USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1961 > Part 35
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(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.
PLACE OF DEATH
Suffolk (County)
CONSEPETIT
Winthrop
(City or Town)
No.
Winthrop Community Hospital
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)
NO
(If deceased is a married, widowed of divorced woman, give also maiden name.)
953 Shirley St.,
St.
(If nonresident, give city or town and State)
Length of stay: In place of death.
.
.years.
months.
10days.
In place of residence
25;
.. years.
-
.... months.
........ days.
MEDICAL CERTIFICATE OF DEATH
PERSONAL AND STATISTICAL PARTICULARS
3 DATE OF
DEATH
September
21
1961
(Month)
(Day)
(Year)
4 I HEREBY CERTIFY,
That I attended deceased from
.Sept .... 11
19.61, to.Sept
21
1961
I last saw h.S.Lalive on
Sept .21
19.
61 death is said to
have occurred on the date stated above, at
11.15 Am.
INTERVAL
BETWEEN
ONSET AND
DEATH
II IF STILLBORN, enter that fact here.
12
AGE 78
Years ....
Months ....
Days
If under 24 hours
Hours
.Minutes
Due To
(b)
Arteriosclerosis
Due To (c)
5 years
14 Industry
or Business :
NEW ENGLAND TEL CO
15 Social Security No. ....
548-36-2664
EAST BOSTON
Was autopsy performed?
No
What test confirmed diagnosis?
5 Was disease or injury in any way related to occupation of deceased? N.Q. If so, specify
(Signed)
Dorothy Cheney appleton
M. D
DOROTHY CHENDY APPLETON
(PRINT OR TYPE SIGNATURE)
(Address) 197 Woodside AVE Date. SEPT 21 19 61
WINTHROP, MASS
6
WINTHROP
WINTHROP
Place of Burial or Cremation
(City or Town)
DATE OF BURIAL
SEPT
23
19.61
7 NAME OF
FUNERAL DIRECTOR
MAURICE W KIRBY
ADDRESS
WINTHROP
MASS,
Received and filed
SEP 22 1961
19
(Registrar )
PARENTS
19 MAIDEN NAME
OF MOTHER
HELEN (UNKNOWN)
20 BIRTHPLACE OF
MOTHER (City)
(State or country)
NATALIE M. SNYDER
21
Informant
(Address)
953 SHIRLEY ST WINTHROP.
I HEREBY CERTIFY that a satisfactory standard certificate of death was filed with me BEFORE -the burial or transit permit was issued: teranno
(Signature of Agent of Board of Health or other)
HO
sek/22/6/1
(Official Designation)
(Date of Issue of Permit)
UCTIONS FOR CERTIFICATE
giving OF DEATH ot enter than one for each b) and (c)
es not mean of dying, heart failure, etc. It means ,. or compli- which caused
ns, if any, ave rise to cause (a), the under- ause last.
tions contrib- eath but not the terminal dition given M.C.
Chapter 137, 954. requires ns to print or e cause or of death on tificates, and 48, Acts of quires Physi- print or type der signature.
6928145
R-301A I
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.
Registered No.
75
2 FULL NAME
Mary E.(GIRBIONS)
Snyder
(First Nante)
(Middle Name)
(Last Name)
8 SEX
FEMALE
9 COLOR
WHITE
MARRIED
WIDOWED
or DIVORCED
WIDOWED
10a If married, widowed, or divorced
HUSBAND of
JOHN A SNYDER
(Give maiden name of wife in full)
(or) WIFE of
(Husband's name in full)
DEATH WAS CAUSED BY : IMMEDIATE CAUSE
(a)
Acute Cerebral Thrombosis
10 days3 Usual
TEL OPERATOR
Occupation :
(Kind of work done during most of working life)
OTHER
SIGNIFICANT
CONDITIONS
16 BIRTHPLACE (City)
(State or country)
IKLASS
17 NAME OF
FATHER
DENNIS H GIBBONS
18 BIRTHPLACE OF
FATHER (City)
IRELAND
(State or country)
IRELAND
10 SINGLE
(write the word)
(a) Residence. No.
(L'sual place of abode)
19
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE.
DATE OF DISCHARGE RANK, RATING
ORGANIZATION AND OUTFIT
SERVICE NUMBER
RULES OF PRACTICE
11
21961 FM
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 person's 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.
I R-301 1
UCTIONS FOR CERTIFICATE
giving OF DEATH
t enter than one for each b) and (c)
es not mean of dying, heart failure, tc. It means , or compli- hich caused
ns, if any, ave rise to ause (a), the under- ause last.
ions contrib- eath but not the terminal dition given C.
Chapter 137, 1954 requires ns to print or e cause or of death on rtificates, and 48, Acts of quires Physi- print or type der signature.
: 930213
PLACE OF DEATH
SUFFOLK ....... (County) WINTHROP (City or Town) 169 MAIN ST
The Commonwealth of Massachusetts KEVIN H. WHITE 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.
[(If death occurred in a hospital or institution, St. ( give its NAME instead of street and number) PHYSICIAN - IMPORTANT
2 FULL NAME
JOHN J. MOYNIHAN (First Name) ( Middle Name) (Last Name)
(1f deceased is a married, widowed or divorced woman, give also maiden name.)
169 MAIN ST.
... St.
( If nonresident, give city or town and State)
35 years
.. years.
... months ..
.. days.
MEDICAL CERTIFICATE OF DEATH
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
MALE
9 COLOR
WHITE
10 CITIZEN
OF U.S.
YES
NO
11 SINGLE MARRIED WIDOWED DIVORCED UNKNOWN
lla If married, widowed or divorced NEVAPAS
HUSBAND of
(Give maiden name of wife in full)
(or) WIFE of
(Husband's name in full)
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
Coronary
(a)
Due To
(b)
Throw 60015
If under 24 hours .. Hours. ...... .Minutes
...
14 Usual
Occupation :
BAR TENDER
(Kind of work done during most of working life)
15 Industry
or Business :
LIQUOR
16 Social Security No.
023-12-4586
BOSTON
What test confirmed diagnosis?
5 Was disease or injury in any way related to occupation of deceased?D. If so, specify
(Signed)
Soucis Escludo
Louis E Schraffa
(Print or Type Name)
M. D.
(Addr 191 Bennong/ anty Dat SE PT 25 10 61
6 WINTHROP Place of Burial of Cremation
WINTHROP
(City or Town)
DATE OF BURIAL SEPT. 28 1941
7 NAME OF
FUNERAL DIRECTOR
MAURICE W KIRBY
ADDRESS
WINTHROP
Received and filed
SEP 27- 1961
19
(Registrar)
A TRUE COPY ATTEST:
PARENTS
18 NAME OF
FATHER
FRANCIS MOYNIHAN
19 BIRTHPLACE OF
FATHER (City)
BOSTON
(State or country)
MASS
20 MAIDEN NAME
OF MOTHER
CATHERINE DEADY
21 BIRTHPLACE OF
MOTHER (City)
(State or country)
N.B.
ADELE MOYNIHAN
22 Informant (Address) ROMAIN ST WINTHROP.
I HEREBY CERTIFY that a satisfactory standard certificate of death was filed with me BEFORE the burial or transit permit was issued : Carpi 8. ercanule, , (Signature of Agent of Board of Health or other) Mattie Clicca
9/27 /6/1
(Official Designation)
(Date of Issue of'Permit)
VRV
3 DATE OF
DEATH
Sept
2.5,
1961
(Month)
(Day)
(Year)
4 I HEREBY CERTIFY
ian 6, 1940
to ..
That I attended deceased from
19 .. 67
I last saw heat.alive on
Sept
6.1., 19.
.. , death is said to
have occurred on the date stated above, at 1 de
Due To
(c)
Hyper Tensiony Hyper-
OTHER
SIGNIFICANT
CONDITIONS
Ten live Heart Discat
101/0
17 BIRTHPLACE (City)
(State or country)
MASS
Was autopsy performed?
ma
Clans ExamTEKS
INTERVAL BETWEEN 12 DATE OF BIRTH ONSET AND DEATH Instant 13 AGE5 7 Years .Months. .. Days
[( Was deceased a U. S. War Veteran,
[if so specify WAR)
NO
(a) Residence. No. (Usual place of abode)
Length of stay: In place of death 33 years. .months days. In place of residence
No.
Registered No.
ST JOHN'S
-
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE.
DATE OF DISCHARGE.
RANK, RATING
ORGANIZATION AND OUTFIT
SERVICE NUMBER
=
1
1
RULES OF PRACTICE
The fulfillment of the purpose of these laws calls for the observance Afrt following rules of practice: SEP 2 71961 AM
(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 froin 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
RM R-302
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
1
PLACE OF DEATH
Middlesex
(County ) Cambridge
(City or Town)
The Commonwealth of Massachusetts JOSEPH D. WARD SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS COPY OF CERTIFICATE OF DEATH
Cambridge
(City or Town making this return)
Registered No. 13/12
( If death occurred in a hospital or Institution,
.St. ¿ give its NAME instead of street and number)
2 FULL NAME
Joseph Lanstein
( Was deceased a
U. S. War Veteran.
No
if so specify WAR
12.LewisAvenue
stWinthrop Mass
( If nonresident, give city or town and State)
Length of stay:
In place of death .......... years .......... months ..
1Gays. In place of residence.
10 ....... months ...
.days.
MEDICAL CERTIFICATE OF DEATH
PERSONAL AND STATISTICAL PARTICULARS
3 DATE OF
DEATH
(Month)
September 27, 1961
(Day)
( Year)
8 SEX
Male
9 COLOR
White
(write the word)
10 SINGLE
MARRIED
WIDOWED
or DIVORCEMarried
4 I HEREBY CERTIFY,
That I
attended
deceased from
Sopt ...... 16
19
61, to ..
Sept ..... 28
19
61
I last saw
LMlive on
Sept ....... 27
...... 61
death is said to
have occurred on the date stated above, at 9:15 .... pm
INTERVAL BETWEEN ONSET AND DEATH
4 days
75
If under 24 hours
Hours ........ Minutes
13 Usual
Occupation:
Cooper
(Kind of work done during most of working life)
14 Industry
or Business :
Retired
15 Social Security No. .
16 BIRTHPLACE (City)
(State or country)
Ruasia
17 NAME OF
FATHER
Samuel Lanstein
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
PARENTS
19 MAIDEN NAME
OF MOTHERGittel - Cannot be learned
(Signed)
Henry S. Robinson
M. D.
363 Washington St
91281, 67 ( Address Somerville ....... ).a.s & Date.
.Lebanon-Zwiller, West Roxbury 6
Place of Burial or Cremation (City or Town)
DATE OF BURIAL September 28
61
Ruby Gordon
21 Informant ( Address ) 42 Lewis Ave. , Winthrop, Mass.
Benjamin Birnbach
ADDRESS
Received and filed OCT. 6. 1961 19
Maas ATTEST :
A TRUE COPY 21 * Frederick N. Burke
DATE FILED
(Registrar of City or Town where death occurred )
Sept. 28, 1961
.19 ...
1
( Registrar of City or Town where deceased resided)
10a If married, widowed, or divorced
HUSBAND of
Leah ... Kramar
(Give maiden name of wife in full)
(or) WIFE of
(Husband's name in full)
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
( a) Bronchopneumonia
Due To
(b)
Left Cerebellar Infarction
(c) ... Severe Cardio-Vascular Disease
OTHER SIGNIFICANT CONDITIONS
18 BIRTHPLACE OF
FATHER (City)
( State or country )
Russia
20 BIRTHPLACE OF
MOTHER (City)
(State or country )
Russia
7 NAME OF FUNERAL DIRECTOR 10 Washington St. , Dorchester
19
50M-9-59-926111
No.
Guardian Hospital .Cambridge
(If deceased is a married, widowed or divorced woman, give also maiden name.)
(a) Residence. No. ( Usual place of abode)
Copies of returns of deaths which occurred in your city or town in case the deceased resided in another city or town THIS IS A PERMANENT RECORD
11 IF STILLBORN, enter that fact here.
12
AGE
Years.
Months .....
Days
SPACE FOR ADDITIONAL INFORMATION DATE OF ENTERING MILITARY SERVICE DATE OF DISCHARGE RANK, RATING ORGANIZATION AND OUTFIT SERVICE NUMBER
PLACE OF DEATH
Middlesex
(County) Cambridge
(City or Town)
The Commonwealth of Massachusetts JOSEPH D. WARD SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS COPY OF CERTIFICATE OF DEATH
Cambridge
(City or Town making this return)
Registered No. 13/12
§ (If death occurred in a hospital or Institution,
.. St. ¿ give its NAME instead of street and number)
2 FULL NAME.
Joseph Lanstein
) (Was deceased a
U. S. War Veteran.
No
(if so specify WAR,
(a) Residence.
No ...
( Usual place of abode)
42 Levis Avenue
st.Winthrop, Mass
Length of stay: In place of death ..
.... years ...
months.
1Gays. In place of residence ..
1Qrs
.. months .......... days.
PERSONAL AND STATISTICAL PARTICULARS
3 DATE OF
DEATH
September 27, 1961
(Month)
(Day)
(Year)
8 SEX
Male
9 .COLOR
White
10 SINGLE
MARRIED
(write the word)
WIDOWED
or DIVORCEHarried
4 I HEREBY CERTIFY,
That I attended deceased from
Sept ..... 16
61
19
to .:
Sept .... 28
19.63
I last saw Himblive on
Sept. 27. 61
.. , death is said to
(Give maiden name of wife in full)
(or) WIFE of.
(Husband's name in full)
11 IF STILLBORN, enter that fact here.
.75
12
AGE.
Years ...
.Months ......
.Days
If under 24 hours
........ Hours ........ Minutes
13 Usual
Occupation:
Cooper
(Kind of work done during most of working life)
14 Industry
or Business :
Retired
15 Social Security No.
16 BIRTHPLACE (City) (State or country) Russia
17 NAME OF
FATHER_
Samuel Lanstein
18 BIRTHPLACE OF
FATHER (City)
(State or country)
Russia
5 Was disease or injury in any way related to occupation of deceased ?
If so, specify
..... NO
(Signed) Henry 'S. Robinson M. D.
363 Washington St
9/20161 ( Address Somerville MassDate.
Kt. Lebanon-Zwiller. West Roxbury 6
Place of Burial or Cremation (City or Town)
DATE OF BURIAL
September 28
61
19
PARENTS
19 MAIDEN NAME
OF MOTHERGittel - Cannot be learned
20 BIRTHPLACE OF
MOTHER (City)
(State or country)
Russia
Ruby Gordon 42 Lewis Ave. , Winthrop, Mass
Benjamin Birnbach
7 NAME OF FUNERAL DIRECTOR 10 Washington St., Dorchester 21
ADDRESS
Received and filed OCT. 6.1961
Maga ATTEST : 19
DATE FILED
( Registrar of City or Town where death occurred )
Sept. 28, 1961
19
1
(Registrar of City or Town where deceased resided)
10a If married, widowed, or divorced
HUSBAND of
Leah ... Kramer
have occurred on the date stated above, at
9:15 pm
INTERVAL BETWEEN ONSET AND DEATH
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a) Bronchopneumonia
4 days
Due To
Left Cerebellar Infarction
(b)
Due To (c) .Severe ... Cardio .. Vascular Disease
OTHER SIGNIFICANT CONDITIONS
Was autopsy performed ?
No
What test confirmed diagnosis ?...
Clinical
21
Informant
( Address )
A TRUE COPY Trederich D. Burke
No ..
Guardian Hospital Cambridge
(If deceased is a married, widowed or divorced woman, give also maiden name.)
( If nonresident, give city or town and State)
MEDICAL CERTIFICATE OF DEATH
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
Registered No.
1 28
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)
No
2 FULL NAME
Richard L Enman
(If deceased is a married, widowed or divorced woman, give also maiden name.)
39 Grovers Ave.
St.
(If nonresident, give city or town and State)
Length of stay : In place of death .............. years ..
3
.. months.
........... days. In place of residence .............. years.
3
months.
.days.
MEDICAL CERTIFICATE OF DEATH
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
9 COLOR
White
MARRIED
WIDOWED
or DIVORCED
Wid
4
I
HEREBY CERTIFY
DEC 24
1954,
to
SEPT 28
I last saw h/Malive on
9/20
19 61
death is said to
DEATH WAS CAUSED BY : IMMEDIATE CAUSE
(a)
CEREBRAL ARTERIOSCLEROSIS
WITH HEMIPARESIS - RIGHT 2WKS
AND PERIPHERAL ARTERIOSCLEROSIS Due To WITH GANGRENE LEFT GREAT TOE (b)
Due To GENERAL ARTERIOSCLEROSIS AND (c)
2YRS
ARTERIOSLEROTIC HEART DISEASE
OTHER
SIGNIFICANT PROSTATIC HYPERTROPHY WITH
CONDITIONS
OBSTRUCTION
1 YR.
Was autopsy performed ?
No
What test confirmed diagnosis ?
CLINICAL
5 Was disease or injury in any way related to occupation of deceased? No. If so, specify
(Signed)
myron h. Rug
M. D.
MYRON IN. KING M.DO
(PRINT OR TYPE SIGNATURE)
(Address) 222 PLEASANT ST WIRTHSL
9/29 /06/
6 Forest Hills
Boston Mass
Place of Burial or Cremation
Oct 2
DATE OF BURIAL
7 NAME OF FUNERAL DIRECTOR Ernest P Caggiano ADDRESS147 Winthrop St Winthrop
19
(Registrar)
PARENTS
17 NAME OF
FATHER
Philip Enman
18 BIRTHPLACE OF
FATHER (City)
(State or country)
Canada
19 MAIDEN NAME
OF MOTHER
Amanda
?
20 BIRTHPLACE OF
MOTHER (City)
(State or country)
Canada
21
Informant
(Address)
Old Age Agent
Town Hall Winthrop
I HEREBY CERTIFY that a satisfactory standard certificate of death was filed with me BEFORE the burial or transit permit was issued: H.O.V Ralph E. Miraun (Signature of Agent of Board of Health or other) aff Josef. 29/6/
(Date of Issue of Permiss
SIVA
TRUCTIONS FOR L CERTIFICATE
n giving OF DEATH not enter e than one se for each , (b) and (c)
does not meon de of dying, heort failure, , etc. It means ase, or compli- which coused n.c.
ions, if ony, gave rise to cause (a), the under- couse lost.
ditions contrib- death but not o the terminol ondition given
Chapter 137, 1954. requires ns to print or e cause or of death on rtificates, and 48, Acts of quires Physi- print or type der signature.
₱ 29 1961 11-59-926662
Sept
(Month)
(Day)
28 1961 (Year)
Male
HUSBAND of
Edna Kite
(Give maiden name of wife in full)
(or) WIFE of
(Husband's name in full)
11 IF STILLBORN, enter that fact here.
12
AGE
8 L'ears
9
Months ..
Days
If under 24 hours
Hours.
.Minutes
13 Usual
Occupation :
Retired Saleman
(Kind of work done during most of working life)
14 Industry
or Business :
Sporting Goods.
15 Social Security No.
031-09-1362 B
16 BIRTHPLACE (City)
(State or country)
Canada
Quebec
(Official Designation)
To be filed for burial permit with Board of Health or its Agent.
No.
Mayflower Nuras14 Home
.........
(a) Residence.
No.
(Usual place of abode)
That I attended deceased from
196/
have occurred on the date stated above, at
520A
m.
INTERVAL
BETWEEN
ONSET AND
DEATH
10 SINGLE
(write the word)
3 DATE OF
DEATH
g address az!
M R-301A A 1
Received and filed
(City or Town)
61
19
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE RANK, RATING
1
ORGANIZATION AND OUTFIT
SERVICE NUMBER
RULES OF PRACTICE
The fulfillment of the purpose of these laws calls for the observande fopthe 91961 /11 following rules of practice : (I) 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.
CHELSEA
18-4-61
The Commonwealth of Massachusetts JOSEPH D WARD SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS STANDARD
CERTIFICATE OF DEATH
Registered No.
120
death occurred in a hospital or institution, WINTHROP CONVALESCENT HOME
SWANSBURG WILLIAM, A 2 FULL NAME
(If deceased is a married, widowed or divorced woman, give also maiden name.)
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