USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1961 > Part 41
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X
R-301A
1
Tirthron
(City or Town)
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.
206
Registered No.
[(If death occurred in a hospital or institution, St. Į give its NAME instead of street and number)
PHYSICIAN - IMPORTANT
2 FULL NAME A John ( First Name) (Middle Name)
Orrall
[ ( Was deceased a ¿ U. S. War Veteran,
(Last Name)
{if so specify WAR)
(If deceased is a married, widowed or divorced woman, give also maiden name.)
(a) Residence. No.
(Usual place of abode)
Length of stay: In place of death ..
.. years.
3
months.
8
.days.
In place of residence .. 5.Q .... years.
months ............ days.
MEDICAL CERTIFICATE OF DEATH
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
Male
9 COLOR
White
MARRIED
WIDOWED
or DIVORCED
Married
10a If married, widowed, or. divorsed
winifred Ives
HUSBAND of
(Give maiden name of wife in full)
(or) WIFE of
(Husband's name in full)
11 IF STILLBORN, enter that fact here.
AGE
Years
Days
If under 24 hours
Hours .............. Minutes
13 Usual
Occupation :
President
(Kind of work done during most of working life)
14 Industry
or Business:
Printing Co.
15 Social Security No.
023-10-9003
16 BIRTHPLACE (City)
Boston
(State or country) Lass.
17 NAME OF
FATHER
George Orrall
18 BIRTHPLACE OF
FATHER (City)
(State or country)
Unable to obtain
19 MAIDEN NAME OF MOTHER
Christine Sissler
20 BIRTHPLACE OF MOTHER (City) (State or country)
Unable to obtain
21 Informant
Winifred Orrall
(Address) 10 Floyd St. Winthrop
I HEREBY CERTIFY that a satisfactory standard certificate of death was filed with me BEFORE the burial, or transit permit was issued:
/ (Signature of Agent of Board of Health or other)
14/25 11
(Official Designation)
(Date of Issue of Permit)
V.B. 1
CTIONS OR ERTIFICATE
iving F DEATH : enter an one or each ) and (c)
s not mean of dying, art failure, c. It means or compli- ich caused
s, if any, ve rise to use (a), ie under- use last.
ons contrib- ath but not he terminal lition given
Chapter 137, 54. requires s to print or cause or f death on ificates, and 48, Acts of uires Physi- print or type er signature.
M. Traunstein, Jr , M. D
(Signed)
M. D In. Traunstein for.
(PRINT OR TYPE SIGNATURE)
(Address) 73 Bartlett Rd.
Date. Oct. 24, 19 61
Winthrop 52, Mass
6 Winthrop
Winthrop
Place of Burial or Cremation
(City or Town)
DATE OF BURIAL Oct. 27 1961
7 NAME OF
FUNERAL
DIRECTOR
Howard S Reynolds
Winthrop, Mass.
ADDRESS
Received and filed
OCT 25 1001
.. 19.
(Registrar)
(Year)
4 I HEREBY CERTIFY,
Oct. 9, 195719
to ..
That I attended deceased from
Oct. 24,
61
19
I last saw himl.alive on
October 24.
61
.. , death is said to
have occurred on the date stated above, at
4:00 a. m.
DEATH WAS CAUSED BY : IMMEDIATE CAUSE
Carcinoma of prostate
(a)
Due To (b)
Due To (c)
OTHER SIGNIFICANT CONDITIONS
Was autopsy performed?
no
What test confirmed diagnosis?
Clinical & laboratory
5 Was disease or injury in any way related to occupation of deceased? If so, specify
.. no ..
PARENTS
St
(If nonresident, give city or town and State)
10 SINGLE
(write the word)
3 DATE OF
DEATH
October
24,
1961
(Month)
(Day)
INTERVAL BETWEEN ONSET AND DEATH 12 yrs
28145
PLACE OF DEATH
Suffolk (County)
No. Winthrop Community Hos ital
10 Floyd Street
12
72
8
Months.
24
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE RANK, RATING
ORGANIZATION AND OUTFIT
SERVICE NUMBER
RECEIVED
OF
TOWA
(IM)
MIN
CLERK
6 5
VTHROR
OCT 251961 PM
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.
COPY OF CERTIFICATE OF DEATH
CERTIFICATE OF DEATH STATE OF NEW HAMPSHIRE
X
1. NAME OF
DECEASED
A. [FIRSTI
B. (MIDOLE)
J.
C. (LAST)
Sullivan
2. DATE
OF
DEATH
10/25/61
3. PLACE OF DEATH
A. COUNTY
Hillsborough
4. USUAL RESIDENCE (WNERE DECEASEO LIVEO. IF INSTITUTION: RESIDENCE
BEFORE ADMISSION.)
A. STATE
Mass.
Suffolk
B. CITY
OR
TOWN
Manchester
C. LENGTH OF
STAY (IN THIS PLACE)
C. CITY (GIVE ACTUAL TOWN OF RESIDENCE. NOT MAILING ADDRESS).
OR
TOWN
Winthrop
D. FULL NAME OF (IF NOT IN NOSPITAL OR INSTITUTION. GIVE STREET ADDRESS OR LOCATION)
HOSPITAL OR
INSTITUTION
D. STREET IIF RURAL, GIVE LOCATION)
ADDRESS
442 Belcher St.
E. IS RESIDENCE
ON FARM?
YES
NO
5. SEX
Male
6. COLOR OR RACE 7.
White
MARRIED
NEVER MARRIED
DIVORCED
WIDOWED
8. NAME OF HUSBAND OR WIFE (MAIDEN NAME IF WIFE)
Mildred F. Mccarthy
9. DATE OF BIRTH
9/7/02
10. AGE {IN TEARS
LAST BIRTHDAY)
59
IF UNOER ! YEAR MONTHS OAYS
IF UNDER 24 NRS NOURS MIN.
-
11A. USUAL OCCUPATION (KIND OF WORK
OOHE OURING MOST OF WORKING LIFE, EVEN IF RETIRED)
Salesman - Sav.
rod. Co.
INDUSTRY
12. BIRTHPLACE ICITY OR TOWN. STATE
OR FOREIGN COUNTRYI
East Boston, Mass.
13. CITIZEN OF WHAT
COUNTRY?
USA
14. FATHER'S NAME
John J. Sullivan
15. MOTHER'S MAIDEN NAME
Mary A. Green
16. WAS DECEASED EVER IN U.S. ARMED FORCES?|17. SOC. SEC. NO.
(YES. NO. OR UNKNOWN) | [IF YES, GIVE WAR OR DATES OF SERVICE)
No
18A. INFORMANT
John Sullivan
18B. ADDRESS
42 Belcher St.
Winthrop, Mass.
19. CAUSE OF DEATH (ENTER ONLT ONE CAUSE PER LINE FOR (A). (Bl. ANO (CI
PART I DEATH WAS CAUSED BY,
Coronary thrombosis
IMMEDIATE CAUSE (AI
to
and last saw
alive on
22. I attended the deceased from
Death occured at
6:15P.
im on the date stated above; and to the best of my knowledge, from the causes stated.
23A. SIGNATURE
L. D. Lavoie, Med. Ref.
23B. ADDRESS
Manchester, N. H.
23C. OATE SIGNED
10/25/61
24A. BURIALXXCREMATION
ENTOMBMENT
REMOVAL
248. DATE
10/30/61 Winthrop Cem.
24D. LOCATION (CITT. TOWN. OR COUNTY)
Winthrop, Mass.
IF ENTOMBED
24E. PLACE OF BURIAL
(NAME OF CEMETERY)
LOCATION (CITY. TOWN. COUNTT) ( STATE)
DATE
25. FUNERAL DIRECTOR'S SIGNATURE
A. Maley, Winthrop, Mass.
ADDRESS
COUNTERSIGNED - AGENT (CITY BO. OF HEALTH) DATE
James J. Powers, M.D. 10/27/61
DATE REC'D BY TOWN OR CITY CLERK
10/27/61
CLERK'S OWN SIGNATURE
M. J. Quinn
CLERK OF
Manchester, N. H.
0 19
A true copy, Attest:
Clerk of.
Manchester
Dated.
11/8/ ,61
V$ 17
C.O.22621-6-60-10M
AV.B.V
207
845
TOWN OR CITY
CLERK'S NO.
(MONTN)
(DAY)
{TEARI
(TYPE OR PRINT)
William
24 c. NAME OF CEMETERY OR
CREMATORY
(STATE)
(DEGREE OR TITLE)
INTERVAL BETWEEN
ONSET AND DEATH
Sudden
her
him
118. KIND OF BUSINESS OR
Sacred Heart Hospital
TO!
12.
1
1
6. 5
NOV -91981 MY
X PLACE OF DEATH
Suffolk County ) LesTore 17-4-11
Winthrop (City or Town)
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.
MOUNTS CONVALESCENT HOMESt. I give its NAMI No. FRANCES BONNEY
2 FULL NAME
(If deceased is a married, widowed or divorced woman, give also maiden name.)
189 Brooks St.
.St.
East.Poston
(If nonresident, give city or town and State)
days. In place of residence
.. years.
months ..
days.
MEDICAL CERTIFICATE OF DEATH
PERSONAL AND STATISTICAL PARTICULARS
3 DATE OF
DEATH
OCTOBER 28,
1961
(Year)
(Month)
(Day)
4 I HEREBY CERTIFY,
That I attended deceased from
FEB8
, 1956, to OCT 28,
19.61
I last saw hA Qalive on
OCT 28
1961, death is said to
have occurred on the date stated above, at
12 45 P.m.
INTERVAL
BETWEEN
ONSET ANO
DEATH
11 IF STILLBORN, enter that fact here.
12
76
24 bes
AGE
Years.
Months ..
Days
If under 24 hours
Hours.
Minutes
13 Usual
Occupation :
housework
14 Industry
or Business :
own home
15 Social Security No.
Gloucester
SIGNIFICANT
CONDITIONS
OTHER
PAGETS DISEASE
OFBONES
20 YRS
Was autopsy performed ?
What test confirmed diagnosis ?
5 Was disease or injury in any way related to occupation of deceased1/0. If so, specify
(Signed)
a.M. Caplan M. D. A. M. CAPLAN/ MO (PRINT OR TYPE SIGNATURE)
(Address) 186 PRINCETON ST 10-28 1961
FAST BOSTON MASS
Everett.
Place of Burial or Cremation
DATE OF BURIAL
Nov. 7(City or Town) 61
19
7 NAME OF
FUNERAL DIRECTOR
Frederick J. Magrath
ADDRESS
325 Chelsea St. E. Foston
Received and filed OCT 31 1961 19
(Registrar)
PARENTS
18 BIRTHPLACE OF
FATHER (City)
(State or country)
NovaScotia
19 MAIDEN NAME
OF MOTHER
Mary A. Forbes
20 BIRTHPLACE OF MOTHER (City) (State or country)
"Nova Scotia
Gladys Dowe
21
Informant
(Address)
189 Frooks St. E. Boston
I HEREBY CERTIFY that a satisfactory standard certificate of death was filed with me BEFORE the burial or transit permit was issued:
(Signature of/Agent of Board of Health of other)
10/31/6/
(Date of Issue of Permit)
.
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- ich caused
, if any, e rise to use (a), e under- use last.
ns contrib- th but not he terminal ition given
apter 137, . requires to print or cause or death on cates, and Acts of res Physi- nt or type signature.
0-925686
(Official Designation)
V
Registered No.
208
[(If death occurred in a hospital or institution,
PHYSICIAN - IMPORTANT
f(Was deceased a
U. S. War Veteran,
no
[if so specify WAR)
(a) Residence. No.
(Usual place of abode)
Length of stay: In place of death 4
years 10 months 21
8 SEX
female
9 COLOR
white
10 SINGLE
(write the word)
MARRIED
WIDOWERowed
or DIVORCED
10a If married, widowed, or divorced
HUSBAND of
(Give maiden name of wife in full)
(or) WIFE of
Calvin Zonney
(Husband's name in full)
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a)
CARDIAC FAILURE
MYOCARDITIS
Due
(b)
ARTERIOSCLEROSE
HEART DISEASE
10YRS
Due To
BRONCHOPNEUMONIA
(c)
24 HRS
16 BIRTHPLACE (City)
(State or country)
Mass
17 NAME OF
FATHER
Ruben Cahoon
6 Woodlawn
X
WT
(Kind of work done during most of working life)
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE.
DATE OF DISCHARGE RANK, RATING
ORGANIZATION AND OUTFIT
SERVICE NUMBER
1
OCT 33.1961 TR
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.
X
PLACE OF DEATH
(County) Winthrop (City or Town)
No.
117" Share
The Commonwealth of Massachusetts JOSEPH D. WARD SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS
STANDARD CERTIFICATE OF DEATH
Registered No.
209
Drive
[(If death occurred in a hospital or institution,
St. ¿ give its NAME instead of street and number)
PHYSICIAN - IMPORTANT
f(Was deceased a
U. S. War Veteran,
(if so specify WAR)
No
(If deceased is a married, widowed or divorced woman, give also maiden name.)
11705 here
(a) Residence. No.
(Usual place of abode)
Length of stay: In place of death.
23
years
.. months ...........
.days. In place of residence.
years.
.. months .....
......
... days.
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
DEATH
Cetober
28
1961
(Month)
(Day)
(Year)
4 I HEREBY CERTIFY,
That I attended deceased from
19
19 to.
I last saw h ........ alive on
19 ...
... , death is said to
have occurred on the date stated above, at 2.20 P.m.
INTERVAL BETWEEN ONSET AND DEATH
DEATH WAS CAUSED BY: IMMEDIATE CAUSE (a) Death brinsand
bly due to
probably natural causes Due To (b) acute coronary conclusion
que to hypertensive Coronary artery hearts
OTHER
SIGNIFICANT
Winthrop Board of CONDITIONS Charles Liberty 3.
Was autopsy performed ?
What test confirmed diagnosis?
5 Was disease or injury in any way related to occupation of deceased ? If so, specify
(Signed) CHARLES LIBERMAN MID.
(Address)
(PRINT OR TYPE SIGNATURE) Winthrop, Mass Date 10/28/1961
Tifereta Des of Winthrop ver It 6
(City or Town)
DATE OF BURIAL
7 NAME OF FUNERAL DIRECTOR ERF tuno. 1-Service are
ADDRESS Washun, the care Elulsin
Received and filed
19
(Registrar)
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
11
9 COLOR
10 SINGLE
MARRIED
WIDOWED Married
or DIVORCED
10a If married, widowed, or divorced Lena Weinstein HUSBAND of (Give maiden name of wife in full)
(or) WIFE of
(Husband's name in full)
11 IF STILLBORN, enter that fact here.
12
AGE 64 Years
Months ...
.......
.Days
If under 24 hours
Hours.
Minutes
13 Usual
Occupation :
Watch Maker
(Kind of work done during most of working life)
14 Industry
or Business :
Jewelry Stare
15 Social Security No. Net /Amo-lobyly
016-26-957
16 BIRTHPLACE (City)
(State or country)
Russia.
17 NAME OF
FATHER
Levy 'LASER
18 BIRTHPLACE OF
FATHER (City)
(State or country)
ThisSia
19 MAIDEN NAME
OF MOTHER
20 BIRTHPLACE OF
MOTHER (City)
(State or country)
7
-0155ml
21
Informant
(Address)
Damon Rd. Medford
I HEREBY CERTIFY tbat a satisfactory standard certificate of death was filed with me BEFORE the burial or translt permit was issued:
(Signature of Agent of Board of Health or other)
12+16/
(Official Designation)
(Date of Issue of Permit) /
1
Released by Click of
CTIONS OR ERTIFICATE iving F DEATH enter an one or each ) and (c)
s not mean of dying, art failure, c. It means or compli- ich caused
, if any, re rise to use (a), se under- use last.
ons contrib- ith but not he terminal ition given
.
hapter 137, 4. requires to print or cause death on icates. and 1, Acts of res Physi- nt or type signature.
30 1961
59-925686
EPIT
2 FULL NAME Leonard
G
Glaser
Drive
.St.
(If nonresident, give city or town and State)
23
To be filed for burial permit with Board of Health or its Agent.
R-301A H 1
PARENTS
DR. GEORGE GLASER (SON)
Place of Burial or Cremation
Oct, 29
1961
isease
Health
(write the word)
A
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE
TO.
RANK, RATING
ORGANIZATION AND OUTFIT
SERVICE NUMBER
٠٧.
6 2M
RULES OF PRACTICE OCT 301961 AM
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.
1.
L
X
PLACE OF DEATH
Suffock (Cour y)
CINSEPETIT
Winthrop (City or Town)
NOWinthrop Community Hospital
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.
S(If death occurred in a hospital or institution, St. ] give its NAME instead of street and number) (Sweeney,
PHYSICIAN - IMPORTANT
[ (Was deceased a ¿U. S. War Veteran,
(if so specify WAR)
.....
(If deceased is a married, widowed or divorced woman, give also maiden name.)
(a) Residence. No. ... 83 Woodside Av. Winthrop. Mass .. St.
(Usual place of abode )
Length of stay: In place of death ..
years .
27
.days.
In place of residence ..
1 7 years.
.. months.
days.
MEDICAL CERTIFICATE OF DEATH
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
f -male
9 COLOR
urcite
10 SINGLE
(write the word).
MARRIED
widowed
WIDOWED
or DIVORCED
4 I HEREBY CERTIFY,
That I attended deceased from
10-4-61
19 ... 6.1, to.
10-31
1961.
I last saw h ........ alive on 10-31-1961
19.
death is said to
have occurred on the date stated above, at
6 321 m.
INTERVAL
BETWEEN
ONSET AND
DEATH
11 IF STILLBORN, enter that fact here.
AGE ... £.1.Years .......
07
.. Months
Days
If under 24 hours
Hours.
.. Minutes
Due To
(b)
Hypertensive Heart disease
Due To
(c)
Cerebral Hemorrhage
OTHER
SIGNIFICANT
Left Hemiplegia
CONDITIONS
Was autopsy performed?
No
What test confirmed diagnosis?
5 Was disease or injury in any way related to occupation of deceased? If so, specify
NO
ar Caplan
M. D
(Signed) A "NICAPLAN MI) "PRINT OR TYPE SIGNATURE) (Address) 180 PRINCELONS Date 10-31 1961 FAST BOSTON MASS
6
Place of Burial or Cremation (City or Town)
DATE OF BURIAL
19
7 NAME OF
FUNERAL DIRECTOR
alfred B. Marche
ADDRESS
......
Received and filed
11-2-1001
(Registrar)
PARENTS
18 BIRTHPLACE OF
FATHER (City)
County cork
(State or country)
Treland
19 MAIDEN NAME
OF MOTHER
Tapparet Kelley
20 BIRTHPLACE OF
Boston
MOTHER (City)
(State or country)
Lessachusetts
21 Informant (Address)
I HEREBY CERTIFY that a satisfactory standard certificate of death was filed with me BEFORE the burial or transit permit was issued: Taxiet
(Signature of Agent of Board of Health or other)
11/5/6/
(Official Designation)
(Date of Issue of Permit)
T V. BV
CTIONS R ERTIFICATE
iving F DEATH : enter an one or each ) and (c)
not meon of dying, art foilure, c. It meons or compli- ich coused
, if ony, ve rise to use (o), te under- use last.
ons contrib- ith but not he terminol ition given
Chapter 137, 54. requires s to print or cause or death on ificates, and 18, Acts of lires Physi- rint or type er signature.
28145
10a If married, widowed, or divorced
HUSBAND of
(Give maiden name of wife in full)
(or) WIFE of
Charles Edwin Theall
(Husband's name in full)
13 Usual
Occupation :
houserice
(Kind of work done during most of working life)
3 Weeks4 Industry
own home
or Business :
3 . WeeksSocial Security No. .......
032-03-3939-D
16 BIRTHPLACE (City) (State or country) essobreatto
Boston
17 NAME OF
FATHER
Patrick Creency
0
Agnes
Theall
2 FULL NAME
Mary
(First Name)
( Middle Name)
(Last Name)
(If nonresident, give city or town and State)
3 DATE OF
DEATH
Oct.31 ...... 1961
(Month)
(Day)
(Year)
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a) Congestive ........ Heart Failure
R-301A 1
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE RANK, RATING
ORGANIZATION AND OUTFIT
SERVICE NUMBER.
5
NOV - 21961 AM
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.
PLACE OF DEATH
Suffolk (County)
Brighton ((Vy or Town) St. Elizabeth's Hospital No.
The Commonwealth of Massachusetts JOSEPH D. WARD SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS STANDARD
CERTIFICATE OF DEATH
211 To be filed for burial permit with Board of Health of it. Apeni 028.3.2
Registered No.
[(If death occurred in a hospital or institution. St. } give its NAME instead of street and numher)
PHYSICIAN - IMPORTANT
2 FULL NAME Baby Boy ( First Name) ( Middle Name) ( Last Name)
Williams
[ { Was deceased a
(If deceased is a married, widowed or divorced woman, give also maiden name.)
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