USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1962 > Part 3
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· WATERSIDE CEM, MARBLEHEAD
(City or Town)
Place of Burial or Cremation
JAN. 20 , 1962
19
DATE OF BURIAL
7 NAME OF
FUNERAL DIRECTOR
GLOVER G. EUSTIS
ADDRESS
142 ELM ST, MARBLEHEAD)
Received and filed ..... JAM I: RO. 19
(Registrar)
PARENTS
5 Was disease or injury in any way related to occupation of deceased? C If so, specify
(Signed)
JOSEPRI ERESCRIE
(PRINT OR TYPE SIGNATURE)
1/17 062
(Address)
ASSITE-
OTHER
SIGNIFICANT
CONDITIONS
arcetes
3 month
Was autopsy performed?
What test confirmed diagnosis?
years
Due To
(c)
Due
Due To
(b)
Carcinoma of liver
INTERVAL BETWEEN ONSET AND DEATH
DEATH WAS CAUSED BY : IMMEDIATE CAUSE
Carcinomatoris
(a)
weeken
10a If married, widowed, or divorced
HUSBAND of
(Give maiden name of wife in full)
WIDOWED
or DIVORCED
19
tto CAN, 17
(If nonresident, give city or town and State)
[(Was deceased a U. S. War Veteran,
{if so specify WAR)
Winthrop (City or Town)
Winthrop Community Hospital
No.
RM R-301A 1
4-60-928145
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE
RANK, RATING
ORGANIZATION AND OUTFIT
SERVICE NUMBER
THROW
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 - D
1
( Registrar of City or Town where deceased resided )
8 SEX
Male
9 COLOR
White
10 SINGLE
( write the word)
DEATH
(Month)
(Day)
( Year)
4 I HEREBY
CERTIFY,
That I attended deceased
from
12-3
61
1-20
62
19
I last saw
h
1 Give on
to ...
1-20
,02
...
death is said to
have occurred on the date stated above, at
INTERVAL BETWEEN ONSET AND DEATH
11 IF STILLBORN, enter that fact here.
12
AGE.
.. Years.
Months.
1
Days
...
If under 24 hours
Hours .......
Minutes
13 Usual
Occupation:
Real Estate
(Kind of work done during most of working life)
14 Industry
or Business :
Self Employed
15 Social Security No.
16 BIRTHPLACE (City)
(State or country)
Trass:
17 NAME OF FATHER Abraham Yorks
18 BIRTHPLACE OF
FATHER (City)
(State or country )
Lithuania
19 MAIDEN NAME
M. D.
OF MOTHER
Rose Kapulsky
20 BIRTHPLACE OF
MOTHER (City)
(State or country)
"Lithuania
Place of Burial or Cremation
DATE OF BURIAL
January 21;
19
7 NAME OF
FUNERAL
IRECTOR
Washington St. Porchester
ADDRESS
Received and filed Fex. M.
19
I
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
Cambridre
(City or Town making this return)
Registered No.
91
11
§ ( If death occurred in a hospital or institution, St. ¿ give its NAME instead of street and number)
Max Yorks
(If deceased is a married. widowed or divorced woman, give also maiden name.)
( Was deceased a
U. S. War Veteran.
290 River St. . .
winthrop
(a)
Residence.
No ..
( Usual place of abode)
1
20
( If nonresident, give city or town and State)
Length of stay:
In place of death .......... years.
.months.
17
days. In place of residence.
.years.
.months .....
..... days.
MEDICAL CERTIFICATE OF DEATH
PERSONAL AND STATISTICAL PARTICULARS
MARRIED
WIDOWEDTarried
or DIVORCED
10a If married. widowed. or divorcesi HUSBAND of (Give maiden name of wife in full)
(or) WIFE of
(Husband's name in full)
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
Glioma of Brain
(a)
OTHER
SIGNIFICANT
CONDITIONS
Was autopsy performed ?
yes
What test confirmed diagnosis ?
no
5 Was disease or injury in any way related to occupation of deceased ? If so, specify
Samuel Lowis
(Signed)
( Address )
475 Comm.Avo.Boston 1-21
62
Date.
Ohel Jacob Cem.
Woburn
(City or Town)
62
21
Informant
( Address)
60 Sawmiti Rd. Bristol,conn.
A TRUE COPY Sobre namara
ATTEST.
DATE FILED
(Registrar of City or Town where death occurred)
Jan. 23
62
.19 ...
V
Due To (b) 6 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 Copies of returns of deaths which occurred in your city or town in case the deceased resided in another city or town Due To (c)
THIS IS A PERMANENT RECORD
PARENTS
50M-9-59-926111
Ben jamin Birnbach
George Yorks
Mt. Auburn Hospital No ..
2 FULL NAME.
3 DATE OF
January 20, 1962
if so specify WAR,
.. St.
19
6:18P.
m.
Owks.
54
8
E.Boston
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE DATE OF DISCHARGE RANK, RATING ORGANIZATION AND OUTFIT SERVICE NUMBER
× Suffolk (County) Winthrop (City or Town) 6 Hutchinson No. PLACE OF DEATH Eric Brian Stone
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.
12
§(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)
(If deceased is a married, widowed or divorced woman, give also maiden name.) 6 Hutchinson St.
.......
(If nonresident, give city or town and State)
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
JAN
24
1962
(Month)
(Day)
(Year)
4 I HEREBY
CERTIFY,
That I attended deceased from
JAN. 22
1962, to ..
JAN
14
19
62
I last saw hikalive on
Jan 24
1962, death is said to
have occurred on the date stated above, at
10
8 10
A
„.m.
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
Acute gastroenteritis
(a)
Due To
Acute pharyngitis otilitis
(b)
medu PHARYNGITIS VITIS
Due To
(c)
OTHER
SIGNIFICANT
CONDITIONS
Sepsis
Moderato dehydration
....
Iday.
Was autopsy performed?
No
What test confirmed diagnosis ?
5 Was disease or injury in any way related to occupation of deceased? If so, specify
William aplazar
M. D).
(Signed)
William
Eldzier M.D.
(PRINT OR TYPE SIGNATURE)
(Address) Date ....
6.
Sharonmen Pack
Shacer
Place of Burial or Cremation
(City or Town)
DATE OF BURIAL
Jan 25
1962
7 NAME OF
FUNERAL DIRECTORL
Jork Funeral direction
ADDRESS
Received and filed
JAN-25-1962
.. 19
(Registrar)
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
make
9 COLOR
White
10 SINGLE
(write the word)
MARRIED
WIDOWED
or DIVORCED
Single
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
AGE.
0
Years.
8
Months.
13
.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.
16 BIRTHPLACE (City)
(State or country)
Boston mass
17 NAME OF
FATHER
Aubert & Stora
18 BIRTHPLACE OF
Boston
FATHER (City)
(State or country)
mass
19 MAIDEN NAME
OF MOTHER
anita Casalan
Everest
20 BIRTHPLACE OF
MOTHER (City)
(State or country)
mais
21 Informant
Huberth Stone
(Address) C Hutchumion yt 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) 1,44, 62
(Official Designation)
(Date of Issue of Permit)
OM-11-59-926662
ORM R-301A 1
€830
INSTRUCTIONS FOR DICAL CERTIFICATE
In giving CUSE OF DEATH do not enter more than one cause for each (a), (b) and (c)
his does not mean mode of dying, s'? os heart foilure, arenio, etc. It means tł disease, or compli- Ctons which coused di h.
onditions, if ony, hich gove rise to ove cause (o), oting the under- ing couse lost.
Conditions contrib- ug to deoth but not veted to the terminal Hise condition given
te :- Chapter 137, of 1954. requires icians to print or the cause or s of death on certificates, and ter 48, Acts of requires Physi- es to print or type under signature.
M
2 FULL NAME
(a) Residence. No.
(Usual place of abode)
INTERVAL
BETWEEN
ONSET ANO
DEATH
2 days
2days
.19 ..
PARENTS".
Registered No.
SPACE FOR ADDITIONAL INFORMATION DATE OF ENTERING MILITARY SERVICE DATE OF DISCHARGE RANK, RATING ORGANIZATION AND OUTFIT SERVICE NUMBER
X
PLACE OF DEATH ..
ORM R-301A 1 Suffolk (County) Winthrop (City or Town) € 830 6 Hutchinson No. Eric Brian Stone
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.
[(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)
6 Hutchinson St.
(If nonresident, give city or town and State)
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
8 SEX
make
9 COLOR
White
10 SINGLE
(write the word)
MARRIED
WIDOWED
or DIVORCED
Single
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
AGE.
0
Years
8
Months.
13
Days
Hours.
.Minutes
13 Usual
at home.
Occupation :
(Kind of work done during most of working life)
14 Industry
or Business :
none
15 Social Security No.
16 BIRTHPLACE (City)
(State or country)
Boston mass
17 NAME OF
FATHER®
Aubert & Stone
18 BIRTHPLACE OF
Boston
FATHER (City)
(State or country)
mass
19 MAIDEN NAME
M. D.
OF MOTHER
anita Casalan
20 BIRTHPLACE OF
MOTHER (City)
(State or country)
Everest
(Address) Date ....
-
19
6
Sharonmeny Pack
Shacon
(City or Town)
DATE OF BURIAL
Place of Burial or Cremation
Jan 25
1962
7 NAME OF
Dorf Funeral dissects
ADDRESS
Received and filed JAN-25-1962
...... .19.
(Registrar)
.PARENTS"
21 Informant
Huberth Stone
(Address) C Hetchemin et Withon
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)
1/14/ 1.8
(Official Designation)
(Date of Issue of Permit)
3 DATE OF
DEATH
JAN
24
1962
(Month)
(Day)
(Year)
4 I HEREBY CERTIFY,
That I attended deceased from
JAN. 22
1962
to ...
JAN
14
19
61
I last saw h.l.k-alive on
Jan 24
1962, death is said to
have occurred on the date stated above, at
8 ºA
DEATH WAS CAUSED BY : IMMEDIATE CAUSE
Acute gastroenteritis
(a)
Due To
(b)
Acute pharyngitis otilitis
medu PHARYNGITIS
MEDI
Due To
(c)
OTHER
Moderate dehydration
SIGNIFICANT
CONDITIONS
Sepsis
Iday.
Was autopsy performed?
No
What test confirmed diagnosis ?
5 Was disease or injury in any way related to occupation of deceased ?
If so, specify .......
(Signed)
William
Eldzier M.D.
(PRINT OR TYPE SIGNATURE)
INTERVAL
BETWEEN
ONSET AND
DEATH
2 days
-
2days
unditions, if any, hich gave rise to ove cause (a), iting the under- ing cause last.
Conditions contrib- ut? to death but not aled to the terminal lis se condition given
te :- Chapter 137, of 1954, requires icians to print or the cause or s of death on certificates, and ter 48, Acts of requires Physi- to print or type under signature.
OM-11-59-926662
2 FULL NAME
(If deceased is a married, widowed or divorced woman, give also maiden name.)
(a) Residence. No. (Usual place of abode)
INSTRUCTIONS FOR ADICAL CERTIFICATE
In giving CUSE OF DEATH do not enter more than one cause for each (a), (b) and (c)
his does not mean h mode of dying, N as heart failure, Lenia, etc. It means h disease, or compli- ans which caused Le h.
If under 24 hours
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE. RANK, RATING
ORGANIZATION AND OUTFIT
SERVICE NUMBER
RULES OF PRACTICE JAN 2 51962h&M
The fulfillment of the purpose of these laws calls for the observance following rules of practice: ^ (1) Attending physicians will certify to such deaths only as those of persons to whom they have giver. 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.
ORM R-302 1
PLACE OF DEATH
Essex
(County)
Lynn
(City or Town)
CERTIFICATE OF DEATH
Registered No.
Lynnview Hospital No.
S(If death occurred in a hospital or institution,
St. { give its NAME instead of street and number)
VotingK · Lillian Anne Piper (Hartin)
(If deceased is a married, widowed or divorced woman, give also maiden name.)
(a) Residence. No .. 97 Washington Avenue
St
Winthrop
(Usual place of abode)
Length of stay: In place of death .......... years
2
months.
days. In place of residence
months.
.days.
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
DEATH
January 29.1962
(Month)
(Day)
(Year)
4 I HEREBY CERTIFY,
That I attended deceased from
Jan. 8
19
62
Jan. 29/62
to ....
19
I last saw
h. emlive on
Jan ...
27/62, 19
....... , death is said to
have occurred on the date stated above, at 1:20 .... a
..... m.
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
Adenocarcinoma of pancreas
(a)
INTERVAL BETWEEN ONSET AND DEATH
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 ?. no. If so, specify
(Signed)
Clarence London
M. D.
(Address)
Lynnview Hosp.
Date.
1/29/62,
Forest Hills
Boston
Place of Burial or Cremation
(City or Town)
DATE OF BURIAL
February 1/62
19
7 NAME OF
FUNERAL DIRECTOR
Maurice W. Kirby
ADDRESS
Winthrop Mass.
Received and filed.
Tel. 5. 12.0
19
(Registrar of City or Town where deceased resided)
PERSONAL AND STATISTICAL PARTICULARS
8 SEX female
9 COLOR
white
10 SINGLE
(write the word)
MARRIED
WIDOWED
or DIVORCED
widow
10a If married, widowed, or divorced
HUSBAND of
Harold W. Piper
(Give maiden name of wife in full)
(or) WIFE of
(Husband's name in full)
11 IF STILLBORN, enter that fact here.
12
AGE 68
1 yr.
Years.
1
Months.
0
Days
If under 24 hours
Hours .......
Minutes
13 Usual
Occupation :
Clerk
(Kind of work done during most of working life)
14 industry
Town Hall, Winthrop
or Business :
15 Social Security No.
16 BIRTHPLACE (City)
Bo.st.on
(State or country)
Mass.
17 NAME OF
FATHER
John J. Hartin
18 BIRTHPLACE OF
FATHER (City).
(State or country)
Ireland
19 MAIDEN NAME
OF MOTHER
Elizabeth McElroy
20 BIRTHPLACE OF
MOTHER (City)
Boston
(State or country)
Mass.
21 Miss Virginia Keeler
Informant.
(Address)
Havolon Rd., Milton, Mass
A TRUE COPY
ATTEST:
(Registrar of City or Town where death occurred)
DATE FILED
Jan. 31/62
19
V.A.
MARGIN RESERVED FOR BINDING
WRITE PLAINLY, WITH UNFADING BLACK INK - THIS IS A PERMANENT RECORD
Due To (1)) 6 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 Copies of returns of deaths which occurred in your city or town in case the deceased resided in another city or town Due To (c)
25M-8-56-918227
X
The Commonwealth of Massachusetts EDWARD J. CRONIN SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS COPY OF
Lynn
(City or Town making this return)
2 FULL NAME
(Was deceased a
U. S. War Veteran,
if so specify WAR)
(If nonresident, give city or town and State)
40years
S
PARENTS
RM R-301A 1
IST
VOT ...
STRUCTIONS FOR D'AL CERTIFICATE
In giving LE OF DEATH
not enter rre than one cise for each ), (b) and (c)
h does not meon tode of dying, s heart foilure, en, etc. It meons leose, or compli- 01 which caused
o. itions, if any, h' gove rise to ber cause (o), ag the under- couse lost.
(nditions contrib- go deoth but not le to the terminol as condition given
Ne :- Chapter 137, ctof 1954. requires hy cians to print or p the cause or us of death on ·a certificates, and hater 48, Acts of 51 requires Physi- to print or type in under signature.
60-928145
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.
[(If death occurred in a hospital or institution, St. ¿ give its NAME instead of street and number)
PHYSICIAN - IMPORTANT
2 FULL NAME
Edward Everett Sargent
(First Name)
(Middle Name)
(Last Name)
(If deceased is a married, widowed or divorced woman, give also maiden name.)
(a) Residence. No.
195 Winthrop Street
St.
(If nonresident, give city or town and State)
(Usual place of abode)
Length of stay: In place of death.
.years ..
9
months.
.days. In place of residence.
4.Q
Years.
months ....
......
.. days.
MEDICAL CERTIFICATE OF DEATH
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
male
9 COLOR
white
10 SINGLE
(write the word)
married
MARRIED
WIDOWED
or DIVORCED
I last saw him.alive February 3
19 .. 62
death is said to
have occurred on the date stated above, at
7:55 a.
n.
INTERVAL BETWEEN ONSET AND
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
Arteriosclerotic & hypertensive
(a) Heart Disease
DEATH
2 yrs.
3 yrs .
13 Usual
retired printer
Occupation :
(Kind of work done during most of working life)
14 Industry
Commercial Printing ... Co.
15 Social Security No.
023-16-9856
16 BIRTHPLACE (City)
(State or country)
Massachusetts
17 NAME OF
FATHER
David Pillsbury Sargent
18 BIRTHPLACE OF
FATHER (City)
Haverhill
19 MAIDEN NAME
20 BIRTHPLACE OF
MOTHER (City)
(State or country)
Haverhill, Mass,
21 Mrs. Edward E. Sargent
Informant
(Address)
364 Winthrop 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.
(Signature of Agent of Board of Health or other)
2/6/12
(Official Designation) vV
(Date of Issue of Permit)
r
PARENTS
6
Woodlawn Cemetery
Everett, Mass ...
Pla
crematron
(City or Town)
February 6, 62 DATE OF BURIAL 19.
7 NAME OF
FUNERAL
DIRECTOR
alfred B. Marche
ADDRESS 174 Winthrop St Winthrop .....
Received and filed FEB-6-1962 19
(Registrar)
10a If married, widowed, or divorced Rose Andrews
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
AGE.
9.2Ye
3 ... Months.
1.5 Days
If under 24 hours
Hours.
Minutes
Due To
Generalized arteriosclerosis
(b)
Due To (c)
OTHER
Prostatic hypertrophy
SIGNIFICANT
CONDITIONS
3 yrs
Was autopsy performed?
NO
What test confirmed diagnosis?
Clinical & Laboratory
5 Was disease or injury in any way related to occupation of deceased? ... N.O .... If so, specify
(Signed)
M.
Traunstein,
JY.
M.D.
Maurice Traunstein, de
M. D
(State or country)
Massachusetts
(PRINT OR TYPE SIGNATURE)
19 73 Bartlett Rd. FEB. 5 10 62 OF MOTHER E. Bartlett May ,
(Address)
Winthrop 52, Massachusetts
(Year)
4 I HEREBY CERTIFY
February 16
61
February 4,
19.
to ..
That I attended deceased from 62"
19
3 DATE OF
DEATH
February
4
1962
(Month)
(Day)
[(Was deceased a
U. S. War Veteran,
NO.
(if so specify WAR)
Registered No.
No.
Bay View Nursing Home
T
Haverhill
,
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 1962 FM 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.
RM R-301A 1
STRUCTIONS FOR O AL CERTIFICATE
In giving UE OF DEATH
not enter n're than one c. se for each ), (b) and (c)
he does not mean ode of dying, s heart failure, ent, etc. It means azase, or compli- which k
n'tions, if any, hi: gave rise to yo cause (a), ug the under- cause last.
Ciditions contrib- gb death but not eito the terminal Isu condition given a)
N.c :- Chapter 137, stoof 1954, requires ly cians to print or pe the cause or uts of death on at certificates, and a er 48, Acts of $9 requires Physi- m to print or type under signature.
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