACHERN
20 BIRTIIPLACE OF
MOTHER (City)
GLIVINSTER.
(State or country )
MASS
21 Informant
MiPS ELLA SHARNEY
( Address)
19 BUCHANAN ST WINTHROP MASS
HEREBY CERTIFY that a satisfactory standard certificate of death is filed with me BEFORE The burial or transit permit was issued: Prima T. Manmale (Signature ol Agent ol Board of Health or other)
14945 1/31/63.
(Registrat)|| (Official Designation)
(Date of Issue of Permit)
1., V
A TRUE COPY ATTEST:
The Commonwealth of Massachusetts KEVIN H. WHITE SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS
38
(City or Town making this return)
1
BOSTON
(City or Town)
NMASSACHUSETTS GENERAL HOSPITAL
PHYSICIAN - IMPORTANT
) (Was deceased a
U. S. War Veteran, 29 is IT
if so specify WAR
(a) Residence. No .....
(Usual place of abode)
St ..
PERSONAL AND STATISTICAL PARTICULARS
PARENTS
INTERVAL BETWEEN ONSET ANO DEATH 2 mos
TOW
: 32
1-10
LERK
WI
THROW
APR -51963 AM
1
ORM R-301 -
-
PLACE OF DEATH
Suffolk
County) Barton (City or Town) BOSTON CITY TOSPITAL
CERTIFICATE OF DEATH
Registered No.
1174
S(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.)
2 Lorean ferr.
St Winthrop, Mass.
(a) Residence. No.
(Usual place of abode)
Length of stay: In place of death ....
years ...... months! 9 days. In place of residence 2 years.
. .. . months davs.
MEDICAL CERTIFICATE OF DEATH
PERSONAL AND STATISTICAL PARTICULARS
8 SEX 7
9 COLOR
10 SINGLE
(write the word)
MARRIED
WIDOWED,;
DIVORCED Vuelound
UNKNOWN
11 if married, widowed. or divorced HUSBAND of
(Give maiden name of wife in full
//( Husband's name in full)
If under 24 hours
Hours ..
Minutes
13 t'sual
Lecretary
Occupation
( Kind of work done during most of iworking life)
14 Industry
or Business
unknown Social Security
036-04-6140
16 BIRTHPLACE (City).
(State or country )
17 NAME OF
FATHER
John F. Harding
18 BIRTHPLACE OF
FATHER (City)
(State or country)
Vermont
19 MAIDEN NAME
OF MOTHER
Current Lassen
20 BIRTHPLACE OF
MOTHER (City)
(State or country)
41.4
21 Informant
ant Jeannette Paturiquel
in Coper Law Firentry Course
I HEREBY CERTIFY that a satisfactory standard certificate of death was hled with me BEFORE the burial or transit permit was issued: Durata
.......
(Signature of Agent of Board of Health or other)
14 960
2/1/63
(Official Designation)
(Date of Issue of Permit)
TVRV
A TRUE COPY ATTEST:
within Olan all, M. D).
M. WINTHROP O'CONNELL, M.D. (Print fr Type Name) BOSTON CITY HOOPHAL Date 1-31-63
6 Place of Burial or Cremation Fel 19.63
(City of Town)
DATE OF BURIAL
7 NAME OF FUNERAL DIRECTOR
W. C. Parker
ADDRESS
Recemed and filed
FEB 5 10 3 1.19 Charles et Mackie
( Registrar)
The Commonwealth of Massachusetts KEVIN H. WHITE SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS STANDARD
40
(City or Town making this return)
or nur:al permit a's o. Heaith
RUCTIONS FOR . CERTIFICATE
OR TYPE OR CAUSES DEATH not enter : than one e for each (b) and (c
does not mean de of dying. heart failure. el: 18 means se, or ( pl- which caused
give rise to cause (a). the under. cause last.
litions contrib- death but not o the terminal condition giver
1.C.
443
×
5 1963
2-133404
3 DATE OF
January 30, 1963
DEATH
( Month) (Day) Was a patient
4 1 HERE Jan. 21, 1963 FY, Jan. 30,.1963
1
alive of 4:15 P.M
Cardiac Insufficiency
Due l'o
(h)
( Clinical)
Due To (c) Hypertensive Cardiac Disease
OTHER SIGNIFICANT CONDITIONS
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
PARENTS
No.
Martha Smith
(HARDING)
( Was deceased a U. S. War Veteran, if so specify WARY
(C'ity or town and State)
have occurred on the date stated above, at ·INTERVAL BETWEEN DEATH WAS CAUSED BY: IMMEDIATE CAUSE ONSET AND (or) WIFE of. 12 DEATH days AGE GSTea Years 0 Months 23 Days
death is said to
RECEIVED
OF TOW 17 12 -- -
1
: CLERK
VIN
/THROP
APR -51963 AM
1
41
To be filed for burial permit with Board of Health } or its Agent.
No.
St ...... Elizabeth's ..... Hospital
(If death occurred in a hospital or institution,
St. { give its NAME instead of street and number)
FRANCIS
J.
SHEA
[ ( Was deceased a
U. S. War Veteran,
(if so specify WAR) WW .... ]
(If deceased is a married, widowed or divorced woman, give also maiden name.)
63 PAINE
WINTHROP
(a) Residence. No.
( l'sual place of abode )
(If nonresident, give city or town and State)
Length of stay :
In place of death .. ....
years .. ....
.. months
.days.
In place of residence 35
years ..
months.
.days.
MEDICAL CERTIFICATE OF DEATH
PERSONAL AND STATISTICAL PARTICULARS
(write the word)
3 DATE OF
DEATH
FEB
4
1963
(Month)
(Day)
(Year)
4 1
HEREBY
CERTIFY,
That I attended deceased from
14
1/20
19
to ...
63
I last saw hin
...... alive on
2/4
19 43
death is said to
have occurred on the date stated above, at
10 2- 0m.
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a)
MULTIPLE
MYELOMA
Due To
(b)
PATHOLOGIC FRACTURES
( OVER)
Due To
(c)
OTHER
SIGNIFICANT
CONDITIONS
Was autopsy performed?
YES
What test confirmed diagnosis?
5 Was disease or injury in any way relatry to occupation of deceased? If so, specify
(Signed)
M. D ASSETHAT A. MARTINS
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