Town of Winthrop : Record of Deaths 1961, Part 35

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


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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