Town of Winthrop : Record of Deaths 1961, Part 48

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


USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1961 > Part 48


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PLACE OF DEATH


Suffolk (County)


"inthrop


(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.


214


Mayflower Nursing Home No.


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


PHYSICIAN - IMPORTANT


(Middle Name)


(Last Name)


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


24 Cary Ave.


St


Revere


(a) Residence. No.


( Usual place of abode)


Length of stay: In place of death.


.years ..


2


.. months.


.days. In place of residence


.years ..


.. months.


... days.


MEDICAL CERTIFICATE OF DEATH


PERSONAL AND STATISTICAL PARTICULARS


3 DATE OF


December 10, 1961


DEATH


(Month)


(Day)


(Year)


4 I HEREBY


CERTIFY,


MARIO


1955


to .........


12-10


I last saw h& valive on


DEC 7


19 41, death is said to


have occurred on the date stated above, at


10.15 A.m.


INTERVAL


BETWEEN


ONSET AND


DEATH


3YRS


68


3


Months


25


Days


If under 24 hours


Hours ....


.......


Minutes


13 Usual


Occupation :


At Home


(Kind of work done during most of working life)


14 Industry


or Business :


None


15 Social Security No ..


326 - 28 -6756


Chicago


16 BIRTHPLACE (City) (State or country) Illinois


17 NAME OF


FATHER


James Hughes


18 BIRTHPLACE OF


Albany


FATHER (City) (State or country) New York


19 MAIDEN NAME OF MOTHER


Wary Courtney


20 BIRTHPLACE OF


Holyoke


MOTHER (City) (State or country)


Mass.


21 Raymond G. Dahl


Informant (Address) 24 Cary Ave Revere Mass


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


ADDRESS


305 Beach St. Revere 51, Mass. Parkh E. 1191avis


(Signature of Agent of Board of Health or otber)


12/11/61


(Official Designation)


(Date of Issue of Permit)


X


RUCTIONS FOR CERTIFICATE


giving OF DEATH


10t enter than one è for each (b) and (c)


oes not mean e of dying, heart failure, etc. It means se, or compli- which caused


ons, if any, gave rise to cause (a), the under- cause last.


itions contrib- death but not the terminal ndition given


- Chapter 137, 1954, requires ans to print or he cause or of death on ertificates, and 48, Acts of ¿quires Physi- print or type der signature.


-928145


( Registrar)


8 SEX


Female


9 COLOR


White


10 SINGLE


(write the word)


MARRIEDWidowed


WIDOWED!


or DIVORCED


10a If married, widowed, or divorced


HUSBAND of


Arthur C. Dahl


(Give maiden name of wife in full)


(or) WIFE of


(Husband's name in full)


DEATH WAS CAUSED BY : IMMEDIATE CAUSE


(a)


CARCINOMA OF BREAST


Due To


(b)


CARCINOMAOFLUNGS


Due To (c)


OTHER SIGNIFICANT CONDITIONS


Was autopsy performed?


mi


What test confirmed diagnosis?


clinnalo SURGICAL


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


NO


(Signed)


William J. Junior


M. D.


William.P ...... Finnegan


(PRINT, OR TYPE SIGNATURE)


(Address)


647 Broadway Chelsea 12/14061


St Josephs Cem. River Grove Illinois


6


(City or Town)


Place of Burial or Cremation


December 13, 1961


DATE OF BURIAL


19


7 NAME OF


FUNERAL DIRECTOR


Leslie W. Pike


Received and filed


DEC 11 1961


. 19.


39 Grovers Ave. Julia Dahl (First Name)


(Hughes )


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


lif so specify WAR)


(If nonresident, give city or town and State)


5


Registered No.


2 FULL NAME


MELERE. 27-8-1.


M R-301A 1


O PARENTS


11 IF STILLBORN, enter that fact here.


12


AGE


Years


8 11OS


That I attended deceased from


1941


SPACE FOR ADDITIONAL INFORMATION


DATE OF ENTERING MILITARY SERVICE


DATE OF DISCHARGE.


TO


RANK, RATING


ORGANIZATION AND OUTFIT


SERVICE NUMBER


5


6 5


RULES OF PRACTICE DEC 111961 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.


PLACE OF DEATH


Suffolk (County)


Winthrop (City or Town)


No.


69 Bay View Ave


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


STANDARD CERTIFICATE OF DEATH


Registered No.


215


(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)


69 Bay View Ave. (Usual place of abode)


St.


(If nonresident, give city or town and State)


.years


.. months.


days. In place of residence.


.years ........


... months ...


.. days.


MEDICAL CERTIFICATE OF DEATH


PERSONAL AND STATISTICAL PARTICULARS


3 DATE OF


DEATH


December 12 1961


(Month) (Day)


(Year)


8 SEX


Female


9 COLOR


White


10 SINGLE


MARRIED


WIDOWED


or DIVORCELidoW


10a If married, widowed, or divorced


HUSBAND of


. (Give maiden name of wife in full)


(or) WIFE of


Daniel T Felch


(Husband's name in full)


11 IF STILLBORN, enter that fact here.


AGE


Years


Days


If under 24 hours


Hours.


.Minutes


13 Usual


Occupation :


Housewife


(Kind of work done during most of working life)


14 Industry


or Business :


Own Home


15 Social Security No.


023-07-0159


16 BIRTHPLACE (City)


(State or country)


Lass.


17 NAME OF


FATHERWillard Shattuck


18 BIRTHPLACE OF


Westwood


FATHER (City) (State or country) Mass


19 MAIDEN NAME


OF MOTHER


Harriet Renele


20 BIRTHPLACE OF MOTHER (City) (State or country) lass


Lillian DeMoucell


21 Informant (Address) Bellerica L'ass


I HEREBY CERTIFY that a satisfactory standard certificate of. death was filed with me BEFORE the burial or fransit permit was issued: Taifas telaune (Signature of Agent of Board of Health or other) 12/15/61


170


(Official Designation)


(Date of Issue of Permit)


STRUCTIONS FOR AL CERTIFICATE


In giving E OF DEATH


p not enter re than one se for each ). (b) and (c)


does not mean code of dying, s heart failure, a, etc. It means tease, or compli- which caused


itions, if any, gave rise to cause (a). the under- cause last.


nditions contrib- o death but not to the terminal condition given M.C.


Chapter 137, 1954. requires ans to print or he cause or of death on ertificates, and 48, Acts of quires Physi- print or type nder signature.


-11-59-926662


(Registrar)


sudden


5 yrs.


OTHER


SIGNIFICANT


CONDITIONS


Diabetes Mellitus


2 yrs


Was autopsy performed? no


What test confirmed diagnosis? post-mortem judgement


5 Was disease or injury in any way related to occupation of deceased ? No. If so, specify


Arthur C. Munay. D. Arthur C. Murray (BRINT OR TYPE SIGNATHY Winthrop Board of Hearte 14 Dec 1 61


6 Winthrop


winthrop


(City or Town)


Place of Burial or Cremation


DATE OF BURIAL


Dec.


16


19. 61


7 NAME OF


FUNERAL DIRECTOR


Howard S Reynolds


ADDRESS


Winthrop, Lass


Received and filed


19.


INTERVAL BETWEEN OKSET AND DEATH


DEATH WAS CAUSED BY : IMMEDIATE CAUSE


(a)


Natural


Causes


Presumably Due To (b)


Coronary Occlusion


· Arteriosclerotic Heart Disease


(c)


10 Nov


59


to.


27 Nov


61


I last saw her.alive on


27 Nov, 1961


death is said to


have occurred on the date stated above, at


7:50 pm.


45


Length of stay: In place of death


45


Lillian I (Shattuck) Felch


2 FULL NAME


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


(a) Residence. No.


4 I HEREBY CERTIFY,


That I attended deceased from


(write the word)


12


83


0


Months


1


Boston


Needham


PARENTS


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


IM R-301A 1


X


SPACE FOR ADDITIONAL INFORMATION


DATE OF ENTERING MILITARY SERVICE


DATE OF DISCHARGE RANK, RATING ORGANIZATION AND OUTFIT


SERVICE NUMBER


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.


FORM R-302


WRITE PLAINLY, WITH UNFADING BLACK INK OR USE APPROVED BLACK TYPEWRITER RIBBON - THIS IS A PERMANENT RECORD


Copies of returns of deaths which occurred in your city or town in case the deceased resided in another city or town 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


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)


1792 216


Sancta Maria Hospital No


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


Percy J. Vance


2 FULL NAME


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


89 lorman Street,


"inthrop, Dass.


St


(a) Residence. No. ( Usual place of abode)


(If nonresident, give city or town and State)


Length of stay:


In place of death .......... years .......... months


4 .days. In place of residence ... .. years .......... months .......... days.


PERSONAL AND STATISTICAL PARTICULARS


3 DATE OF


December 12, 1961


DEATH


(Month)


(Day)


(Year)


8 SEX


Male


9 COLOR


hite


MARRIED


WIDOWED


or DIVORCED


Married


I HEREBY CERTIFY,


That I attended deceased from


61


61


Dec.


12


Jay ....


19.


Det. IT


I last saw h ...... alive on 19 ........ , death is said to


5:30a.


have occurred on the date stated above, at


.. m.


(or) WIFE of.


( Husband's name in full)


DEATH WAS CAUSED BY: IMMEDIATE CAUSE


Acuto general peritonitis


(a)


INTERVAL


BETWEEN


ONSET AND


DEATH


118hrs


11 IF STILLBORN, enter that fact here.


12


64


AGE.


. Years.


Months .....


.Days


If under 24 hours


Hours ........ Minutes


13 Usual


Occupation:


( Kind of work done during most of working life)


automobile


14 Industry


or Business :


030-09-0120


15 Social Security No.


mulden


16 BIRTHPLACE (City)


(State or country)


Mass.


17 NAME OF FATHERILliam Vance


18 BIRTHPLACE OF


FATHER (City)


( State or country)


Ireland


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


Michael E. McGarty


( Signed)


M. D. 520 Comm. Ave. Boston 12/12/6


( Address )


Winthrop Cemetery inthrop


6 Place of Burial or Crematinyec. 15, DATE OF BURIAL 19.


(City or Town) 61


21


Informant


(Address )


30 Hayman Sty Anthrop


7 NAME OF FUNERAL DIRECTOR


Maurice .. Kirby


ADDRESS


winthrop,


Received and filed 19


( Registrar of City or Town where deceased resided )


A TRUE COPY


ATTEST :


( Registrar of City or Town where death occurred)


DATE FILED


Dec. 15,


19:


61


1V


50M-9-59-926111


(b)


Due TSepticemia


(c)


48hrs


OTHER SIGNIFICANT CONDITIONS


Was autopsy performed? ....


Autopsy


What test confirmed diagnosis ?


PARENTS


19 MAIDEN NAME


Annie Mullon


OF MOTHER


20 BIRTHPLACE OF


Cholsoa


MOTHER (City)


(State or country)


Mrs. Anna B. Stober Vance


Salesman


Due Truptured diverticula


4days


.


19


10a If married, widowed, orAiresced B. Stober


HUSBAND of


(Give maiden name of wife in full)


Dec.


( Was deceased a


U. S. War Veteran.


No


if so specify WAR,


37


10 SINGLE


( write the word)


MEDICAL CERTIFICATE OF DEATH


1


Registered No.


RECEIVED


TOWA


11 12. 1


10.


...


0


ir)


ERK


TH


JAN -91962 AM


SPACE FOR ADDITIONAL INFORMATION


DATE OF ENTERING MILITARY SERVICE


DATE OF DISCHARGE RANK, RATING


ORGANIZATION AND OUTFIT


SERVICE NUMBER


RM R-303


X 1


PLACE OF DEAT


SUFFOLK


(County) WINTHROP


(City or Town)


The Commonwealth of Massachusetts KEVIN H. WHITE SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS MEDICAL EXAMINER'S CERTIFICATE OF DEATH


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


217


56 Crystal Cove Avenue, Winthrop No.


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


2 FULL NAME STEPHEN KILBURY (First Name) ( Middle Name) (Last Name)


PHYSICIAN - IMPORTANT


[ ( Was deceased a


U. S. War Veteran,


(if so specify WAR)


(a) Residence. No. 56 Crystal Cove Avenue, Winthrop


(L'sual place of abode)


Length of stay :


In place of death.


years .....


.. months.


days. In place of residence.


years ............ months.


days.


MEDICAL CERTIFICATE OF DEATH


3 DATE OF DEATH December 13. 1961


(Month)


(Day)


(Year)


4 I HEREBY CERTIFY that I have investigated the death of the person above-named and that the CAUSE AND MANNER thereof are as follows : (If an injury was involved, state fully.)


Broncho pneumonia


5 Accident, suicide, or homicide (specify) Date and hour of injury 19


IF ACCIDENTAL, was injury causally related to the death ? Where did Injury occur ?


(City or town and State) Did injury occur in or about home, on farm, in industrial place, or \in public place ?


Manner of


(How did injury occur ?)


While at work ?


Was autopsy performed


6 Was disease or injury in any way related to occupation dece ased ?


If so, specify


(Signed) George W. Cortis, 4.


M. D.


(Print or Type ) Calle)


(Address) Boston


12/13 1961


Winthrop Cemetery Winthrop 7


Place of Burial, or Cremation.


(City or Town)


19 DATE OF BURIAL Dec. 14, 61


8 NAME OF


FUNERAL DIRECTOR


Ernest P. Caggiano


ADDRESS 147 Winthrop St. Winthrop


Received and filed


DEC 14 1961


19


PERSONAL AND STATISTICAL PARTICULARS


9 SEX


Mele


10 COLOR


White


11 CITIZEN


OF U.S.


YES


NO


12 SINGLE MARRIED WIDOWED DIVORCED UNKNOWN


12a If married, widowed, or divorced HUSBAND of


(Give maiden name of wife in full) (or) WIFE of


(Husband's name in full)


13 DATE OF BIRTH


12, 1961


14 AGE Years ...


2


Months .......... .. Days


If under 24 hours Hours .Minutes


15 Usual Occupatio :


(Kind { work done during most of working life)


16 Industry Business


No.


18 BIRTHPLACE (City)


(State or country)


Chelsea


Mass.


19 NAME OF


FATHER


Bud Kilbury


20 BIRTHPLACE OF FATHER (City) (State or country) N. Dakota


21 MAIDEN NAME OF MOTHER Margie Mi Robbins


22 BIRTHPLACE OF MOTHER (City) (State or country) Washington


Bud Kilbury


23


Informant


(Address)


56 Crystal Carte Ave, 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) 1.


12/14.11


1


A TRUE COPY ATTEST: (Registrar)


(Official Designation)


(Date of Issue of Permit)


Injury §§ 44-48. If deceased was a U. S. War Veteran, G.L. Chap. 46, Section 10, requires physicians to insert a recital to that effect. of Death. See reverse side for additional Information. See also Chap. 38, §§ 6, 20; Chap. 46, §§ 9, 10; Chap. 114, DEATH in plain terms, so that it may be properly classified under the International Classification of Causes information should be carefully supplied. MEDICAL EXAMINERS should state CAUSE AND MANNER OF 50M - 3-61-930213 N. B .- WRITE PLAINLY, WITH UNFADING BLACK INK-THIS IS A PERMANENT RECORD. Every item of Nature of Injury


Registered No.


f(If death occurred in a hospital or institution,


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


St


(If nonresident, give city or town and State)


Tacoma


Date


PARENTS


(Specify type of place)


SPACE FOR ADDITIONAL INFORMATION


DATE OF ENTERING MILITARY SERVICE


DATE OF DISCHARGE


RANK, RATING


10


ORGANIZATION AND OUTFIT


SERVICE NUMBER


6


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 DEot theyHave given bedside care during a last illness from disease unrelated 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 poison) , thermal, or electrical agents, and deaths following abortion, but also deaths from disease resulting from injury or infection related to occupation, the sudden deaths of persons not disabled by recognized disease, and those of persons found dead.


STATEMENT OF CAUSE OF DEATH


Medical Examiners in certifying to a death will state the cause and manner thereof, and will specify: (1) Under cause the nature of an injury and of its consequences; and (2) under manner the mode of its production together with the circumstances when these are known. For example: "Compound fracture of the femur with ensuing septicemia (gas bacillus) caused by a collision of railroad train and automobile." "Pistol shot wound of the chest with associated hemorrhage, homicidal." "Asphyxiation by suspension, suicidal." "Syncope while under the influence of ether administered as a surgical anaesthetic for (enter name of operation and disease or condition requiring surgery)." "Fracture of the skull with associated internal injury sustained under circumstances unknown."


If disease or injury was related to occupation, specify. If investigation shows the death to have been due to disease, specify: (1) Under cause its known or presumable nature; and (2) under manner, indicate the circumstances leading to medico-legal inquiry. For example: "Hemorrhage spontaneous of the brain (basal ganglia) (found dead in bed)." "Heart disease, presumably coronary sclerosis. (Sudden death.)"


PLACE OF DEATH


Suffolk


PENSI


(County)


Winthrop


(City or Town)


No.


911 Shirley St.


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. 218


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


PHYSICIAN - IMPORTANT


2 FULL NAME Christina C (MacDonald) Mackenzie


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


(a) Residence. No.


911 Shirley St.


St.


(If nonresident, give city or town and State) 9


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


3 DATE OF


DEATH


(Month)


(Day)


(Year)


4 I HEREBY CERTIFY


Vin 12-1959


to ...


22,13


That I attended deceased from


19.


61


I last saw h .. Jalive on


19 61, death is said to


have occurred on the date stated above, at


.... hf.


(or) WIFE of


Lewis Mackenzie


(Husband's name in full)


11 IF STILLBORN, enter that fact here.


90


11


27


If under 24 hours


Hours.


Minutes


13 Usual


Occupation :


Housewife


(Kind of work done during most of working life)


14 Industry


or Business: At home


15 Social Security No.


None


16 BIRTHPLACE (City)


(State or country)


Nova Scotia


17 NAME OF


FATHER


Hugh MacDonald


18 BIRTHPLACE OF FATHER (City) (State or country) Nova Scotia


19 MAIDEN NAME


OF MOTHER


Catherine Stewart


20 BIRTHPLACE OF


MOTHER (City)


(State or country)


Nova Scotia


Ethel Koch


21 Informant (Address) 911 Shirley St. Winthrop, Lass.


I HEREBY CERTIFY that a satisfactory standard certificate of death was filed with me BEFORE the burial or transit permit was issued: Ralph S: Aireanni (Signature of Agent of Board of Health or other) Hola19 15/1/6/


(Official Designation)


(Date of Issue of/Permit)


TX


1


NSTRUCTIONS FOR CAL CERTIFICATE


In giving SE OF DEATH lo not enter pre than one use for each a), (b) and (c)


does not mean node af dying, as heart failure, ia, etc. It means sease, ar campli- which caused


litions, if any, h gave rise to e cause (a), ng the under- cause last.


onditions contrib- ta death but not ta the terminal conditian given M.C.


- Chapter 137, 1954. requires ians to print or the cause or of death on ertificates, and r 48, Acts of equires Physi- o print or type nder signature.


-11-59-926662


(Registrar)


PAR


(Address) 194 nowhixtonAtt Date


2/13 19.61


6


Winthrop


Winthrop


Place of Burial or Cremation DATE OF BURIAL


Dec. 16


(City or Town) 19 61


7 NAME OF


FUNERAL DIRECTOR Howard S Reynolds


ADDRESS


inthrop, Mass


19


8 SEX


Female


9 COLOR


White


10 SINGLE


MARRIED)


WIDOWED


or DIVORCED


(write the word)


wido:


DEATH WAS CAUSED BY : IMMEDIATE CAUSE (a) pierwsclarotic


INTERVAL BETWEEN ONSET AND DEATH


V


Due To Aver as clegises (b) Cerea Vule 20 cl


Due To (c)


OTHER


Carcinoince & final


CONDITIONS


Was autopsy performed ? What test confirmed diagnosis ?


5 Was disease or injury in any way relate If so, specify ....


JOSEPH GREGORIE, M. D. 194 Washington Avenue Winthrop 52, Mass.


(Signed) Google Presque


M. D.


(PRINT OR TYPE SIGNATURE)


un


10a If married, widowed, or divorced


HUSBAND of


(Give maiden name of wife in full)


12


AGE.


Years.


Months.


Days


f(Was deceased a U. S. War Veteran, (if so specify WAR)


(Usual place of abode)


9


Received and filed


DEC 15 1961


RM R-301A 1


SPACE FOR ADDITIONAL INFORMATION


DATE OF ENTERING MILITARY SERVICE


DATE OF DISCHARGE RANK, RATING ORGANIZATION AND OUTFIT


SERVICE NUMBER


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.




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