Town of Winthrop : Record of Deaths 1963, Part 4

Author: Winthrop (Mass.)
Publication date: 1963
Publisher:
Number of Pages: 574


USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1963 > Part 4


Note: The text from this book was generated using artificial intelligence so there may be some errors. The full pages can be found on Archive.org (link on the Part 1 page).


Part 1 | Part 2 | Part 3 | Part 4 | Part 5 | Part 6 | Part 7 | Part 8 | Part 9 | Part 10 | Part 11 | Part 12 | Part 13 | Part 14 | Part 15 | Part 16 | Part 17 | Part 18 | Part 19 | Part 20 | Part 21 | Part 22 | Part 23 | Part 24 | Part 25 | Part 26 | Part 27 | Part 28 | Part 29 | Part 30 | Part 31 | Part 32 | Part 33 | Part 34 | Part 35 | Part 36 | Part 37 | Part 38 | Part 39 | Part 40 | Part 41 | Part 42 | Part 43 | Part 44 | Part 45 | Part 46 | Part 47 | Part 48 | Part 49 | Part 50 | Part 51 | Part 52 | Part 53 | Part 54


Alexander Rosenauer


(Husband's name in full)


11 IF STILLBORN, enter that fact here.


12


AGE


90


Years


Months ...


.. Days


If under 24 hours


Hours.


Minutes


13 Usual


Occupation :


Housewife


(Kind of work done during most of working life)


14 Industry


or Business :


15 Social Security No. ........ none.


16 BIRTHPLACE (City) u.s.sia


(State or country)


17 NAME OF


FATHER


Hyman Sansiper


18 BIRTHPLACE OF FATHER (City) (State or country) Russia


19 MAIDEN NAME


OF MOTHER


Inna Levine


20 BIRTHPLACE OF MOTHER (City) (State or country) Russia


21 Miss Dorothy Rosen uer


Informant


(Address)


5 Common St., Quincy, Mass.


I HEREBY CERTIFY that a satisfactory standard certificate of death was filed with me BEFORE the burial or transit permit was issued: Kaiples & funny 3.2 1)


(Signature of Agent of Board of Health or other)


van 2× 1963


(Official Designation)


(Date of Issue of Permit)


1 1


1


TRUCTIONS FOR L CERTIFICATE


giving OF DEATH not enter e than one e for each (b) and (c)


does not mean de of dying, heart failure, etc. It means se, or compli- which caused


ions, if any, gave rise to cause (a), the under- cause last.


ditions contrib- death but not o the terminal condition given


:- Chapter 137, of 1954. requires cians to print or the cause or of death on certificates, and er 48, Acts of requires Physi- to print or type under signature.


Knights of Liberty,


Woburn(Montvale)


6


Place of Burial or Cremation (City or Town)


DATE OF BURIAL


January. ....... 29, ...... 19 .. 63


7 NAME OF


FUNERAL DIRECTOR


Benjamin F. Solomon


ADDRESS


420 Harvard Street, Brookline.


JAN 28 1963 19


John Clark


(Registrar)


PARENTS


5 Was disease or injury in any way related to occupation of deceased? If so, specify NO


(Signed)


4. B. Greenfield


M. D


447 S (PRINT OR TYPE SIGNATURE)


(Address) Winthropmass Date. 1-27 63 ....


7 days


Due To


(c)


Senility


OTHER


SIGNIFICANT


CONDITIONS


Was autopsy performed?


No


What test confirmed diagnosis?


INTERVAL BETWEEN ONSET AND DEATH


DEATH WAS CAUSED BY : IMMEDIATE CAUSE


cerebral thrombosis


(a)


Due To


(b)


arteriosclerosis


19


63


.....


4 I HEREBY CERTIFY, That I attended deceased from


Jan


27


Den 21


... (.2 .. , to ........


Plast saw h.& .... alive on


Javis


27


death is said to


have occurred on the date stated above, at


12: 50pm.


.. 19 bs


5 Common Street


St Quincy, Mass.


(If nonresident, give city or town and State)


Bat View Nursing Home


No.


Quincy


M R-301A 1


60-928145


(write the word)


-


SPACE FOR ADDITIONAL INFORMATION


DATE OF ENTERING MILITARY SERVICE


DATE OF DISCHARGE


RANK, RATING


ORGANIZATION AND OUTFIT


SERVICE NUMBER


K


JAN 2 81963 PM


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.


M R-301A 1


PLACE OF DEATH


Suffolk


(County)


Winthrop


(City or Town)


Mayflower Nursing Home No.


The Commonwealth of Massachusetts JOSEPH D WARD SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS


STANDARD CERTIFICATE OF DEATH


Registered No.


16


[(If death occurred in a hospital or institution, St. ¿ give its NAME instead of street and number)


Helen (Huse) Smith


2 FULL NAME


(If deceased is a married, widowed or divorced woman, give also maiden name.)


10 Wave Way Ave.


St.


(If nonresident, give city or town and State)


7


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


Jan:


(Month)


(Day)


27


1963


(Year)


8 SEX


Female


9 COLOR


White


10 SINGLE


(write the word)


MARRIED


WIDOWED)


or DIVORCED


Widow


63


4 I HEREBY CERTIFY, That I attended deceased from


Nov.


1961, to.


Jan


27


19


I last saw heY .. alive on


Jan.


26


1963


death is said to


have occurred on the date stated above, at 2:00 A.m.


INTERVAL


BETWEEN


DEATH WAS CAUSED BY : IMMEDIATE CAUSE


ONSET AND


DEATH


5 days.


75


(a)


Cerebral Hemorrhage


Due To


Hypertension


(b)


6yrs.


Due To (c)


OTHER


SIGNIFICANT


CONDITIONS


Diabetes Mellitus


6yrs.


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


Charles


(Signed)


CHARLES LIBERMAN


(PRINT OR TYPE SIGNATURE)


(Address)


WINTHROP


Date.


1/28/ 1963


6


. interop


winthrop


Place of Burial or Cremation


(City or Town)


DATE OF BURIAL


Jan. 2%


53


19


7 NAME OF


FUNERAL, DIRECTOR


Howard & Reynolds


ADDRESS


..


int! UD, 1.265


Received and filed


JAN 29 1963


. 19 .


(Registrar)


PARENTS


18 BIRTHPLACE OF FATHER (City) (State or country) Maine


19 MAIDEN NAME OF MOTHER Eliza Dwyer


20 BIRTHPLACE OF


.. . MOTHER (City) (State or country)


Ihine


21 Informant (Address) ashland hass.


I HEREBY CERTIFY that a satisfactory standard certificate of death was filed ,with me BEFORE the burial or transit permit was issued:


texansil


(Signature of Agent of Board of Health or other)


tev 2%/16-3


(Official Designation)


(Date of Issue of Permit)


TX


10a If married, widowed, or divorced


HUSBAND of


. (Give maiden name of wife in full)


Benjamin D. Smith


(or) WIFE of


(Husband's name in full)


11 IF STILLBORN, enter that fact here.


12


AGE


Years ..


6


23


Months.


Days


If under 24 hours


Hours.


.Minutes


13 Usual


Occupation :


Housewife


(Kind of work done during most of working life)


14 Industry


or Business :


Own Home


None


15 Social Security No. Boston


16 BIRTHPLACE (City)


(State or country)


17 NAME OF


FATHER


George Huse


. D.


TRUCTIONS FOR L CERTIFICATE


giving OF DEATH


not enter e than one e for each (b) and (c)


does not mean de of dying, heart failure, etc. It means ase, or compli- which caused


ions, if any, gave rise to cause (a), the under- cause last.


ditions contrib- death but not to the terminal condition given


· Chapter 137, 1954. requires ans to print or he cause or of death on ertificates, and 48. Acts of quires Physi- print or type nder signature.


1-6-59-925686


PHYSICIAN - IMPORTANT [(Was deceased a U. S. War Veteran, [if so specify WAR)


(a) Residence. No. (Usual place of abode)


17


To be filed for burial permit with Board of Health or its Agent.


Lillian H Smith


SPACE FOR ADDITIONAL INFORMATION


DATE OF ENTERING MILITARY SERVICE


DATE OF DISCHARGE


RANK, RATING


ORGANIZATION AND OUTFIT


SERVICE NUMBER


RULES OF PRACTICE


JAN 2 91963 AM 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.


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. 17


[(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 ..... 52 Bellevue Avenue


Winthrop.s.Mass.


(If nonresident, give city or town and State)


months .......... days.


MEDICAL CERTIFICATE OF DEATH


3 DATE OF


DEATH


January.


28


1963


(Month)


(Day)


(Year)


4 I HEREBY CERTIFY


Jan


19.


to ...


26


That I attended deceased from


192-1


I last saw himmalive on


Jan. 7


19.62, death is said to


have occurred on the date stated above, at


DiciA.m.


INTERVAL BETWEEN ONSET AND DEATH


Due To-


arteriosclerosis-gem


(b)


Due To


(c)


Senility


430


14. Industry Ciot Businesof Cambridge Fire Dept


15 Social Security No ...... no.n.e.


16 BIRTHPLACE (City) (State or country)


Cambridge. s.s.


17 NAME OF


FATHE


Charles Henry Cutting


18 BIRTHPLACE OF


Charlestown


FATHER (City).


(State or country)


Kass


19 MAIDEN NAME


OF MOTHER


Fannie Coleman


Cambridge 20 BIRTHPLACE OF MOTHER (City) (State or country) Mass.


21 Infor MESGrace D. Cutting


(Address) Bellevue Ave. Winthrop, Mass


T


I HEREBY CERTIFY that a satisfactory standard certificate of death wassfiled with me BEFORE the burial or transit permit was issued: Piept de. Siriania (3)


(Signature of Agent of Board of Health or other) Health Officer Law. 791463


(Registrar) || (Official Designation)


(Date of Issue of Permit)


TVILL


A TRUE COPY ATTEST:


PERSONAL AND STATISTICAL PARTICULARS


8 SEX


male


9 COLOR


white


10 SINGLE


MARRIED


WIDOWED


DIVORCED


UNKNOWN


(write the word) married


Il If married, widowed, or divorceder


Grace Vivien Dodge


HUSBAND of


(Give maiden name of wife in full)


(or) WIFE of.


(Husband's name in full)


12


AGE Years 79


Months. 7


Days


29


Hours ....... Minutes


13 Usual


Occupation :..


retired fireman


(Kind of work done during most working life)


OTHER


SIGNIFICANT


CONDITIONS


Parkinson's Disease


Was autopsy performed?


What test confirmed diagnosis ?


5 Was disease or injury in any way related to occupation of deceased ?" ....


If so, specify


Signature) maple treevel M. D.


(Address)


Joseph GRIEGORIE


(Print or Type Name)


199 Washing frances Date 1/28


Winthrop Cemetery


Winthrop,Mass


Place of Burial or Cremation


(City or Town)


DATE OF BURIAL


7 NAME OF


FUNERAL DIRECTOR


alfred B. March


ADDRESS


174 Winthrop St. Winthrop,


19


Received and filed


JAN 29-1963


-62-932382


FORM R-301


for burial permit oard of Health its Agent. STRUCTIONS FOR IL CERTIFICATE


T OR TYPE : OR CAUSES DEATH not enter re than one se for each ), (b) and (c)


itions, if any, gave rise to : cause (a), g the under- cause last.


nditions contrib- o death but not to the terminal condition given


No. Mayflower Nursing Home


2 FULL NAME


Henry Arthur Cutting


(If deceased is a married, widowed or divorced woman, give also maiden name.)


(Usual place of abode)


Length of stay: In place of death .... .years .......... months .......... days. In place of residence. 3Qears.


1


does not mean ode of dying, s heart failure, 1, etc. It means ease, or compli- which caused (a) maucardial Heart


DEATH WAS CAUSED BY: IMMEDIATE CAUSE


( D),SEUS


If under 24 hours


PARENTS


January 20, 1963:


19


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 dare 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.


PLACE OF DEATH


SUFFOLK


(County)


1


Winthrop (City or Town)


No Winthrop Community Hospital


(If death occurred in a hospital or institution, St. { give its NAME instead of street and number)


PHYSICIAN - IMPORTANT


2 FULL NAME


Ruggiero Baby Girl


(If deceased is a married, widowed or divorced woman, give also maiden name.)


2 St. Andrew Rd. E. Boston


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 ...


PERSONAL AND STATISTICAL PARTICULARS


8 SEX F


9 COLOR


white


10 SINGLE


(write the word)


MARRIED


WIDOWED


DIVORCED


UNKNOWN


Single


1I If married, widowed, or divorced HUSBAND of


(or) WIFE of.


(Husband's name in full)


12


AGE


Years ............ Months .........


.Days


If under 24 hours


...... Hours ... 2 Minutes


13 Usual


Occupation :


none


(Kind of work done during most working life)


14 Industry


or Business:


15 Social Security No.


none


16 BIRTHPLACE (City)


(State or country }


Winthrop, Mass.


17 NAME OF


FATHER


Joseph Ruggiero


18 BIRTHPLACE OF


FATHER (City)


(State or country)


Boston


Mass


19 MAIDEN NAME


OF MOTHER


Josephine Pignato


20 BIRTHPLACE OF


MOTHER (City).


(State or country )


Boston


Masa


21 Informant


Joseph Ruggiero (father)


(Address)


2 St. Andrew Rd., East Boston, Mass.


I HEREBY CERTIFY that a satisfactory standard certificate of death was filed with me BEFORE the burial or transit permit was issued :


Je vanner


................


(Signature of Agent of Board of Health or other) the Office Jef 1-196-3


(Date of Issue of Permit)


-62-932382


A TRUE COPY ATTEST:


30


1963.


(Month)


(Day)


(Year)


4 I HEREBY CERTIFY, That I attended deceased from


to ..


1 -3C


1-30


19 63


1963


I last saw HG .... alive on


1-30


19 ...


6, death is said to


have occurred on the date stated above, at


DEATH WAS CAUSED BY: IMMEDIATE CAUSE


(a)


ANIXIA.


Due To


(b)


Pulmonary Atalectasis


Due To


PREMATURITY


(c)


OTHER


SIGNIFICANT


CONDITIONS


Was autopsy performed ?


What test confirmed diagnosis ?


5 Was disease or injury in any way related to occupation of deceased ? L4. If so, specify


(Signature)


qual & Bebe


M. D.


JACOB B. BURKE


(Print or Type Name)


(Address)


42 CRESCENT AVLS


Date .....


1.30 19 63 CHELSEA Holy Cross Cemetery Malden


6


Place of Burfal or Cremation


(City or Town)


Feb. 2.


19.


63


7 NAME OF


FUNERAL DIRECTOR


Vincent Kapino


ADDRESS


9 Chelsea St. East Boston, Mass.


FEB 1-1863


Received and filed


19


Besten


The Commonwealth of Massachusetts KEVIN H. WHITE SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS W11.3140 . STANDARD CERTIFICATE OF DEATH


(City or Town making this return)


Registered No.


18


d for burial permit board of Health its Agent. TRUCTIONS FOR L CERTIFICATE


T OR TYPE OR CAUSES DEATH


not enter e than one se for each , (b) and (c)


does not mean ode of dying, heart failure, , etc. It means ase, or compli- which caused


tions, if any, gave rise to cause (a), g the under- cause last.


ditions contrib- death but not to the terminal condition given


PARENTS


(Registrar) | (Official Designation)


X


.. days.


MEDICAL CERTIFICATE OF DEATH


3 DATE OF


DEATH


JAN.


(a) Residence. No.


(Usual place of abode)


(Was deceased a


U. S. War Veteran,


if so specify WAR).


no


(Give maiden name of wife in full)


INTERVAL BETWEEN ONSET AND DEATH 145am


DATE OF BURIAL


FORM R-301


-


SPACE FOR ADDITIONAL INFORMATION :.......


DATE OF ENTERING MILITARY SERVICE


FEB 1 1363 PM


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.


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.


:


X


PLACE OF DEATH


(County)


I


WINTHROP


(City of Town)


The Commonwealth of Massachusetts KEVIN H. WHITE SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS COPY OF .


CERTIFICATE OF DEATH


Registered No.


10


S(If death occurred in a hospital or institution, .St. ¿ give its NAME instead of street and number)


2 FULL NAME CAMILLE


COLANGELO


(If deceased is a married, widowed or divorced woman, give also maiden name.)


Residence. No. 1048 PEAR SARATOGA (Usual place of abode)


Length of stay: In place of death .......... years ......


3 months.days. In place of residence.


..... years .......... months .......... days.


MEDICAL CERTIFICATE OF DEATH


PERSONAL AND STATISTICAL PARTICULARS


8 SEX


tenale


9 COLOR


White


10 SINGLE MARRIED WIDOWED DIVORCED UNKNOWN


(write the word) Widened


11 If married, widowed, or divorced HUSBAND of


(or) WIFE


Of FRANCESCO


(Give maiden name of wife in full) CoLanceLa (Husband's name în full)


12 AGFŐO.Years .... 3 Months ... . Days


If under 24 hours


Hours ........ Minutes


13 Usual


Occupation :


(Kind of work done during most working life)


14 Industry


or Business:


15 Social Security No.


16 BIRTHPLACE (City) (State or country ) Etaty


17 NAME OF FATHER


PARENTS


18 BIRTHPLACE OF FATHER (City). (State or country)


Italy


19 MAIDEN NAME OF MOTHER


Suciation


20 BIRTHPLACE OF MOTHER (City) .... (State or country)


suche Etangelo (for


21 Informant ( Adchessy 10h & Paratoga & EB.


I HEREBY CERTIFY that a Satisfactory standard certificate of death was filed with me BEFORE the burial or transit permit was issued:


Lescanner3, (Signature of. Agent of Board of Health or other) Health officer JeLi 1963


(Official Designation) (Date of Issue of Permit)


X


A TRUE COPY ATTEST:


PHYSICIAN - IMPORTANT


(Was deceased a


U. S. War Veteran,


(if so specify WAR,


E13.


St


(If nonresident, give city or town and State)


3 DATE OF


DEATH


JAN


3/


1963


(Year)


(Month)


(Day)


That I attended deceased from


1963


I last saw hetalive on


have occurred on the date stated above, at


6 7.


DEATH WAS CAUSED BY: IMMEDIATE CAUSE


Carcinmia Calin


(a)


INTERVAL BETWEEN ONSET AND DEATH


3 mes.


Due To (b)


Due To (c)


OTHER SIGNIFICANT CONDITIONS


mesashuse to Bram


Was autopsy performed ?


200


What test confirmed diagnosis ? -


5 Was disease or injury in any way related to occupation of deceased? If so, specify


(Signed) . GUY GRANDE UND. M. D.


(Print or Type Name) 20 SARATOGA ST. EAST BOSTI (Address] .Date .. 2-1 1963


6 Place Burial or Cremation


MalQue (City or Town)


DATE OF BURIAL .


63


7 NAME OF FUNERAL DIRECTO Khu Quelle Jour


ADDRESS


Copper & Bathy


Received and filed FEB 4 1963


19 ..


(Registrar of City or Town where deceased resided)


27-63


SENSE PETIT EP


(City or Town making this return)


NOWINTheCD LERY HonRE


(a)


RUCTIONS FOR . CERTIFICATE


giving OF DEATH not enter : than one e for each (b) and (c)


does not mean de of dying, heart failure, etc. It means Ise, or compli- which caused


ions, if any, gave rise to cause (a), the under- cause last.


ditions contrib- death but not o the terminal condition given


021


te :- Chapter 137, of 1954 requires icians to print or the cause or es of death on certificates, and ter 48, Acts of requires Physi- to print or type e under signature.


11-61-931825


ORM R-301


d for burial permit Board of Health its Agent.


4 I HEREBY CERTIFY


Oct2


1962


Can 31


to ...


30


19.63, death is said to


SPACE FOR ADDITIONAL INFORMATION


DATE OF ENTERING MILITARY SERVICE


DATE OF DISCHARGE RANK, RATING


ORGANIZATION AND OUTFIT


SERVICE NUMBER


RULES OF PRACTICE


FEB -41963 TM


The fulfillment of the purpose of these laws calls for the observance of 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 Examinera 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.




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