USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1960 > Part 52
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St. [ give its NAME instead of street and number)
PHYSICIAN - IMPORTANT
2 FULL NAME
no
(Was deceased a U. S. War Veteran, if so specify WAR)
st. Winthrop, Mass
housewife
X
A TRUE COPY ATTEST:
Charles it Mackie
City Registrar
TOW
OF
OFF!
BLEKK
7
6
INT
HROP
NOV 301960 AM
FORM R-302
comes & per- THIS IS A PERMANENT RECORD permanent curate and at the time of death should be transmitted on Form R-302 to the clerk of the city or town in which the deceased Copies of returns of deaths which occurred in your city or town in case the deceased resided in another city or town resided as soon as possible. after the close of the month in which the dea h occurred. (See Chap. 46, Sec. 12. G. L.) legal zec- en properly d. WRITE PLAINLY, WITH UNFADING BLACK INK OR USE APPROVED BLACK TYPEWRITER RIBBON - write plam!
X
PLACE OF DEATH
ity)
The Commonwealth of Massachusetts JOSEPH D. WARD SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS COPY OF
WINTHROP
(City or Town making this return)
1 WASHINGTON. D. C.
(City or Town )
CERTIFICATE OF DEATH
Registered No. 239
No ...
WALTER REED GENERAL HOSPITAL Washington, D. Co ARTHUR ... FRANCIS ... MCDONALD
S (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.) U. S. War Veteran, (Date of Death: September 2]if $1960y
WAR,
,a) Residence. No .. 102 Loring Road
( Usual place of abude)
If nonresident, give city or town and State)
DISTRICT OF COLUMBIA DEPARTMENT OF PUBLIC HEALTH CERTIFICATE OF DEATH
1. PLACE OF DEATH
NAME OF HOSPITAL OR INSTITUTION (If not in hospital, give street address)
Washington, D. C.
Walter Reed General Hospital, Washington, D C
2. USUAL RESIDENCE (Where deceased lived. If institution: Residence before admission)
a. STATE
b. COUNTY
C. CITY, TOWN, OR LOCATION
Massachusetts
Suffolk
Winthrop
d. STREET ADDRESS
a. IS RESIDENCE INSIDE CITY LIMITS?
1. IS RESIDENCE ON A FANMT
102 Loring Road
YES &
NO O
YES
No OF
Pirat
Middle
Last
Month
Dey
Year
3. NAME OF DECEASED (Type or print)
Arthur
Francis
MCDONALD
S. SEX
6. COLOR OR RACE 7. MARRIED
NEVER MARRIED
8. DATE OF BIRTH
Last birthday)
Months Days
Hours Min.
Malo
Caucasian
WIDOWED
DIVORCED
11. BIRTHPLACE
12. CITIZEN OF WHAT COUNTRY?
10a. USUAL OCCUPATION (Give kind of work done 10b. KIND OF BUSINESS OR "Song ofporking li's com if retired) - retired INDUSTRY U'S ATMY
(State or foreign country) Massachusetts
USA
13a. FATHER'S NAME
13b. MOTHER'S MAIDEN NAME
14. NAME OF SURVIVING SPOUSE
Joseph McDonald
Elizabeth Murphy
IS. WAS DECEASED EVER IN U. S. ARMED FORCES?
16. SOCIAL SECURITY NO.
17. DIFORMANT RELATIONSHIP TO DECEASED Josephine McMullin - sister
5911
18. CAUSE OF DEATH |Enter only one cause per line for (a), (b); and (c).]
ONEET AND MATIL
PART I. DEATH WAS CAUSED BY: IMMEDIATE CAUSE (a)
Peritonitis
MEDICAL CERTIFICATION
20c, ACCIDENT SUICIDE HOMICIDE
20b. DESCRIBE HOW INJURY OCCURRED. (Enter nature of injury in Part I or Part I! af item 18.)
0
200 TIME OF Hour INJURY 4 ML
Month, Day, Your
20d. INJURY OCCURRED
200. PLACE OF INJURY (c. o., in or about home, 201. CITY, TOWN, OR LOCATION farm, factory, street, office bidg., etc.)
COUNTY
STATE
WHILE AT XOT WHAS
WORK
21. A alended the deceased from
and last saw 225% alive on him
21 Sept 69
Death occurred at 1:33 AM m en the date stated above; and to the best of my knowledge, from the causes stated.
22a. SIGNATURE
22b. ADDRESS Walter Reed General Hospital, Washington D C
23a. BURIAL 236 BATE 23c. NAME OF CEMETERY OR CREMATORY
23d. LOCATION (Cuy, lova, or county)
(Sipte)
de
curred)
CREMATION 9/23/60 Arlington Nat'l
Arlington, Va.
REMOVAL
24. FUNERAL HOME W. W.Chamber Co. Inc.
REGISTRATION
32
ADDRESS 1500 Chasing St. N.W.
NUMBER
CULARS
( write the word) )
.D
₹CED
ife in full)
full )
tin te.
hours
.Minutes
ing life)
.........
....
DUE TO (b)
Perforated duodenal stumo, following sub-total
Conditions, if, ony, which gave rise to ObOVE COMME (.). stating the under- Lin conse laut.
DUE TO (c)
gastrectomy for duodenal ulcers
PART II. OTHER SIGNIFICANT CONDITIONS
CONTRIBUTING TO DEATH BUT NOT RELATED TO THE TERMINAL MIOLANE CONDITION GIVEN IN PART 1(0)
19. WAS AUTOPSY PERFORMED? YES NO
fais" of service)
unk
------....
...
13 Bapt 1960 . 21 Sapt 1960
22c. DATE NIFIED
M. D.
...
19
X
MARGIN RESERVED FOR BINDING
50M-9 39-926111
OV 16 1960
UNDERTAKER'S SIGNATURE SE Tolan
( Was deceased a
60 7174
LENGTH OF STAY IN Washington, D. C. Hospital
4 DATE OF DEATH September 21 1960
12 December 1903 56
SPACE FOR ADDITIONAL INFORMATION DATE OF ENTERING MILITARY SERVICE DATE OF DISCHARGE RANK, RATING ORGANIZATION AND OUTFIT SERVICE NUMBER
X
PLACE OF DEATH
Suffolk (County)
PENSEP
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.
240
St. ¿ give its NAME instead of street and number) No. WinthropCommunity Hospital
2 FULL NAME
Nellie Lucy Bacon
(If deceased is a married, widowed or divorced woman, give also maiden name.)
(a) Residence. No.
30 Willow Avenue
(Usual place of abode)
Length of stay: In place of death .............. years.
1
months .. 6 days. In place of residence.4.0
.years ...
.. months ...........
.days.
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
DEATH
November
2
1960
(Month)
(Day)
(Year)
4 I HEREBY CERTIFY,
FEB
That I attended deceased from
19.60
I last saw h .¿ Ralive on
Nov
19.60, death is said to
have occurred on the date stated above, at
4 30
4 m.
INTERVAL
BETWEEN
ONSET AND
DEATH
11 IF STILLBORN, enter that fact here.
12
4 DAYS
AGE
87 Years.
1
.Months.
10Days
If under 24 hours
Hours ............
Minutes
13 Usual
Occupation :
house work
(Kind of work done during most of working life)
14 Industry
or Business :
own home
15 Social Security No.
none
Ravenna
16 BIRTHPLACE (City)
(State or country)
Ohio
17 NAME OF
FATHER
James Bacon
18 BIRTHPLACE OF
FATHER (City)
Charlestown
(State or country)
New Hampshire
19 MAIDEN NAME
OF MOTHER
Electa Sanders
20 BIRTHPLACE OF
MOTHER (City)
Wellsboro
(State or country)
Pennsylvania
Howard Bacon
21
Informant
(Address) 400 Cole Avenue, Providence
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)
Received and filed NOV _~ 1960
19.
(Registrar)
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
Female
9 COLOR
White
10 SINGLE
(write the word)
MARRIED Single
WIDOWED
or DIVORCED
10a If married, widowed, or divorced
HUSBAND of
(Give maiden name of wife in full)
(or) WIFE of
(Husband's name in full)
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
BRONCHO PNEUMONIA
(a)
...
Due To
CEREBRAL HEMORRHAGE
(b)
37 DAYS
Due To
HYPERTENSION
(c)
4 YRS.
OTHER
SIGNIFICANT
CONDITIONS
Was autopsy performed?
NO
What test confirmed diagnosis ?
5 Was disease or injury in any way related to occupation of deceased? NO If so, specify .....
(Signed)
....
Louis 7. Salerno
M. D.
LOUIS F SALERNO
(PRINT OR TYPE SIGNATURE)
(Address) 175 PLEASANT ST Date.
Nov 3
1960
Winthrop Cemetery Winthrop, Mass 6
Place of Burial or Cremation
(City or Town)
DATE OF BURIAL November 4, 1960
7 NAME OF
FUNERAL DIRECTOR
Defred B Marsh 19.
ADDRESS
174 Winthrop St. Winthrop, Mass.
(Official Designation)
(Date of Issue of Permit)
-
M R-301A 1
STRUCTIONS FOR AL CERTIFICATE
In giving E OF DEATH not enter re than one se for each ), (b) and (c)
does not mean ode of dying, s heart failure, 1, etc. It means ease, or compli- which caused
itions, if any, h gave rise to e cause (a), ng the under- cause last.
nditions contrib- o death but not to the terminal condition given
:- Chapter 137, f 1954. requires ians to print or the cause or of death on certificates, and er 48, Acts of requires Physi- to print or type under signature.
M-6-59-925686
Registered No.
S(If death occurred in a hospital or institution,
PHYSICIAN - IMPORTANT
[(Was deceased a ¿ U. S. War Veteran, lif so specify WAR)
NO.
. St.
(If nonresident, give city or town and State)
19 50
to ..
NOV.
2
PARENTS
SPACE FOR ADDITIONAL INFORMATION
RECEBEU
DATE OF ENTERING MILITARY SERVICE
TO !!!
DATE OF DISCHARGE
RANK, RATING
ORGANIZATION AND OUTFIT
SERVICE NUMBER
6
1.
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.
NOV - 41960 AM
X PLACE OF DEATH
Suffolk (County)
Winthrop
(City or Town)
2
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.
241
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)
(a) Residence. No ..
(Usual place of abode)
St.
(If nonresident, give city or town and State)
Length of stay: In place of death
10
years
months
days. In place of residence.LO yea
months
days.
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
DEATH
November
4
1960
(Month) (Day)
(Year)
4 I HEREBY CERTIFY, That I attended deceased from March 7 19. 53, to November 4 19.60
I last saw himalive on
November 4, 1960, death is said to
have occurred on the date stated above, at
3:50 Pm.
DEATH WAS CAUSED BY: IMMEDIATE CAUSE Arteriosclerotic heart disease (a)
Due ToGeneralized arteriosclerosis (b)
Due To (c)
OTHER
SIGNIFICANT
CONDITIONS
trophy
Benign prostatic hyper-
3 yrs
Was autopsy performed?
no
What test confirmed diagnosis ?.
Clinical & Laboratory
5 Was disease or injury in any way related to occupation of deceased?no If so, specify.
(Signed)
MiTraumetzen
M. D.
(Address). 73 Bartlett Road
Date Nov. 5 1,60
6
Riverside GAL Lewiston, Maine Place of Burial or Cremation (City or Town) DATE OF BURIAL Nov. 7, .19.60
7 NAME OF
FUNERAL DIRECTOR
Howard S Reynolds
ADDRESS Winthrop, Mass.
19
(Registrar)
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
Male
9 COLOR
White
10 SINGLE
(write the word)
MARRIED
WIDOWED
or DIVORCED
Widowed
10a If married, widowed, or divorced
Lvangiline Getchell
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
87
AGE
Years
4 Months 24 Days
If under 24 hours
Hours ..._ Minutes
13 Usual
Occupation :
Cook
10 yrs (Kind of work done during most of working life)
14 Industry
or Business:
Club
15 Social Security No.
Nonc
Berwick
16 BIRTHPLACE (City)
(State or country)
Maine
17 NAME OF
FATHER
Alonzo E Nelson
PARENTS
18 BIRTHPLACE OF
Newburyport
FATHER (City)
(State or country)
Mass
19 MAIDEN NAME
OF MOTHER
Minnie Parker
20 BIRTHPLACE OF
MOTHER (City)
(State or country)
Maine
Berwick
21
Informant
Theodore Springall
(Address) 350 Winthrop St. Winthrop, lass.
I HEREBY CERTIFY that a satisfactory standard certificate of death was filed with me BEFORE the burial or transit permit was issued: Ralph E. Dercarne (Signature of Agent b Board of Health or other)
H.O
702.15-1960
(Official Designation)
(Date of Issue of Permit)
TRUCTIONS FOR IL CERTIFICATE
n giving OF DEATH not enter e than one se for each , (b) and (c)
does not mean de of dying, heart failure, etc. It means ase, or compli- which caused
311 ions, if any, gave rise tto cause (a). the under- cause last.
itions contrib -- death but not to the terminal condition given
· Chapter 137, 1954, requires ans to print or he cause or of death on
. Centres
11-14-60 Joue
50M-1-58-921876
Received and filed
Leon L Nelson
2 FULL NAME
(If deceased is a married, widowed or divorced woman, give also maiden name.)
39 Grovers Ave.
Registered No.
N&Grovers Ave.
MR-301A I
INTERVAL BETWEEN ONSET AND DEATH
7 yrs
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 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 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 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 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 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
X SUFFOLK (County)
POSTEN
LINSE PETIT
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.
242
S(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 Ralph Robert Lippens
(If deceased is a married, widowed or divorced woman, give also maiden name.)
(a) Residence. No. 198 Faywood Ave. East Boston, Mass. (Usual place of abode)
12R
(If nonresident, give city or town and State)
Length of stay: In place of death .............. years ..
months
days. In place of residence .............. years .........
months .............. days.
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
DEATH
Nov.
7. 1960
(Month)
(Day)
(Year)
4 I
HEREBY CERTIFY,
That I attended, deceased from
11/7/60
19
I last saw h& Malive on
11/7
19.60, death is said to
have occurred on the date stated above, at
11
P.
.m
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a)
Atelectasis, (congenital)
Due To (b)
Due To (c)
OTHER SIGNIFICANT CONDITIONS
Was autopsy performed?
No.
What test confirmed diagnosis ? Clinical ..... Test
5 Was disease or injury in any way related to occupation of deceased ? NO .. If so, specify
(Signed) Somi 2Schimpfe M. D.
(PRINT OR TYPE SIGNATURE)
(Address)
6 Holy Cross
Malden
Place of Burial or Cremation DATE OF BURIAL November 9,
19 60
7 NAME OF
FUNERAL DIRECTOR
Frederick J. Magrath
ADDRESS East oston
NOV. 8.1960 19
Received and filed
(Registrar)
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
Male
9 COLOR
White
10 SINGLE
MARRIED
WIDOWED
or DIVORCED
(write the word)
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 ...
Years ...
Months ...
......
Days
If under 24 hours
1 ...
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
FATHER
Peter Lippens
18 BIRTHPLACE OF
FATHER (City)
(State or country)
Evanston
Ill.
19 MAIDEN NAME
OF MOTHER
Rita Camerlengo
20 BIRTHPLACE OF
MOTHER (City)
(State or country)
Foston
Mass.
21 Peter Lippens
Informant (Address)
198 Faywood Ave. E. Poston
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)
11/8/66
(Official Designation)
(Date of Issue of Permit)
X
RM R-301A 1
INSTRUCTIONS FOR CAL CERTIFICATE
In giving SE OF DEATH do not enter ore than one use for each a), (b) and (c)
's does not mean mode of dying. as heart failure, sia, etc. It means isease, or compli- s which caused
ditions, if any, ich gave rise to ve cause (a). ing the under- cause last.
Conditions contrib- to death but not d to the terminal e condition given
e :- Chapter :37, of 1954. requires cians to print or the cause or s of death on certificates, and er 48, Acts of requires Physi- to print or type under signature.
M-11-59-926662
PLACE OF DEATH
Winthrop (City or Town) No Win. Comm. Hospital
Registered No.
Winthrop
PARENTS
(City or Town)
19
6
to.
11/7
INTERVAL
BETWEEN
ONSET AND
DEATH
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.
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