USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1960 > Part 6
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(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
PLACE OF DEATH
Suffolk (County)
Chelseaw
The Commonwealth of Massachusetts JOSEPH D. WARD SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS COPY OF MEDICAL EXAMINER'S CERTIFICATE OF DEATH
(City of town making return)
Registered No.
22
S(If death occurred in a hospital or institution, give its NAME instead of street and number)
2 FULL NAME 11 (If deceased is amarried was). KabWed or divorced woman, give also maiden name.)
[(Was deceased a { U. S. War Veteran,
[if so specify WAR)
(a) Residence. No. 190 Shore Drive ....
+
(Usual place of abode)
(If honresident, '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
Malon. 1,1960 (Year)
4 I HEREBY CERTIFY that I have investigated the death of the person above-named and that the CAUSE AND MANNER thereof are as follows: (If an injury was involved, state fully.)
"Acute myocardial infarction.
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)
Did injury occur in or about home, on farm, in industrial place, or in
public place ?
Manner of
Injury
(How did injury occur ?)
Nature of
Injury
While at work ? .Was autopsy performed?
6 Was disease or injury in any way related to occupation of deceased? If so, specify
M. D.
Date- 1/1/60
7
DATE OF BURIAL Jan. 3, 1960 19
& NAME OF FUNERAL DIRECTOR Arnold Golov
ADDRESS 1668 Peacon Brookline
Received and filed 19
(Registrar of City or Town where deceased resided)
9 SEX
10 COLOR
11 SINGLE
(write the word)
MARRIED
WIDOWED
or DIVORCED
married, widowed, or tivotted
single
lla If mart
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
AGEST
Years
Months ..
Days
If under 24 hours Hours. ....... Minutes
14 Usual
Occupation :
(Kind & work done luciaglibest of working life)
15 Industry or Business : .......... Standard Machinery Supply
16 Social Security No. ....
17 BIRTHPLACE (City) (State or country) Fast Botton, Hass.
18 NAME OF
FATHER
Lax
19 BIRTHPLACE OF FATHER (City) (State or country)
20 MAIDEN NAME
OF MOTHER
Esther Lebowitz
21 BIRTHPLACE OF MOTHER (City) (State or country) Russia
22 Informant (Address) I00 rober
A TRUE COPY.
190 hore Drive-winthrop
ATTEST:
Jan. 2,1960
DATE FILED
19
Copies of returns of deaths which occurred in your city or town in case the deceased resided in another city or town at
the time of death should be transmitted on Form R-305 to the clerk of the city or town in which the deceased resided
25M-4-59-925100
18 1960
as soon as possible after the close of the month in which the death occurred. (See Chap. 46, Sec. 12, G. L .. )
R-305 1
PARENTS
Russia
(Signed) (Address) Loston, Dass.
(Specify type of place)
No. en route to Chelsea Memorial Hosp
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE RANK, RATING
FEB 1 0 1930 /"
ORGANIZATION AND OUTFIT
SERVICE NUMBER
X
Suffolk
(County)
Revere
(City or Town)
The Commonwealth of Massachusetts EDWARD J. CRONIN SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS COPY OF
Revere
(City or Town making this return)
Registered No.
23
$(If death occurred in a hospital or institution, St. { give its NAME instead of street and number)
2 FULL NAME Elizabeth Louise Bisbee (Farren)
(If deceased is a married, widowed or divorced woman, give also maiden name.)
24 Ocean Ave.
x
Winthrop
(a) Residence.
No.
(Usual place of abode)
Length of stay: In place of death ........ years ...
3
.months.
2
days.
In place of residence.
years.
months.
.... days.
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
DEATH
January
11.
1960
(Month)
(Day)
(Year)
4 I HEREBY CERTIFY,
Oct. 919 59
to ....
Jan. 11
That I attended deceased from
60
I last saw h.Q.lalive on
Jan. ..... 11 , 1960, death is said to
have occurred on the date stated above, at 6:30A. .. m.
DEATH WAS CAUSED BY: IMMEDIATE CAUSE Uremia
(a)
INTERVAL BETWEEN ONSET AND DEATH 24hrs
9mos.
accident
Due To
(c)
OTHER SIGNIFICANT CONDITIONS
Was autopsy performed?
What test confirmed diagnosis?
Clinical signs
5 Was disease or injury in any way related to occupation of deceased ?.. If so, specify
no
(Signed).
James F. Burns
M. D.
(Address).Everett
Woodlawn
Everett
6
Place of Burial or Cremation
(City or Town)
DATE OF BURIAL
January
13
60
19
7 NAME OF FUNERAL BIRECILincoln Ave., Saugus
ADDRESS
Received and filed.
FEB-18-1960
19
(Registrar of City or Town where deceased resided)
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
9 COLOR
White
MARRIED
WIDOWEDWidowed
or DIVORCED
10a If married, widowed, or divorced
HUSBAND of.
(Give maiden name of wife in full)
Ernest E. Bisbee
(or) WIFE of
(Husband's name in full)
11 IF STILLBORN, enter that fact here.
12
AGE7
6
17
If under 24 hours
Hours ........ Minutes
13 Usual
Occupation :
Housewife
14 Industry
or Business:
Own home
15 Social Security No ............ ne
16 BIRTHPLACE (City) ......
(State or country)
N. B.
17 NAME OFEdward Farren FATHER
18 BIRTHPLACE OF
FATHER (City)
St. John
(State or country)
N. B.
19 MAIDEN NAME
Jane Kellawaey
OF MOTHER
20 BIRTHPLACE OF
St. John
MOTHER (City)
(State or country)
N. B.
21 Mrs. Guy Pigeon Informant (Address4 Ocean Avenue, Winthrop
A TRUE COPY
ATTEST:
(Registrar of City or Town where death occurred)
DATE FILED
January
13 19 60
19
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. [ .. ) at the time of death should be transmitted on Form R-302 to the clerk of the city or town in which the deceased
ZUM-2-58-922072
18 1960
PLACE OF DEATH
R-302 1
Grover Manor Hospital No.
CERTIFICATE OF DEATH
(Was deceased a
U. S. War Veteran,
if so specify WAR)
(If nonresident, give city or town and State)
6
10 SINGLE
(write the word)
Female
Years.
Months .:
.Days
(Kind of work done during most of working life)
St.
PARENTS
537 Broadway
Date.
1/11
1960
Bisbee & Son
19.
Due To Cerebral vascular (b))
FEB 1 SKO1 .
X
PLACE OF DEATH
Middlesex (County)
SN Ý
Waltham
(City or Town)
The Commonwealth of Massachusetts JOSEPH D. WARD SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS COPY OF CERTIFICATE OF DEATH
Waltham
(City or Town making this return)
32
24
Registered No.
[ {If death occurred in a hospital or institution,
No ...
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.)
(a) Residence.
No.
200 Shirley
Winthrop, Mass.
St
( 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
PERSONAL AND STATISTICAL PARTICULARS
January
16
1960
(Month)
(Day)
( Year)
8 SEX
male
9 COLOR
white
10 SINGLE
MARRIED
WIDOWED
or DIVORCED
single
4 I HEREBY CERTIFY,
Jan. 1
19.5.9
....
to ...
Jan.
16
That I attended deceased from
1960
I last saw h.1.mive on .
Jan .....
15
16.0 .. , death is said to
have occurred on the date stated above, at 7 ..... 30amm.
INTERVAL
BETWEEN
ONSET AND
DEATH
(or) WIFE of
(Husband's name in full)
11 IF STILLBORN. enter that fact here.
12
AGEI.
.. Years.
Months.
Days
If under 24 hours
.Hours ....
.Minutes
13 Usual
Occupation :
None
(Kind of work done during most of working life)
14 Industry
or Business :
15 Social Security No. Winthrop
16 BIRTHPLACE (City)
(State or country)
Mass
17 NAME OF
FATHER
Bernet Kaplovitz
18 BIRTHPLACE OF
FATHER (City)
(State or country )
Russia
19 MAIDEN NAME
Rebecca Cohen
OF MOTHER
20 BIRTHPLACE OF
MOTHER (City)
(State or country)
Russia
WEF School
DATE OF BURIAL January 17 19
60
21 Informant
(Address )
Waverley, Mass.
7 NAME OF FUNERAL DIRECTOR Torf Funeral Service
ADDRESS Chelsea. .... Mass
Received and filed
MAR 10 1960
19
( Registrar of City or Town where deceased resided)
A TRUE COPY
ATTEST :
(Registrar of City or Town where death occurred)
DATE FILED
January 25
60
19
X.
WU HANLA INN UR USE APPKUVED BLACK TYPEWRITER RIBBON -
THIS IS A PERMANENT RECORD
3 DATE OF DEATH 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 CONDITIONS
Due To Congenital .... cerebral .... s.pas.tic infantile paralyses
life
OTHER SIGNIFICANTMental ..... deficiency.
life
Was autopsy performed?
What test confirmed diagnosis ? clinical
5 Was disease or injury in any way related to occupation of deceased ? . NO.
If so, specify
(Signed) L. K. Kelley
M. D.
Walt ham, Mass.
1-18
( Address )
Date.
19
Adath Seshurun, W. Roxbury 6 Place of Burial or Cremation
(City or Town)
PARENTS
50M-9-59-926111
(b) Copies of returns of deaths which occurred in your city or town in case the deceased resided in another city or town Due To (c)
ORM R-302
DEATH WAS CAUSED BY : IMMEDIATE CAUSE
(a) Coronary thrombosis
3hrs
10a If married, widowed, or divorced
HUSBAND of
(Give maiden name of wife in full)
41
8
28
...
( write the word)
( Was deceased a
U. S. War Veteran,
(if so specify WAR
Charles Kaplovitz
Walter E. Fernald State School
1
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE DATE OF DISCHARGE RANK, RATING ORGANIZATION AND OUTFIT SERVICE NUMBER
A
Suffolk
(County)
Revere
(City or Town)
The Commonwealth of Massachusetts EDWARD J. CRONIN SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS COPY OF CERTIFICATE OF DEATH
Revere
(City or Town making this return)
Registered No. 25
"(If death occurred in a hospital or institution, St. { give its NAME instead of street and number)
2 FULL NAME Frances Magee (Sampson)
(If deceased is a married, widowed or divorced woman, give also maiden name.)
(a) Residence. No.
6 Court Road
(Usual place of abode)
Winthrop
(If nonresident, give city or town and State)
Length of stay: In place of death ............ years .....
months.
19lays. In place of residence ............ years ...
months ....
........ days.
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
DEATH
January
24,
1960
(Month) (Day)
(Year)
4 I HEREBY CERTIFY,
That I attended deceased from
December 5 19 59
January
24.
1,60
I last saw he.Talive on
Jan. 24, 19 60 death is said to
have occurred on the date stated above, at
11:30P.
INTERVAL BETWEEN ONSET AND DEATH 18hrs.
6mos.
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
Female
9 COLOR
White
10 SINGLE
MARRIED
WIDOWER dowed
or DIVORCED
10a If married, widowed, or divorced
HUSBAND of.
(Give maiden name of wife in full)
(or) WIFE of
James E. Magee
(Husband's name in full)
11 IF STILLBORN, enter that fact here.
12
AGE3
Years
Months ............ Days
If under 24 hours
Hours ........ Minutes
Housewife
13 Usual
Occupation :
(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)
N. S.
17 NAME OF
FATHER
Joseph Sampson
18 BIRTHPLACE OF
FATHER (City)
(State or
N.S.
19 MAIDEN NAME
OF MOTHER
Maria (Cannot be learned)
20 BIRTHPLACE OF
MOTHER (City) ...
(State or country)
N. S.
21 James Magee
Informant
(Address) Court Rd., Winthrop
A TRUE COPY
ATTEST:
(Registrar of City or Town where death occurred)
DATE FILED
January
28,
19 60
(Registrar of City or Town where deceased resided)
PARENTS
(Signed James F. Burns M. D.
Broadway
(Address)
Everett
Date.
1/26
,60
6 Winthrop
Winthrop
Place of Burial or Cremation
(City of Town)
28
DATE OF BURIAL
January
,60
7 NAME OF
Maurice W. Kirby
FUNERAL PREGARthrop St., winthrop
ADDRESS
Received and filed. FEB 18-1960 19
B 18 1950
WALL VASAVANV DURVA INA - INIS IS A PERMANENT RECORD
(a) (b) resided as soon as possible, after the close of the month in which the death occurred. (See Chap. 46, Sec. 12, G. I .. ) 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 Due To (c)
LM-2-58-922072
PLACE OF DEATH
RA R-302 1
Due ToCarcinoma of stomach
OTHER
SIGNIFICANT
CONDITIONS
no
Was autopsy performed?
Clinical signs
What test confirmed diagnosis?
5 Was disease or injury in any way related to occupation of deceased ?. If so, specify ..
no
Grover Manor Hospital No ..
(Was deceased a
U. S. War Veteran,
if so specify WAR)
(write the word)
DEATH WAS CAUSED BY: IMMEDIATE CAUSE Uremia
FEB 1 81960 78
X 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.
26
[(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 divorged woman, give also maiden name.)
(a) Residence. No. 55 Gottage Are
(Usual place of abode)
Length of stay: In place of death Lyears
months days. In place of residence.
10 years months. .. days.
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
DEATH
February 1, 1960
(Month)
(Day)
(Year)
4 I HEREBY CERTIFY,
That I attended deceased from
March 1, ., 19.448,
to
Feb. ....
1960
I last saw-himalive on
Jan. 31, , 19.60, death is said to
have occurred on the date stated above, at
7:10 am.
INTERVAL BETWEEN ONSET AND DEATH
6 yrs.
12
AGE Z& Years
Months
Days
If under 24 hours
-Hours ......
Minutes
13 Usual
Occupation:
Retired Meat Gutter
(Kind of work done during most of working life)
10 yrs
Due To
Btxbe
(c)
OTHER
SIGNIFICANT
Diabetes Mellitus
CONDITIONS Bilateral Leg Amputations
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, specifyM. Traunstein, Jr.
(Signed)
Mr. Traunstein M.M. D.
M. D.
(Address). 73 Bartlett, Winthrop. Feb. 1,1960
6
St. Josephis
Place of Burial or Cremation
DATE OF BURIAL February 3, 19.60
7 NAME OF
FUNERAL DIRECTOR
John G. Kelly
ADDRESS 286 Meridian St., E. B.0
Received and filed 19
FEB 1- 1960
(Registrar)
PARENTS
17 NAME OF
FATHER
Edward W. Rhyno
18 BIRTHPLACE OF
FATHER (City)
(State or country)
U.S.
19 MAIDEN NAME
OF MOTHER
Clara C. Hayes
20 BIRTHPLACE OF MOTHER (City) (State or country) U. S.
21 Mrs. Marjorie M. Kiulin
Informant
(Address)
55 Cottage fre Win.
I HEREBY CERTIFY that a satisfactory standard certificate of death was filed with me BEFORE the burial or transit permit was issued: Halkle Jereannes). (Signature of Agent of Board of Health or other)
Health Officer
2/1/60
(Official Designation)
(Date of Issue of Permit)
X
8 SEX Male
9 COLOR
White
10 SINGLE MARRIED WIDOWED or DIVORCED
(write the word) Married Allen
10a If married, widowed, or divorced
HUSBAND of
Minnie 2.
(Give maiden name of wife in full)
(or) WIFE of
(Husband's name in full)
11 IF STILLBORN, enter that fact here. -
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a) Arteriosclerotic heart disease
- (b) Due To Generalized arteriosclerosis
14 Industry
or Business:
Provision
15 Social Security No ..
020-14-9360A
16 BIRTHPLACE (City)
(State or country)
4.5.
12 yrs 11 yrs
MR-301A
-THIS IS A ANENT RECORD. se only E APPROVED cink or black criter ribbon.
N 'RUCTIONS FOR C. CERTIFICATE
giving SI OF DEATH
Ichot enter o than one u: for each a (b) and (c)
udoes not mean me of dying, heart failure,
a te etc. It means isse, or compli- s which caused
di ns, if any, have rise to le cause (a), the under- & cause last.
on ions contrib- todeath but not the terminal ondition given e
e: Chapter 137, 01.954, requires icl is to print or cause or sf death on ‹ tificates. CIAP. 46, 55 9 & CHP. 114 $$ 45, ( AP. 38 § 6.)
IM -58-923886
Mayflower Nursing Home
No .... 39 Irovers pe George W. Rhyno
Registered No.
PHYSICIAN - IMPORTANT
(Was deceased a
U. S. War Veteran,
210
if so specify WAR)
St. Winthrop
(If nonresident, give city or town and State)
PERSONAL AND STATISTICAL PARTICULARS
Mass Boston (City or Town)
-
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 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.
FEB -11960 FM
X 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
Registered No.
27
[(If death occurred in a hospital or institution, St. ¿ give its NAME instead of street and number)
No PHYSICIAN - IMPORTANT ((Was deceased a U. S. War Veteran, {if so specify WAR)
2 FULL NAME
Burton Barnes
(If deceased is a married, widowed or divorced woman, give also maiden name.)
158 Highland Ave., Winthrop, Mass. St.
13
(If nonresident, give city or town and State) 2
Length of stay: In place of death. .... .. ... years .. ... months days. In place ofresidence.
years. months .. ... .. ... days.
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
DEATH
February 2,1960
(Month)
(Day)
(Year)
4 I HEREBY
Jan. 21
CERTIFY
19
Feb,2
I last saw h ........ alive on
19
death is said to
have occurred on the date stated above, at
3.09
A.M
DEATH WAS CAUSED BY : IMMEDIATE CAUSE
(a) Coronary Embolus
Due To (b)
Due To (c)
OTHER SIGNIFICANT CONDITIONS
Fracture Left Femur
13 Days
Was autopsy performed?
NO
What test confirmed diagnosis ?
X*Ray
No
5 Was disease or injury in any way related to occupation of deceased ? If so, specify/ .... Vation 7. Carlino Muito M. D.
(Signed)
John F Collins M.PORE)
(Address) ..... Revere Mass. Date. 2/2/60
6 Puritan Lawn . em.
Deabody
Place of Burial or Cremation DATE OF BURIAL February 5, 196C
7 NAME OF FUNERAL DIRECTOR ...... orcella Funer.l Service. 876 Winthro, Ive., Revere
ADDRESS
Received and filed
19
(Registrar)
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
'ale
9 COLOR
Thite
10 SINGLE
(write the word)
MARRIED
WIDOWED
or DIVORCED .ar ie
HUSBAND of ......
(Give maiden name of wife in full)
(or) WIFE of
(Husband's name in full)
11 IF STILLBORN, enter that fact here.
AGE
Years
1
Months.
17 Days
If under 24 hours
Hours.
.......
Minutes
13 Usual
Occupation :
Retire
(Kind of work done during most of working life)
14 Industry
or Business :
Manager -..... Ins.Co.
15 Social Security No.
Revere
16 BIRTHPLACE (City)
(State or country)
MaES
17 NAME OF
FATHER
James Barnes
18 BIRTHPLACE OF
FATHER (City)
New Brunswick
(State or country)
Canada
19 MAIDEN NAME
OF MOTHER
Eleanor Dalley
20 BIRTHPLACE OF
MOTHER (City)
(State or country)
England
21 Informant (Address)
Henrietta F. Coffill
I HEREBY CERTIFY that a satisfactory standard certificate of death filed with me/BEFORE the burial or transit permit was issued:
(Signature of Agent oy Board of Health or other) Health Alicer 2/4/60
(Official Designation)
(Date of Issue of Permit) /
X
: RUCTIONS FOR I CERTIFICATE
1 giving SJOF DEATH o ot enter at than one u for each (b) and (c)
bes not mean me of dying, a heart failure, ja etc. It means see, or compli- which caused
fins, if any, k'ave rise to e cause (a), mithe under- rause last.
intions contrib- toleath but not the terminal ndition given
Chapter 137. f )54. requires s to print or cause or death on seificates, and fr 48, Acts of eires Physi- print or type rer signature.
M.S.
13 4 - 1960 1 59-925686
(a) Residence. No. (Usual place of abode)
Feb. 2,
That I attended deceased frem
60
60
19
10a If married, widowed, or divorced
henriet & F. Coffill
INTERVAL
BETWEEN
ONSET AND
DEATH
11/2 Hrs2
67
To be filed for burial permit with Board of Health or its Agent.
Winthrop Community Hospital No.
E1 R-301A 1
-
......
PARENTS
(City or Town)
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.
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