USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1962 > Part 26
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§§ 44-48.
50M-9-61-931348
mc.
If deceased was a U. S. War Veteran, G.L. Chap. 46, Section 10, requires physicians to insert a recital to that effect.
Accident.
14 AGE 85 Years ... 1 .Months
Days
If under 24 hours Hours Minutes
15 Usual Occupation
Housewife
(Kind of work done during most of working life)
16 Industry Business
at Home
Social Security No.
Plymouth
48 BIRTHPLACE (City)
(State or country)
masa
19 NAME OF FATHER Unknown Lucas EPC.
.... M. D.
Luongo, M. D.
19
Place of Burial, or Cremation.
D
(Month)
(Day)
(Year)
4I 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.)
Cerebro vascular accident following
fracture of femur.
Female
PHYSICIAN - IMPORTANT
(If nonresident, give city or town and State)
1/11/62
OM R-303 ·for burial permit lard of Health ts Agent.
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 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.)" .
RI R-301 1
PLACE OF DEATH
Suffolk (Gounty) Winthrop (City or Town 78 Cottage
The Commonwealth of Massachusetts KEVIN H. WHITE SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS
STANDARD
CERTIFICATE OF DEATH
Registered No.
[(If death occurred in a hospital or institution,
St. { give its NAME instead of street and number)
PHYSICIAN - IMPORTANT
William G. Greenfield (First Name) ( Middle Name)
(If deceased is a married, widowed or divorced woman, give also maiden name.)
78 Cottage
Ave
Winthrop
St. (If nonresident, give city or town and State)
Length of stay: In place of death.
years ..
....... months.
.days. In place of residence
1
years
6
.. months ..
.days.
MEDICAL CERTIFICATE OF DEATH
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
Male
9 COLOR
White
10 CITIZEN
OF U.S.
YES
NO
11 SINGLE
MARRIED
WIDOWED
DIVORCED
UNKNOWN
4 I HEREBY
CERTIFY,
19 .........
.. , to ..
19
I last saw h ........ alive on
19 ...
., death is said to
have occurred on the date stated above, at
7.P.M.m.
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a) Sudden Death - Probably coronary
INTERVAL BETWEEN ONSET AND DEATH
12 DATE OF BIRTH
Nov. 29, 1913
13
€/8
7
Months.
AGE.
Years ....
Days
If under 24 hours Hours Minutes
Steamship
Cheek
(Kind of work done during most of working life)
15 Industry
or Business
Local 1066 I.L.A.
16 Social Security No.
025-03-7712
17 BIRTHPLACE (City) EAST BOSTONT
MASS.
5 Was disease or injury in any way related to occupation of deceased? .no.
If so, specify
Boston
(Signed)
Actu 7. Collins rs
19 BIRTHPLACE OF
FATHER (City)
M. D.
(State or country)
MASS,
John F. Collins
(Print or Type Name) /
27 Bennington St Beachmont 7/18
19.
62
for Winthrop Board of Health ,Winthrop; "Ma
Holy CROSS
MALder
6
Place of Burial or Cremation
July 20
.1962
(City or Town)
DATE OF BURIAL
7 NAME OF
FUNERAL DIRECTOR
FREDERICK J. MAGRATH
325 Chelsea St. E. Boston
ADDRESS
Received and filed
JUL .19 1962
19
d'ARENTS
20 MAIDEN NAME
OF MOTHER
MARY AnGel
21 BIRTHPLACE OF
MOTHER (City)
(State or country)
New Found land
Thomas
Green Field
22 Informant (Address) 10 Cottage 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)
7/19/6
(Official Designation)
(Date of Issue of Permit)
VX
MICTIONS IR IL ERTIFICATE
niving OF DEATH a: enter renan one se or each ) and (c)
ds not mean od of dying, sMart failure, c. It means & or compli- ich caused
tis, if any, I've rise to use (a), ghe under- use last.
id ons contrib- ath but not tothe terminal edition given
te Chapter 137, 01954 requires mins to print or e cause or ¿of death on rtificates, and 48, Acts of quires Physi- print or type der signature.
.930213
A TRUE COPY ATTEST:
3 DATE OF
DEATH
July
17,
1962
(Month)
(Day)
(Year)
That I attended deceased from
lla If married, widowed, or divorced HUSBAND of (Give maiden name of wife in full)
(or) WIFE of
(Husband's name in full)
heart disease.
Due To Usual (b) Pre-existing coronary heart disease Due To ( Treated at M.G.H. 1961, 1962(12 years ) Occupation: (c)
OTHER
SIGNIFICANT
CONDITIONS
none
Ave
No.
2 FULL NAME
[(Was deceased a
U. S. War Veteran,
(Last Name)
[if so specify WAR)
WW 2
(a) Residence. No. (Usual place of abode)
(Registrar)
110
To be filed for burial permit with Board of Health or its Agent.
Was autopsy performed?no.
What test confirmed diagnosis? Previous hospital admissionsState or country)
18 NAME OF
FATHER
Charles Green Field
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE. 2 - 12 - 42
DATE OF DISCHARGE.
11 - 4 - 45
CORP.
RANK, RATING
ORGANIZATION AND OUTFIT Hatas. Sadm 11th Air Dep. GRp U.S. A
SERVICE NUMBER
31 064 626
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 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.
RM R-301
dor burial permit Erd of Health 's Agent. S UCTIONS FOR A CERTIFICATE
MOR TYPE R CAUSES EATH ot enter r than one s for each )[b) and (c)
res not mean 1: of dying, s heart failure, m,etc. It means ee, or compli- which caused
ns, if any, kave rise to ecause (a), the under- cause last.
a tions contrib- Lieath but not the terminal ndition given I.C.
X
PLACE OF DEATH
Suffolk (County)
The Commonwealth of Massachusetts KEVIN H. WHITE SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS STANDARD CERTIFICATE OF DEATH
WINTHROP
(City or Town making this return)
I
Winthrop
(City or Town)
Winthrop Community Hospital No.
[(If death occurred in a hospital or institution, .St. Į give its NAME instead of street and number)
PHYSICIAN - IMPORTANT
2 FULL NAME Jennie E ..
(If deceased is a married, widowed or divorced woman, give also maiden name.)
(a) Residence. No ..
147 Shirley
(Usual place of abode)
.. St. Winthrop
(If nonresident, give city or town and State)
Length of stay: In place of death .......... years .......... months.
28
days. In place of residence .......... years .......... months .........
days.
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
9 COLOR
FEMALE WHITE
10 SINGLE
(write the word)
MARRIED
WIDOWED
DIVORCED
UNKNOWN MARRIED
11 If married, widowed, or divorced
HUSBAND of
(Give maiden name of wife in full)
RESNICK
(or) WIFE of
ISHOCKE
(Husband's name in full)
12
AGE 65 Years
Months.
Days
If under 24 hours
Hours ...
Minutes
13 Usual
HOUSE WIFE
Occupation :
(Kind of work done during most working life)
or Business :
OWN HOME
15 Social Security No ...
16 BIRTHPLACE (City)
(State or country )
RUSSIA
17 NAME OF
FATHER
MORRIS WISEMAN
18 BIRTHPLACE OF
FATHER (City)
(State or country)
RUSSIA
19 MAIDEN NAME
OF MOTHER
CLARA ORNSTEIN
20 BIRTHPLACE OF
MOTHER (City)
(State or country)
RUSSIA
21 Informant
MAURICE RESNICK
(Address)
112 IRVINGST. EVERETT
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)/t
(Registrar) || (Official Designation)
A TRUE COPY ATTEST:
17
1962
(Month)
(Day)
(Year)
I-HEREBY CERTIFY
July 11
1962
July
That I
17
19
.6.2
I last saw
helalive on
July 16
19 62 death is said to
have occurred on the date stated above, at
4:15Pm
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a)
Carcinoma of lungs
Due To (b)
Due To (c)
OTHER
SIGNIFICANT
CONDITIONS
Diabetes Mellitus
Was autopsy performed?
What test confirmed diagnosis ?
X-rays
5 Was disease or injury in any way related to occupation of deceased?
If so, specify
John 7. Colline It
M. D.
(Signature)
John F. Collins, I. D.
. (Print or Type Name)
(Address) / Pennington 20
Date.
July 17 62
ass
AMERICAN FRIENDSHIP,W. ROXBURY
6
Place of Turial or Cremation
DATE OF BURIAL JULY 18 1967
(City or Town)
7 NAME OF
FUNERAL DIRECTOR
TORFFUNERAL SERVICE
ADDRESS CHELSEA
Received and filed
July 18
1962
.........
Registered No. ....
(Was deceased a
U. S. War Veteran,
(if so specify WAR)
NO
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
DEATH
July
attended deceased from
INTERVAL BETWEEN ONSET AND DEATH
14 Industry
PARENTS
(Date of Issue of Permit)
2-932382
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 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.
IM R-303
ed or burial permit Bird of Health Es Agent.
PLACE OF DEATH
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
(City or Town making this return)
Registered No.
133
[(If death occurred in a hospital or institution, ¿ give its NAME instead of street and number) No.
PHYSICIAN - IMPORTANT
2 FULL NAME
DANIEL HERBERT Jr
First Name)
(Middle Name)
(Last Name)
[ ( Was deceased a
₹U. S. War Veteran,
No
{if so speciiy WAR)
(If deceased is a married, widowed or divorced woman, give also maiden name.) 244 Grand View Avenue, Winthrop
St.
( If nonresident, give city or town and State)
Length of stay:
In place of death ..
years.
.. months .... .
... days. In place of residence 2.
years 7
.months.
1.3.days.
9 SEX
Male
10 COLOR
White
11 SINGLE
MARRIED
WIDOWED
DIVORCED
UNKNOWN
Single
12 If married, widowed, or divorced HUSBAND of
(or) WIFE of
(Husband's name in full)
13 DATE OF BIRTH
14
AGE:
2
Years.
Months.
If under 24 hours Hours Minutes
15 Usual
(Kind & work done during most of working life)
No.
18 BIRTHPLACE (City)
Winthrop
(State or country)
Mass
19 NAME OF
FATHER
Daniel J. Herbert
20 BIRTHPLACE OF
FATHER (City)
Boston
(State or country)
MASS
21 MAIDEN NAME
OF MOTHER
Margaret Jones
22 BIRTHPLACE OF
MOTHER (City)
Winthrop
(State or country) Mass
7
Winthrop Cemetery
Winthrop
Place of Burial, or Cremation.
(City or Town)
(Address)
244 Grand View Ave Winthrop
DATE OF BURIAL
July 20,
062
8 NAME OF
FUNERAL DIRECTOR
Arthur J. O' Maley
ADDRESS Winthrop Mass
Received and filed 7-20 1962
A TRUE COPY ATTEST: (Registrar)
PERSONAL AND STATISTICAL PARTICULARS
1962
(Year)
4I 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.) Asphyxia due to drowning,
(a) Residence. No.
( L'sual place of abode)
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
18,
DEATH
July
(Month)
(Day)
5 Accident, suicide, or homicide (specify)
Accident.
Date and hour of injury
July 18,
19
Where did
Injury occur ?
Winthrop, Massachusetts.
(City or town and State)
(How did injury occur ? ) ga
Nature of
Injury
(Sig
Michael A. Luongo,
Boston
(Print or Type Name)
(Address)
Date
§§ 44-48.
OR TVDE PHP CAHISH OR CAUSES OF DRATH ON DEATH GERNINGALES
While at work ?
Was awysy Performed ?
......
public place ?
(Specify type of place)
Manner ofAccidental fall, wall into
Injury
Water
Yes
6 Was disease or injury in any way related to a cupation of deceased?
M. D.
7/18 62
19
PARENTS
50M-9-61-931348
X 1
N. B .- WRITE PLAINLY, WITH UNFADING BLACK INK-THIS IS A PERMANENI KELORD. Every item of 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
If deceased was a U. S. War Veteran, G.L. Chap. 46, Section 10, requires physicians to insert a recital to that effect.
62
IF ACCIDENTAL, was injury causally related to the death ?
Yes
Did injury occur
'Water's 87 Boston" HarBalplace, or
in
(Give maiden name of wife in full)
January 5, 1960
23
Informant
Margaret Herbert
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) Talet Offici
7/19/62
(Official Designation)
(Date of Issue of Permity
( write the word )
Waters of Boston Harboroff Winthrop ..
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 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.)"
R-301A 1
AUCTIONS FOR CERTIFICATE
giving OF DEATH ot enter than one for each (b) and (c)
ves nat mean e aj dying, heart failure, etc. It means se, ar campli- which caused
dons, if any, gave rise ta cause (a), the under- cause last.
o'itians contrib- L death but nat Up the terminal ondition given - 0
Chapter 137, 954. requires ns to print or e cause or of death on tificates, and €. 48, Acts of Iquires Physi - print or type der signature.
11-59-926662
PLACE OF DEATH
Suffolk (County)
Winthrop (City or Town)
The Commonwealth of Massachusetts JOSEPH D. WARD SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS STANDARD CERTIFICATE OF DEATH
To be filed for burial permit with Board of Health or its Agent.
134
S(If death occurred in a hospital or institution, St. ¿ give its NAME instead of street and number)
PHYSICIAN - IMPORTANT
[(Was deceased a U. S. War Veteran, [if so specify WAR)
W.W.1
(If deceased is a married, widowed or divorced woman, give also maiden name.)
(a) Residence. No.
77 Bartlett Road
(Usual place of abode)
13
13
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
July
18
1962
DEATH
(Year)
(Month)
(Day)
4 I HEREBY
CERTIFY
June
50
to.
July 18
I last saw h./ .. yralive on
July
17, 19 62 death is said to
have occurred on the date stated above, at
11:10 Km.
INTERVAL
BETWEEN
ONSET AND
DEATH
11 IF STILLBORN, enter that fact here.
AGE
Years.
Days
If under 24 hours
Hours.
Minutes
13 Usual
Occupation :
(Kind of work done during inost of working life)
14 Industry
Federal Reserve Bank
or Business :
15 Social Security No.
025-26-4198
Bristol
16 BIRTHPLACE (City Rhode Island (State or country)
17 NAME OF
FATHER
George Johnson
18 BIRTHPLACE OF
FATHER (City)
(State or country)
England
19 MAIDEN NAME
OF MOTHER
Clara Bradshaw
20 BIRTHPLACE OF
Rhode Island
MOTHER (City)
(State or country)
Bristol
Ruth
John son
(Address) 77 Bartlett Rd. Winthrop, Mass
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)
Kalch Affiche
7/20/62
"(Official Designation
(Date of Issue of Permit)
(Registrar)
PARENTS
(A
(PRINT OR TYPE SIGNATURE) 19 4Washingtonu Date ....
7/19 1962
6 Forrest Dale
Målden
Place of Burial or Cremation
DATE OF BURIAL
July 2 gity or Town)
62
19
7 NAME OF
FUNERAL DIRECTOR
Howard S Reynolds
ADDRESS Winthrop .. Mas.s
Received and filed JUL 20 1962 19
8 SEX
Male
9 COLOR
./hite
10 SINGLE
(write the word)
Married
MARRIED
WIDOWED
or DIVORCED
10a If married, widowed, or divorsedth Baker
HUSBAND of
(Give maiden name of wife in full)
(or) WIFE of
(Husband's name in full)
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a) myocardial Heart
JD,52952
Due To
(b)
Coronary artery
disease
Due arteriosclerosis - gen
(c)
OTHER SIGNIFICANT CONDITIONS
Was autopsy performed?
What test confirmed diagnosis ?
5 Was disease or injury in any way related to occupation of deceased? NO If so, specify
(Signed)
., M. D. Joseph GREGORIE
21 Informant ry
Registered No.
No.
77 Bartlett Road
2 FULL NAME
Frank
E Johnson
St.
(If nonresident, give city or town and State)
That I attended deceased from
19.
62
12
63
8
Months.
8
Clerk
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICEOctober 30, 1918
DATE OF DISCHARGE
December 5. 1918
RANK, RATING Private
ORGANIZATION AND OUTFIT Army
SERVICE NUMBER
2801629
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.
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