USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1960 > Part 10
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FEB 2 41960 /M
1 PLACE OF DEATH
Suffolk (County)
Winthrop (City or Town)
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.
39
1
No.
Mount's Convalescent Home, Inc.
J(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)
2 FULL NAME .. Samuel Ellman (If deceased is a married, widowed or divorced woman, give also maiden name.) 6 Hutchinson St. Winthrop
(a) Residence. No. (Usual place of abode)
St.
(If nonresident, give city or town and State)
Length of stay: In place of death years 6 months .days. In place of residence. years. .months days.
MEDICAL CERTIFICATE OF DEATH
PERSONAL AND STATISTICAL PARTICULARS
DATE O
February 23, 1960
DEATH
(Month)
(Day)
(Year)
That I
attended deceased from
4 I HEREBY CERTIFY.
Oct. 20
59
Feb.
23
19
to
im Feb. 22
19.60
death is said to
10a If married, widowed, or divorced
HUSBAND of ......
SOPHIE
(or) WIFE of ....
(Husband's name in full)
11 IF STILLBORN, enter that fact here.
12 G
AGE
.Years
Months
Days
If under 24 hours
Hours .... Minutes
13 Usual
Occupation :
STITCHER
14 Industry
or Business :.
GARMENT MANUFACTURER
15 Social Security No. ..
030-03-2242
6 mos
16 BIRTHPLACE (City). ... Russia. (State or country)
17 NAME OF
FATHER
Simón ELLNIAN
18 BIRTHPLACE OF
FATHER (City)
(State or country)
RUSSIA
19 MAIDEN NAME OF MOTHER
GERTRUDE ASHKENA9
20 BIRTHPLACE OF
MOTHER (City)
(State or country)
C
RUSSIA
21 Informant (Address)
SOPHIE HAS BAN
KHUO CHINSON Winther
I HEREBY CERTIFY that a satisfactory standard certificate of death was filed with me BEFORE the burial or transit permit was issued: TalkSureanuex-
(Signature of Agent of Board of Health or other)
2/23/60
(Official Designation)
(Date of Issue of Permit)
X
8 SEX
M
9 COLOR OR RACE
W
10 SINGLE
(write the word)
MARRIED
WIDOWED
or DIVORCED Widowed
(Give maiden name of wife in full)
FLEISHER
have occurred on the date stated above, at
12:15 p
m.
INTERVAL BE- TWEEN ONSET AND DEATH
DISEASE OR CONDITION
DIRECTLY LEADING
Chronic Myocarditis
TO DEATH (a)
ANTE CEDENT (b) CAUSES
Due To Cardiac Decompensation
Due To (c) Arteriosclerotic Heart Disease
OTHER
SIGNIFICANT
Post-operative resection CONDIFLANSobstruction of bowel
Major findings: Of operations.
Date of operation
.Was autopsy performed?
What test confirmed diagnosis?
5 Was disease or injury in any way related to occupation of deceased?
If so, specify
(Signed)
(Address)
6 LINCOLN PARK WARRICK RI (City or Town) Place of Burial or Cremation 1.24 19.40
DATE OF BURIAL
7 NAME OF
FUNERAL DIRECTOR
ADDRESS
PROVIDENCE
R.I.
Received and filed.
FEB 23-1960
19
(Registrar)
PARENTS
50M-3-53-909098
RM R-301A 1
1-1963
ISTRUCTIONS FOR CAL CERTIFICATE In giving SE OF DEATH
o not enter re 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.
5 . mi
MAX SUGARMAN
60
19
I last saw h
.alive on
6 mos
6 mos
(Kind of work done during most of working life)
Registered No.
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 deceased, 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 imme- 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 seventecn. 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 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 casc 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 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 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 he 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 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 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 done 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
erna ....
X
PLACE OF DEATH
Suffolk (County)
LANSE
Winthrop (City or Town)
The Commonwealth of Massachusetts JOSEPH D. WARD SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS
STANDARD CERTIFICATE OF DEATH
Registered No.
40
§(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.
(If deceased is a married, widowed or divorced woman, give also maiden name.)
(a) Residence. No.
181 Court Road
(Usual place of abode)
St.
(If nonresident, give city or town and State)
Length of stay: In place of death ..
J ........ years ... 4.
.. months .............. days. In place of residence. 4 .. years. &.months .............. days.
MEDICAL CERTIFICATE OF DEATH
PERSONAL AND STATISTICAL PARTICULARS
3 DATE OF
DEATH
February
26
1960
(Year)
(Month) (Day)
4 I HEREBY CERTIFY,
That I attended deceased from
February 5,
19 ..
60
to ....
February 26
1960
I last saw hm .. alive on
February 22,, 19 60, death is said to
have occurred on the date stated above, at
8:18 .... a.m.
INTERVAL
BETWEEN
ONSET AND
DEATH
11 IF STILLBORN, enter that fact here.
12
AGE ..... Years ........... Months ..... ] ... (., Days
If under 24 hours Hours ...... .Minutes
13 Usual
Occupation :
Warehouseman ..... and .... mover
(Kind of work done during most of working life)
14 Industry
or Business :
.general .... moving ..... business
15 Social Security No. ....
011-12-5583
Winthror
16 BIRTHPLACE (City)
(State or country)
Mas's
17 NAME OF
FATHER
Harry Nathen Bangs
18 BIRTHPLACE OF
Durham
FATHER (City)
(State or country)
Maine
19 MAIDEN NAME
M. D. OF MOTHER Helen MacDonald
20 BIRTHPLACE OF
Durham
MOTHER (City)
(State or country)
Maine
6 Winthrop Cemetery Winthrop, Mass.
Place of Burial or Cremation
(City or Town)
DATE OF BURIAL February 29, 1960
7 NAME OF
FUNERAL DIRECTOR
Cached 13. Marste
ADDRESS 174 Winththrop St. Winthrop, Mass.
19
Received and filed
FEB 29-1960
(Registrar)
8 SEX
male
9 COLOR
white
10 SINGLE
(write the word)
MARRIED married
WIDOWED
or DIVORCED
10a If married, widowed, or divorced
HUSBAND of
Margaret
Lillian Crane
(Give maiden name of wife in full)
(or) WIFE of
(Husband's name in full)
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a) ........ Coronam ...... Thrombogi.s.
Due To (b)
Due To (c)
OTHER
SIGNIFICANT
Diverticulosis of color
CONDITIONS
e wrs.
Was autopsy performed? no. What test confirmed diagnosis ? clinical.
5 Was disease or injury in any way related to occupation of deceased? If so, specify 00
(Signed
John ......... Collins ........... D.
(PRINT OR TYPE SIGNATURE)
(Address)7 Bennington Street Dat Feb 27, 160 Kevero
PARENTS
Informant
(Address)
Mrs. Allan C. Bangs 181 Court Road, 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)
Healthi Olice 2/29/60
Il (Official Designation)
(Date of Issue of Permity /
V.R.l
TRUCTIONS FOR L CERTIFICATE
giving : OF 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
tions, if any, gave rise to cause (a), g the under- cause last.
ditions contrib- death but not to the terminal condition given
:- Chapter 137, 1954, requires ans to print or the cause or of death on ertificates, and r 48, Acts of equires Physi- o print or type nder signature.
MIS
1-6-59-925686
4
2 hrs
......
5kg
To be filed for burial permit with Board of Health or its Agent.
No. 181 Court Road
2 FULL NAME
Allan .Clifford ... Bangs
M R-301A 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 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.
1
1
6
FEB 2 01960 ""!
PLACE OF DEATH
X Suffath thay pad Revere Mars PENSE PPT OVTETEN (City or Town) May flower
The Commonwealth of Massachusetts JOSEPH D. WARD SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS
STANDARD
CERTIFICATE OF DEATH
Registered No.
[(If death occurred in a hospital or institution,
St. ¿ give its NAME instead of street and numher)
PHYSICIAN - IMPORTANT [(Was deceased a (U. S. War Veteran, {if so specify WAR) Revere Mass
(a) Residence. No.
(Usual place of ahode)
Length of stay: In place of death .............. years.
months.
.days. In place of residence.
39
St.
(If nonresident, give city or town and State)
... years .............. months .... .. days.
MEDICAL CERTIFICATE OF DEATH
PERSONAL AND STATISTICAL PARTICULARS
3 DATE OF
DEATH
Feb 26-1960
(Month)
(Day)
(Year)
4 I HEREBY CERTIFY,,
Feb-6
19 60, to Feb
26
That I attended deceased from
1960
I last saw him.2.alive on
Feb 26,
19 60, death is said to
have occurred on the date stated above, at 1 2:45A.m.
INTERVAL
BETWEEN
ONSET AND
DEATH
10a If married, widowed, or divorced 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 55 Years.
Months ... Days
If under 24 hours
Hours ......
.Minutes
13 Usual
Occupation :
Carpenter
Due To
CARCINOMA BILATERAL
(b)
KidNeys.
3MMOS
Due (c)
CARCINOMA OF. Intestines ,
OTHER
SIGNIFICANT
CONDITIONS
CARDIAC FAILURE
Was autopsy performed?
What test confirmed diagnosis ?
5 Was disease or injury in any way related to occupation of deceased? If so, specify
-1
(Signed) andrew Cartina, M. D. ANDREW CATINO MD (PRINT OR TYPE SIGNATURE)
(Address) 603 Breading Per Date: Feb 2/1960
Holy cross Wilden 6
Place of Burial or Cremation DATE OF BURIAL
(City or Town) 2.8 1950
7 NAME OF FUNERAL DIRECTOR 20 minis Semente
ADDRESS
224 wrath St Boston miss
Received and filed
FEB-2-9-1960
19
(Registrar)
PARENTS
19 MAIDEN NAME OF MOTHER
Rosolia Campagna
20 BIRTHPLACE OF MOTHER (City) (State or country)
giovanni Bartolomucci
21 Informant (Address)
04702 Revere St
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 Beard of Health or other)
2/29/60
(Official Designation)
(Date of Issue of Permit)
RUCTIONS FOR CERTIFICATE
giving OF 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
Chapter 137, 1954. requires ns to print or e cause or of death on rtificates, and 48, Acts of quires Physi- print or type der signature.
1
-6-59-925686
I R-301A 1
No.
2 FULL NAME.
(If deceased is a married, widowed or divorced woman, give also maiden name.) 402 Revere
8 SEX
Male
9 COLOR
White
10 SINGLE
MARRIED
(write the word)
WIDOWED
or DIVORCED Sinale
DEATH WAS CAUSED BY : IMMEDIATE CAUSE
CARCINOMA LUNES
(a)
(Kind of work done during most of working life)
14 Industry
or Business:
Cabinet Navios
15 Social Security No.
16 BIRTHPLACE (City) (State or country)
.... Italy
17 NAME OF
FATHER angelomarin
marina Bartolomucci
18 BIRTHPLACE OF FATHER (City) (State or country)
Italy
Hale
3mois
1 day
4
Home
Genesio Bartolomucca
:
To he filed for hurial permit with Board of Health or its Agent.
2961.11
40
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE.
DATE OF DISCHARGE RANK, RATING ORGANIZATION AND OUTFIT SERVICE NUMBER.
RULES OF PRACTICE
The fulfillment of the purpose of these laws calls for the observance of the following rules of practice :
(1) Attending physicians will certify to such deaths only as those of persons to whom they have given bedside care during a last illness from disease un. related to any form of injury.
(2) Board of Health physicians will certify to such deaths only as those of persons who, though disabled by recognized disease unrelated to any form of injury, have died without recent medical attendance or whose physician is absent from home when the certificate of death is needed.
(3) Medical Examiners will investigate and certify to all deaths supposably due to injury. These include not only deaths caused directly or indirectly by traumatism (including resulting septicemia), and by the action of chemical (drugs or poisons) thermal, or electrical agents, and deaths following abortion, but also deaths from disease resulting from injury or infection related to occu- pation, the sudden deaths of persons not disabled by recognized disease, and those of persons found dead.
Statement of Cause of Death .- l'hysicians: 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.
FEB 201000 01
×
PLACE OF DEATH
SUFFOLK
(County) WINTHROP (City or Town)
The Commonwealth of Massachusetts JOSEPH D. WARD SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS MEDICAL EXAMINER'S CERTIFICATE OF DEATH
Sail.
FEL
To be filed for burial permit with Board of Health or its Agent.
Registered No. 42
30 Grovers Avenue, Winthrop
§ (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).
(If deceased is a married, widowed or divorced woman, give also maiden name.)
30 Grovers Avenue, Winthrop
St
(If nonresident, give city or town and State)
5
days. In place of residence .............. years ....
months
.days.
PERSONAL AND STATISTICAL PARTICULARS
9 SEX
10 COLOR
11 SINGLE
(write the word)
Male
white
MARRIED
WIDOWED)
or DIVORCED Single
11a If married, widowed, or divorced
HUSBAND of
(Give maiden name of wife in full)
(or) WIFE of
(Husband's name in full)
12 IF STILLBORN, enter that fact here.
13
AGE ...
Years ..
5
Months.
13
Days
Hours .
.Minutes
14 Usual
Occupation :
(Kind of work done during most of working life)
15 Industry
or Business :
16 Social Security No.
17 BIRTHPLACE (City):inthrop
(State or country) Mass.
18 NAME OF FATHER John K Mitchell
19 BIRTHPLACE OF
FATHER (City)
(State or country)
Mass
Holyoke
20 MAIDEN NAME OF MOTHER Barbara Pierce
21 BIRTHPLACE OF
MOTHER (City)
(State or country)
M'a ss
Winthrop
22
John K Mitchell
Informant2
(Address) 30 Grovers Ave. Winthrop
I HEREBY CERTIFY that a satisfactory standard certificate of death was filed with me BEFORE the burial or transit permit was issued: ThalkleC. Percanales.
(Signature of Agent of Board of Health or other)
Health Officer 2/29/60
(Official Designation)
(Date of Issue of Permit)
(Registrar)
PARENTS
60
Feb. 29
60
8 NAME OF FUNERAL DIRECTOR Howard S Reynolds
Winthrop Mass
ADDRESS
FEB 2-9-1960
Received and filed 19
rt
No. CRAIG MITCHELL
2 FULL NAME (a) Residence. No. (Usual place of abode) Length of stay : In place of death .............. years. 5 months. 13 MEDICAL CERTIFICATE OF DEATH 3 DATE OF DEATH February 26, 1960 (Month) (Day) (Year) 5 Accident, suicide, or homicide (specify) Date and hour of injury 19 IF ACCIDENTAL, was injury causally related to the death? Where did Injury occur ? (City or town and State) public place ? Manner of (Specify type of place) Injury (How did injury occur ?) Nature of Injury 6 Was disease or injury in any way related to occupation of deceased ? If so, specify (Signed) Leonard Atkins, M.D. (Print or Type Signature) (Address) 25 Shattuck St. Date 2/26 19 Winthrop Winthrop 7 Place of Burial, or Cremation. (City or Town) of Death. See reverse side for additional information. See also Chap. 38, §§ 6, 20; Chap. 46, §§ 9, 10; Chap. 114, 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 §§ 44-48. If deceased was a U. S. War Veteran, G.L. Chap. 46, Section 10, requires physicians to insert a recital to that effect. DATE OF BURIAL 19. N. B .- WRITE PLAINLY, WITH UNFADING BLACK INK-THIS IS A PERMANENT RECORD. Every item of While at work? Was autopsy performed ? YES
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