USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1960 > Part 32
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WV 09618 & Nnr
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₹-301A 1
ITIONS
CERTIFICATE
ging DEATH renter on one 1. each 1 and (c)
a not mean of dying, u't failure, t It means por compli- kh caused
nif any, 11 rise to de (a), tà under- last.
tues contrib- ei but not & terminal noion given
CIpter 137, requires S print or ause or f eath on tifates, and 48 Acts of uis Physi- ri or type e gnature.
-5 25686
CONSE. PLACE OF DEATH Suffolk (County) WINTHROP (City or, Town) WINTHROP COMMUNITY HOSPITALIE
The Commonwealth of Massachusetts JOSEPH D. WARD 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.
141
Registered No.
occurred i
St. ( give its NAME instead of street and number) .....
COHEN, SAMUEL
(If deceased is a married, widowed or divorced woman, give also maiden name.)
66 SAGAMORE AVE
PHYSICIAN - IMPORTANT
{(Was deceased a
¿ U. S. War Veteran,
No
[if so specify WAR)
WINTHROP
MASSA
St.
(If nonresident, give city or town and State)
.years ..
............ months ............
.days.
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
June
22
1960
DEATH
(Month)
(Day)
(Year)
19
4 I HEREBY CERTIFY , That I attended deceased from
October
58
June 22
60
I last saw h.l.Y lalive on
June
22, 1960, death is said to
have occurred on the date stated above, at
7:65 km.
INTERVAL BETWEEN ONSET AND
DEATH
5yrs.
12
AGE.7.9.
Years
Months .............. Days
If under 24 hours
Hours.
Minutes
13 Usual
Occupation :
Retired
(Kind of work done during most of working life)
14 Industry
or Business :
clothing
15 Social Security No.
16 BIRTHPLACE (City)
(State or country)
Russia
17 NAME OF
FATHER
Isaac Cohen
18 BIRTHPLACE OF
FATHER (City)
(State or country)
Russia
19 MAIDEN NAME
Sarah (unknown)
20 BIRTHPLACE OF
MOTHER (City)
(State or country)
Mrs. Rebecca Cohen
21
Informant
(Address)
66 Sagamore Ave., Winthrop
I HEREBY, CERTIFY that a satisfactory standard certificate of death
2
was filed with me BEFORE the burial or transit permit was issued:
1
1
(Signature of Agent of Board of Health or other)
Theredi
52 160
(Official Designation)
(Date of Issue of Permit)
(Registrar)
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
Male
9 COLOR
White
10 SINGLE
(write the word)
MARRIED
WIDOWED
or DIVORCED
DMarried
10a If married, widowed, or divorcedRebecca Pergolna
HUSBAND of
(Give maiden name of wife in full)
(or) WIFE of
(Husband's name in full)
DEATH WAS CAUSED BY : IMMEDIATE CAUSE
(a) Arteriosclerotic Heart Disease
Due
To Coronary Heart Disease
(b)
5yrs.
Due To (c)
OTHER
Acute Coronary Occlusion
CONDITIONS Myocardial Infarction
3days
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
(Signed) CHARLES
LIBERMAN
(Address)
(PRINT OR TYPE SIGNATURE) WINTHRO PMASS Date 6/22/1960
Moses Mendelsohn
6
West Roxbury
Place of Burial or Cremation
DATE OF BURIAL
(City or Town)
June
23
1960
7 NAME OF
FUNERAL DIRECTOR
Morris W Brezniak
170 Harvard St., Brookline
ADDRESS
JUNE 23 1960
Received and filed
No.
2 FULL NAME.
(a) Residence. No. . (Usual place of abode)
Length of stay: In place of death. ............. years .... months. 2 .days. In place of residence. 27
11 IF STILLBORN, enter that fact here.
PARENTS
Librequan
M. D.
OF MOTHER
Russia
V. B.
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.
WY 09618 2 NAP
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601
X PLACE OF DEATH
Suffolk (County) WINTHROP (City or Town)
49 IRWin No.
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.
Registered No. 142
f(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)
no
(If deceased is a married, widowed or divorced woman, give also maiden name.)
49 IRWIN
St.
(If nonresident, give city or town and State)
Length of stay: In place of death
... years
months
days. In place of residence3 .. ).
years
_months.
days.
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
DEATH
June
(Month)
24
1960
(Day)
(Year)
4 I HEREBY CERTIFY,
That I attended deceased from
to ...
June 24
1960
oct. 1
1959
I last saw he.Yalive on
June 23, 1960, death is said to
have occurred on the date stated above, at
11:05 p.m.
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
Cancer of Mouth.
(a)
INTERVAL
BETWEEN
ONSET AND
DEATH
Jur.
11 IF STILLBORN, enter that fact here.
12
AGE
65 Years
K
Months
Days
If under 24 hours
Hours
Minutes
13 Usual
Occupation :
(Kind of work done during most of working life)
14 Industry
or Business:
AT HOME
15 Social Security No.
16 BIRTHPLACE (City)
(State or country)
StenatsA, Greece
17 NAME OF
. FATHER
CHRISTY COUROUSis
18 BIRTHPLACE OF
StemnitsA
FATHER (City)
(State or country)
Greece
19 MAIDEN NAME
OF MOTHER
ULÓA SAMARAS
(Signed)
Charles Libe que . D.
20 BIRTHPLACE OF
(Address) Winthropmass Date 6/26/
.. 1960
MOTHER (City)
StemnitSA,
Winthrop Cemetery - Willing 6
Place of Burial or Cremation (City or Town)
DATE OF BURIAL
June 25,14/c
19
7 NAME OF
ADDRESS 48 8%.
MAURIS + MAURIS Co omman St. Lynn JUN 27 1960 19
Received and filed
(Registrar)
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
temaLE
9 COLOR
WHITE
10 SINGLE
MARRIED
(write the word) Widowed
or DIVORCED
10a If married, widowed, or divorced
HUSBAND of
JAMES BELLAS
(Give maiden name of wife in full)
(or) WIFE of.
(Husband's name in full)
Due To (b)
Due To (c)
OTHER
SIGNIFICANT
CONDITIONS
None.
Was autopsy performed?
No
What test confirmed diagnosis? Clinical Pathological
5 Was disease or injury in any way related to occupation of deceased ? )\ If so, specify
PARENTS
(State or country)
Greece
21
Informant
(Address)
Alexander BELLAS (Son) 49 IRWin St. Winthrop
I HEREBY CERTIFY that a satisfactory standard certificate of death was filed with me BEFORE the burial or transit permit was issued :
1
(Signature of Agent of Board of Health or other)
6/27/0
(Official Designation) LL (Date of Issue of Permit)
UCTIONS OR CERTIFICATE
riving
OF DEATH t enter ehan one sifor each ; )) and (c)
es not mean a of dying, Heart failure, , c. It means a or compli- sich caused
io, if any, l'e rise to use
-
(a), he under- use
last.
dit is contrib- - uth but not to he terminal co ition given
:- napter 137, f 14, requires iar to print or the cause or o death on :er icates.
SOM-5-56-917573
[R-301A 1
2 FULL NAME_
MURS. PANAYOTA COUROUSIS BELLAS
(a) Residence. No.
(Usual place of abode)
Housewife
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 dicd, 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 hy section forty-five of chapter one hundred and four- teen, shall. if the deceased, to the hest 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 sixtecn 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 ohtained 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 renioval 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 ohtained 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.
Na 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 hy 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 fesulting 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 tace 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
1 R-301A 1
HRUCTIONS FOR I CERTIFICATE
1 giving JOF DEATH
o ot enter i than one u for each )(b) and (c)
es not mean of dying, is heart failure, aetc. It means ee, or compli- which caused
fitas, if any, hive rise to e ause (a), ng'he under- : suse last.
mions contrib- to eath but not t the terminal c dition given
- hapter 137, 54. requires la. to print or th cause or death on cesficates, and er 8, Acts of recires Physi- to int or type inc. signature.
M-69-925686
X
PLACE OF DEATH
Suffolk
(County)
Winthrop
(City or Town) 19 Lewis Ave.
The Commonwealth of Massachusetts JOSEPH D. WARD 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.
Registered No. 143
f(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)
19 Lewis Ave.
St
(If nonresident, give city or town and State)
Length of stay: In place of death ..
27
.. years.
months
.. days. In place of residence
.years
months.
days.
MEDICAL CERTIFICATE OF DEATH
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
Female
9 COLOR
White
10 SINGLE
(write the word)
MARRIED
WIDOWED
or DIVORCED Widow
10a If married, widowed, or divorced
HUSBAND of
(Giye maiden name of wife in full)
(or) WIFE of
Charles Willis
(Husband's name in full)
11 IF STILLBORN, enter that fact here.
12
80
8
14
If under 24 hours
Hours ............. Minutes
13 Usual
Occupation :
Housewife
14 Industry
or Business :
Own Home
15 Social Security No.
St. John
16 BIRTHPLACE (City),
(State or country)
New Brunswick
17 NAME OF
FATHER
Thomas Garnett
18 BIRTHPLACE OF
FATHER (City)
(State or country)
England
19 MAIDEN NAME
OF MOTHERElizabeth Slack
20 BIRTHPLACE OF
St John
MOTHER (City)
(State or country) New Brunswick
21 Florence R Willis
Informant
(Address)
19 Lewis Ave. Winthrop
I HEREBY CERTIFY that a satisfactory standard certificate of death was filled with me BEFORE the burial or transit permit was issued:
(Signature of Agent of Board of Health or other)
6/27/60
(Official Designation)
(Date of Issue of Permit)
+
(Registrar)
PARENTS
6 Winthrop
Winthrop
Place of Burial or Cremation
DATE OF BURIAL
(City or Town) June 27
,60
7 NAME OF
FUNERAL DIRECTOR .Howard S Reynolds
ADDRESS "inthron lass.
Received and filed JUN 27 1960
19
60
I last saw h.Z alive on
JUNE 24
1960, death is said to
have occurred on the date stated above, at
10:45 Am.
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
HOUTE MYOCARDIAL INSUFFICIENCY
(a)
INTERVAL
BETWEEN
ONSET AND
DEATH
3DAYS
(b) ABTORIOSCHEMATIC HEART DISEASE
5YRS
Due To (c)
OTHER SIGNIFICANT CONDITIONS
Was autopsy performed?
No
What test confirmed diagnosis ?
5 Was disease or injury in any way related to occupation of deceased ? If so, specify
No
Fototh Chaney (Signed) Destur CHENET Eoraleon m.A.
M. D.
197 Woodside AVE
(PRINT OR TYPE SIGNATURE) WINTHROP, MASS
Date Chance 2K 1960
(Address)
JUNE
24
1960
(Year)
(Month)
(Day)
That I attended deceased from
4 I HEREBY CERTIFY,
SEAT 24
192 9., to ..
JarE xt
(a) Residence. No. ( Usual place of abode)
No.
2 FULL NAME
Ada (Garnett) Willis
(If deceased is a married, widowed or divorced woman, give also maiden name.)
35
3 DATE OF
DEATH
AGE
Years.
Months.
.Days
(Kind of work done during most of working life)
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. i
(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.
Y PLACE OF DEATH
Suffolk
(County)
Winthrop
(City or Town)
The Commonwealth of Massachusetts JOSEPH D. WARD 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.
2 FULL NAME.
Stillborn Male Sparacino
(If deceased is a married, widowed or divorced woman, give also maiden name.)
(a) Residence. No.
234 LEXINGTON
EAST BOSTON
(Usual 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 .............. years .............. months .............. days.
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
JUNE
26
1960
DEATH
(Month)
(Day)
(Year) 2=Pic
4 I HEREBY CERTIFY,
That I attended deceased from
19
.. , to ...
19
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.
STILL BORN
12
AGE
.. Years.
.Months.
Days
If under 24 hours
Hours.
.. Minutes
13 Usual
Occupation :
(Kind of work done during most of working life)
14 Industry
or Business :
15 Social Security No.
16 BIRTHPLACE (City)
(State or country)
MASS
17 NAME OF FATHE FRANK SPARACINO
18 BIRTHPLACE OF
FATHER (City)
NEW YORK
(State or country)
NEW YORK
19 MAIDEN NAME
OF MOTHER THERESA CUNHA
BOSTON
20 BIRTHPLACE OF
MOTHER (City)
(State or country)
MASS.
FRANK SPARACINO
21
Informan
(Address) 34 LEXINGTON ST, E.B.
I HEREBY CERTIFY that a satisfactory standard certificate of death was filed with me BEFORE the burial or transit permit was issued: EU
4
Received and filed
19
(Registrar)
PARENTS
2 JARA!OCH
(Address)
6 HOLY CROSS
MALDEN
(City or Town)
Place of Burial or Cremation DATE OF BURIAL JUNE 29, 60
7 NAME OF FUNERAL DIRECTODIPIETROXVAZZA ADDRESS/ /HENRY ST, EAST BOSTON
(Signature of Agent of Board of Health or other) }
(Official Designation)
(Date of Issue of Permit)
RUCTIONS FOR CERTIFICATE
[ giving EOF DEATH ot enter r than one s for each b) and (c)
es not mean o of dying, s teart failure, ,tc. It means ei, or compli- hich caused
itis, if any, atve rise to Isuse (a), ug he under- use last.
naions contrib- o ath but not tithe terminal c dition given
hapter 137, f 54. requires ia th
to print or cause or t death on ceificates, and :r 3, Acts of recires Physi- :o int or type inc. signature.
4-69-925686
PERSONAL AND STATISTICAL PARTICULARS
(write the word)
8 SEX
M
9 COLOR
white
10 SINGLE
MARRIED
WIDOWEDSingle
or DIVORCED
I last saw h ........ alive on
19
., death is said to
have occurred on the date stated above, at
m.
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a)
SANBORN
Due To (b)
Due To (c)
OTHER
SIGNIFICANT
CONDITIONS
Was autopsy performed?
YES
What test confirmed diagnosis ?
5 Was disease or injury in any way related to occupation of deceased ? If so, specify
(Signed)
G- GUY GRANDE
M. D.
(PRINT OR TYPE SIGNATURE)
Date.
Registered No.
141
No.
BasTone 29-6-15
Winthrop Community Hospital
§ (If death occurred in a hospital or institution,
St. Į give its NAME instead of street and number)
PHYSICIAN - IMPORTANT [(Was deceased a ₹U. S. War Veteran, [if so specify WAR)
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