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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