USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1946 > Part 45
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STATEMENT OF CAUSE OF DEATH
Medical Examiners in certifying to a death will state the cause and manner thereof, and will apecify: (1) Under cause, the nature of an injury and of its consequences; and (2) under manner, the mode of its production together with the circumstances when these are known. For example: "Com- pound fracture of the femur with ensuing septicemia (gas bacillus) caused by a steam railway accident." "Pistol shot wound of the chest with asso- ciated hemorrhage, homicidal." "Asphyxiation by suspension, suicidal." "Syncope while under the influence of ether administered as a surgical anaesthetic." "Fracture of the skull with asaociated internal injury sus- tained under circumstances unknown."
If disease or injury was related to occupation, specify. If investigation shows the death to have been due to disease, specify : (1) Under cause its known or presumable nature; and (2) under manner, indieate the circum- stances leading to medico-legal inquiry. For example : "Licmorrhage spon- taneous of the brain (basal ganglia) (found dead in bed)." "}leart disease, presumably coronary sclerosis. (Sudden death.)"
DESCRIPTION (for unknown person)
NOTICE TO UNDERTAKERS: No embalming fluid, or any substitute therefor, shall be injected into the body of any person supposed to have met his death by violence, until a permit, signed by the Medical Examiner, has first been obtained .- General Laws, Chap. 38, Sec. 14.
THIS CERTIFICATE CONSTITUTES SUCH PERMIT
1
11 A
1
PLACE OF DEATH
(County} Winthofft (City of Town)
No.
ya' hotife 2/10/46
The Commonwealth of Massachusetts OFFICE OF THE SECRETARY DIVISION OF VITAL STATISTICS STANDARD CERTIFICATE OF DEATH
To be filed for burial pormit with Board of Health or its Agent 120
Registered No.
St. { (If death occurred in a hospital or institution, { give its NAME instead of street and number)
2 FULL NAME
Charles H. Penderfint
( If deceased Is a married, widowed og divorced woman give also maiden name.)
67 Ouder
St.
(If nonresident, give city or town and State)
Length of stay: In nosoltal ar Institution
(Before death)
(Specify whether)
years months = days.
in this community
mos.
days.
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
4 COLOR OR RACE
White
5 SINGLE
( write the word)
MARRIED
Widowed
or DIVORCED
Sa If married, widowed. HUSBAND of
(or) WIFE of
( Husband's name In full)
6 Age of husband or wife if alive
years
7 IF STILLBORN, enter that fact here.
8 AGE 16 Years
Months Days
If less than 1 day
Hours
Minutes
Usual
9 Occupation :
Shoe maker
Industry
10 or Business :
the
11 Social Security No. 033-03-0383
12 BIRTHPLACE (City)
( Siate or country)
Maine
13 NAME OF
FATHER
Wm. W. Pendugast
PARENTS
14 BIRTHPLACE OF
FATHER (City)
(State or country)
Maine
15 MAIDEN NAME
OF MOTHER
Blive Elweed
16 BIRTHPLACE OF
MOTHER (City)
(State or country)
17 Informant ( Address)
I HEREBY CERTIFY chat a satisfactory standard, certificate of death was filed with me BEFORE the burjab of transit permit was Issued :
(Signature of Sweat of Board of Health or other)
Health Mich to 7/1/45
( Date of Trque of Permit)
18 DATE OF
7
DEATH
( Month)
(Day)
(Year)
19 | HEREBY CERTIFY,
That I attended deosased from
LEY, 12. 19 40 to June 29
....
1946
I last saw him alive on .......
June 28, 1946, death is said to
have occurred on the date stated above, at ..
9:15 Pm
immediate cause of death hugocardial degeneration
Due to
Carcinomatoria
Due to.
Other conditions.
( Include pregnancy within 8 months of death)
Major findings: Of operations
Date of
Of autopsy.
What test confirmed diagnosis ?
Physical exam
-
20 Was disease or injury in any way related to occupation of deceased ?. If so, specify
( Signed) Jotun A. Bunting
M. D.
(Address) 23 Broad St Lymanto June 29 1946 giove
Place of Burial, Cremation or Removal. (City or Rown)
DATE OF BURIAL
1946
22 NAME OF FUNERAL DIRECTOR FOR Hilton La Targu
ADDRESS
35 Franklin St. Lynn
Received and fled.
JUL 2 1940
19
( Registrar)
mul pory and
Duration 3 minutes IMPORTANT
5 m. ....
...
IMPORTANT
Physician Underline the cause to which death should be charged sta. tistically.
21
Relation Wany
100m(i)-1-44.13634
"( Oficial Designation)
MEDICAL CERTIFICATE OF DEATH
194.6
(Que maiden name of wife In fun
maker
have
PHYSICIAN - IMPORTANT
(Was deceased a
U. S. War Veteran,
if so specify WAR).
(a) Residence. No.
(Usual place of abode)
EXTRACTS FROM THE LAWS OF THE COMMONWEALTH OF MASSACHUSETTS GOVERNING THE RETURN OF CERTIFICATES OF DEATH
A physician or registered hospital medical officer shall forthwith, after the death of a person whom he has attended during his last illness, at the request of an undertaker or other authorized person or of any member of the family of the deceased, furnish for registration a standard certificate of death, stating to the hest of his knowledge and helief the name of the deceased, his supposed age, the disease of which he died, defined as re- quired hy section one, where same was contracted, the duration of his last illness, when last seen alive hy the physician or officer and the date of his death ... Gen. Laws, Chap. 46, Sec. 9.
A physician or officer furnishing a certificate of death as required by the preceding section or by section forty-five of chapter one hundred and four- teen, shall, if the deceased, to the best of his knowledge and helief, served in the army, navy or marine corps of the United States in any war in which it has been engaged, insert in the certificate a recital to that effect, speci- fying the war, and shall also certify in such certificate both the primary and the secondary or immediate cause of death as nearly as he can state the same. For neglect to comply with any provision of this section, such physician or officer shall forfeit ten dollars. For the purposes of this sec- tion and of sections forty-five, forty-six and forty-seven of said chapter one hundred and fourteen, the word "war" shall include the China relief expedition and the Philippine insurrection, which shall, for said purposes, be deemed to have taken place between February fourteenth, eighteen hundred and ninety-eight and July fourth, nineteen hundred and two, and the Mexican border service of nineteen hundred and sixteen and nine- teen hundred and seventeen. G. L. Chap. 46, Sec. 10.
No undertaker or other person shall bury or otherwise dispose of a human body in a town, or remove therefrom a human body which has not been buried, until he has received a permit from the board of health, or its agent appointed to issue such permits, or if there is no such board, from the clerk of the town where the person died; and 110 undertaker or other person shall exhume a human body and remove it from a town, from one cemetery to another, or from one grave or tomb other than the receiving tomb to another in the same cemetery, until he has received a permit from the board of health or its agent aforesaid or from the clerk of the town where the body is buried. No such permit shall be issued until there shall have been delivered to such board, agent or clerk, as the case may be, a satisfactory written statement containing the facts required by law to be returned and recorded, which shall be accompanied, in case of an original interment, by a satisfactory certificate of the attending physician, if any, as required by law, or in lieu thereof a certificate as hereinafter provided. If there is no attending physician, or if, for sufficient reasons, his certificate cannot be obtained early enough for the purpose, or is insufficient, a physi- cian who is a member of the board of health, or employed by it or by the selectmen for the purpose, shall upon application make the certificate re- quired of the attending physician. If death is caused by violence, the medi- cal examiner shall make such certificate. If such a permit for the removal of a human body, not previously interred, from one town to another within the commonwealth cannot be obtained early enough for the purpose, the certificate of death made as above provided and in the possession of the undertaker desiring to make such removal shall constitute a permit for such removal; provided, that such body shall be returned to the town from which it was removed within thirty-six hours after such removal, unless a permit in the usual form for the removal of such body has been sooner obtained hereunder. If the death certificate contains a recital, as required
by section ten of chapter forty-six, that the deceased served in the army, navy or marine corps of the United States in any war in which it has been engaged, such recital shall appear upon the permit. The board of health, or its agent, upon receipt of such statement and certificate, shall forthwith countersign it and transmit it to the clerk of the town for registration. The person to whom the permit is so given and the physician certifying the cause of death shall thereafter furnish for registration any other neces- sary information which can be obtained as to the deceased, or as to the manner or cause of the death, which the clerk or registrar may require .- Chap. 114, Sec. 45, G. L., (Tercentenary Edition).
Medical examiners shall make examination upon the view of the dead bodies of only such persons as are supposed to have died by violence. If a medical examiner has notice that there is within his county the body of such a person, he shall forthwith go to the place where the body lies and take charge of the same; . . . - General Laws, Chap. 38, Sec. 6.
No undertaker or other person shall bury a human body or the ashes thereof which have been brought into the commonwealth until he has re- ceived a permit so to do from the board of health or its agent appointed to issue such permits, or if there is no such board, from the clerk of the town where the body is to be buried or the funeral is to be held, or from a person appointed to have the care of the cemetery or burial ground in which the interment is made. . .. Chap. 114, Sec. 46, G. L., (Tercentenary Edition).
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 unrelated 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 phy- sician is ahsent from home when the certificate of death is needed.
(3) Medical Examiners will investigate and certify to all deaths sup- posably 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 occupation, the sudden deaths of persons not disabled by recognized disease, and those of persons found dead.
Statement of Cause of Death .- Cause of death means the disease, or complication which causes death, not the mode of dying, e. g., heart failure, asphyxia, asthenia, etc. As principal cause name the disease causing death. As related causes, name earlier morbid conditions, if any, related to the principal cause and any important complication of the principal cause.
Statement of Occupation .- Precise statement of occupation is very im- portant, 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 occupation had been given up or changed on account of the disease causing death, report the usual occupation prior to illness. If the deceased had retired from business, report the usual occupation prior to retirement. Children 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, how- ever, designate the occupation by the appropriate terms, as housekeeper- private family, cook-hotel, etc. For a person who had no occupation whatever write none.
SPACE FOR ADDITIONAL INFORMATION
301A
Suffolk (County)
The Commonwealth of Massachusetts OFFICE OF THE SECRETARY DIVISION OF VITAL STATISTICS STANDARD
To be filed for burial permit- with Board of Health or its Agent.
2 FULL NAME
Annie Keir Wormhood
(If deceased is a married, widowed or divorced woman, give also maiden name.)
(a) Residence.
No.
19 Egleton Park
(Usual place of abode)
Length of residence in city or town where death occurred
36 years
months
days.
How long in U.S., if of foreign birth?
years
mouths
days.
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
Female
4 COLOR OR RACE
White
6 SINGLE
MARRIED
WIDOWED
or DIVORCED
(write the word)
Married
5a If married, widowed, or divorced
HUSBAND of
Hermanyeniden name of wife in full)
(or) WIFE of
.........
(Husband's name in full)
6 IF STILLBORN, enter that fact here.
AGE 74 Years 1 .Months ........ Days
If less than 1 day
.Hours.
Minutes
8 Trade, profession, or particular
kind of work done, as spinner, Housewife
sawyer, bookkeeper, etc ....
.....
9 Industry or business in which
work was done, as silk mill,
saw mill, bank, etc ......
10 Date deceased last worked at
11 Total time (years)
this occupation (month and
spent in this
occupation
12 BIRTHPLACE (City)
Rochester,
(State or country)
New Hampshire.
13 NAME OF
FATHER
John B. Keir.
14 BIRTHPLACE OF
FATHER (City)
Not know
(State or country)
Scotland.
15 MAIDEN NAME
OF MOTHER
Jane King,
16 BIRTHPLACE OF
MOTHER ~City)
Not know ...
(State or country)
Scotland.
17 Herman Wormhood
Husband.
(Address)
19 Egleton Park, Winthrop, Mass
I HEREBY CERTIFY that a satisfactory standard certificate of death was flod with me BEFORE the burial or transit permit was issued: Walter A. Baker
(Signature of Agent . (Heard of Health or other) Health Office 6130 /46
(Date of Issue of Permit)
MEDICAL CERTIFICATE OF DEATH
18 DATE OF
DEATH
June
29,
(Month)
(Day)
(Year)
19 I HEREBY CERTIF
min. 3
1945, 10 max 29, 1966
i last saw b & alive on Jamal 29 19 .... (., death is sald to have occurred on the date stated above, at 4, 10Pm. The principal cause of death and related causes of Importance in order of onset were as follows:
Date of Onset IMPORTANT
....
meta stasis
Contributory causes of Importance not related to principal cause:
Name of operation.
What test confirmed diagnosis ?.
Was there an autopsy?
Date of
20 Was disease or Injury in any way ralated to occupation of deceased?
If so, spacify .... comey M. D.
(Signed)
Than on Date 6-30-19 46
21 .. 5. Cemetery ,Rochester, N .H.
Relation, if any Place of Burial, Creination or Removal. (City or Town)
DATE OF BURIAL ..
2
1946
22 NAME OF
UNDERTAKER
Tas H. CLocaly
ADDRESS
Rochester, N. H.
19
Recelvad and filed ... JUL 2 - 1946 ..... ..........
(Registrar)
(Oficial Designation)
100m 11.'36. No. 9080-F
1 7 PARENTS OCCUPATION Informant in plain terms, so that it may be property classified. Date of onset and exact statement of vecurAllvn are very year) important. See instructions and extracts from the laws on back of certificate.
Winthrop
121
(City or Town)
CERTIFICATE OF DEATH
Registered No.
No
19 Egleton Park
(If death occurred in a hospital or institution,
.St.,
.Ward
give its NAME' instead of street and number)
-
PLACE OF DEATH
(If U. S.
War Veteran
specify WAR)
.St.
.Ward,
(If nonresident, give city or town and state)
1946
That i attended deceased from
(Address) ......
Statement of occupation. -- l'recise statement of occupation is very important, so that the relative healthfulness of various pur- suits can be known. Make some entry in this section for every person aged 10 years or over. If the occupation had been given up or changed on account of the disease causing death, report the occupation prior to illness. If the deceased had retired from bus- iness, report the occupation prior to retirement. Children 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 in answer to Question 8 and OWN HOME in answer to Question 9. 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.
To be complete, an occupation return must state :
8 .- The trade, profession, or particular kind of work done.
9 .- The industry or business in which the work was done.
10 .- The month and year the deceased last worked at the occupation.
11 .- The number of years the deceased followed the occupation.
In stating the occupation, avoid the use of such indefinite terms as "einployec." "worker," "operative," etc. Find out the partic- ular kind of work done and return that, as SPINNER, WEAVER, etc.
In stating the industry or business, avoid the use of such gen- eral terms as "store," "factory," "mill," etc. State the particular kind of store, factory, mill, etc., as GROCERY STORE, SOAP FACTORY, COTTON MILL, ctc.
Distinguish carefully the different kinds of engineers by stating the full descriptive titles, as CIVIL ENGINEER, MECHANICAL ENGIN- EER. MINING ENGINEER, STATIONARY ENGINEER, etc. Avoid the term "laborer" when a more precise statement of the occupation can be securcd. Do not use the word "mechanic," but give the" exact occupation, as CARPENTER, PAINTER, MACHINIST, etc. Distinguish carefully between RETAIL MERCHANTS AND WHOLESALE MERCHANTS. A person who sells goods should be called a SALESMAN and not a CLERK.
Statement of Cause of Death. -- Cause of death means the disease, or complication which causes death, NOT the mode of dying, E. G., heart failure, asphyxia, asthenia, etc. . As principal cause name the disease causing death. . As related causes, name earlier morbid conditions, if any, related to the principal cause and any important complication of the principal cause. Under contributory causes of importance not related to principal causc, name other important diseases.
Example
'The principal cause of death and related causes of importance in order of onset were as follows:
Date of Onset
Arteriosclerosis
1915
Chronic interstitial nephritis
1921
Cerebral hemorrhage
July 5. 1927
Contributory causes of importance not related to principal cause :
In a group of causes containing the principal cause and related causes, the causes should be given in the order of onset, so that in a group of three causes the principal cause may appear in either first, second, or third position. The principal cause in the above example happens to be the second cause given.
last illness, at the request of an unuertaker of owner autiivriscu person or of any member of the family of the deceased, furnish for registration a standard certificate of death, stating to the best of his knowledge and belief the name of the deceased, his sup- posed age, the disease of which he died, defined as required by section one, where same was contracted, the duration of his last illness, when last seen alive hy the physician or officer and the date of his death. . GEN. LAWS, CHAP. 46, SEC. 9.
No undertaker or other person shall bury or otherwise dispose of a human body in a town, or remove therefrom a human body which has not been buried, until he has received a permit from the board of health or its agent appointed to issue such permits, or if there is no such board, from the clerk of the town where the person died; and no undertaker or other person shall exhume a human body and remove it from a town, from one cemetery to another, or from one grave or tomb other than the receiving tomb to another in the same cemetery, until he has received a permit from the board of health or its agent aforesaid or from the clerk of the town where the body is buried. No such permit shall be issued until there shall nave been delivered to such board, agent or clerk. as the case may be, a satisfactory written statement con- taining the facts required by law to he returned and recorded. which shall be accompanied, in case of an original interment, hy a satisfactory certificate of the attending physician, if any, as re. quired by law, or in lieu thereof a certificate as hereinafter pro- vided. If there is no attending physician, or if, for sufficient rea- sons, his certificate cannot he obtained early enough for the pur- pose. or is insufficient, a physician who is a member of the board of health, or employed by it or by the selectmen for the purpose, shall upon application make the certificate required of the attend- ing physician. If death is caused by violence, the medical examiner shall make such certificate. If such a permit for the removal of a human body, not previously interred, from one town to an- other within the commonwealth cannot be obtained early enough for the purpose, the certificate of death made as above provided and in the possession of the undertaker desiring to make such a removal shall constitute a permit for such removal : provided, that such body shall be returned to the town from which it was re- moved within thirty-six hours after such removal, unless a permit in the usual form for the removal of such hody has been sooner obtained hereunder. If the death certificate contains a. recital. as required by section ten of chapter forty-six. that the deceased served in the army, navy or marine corps of the United States in any war in which it has been engaged, such recital shall ap- pear upon the permit. The board of health, or its agent, upon receipt of such statement and certificate, shall forthwith counter. sign it and transmit it to the clerk of the town for registration. The person to whom the permit is so given and the physician cer- tifying the cause of death shall thereafter furnish for registration any other necessary information which can be obtained as to the deceased, or as to the manner or cause of the death. which the clerk or registrar may require .- CHAP. 114, SEC. 45, G. L. (TER- CENTENARY EDITION.)
Medical examiners shall make examination upon the view of the dead bodies of only such persons as are supposed to have died by violence. ...- GEN. LAWS, CHAP. 38, SEC. 6.
.... He shall in all cases certify to the town clerk or registrar in the place where the deceased died his name and residence, if known; otherwise a description as full as may be, with the cause and manner of death .- GEN. LAWS, CHAP. 38, SEC. 7.
No undertaker or other person shall bury a human body or the ashes thereof which have been brought into the commonwealth until he has received a permit so to do from the hoard of health or its agent appointed to issue such peintits, or if there is no such board, from the clerk of the town where the body is to be huried or the funeral is to be held, or from a person appointed to have the care of the cemetery or burial ground in which the interment is made. . . .- CHAP. 114, SEC. 46, G. L. (TERCENTENARY EDITION.)
RULES OF PRACTICE
The fulfillment of the purpose of these laws calls for the ob- servance 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 unrelated 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 ahsent 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 septi- cemia), 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 occupation, the sudden deaths of persons not disabled by recognized disease, and those of persons found dead.
302
PLACE OF DEATH
(County)
1
(City or Town)
The Commonwealth of Massachusetts OFFICE OF THE SECRETARY DIVISION OF VITAL STATISTICS COPY OF CERTIFICATE OF DEATH
(City or town making return)
Registered No.
122
5 (If death occurred in a hospital or institution, give its NAME instead of street and number)
1 (If U. S.
2 FULL NAME
FRE- -DS
& TH
JAN
Certificate of Death
FILED
916 APR 8 PM 9 07
1. NAME OF DECEASED (Print or Typewrite)
Middle Name
PERSONAL PARTICULARS (To be filled in by Funeral Director)
L'ass .
3 UOVAL RESIDENCEI (a) Statt.
Arve-But.
(4) Post Office Winthrop und Zeos
5a lf married, HUSBAND of
Ave St
(or) WIFE of
Occupation
(If in rural ares, give location? (*) Length of residence or stay in City of NOW RESIDENT New York immediately prior to death 1 week
(d) Length of stay at place of death immediately prior to death WEEK
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