USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1962 > Part 28
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19
.62
have occurred on the date stated above, at
9: 50A.
... m.
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a) Acute myocardial infarction
Due To (b)
Due To (c)
OTHER
SIGNIFICANT
CONDITIONS
Was autopsy performed?
No
What test confirmed diagnosis?
Clinical ... & ... Lab ... Findings
5 Was disease or injury in any way related to occupation of deceased? If so, specify
(Signed)
Exiphen G. Pulite
Stephen.A ..... Kulick
M. D.
(Address)
VAH, Boston, Mass ....... Date.July .... 24
... 19 ...
62
Pride of Boston Cem., Woburn, Mass.
6 Place of Burial or Cremation
DATE OF BURIAL
July 25
19 ... 62
7 NAME OF
FUNERAL DIRECTOR
Torf Funeral Chapel
ADDRESS 151 Washington Ave., Chelsea, Mass.
JUL 254962
Recenla ma Med- Charles if im
....
(Registrar) (Official Designation)
A TRUE-COPY ATTEST:
INTERVAL BETWEEN ONSET AND DEATH 24 hrs
12 DATE OF BIRTH
June 9, 1900
AGE
·13
62 Years.
1
Months.
.. 1.5 .... Days
If under 24 hours .. Hours .......... .. Minutes
14 Usual
Occupation :
RETIRED SUPPLY OFICER
(Kind of work done during most of working life)
15 Industry
(RETIRED CIVILIAN- ARMY
16 Social Security No.
17 BIRTHPLACE (City)
(State or country)
Mass.
18 NAME OF
FATHER
Jacob Abrams
19 BIRTHPLACE OF
FATHER (City)
(State or country)
Russia
20 MAIDEN NAME
OF MOTHER
Mary Krutchinsky
21 BIRTHPLACE OF
MOTHER (City)
(State or country)
Poland
22 V. A. Hospital Records, 150 S.
Informant (Address) Huntington Ave., Boston, Mass.
I HEREBY CERTIFY that a satisfactory standard certificate of death was Eled with me BEFORE the burial or transit permit was issued: J.Rogeron
(Signature of Agent of Board of Health or other;
B12219
7-24-62
(Date of Issue of Permit)
R& R-301 -
TICTIONS
L ERTIFICATE
miving CF DEATH #: enter enan one or each ›) and (e)
as mot mean of dying, eart failure. c. It means , or compli- hich caused
Qis, if any, Ive rise ta jause (a), he under- muse last.
ions contrib eath but not t the terminal dition 2
420 81 X70
- Chapter 137. 1954 requires ans to print or he cause or of death on ertificates, and : 48. Acts of equires Physi- o print or type nder signature.
Medical Examiner Declines $ 28 1982
I-930213
PHYSICIAN - IMPORTANT
[ (Was deceased a
U. S. War Veteran.
WWI
(if so specify WAR)
(a) Residence. No.
(If nonresident, give city or town and State)
3 DATE OF
DEATH
July
24
1962
(Month)
(Day)
MA (Year)
., death is said to
lla If married, widowed, or divorced HUSBAND of (Give maiden name of wife in full)
(or) WIFE of
(Husband's name in full)
....
Boston
(Print or Type Name)
PARENTS
(City or Town)
Veterans Administration Hospital
'A TRUE COPY ATTEST: Charles Et Mackie City Registrar
AUG :2 81962 AM
X PLACE OF DEATH
Suffolk (County ) WINTHROP (City or Town)
8-7-22
The Commonwealth of Massachusetts JOSEPH D WARD SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS
STANDARD
CERTIFICATE OF DEATH
Registered No. 141
[(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)
NO
(If deceased is a married, widowed or divorced woman, give also maiden name.)
168
(a) Residence. No.
(Usual place of abode)
Length of stay: In place of death. 2 years. 5
months
20days. In place of residenceAZ
....... years.
months .. ........ days.
MEDICAL CERTIFICATE OF DEATH
PERSONAL AND STATISTICAL PARTICULARS
3 DATE OF
DEATH
August
(Day)
1962 (Year)
8 SEX
FEMALE
9 COLOR
WHITE
10 SINGLE
MARRIE1)
(write the word) WIDOWEDSINGLE or DIVORCED
4 I HEREBY MARCH 12 $19.60 , to .. AuguSTI
62
10a If married, widowed, or divorced HUSBAND of
(Give maiden name of wife in full)
(or) WIFE of
(Husband's name in full)
11 IF STILLBORN, enter that fact here.
12
AGE8%
Years ..
Months.
.Days
If under 24 hours
Hours ..
Minutes
13 Usual
GARMENT FINISHER (RETIRED)
(Kind of work done during most of working life)
14 Industry or Business CLOTHING FACTORY
15 Social Security No. NONE
16 BIRTHPLACE (City) (State or country) ITALY
17 NAME OF ERSABATINO D'AGOSTINO
18 BIRTHPLACE OF
FATHER (City) (State or country)
ITALY
19 MAIDEN NAME OF MOTHER ERINA D'AGRESTA
20 BIRTHPLACE OF MOTHER (City) (State or country)
ITALY
21 GIUSEPPE D'AGOSTINO (Addres 168 GOVE STEASTBOSTON
I HEREBY CERTIFY that a satisfactory standard certificate of death was filed with me BEFORE the burial or transit permit was issued:
( Signature of Agent of Board of Health of other) Healleta officer
5/2/62
(Date of Issue of Permit)
(Official Designation)
(Registrar)
PARENTS
5 Was disease or injury in any way related to occupation of deceased ? If so, specify
(Signed)
John F. Petr M. D.
JOHN F. PERUI MD.
(PRINT OR_TYPE SIGNATURE) East Boston, Mase ang. 1, 62
(Address)
6 HOLY CROSS
MALDEN (City or Town)
Place of Burial or Cremation DATE OF BURIAL AUG. 4 62
7 NAME OF
DIPIETROXVAZZA ADDRESS IHENRY ST EAST BOSTON
Received and filed AUG 2-1962
19
INTERVAL BETWEEN ONSET AND DEATH
8 400
Due To (b)
Due To (c)
OTHER SIGNIFICANT CONDITIONS VASCULA Accident 189m.
Was autopsy performed?
NO
What test confirmed diagnosis ?
-
ucions, if any, ic gave rise to cause (a), ti the under- , cause last.
Cdditions contrib- death but not do the terminal e ondition given >
t . Chapter 137, ( 1954. requires i ins to print or le cause or of death on ertificates, and f 48, Acts of quires Physi- . print or type eider signature.
X -6-59-925686
AI R-301A -
WINTHROP CONVALESCENT HOME No. GEMMA MARIA
D'AGOSTINO
GOVE STREET
St.
EAST BOSTON MASS.
(If nonresident, give city or town and State)
2 FULL NAME
N RUCTIONS FOR C CERTIFICATE
giving S OF DEATH not enter c than one 1: for each a (b) and (c)
s'oes not mean nie of dying, & heart failure, si etc. It means is se, or compli- s which caused
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a)
ARTERIOSCLEROTIC
HEART DISEASE
(Month) CERTIFY That I attended deceased from 19
I last saw hMalive on
August 1,, 1962, death is said to
have occurred on the date stated above, at 8: 20 P. m.
OLD CEREBRO
To be filed for burial permit with Board of Health or its 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 un- related to any form of injury/: 110 (2) Board of Health physicians wil 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.
ORM 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
at the time of death should be transmitted on Form R-302 to the clerk of the city or town in which the deceased
resided as soon as possible, after the close of the month in which the death occurred. (See Chap. 46, Sec. 12, G. L.)
PLACE OF DEATH
Middlesex (County)
Somerville
(City or Town)
Little Sisters of the Poor 186 Highland Avenue No ......
(If death occurred in a hospital or institution, St. ¿ give its NAME instead of street and number)
Nellie V. Johnson
(If deceased is a married, widowed or divorced woman, give also maiden name.)
35 Summitt Avenue
Winthrop, Mass.
(a) Residence. No ..
(Usual place of abode)
(If nonresident, give city or town and State)
Length of stay: In place of death - years 3 months 2 days. In place of residence 1.
.. years ........ months ....... days.
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
DEATH
August
1
1962
(Month)
(Day)
(Year)
4 I HEREBY CERTIFY, That
៛
attended deceased from
Jul.y ..... ] ...... , 19.62 .... , to ....
Aug.
19.62
1
I last saw Oralive on
July ...... 29
19.62 death is said to
have occurred on the date stated above, at 0 :. 35A ..... m.
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
Carcinoma of Bowel
(Large )
1yr
Due To (b)
Due To (c)
OTHER Generalized Arterioscleros unknown
Was autopsy performed?
No
What test confirmed diagnosis ?
Clinical Evidence
5 Was disease or injury in any way related to occupation of deceased O. If so, specify
(Signed)
John A. Fraser
M. D.
John A. Fraser, M.D.
172 Summer St
(Address)
Somerville, Mass Date.
8-2
62
New Calvary Com. Boston, Mass.
Place of Burial or Cremation
(City or Town)
DATE OF BURIAL
Aug. 4,
62
7 NAME OF
FUNERAL, DIRECTOR
Joseph P. Murphy
ADDRESS
322 Bunker Hill St. CharlestownTRUE COPY
Received and filed
SEP10 1962
19
(Registrar of City or Town where deceased resided)
8 SEX
9 COLOR
(write the word)
Female White
10 SINGLE
MARRIED
WIDOWED
DIVORCED
UNKNOWN Single
11 If married, widowed, or divorced
HUSBAND of
--
-
(or) WIFE of.
12
AGE .. 77 Years ... 9
Months ..
19 Days
If under 24 hours
Hours.
Minutes
13 Usual
Occupation :
IndustrialNurse
(Kind of work done during most working fife)
14 Industry
or Business :
Q IS Social Security No 025-09-6714
PARENTS
18 BIRTHPLACE OF
FATHER (City).
(State or country)
England
19 MAIDEN NAME
OF MOTHER
Bridget Keane
Galway,
20 BIRTHPLACE OF
MOTHER (City).
(State or country)
Ireland
Little Sisters of the Poor
21 Informant
(Address)
"Record
186 Highland Ave.Som.
ATTEST:
William
(Registrar of City of Town where death occurred)
Aug ...... 2, ..... 196219
DATE FILED
50M - 10-61-931673
X I
The Commonwealth of Massachusetts KEVIN H. WHITE SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS
Somerville (City or Town making this returnd
COPY OF CERTIFICATE OF DEATH
Registered No. 433
(Was deceased a
U. S. War Veteran,
(if so specify WAR
St.
PERSONAL AND STATISTICAL PARTICULARS
(Give maiden name of wife in full)
(Husband's name in full)
INTERVAL
BETWEEN
ONSET AND
DEATH
SIGNIFICANT CONDITIONS
boston
16 BIRTHPLACE (City)
(State or country)
Mass
17 NAME OF
FATHER
William H. Johnson
MI C.
2 FULL NAME
SPACE FOR ADDITIONAL INFORMATION DATE OF ENTERING MILITARY SERVICE DATE OF DISCHARGE. RANK, RATING ORGANIZATION AND OUTFIT SERVICE NUMBER
1
-
JERK
6
THROW
SEP 1 01962 AM
FORM R-301
G 1 for burial permit .oard of Health its Agent. L;TRUCTIONS FOR WILL CERTIFICATE
UT OR TYPE :: OR CAUSES ' DEATH
not enter Ere than one e se for each ), (b) and (c)
& does not mean ode of dying, Is heart failure, 21, etc. It means Mease, or compli- which caused
o'itions, if any, ih gave rise to be cause (a), kig the under- n' cause last.
Unditions contrib- wto death but not it to the terminal condition given
M.c.
X PLACE OF DEATH
Suffolk
(County)
1
Winthrop
(City or Town)
The Commonwealth of Massachusetts KEVIN H. WHITE SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS STANDARD CERTIFICATE OF DEATH
(City or Town making this return)
r
Registered No.
143
[(If death occurred in a hospital or institution, St. ¿ give its NAME instead of street and number)
PHYSICIAN - IMPORTANT
Laura V. (Colburn) Garland
(If deceased is a married, widowed or divorced woman, give also maiden name.)
(a) Residence. No ..
31 Villa Avenue
St
(If nonresident, give city or town and State)
(Usual place of abode)
Length of stay: In place of death .......... years .......... months.2 .. ] .. days. In place of residence ....... 2 ears .......... months .......... days.
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
DEATH
AUG
6
1962
(Month)
(Day)
(YYear)
4 I HEREBY CERTIFY
That I attended deceased from
Nov 11
1959
I last saw highalive on
AUG-6, 196? death is said to
have occurred on the date stated above, at
12ºPm.
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a) ARTERIO SCLEROTIC HEART
INTERVAL
BETWEEN
ONSET AND
DEATH
6 mo
Due To
(b)
GENERAL ARTERIOSCLEROSIS
3 YRS
Due To (c)
OTHER
SIGNIFICANT
CONDITIONS
NINE
Was autopsy performed?
10
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. KINGAM.D
(Print or Type Name)
(Address).
272 PLEASANT 5
Date.
8/6 1962
6 Mt. .... Feake .... Cemetery ...... Waltham ..... Mass Place of Burial or Cremation (City or Towif)
DATE OF BURIAL
August .......... 8.
19 .. 6.2.
7 NAME OF
FUNERAL DIRECTOR
Alfred B ;. Marsh
ADDRESS_74 Winthrop St. Winthrop
Received and filed
AUG 7-1962
19
(Registrar)
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
female
9 COLOR
white
IO SINGLE
(write the word)
MARRIED
WIDOWED
DIVORCEWidowed
UNKNOWN
11 If married, widowed, or divorced HUSBAND of
(Give maiden name of wife in full)
(or) WIFE ofGeorge ..
Franklin Garland
(Husband's name in full)
12
AGE 91 Years 7
Months ..
27 Days
If under 24 hours
Hours.
.. Minutes
13 Usual
Homemaker
Occupation :
(Kind of work done during most working life)
14 Industry
or Business :
At home
15 Social Security No ....... none
16 BIRTHPLACE (City).
(State or country)
Northhampton, Mass ...
17 NAME OF
FATHER
William Colburn
18 BIRTHPLACE OF
FATHER (City)
Wilton, Maine
(State or country)
19 MAIDEN NAME
OF MOTHER Laura Ann Chamberlain
20 BIRTHPLACE OF
MOTHER (City).
Ohio, New York
(State or country)
Colburn Olmstead
(.s.o.n.).
21 Informant
(Address)
291 Pearl St, Cambridge, Mass
I HEREBY CERTIFY that a satisfactory standard certificate of death was filed with me BEFORE the burial or transit permit was issued: Walker C. Streaming
(Signature of Agent of Board of Health of other) Health Officer
(Official Designation)
(Date of Issue of Permit) 8/7/62
C 2-62-932382
Mayflower Nursing Home No
2 FULL NAME ..
(Was deceased a
U. S. War Veteran,
if so specify WAR).
.........
...
PARENTS
to ...
AUG6
19.6 L
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: PJJ (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.
×
SUFFOLK
1
(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
Winthrop
(City or Town making this return )
Registered No.
144
S(If death occurred in a hospital or institution, St. ¿ give its NAME instead of street and number) No.
Jawn
2 FULL NAME
ARTHUR
15.
WESTPHAL
(First Name)
(Middle Name)
(Last Name)
[if so specify WAR)
NO.
(If deceased is a married, widowed or divorced woman, give also maiden name.)
306 Revere St., Winthrop
H
(a) Residence. No.
( L'sual place of abode)
Length of stay :
In place of death.
......... years ..
3
.months.
.days. In place of residence.
years ..
3 .. months.
.days.
MEDICAL CERTIFICATE OF DEATH
PERSONAL AND STATISTICAL PARTICULARS
9 SEX
10 COLOR
11 SINGLE
MARRIED
WIDOWED
DIVORCED
UNKNOWN
( write the word )
divorced
(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.) Coronary artery disease.
12 If married, widowed, or divorced
HUSBAND of
June ...... Gregory.
(Give maiden name of wife in full)
(or) WIFE of
(Husband's name in full)
13 DATE OF BIRTH
14 AGE. .6.2Years.
.Monthe.
If under 24 hours Hours .. Minutes
15 Usual
Occupation
Belf employed
(Kind okwork done during most of working life)
(City or town and State)
Did injury occur in or about home, on farm, in industrial place, or public place ?
(Specify type of place)
Manner of
Injury
(How did injury occur ?)
Nature of Injury
While at work ? Was autmesy performed ?
6 Was disease or injury in any way related to occurf tom deces sed ?
(Signed) Michael
Quango, M.D.
(Print or T.pe Name)
8/7 62
(Address)
Date
19
Winthrop Cemetery Winthrop, Mass 7
Place of Burial, or Cremation. (City or Town)
August 9 1962
DATE OF BURIAL
alfred BMarch
ADDRESS 174 Winthrop St ... Winthrop ...
9 1962
19
PARENTS
21 MAIDEN NAME OF MOTHER Jeanette Nicholson
22 BIRTHPLACE OF MOTHER (City) Detroit (State or country) Michigan
23 Carole Edwina McIntosh
· Informant (Address) 306 Revere St. Winthrop
I HEREBY CERTIFY that a satisfactory standard certificate of death was filed with me BEFORE the burial or transit permit was issued:
Mass.
Malkle E Pereaux
(Signature of, Agent of Board of Health or other) Health Officer
5/9/62
(Official Designation)
(Date of Issue of Permit)/.
A TOTIS CADV
If deceased was a U. S. War Veteran, G.L. Chap. 46, Section 10, requires physicians to insert a recital to that effect. §§ 44-48.
50M-9-61-931348
RM R-303
il for burial permit hoard of Health its Agent.
N. B .- WRITE PLAINLY, WITH UNFADING BLACK INK-THIS IS A PERMANENT RECORD. 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
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 ?
16 Industry Or Business
eterinarian
17 Social Security No.
025-12-0950
Windsor
V8 BIRTHPLACE (City)
(State or country)
Canada
19 NAME OF
FATHER
William Westphal
20 BIRTHPLACE OF
Detroit
FATHER (City)
(State or country)
Michigan
M. D.
Boston
8 NAME OF FUNERAL DIRECTOR
Received and filed
PLACE OF DEATH
306 Revere Street, Winthrop
PHYSICIAN - IMPORTANT
[ ( Was deceased a U. S. War Veteran,
St.
(If nonresident, give city or town and State)
3 DATE OF
DEATH
August
6, 1962
male
white
rformed? No.
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE
RANK, RATING
ORGANIZATION AND OUTFIT
SERVICE NUMBER
RECEIVED
OF
TOWN 1
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 death's only. Ynas Those of persons who, though disabled by recognized disease unrelated to any form of injury, have died' itHour Tepentmedical attendance or whose physician is absent from home when the certificate of death is needed.
(3) Medical Examiners will investigate and certify to all Hupposably 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 death Ut 191962 PMisabled 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.)"
FIR-301A 1
V.A
NIRUCTIONS FOR C. CERTIFICATE ] giving 31 OF DEATH Giot enter 01 than one u for each a' (b) and (c)
idoes not mean me of dying, a heart failure, ic etc. It means isse, or compli- s which caused
dins, if any, hgave rise to i cause ( a ) , in the under- & cause
last. mc ortions contrib. t death but not d) the terminal condition given ).
te Chapter 137, € 1954, requires dans to print or le cause of es of death on
ertificates.
PLACE OF DEATH
Suffolk (County) Winthrop (City or Town)
The Commonwealth of Massachusetts EDWARD J. CRONIN SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS STANDARD CERTIFICATE OF DEATH
To be filled for burial permit with Board of Health or its Agent.
Registered No. 145
f(If death occurred in a hospital or institution, St. (give its NAME instead of street and number)
Jennie Lydia (Browne) Anderson
(If deceased is a married, widowed or divorced woman, give also maiden name.)
(a) Residence.
No.
17 Pleasant Street
(Usual place of abode)
Length of stay: In place of death
6
ars.
years.
months
days. In place of residence.
4 Gears
months ____. days.
MEDICAL CERTIFICATE OF DEATH
PERSONAL AND STATISTICAL PARTICULARS
DEATH
3 DATE OF
AUGUST
11
1962
(Year)
(Month)
(Day)
8 SEX
female
white
10 SINGLE
(write the word)
MARRIED
widowed
or DIVORCED
4 I HEREBY CERTIFY, That I attended deceased from
MAY
19
40, to.
AUG. 11
1962
I last saw hikalive on
AUG 10
, 19 64, death is said to
have occurred on the date stated above, at
600 A.m.
10a If married, widowed, or divorced
HUSBAND of
(Give maiden name of wife in full)
(or) WIFE of
John T. Anderson
(Husband's name in full)
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
BRONCHO PNEUMONIA
(a)
INTERVAL
BETWEEN
ONSET AND
DEATH
7 DAYS
11 IF STILLBORN, enter that fact here.
12
AGE
9.9 Years
9 Months
.27 Days
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