USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1963 > Part 34
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If so, specify
Michael J.Baccari,
M.D.
(Signature)
michael & Bass
M. D.
July 179 63
PARENTS
(Address)
(Print or Type Name)
VAH Boston, Mass.
Woodlawn Cem. Everett, Mass. 6 Place of llurial or Cremation (City or Town)
DATE OF BURIAL
7-20-63
19.
7 NAME OF
FUNERAL DIRECTOR
Brown F.H.
11 Pembroke St., Medford, Mass.
ADDRESS
belliam & Kane.
JUL-2 4.1963 ..
63
11 If married, widowed, HUSBAND of
(or) WIFE of.
(Husband's name in full)
12
AGE.70
0
Months
7
ars ..
Days
1f under 24 hours
Hours . Minutes
13 Usual
Occupation.
(Kind of work done during most of working life)
14 Industry
or Business ..
1
15 Social Security No.
013-22-7527
16 BIRTHPLACE (City).
(State or country )
17 NAME OF
FATHER
Lars
18 BIRTHPLACE OF
FATHER (City). ...
(State or country)
.. Norway
19 MAIDEN NAME
OF MOTHER
Henrietta Von Schoppe
20 BIRTHPLACE OF
MOTHER (City).
(State or country )
21 Informant
V.A. Hospital Records 150 S. Huntington Ave. Boston, Mass
I HEREBY CERTIFY that a satisfactory standard certificate of death was filed with me BEFORE the burialfr transit peryen was issued: aqueline Dasole ris: Signature of Agent of Board of Health or other)
112491
7/19/03
(Date of Issue of Permit )
( Registrar) | (Acial Designation)
THUISPADV ITTPIT.
R-301
1 permit ealth
ATE
PE SES
C 2 (c) mean ying. ilure. mpli- used
y, 10 er- st. strib- t mot minal given
i ed Opy
7/ 1963 $3
1
(City or Town)
Veterans Administration Hospital
No
Registered No.
f(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,
WW 1
if so specify WARI
Winthrop, Mass
.. St
1 10 Length of stay : In place of death .......... years.
17
1963
3 DATE OF
DEATH
July
That I attended deceased from
(Give maiden name of wife in full)
liver
2 mos
Plumber, retired
Nova Scotia
Nova Scotia
( Address)
A TRUE COPY ATTEST:
Williaml. Kane. City Registrar
TU
5
0
THROP
SEP 2 31963 AM
1
X
PLACE OF DEATH
Suffolk
(County)
Boston
The Commonwealth of Massachusetts KEVIN H. WHITE SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS
OUT - OF
167 TOWN
(City or Town making this return)
07593
Registered No.
[(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.)
12 Sewall Ave.
Ist
Winthrop, Mass'
(City or town and State)
Length of stay: In place of death ......... years .......... months ...
.years .......... months.
.. days.
MEDICAL CERTIFICATE OF DEATH
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
Male
9 COLOR
white
0 SINGLE
MARRIED MATT
WIDOWED
DIVORCED
UNKNOWN
aord)
--
11 If married, widowed,.
HUSBAND of
Maude Phillips
(Give maiden name of wife in full)
(ot) WIFE of.
(Husband's name In full)
12
AGE .. 67. Years.11
.Months .. 28
.Days
If under 24 hours
Hours.
.. Minutes
13 Usual
Occupation
Ret. Grill Man
(Kind of work done during most of working life)
14 Industry
of Business
023 10 3896
15 Social Security No ...
Swampscott
16 BIRTHPLACE (City)
(State or country}
Mass.
17 NAME OF
FATHER
George
18 BIRTHPLACE OF
France
FATHER (City).
(State or country)
19 MAIDEN NAME
OF MOTHER
Whorf
20 BIRTHPLACE OF
MOTHER (City) ...
(State or country)
Massachusetts
West Lawn Cem. Lowell, Mass. 6
Place of Ilurial or Cremation
(City of Town)
DATE OF BURIAL
July .... 27 ..
1963
19.
7 NAME OF
FUNERAL DIRECTOR
Reynolds F.H.
ADDRESS
I HEREBY CERTIFY that a satisfactory standard certificate of death 180 Winthrop St., Winthrop, Mass' wasfiled with my BEFORE (the burial or transit permit was issued;
Leonauf. Kace.
3
JUL 32 1958
(Registrar)
A TRUE COPY ATTEST:
Wic 1
with mural thrombosis
Due TRt Chronio .pyelonephritis (c)
yrs
OTHER
SIGNIFICANT
CONDITIONS
Was autopsy performed ?
Yes
What test confirmed diagnosis?
Autopsy
5 Was disease or injury in any way related to occupation of deceased ? If so, specify
(Signature)
M. D.
D. OBrien M.D.
(Print or Type Name)
(Address) ... VAR Boston, Mass Date July 251963
PARENTS
V.A. Hospital Records 150 S.
21 Informant
Huntington Ave., Boston, Mass.
(Address)
Al (Signature of Agent of Board of Health or other)
18835-
7/26/63
(Official Designation) (Date of Issue of Permit)
553
ial permit Health t.
CATE
PE JSES
r he ch (e) mean dying, ailure. means ompli- caused
any, 10 (a). der- last. ontrib- ut not rminal given .
20
1
(City or Town)
Veterans Administration Hospital
No
George A. _ WOOD
(a) Residence. No.
(Usual place of abode)
24.
1963
3 DATE OF
DEATH
K July
(Month)
(1)ay)
(Year)
A LHEREBY CERTIF 63 July 24
to
That
attended deceased
63
19
XXXXXXXX death is said to
have occurred on the date stated above, at 2: 00P .m.
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
INTERVAL BETWEEN ONSET AND DEATH
(a) Recent ... infarction .. Rt ... cerebellum 4day
Due To Septal myocardial infarction (b)
July 16 19.
( Was deceased a
U. S. War Veteran,
WW I
(if so specify WAR).
.days. In place of residence. 23
STANDARD CERTIFICATE OF DEATH
R-301
A TRUE COPY ATTEST:
William). Kance
City Registrar OF TOW.
11.12
FFICE
CLERK
MIN
5
WII
MA
OCT 31963 PM
1
R-302
No ...
( Usual place of abode)
( Month)
8/13
19
630.
I last saw
h.
(b)
(c)
OTHER
SIGNIFICANT
CONDITIONS
6
Holy .... Cross
Copies of returns of deaths which occurred in your city of town in case the deceased resided mit another city of town
Due To
Brain tumor
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.)
3 DATE OF
DEATH
August 14, 1963
(Day)
(Year)
8 SEX
Female
9 COLOR
White
10 SINGLE
( write the word)
MARRIED
WIDOWED
or DIVORCED
Married
4 I HEREBY CERTIFY.
That I attended deceased from
8/14
19
63
19.
63 death is said to
have occurred on the date stated above, at
11:40P
... m.
INTERVAL
BETWEEN
ONSET AND
DEATH
24 hrs
11 IF STILLBORN, enter that fact here.
12
AGI
32
Years ...
-
.Months ....
...... Days
If under 24 hours
Hours ........ Minutes
13 Usual
Occupation:
Reg ....... Nurse
(Kind of work done during most of working life)
14 Industry
or Business :
Nursing
15 Social Security No.
029-24-8220
16 BIRTHPLACE (City)
(State or country)
Winthrop,
Mass
17 NAME OF
FATHER
George H. Ostman
18 BIRTHPLACE OF
FATHER (City)
Winthrop,
(State or country )
Mass,
19 MAIDEN NAME
OF MOTHER
Bridie Feeney
20 BIRTHPLACE OF
MOTHER (City)
( State or country )
Ireland
21
Informant
Bridie Ostman
( Address )
100 Marshall St. ,Winthrop
7 NAME OF
FUNERAL DIRECTOR
Arthur J. O' Maley
ADDRESS Winthrop, Mass
A TRUE COPY
ATTEST :
Client Y. Lilym
( Registrar of City or Town where death occurred )
Received and filed
XXXXXXXXXX 19
SEP 16 1963
DATE FILED
August 19,
63
19.
....
TVAV
1
Lynn
(City or Town)
The Commonwealth of Massachusetts JOSEPH D. WARD SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS COPY OF CERTIFICATE OF DEATH
Lynn
(City or Town making this return)
168 ...
S (If death occurred in a hospital or institution,
.St. ¿ give its NAME instead of street and number)
2 FULL NAME
Claire Caruso
(Ostman)
(If deceased is a married, widowed or divorced woman, give also maiden name.)
(a) Residence. No ...
100 Marshall
St
Winthrop
( If nonresident, give city or town and State)
Length of stay: In place of death .......... years ....
.. months.
1
days. In place of residence
years.
.months.
........ days.
32
MEDICAL CERTIFICATE OF DEATH
PERSONAL AND STATISTICAL PARTICULARS
10a If married, widowed, or divorced
HUSBAND of
(Give maiden name of wife in full)
(or) WIFE of
Nicholas W. Caruso
(Husband's name in full)
DEATH WAS CAUSED BY : IMMEDIATE CAUSE
(a)
Cardiac failure
mos
PARENTS
( Signed )
Sidney Paly
M. D.
( Address )
Swampscott.
Date
8/16
. 19 63
Mal.den
Place of Burial or Cremation ( City or Town)
DATE OF BURIAL Aug ........ 17,
19
63
50M-9-59-926111
PLACE OF DEATH
Essex
(County)
Registered No.
Lynn Hospital
( Registrar of City or Town where deceased resided )
no
5 Was disease or injury in any way related to occupation of deceased ?
If so, specify
Was autopsy performed?
What test confirmed diagnosis ?
.x-ray.
281 Humphrey St.
Due To
Hydrocephalus
Ło.,
8/1/1
( Was deceased a
U. S. War Veteran.
if so specify WAR,
TON
ông Hả Đường, ha,
.LEIK
WINTHROP
6
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE DATE OF DISCHARGE RANK, RATING ORGANIZATION AND OUTFIT SERVICE NUMBER
SEP 1 61963 AM
M R-302
1
PLACE OF DEATH
Middlesex (County) Cambridge
The Commonwealth of Massachusetts KEVIN H. WHITE SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS COPY OF CERTIFICATE OF DEATH
169
Cambridge
(City or Town making this return)
Registered No.
1208
[(If death occurred in a hospital or institution, St. ¿ give its NAME instead of street and number)
Ralph James Paone
2 FULL NAME
(If deceased is a married, widowed or divorced woman, give also maiden name.)
38 Paine St.
St
(if so specify WAR, "inthrop, Mass.
(a)
Residence. No ..
(Usual place of abode)
22
21
(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
August 16, 1963
DEATH
(Month)
(Day)
(Year)
4 I HEREBY CERTIFY
July
63
19 ..
That I attended deceased from
16
19
53
I last saw h.
Lative on
19
19.
to.
Aus.
16,
O death is said to
have occurred on the date stated above, at
10:30a.
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
Peritonitis
INTERVAL BETWEEN ONSET AND DEATH 2wks.
Due To
Ca. Stomach
(b)
Due To (c)
OTHER
SIGNIFICANT
CONDITIONS
Was autopsy performed?
yes
What test confirmed diagnosis ?
Autopsy
5 Was disease or injury in any way related to occupation of deceased ? . If so, specify
(Signed)
Albert S. Murphy
M. D.
(Address)
Boston, Mass.
Date
8-16. 63
winthrop Com.
Winthrop, Mass.
Place of Burial or Cremation
Au ;. 19
19.
FUNERAL DIRECTOR
ADDRESS
210 Winthrop St. Winthrop
Received and filed
SEP 11 1963
19
(Registrar of City or Town where deceased residled)
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
Male
9 COLOR
Whi to
10 SINGLE
(write the word)
MARRIED
WIDOWED Married
DIVORCED
UNKNOWN
11 If married, widored orfdiyorfed Venti
HUSBAND of
(or) WIFE of.
(Husband's name in full)
12
57
AGE
Years
Months .......
.. Days
If under 24 hours
.Hours ........ Minutes
13 Usual
Occupation :.
(Kind of work done during most working life)
14 Industry
Sunshine Biscuit
or Business:
012-10-1638
15 Social Security No.
16 BIRTHPLACE (City) ....... 33%
(State or country)
17 NAME OF
FATHER
Cosmo Paone
18 BIRTHPLACE OF
FATHER (City)
(State or country)
Italy
19 MAIDEN NAME
OF MOTHER
(c.n.b.l.) Albano
20 BIRTHPLACE OF
MOTHER (City).
(State or country)
Italy
Mrs. Ralph Paone
21 Informant
(Address)
38 Paino St. inthrop
A TRUE COPY
ATTEST :
(Registrar of City or Town where death occurred)
DATE FILED
Aug . 19,
19 6
TVK
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
50M - 10.61-931673
C.
resided as soon as possible, after the close of the month in which the death occurred. (See Chap. 46, Sec. 12, G. L.)
(City or Town)
Mount Auburn Hospital
No ..
7 NAME OF
Maurice ... Kirby
(City or Town)
63
DATE OF BURIAL
PARENTS
Salesman
6mos.
(Give maiden name of wife in full)
(a)
Aus,
(Was deceased a
U. S. War Veteran,
no
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE DATE OF DISCHARGE RANK, RATING ORGANIZATION AND OUTFIT SERVICE NUMBER
ROP MASS
SEP 11 11963 AM
R-301
rial permit E Health ent. ONS
IFICATE
TYPE AUSES TH ter one each nd (c)
ot mean dying, failure. It means compli- caused
f any, rise to (a), under- last.
contrib- but not terminal on given
PLACE OF DEATH
Suffolk (County)
SENSE
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)
120
S(If death occurred in a hospital or institution, No
St. } give its NAME instead of street and number)
PHYSICIAN - IMPORTANT
2 FULL NAME
Albertine Cecelia (Bolm) Drake
(If deceased is a married, widowed or divorced woman, give also maiden name.)
(a) Residence. No ..
25 Sargent Street
(Usual place of abode)
St
(If nonresident, give city or town and State)
Length of stay: In place of death ... 4 .. years.
... months .......... days. In place of residence ..
4 Years.
......... months .......... days.
MEDICAL CERTIFICATE OF DEATH
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
female
9 COLOR
white
10 SINGLE
MARRIED
WIDOWED
DIVORCED
UNKNOWN
(write the word)
Widowed
11 If married, widowed, or divorced HUSBAND of
(Give maiden name of wife in full)
(or) WIFE of .... MillardLlewellynDrake
(Husband's name in full)
12
82
2
6 hp
AGE.S.IYears
2
Months.
21
Days
If under 24 hours
Hours .....
Minutes
13 Usual
Occupation :
Housewerk
(Kind of work done during most working life)
14 Industry
or Business OWN At Home
15 Social Security No ....
022-10-64.88
16 BIRTHPLACE (City) ... Boston, Mass, (State or country)
17 NAME OF
FATHER
Leon Bohm
18 BIRTHPLACE OF
FATHER (City).
(State or country)
Germany ......... (Europe)
19 MAIDEN NAME
OF MOTHER
Louise A. Favier
20 BIRTHPLACE OF
MOTHER (City).
(State or country )
Weshington, D. C .......
Winthrop, Cemetery
Winthrop
Place of Burial or Cremation
(City or Town)
DATE OF BURIAL
September 3,
19.63
7 NAME OF
FUNERAL DIRECTOR
Alfred B. Marsh
alfred 75. March
ADDRESS 174 Winthrop St. winthrop.
Received and filed
SEP 3 1963
19
(Registrar)
A TRUE COPY ATTEST:
Sagst.
1
1963
(Year)
(Month)
(Day)
4 IHEREBY CERTIFY, That I attended deceased from
aug31, 1962
to 01
Senti
I last saw \he falive on
Levy 31
1963, death is said to
have occurred on the date stated above, at
0.00Am.
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a) Cerebro Vascular hemorrhag
INTERVAL BETWEEN ONSET AND DEATH
Due
(b)
arteriosclerosis gen.
....
Due To (c)
OTHER
SIGNIFICANT
CONDITIONS
Was autopsy performed?
NO
What test confirmed diagnosis ?
5 Was disease or injury in any way related to occupation of deceased ? " ..... If so, specify
(Signature)
....
M. D. Joseph GREGORIE
(Print or Type, Name)
(Address)
My Washing tone and Date
9/2
19
60
PARENTS
Millard ... L. Drake
(son)
21 Informant
(Address)
415 horti Clay Street
Hinsdale, Illinois
I HEREBY CERTIFY that a satisfactory standard certificate of death was filed with me BEFORE the burial or transit permit was issued: Pauph & Sirianni /B/
(Signature of Agent of Board of Health or other)
Health Officer
Vept 3,196V
(Official Designation) (Date of Usue of Permit)
TUB
2382
I
Registered No.
25 Sargent Street, Winthrop
(Was deceased a U. S. War Veteran, (if so specify WAR)
3 DATE OF
DEATH
SE
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE
RANK, RATING
ORGANIZATION AND OUTFIT
SERVICE NUMBER
RULES OF PRACTICE
6
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 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 certificata 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.
I R-302
1
PLACE OF DEATH
Middlesex (County) Cambridge
(City or Town)
No ...
Holy Ghost Hospital
[(If death occurred in a hospital or institution, St. { give its NAME instead of street and number)
Barbara Bowman
2 FULL NAME
(If deceased is a married, widowed or divorced woman, give also maiden name.)
3 Paine Street
(a) Residence. No.
(Usual place of abode)
Length of stay: In place of death.
5 years 6
.. months
16
35
days. In place of residence. ... years ..... ... months .......... days.
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
DEATH
September 4, 1963
(Month)
(Day)
(Year)
4 IHEREBY CERTIFY, Feb. 19 ..... ,>19
58 Sept.
That I
attended deceased from
03
I last saw
& live on
Sept. 320.
63
death is said to have occurred on the date stated above, at 1:50A,
DEATH WAS CAUSED BY: IMMEDIATE CAUSE Acute diffuse peritonitis (a) (runtured gallbladder)
INTERVAL BETWEEN ONSET AND DEATH
Due To Pulmonary congestion & edema
Due To (c) ....
extensively involving the partetal, temporal and
SIGNIFICANT Occipital lobes. CONDITIONS art. scl.& Hypertensive heart BIRTHPLACE (City)
disease
yes
Was autopsy performed ?
What test confirmed diagnosis ?
17 NAME OF
FATHER
Peter ?. Bowman
18 BIRTHPLACE OF
Queboc
FATHER (City)
(State or country)
Canada
19 MAIDEN NAME
OF MOTHER
Delia B. Robinson
20 BIRTHPLACE OF
MOTHER (City)
(State or country)
Froland
Ellen F. Bowman
21 Informant
(Address)
8 Paino St. Winthrop
A TRUE COPY
ATTEST:
(Registrar of City or Town where death occurred) Sept. 5, 6
19
VB
.
(Registrar of City or Town where deceased resided)
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
Female
9 COLOR
white
10 SINGLE
MARRIED
WIDOWED
DIVORCED
UNKNOWN
(write the word)
Single
11 If married, widowed, or divorced
HUSBAND of
(or) WIFE
(Husband's name in full)
12
AGE
Years
Months.
Day3
If under 24 hours
Hours ........ Minutes
13 Usual
Occupation :.
(Kind of work done during most working life)
14 Industry
or Business:
Shoe
15 Social Security No.
rone
(State or country)
Canada
5 Was disease or injury in any way related to occupation of deceased?
If so, specify
(Signed)
John F. Lee
M. D.
(Address)
Holy Ghost Hosp, 0-4
63
Winthrop Cem.
winthrop
Place of Burial or Cremation
(City or Town)
DATE OF BURIAL
19
7 NAME OF
FUNERAL DIRECTOR
Anthony J. O'Maley
ADDRESS .....
Winthrop, Mass.
Received and filed OCT 4 1963 19
50M - 10-61. 931673
(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 OTHER
171
Cambridge
(City or Town making this return)
Registered No.
1293
(Was deceased a
U. S. War Veteran,
no
(if so specify WAR
winthrop, Mass.
St
(If nonresident, give city or town and State)
(Give maiden name of wife in full)
88
Stitcher - Retired
old Forebral infarcts
left
19
PARENTS
Sept. 7,
63
DATE FILED
The Commonwealth of Massachusetts KEVIN H. WHITE SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS COPY OF QVIỆTEM CERTIFICATE OF DEATH
19
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE DATE OF DISCHARGE RANK, RATING ORGANIZATION AND OUTFIT SERVICE NUMBER
RECEIVED
TOWA
OF
11 12 1
OFFIC
in.
MIN
in
İLERK
WI
6
"5
ASS
HRO
OCT 41963 AM
303 urial permit of Health gent.
Injury of Death. See reverse side for additional information. See also Chap. 38, §§ 6, 20; Chap. 46, §§ 9, 10; Chap. 114, §§ 44-48. DEATH in plain terms, so that it may be properly classified under the International Classification of Causes Nature of Injury If deceased was a U. S. War Veteran, G.L. Chap. 46, Section 10, requires physicians to insert a recital to that effect.
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.
122
[(If death occurred in a hospital or institution, St. ? give its NAME instead of street and number) No.
MILDRED
HOWE
(First Name)
(Middle Name)
(Last Name)
(If deceased is a married, widowed or divorced woman, give also maiden name.)
16 Court Road, Winthrop
(a) Residence. No.
(Usual place of abode)
Length of stay: In place of deathyears months .... days. In place of residence
55 je
.. years .............. months .......
... days.
MEDICAL CERTIFICATE OF DEATH
PERSONAL AND STATISTICAL PARTICULARS
3 DATE OF
DEATH
September
7,
1963
(Month)
(Day)
(Year)
FEMALE
10 COLOR
WHITE
11 SINGLE MARRIED WIDOWED DIVORCED UNKNOWN WIDOWED (write the word)
12 If married, widowed, or divorced HUSBAND of
(or) WIFE of CHARLES
(Give maiden name of wife in full) HOWE
(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 In public place ?
(Specify type of place)
Manner of
.....
(How did injury occur ?)
While at work ? Was zutopsy performed. ... ... No
6 Was disease or injury in any wayunted to og qua ion of deceased ?
(Signed Stanach Michael A. Trong6, M.D.
M. D.
Boston ( Print or Type Kame)
Date 9/7 63
7 WINTHROP Place of Burial or Cremation. (City or Town)
DATE OF BURIAL SENT 10 1963
8 NAME OF
FUNERAL DIRECTOR
MAURICE W KIRBY
ADDRESS WINTHROP
Received and filed
SEP 9 1963
19
A TRUE COPY ATTEST:
(Registrar)
PARENTS
19 BIRTHPLACE OF
FATHER (City)
(State or country)
MASS
20 MAIDEN NAME
OF MOTHER
ANNA BOYCE
21 BIRTHPLACE OF MOTHER (City) (State or country) MASS
22 Informant (Address)
MPS NANCU EVANS
ZIL COURT RD WINTHROP,
I HEREBY CERTIFY that a satisfactory standard certificate of death was filed with me BEFORE the burial or transit permit was issued: Paph G Serianni (8)
(Signature of Agent of Board of Health or other) Health Officer Sept 9,19613 (Official Designation) (Date of Issue of Permit)
TV .....
13 45v .Years ..... Months ...... ......
If under 24 hours Hours Minutes
14 Usual
Occupation :
NOME KERER.
(Kind of work done during most of working life)
15 Industry on Business :
HOME
NINE
N Social Security \No.
FAST BOSTON
17 BIRTHPLACE (City) (tate of country) MASS
18 NAME OF FATHER DAVID J MAHUNY
RANDOLPH.
CAMBRIDGE
(Address)
WINTHROP
100M - 3-62-932695
PHYSICIAN - IMPORTANT
(Was deceased a U. S. War Veteran, if so specify WAR)
St
(If nonresident, give city or town and State)
16 Court Road, Winthrop
2 FULL NAME
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.) Arteriosclerotic heart disease. (77).
9 SEX
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE
i RANK, RATING
ORGANIZATION AND OUTFIT
SERVICE NUMBER SET - 91953 KM
RULES OF PRACTICE
The fulfillment of the purpose of these laws calls for the observance of the following rules of practice:
(1) Attending physicians will certify to such deaths only as those of persons to whom they have given bedside care during a last illness from disease unrelated to any form of injury.
(2) Board of Health physicians will certify to such deaths only as those of persons who, though disabled by recognized disease unrelated to any form of injury, have died without recent medical attendance or whose physician is absent from home when the certificate of death is needed.
(3) Medical Examiners will investigate and certify to all deaths supposably due to injury. These include not only deaths caused directly or indirectly by traumatism (including resulting septicemia), and by the action of chemical (drugs or poison) , thermal, or electrical agents, and deaths following abortion, but also deaths from disease resulting from injury or infection related to occupation, the sudden deaths of persons not disabled by recognized disease, and those of persons found dead.
STATEMENT OF CAUSE OF DEATH
Medical Examiners in certifying to a death will state the cause and manner thereof, and will specify: (1) Under cause the nature of an injury and of its consequences; and (2) under manner the mode of its production together with the circumstances when these are known. For example: "Compound fracture of the femur with ensuing septicemia (gas bacillus) caused by a collision of railroad train and automobile." "Pistol shot wound of the chest with associated hemorrhage, homicidal." "Asphyxiation by suspension, suicidal." "Syncope while under the influence of ether administered as a surgical anaesthetic for (enter name of operation and disease or condition requiring surgery)." "Fracture of the skull with associated internal injury sustained under circumstances unknown."
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