USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1962 > Part 21
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PERSONAL AND STATISTICAL PARTICULARS
3 DATE OF
DEATH
May
21
1962
(Month)
(Day)
(Year)
4THEREBY
CERTIFY
That Weattended deceased from
May 8
162
to
May 21
19.62
I last saw he Blive on May
2.1 ........ , 162., death is said to
have occurred on the date stated above, at
1:00pm".
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
Pulmonary Emboli
INTERVAL
BETWEEN
ONSET ANO
DEATH
Mins
1 wk
Due To
(c)
Cercbollar .... Homorrhage
2 wks
OTHER
SIGNIFICANT
CONDITIONS
Was autopsy performed ?
yes
What test confirmed diagnosis?
autopsy
5 Was disease or injury in any way related to occupation of deceased?
If so, specify
ChoClay
(Signature)
Chorles L. Cloy, M. D. (Print or Type Name)
(Address)Ass't. Dir., Mass. Gen'l. Hosp. Date.
May 21, 62
Winthrop 6
Winthrop
Place of Burial of Cremation (City or Town)
DATE OF BURIAL
May 23
10.62
7 NAME OF
FUNERAL DIRECTOR
Arthur J. OMaley
ADDRESS Winthrop Mass
Received and filed
MAY 2 4 1962
19 Charles H. Mackie
Female
9 COLOR
White
10 SINGLE
MARRIED
WIDOWED
DIVORCED
UNKNOWN
Widowed
11 If married, widowed, or divorerd HUSBAND ol (or) WIFE ol Mfe in lull) Seymour V. Mcharen
( Husband's name in full)
12
AGE 8 /. Years
Month -.
Days
If under 24 hours
Hours .
Minutes
13 [ snal
Occupation :
( kind of work done during most working life)
14 Industry
or Business:
Own Home
15 Social Security No
16 BIRTIIPLACE (City)
(State or country)
Boston
Mais
17 NAME OF
FATHER
Sahil Tinnell
18 BIRTHPLACE OF
FATIIER (City).
(State or country)
Cannot be learned
19 MAIDEN NAME
OF MOTHER
Augusta Anderson
20 BIRTIIPLACE OF
MOTIIER (City) ..
(State or country)
Stockholm
Sweden
21 Informant
Donald McLaren
( Address)
Milford. N.H.
I HEREBY CERTIFY that a satisfactory standard certificate of death was filed with me BEFORE the burial or transit permit was issued: Jacqueline Serate (Signature of Agent of Board of Health or other) 735-5 5/12/62
( Registrar) | (Official Designation)
(Date of Issue of Permit)
A TRUE COPY ATTEST:
MASSACHUSETTS GENERAL HOSPITAL No.
Registered No. .
- (Was deceased a U. S. War Veteran, (if so specify WARY No
(a) Residence.
.sWinthrop, Massachusetts (If nonresident, give city or town and State)
( write the word)
MEDICAL CERTIFICATE OF DEATH
(a)
(1)
nlobothrombosis, ...... t .... Log.
Housewife
PARENTS
M. D.
1
A TRUE COPY ATTEST: Charles it Mackie City Registrar
F TO!
11.97
CLERK
THROP
JUL - 61962 AM
RM R-303 fil for burial permit Board of Health its Agent.
X PLACE OF DEATH
SUFFOLK (County ) BOSTON (City or Town)
The Commonwealth of Massachusetts KEVIN H. WHITE SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS MEDICAL EXAMINER'S CERTIFICATE OF DEATH
OUT - OF - TOWN 107, (City or Town making this return ) 05496 Registered No.
EN ROUTE TO EAST BOSTON RELIEF STATION No.
death occurred in a hospital or institution,
2 FULL. NAME
ROBERT
J.
LAIDLEY
( First Name)
( Middle Name)
( Last Name )
(If deceased is a married widnwed or divorced wnman, give also maiden name.)
STREET
St
WINTHROP, MASS.
Length of stay :
In place of death
.years ... . ..
.. months
days. In place of residence.
18. years ..
......... months
.days.
PERSONAL AND STATISTICAL PARTICULARS
9 SEX
Male
10 COLOR
White
IT SINGLE
MARRIED
WIDOWED
DIVORCED
UNKNOWN
Single
12 If married, widowed, or divoreed HUSHIAND of
(Give maiden name of wife in full)
(or) WIFE of
(Husband's name in full)
13 DATE OF BIRTHI Jan. 4,1944
14 AGE 18veare
2.5
Daye
If under 24 hours
Hours
Minutes
15 Usual
Occupation
Student (Kind &work done during most of working life)
School
or Business
17 Social Security No. ...
030-32-9873
18 IDERTHIPLACE (City)
Boston
STRUCK
(State of country)
Mass.
19 NAME OF
FATHER
Frederick F. Laidley
20 BIRTHPLACE OF
FATHER (City)
(State or country)
Boston
Mass.
21 MAIDEN NAME
OF MOTHER
Florence Ciampa
Boston
22 BIRTHPLACE OF
MOTHER (City)
(State or country)
Mass.
23
Informant
Mr. Frederick F. Laidley-fathe
Place of Burial, or Cremation, (City or Town) (Address) 50 Main St. Winthrop, Mass.
DATE OF HURIAL
June 2nd
.19 62
A NAME OF FUNERAL DIRECTORRichard C. Kirby, Inc. 917 Bennington St. ,E.Boston ADDRESS JUN 4 1962
Ro Wed And filed Charles & Mackie 19
A-07473 1/31/62
(Official Designation)
(Date of Issue of Permit)
A TRUE COPY ATTEST: (Registrar)
50M-9-61-93134x 13 . X97 X
(a) Residence. Nn.
50 MAIN
( ['sual place of abode)
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
DEATH
Injury oceur ?
(City of town and State)
puhhe place ?
PUBLIC
HIGHWAY
Manner of
(Specify type of place)
DRIVER OF AUTO THAT
Injury
Nature of
MTA POGGI jury necur?)
Injury
CRUSHING INJURY OF
If so, specify
a U. S. War Veteran, G.1 .. Chap. 46, Section 10, requires physicians to insert a recital to that effect.
(Address)
Vecea .:
§§ 44-48
OS of Death. See reverse side for additional information. See also Chap. 38, § 6, 20; Chap. 46, §§ 9, 10; Chap. !! I,
DEATA 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
N. B .- WRITE PLAINLY, WITH UNFADING BLACK INK-THIS IS A PERMANENT RECORD. Every item of
White at work ?
W'as aurusy Performed ?
MAY
29
1962
(Month)
(Day)
(Year)
41 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.)
CRUSHING INJURY OF CHEST AND NECK WITH LACERATION OF NECK AND SEVERING OF TRACHEA.
5 Accident, suicide, or homicide (specify)
ACCIDENT
Date and hour of injury
MAY
29 10) 62
IF ACCIDENTAL, was injury causally related to the death? YES
Where did
EAST BOSTON, MASS.
Did injury occur in or about home, on farm, in industrial place, or n
CHEST AND NECK NO
6 Was disease or injury in any way related to occupation & deceased?
Herald Cochin MI. 1).
PARENTS
(Signed)
LEONARD ATKINS, M.D.
(Print or Type Aanfe) 25 SHATTUCK/ST. Date MAY 30 1 62
Winthrop Cemetery, Winthrop 7
I HEREBY CERTIFY that a satisfactory standard certificate of death was filled with me BEFORE the burial or transit permit was issued:
(Sixnature of Skept of Board of Health gr other)
PHYSICIAN - IMPORTANT
( ( Was deceased a
{U. S. War Veteran,
No
(if so specify WAR)
( If nonresident, give city or town and State)
( write the word )
Months
A TRUE COPY ATTEST: Charles it Mackie City Registrar
RECE VEC
1
ERK
0
THROP
JUL = 61962 AM
X 1
PLACE OF DEATH
Suffolk (County)
Winthrop (City or Town)
The Commonwealth of Massachusetts KEVIN H. WHITE SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS
STANDARD CERTIFICATE OF DEATH
Registered No.
108
[(If death occurred in a hospital or institution,
St. ( give its NAME instead of street and number)
PHYSICIAN - IMPORTANT
2 FULL NAME. Margaret Grant (hite)
(If deceased is a married, widowed or divorced woman, give also maiden name.)
(Was deceased a
U. S. War Veteran,
(if so specify WAR)
(a) Residence. No.
437 Winthrop St. Winthrop
St
(Usual place of abode)
Length of stay: In place of death .......... years .......... months.
1
.. days. In place of residence. 40years.
... months ..
days.
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
DEATH
June
(Month)
(Day)
1962 (Year)
4 I HEREBY CERTIFY, That I attended deceased from
Dec
19.59
June i
19.
62
I last saw hebalive on
June 1
., 1962 death is said to
have occurred on the date stated above, at
9:10 Pm.
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a)
Coronary
Deelysion
acut
(b)
Hypertension
Due Ty
(c)
Arterio Selerotic Heart Disease
OTHER
SIGNIFICANT
CONDITIONS
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
(Signature)
. D.
CHARLES
LIBERMAN
(Print or Type Name) (Address) WINTHROP Date .. 6/1/ 19.62
0
Winthrop
Winthrop
Place of Burial or Cremation
(City or Town)
DATE OF BURIAL
19
7 NAME OF
FUNERAL DIRECTOR
Howard S Reynolds
ADDRESS
Winthrop, Lass
Received and filed
JUN 4 1962
19
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
Female
9 COLOR
White
10 SINGLE
MARRIED
WIDOWED
DIVORCED
UNKNOWN
(write the word)
Widow
11 If married, widowed, or divorced
HUSBAND of
(Give maiden name of wife in full)
(or) WIFE of
Charles ...
Grant
(Husband's name in full)
12
66
Years
7
Months.
20
.Days
If under 24 hours
Hours ........ Minutes
13 Usual
Occupation :
Inspector
(Kind of work done during most working life)
14 Industry
or Business :
Typerwriter factory
15 Social Security No 011-01-5118
16 BIRTHPLACE (City Last Boston
(State or country)
17 NAME OF
FATHER
Janes White
PARENTS
18 BIRTHPLACE OF
FATHER (City)
(State or country Ecotland
19 MAIDEN NAME
OF MOTHER
Jeanie Watson
20 BIRTHPLACE OF
MOTHER (City)
(State or country)
Scotland
21 Informant
Mary Hersey
(Address) 142 Cliff Ave. Winthrop, Mass
I HEREBY CERTIFY that a satisfactory standard certificate of death was filed with me BEFORE the burial of transit permit was issued: terazles
(Signature of Agent of Board of Health or other)
6/4/62
(Registrar)|| (Official Designation)
(Date of Issue of Permit)
KUIV
FIRM R-301
ecor burial permit E rd of Health I Agent. ST CTIONS )R CERTIFICATE
T IR TYPE CAUSES EATH it enter rehan one s'or each >) and (c) :
is nat mean og of dying, eart failure, 5 c. It means es or campli- sich caused
ints, if any, ve rise to nuse (a), the under- luse last.
ians contrib- eath but nat I the terminal E ditian given
-- 932382
A TRUE COPY ATTEST:
INTERVAL BETWEEN ONSET AND DEATH 2days AGE.
3yrs,
Byrs
June
5
52
(City or Town making this return)
No. Winthrop Community Hospital
(If nonresident, give city or town and State)
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 d'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.
ORM R-301
1
PLACE OF DEATH
Suffolk (County)
Winthrop (City or Towrt)
The Commonwealth of Massachusetts KEVIN H. WHITE SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS STANDARD CERTIFICATE OF DEATH Registered No.
(City or Town making this return)
109
[(If death occurred in a hospital or institution,
St. ( give its NAME instead of street and number)
( Munnis
)
PHYSICIAN - IMPORTANT
(Was deceased a U. S. War Veteran, (if so specify WAR).
NO
<
(a)
Residence. No ..
79 Woodside Ave
(Usual place of abode)
St.
Winthrop
nonresident, give city or town and State)
Length of stay:
In place of death ..
.... years
... months.
10
days. In place of residence ..
5
years.
months.
.. days.
MEDICAL CERTIFICATE OF DEATH
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
9 COLOR
White
10 SINGLE
MARRIED
WIDOWED
DIVORCED
UNKNOWN
(write the word)
Widowed
11 If married, widowed, or divorced HUSBAND of
(Give maiden name of wife in full)
(or) WIFE of
William A. Harrison
(Husband's name in full)
12
AGE.6.2 Years.
Months.
.. Days
If under 24 hours
Hours. ...
Minutes
13 Usual
Occupation :
Housewife
(Kind of work done during most working life)
14 Industry
or Business :
Own .... Home
15 Social Security No.
16 BIRTHPLACE (City)
(State or country)
Somerville
Mass
17 NAME OF
FATHER
John Munnis
18 BIRTHPLACE OF FATHER (City). (State or country)
Ireland
19 MAIDEN NAME
OF MOTHER
Sarah Martin
20 BIRTHPLACE OF MOTHER (City) (State or country) Ireland
21 Informant
Robert ..... Harrison
(Address)
79 Woodside Ave., Winthrop
I HEREBY, CERTIFY that a satisfactory standard certificate of death was filed with me BEFORE the burial or transit permit was issued: Mais le E- Serianni
(Signature of Agent of Board of Health of other) Meabile pflicht
6/5/62
(Date of Issue of Pormit)
A TRUE COPY AT ATTEST:
(Year)
4 I HEREBY CERTIFY , That I attended deceased, from
FEB 21, 1962
JUNG3
1962
I last saw hEtblive on
JUNE 3 1962
death is said to
have occurred on the date stated above, at
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a) MYOCARDIAL ISCHEMIA.
INTERVAL BETWEEN ONSET AND DEATH SMO
Due To RHEUMATIC & ARTERIO SCHETTO (b)
HEART DIS WITH.
(c)
Due To
CONGESTIVE HEART FAILURE
OTHER
SIGNIFICANT
CONDITIONS
none
Was autopsy performed?
100
What test confirmed diagnosis ?
CLINICAL
5 Was disease or injury in any way related to occupation of deceased ?.... If so, specify
(Signature)
M. D. MYRON N KING AND
(Print or Type Name)
(Address) 422 PLEASANT 51 Date. 6/4 62
WINTHROP
6 Woodlawn Everett, Mass
Place of Turial or Cremation
(City of Town)
DATE OF BURIAL June 6, 19 62
7 NAME OF
FUNERAL DIRECTOR
Arthur J. O'Maley
ADDRESS
Winthrop, Mass.
Received and filed JUN 5 1962 19.
62-932382
le for burial permit Jard of Health orts Agent. IN RUCTIONS FOR IGI CERTIFICATE
IN OR TYPE SEOR CAUSES OIDEATH
de not enter ng than one at: for each (a (b) and (c)
isloes not mean mle of dying, a heart failure, nin etc. It means dis se, or compli- 's which caused
naions, if any, iç gave rise to U cause (a), the under- tin ng cause last.
Calitions contrib- I death but not do the terminal se ondition given
2 FULL NAME
No ... Winthrop Ruth A. Harrison Harrison
.Community ..... Hospital
(Munnis )
Ruth
(If deceased is a married, widowed or divorced woman, give also maiden name.)
......
3 DATE OF
DEATH
June
3
1962
(Month)
(Day)
Female
(Registrar)| (Official Designation)
PARENTS
5
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE
RANK, RATING
TTOW.
ORGANIZATION AND OUTFIT
SERVICE NUMBER
CEFI
1-7
ER
2
5
6
NT
ROP MAS
RULES OF PRACTICE
The fulfillment of the purpose of these laws calls for the poservanceCof Preil 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 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.
X
PLACE OF DEATH
Suffolk
(County)
Winthrop
(City or Town)
No.
36 Pleasant Street
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. 110
f(If death occurred in a hospital or institution, St. { give its NAME instead of street and number)
PHYSICIAN - IMPORTANT
Irene G (Strout) Perry
(First Name)
()liddle Name)
(Last Name)
(If deceased is a married. widowed or divorced woman, give also maiden name.)
36 Pleasant
Street
St.
(If nonresident, give city or town and State)
.months.
.days.
MEDICAL CERTIFICATE OF DEATH
PERSONAL AND STATISTICAL PARTICULARS
3 DATE OF
DEATH
JUNE 3 1962
(Month)
(Day)'
(Year)
8 SEX
FEMALE
9 COLOR
White
10 SINGLE
(write the word)
MARRIED
WIDOWED
or DIVORCED IdOW
10a If married, widowed, or divorced
HUSBAND of
(Give maiden name of wife in full)
(or) WIFE of
Newell A Perry
(Husband's name in full)
11 IF STILLBORN, enter that fact here.
DEATH
3 days
12
84
8
Months.
3
Days
AGE
Years
If under 24 hours
Hours.
........
.Minutes
13 Usual
Housewife
Occupation :
(Kind of work done during most of working life)
14 Industry
or Business :
Own home
15 Social Security No. ...... one
16 BIRTHPLACE (City)
(State or country)
Laine
17 NAME OF
FATHER
Uriah Strout
18 BIRTHPLACE OF
FATHER (City)
(State or country)
Unable to obtain
19 MAIDEN NAME
OF MOTHER
Isadora Strout
20 BIRTHPLACE OF
MOTHER (City)
(State or country)
Unable to obtain
21
Informant
Stewart S Perry
(Address) 35 Pleasant St. Winthrop, Mass
I HEREBY CERTIFY that a- satisfactory standard certificate of death was filed with me BEFORE the burial or transit permit was issued: Talkte (, Sereaunty (Signature of Agent of Board of Health or other).
IhreXE
6/4/62
(Official Designation) 12
(Date of Issue of Permit) /
IS UCTIONS FOR CA CERTIFICATE
Lgiving EOF DEATH
a ot enter onthan one un for each b) and (c)
es nat mean no . of dying, as heart failure, ia,etc. It means sen, or campli- hich caused
duns, if any, have rise to rause (a), MEthe under- sause last.
on'ions contrib- to'eath but nat Ii the terminal Indition given
C.
te Chapter 137, c 1954, requires sinns to print or le cause or e of death on hortificates, and at 48, Acts of quires Physi- & print or type e .der signature.
DATE OF BURIAL
June 7
52
19
7 NAME OF
FUNERAL DIRECTOR
Howard $ Reynolds
ADDRESS
winthrop, Mass
Received and filed
JUN -4 1962
... 19 ..
(Registrar)
PARENTS
JUNE 3 .19 62
6 Forrest Hills Cemetery Harrington, Maine (City or Town)
No
5 Was disease or injury in any way related to occupation of deceased? If so, specify
(Signed) wallace Haley WALLACE HALEY 0 (PRINT OR TYPE SIGNATURE) 213 PAULINE St WINTHROP (Address)
M. D
ARTERIOSCLEROSISBEND YEARS
ADVANCE & CARCINOMA
OTHER
SIGNIFICANT
CONDITIONS
of Right BREAST
No
Was autopsy performed?
What test confirmed diagnosis?
CLINICAL
INTERVAL BETWEEN ONSET AND
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
HypoSTATIC PNEUMONIA
(a)
Due To
(b)
MyoCARDITIS
1 YEAR
Due To
(c)
That I attended deceased from
3
1962
I last saw hERalive on
JUNE
-
19.a.L., death is said to
have occurred on the date stated above, at
9 A. m.
[(Was deceased a U. S. War Veteran,
if so specify WAR)
(a) Residence. No. (Usual place of abode)
Length of stay: In place of death ..
56 years.
months
days.
In place of residence
.. years.
56
2 FULL NAME
6-1-928145
R-301A 1
Harrington
Place of Burial or Cremation
4 I HEREBY CERTIFY,
DEC.5
1961, to JUNE
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.
X PLACE OF DEATH
Suffolk (County)
IMSE PET
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.
111
[(If death occurred in a hospital or institution, St. ¿ give its NAME instead of street and number)
PHYSICIAN - IMPORTANT
2 FULL NAME
Charles Emerson .... Seabury
(First Name)
( Middle Name)
(Last Name)
(If deceased is a married, widowed or divorced woman, give also maiden name.)
[(Was deceased a U. S. War Veteran,
(if so specify WAR)
NO ..
(a) Residence. No. ..
(Usual place of abode)
14 Pleasant Park Road
St
(If nonresident, give city or town and State)
Length of stay :
In place of death ... O.
years
... months.
.days.
In place of residence.
40
.years
months.
days.
MEDICAL CERTIFICATE OF DEATH
PERSONAL AND STATISTICAL PARTICULARS
3 DATE OF
DEATH
June
6
19.6.2
(Month)
(Day)
(Year)
4 I HEREBY CERTIFY,
N.O.v ......... 21 ....
19.60
to ....
June .... 6.
That I attended deceased from
196.2
62
I last saw himalive on
June 6,
19
.. , death is said to
have occurred on the date stated above, at
10: 45 pm.
INTERVAL
BETWEEN
ONSET AND
DEATH
11 IF STILLBORN, enter that fact here.
12
73
Years
1
Months
28 Days
Hours.
.. Minutes
13 Usual
retired maintenance man
Occupation :
....
(Kind of work done during most of working life)
14 Industry
or Business :
Nickle Alloy Mig. Co.
15 Social Security No.
012-01-1340
Brighton
16 BIRTHPLACE (City)
(State or country)
Massachusetts
17 NAME OF
FATHER
Charles Thomas Seabury
18 BIRTHPLACE OF
FATHER (City)
Parkman
M. D
(State or country)
Maine
19 MAIDEN NAME
OF MOTHER
Martha Harvey
20 BIRTHPLACE OF
Parkman
.
MOTHER (City)
(State or country)
Maine
Ralph H .Seabury
21
Informant
(Address)
52 Aberdeen Rd, Arlington
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) Health Officer 6/5/65
(Official Designation)
(Date of Issue of Permit) / V.B.L
STJCTIONS OR ALCERTIFICATE Ia:iving EDIF DEATH It enter ne han one sifor each ) b) and (c)
g:s not mean of dying, sheart failure, atc. It means el, or compli- hich caused
ifis, if any, hive rise to e ause (a), the under- nuse last.
mions contrib- o cath but not &the terminal edition given
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