USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1962 > Part 38
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SERVICE NUMBER
FORM R-301
1
No PLACE OF DEATH 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. 187
[(If death occurred in a hospital or institution,
St. ¿ give its NAME instead of street and number)
PHYSICIAN - IMPORTANT
2 FULL NAME.
Sebastiano Bordinaro
(If deceased is a married, widowed or divorced woman, give also maiden name.)
94 Summiaide Que
St
(If nonresident, give city or town and State)
Length of stay: In place of death. 0 years months days. In place of residence 0 years months days.
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
DEATH
October
24
1962
(Month)
(Day)
(Year)
4 I HEREBY CERTIFY , That I attended deceased from
19
62
to ...
Oct. 24
19.
62
I last saw hivalive on
10/221
19.62, death is said to
have occurred on the date stated above, at
11:30 A.m.
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a) Cancer of Prostate
INTERVAL BETWEEN ONSET AND DEATH 5yrs.
Due To (b)
Due To (c)
OTHER
CONDITIONS
Carcinomatosis due Above.
4 yrs.
Was autopsy performed?
No
What test confirmed diagnosis
Clinical: Pathological.
5 Was disease or injury in any way related to occupation of deceased ?/V If so, specify
(Signature)
M. D. CHARLES LIBERMAN
(Print or Type Name)
Winthrop Wass Date 10/25/1962
(Address)
JA Michaels
Boston Maso
(City or Town)
DATE OF BURIAL
..........
7 NAME OF
FUNERAL DIRECTOQ
Ernest Playgiano 147 Winthrop St Winthrop
Received and filed DE1 961002
19
PERSONAL AND STATISTICAL PARTICULARS
8 SEX Male
9 COLOR
White
10 SINGLE MARRIED WIDOWED DIVORCED UNKNOWN
(write the word) Widowed
11 If married, widowed or divorced HUSBAND of Sabastiana Vernullo
(Give maiden name of wife in full)
(or) WIFE of.
(Husband's name in full)
12
77
AGE
Years.
8
.Months.
10
.Days
If under 24 hours
Hours .....
Minutes
13 Usual
Occupation :
(Kind of work done during most working life)
14 Industry
or Business :
Building Cont.
15 Social Security No.
16 BIRTHPLACE (City)
(State or country )
Italy
17 NAME OF FATHER Joseph Bordonaro
18 BIRTHPLACE OF
FATHER (City).
(State or country)
Italy
19 MAIDEN NAME
OF MOTHER
antonietta Friscia
20 BIRTHPLACE OF
MOTHER (City)
(State or country)
Italy
Wra Ruce Morattia
21 Informant
(Address)
116 Summit 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) Hechte Afin 11/26/62
(Registrar){} (Official Designation)
(Date of Issue of Permit)
-X
fid for burial permit th loard of Health its Agent. I TRUCTIONS FOR DIL CERTIFICATE
RIT OR TYPE U!, OR CAUSES (' DEATH
not enter rre than one c.se for each f ), (b) and (c)
Ti. does not mean code of dying, h s heart failure, hea, etc. It means :case, or compli- io which caused it
Cilitions, if any, w.h gave rise to le cause (a). ing the under- yt cause last.
Conditions contrib- in to death but not a! to the terminal e: condition given 1.
2-62-932382
A TRUE COPY ATTE ITEST:
Cot 27
19 62
ADDRESS
X 508801K (County)
94 Junnyade ave
(City or Town making this return)
(a)
Residence. No ....
(Usual place of abode)
(Was deceased a U. S. War Veteran, (if so specify WAR)
Retired Laborer
PARENTS
6 Place of I urial or Cremation
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE.
DATE OF DISCHARGE RANK, RATING
ORGANIZATION AND OUTFIT
SERVICE NUMBER
11 12
ERK
5
HI
OCT 2 61962-AM
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.
X
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
(City or Town making this return)
Registered No. 188
[(If death occurred in a hospital or institution, St. ¿ give its NAME instead of street and number)
PHYSICIAN - IMPORTANT
2 FULL NAME.
(If deceased is a married, widowed or divorced woman, give also maiden name.)
14 Waldemar Ave
Winthrop
(a)
Residence. No ...
(Usual place of abode)
Length of stay: In place of death .......... years .......... months.
10
days. In place of residence .......... years .......... months .......... days.
MEDICAL CERTIFICATE OF DEATH
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
M
9 COLOR
White
10 SINGLE
MARRIED
WIDOWED
DIVORCED
UNKNOWN
Jessica;
(write the word) -
11 If married, widowed, or divorced HUSBAND of
(or) WIFE of
(Husband's name in full)
12
AGE 73 Years.
Months.
„Days
If under 24 hours
Hours .....
.Minutes
13 Usual
Occupation :
Porter
(Kind of work done during most working life)
14 Industry
or Business :
Hospital.
15 Social Security No ..
16 BIRTHPLACE (City)
(State or country)
Bastone Mass
17 NAME OF
FATHER
Clarence
Poland.
18 BIRTHPLACE OF
FATHER (City).
(State or country)
mais.
Wischenden
19 MAIDEN NAME
OF MOTHER
marry
20 BIRTHPLACE OF
MOTHER (City) ..
(State or country)
nass
Winchendone
Hospital Record
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).
10/25/62
(Official Designation)/ 11
(Date of Issue of Permit)
TAV
A TRUE COPY ATTEST:
25
1962
(Month)
(1)ay)
(Year)
4 IHEREBY CERTIFY , That I, attended deceased from
10/15
1962
to ...
10/25
1962
I last saw hallalive on
10/20
19.6 %, death is said to
have occurred on the date stated above, at
720Am.
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
ACUTE PULMONARY ENIBOLUS
(a)
15 MIN
Due To
ACUTE PRECMENITIS
(b)
10 DAYS
Due To (c)
OTHER
SIGNIFICANT
CONDITIONS
NONE
Was autopsy performed?
What test confirmed diagnosis ?
CLINICAL
5 Was disease or injury in any way related to occupation of deceased ?/1 ... If so, specify
(Signature)
M. D. MYRON N KING
(Print or Type Name)
(Address)22 D'LEHSAAT SI
Date 10/25 1962
6
Place of Turial or Crometien
(City or Town)
DATE OF BURIAL Oct. 29 1962
7 NAME OF
FUNERAL DIRECTOR
David malcolm
ADDRESS Reading Pass.
Received and filed 00: 95 1902 ... 19 ..
(Registrar)
2-62-932382
ORM R-301
le for burial permit Jard of Health orts Agent. IN: RUCTIONS FOR IC. CERTIFICATE
IN OR TYPE SIOR CAUSES O. DEATH d not enter ne: than one a'e for each (1 (b) and (c)
isdoes not mean 1de of dying, heart failure, 'n etc. It means diase, or compli- n. which caused
tions, if any, si, gave rise to o cause (a), ug the under- cause last.
(sditions contrib- > death but not e to the terminal us condition given
Winthrop Community Hospital No Clarence Foster Poland
.........
St
(Was deceased a
U. S. War Veteran,
if so specify WAR)
(If nonresident, give city or town and State)
nichole
(Give maiden name of wife in full)
INTERVAL
BETWEEN
ONSET AND
DEATH
3 DATE OF
DEATH
October
1
Readings man
PARENTS
21 Informant
(Address)
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 imfec siom related to oger- pation, the sudden deaths of persons not disabled by ludgnized) disease, land 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.
FI R-301 1
ISIUCTIONS FOR SI CERTIFICATE
] giving JJOF DEATH got enter o than one u for each a (b) and (c)
s oes not mean n'e of dying, a heart failure, & etc. It means se, or compli- which caused
a ons, if any, gave rise to cause (a), the under- i cause last.
clitions contrib- death but not to the terminal ondition given 1.C.
e :- Chapter 137, of 1954 requires cians to print or the cause or s of death on certificates, and ter 48, Acts of requires Physi- to print or type under signature.
- 61-930213
PLACE OF DEATH
X SUFFOLK (County) WINTHIPOP (City or Town)
The Commonwealth of Massachusetts KEVIN H. WHITE SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS STANDARD
To be filed for burial permit with Board of Health or its Agent.
209 SHIRLEY ROSEANNEI ROSANNA THERRIEN
2 FULL NAME
(First Name)
(Middle Name)
(Last Name)
U. S. War Veteran,
[if so specify WAR)
NO
(If deceased is a married, widowed or divorced woman, give also maiden name.)
(a) Residence. No. (Usual place of abode)
209 SHIRLEY
.. St.
(If nonresident, give city or town and State)
Length of stay: In place of death
5 years
.. months.
.. days.
In place of residence.
5 years.
months.
.. days.
MEDICAL CERTIFICATE OF DEATH
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
FEMALE KHITET
9 COLOR
10 CITIZEN
OF U.S.
YES
NO
11 SINGLE
MARRIED
WIDOWED
DIVORCED
UNKNOWN
lla If married, widowed, or divorced HUSBAND of
(Give maiden name of wife in full)
(or) WIFE of
EUGENE MICHEL
(Husband's name in full)
12 DATE OF BIRTH
FEB 29 1874
13
AGE.
Years.
.Months .........
.. Days
If under 24 hours
.. Hours
.. Minutes
14 Usual
HOME MAKER.
Occupation :
(Kind of work done during most of working life)
15 Industry
or Business :
HOME.
16 Social Security No. CANADA
17 BIRTHPLACE (City)
(State or country)
18 NAME OF FATHER ONNNOWY) THERBIEN
19 BIRTHPLACE OF
FATHER (City)
(State or country)
CANADA
20 MAIDEN NAME
OF MOTHER UNKNOWN/ LAFONDE
21 BIRTHPLACE OF
MOTHER (City)
(State or country)
MRS GEO MO DUFFEL
22
Informant
(Address)
209 SHIRLEYST WINTHROP
I HEREBY CERTIFY that a satisfactory standard certificate of death was filed with me BEFORE the burial or transit permit was issued: RalphE Seranni
(Signature of, Agent of Board of Health or other)
Health Offen
Oct 26,1962
(Date of Issue of Permit)
TX
A TRUE COPY ATTEST:
(Registrar)
PARENTS
MIT CALVERY MANCHESTER NM 6
(City or Town)
DATE OF BURIAL OCT 29 1942
7 NAME OF
FUNERAL DIRECTOR
MAURICE W KIRBY
ADDRESS WINTHROP.
Received and filed
OCT 31-1962
... 19.
CERTIFICATE OF DEATH ST.
Registered No.
189
§(If death occurred in a hospital or institution,
St. { give its NAME instead of street and number)
PHYSICIAN - IMPORTANT
MICHEL [(Was deceased a
(Month)
(Day)
(Year)
4 I HEREBY CERTIFY,
19
to.
That I attended deceased from
19.
I last saw h ........ alive on
19
.. , death is said to
have occurred on the date stated above, at
5:45pm.
DEATH WAS CAUSED BY : IMMEDIATE CAUSE
(a)
Natural Causes
INTERVAL
BETWEEN
ONSET AND
DEATH
Due To
(b)
· Presumably Coronary Occlusion
(c)
Due To
Arteriosclerotic Heart Disease
OTHER
SIGNIFICANT
CONDITIONS
none
Was autopsy performed?
no
What test confirmed diagnosis? post mortem judgement
5 Was disease or injury in any way related to occupation of deceased? no If so, specify Arthur C. Murray M. D.
Arthur C. Murray
(Print or Type Name)
Winthrop Board of Health
Date
26 Oct
1962
Place of Burial or Cremation
October
26
1962
3 DATE OF
DEATH
No.
(Official Designation)
CANADA.
86
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.
OGIsaply 1 1962 FM
(3) Medical Examiners will investigate and certify to all deaths 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
Essex
The Commonwealth of Massachusetts KEVIN H. WHITE SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS TIM COPY OF CERTIFICATE OF DEATH
Danvers
(City or Town making this return)
Registered No.
190
(City of Town)
Danvers State Hospital Hathorne
[(If death occurred in a hospital or institution,
St. ¿ give its NAME instead of street and number)
Mary E. Lawson
2 FULL NAME ...
(If deceased is a married, widowed or divorced woman, give also maiden name.)
17 Girdlestone Road
(a) Residence. No.
(Usual place of aboder
4
22
Length of stay: In place of death .......
.years.
.months .......... days. In place of residence .......... years .......... months.
.. days.
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
female
9 COLOR
white
10 SINGLE
MARRIED
WIDOWED
DIVORCED
UNKNOWN
single
11 If married, widowed, or divorced HUSBAND of (Give maiden name of wife in full)
(or) WIFE of.
(Husband's name in full)
12
63
8
If under 24 hours
Hours .....
.Minutes
AGE
......... Y'ears.
Months ........
.. Dayz
factory worker
13 Usual
Occupation :
(Kind of work done during most working life)
14 Industry
or Business :
Greeting Cards
022-03-3982
15 Social Security No ........
Montrest
16 BIRTHPLACE (City) ..
(State or country )
Cenada
17 NAME OF
FATHER
Faward P. Lawson
18 BIRTHPLACE OF
FATHER (City) ..
(State or country)
Ireland
19 MAIDEN NAME
OF MOTHER
Mory Kerwin
20 BIRTHPLACE OF
MOTHER (City) ..... England
(State or country)
Mary E. Sheehan
Hathorne, dass.
A TRUE COPY
ATTEST:
Daniel Toonly
(Registrar 'of City or Town where death occurred)
DATE FILED
October 31, 19 62
INCK
+ V.B.V
(Registrar of City or Town where deceased resided)
PARENTS cd
holy Cross Cemetery, Talden
6 Place of Burial or Cremation
(City or Town)
October 30,
62
DATE OF BURIAL
19
7 NAME OF
Arthur J. O'Meley
FUNERAL DIRECTOR
Winthrop, Mass.
ADDRESS
Received and filed
NOV 1 1962
19
INTERVAL BETWEEN ONSET AND DEATH
OTHER
SIGNIFICANT
CONDITIONS
Uremia
No
Was autopsy performed ?
Clinical & Laboratory
What test confirmed diagnosis ?
5 Was disease or injury in any way related to occupation of deceased ? If so, specify
Willard M. Hausman
(Signed)
Willard M Hausman M. D.
(Address)
Hp thorne, Mass
10/27/
62
.Date
19
SOM - 10-61-931673
Due To (b) 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)
WRITE PLAINLY, WITH UNFADING BLACK INK OR USE APPROVED BLACK TYPEWRITER RIBBON -
WANNWARSTWA ROD BINDING THIS IS A PERMANENT RECORD
m.c.
DRM R-302
1
(County )
Denvers
No
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
DEATH
(Month)
(Day)
(Year)
4 JuhEREBY CERTIFOCEBBdrattadd deceased Con
er ...
19 ...
October
62
19
I last saw h ...... alive on
1.308
.... , death is said to
have occurred on the date stated above, at
m.
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
Acute Pyelonephritis
(a)
October
27,
1962
[ Winthrop,
Mess.
St
(W'as deceased a
U. S. War Veteran,
if so specify WAR
(li nonresident, give city or town and State)
(write the word)
21 Informant
(Address)
SPACE FOR ADDITIONAL INFORMATION DATE OF ENTERING MILITARY SERVICE DATE OF DISCHARGE RANK, RATING ORGANIZATION AND OUTFIT
SERVICE NUMBER
3
6
202.
NOV 1 1962 AM
X 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
Registered No.
191
[(If death occurred in a hospital or institution, St. ( give its NAME instead of street and number)
2 FULL NAME Euphemia (Hodgson) Hatley
(If deceased is a married, widowed or divorced woman, give also maiden name.)
(a) Residence. No. 41 Washington Ave.
(Usual place of abode)
2
35
(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
OCT 29 1962 (Year)
(Month)
(Day)
That I attended deceased from
,62
I last saw h&Ralive on
OCT 29
1962, death is said to
6 30 Pm.
have occurred on the date stated above, at ....
INTERVAL
BETWEEN
DEATH WAS CAUSED BY : IMMEDIATE CAUSE
ACUTE CORONARY OCCLUSION
(a)
ONSET AND
DEATH
15MIN
11 IF STILLBORN, enter that fact here.
12
85
AGE
Years.
10
Months
14 Days
If under 24 hours
Hours
Minutes
13 Usual
Housewife
Occupation :
(Kind of work done during most of working life)
14 Industry
or Business :
At home
15 Social Security No.
None
16 BIRTHPLACE (City) Shelburne.
(State or country) Nova Scotia
17 NAME OF
FATHER
William Hodgson
18 BIRTHPLACE OF
FATHER (City)
(State or country)
Nova Scotia
19 MAIDEN NAME
OF MOTHER
Catherine Locke
20 BIRTHPLACE OF
MOTHER (City)
(State or country)
Nova Scotia
21 Roberta Barter
Informant (Address) 46 Douglas 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:
(Signature of Agent of Board of Health or other)
Gefette officer
10/31/68
(Official Designation)
(Date of Issue of Permit)
1X
N:RUCTIONS FOR CERTIFICATE IC
giving S OF DEATH
donot enter ic than one ale for each 'a (b) and (c)
does not mean rde of dying, heart failure, mi etc. It means liise, or compli- u which caused
n'ions, if any, gave rise to cause (@), tz the under- n cause last.
Ciditions contrib- › death but not to the terminal s condition given
:- Chapter 137, f 1954. requires ians to print or the cause or of death on certificates, and er 48, Acts of requires Physi- to print or type ander signature.
6
Winthrop
winthrop
Place of Burial or Cremation
DATE OF BURIAL
(City or Town)
NOV. I
19
62
7 NAME OF
FUNERAL DIRECTOR
Howard S Reynolds
ADDRESS jinthrop, Mass
Received and filed
OCT 31 1962
19
(Registrar)
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
Female
9 COLOR
White
10 SINGLE
MARRIED)
WIDOWED
or DIVORCED Widow
10a If married, widowed, or divorced
HUSBAND of
(Give maiden name of wife in full)
(or) WIFE of Eugene Hatley
(Husband's name in full)
Due To
ARTERIO-SCLEROTIC
(b)
HEART DIS
8 YRS
Due To
(c)
OTHER SIGNIFICANT NONE 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)
MYRON N. KING M.D
M. D.
(PRINT OR TYPE SIGNATURE) (Address)22 PLEASANT ST. Date.
Wilson
10/30 62
PARENTS
To be filed for burial permit with Board of Health or its Agent.
No. Bay View Nursing Home
PHYSICIAN - IMPORTANT [(Was deceased a U. S. War Veteran, lif so specify WAR)
St.
(write the word)
4 L HEREBY CERTIFY,
MAR 30 50
to ....
Oct: 29
RI R-301A 1
M-6-59-925686
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE
TOW
RANK, RATING
ORGANIZATION AND OUTFIT.
SERVICE NUMBER
0
RULES OF PRACTICE OCT.311962 PM
The fulfillment of the purpose of these laws calls for the observancel 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.
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