USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1963 > Part 29
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I last saw her alive on
JULY 18
1963
death is said to
have occurred on the date stated above, at 1:10 %?
... m.
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a) ACUTE MYOCARDIAL INSUFFICIENCY
INTERVAL BETWEEN ONSET AND DEATH
2days
Due
(b)
MITRAL STENOSISY RECURITATION
10YRS
€45
(Was deceased a
U. S. War Veteran,
(if so specify WAR)
(If nonresident, give city or town and State)
(write the word)
PARENTS
(City or Town making this return)
contrib- but not terminal a given
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.
JUL 191963 At.
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.
PLACE OF DEATH
suffolk
(County)
EPIT
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.
142
2 FULL NAME
Hazel B (Thompson) Magnuson
(If deceased is a married, widowed or divorced woman, give also maiden name.)
100 Terrace Ave.
St.
58
(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
Fel .. clc.
9 COLOR
.hite
10 SINGLE
(write the word)
MARRIED
WIDOWED
or DIVORCED married
10a If married, widowed, or divorced
HUSBAND of
(Give maiden name of wife in full)
(or) WIFE of
Arnold .. Ma nuson
(Husband's name in full)
11 IF STILLBORN, enter that fact here.
12
56
AGE
Years.
9
Months.
.. Days
12
If under 24 hours
Hours.
.. Minutes
13 Usual
Housewife
Occupation :
(Kind of work done during most of working life)
14 Industry
or Business :
L.
101.€
15 Social Security No.
16 BIRTHPLACE (City)
(State or country)
17 NAME OF
FATHER
Joh A Thom son
18 BIRTHPLACE OF
FATHER (City)
(State or country)
France
19 MAIDEN NAME
OF MOTHER
wedi uret niely
20 BIRTHPLACE OF
MOTHER (City)
(State or country)
York
York City
-
101 01
21
Informant
(Address)
I HEREBY CERTIFY that a satisfactory standard certificate of death was filed with me BEFORE the burial or transit permit was issued: Ralph 6. Sirianni (Signature of Agent of Board of Health or other)
Health officer
July, 22, 1963
(Official Designation)
(Date of Issue of Permit)
TVIV
S ICATE
ATH r ne ch (c) mean dying, ailure, means om pli- caused
any, e to (a), der- last. ontrib- ut not rminal given
-
OF ASUENDING COLON
Due To (c)
ULCER OF DUODENUM
OTHER
CHRONIC CHOLECYSTITIS 2
SIGNIFICANT
CONDITIONS
LITHIASIS
HIATUS HELLNHA
Was autopsy performed?
YES
What test confirmed diagnosis ?
AUTOPSY
5 Was disease or injury in any way related to occupation of deceased N.D. If so, specify
(Signed)
M. D. MYRON N.KING
(PRINT OR TYPE SIGNATURE)
(Address) : 222PLEASANT SI WINTER > Date. 7/20 63
0
Place of Burial or Cremation DATE OF BURIAL
Jul
(City or Town)
19
7 NAME OF
FUNERAL DIRECTOR
ADDRESS
!.. /m.t. . ... A ..
-
Received and filed JUL-22 1963 19
(Registrar)
PARENTS
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,
lif so specify WAR)
(a) Residence. No.
(Usual place of abode)
JULY
19
1963
(Month)
(Dầy)
(Year)
4 I, HEREBY CERTIFY,
6126
963,
to ..
That I attended deceased from
17/19
103
I last saw heRalive on
7/19 /08 Am.
3.
death is said to
have occurred on the date stated above, at .......
INTERVAL
BETWEEN
ONSET AND
DEATH
DEATH WAS CAUSED BY : IMMEDIATE CAUSE
EMBOLISM BOTH PULMONARY
(a)
ARTERIES
15 MIN
Due To POST OPERATIVE RESECTION (b)
IA
r 137, quires int or е ог th on s, and cts of Physi- r type ature.
5686
1
Winthrop Community Ho pital No.
7 3
3 DATE OF
DEATH
- SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE
RANK, RATING ORGANIZATION AND OUTFIT
SERVICE NUMBER
RULES OF PRACTICE
The fulfillment of the purpose of these laws calls for the observance of the following rules of practice :
(1) Attending physicians will certify to such deaths only as those of persons to whom they have given. bedside care during a last illness from disease un- related to any form of injury.
(2) Board of Health physicians will certify to such deaths only as those of persons who, though disabled by recognized disease unrelated to any form of injury, have died without recent medical attendance or whose physician is absent from home when the certificate of death is needed.
(3) Medical Examiners will investigate and certify to all deaths supposably due to injury. These include not only deaths caused directly or indirectly by traumatism (including resulting septicemia), and by the action of chemical (drugs or poisons) thermal, or electrical agents, and deaths following abortion, but also deaths from disease resulting from injury or infection related to occu- pation, the sudden deaths of persons not disabled by recognized disease, and those of persons found dead.
Statement of Cause of Death .- Physicians: see explanatory instructions on face side of standard certificate of death.
JUL 2 21563 1 ...
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.
1A
1
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.
143
2 FULL NAME
(If deceased is a married, widowed or divorced woman, give also maiden name.)
55 Washington Ave.
St.
(If nonresident, give city or town and State)
Length of stay: In place of death .............. years.
months
7
days. In place of residence
40
.years ..
months ..
.days.
MEDICAL CERTIFICATE OF DEATH
PERSONAL AND STATISTICAL PARTICULARS
3 DATE OF
DEATH
July
28
1963
8 SEX
Female
9 COLOR
mite
10 SINGLE
(write the word)
MARRIED
WIDOWED
or DIVORCED .-
Tidowed
4 I HEREBY
CERTIFY,
19.
That I attended deceased from
JULY 21
1963
JULY 28
63
I last saw h ........ alive on
EN
July 24
1963,
death is said to
have occurred on the date stated above, at
7:00 Am.
INTERVAL
BETWEEN
ONSET AND
DEATH
12 HRS
Due To
HuberTENSIVE HEART DISEASE
(b)
5YRS
Due To
(c)
HUBERTENSION
OTHER
SIGNIFICANT
CONDITIONS
10YRS
16 BIRTHPLACE (City)
(State or country)
Lass
17 NAME OF
FATHER
William Jone.
18 BIRTHPLACE OF
Unable to obtain
FATHER (City)
(State or country)
Labrador
19 MAIDEN NAME
OF MOTHER
Mary sinnicks
20 BIRTHPLACE OF
Labrador
MOTHER (City)
(State or country)
21
Informant
(Address)
TA Partrouth ave. ucodeor Heats.
Ine& L Brown
Place of Burial or Cremation
DATE OF BURIAL
July
{City or Town) 33
19
7 NAME OF
FUNERAL DIRECTOR
Howard & Lernoldu
ADDRESS
inthrop
JUL 30 1963
19
(Registrar)
PARENTS
(Signed)
Dorothy Cheney appleton
M. D.
DOROTHY Chefey APPLETON
(PRINT OR .TYPE SIGNATURE)
(Address ) 97 Woodside AVE Date .....
7/28
1963
HRON CLASS.
6 1.1
Was autopsy performed ?
No
What test confirmed diagnosis ?
LABORATORYLEKG
5 Was disease or injury in any way related to occupation of deceased ?
If so, specify
No
Received and filed
PLACE OF DEATH
CATE
ATH
e h (c) mean lying, ilure, neans mpli- aused
ny, 10 a), er- st.
ntrib- t not minal given
137, uires nt or : or on , and ts of hysi- type ture.
I HEREBY CERTIFY that a satisfactory standard certificate of death was filed with me BEFORE the burial or transit permit was issued: Aalph 6 Vivianne (Signature of Agent of Board of Health or other) (B)
Health Officer
July 30, 1963
(Official Designation)
(Date of Issue of Permit)
* VIL
10a If married, widowed, or divorced
HUSBAND of
(Give maiden name of wife in full)
(or) WIFE of
Fred M Leonard
(Husband's name in full)
11 IF STILLBORN, enter that fact here.
12
AGE.
74 Years
3
Months.
21
Days
If under 24 hours
Hours ..
Minutes
13 Usual
Occupation :
Housewife
(Kind of work done during most of working life)
14 Industry
or Business :
Oin home
15 Social Security No.
Beverly
586
Suffolk
(County)
No.
Winthrop Community Hos ital
Marion (Jones) Leonard
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)
(a) Residence. No. (Usual place of abode)
(Month)
(Day)
(Year)
DEATH WAS CAUSED BY : IMMEDIATE CAUSE
(a) ACUTE MYOCARDIAL INSUFICIENCIA
To be filed for burial permit with Board of Health or its Agent.
inthrop
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE
RANK, RATING
ORGANIZATION AND OUTFIT
SERVICE NUMBER ٢١
5
ERK
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 deatis el as those of persons to whom they have given bedside care during a last illness Hom 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 attfierce mindless physician is absent from home when the certificate of death Uted
(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.
01A
1
(County) Winthrop Mass.
(City or Town)
The Commonwealth of Massachusetts JOSEPH D. WARD SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS
STANDARD CERTIFICATE OF DEATH
Registered No.
144
No. Winthrop Community Hospital Aaron Gurwitz AAron Hurwitz A/k/A GURWITZ 2 FULL NAME
§(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 of divorced woman, give also maiden name. ) 62 Pleasant St.
St.
2
(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
JULY
30
1963
(Month)
(Day)
(Year)
4 I HEREBY
CERTIFY,
That I attended deceased from
1965
I last saw him).alive on
JULY 30 1963
death is said to
have occurred on the date stated above, at
5.50Pm
UDEATH WAS CAUSED BY : IMMEDIATE CAUSE
CARCINOMA OF the PROSTATE
(a)
WITH. METASTASIS TO Due To RIBS & LUNGS
(b)
1/2YRS.
Due To (c)
OTHER
SIGNIFICANT ARTERIOSCLEROSIS -
CONDITIONS
GENERALIZED
4 YRS
Was autopsy performed? No What test confirmed diagnosis? CLINICAL &X-ray.
5 Was disease or injury in any way related to occupation of deceased? o If so, specify
myron b. King
M. D.
(Signed)
MYRON NAKING M.D
(PRINT OR TYPE SIGNATURE)
(Adl/ress) 222 PLEASANT SI. te JULY 30 63
6 New Monitore COMO -Farmingdale h.l. (City or Town)
Place of Burial or Cremation aug 1 DATE OF BURIAL
7 NAME OF
FUNERAL DIRECTOR
Henry Levine
ADDRESS
Brookline, Mass
Received and filed
JUL 31-1963
19
(Registrar)
PARENTS
21
Informant
(Address)
(AT Gutwitz)
Hurwitz
62 Pleasant St. 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)
Health effacer
Feely. 36 /4 / 3
(Official Designation)
(Date of Issue of Permit)
1
V
8 SEX
M
9 COLOR
White
10 SINGLE
MARRIED
WIDOWED Widowed
or DIVORCED
10a If married, widovel, of divorcetl
HUSBAND of
Celio Mast
(Give maiden name of wife in full)
(or) WIFE of
INTERVAL
BETWEEN
ONSET AND
11 IF STILLBORN, enter that fact here.
(Husband's name in full)
5/7/63
DEATH
3 YRS
.Years ....
12
AGE89
4
.Months .....
Days
If under 24 hours
Hours.
Minutes
13 Usual
Occupation :
Salesman Mast, MIST
(Kind of work done during most of working life)
14 Industry
or Business :
Metal Work
15 Social Security No. 051-09-1680
Russia
16 BIRTHPLACE (City)
(State or country)
17 NAME OF
FATHER
Abraham Hurwitz
18 BIRTHPLACE OF
FATHER (City)
(State or country)
Russia
19 MAIDEN NAME
OF MOTHER
Leah Siegel
×
20 BIRTHPLACE OF MOTHER (City) (State or country) Al
Russia
Medi
NS FICATE EATH ter one ach id (c) t mean dying, failure, means compli- caused n nehberg porsanctions declined any, ise to (a), inder- last.
contrib- but not terminal n given ·
er 137, equires rint or use or ath on es, and Acts of Physi- or type nature.
926662
PLACE OF DEATH
Suffolk
To be filed for burial permit with Board of Health or its Agent.
(a) Residence. No. (Usual place of abode)
PERSONAL AND STATISTICAL PARTICULARS
(write the word)
SEPT 16
59
to ...
JULY 30
KREM
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE
RANK, RATING
ORGANIZATION AND OUTFIT
SERVICE NUMBER
RULES OF PRACTICE
The fulfillment of the purpose of these laws calls for the observance of the following rules of practice:
(1) Attending physicians will certify to such deaths only as those of persons to whom they have given bedside care during a last illness from disease un- related to any form of injury.
(2) Board of Health physicians will certify to such deaths only as those of persons who, though disabled by recognized disease unrelated to any form of injury, have died without recent medical attendance or whose physician is absent from home when the certificate of death is needed.
(3) Medical Examiners will investigate and certify to all deaths supposably due to injury. These include not only deaths caused directly or indirectly by traumatism (including resulting septicemia), and by the action of chemical (drugs or poisons) thermal, or electrical agents, and deaths following abortion, but also deaths from disease resulting from injury or infection related to occu- pation, the sudden deaths of persons not disabled by recognized disease, and those of persons found dead.
Statement of Cause of Death .- Physicians: see explanatory instructions on face side of standard certificate of death.
Statement of Occupation .- Precise statement of occupation is very impor- tant, so that the relative healthfulness of various pursuits can be known. Make some entry in this section for every person aged 10 years or over. If the occupa- tion had been given up or changed, or if the deceased had retired from business, report the kind of work done during most of working life even if retired. Chil- dren not gainfully employed may be returned as at school or at home. For a woman whose only occupation was that of home housework, write housework. For a person engaged in domestic service for wages, however, designate the occupation by the appropriate terms, as housekeeper-private family, cook -- hotel, etc. For a person who had no occupation whatever write none.
.ELEVEN
TO!
.31 BRK
1
6
IN
RO
JUL 311963 AM
.
1
03
rial permit Health ent.
PLACE OF DEATH
SUFFOLK
1
(County)
WINTHROP
(City or Town)
The Commonwealth of Massachusetts KEVIN H. WHITE SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS
(City or Town making this return)
MEDICAL EXAMINER'S CERTIFICATE OF DEATH
Registered No.
145
[(If death occurred in a hospital or institution,
St. ? give its NAME instead of street and number)
No.
78 Locust Street, Winthrop
2 FULL NAME
ELLEN Anne
DEL TERGO
(First Name)
(Middle Name)
(Last Name)
(If deceased is a married, widowed or divorced woman, give also maiden name.)
78 Locust Street, Winthrop
St
(a) Residence. No.
(Usual place of abode)
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
DEATH
July
31. 1963
9 SEX
female
10 COLOR
white
11 SINGLE
MARRIED
WIDOWED
DIVORCEMarried
UNKNOWN
(write the word)
(Month)
(Day)
(Year)
4 I 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.) Endocardial fibro-elastosis.
Congestive heart failure.
(or) WIFE of
(Husband's name in full)
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 ?
(City or town and State)
Did injury occur in or about home, on farm, in industrial place, or fo public place ?
(Specify type of place)
Manner of
(How did injury occur ?)
Nature of Injury
While at work?
Was autopsy performed?
6 Was disease or injury in any was related + Aupa ion of deocased ?
(Signed ....
M. D.
Michzel A. Luongo, Boston ( Print or Type Name) 8/1 63
(Address)
Date
19
Holy CrossCemetery Malden
Place of Burial or Cremation.
(City or Town)
DATE OF BURIAL
August 5.
19 .. 63
8 NAME OF
FUNERAL DIRECTOR
Vincent R Rapino
ADDRESS 9 Chelsea St., Last Boston, Mass
Received and filed
AUG 2 1963
19
(Signature of Agent of Board of Health or other) Health officer
august 2, 1963
A TRUE COPY ATTEST: (Registrar)
(Official Designation)
(Date of Issue of Permit)
/X
12 If married, widowed, or divorced HUSBAND of (Give maiden name of wife in full) Alexander Del Tergo
13 AGE3 Years.
Months ..............
If under 24 hours
Hours
....
Minutes
14 Usual
Occupation :
Housewife
Kind of work done during most of working life)
15 Industry on Business : .........
at home
16 Social Security \No. ... 027-30-0346
17 BIRTHPLACE (City) (State of country) Brookline, Mass.
18
NAME OF
FATHER
Charles J. Egan
19 BIRTHPLACE OF
FATHER (City)
(State or country)
Mass.
Cambridge
20 MAIDEN NAME
OF MOTHER
Alice Ball
21 BIRTHPLACE OF
MOTHER (City)
(State or country)
Mass
Brookline
Alexander Del'ergo (busband)
22
Informant
(Address)
78 Locust St., Winthrop
I HEREBY CERTIFY that a satisfactory standard certificate of death was filed with me BEFORE the burial or transit perinit was issued: Capl & Sirianni (3)
100M - 3-62-932695
7 §§ 44-48. of Death. See reverse side for additional information. See also Chap. 38, §§ 6, 20; Chap. 46, §§ 9, 10; Chap. 114, If deceased was a U. S. War Veteran, G.L. Chap. 46, Section 10, requires physicians to insert a recital to that effect. Injury
PHYSICIAN - IMPORTANT
[(Was deceased a
U. S. War Veteran,
no
(if so specify WAR)
(If nonresident, give city or town and State)
PARENTS
Yes.
....
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 pfiniusy963 PM
(2) Board of Health physicians will certify to such deaths a's 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.)"
X
PLACE OF DEATH
SUFFOLK
(County)
BOSTON
(City or Town)
The Commonwealth of Massachusetts KEVIN H. WHITE SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS STANDARD CERTIFICATE OF DEATH
14.6
146
DITT AT
(City or Town making this return)
Registered No. 06194 [(If death occurred in a hospital or institution, St. ( give its NAME instead of street and number) PHYSICIAN - IMPORTANT
2 FULL NAME
Mary J Collins
(If deceased is a married, widowed or divorced woman, give also maiden name.)
........
St
Winthrop, Mass.
(City or town and State)
Length of stay: In place of death .......... years ..
.. 1 ... months.2.6days. In place of residence.
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