USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1950 > Part 40
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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 import- ant, 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 dore during most of working life even if retired. 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, 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.
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE RANK, RATING ORGANIZATION AND OUTFIT
SERVICE NUMBER
RM R-305 1
PLACE OF DEATH
SUFFOLK (County) BOSTON
(City or Town)
The Commonwealth of Massachusetts OFFICE OF THE SECRETARY DIVISION OF VITAL STATISTICS COPY OF MEDICAL EXAMINER'S CERTIFICATE OF DEATH
BOSTON
(City or town making return)
_6276-
Registered No.
1.20
f(If death occurred in a hospital or institution, St. [ give its NAME instead of street and number)
2 FULL NAME.
(If deceased is a married, widowed or divorced woman, give also maiden name.)
33 Nevada
St.
(If nonresident, give city or town and State)
Length of stay: In place of death
.years.
monthL 3.
.days. In place of residence.
.years.
.. months.
.days.
MEDICAL CERTIFICATE OF DEATH
PERSONAL AND STATISTICAL PARTICULARS
3 DATE OF
DEATH
July 21/50
(Month)
(Day)
(Year)
9 SEX
M
10 COLOR OR RACE
W
11 SINGLE
MARRIED
WIDOWED
or DIVORCED
(write the word) Married
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 ft Death instatus epilepticus precipitated
11a If married, widowed, or divorced HUSBAND of.
Mildred Maged
(Give maiden name of wife in full)
by dural cortical adhesions resultingr) WIFE of. from head injury in automobile accident in New Hampshire Sept. 1949
12 IF STILLBORN. enter that fact here.
13
AGE
30
Years
Months.
Days
If under 24 hours
Hours
Minutes
5 Accident, suicide, or homicide (specify)
Date and hour of injury
19
Where did
Injury occur?
(City or town and State)
Did injury occur in or about home, on farm, in industrial place, or in public
place?
Manner of
Injury
(How did injury occur?)
Nature of
Injury
While at work?
Was autopsy performed?
6 Was disease or injury in any way related to occupation of deceased?
If so, specify
(Signed)
Richard Ford
M. D.
(Address)
Date ..
7-22 10 50
7
Zviller Cem-West Roxbury Mass
Place of Burial, or Cremation.
July 23/50
(City or Town)
DATE OF BURIAL
19
8 NAME OF
FUNERAL DIRECTOR
Louis Levine
ADDRESS Brookline Mass.
Received and filed.
JUL 3 1 1950
19
(Registrar of City or Town where deceased resided)
PARENTS
19 BIRTHPLACE OF
Russia
FATHER (City)
(State or country)
20 MAIDEN NAME OF MOTHER
Sadie Bronstein
21 BIRTHPLACE OF
MOTHER (City)
(State or country)
Russia
David Finn Brother
22 Informant. (Address)
A TRUE COPY.
7
ATTEST:
(Registrar of City or Town where death occurred)
July 25/50
DATE FILED
19
......
Copies of returns of deaths which occurred in your city or town in case the deceased resided in another city or town at the time
after the close of the month in which the death occurred. (See Chap. 46, Sec. 12, G. L.)
25m-(h)-10-48-24658
of death should be transmitted on Form R-305 to the clerk of the city or town in which the deceased resided as soon as possible
No.
Boston City Hospital
.
George Finn
(a) Residence. No. (Usual place of abode)
Winthrop
(Was deceased a
U. S. War Veteran, W W #2
if so specify WAR)
Mass
14 Usual
Occupation :
Accountant
(Kind of work done during most of working life)
15 Industry
or Business:
022-01-4856
17 BIRTHPLACE (City)
(State or country)
Dorchester Mass.
Samuel Finn
18 NAME OF FATHER
Accounting
16 Social Security No.
(Specify type of place)
(Husband's name in full)
WRITE PLAINLY, WITH UNFADING BLACK INK - THIS IS A PERMANENT RECORD
RECEIVEY
TO!
11 12 1
C .!!
6
IP.
JUL 311950 AM
Entered Service Jan.28,1943 Bos ton Discharged Feb.28,1946 Fort Devens Mass. Sergt.Transportation Ships Complement Tech Sec.Unit 900222 Service No. 31271485.
RM R-302 1
PLACE OF DEATH
SUFFOLK "DOST (County)
(City or Town) Boston City Hospital
The Commonwealth of Massachusetts EDWARD J. CRONIN SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS COPY OF CERTIFICATE OF DEATH
BOSTON
(City or town making return)
Registered No.
6349
121
f(If death occurred in a hospital or institution, St. Į give its NAME instead of street and number)
2 FULL NAME
(If deceased is a married, widowed or divorced woman, give also maiden name.)
30 Beale
St.
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.
.years.
.months.
.days.
MEDICAL CERTIFICATE OF DEATH
PERSONAL AND STATISTICAL PARTICULARS
3 DATE OF
DEATH
July 23/50
(Month)
(Day)
(Year)
4 I HEREBY CERTIFY,
June 8
19
50
to
July 23
19
19.
death is said to
have occurred on the date stated above, at.
4;15P
INTERVAL BE-
TWEEN ONSET AND DEATH
DISEASE OR CONDITION
DIRECTLY LEADING
TO DEATH (a)
Pulmonary embolism
2 Hrs
12
AGE
64 Years
0
Months.
18
Days
If under 24 hours
Hours.
. Minutes
ANTE
CEDENT (b)
Due To
Cerebro vascular
rt.and left hemisphere
epilepsy status focal
Due To
(c)
Wks.
OTHER
SIGNIFICANT
CONDITIONS
Major findings:
Of operations.
Date of operation
Was autopsy performed ?.
What test confirmed diagnosis ?.
Clinical
5 Was disease or injury in any way related to occupation of deceased? If so, specify. T Sannella
M. D.
(Address)
Winthrop .Cem Winthrop Mass
(City or Town)
DATE OF BURIAL.
July 26/50
19
21
Informant
(Address)
Mrs A J Hamilton
A TRUE Copy arles & Zuão
ATTEST:
(Registrar of City or Town where death occurred)
July 27/50
DATE FILED
.19
(Registrar of City or Town where deceased resided)
8 SEX
M
9 COLOR OR RACE
W
10 SINGLE
MARRIED
WIDOWED
or DIVORCED
(write the word)
Married
10a If married, widowed, or divorced Anna J Flaherty
HUSBAND of.
(Give maiden name of wife in full)
(or) WIFE of
(Husband's name in full)
11 IF STILLBORN. enter that fact here.
13 Usual
Occupation:
Fireman Boston Fire
(Kind of work done during most of working life)
Dept.
14 Industry
or Business:
15 Social Security No.
014-22-2713
16 BIRTHPLACE (City)
(State or country)
East Boston Mass.
17 NAME OF FATHER Amaziah Hamilton
18 BIRTHPLACE OF
FATHER (City)
(State or country)
Eastport Maine
19 MAIDEN NAME
OF MOTHER
Ellen G Murray
20 BIRTHPLACE OF
MOTHER (City)
(State or country)
Halifax N.S.
6 Place of Burial or Cremation
7 NAME OF
FUNERAL DIRECTOR
R C Kirby
ADDRESS Boston. Mass ..
Received and filed
JUL 3 1.1950
19
OPARENTS
(Signed)
Boston ... City ... Hospt
7-23.19
25m-(b)-11-49-900,475
Copies of returns of deaths which occurred in your city or town in case the deceased resided in another city or town at the time after the close of the month in which the death occurred. (See Chap. 46, Sec. 12, G. L.) of death should be transmitted on Form R-302 to the clerk of the city or town in which the deceased resided as soon as possible CAUSES
WRITE PLAINLY, WITH UNFADING BLACK INK - THIS IS A PERMANENT RECORD
No.
.
George J Hamilton
(Was deceased a
U. S. War Veteran,
if so specify WAR).
(a) Residence. No. (Usual place of abode)
30
That I attended deceased
from
50
I last saw h .............. alive on
embolisın
RECEIVE :
TO !.
OF
11 12
€
5 :
In
" WINT
ROP
JUL 311950 AM -
RM R-302 1
WRITE PLAINLY, WITH UNFADING BLACK INK - THIS IS A PERMANENT RECORD
25m-(b)-11-49-900,475
PLACE OF DEATH
SUFFOLK BOSTON
(City or Town)
Mass. General Hospital
The Commonwealth of Massachusetts OSTON EDWARD J. CRONIN SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS COPY OF CERTIFICATE OF DEATH Registered No.
(City or town making return)
6394-
122
j(If death occurred in a hospital or institution, St. [ give its NAME instead of street and number)
(If deceased is a married, widowed or divorced woman, give also maiden name.)
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.
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
M
9 COLOR OR RACE
W
10 SINGLE
MARRIED
WIDOWED
or DIVORCED
Widowed
10a If married, widowed, or divorced
Clara E Mohr
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
AGE.78
Years.
Months
.Days
If under 24 hours
.Hours .... ..
Minutes
13 Usual
Occupation:
Shipsmith
(Kind of work done during most of working life)
14 Industry
or Business:
Retired
15 Social Security No ..
None
BIRTHPLACE ( Nova Scotia
17 NAME OF
FATHER
George Young
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
P J Young
7 NAME OF
FUNERAL DIRECTOR
M W Kirby
ADDRESS Winthrop Mass.
Received and filed. 19
AUG 7
1950
(Registrar of City or Town where deceased resided)
O PARENTS
21
Informant
(Address)
A TRUE COPY
ATTESTCharles H. Mackie
(Registrar of City or Town where death occurred)
DATE FILED
July 31/50
19
(write the word)
1
(Was deceased a
U. S. War Veteran,
( if so specify WAR)
.
No.
2 FULL NAME.
Frederick Young
(a) Residence. No.
14 Waldemar Ave.
(Usual place of abode)
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
DEATH
July 25/50
(Month)
(Day)
(Year)
4 I HEREBY CERTIFY,
That I attended deceased from
July 20
19
50
to.
July 25
50
19
I last saw h
im
death is said to
alive on
INTERVAL BE-
July 25 19 50
have occurred on the date stated above, at.
12;48P.m.
DISEASE OR CONDITION
TWEEN ONSET
AND DEATH
DIRECTLY LEADING
TO DEATH (a)
Carcinoma of the stomach
1 Yr.
ANTE
CEDENT
(b)
Due To
with extensions to omentum
CAUSES
lymph nodes, peritoneum
and liver
Due To
(c)
OTHER
SIGNIFICANT
Major findings:
Of operations.
Yes
None
Date of operation
Was autopsy performed ?.
What test confirmed diagnosis?
autopsy
5 Was disease or injury in any way related to occupation of deceased?
If so, specify.
(Signed)
CL Clay
M. D.
Mass. "eneral Hospt
7-2519
(Address).
6
Holy Cross Malden Mass.
Place of Burial or Cremation
(City or Town)
DATE OF BURIAL
19
July 28/50
Copies of returns of deaths which occurred in your city or town in case the deceased resided in another city or town at the time
after the close of the month in which the death occurred. (See Chap. 46, Sec. 12, G. L.)
of death should be transmitted on Form R-302 to the clerk of the city or town in which the deceased resided as soon as possible
CONDITIONS
benign prostatic hypertrophy
General arterio sclerosis 9 (State or country)
RECEIVEA
AUG -1950 AM
PLACE OF DEATH
Suffolk (County)
Bouton 9/50
The Commonwealth of Massachusetts EDWARD J. CRONIN SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS STANDARD CERTIFICATE OF DEATH
To be filed for burial permit with Board of Health or its Agent.
123
142 Pleasant St. Winthrop Convalescent Home No.
J(If death occurred in a hospital or institution, St. [ give its NAME instead of street and number)
Catherine E Quinlan (Welsenbach) 2 FULL NAME
(If deceased is a married, widowed or divorced woman, give also maiden name.)
74 Sumner Street
East Boston
St. .
(If nonresident, give city or town and State)
Length of stay: In place of death. years 3 months days. In place of residence 6 years months .days.
MEDICAL CERTIFICATE OF DEATH
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
9 COLOR OR RACE
10 SINGLE (write the word) MARRIED Married WIDOWEDM or DIVORCED
10a If married, widowed, or divorced HUSBAND of ..
(Give maiden name of wife in fuli)
(or) WIFE of
Arthur F. Quinlan (Husband's name in full)
11 IF STILLBORN. enter that fact here.
12 AGE 70 Years 7 Months 18 Days
If under 24 hours Hours Minutes
13 Usual
Occupation :.
none
(Kind of work done during most of working life)
14 Industry or Business: none
15 Social Security No. . none
16 BIRTHPLACE (City) (State or country) Utica, N.Y.
17 NAME OF
FATHER
Jauph Welsenbach unknown
18 BIRTHPLACE OF
FATHER (City) (State or country)
Germany
19 MAIDEN NAME
OF MOTHER
mary Juge un mowir
20 BIRTHPLACE OF
MOTHER (City) (State or country)
unknown freland
:
21 Arthur F Quinlan
Informant (Address) 74 Sumner St, East Boston
I HEREBY CERTIFY that a satisfactory stamlard certificate of death was filed/with me BEFORE the burial or transit permit was issued: Walter & Ballers (Signature of Agent of Board of Health or other)
07/ 28/50
(Date of Issue of Permit)
X
4
HEREBY CERTIFY,
Juf 25
1947 to
That I attended deceased from Jul 20
19
I last sawhen .. alive on.
on. Je
660
. 19 S death is said to
have occurred on the date stated above. at
INTERVAL BE-
TWEEN ONSET AND DEATH
DISEASE OR CONDITION DIRECTLY LEADING TO DEATH (a)
arterialerotic Stecent dixcare
1647
ANTE CEDENT (b) CAUSES
Due To generalinio arteriachoro
11547
Due To (c)
OTHER SIGNIFICANT CONDITIONS
Chroni hephrite
1547
Major findings:
Of operations.
Date of operation
Was autopsy performed?
What test confirmed diagnosis?
5 Was disease or injury in any way related toOccupation of deceased?
If so, specify ..
(Signed)
(Address)
genau gaten
M.
D.
195
6 Mt. Calvary
Boston
Place of Burial or Cremation (City or Town)
DATE OF BURIAL .. ..
July 29,1950
19
7 NAME OF FUNERAL DIRECTOR. Joseph E. Carroll ADDRESS1117 River St, Hyde Park, Mass
Received and filed 19
JUL 3 1 1950
(Registrar)
PARENTS
unknown
8/3/200 John f. Quintas (som)
+50M (B)-12-49-900722
ISTRUCTIONS FOR CAL CERTIFICATE In giving SE OF DEATH o not enter ore than one use for each ), (b) and (c)
his does not mean de of dying, such t failure, asthenia .. means the disease. aplications which death.
orbid conditions. giving rise to the cause (a) stating nderlying cause
ditions contrib- the death but not to the disease or on causing death.
on
RM R-301A 1 Winthrop (City or Town)
Registered No. ..
PHYSICIAN - IMPORTANT (Was deceased a U. S. War Veteran, ( if so specify WAR) No
(a) Residence. No. (Usual place of abode)
uly
26 (Day)
1950 (Year)
2.40p. m.
3 DATE OF DEATH
Female White
Health Oficer (Official Designation)
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 best of his knowledge and belief the name of the deceased, his supposed 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 by 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 deccased, to the best of his knowledge and belief, 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, specifying the war, and shall also certify in such certificate both the primary and the secondary or imine- diate 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 section 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 nineteen 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 therefront 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 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 inter- ment, 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 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 attending 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 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 registra- tion. The person to whom the permit is so given and the physician certifying 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 of 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 bodics of persons as are supposed to have died by violence, or by the action of chemical, thermal or electrical agents or following abortion, or from diseases resulting from injury or infection relating to occupation, or suddenly when not disabled by recognizable disease, or when any person is found dead. - General Laws, Chap. 38, Sec. 6., as amended by Chap. 632, Sec. 4, Acts of 1945.
No undertaker or other persons 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 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 follow- ing 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 deathsonly 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 occupation. 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 import- ant, 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 dore during most of working life even if retired. 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, 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.
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE RANK, RATING ORGANIZATION AND OUTFIT
SERVICE NUMBER
PLACE OF DEATH Sufolle (County)
Chelsea
The Commonwealth of Massachusetts OFFICE OF THE SECRETARY DIVISION OF VITAL STATISTICS MEDICAL EXAMINER'S CERTIFICATE OF DEATH
To be filed for burial permit with Board of Health or Its Agent.
Registered No.
121
J (If death occurred in a hospital or institution, St. Į give its NAME instead of street and number)
2 FULL NAME
Gif deceased is a married, widowed or divorced woman, give also maiden name.)
(a) Residence. No. 913 Broadway
(Usual place of abode)
Length of stay: In place of death .......... years. .. months.
7
days. In place of residence.
... months ............ days.
150
MEDICAL CERTIFICATE OF DEATH
PERSONAL AND STATISTICAL PARTICULARS
3 DATE OF DEATH
(Month) (Day)
27, 1450 (Year)
9 SEX
10 COLOR OR RACE
11 SINGLE
(write the word)
MARRIED WIDOWED or DIVORCED
1
(or) WIFE of
(Husband's name in full)
2 nd + 36 dequale humana of abdomen and though ingumed 12 IF STILLBORN, enter that fact here. while cooking at home
13
GE 76x
Months.
Days
If under 24 hours
Hours.
Minutes
14 Usual
Honesuerte.
Occupation :
(Kind of work done during most of working life)
15 Industry
or Business :.
Qun Homme
C
16 Social Security No ....
17 BIRTHPLACE (City) Cholera Brase (State or country)
18 NAME OF FATHER Harry Smitte
19 BIRTHPLACE OF
JEfichera
FATHER (City) (State or country)
Elizabeth La salle.
21 BIRTHPLACE OF MOTHER (City) (State or country) Salem
22 Informant
(Address) 918, Javadran Gereluca
I HEREBY CERTIFY that a satisfactory standard certificate of death was filed/with me BEFORE the burial or transit permit was issued:
Watter A. Baker
(Signature of Agent of Board of Health of other)
Health ref 7/28/50
(Official Designationy
(Date of Issue of Permit)
Every item of
N. B. - WRITE PLAINLY, WITH UNFADING BLACK INK-THIS IS A PERMANENT RECORD.
of Death. See reverse side for extracts from the laws relative to the return of certificates of death. DEATH in plain terms, so that it may be properly classified under the International Classification of Causes information should be carefully supplied. MEDICAL EXAMINERS should state CAUSE AND MANNER OF
If deceased was a U. S. War Veteran, G.L. Chap. 46, Section 10, requires physicians to insert a recital to that effect.
50m-(g)-10-48-24658
DATE P BURIAL July 27 /ouchan 1950
8 NAME OF
FUNERAL DIRECTOR
ADDRESS 583 Broadway Chelaza
.19
Received and filed. JUL 3 1 1950
(Registrar)
PARENTS
6 Was disease or injury in any way related to occupation of deceased ?. If saspect's
(Signedy .. 25 Shattuck Date 7/07.1950
., M. D.
(A dress)
(Specify type of place)
Manner of
of filled hot cooking and upon
Injury
(How did injury occur?
self.
Injury ...
Nature of
setermine burns
While at work? Was autopsy performed?
5 Accident, suicide, or homicide (specify) Accident
Date and hour of injury
July 19 1950
Where did
Injury occur?
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