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