USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1960 > Part 58
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To be filed for burial permit with Board of Health or its Agent.
267
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)
(a) Residence. No. 74 Beal Street (Usual place of abode) 35
St.
(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
PERSONAL AND STATISTICAL PARTICULARS
3 DATE OF
DEATH
Dec.
(Month)
(Day)
1960 (Year)
8 SEX
Female
9 COLOR
White
10 SINGLE
MARRIED
WIDOWED,
or DIVORCEMarried
4 I HEREBY
CERTIFY , That I attended deceased from
May
1960
to ..
Dec.
1960
I last saw ho .. alive on
NOV.SP, 1960
death is said to
have occurred on the date stated above, at
11.00.
INTERVAL BETWEEN ONSET AND DEATH
IVV
12
AGE
Years
Months.
Days
12
If under 24 hours Hours Minutes
13 Usual
Occupation :
Housewife
14 Industry
or Business :
Own Home
15 Social Security No. None
16 BIRTHPLACE (City) (State or country)
17 NAME OF
FATHER
Charles Schroeder
18 BIRTHPLACE OF FATHER (City) (State or country) Illinois
19 MAIDEN NAME OF MOTHER Marion Bankhammer
20 BIRTHPLACE OF MOTHER (City) (State or country) Conn.
Rockville
(Address) 36 Villa do winthropa
12-11-1960
Mt Auburn Crem tory 6
Cambridce
Place of Burial or Cremation
DATE OF BURIAL
Dec.
(City or Town)
19
7 NAME OF
FUNERAL DIRECTOR
Howard .Reynolds
ADDRESS inthrop Ness
1of 19/0,3-
Received and filed
(Registrar)
10a If married, widowed, or divorced
HUSBAND of
„(Give maiden name of wife in full)
(or) WIFE of
George J Gaw
(Husband's name in full)
DEATH WAS CAUSED BY : IMMEDIATE CAUSE
(a)
Arteriosclerotic
Heart Disease
Due To
Senile Arteriosclerosis
(b)
2 mos
Due To
(c)
Malnutrition
GMIS
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
Nove
(Signed)
M. D.
Joseph Zambella
(PRINT OR TYPE SIGNATURE)
PARENTS
21 Howell Gaw (Address) 14 Belmont Ct. Reading Pass Informant
I HEREBY ,CERTIFY that a satisfactory standard certificate of death was/filed /with me BEFORE the burial or transit permit was issued: Tha w. C. Tereannoy (Signature of Agent of Board of Health or other)
12/14/60
(Official Designation)
(Date of Issue of Permit>
X
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, a, etc. It means ease, or compli- which caused
itions, if any, h gave rise to cause (a), tg the under- cause last.
nditions contrib- o death but not to the terminal condition given 4.5.
- Chapter 137, : 1954, requires ians to print or the cause or of death on ertificates, and r 48, Acts of equires Physi- o print or type nder signature.
1-11-59-926662
CENSE PETIT
2 FULL NAME Dorothy C (Schroeder) Gaw
(If deceased is a married, widowed or divorced woman, give also inaiden name.)
35
Registered No.
(write the word)
11 IF STILLBORN, enter that fact here.
68
4
(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 absent from home when the certificate of death is needed.
(3) Medical Examiners will investigate and certify to all deaths supposable due to injury. These include not only deaths caused directly or indirectly b 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 occ pation, the sudden deaths of persons not disabled by recognized disease, 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.
OFFICE
10
10
MIN
11.12
ASS.
TOWN
GIN
CLERK
RECEIVED
×
ORM R-302
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 death occurred. (See Chap. 46, Sec. 12. G. L.) at the time of death should be transmitted on Form R-302 to the clerk of the city or town in which the deceased
PLACE OF DEATH
Middlesex
( County )
1
. Natick
(City or Town)
The Commonwealth of Massachusetts JOSEPH D. WARD SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS COPY OF CERTIFICATE OF DEATH
Natick
(City or Town making this return)
268
[ {If death occurred in a hospital or institution,
St. { give its NAME instead of street and number)
2 FULL NAME
Mary S. (Rippey) Tewksbury
(If deceased is a married, widowed or divorced woman, give also maiden name.)
24 James ....
Aye,
St
Winthrop Mass.
(a) Residence.
No ..
( Usual place of abode)
(If nonresident, give city or town and State)
Length of stay: In place of death.
....... years ...
... months
21
1
6
.. days. In place of residence ...
.years.
months .......... days.
MEDICAL CERTIFICATE OF DEATH
PERSONAL AND STATISTICAL PARTICULARS
3 DATE OF
DEATH
December 12 1960
( Month)
(Day)
( Year)
8 SEX
F.
9 COLOR
10 SINGLE
MARRIED
WIDOWED Widowed
or DIVORCED
4 I HEREBY CERTIFY,
That I attended deceased from
April
19
60
12/12/
19.
60
I last saw h ...... alive on
12/11/60
19.
death is said to
(Give maiden name of wife in full)
(or) WIFE of
( Husband's name in full)
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a)
Cerebral Thrombosis
5 days
87
12
AGE
.. Years.
Months .......... Days
If under 24 hours
.. Hours ........ Minutes
13 Usual
Occupation:
Housewife
(Kind of work done during most of working life)
14 Industry
or Business :
At home
15 Social Security No.
None
16 BIRTHPLACE (City)
(State or country)
Nova Scotia
17 NAME OF FATHER David Rippey
18 BIRTHPLACE OF
FATHER (City) (State or country) Nova Scotia
(Signed)
Saul S. Radovsky
M. D.
( Address)
Natick
Date.
12/13/60 19
Winthrop
6
Winthrop
Place of Burial or Cremation
(City or Town)
DATE OF BURIAL
Dec.
15,
60
19
Informant
( Address)
118 Pond St., Natick, Mass,
7 NAME OF FUNERAL DIRECTOR
ADDRESS
Marsh Funeral Home Winthrop
Received and filed
Jan/9/19/1 19
(Registrar of City or Town where deceased resided)
A TRUE COPY
ATTEST :
( Registrar of City or Town where death occurred )
DATE FILED
December ... 15, 1960
19
X
10a If married, widowed. or divorced
HUSBAND of
Howard E. Tewksbury
have occurred on the date stated above, at
4:558.
m.
INTERVAL BETWEEN ONSET AND DEATH
Due To (b)
Due To
(c)
OTHER SIGNIFICANT CONDITIONS
No
Was autopsy performed ?
What test confirmed diagnosis ?
Clinical
5 Was disease or injury in any way related to occupation of deceased ? If so. specify
No
PARENTS
19 MAIDEN NAME
OF MOTHER
Cannot be learned
20 BIRTHPLACE OF
MOTHER (City)
(State or country)
Nova Scotia
21 Mrs. Paul Mcwhorter
50M-9-59-926111
WRITE PLAINLY, WITH UNFADING DLACA INA UK USE AFFROVED BLACK LIFEWKIIEK KIDDON- THIS IS A PERMANENT RECORD
Hanson Rest Home (Phillips House) No
Registered No.
( Was deceased a
U. S. War Veteran.
(if so specify WAR
( write the word)
er
to
11 IF STILLBORN, enter that fact here.
=== = : 50
== CE : 50
TOM
TO
/J.IT
,
SPACE FOR ADDITIONAL INFORMATION
. ..
6
THROP.
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE RANK, RATING
JAN :01961 AM
JAN - 91861 :4
ORGANIZATION AND OUTFIT
SERVICE NUMBER
1
PLACE OF DEATH
Suffolk (County)
Winthrop (City or Town)
No.
264 Court Road
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.
269
[(If death occurred in a hospital or institution, St. } give its NAME instead of street and number)
2 FULL NAME Ellen S Bloomfield
(If deceased is a married, widowed or divorced woman, give also maiden name.)
264 Court Road
St.
(If nonresident, give city or town and State)
years .. .. months .. .days.
MEDICAL CERTIFICATE OF DEATH
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
Female
9 COLOR
White
10 SINGLE
(write the word)
MARRIED
WIDOWESingle
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)
11 IF STILLBORN, enter that fact here.
12
93
10
Months.
13 Days
If under 24 hours
Hours
Minutes
13 Usual
Occupation :
Teacher
(retired)
(Kind of work done during most of working life)
14 Industry
or Business :
Public School
15 Social Security No.
None
Liverpool
16 BIRTHPLACE (City)
(State or country)
England
17 NAME OF
FATHER
Henry Bloomfield
18 BIRTHPLACE OF FATHER (City) (State or country) England
19 MAIDEN NAME
OF MOTHER
Maria Jamieson
20 BIRTHPLACE OF MOTHER (City) (State or country)
Montrose
Scotland
6
Winthrop
Winthrop (City or Town)
Place of Burial or Cremation
DATE OF BURIAL
Dec . 17 19
6@
21
Informant
(Address)
264 Court Rd, 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)
Hil
Xxe 16 - 1964
(Official Designation)
(Date of Issue of Permit)
V.B
A R-301A
RUCTIONS FOR . CERTIFICATE giving OF DEATH
not enter than one e for each (b) and (c)
does not mean de of dying, heart failure, etc. It means se, or compli- which caused
1.5.
ions, if any, gave rise to cause (a), the under- cause last.
ditions contrib- death but not o the terminal ondition given
Chapter 137, 1954. requires ns to print or le cause or of death on rtificates, and 48, Acts of quires Physi- print or type der signature.
7 NAME OF
FUNERAL DIRECTOR,
Howard S Reynolds
ADDRESS Winthrop Mass
Received and filed Dec 16 1960
(Registrar)
10 YEARS
Was autopsy performed?
NO
What test confirmed diagnosis ?
5 Was disease or injury in any way related to occupation of deceased? 16 If so, specify
(Signed) Dorothy Chenay appleton M. D. DOROTHY CHENEY APPLETON (PRINT OR TYVE SIGNATURE)
(Address) 197 Woodside QUE WINTHROP, DAS
12/15 1960
PARENTS
DECEMBER 15 1960
(Month)
(Day)
(Year)
4 I HEREBY CERTIFY
That I attended deceased from
to ......
AUGUST 11
1951
DECEMBER 15
60
I last saw h ........ alive on
DECEMBER 14, 1960, death is said to
have occurred on the date stated above, at 3:20 A
.. m.
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
BRONCHO PNEUMONIA
(a)
INTERVAL
BETWEEN
ONSET AND
DEATH
5 DAYS
Due To (b)
Due To (c)
OTHER
SIGNIFICANT
CONDITIONS
GENERALIZED ARTERIOSCLEROSIS
Registered No.
PHYSICIAN - IMPORTANT [(Was deceased a { U. S. War Veteran, {if so specify WAR)
(a) Residence. No.
(Usual place of abode)
65
Length of stay : In place of death. .. years. months. . ... days. In place of residence
65
3 DATE OF
DEATH
6-59-92 5686
Lydia Bloomfield
AGE
Years ...
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.
GLERK
SS
NMOL
11 12 1
MIN
OF
0
6
OFFICE
DEC (161960 AM
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.
PLACE OF DEATH
REVERE 19-6-1
Suffolk (County)
Winthrop (City or Town)
No.
Winthrop Comunity Hospital
[(If death occurred in a hospital or institution, St. ¿ give its NAME instead of street and number)
PHYSICIAN - IMPORTANT
(W'as deceased a U. S. War Veteran, lif so specify WAR) No
(a) Residence. No.
(Usual place of abode)
7 Belle Isle Ave.
St.
Revere
(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
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
Female
9 COLOR
White
10 SINGLE
MARRIED)
WIDOWED
or DIVORCED
(write the word)
Single
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
5
... Hours.
2.9
.Minutes
13 Usual
Occupation :
(Kind of work done during most of working life)
14 Industry
or Business :
15 Social Security No.
None
16 BIRTHPLACE (City) (State or country) Mass.
17 NAME OF
FATHER
Albert A. Balboni
18 BIRTHPLACE OF FATHER (City) (State or country) Boston Mass
19 MAIDEN NAME OF MOTHER Lorraine Paziano
20 BIRTHPLACE OF
MOTHER (City)
(State or country)
Boston
Mass.
21 Albert A ..... Balboni 7 Belle Isle Ave., Revere
Informant (Address)
I HEREBY CERTIFY tbat a satisfactory standard certificate of deatb was filed with me BEFORE the burial or transit permit was issued: Ralph E. CAC Dec 19-1960 (Signature of Agent of Board of Health or other)
HO
(Official Designation)
(Date of Issue of Permit)
(Registrar)
PARENTS
(Signed) a Paul Dur Hagopian I.s M. 1).
A Paul DER HAGOPIAN M.D. (PRINT OR TYPE SIGNATURE) (Addre 39 CARY AV CHELSEA Date: Dec. 16 .. 1960
6 Holy Cross
Mal.den
Place of Burial or Cremation DATE OF BURIAL
(City or Town)
Dec .. 19 ... .... 19 .... 60
7 NAME OF FUNERAL DIRECTOR Arthur S .Porcella
ADDRESS
876 Winthrop Ave. Revere
Received and filed Dec. 19 1940
The Commonwealth of Massachusetts JOSEPH D. WARD SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS
To be filed for burial permit with Board of Health or its Agent
STANDARD
CERTIFICATE OF DEATH
Registered No.
270
2 FULL NAME ...
Premature Baby Girl Balboni (If deceased is a married, widowed or
divorced woman, give also maiden name.)
NSTRUCTIONS FOR CAL CERTIFICATE
In giving SE OF DEATH lo not enter ore than one use for each a), (b) and (c)
s does not mean mode of dying, as heart failure, ia, etc. It means isease, or compli- s which caused
ditions, if any, ch gave rise to ve cause (a), ing the under- g cause last.
onditions contrib- to death but not i to the terminal condition given
:- Chapter 137, f 1954. requires cians to print or the cause or of death on certificates, and er 48, Acts of requires Physi- to print or type under signature.
M-11-59-926662
December 16. (Day) (Month)
1960 (Year)
4 I
HEREBY CERTIFY, That, I attended deceased from
Dec. 16
1960
to December 16
1960
I last saw he ) .. alive on
December-16, 1960, death is said to
have occurred on the date stated above, at 1 0:14Am.
INTERVAL BETWEEN ONSET AND DEATH
DEATH WAS CAUSED BY : IMMEDIATE CAUSE
Prematurity
(a)
Birth weight/ 2 lbs 1 0g
Due To Spontanious Primatrine (b)
la or. Bon at 4:45 Am.on
Due To (c) December 16- 1960
OTHER
SIGNIFICANTExpected date
CONDITIONS
march 15- 1961
Was autopsy performed ? What test confirmed diagnosis ?
5 Was disease or injury in any way related to occupation of deceased ? If so, specify
Winthrop AV.k
3 DATE OF
DEATH
RM 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
IF TON
11 12 3
in
00
111
6
INTHROP
DEC 191960 PM
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 wili 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.
+
M R-301A
1
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.
271
S(If death occurred in a hospital or institution, St. ¿ give its NAME instead of street and number)
2 FULL NAME
Joseph Ethan Davison
(If deceased is a married, widowed or divorced woman, give also maiden name.)
[if so specify WAR)
(a) Residence. No. 31 Lincoln Street St.
(Usual place of abode)
(If nonresident, give city or town and State)
Length of stay: In place of dea
34 years
... months .............. days. In place of residence ........ years .............. months .......... ... days.
MEDICAL CERTIFICATE OF DEATH
PERSONAL AND STATISTICAL PARTICULARS
3 DATE OF
DEATH
December 16, 1960
(Month)
(Day)
(Year)
4 I HEREBY CERTIFY,
That I attended deceased from
JANUARY 10
1959,
to ...
DECEMBER 16
1960
I last saw him alive on
DECEMBER 15, 1966, death is said to
have occurred on the date stated above, at
2:15 P.m.
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a)
ACUTE MYOCARDIAL INSUFFICIENCY
INTERVAL
BETWEEN
ONSET AND
DEATH
11 IF STILLBORN, enter that fact here.
12
AGE34
Years
2 Months.
3 Days
If under 24 hours
Hours ..........
Minutes
13 Usual
Occupation :
retired Printer
(Kind of work done during most of working life)
14 Industry
or Business :
self employed
15 Social Security No.
012-01-7293
16 BIRTHPLACE (City)
(State or country)
Massachusetts
17 NAME OF
FATHER
John Woodbury Davison
18 BIRTHPLACE OF
FATHER (City)
Gloucester
(State or country)
Massachusetts
19 MAIDEN NAME
OF MOTHER
Lovicy Paddock White
20 BIRTHPLACE OF
MOTHER (City)
Plymouth
(State or country)
Vermont
Winthrop Cemetery, Winthrop, Mass 6
Place of Burial or Cremation
(City or Town)
19 DATE OF BURIAL December 19, 60
7 NAME OF
FUNERAL DIRECTOR
alfred B. Marche
ADDRESS
174 Winthrop St. Winthrop.
Received and filed
Lea. 19 19 60
(Registrar)
8 SEX
Lale
9 COLOR
white
10 SINGLE
(write the word)
MARRIED
WIDOWED
or DIVORCED
married
10a If married, widowed of divorced larke
HUSBAND of
(Give maiden name of wife in full)
(or) WIFE of
(Husband's name in full)
3 DAYS
Due To ARTERIESCL EROTIC HEART DISEASE (b)
5 YRS
(c)
...
GENERALIZED ARTERIOSCLEROSIS
54RS
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). Dorothy Cheney appleton M. D. DOROTHY CHENEY APPLETON (PRINT OR TYPE SIGNATURE)
(Address) 197Woodside AUG ; Date Deo. 17 1966
PARENTS
21 Informant Urs. Joseph F. Davison
(Address)
31 Lincoln Street Winthrop
I HEREBY CERTIFY that a satisfactory standard certificate of death was filed with me BEFORE the burial or transit permit was issued:
Lass ....
Jackh S.
(Signature of Agent of Board of Health or other)
12/19/60
(Official Designation)
(Date of Issue of Permit)
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
1.5.
ions, if any, gave rise to cause (a), the under- cause last.
ditions contrib- death but not o the terminal condition given
- Chapter 137, 1954. requires ans to print or he cause or of death on ertificates, and · 48, Acts of quires Physi- print or type der signature.
-6-59-925686
No.
31 Lincoln Street
PHYSICIAN - IMPORTANT f(Was deceased a U. S. War Veteran,
Registered No.
Winthrop
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.
DEC 1 91960 AM
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.
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