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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