Town of Winthrop : Record of Deaths 1961, Part 12

Author: Winthrop (Mass.)
Publication date: 1961
Publisher:
Number of Pages: 542


USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1961 > Part 12


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No


(If deceased is a married, widowed or divorced woman, give also maiden name.)


(a) Residence. No. 90 Undine Avenue, Winthrop 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


8 SEX M


9 COLOR


W


(write the word)


10 SINGLE


MARRIED


WIDOWED


or DIVORCE Single


4 I HEREBY CERTIFY,


That I attended deceased from


Mar.23


19.


61 to .... Mar ...


23


61


I last saw h


1mive on


Mar. 23


19 ....


61 death is said to


have occurred on the date stated above, at


10.03 PM


DEATH WAS CAUSED BY: IMMEDIATE CAUSE


Prematurity- 18 weeks


(a)


INTERVAL


BETWEEN


ONSET AND


DEATH


12


18 minGE


Years.


Months.


Days


13 Usual


Occupation :


None


(Kind of work done during most of working life)


14 Industry


or Business :


None


15 Social Security No.


None


16 BIRTHPLACE (City)


(State or country)


Winthrop


Mass.


17 NAME OF


FATHER


Robert Frost


Portland


18 BIRTHPLACE OF


FATHER (City)


(State or country)


Maine


19 MAIDEN NAME


20 BIRTHPLACE OF


MOTHER (City)


Boston


(State or country)


Mass.


21


Mr. Robert Frost-father


Informant


(AddresDO Undine Ave. Winthrop Mass


I HEREBY CERTIFY that a satisfactory standard certificate of death was filed with me BEFORE the burial or transit permit was issued : alph E. Sirianni (Signature of Agentfo Board of Health or other)


HO


3/24/6/


(Official Designation)


(Date of Issue of Permit)


X


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.


If under 24 hours


Hours.


Minutes


Due To


(b)


Prolapse of cord


Due To (c)


OTHER


Club foot - rt.


SIGNIFICANT


CONDITIONS


Was autopsy performed?


NoClinical & Lab.


What test confirmed diagnosis ?


No


5 Was disease or injury in any way related to occupation of deceased? If so, specify .....


MiTraumetEen


M. D.


OF MOTHER


Laura Zawtsos


(Signed)


M.


Traunstein , J.r. M.D ....


(PRINT OR TYPE SIGNATURE)


73 Bartlett Rd .Dadinthropy


(Address)


Woodlawn Cemetery, Wierett, Mass. 6


Place of Burial or Cremation


(City or Town)


DATE OF BURIAL


March 24th


19


61


7 NAME OF L DIRECTORRichard C. Kirby, Inc ADDRESS 917 Bennington St. , E. Boston


Received and filed MAR 2.4 1961 19.


(Registrar)


PARENTS


To be filed for burial permit with Board of Health or its Agent.


54.


No.


Winthrop Community Hospital


Male Frost


2 FULL NAME


CTIONS IR ERTIFICATE


ving F DEATH enter an one or each ) and (c)


not mean of dying, art failure, . It means or compli- ich caused


, if any, e rise to use (a), e under- use last.


ins contrib- th but not he terminal ition given


apter 137. . requires o print or cause or death on cates, and Acts of Les Physi- mit or type esignature.


769-926662


R-301A 1


-


2 hrs.


3 DATE OF


DEATH


March


23


1961


(Month)


(Day)


(Year)


RECE VED


TOW


SPACE FOR ADDITIONAL INFORMATION


12


DATE OF ENTERING MILITARY SERVICE


$50


DATE OF DISCHARGE


RANK, RATING


6 5


THRORN


ORGANIZATION AND OUTFIT


SERVICE NUMBER MAR- 2-41061. .. PH.


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.


2-301A 1


TIONS


RTIFICATE


ing DEATH enter n one each and (c)


not mean of dying, t failure, It means compli- caused


if any, t rise to le (a), Å under- e last.


es contrib- u but not A terminal d'on given


Ipter 137, requires print or ause or cath on ites, and Acts of s Physi- or type gnature.


5.25686


X PLACE OF DEATH


Suffolk (County)


PENSE


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.


55


[(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.


226 Woodside Avenue


......


St.


(Usual place of abode)


(If nonresident, give city or town and State)


Length of stay: In place of death .............. years ...


......


months.


14


.days. In place of residence ..


.years ..


......


months


14 days.


MEDICAL CERTIFICATE OF DEATH


3 DATE OF


DEATH


March


2.5


19.61


(Month)


(Day)


(Year)


4 I HEREBY CERTIFY,


That I attended deceased from


MAR. 20, 1961


to


MAR. 25, 1961


I last saw he Ralive on


death is said to


have occurred on the date stated above, at


4:45 Pm.


INTERVAL


BETWEEN


ONSET AND


DEATH


11 IF STILLBORN, enter that fact here.


Years


12


AGE.9.4


6


Months.


13 Days


If under 24 hours


Hours.


Minutes


13 Usual


retired mill worker


Occupation


(Kind of work done during most of working life)


14 Industry


or Business:


woolen mills


15 Social Security No. none


16 BIRTHPLACE (City)


(State or can -1


Canada


17 NAME OF


FATHER


Louis Paul May


18 BIRTHPLACE OF


FATHER (City)


(State or country)


Canada


19 MAIDEN NAME


Fragone


M. D.


OF MOTHER


Emelienne Derosier


Joseph Greenrie NE


(PRINT QR TYPE SIGNATURE)


(Addres 194 Washington AV


Mar . 27,61


St. Charles Cemetery Dover N. H. 6


Place of Burial or Cremation


(City or Town)


DATE OF BURIAL


March ..... 28.1961


19


7 NAME OF


FUNERAL DIRECTOR


ADDRESS


alfred B. March


Winthrop, Mass.


Received and filed MAR 2-8 1961 19


(Registrar)


PERSONAL AND STATISTICAL PARTICULARS


8 SEX


9 COLOR


10 SINGLE


(write the word)


MARRIED widowed


WIDOWED


or DIVORCED


female


white


10a If married, widowed, or divorced


HUSBAND of


(Give maiden name of wife in full)


(or) WIFE of


Narcisse.Paul


(Husband's name in full)


DEATH WAS CAUSED BY : IMMEDIATE CAUSE


(a)


Myocardial Heart disease


Vro


.


Due To


Arterio sclerosis ,


(b)


generalized


yrs


Due To


(c) .....


Senility


OTHER


SIGNIFICANT


CONDITIONS


Was autopsy performed?


What test confirmed diagnosis ?


5 Was disease or injury in any way related to occupation of deceased? If so, specify


PARENTS


20 BIRTHPLACE OF


MOTHER (City)


(State or country)


Canada


21


Mrs. Albert E.Olsen


226 Woodside Ave. Winthrop


Informant


(Address)


.....


I HEREBY CERTIFY that a satisfactory , standard certificate of death


was filed with me BEFORE the burial or transit permit was issued:


Ralph


serianni-


(Signature of Agent of Board of Health or other)


3/28/61


H.O


4


(Official Designation) (Date of Issue of Permit)


To be filed for burial permit with Board of Health or its Agent.


No. 226 Woodside Avenue


2 FULL NAME


Oralie Marie Paul ( Gagnon).


(If deceased is a married, widowed or divorced woman, give also maiden name.)


NO ..


MAR 20, 19 61


4


(Signed)


SPACE FOR ADDITIONAL INFORMATION


DATE OF ENTERING MILITARY SERVICE


DATE OF DISCHARGE


F TOW.


RANK, RATING


ORGANIZATION AND OUTFIT


SERVICE NUMBER.


RULES OF PRACTICE


The fulfillment of the purpose of these laws calls for the observance for the 8 1961 PM 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 bad 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.


.


I R-302


X


PLACE OF DEATH


Essox (County)


FINDE PETT


1


Danvers


(City or Town)


The Commonwealth of Massachusetts JOSEPH D. WARD SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS TCHY COPY OF CERTIFICATE OF DEATH Registered No. 56


(City or Town making this return)


NDanversState Hospital Hathorne. ... St.


(If death occurred in a hospital or institution, ¿ give its NAME instead of street and number)


Winters


) ( Was deceased a


U. S. War Veteran. No


(if so specify WAR,


(a) Residence. No ..


207 Winthrop Street, Winthrop, Mass. ( Usual place of abode)


(If nonresident, give city or town and State)


Length of stay: In place of death. 2. .years .... 9 months 0 days."In place of residence .......... years .......... months .......... days.


PERSONAL AND STATISTICAL PARTICULARS


3 DATE OF


DEATH


March 25, 1961


(Month)


(Day)


(Year)


4 I HEREBY


CERTIFY.


That I attended deceased from


June 25,


19 58 March 25. 19


61


death is said to


have occurred on the date stated above, at 4:40am.


INTERVAL BETWEEN ONSET AND DEATH


11 IF STILLBORN. enter that fact here.


Years.


Months = 60


5


Months.


8


Days


If under 24 hours


. Hours ........ Minutes


13 Usual


Occupation :


Painter


(Kind of work done during most of working life)


14 Industry or Business :


15 Social Security No.


025-03-3449


16 BIRTHPLACE (City)


(State or country)


Mass.


17 NAME OF


FATHER


Arthur E. Winter


18 BIRTHPLACE OF


Peabody


FATHER (City)


(State or country)


Mass.


(Signed)


Andrew Nichols III


M. D.


Andrew Nichols III


(Address )


Hathorne., ..... M.a.S.SDate .....


3/25/61


Holy Cross Cemetery, Malden, 6


Place of Burial or Cremation (City or Town) DATE OF BURIAL March 28, 61 19


21


Informant


( Address )


Mary E. Sheehan


Hathorne Mass.


7 NAME OF


FUNERAL DIRECTOR


Arthur J. O'Maley


ADDRESS Winthrop, Mass.


Received and filed APR 11 1961 19


( Registrar of City or Town where deceased resided)


8 SEX


Male


9 COLOR


White


10 SINGLE


MARRIED


WIDOWED


or DIVORCED


(write the word)


Separated


10a If married, widowh down


HUSBAND of


(Give maiden name of wife in full)


(or) WIFE of


(Husband's name in full)


DEATH WAS CAUSED BY : IMMEDIATE CAUSE


(a) Carcinomatosis ? Pancreatic Primary Site,


OTHER SIGNIFICANT CONDITIONS


Was autopsy performed ?


Yes


What test confirmed diagnosis ?


Autopsy


5 Was disease or injury in any way related to occupation of deceased ? If so, specify


PARENTS


19 MAIDEN NAME OF MOTHER Mary Miller


20 BIRTHPLACE OF


Unknown


MOTHER (City)


Mass


( State or country )


Ireland


A TRUE COPY Daniel Toomey


ATTEST :


( Registrar of City or Town where death occurred)


DATE FILED


April 4,


19.61


50M-9-59-926111


Due To (b) 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 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)


2 FULL NAME WINTER, Arthur H. (Also known as Henry (If deceased is a married, widowed or divorced woman, give also maiden name.)


MEDICAL CERTIFICATE OF DEATH


I last saw himlive on March ... 25. . , 19.61


to


Revere,


TOW


10


9


-


0


SPACE FOR ADDITIONAL INFORMATION


DATE OF ENTERING MILITARY SERVICE DATE OF DISCHARGE RANK, RATING ORGANIZATION AND OUTFIT SERVICE NUMBER


PLACE OF DEATH


SUFFOLK (County) Winthrop (City or Town)


PINSE PI


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.


5.2


2 FULL NAME


Frank_3. Fratas


(If deceased is a married, widowed or divorced woman, give also maiden name.)


(a) Residence. No.


27 Thornton Street


St.


(If nonresident, give city or town and State)


Length of stay: In place of death .............. years .......


.. months.


2


days. In place of residence


12.


.years


.... months.


.days.


MEDICAL CERTIFICATE OF DEATH


PERSONAL AND STATISTICAL PARTICULARS


8 SEX


Male


9 COLOR


White


10 SINGLE


MARRIED


WIDOWED


or DIVORCEDMarried


10a If married, widowed, or divorced


HUSBAND of


Molly


(CBL)


(Give maiden name of wife in full)


(or) WIFE of


(Husband's name in full)


11 IF STILLBORN, enter that fact here.


12


AGE7.5


Years.


4 .. Months


8 ... Days


If under 24 hours


Hours.


Minutes


13 Usual


Occupation :


Candy maker


(Kind of work done during most of working life)


14 Industry


or Business :


Candy


15 Social Security No.


16 BIRTHPLACE (City)


(State or country)


Portugal


17 NAME OF


FATHER


Joseph Fratas


18 BIRTHPLACE OF


FATHER (City)


(State or country)


Portugal


19 MAIDEN NAME


OF MOTHER


Gloria M. Sousa


20 BIRTHPLACE OF


MOTHER (City)


(State or country)


Portugal


21


Mr. Albert C.Knox friend


Informant


(Address)


27 Thornton St. Winthrop


I HEREBY CERTIFY that a satisfactory Standard certificate of death was filed with me BEFORE the burial or transit permit was issued: Ralph E.


(Signature for Agent of Board of Health or other)


0


3/27/6/


Received and filed


19


(Registrar)


1


Due To


(b)


....


1


Due To


(c)


OTHER


SIGNIFICANT


CONDITIONS


Was autopsy performed ?


What test confirmed diagnosis ?


5 Was disease or injury in any way related to occupation of deceased? If so, specify


1


(Signed) .......


M. I).


(PRINT OR TYPE SIGNATURE)


(Address)


Date " June 1961


6 Holy Cross Cemetery ,Malden


Place of Burial or Cremation


March 29th


19


(City or Town) 61


DATE OF BURIAL


7 NAME OF FUNERAL DIRECTOR Richard C. Kirby, Inc. ADDRES917Bennington St. E.Boston


27 1961


9-926662


5


1901


{ "(Month)


(Day)


(Year)


4 I HEREBY CERTIFY,


That I attended deceased from


to ... 194km.


I last saw h./.Lalive on


.. ,


19


., death is said to


have occurred on the date stated above, at )) m.


DEATH WAS CAUSED BY: IMMEDIATE CAUSE


(a)


1


INTERVAL


BETWEEN


ONSET AND


DEATH


R-301A 1


CTIONS R ERTIFICATE


ving F DEATH enter an one or each ) and (c)


not mean of dying, art failure, It means or compli- ch caused


if any, e rise to use (a), e under- se last.


ns contrib- th but nat e terminal ction given


Dipter 137, .requires print or ause or death on ates, and Acts of es Physi- t or type ignature.


PARENTS


Registered No.


[(If death occurred in a hospital or institution,


St. { give its NAME instead of street and number)


PHYSICIAN - IMPORTANT


((Was deceased a U. S. War Veteran,


[if so specify WAR)


No


(write the word)


3 DATE OF


DEATH


(Usual place of abode)


No. inthron Community Hospital


(Official Designation) (Date of Issue of Pormit)


SPACE FOR ADDITIONAL INFORMATION


DATE OF ENTERING MILITARY SERVICE


DATE OF DISCHARGE


8.62.3.1.60


RANK, RATING


ORGANIZATION AND OUTFIT


SERVICE NUMBER.


0


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 terins, as housekeeper-private family, cook -- hotel, etc. For a person who had no occupation whatever write none.


X


Suffolk


(County)


Winthrop


(City or Town)


No. 41.Washington Ave,


The Commonwealth of Massachusetts JOSEPH D. WARD SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS


STANDARD CERTIFICATE OF DEATH


Registered No.


Bay View Nursing Home (If death occurred in a hospital or institution, St. ( give its NAME instead of street and number)


Gertrude (Henderson) Nickerson


2 FULL NAME


(If deceased is a married, widowed or divorced woman, give also maiden name.)


52 Winthrop Street


St.


50


Length of stay: In place of death


.years.


8


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 DIVORCEWidow


4 I HEREBY CERTIFY


12/26


19


49.


to.


4.


12


That I attended deceased from


61


I last saw h .. ERalive on


1/31/61


.19.


., death is said to


have occurred on the date stated above, at


10 45 P.m.


DEATH WAS CAUSED BY : IMMEDIATE CAUSE


ACUTE CORONARY Occlusion


(a)


INTERVAL


BETWEEN


ONSET AND


DEATH


11 IF STILLBORN, enter that fact here.


15min


Years.


11


Months


16


Days


12


AGE 77


If under 24 hours


Hours.


.Minutes


13 Usual


Housewife


Occupation :


(Kind of work done during most of working life)


14 Industry


or Business :


023-07-3987


15 Social Security No.


Springhill


(State or country) Nova Scotia


17 NAME OF


FATHER


Unable to obtain


18 BIRTHPLACE OF


FATHER (City)


(State or country)


Unable to obtain ||


19 MAIDEN NAME


M. D.


OF MOTHER


Unable to obtain


20 BIRTHPLACE OF


MOTHER (City)


(State or country)


Unable to obtain


21 Mortimer Nickerson


Informant-


(Address) 34 Thornberry Rd. Winchester


7 NAME OF


FUNERAL DIRECTOR


Howard S Reynolds


ADDRESS


winthrop.


Mass


Received and filed


APR 4 1961


19


(Registrar)


PARENTS


(Signed)


MYRONON. KING/MD


(Addres 22 PLANT OR TYPE SIGNATURE)


EHSANT ST. WINTHER!


4/3


061


6 winthrop


Winthrop


Place of Burial or Cremation


DATE OF BURIAL


April


5


(City or Town)


61


gyes


Due To


NEPHROSCLEROSIS.


(c)


2YRS


OTHER


NONE


SIGNIFICANT


CONDITIONS


Was autopsy performed?


No


What test confirmed diagnosis ?


CLINICAL


5 Was disease or injury in any way related to occupation of deceased


If so, specify


pter 137. requires print or ause or eath on ifates, and Acts of Is Physi- nor type gnature.


1 -926662


PLACE OF DEATH


R-301A 1


TIONS


RTIFICATE


JURISDICTION.


Fing DEATH enter tin one r each and (c)


i not mean of dying. art failure, It means dor compli- gh caused


if any, rise to (a), under- last.


se



tas contrib- Ich but not : terminal ion given


MED. EXAM. CALLED + DECLINED


3 DATE OF


APRIL


2


1961


DEATH


(Year)


(Month)


(Day)


PHYSICIAN - IMPORTANT


((W'as deceased a


U. S. War Veteran,


[if so specify WAR)


58


(a) Residence. No.


(Usual place of abode)


7


(If nonresident, give city or town and State)


10a If married, widowed, or divorced


HUSBAND of


(Give maiden name of wife in full)


Mortimer Nickerson


(or) WIFE of


(Husband's name in full)


(b)


ARTERIOSCLEROSIS-GENERALIZED


VARTERIO SOLEROTIC HERVRI DIS


4 HYPERTENSIVE HEART DIS


Own Home


16 BIRTHPLACE (Citx)


I HEREBY CERTIFY that a satisfactory standard certificate of death was filed with me BEFORE the burial or transit permit was issued: Ralph E Lercanm (Signature of Agent of Board of Health or other) HOV 4/4/61


(Official Designation) (Date of Issue of Permit)


To be filed for burial permit with Board of Health or its Agent.


SPACE FOR ADDITIONAL INFORMATION


DATE OF ENTERING MILITARY SERVICE


RECEIVED


DATE OF DISCHARGE


TOW


11.12. 1


RANK, RATING


ORGANIZATION AND OUTFIT


SERVICE NUMBER


RULES OF PRACTICE APR- 41961 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 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.


Hans StanETsky Cap


:TIONS R RTIFICATE


ving DEATH enter an one r each and (c)


not mean of dying, rt failure, It means or compli- h caused


if any, rise to se


(a), under- se last.


Due To (c)


OTHER


CORONARY THROMBOSIS


CONDITIONS


SMO


Was autopsy performed?


NO


What test confirmed diagnosis ?


5 Was disease or injury in any way related to occupation of deceased ? If so, specify


(Signed)


a. n. Caplan


A. N. CAPLAN MD


(Address) 186 PRINCETON ST F BOSTONat 4- 3 - 196/


UNION FIELD


6


Place of Burial or Cremation


DATE OF BURIAL


APRIL


4


61


(City or Town)


7 NAME OF


FUNERAL DIRECTOR




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