Town of Winthrop : Record of Deaths 1963, Part 5

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


USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1963 > Part 5


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


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.


1


I R-305 1


PLACE OF DEATH


Essex (County)


Danvers


The Commonwealth of Massachusetts KEVIN H. WHITE SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS COPY OF MEDICAL EXAMINER'S CERTIFICATE OF DEATH


Danvers


(City or town making return) -


20


Registered No.


[(If death occurred in a hospital or institution,


Danvers State Hospital, Hathorne St. ( give its NAME instead of street and number) No.


2 FULL NAME


Mary Ann Davis


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


(if so specify WAR)


(a) Residence. No. 396 Grovers Avenue


St.


Winthrop, Mass.


(If nonresident, give city or town and State)


Length of stay: In place of death


0


... years ...


2


.months.


3


.days. In place of residence .............. years ....


.. months ..


.days.


MEDICAL CERTIFICATE OF DEATH


January


31,


1963


(Month)


(Day)


(Year)


9 SEX


female


10 COLOR


white


11 CITIZEN


OF U.S.


YES


NO


12 SINGLE


MARRIED


WIDOWED


DIVORCED


UNKNOWN


12a If married, widowed, or divorced


HUSBAND of


(Give maiden name of wife in full)


(or) WIFE of


(Husband's name in full)


13 DATE OF BIRTH March 28, 1876


14


AGE86 Years


10


Months ...


3


Days


If under 24 hours


.. Hours


.Minutes


15 Usual


Occupation :


Proof Reader


(Kind of work done during most of working life)


16 Industry or Business :


17 Social Security No.


Not Determined


Boston


18 BIRTHPLACE (City)


(State or country)


Mass.


....


19 NAME OF


FATHER


Joseph H. Davis


20 BIRTHPLACE OF


FATHER (City)


(State or country)


Ireland


21 MAIDEN NAME


OF MOTHER


Mary Baker


22 BIRTHPLACE OF


MOTHER (City)


(State or country)


Ireland


23


Mary E


Sheehan


Informant


(Address)


Hathorne, Mass.


A TRUE COPY.


ATTEST:


......


(Registrar of Citylor Town where death occurred)


DATE FILED


February 5,19


63


(Registrar of City or Town where deceased resided)


PERSONAL AND STATISTICAL PARTICULARS


4I 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.) Fracture Rt. Hip


5 Accident, suicide, or homicide (specify)


accident


Date and hour of injury


Oct ...


31,


1963


If accidental, was injury causally related to the death ?


yes


Injury occur ?


Winthrop ...


Mass ..


(City or town and State)


Did injury occur in or about home, on farm, in industrial place, or in


public place ?


Nursing Home


(Specify type of place)


Manner of


Fell to floor


(How did injury occur ?)


While at work ? no Was autopsy performed? yes


6 Was disease or injury in any way related to occupation of deceased no ...


karty


LeCorthy


M. D.


(Address)


Peabody.


ass


2/1/


1963


Dat


St. Joseph's Cemetery


Roxbury


Place of Burial or Cremation.


(City or Town)


February 5,


19 63


& NAME OF


FUNERAL DIRECTOR


East Boston Mass


Richard C Kirby,. Ir c


ADDRESS ........ FEB 6 1963


Received and filed


19


Copies of returns of deaths which occurred in your city or town in case the deceased resided in another city or town at THIS IS A PERMANENT RECORD


9


PARENTS


(City or Town)


(Usual place of abode)


3 DATE OF


DEATH


Bronchopneumonia


Where did


Injury


Nature of


If so, specify ............


.....


(Signed)


Re.Ipl


7


DATE OF BURIAL


25M-3-61-930213


as soon as possible after the close of the month in which the death occurred. (See Chap. 46, Sec. 12, G. L.)


the time of death should be transmitted on Form R-305 to the clerk of the city or town in which the deceased resided


Injury


as above


[(Was deceased a


U. S. War Veteran,


SPACE FOR ADDITIONAL INFORMATION


DATE OF ENTERING MILITARY SERVICE DATE OF DISCHARGE RANK, RATING ORGANIZATION AND OUTFIT SERVICE NUMBER


FORM R-302


WRITE PLAINLY, WITH UNFADING BLACK INK OR USE APPROVED BLACK TYPEWRITER RIBBON - THIS IS A PERMANENT RECORD


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


X


PLACE OF DEATH


Plymouth


(County) Brockton


VIELL


COPY OF CERTIFICATE OF DEATH


Registered No.


21


Veterans Administration Hospifundath occurred in a hospital or institution,


.St. ¿ give its NAME instead of street and number)


John. E. Downey


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


(a) Residence. No


141 Brook


St


(Brighton,) Ness.


(Usual place of abode)


0 22


59


2


(If nonresident, give city or town and State)


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


.days. In place of residence.


.... years .......... months.


.days.


MEDICAL CERTIFICATE OF DEATH


3 DATE OF


January 14, 1963


DEATH


(Month)


(Day) /VA


(Year)


4 IHEREBY CERTIFY Jahat yai ended/ deceased Dom 19 to. 19


have occurred on the date stated above, at


3:55 PM


DEATH WAS CAUSED BY: IMMEDIATE CAUSE


Acute myocardial infarct.


(a)


INTERVAL


BETWEEN


ONSET AND


DEATH


Due To (b)


Due To (c)


OTHER SIGNIFICANT CONDITIONS


Was autopsy performed?


no


What test confirmed diagnosis?


no


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


Leo Waitzkin


M. D.


(Address)


Date


19


inthrop Cemetery, Winthrop, Mass 6


Place of Burial or Cremation


January (197or Town)


63


DATE OF BURIAL


7 NAME OF


John . .. CAvoy


19


FUNERAL DIRECTORAvC., Arlington, Mass."


ADDRESS


Received and filed


FEB 15 1963


19


(Registrar of City or Town where deceased resided)


PERSONAL AND STATISTICAL PARTICULARS


8 SEX


male


9 COLOR


white


10 SINGLE


MARRIED


WIDOWED


DIVORCED


UNKNOWN


(write the word) married


11 1f married, widowed pedirorcfd. Grant


(or) WIFE of.


(Husband's name in full)


12


67


2


28


If under 24 hours


AGE


Years.


Months ......


Dayz


Hours ........ Minutes


13 Usual


Electrician


Occupation :


(Kind of work done during most working life)


14 Industry


Electrical


or Business :


15 Social Security No ..


16 BIRTHPLACE (City) .... Massachusetts. (State or country)


17 NAME OF


FATHER


John i. Downey


Charlestown


18 BIRTHPLACE OF


Massachusetts


19 MAIDEN NAME Catherine . Keough OF MOTHER


Pevere


20 BIRTHPLACE OF


MOTHER (City) ..


(State or country)


Massachusetts


VA Hospital lecords


21 Informant


(Address)


.. Brockton, Massachusetts


A TRUE COPY


ATTEST:


(Registrar of City or Town where death occurred)


Jan. 15


63


DATE FILED


19


50M - 10-61.931673


resided as soon as possible, after the close of the month in which the death occurred. (See Chap. 46, Sec. 12, G. L.)


1


(City or Town)


No ..


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


Brockton


(City or Town making this return)


2 FULL NAME.


(Was deceased a


U. S. War Veteran,


if so specify WAR Boston


I


PARENTS


(Signed)


VA HOSP.


Brockton, Mass.


1/15/63


FATHER (City) (State or country)


(Give maiden name of wife in full)


I Tast saw h ...... aliv


XXXX


death is said to


HUSBAND of


SPACE FOR ADDITIONAL INFORMATION


DATE OF ENTERING MILITARY SERVICE.


July 14, 1916


...


DATE OF DISCHARGE


April 28, 1919


RANK, RATING


Corporal


U. S. Army


ORGANIZATION AND OUTFIT


62 608


SERVICE NUMBER


....


FED 1 51063 AF


1


FORM R-301


for burial permit oard 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


, C


PLACE OF DEATH


Suffolk (County)


TEM


1


Winthrop


(City or Town)


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


STANDARD CERTIFICATE OF DEATH


Registered No.


22


§(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 ...


24 Hawthorne Avenue


(Usual place of abode)


St


Winthrop


(If nonresident, give city or town and State)


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


.. L.days. In place of residence .. /3 years .......... months .......... days.


PERSONAL AND STATISTICAL PARTICULARS


8 SEX


9 COLOR


White


10 SINGLE


MARRIED


WIDOWED


DIVORCED


UNKNOWN


(write the word)


Marnie


11 If married, widow , or divorced


HUSBAND of


ma Juinteald


(Give maiden name of wife in full)


(or) WIFE of


(Husband's name in full)


12


51.57


50%


AGES F Years.


Months ....


.Days


If under 24 hours


Hours.


Minutes


13 Usual


Occupation :


Producten


(Kind of work done during most working life)


14 Industry


Or Business Vaseline Station


15 Social Security No.


16 BIRTHPLACE (City) (State or country)


Russia


17 NAME OF


FATHER


(EBX) Gleditors.


18 BIRTHPLACE OF


FATHER (City).


(State or country)


Ricerca


19 MAIDEN NAME


OF MOTHER


Z. B.Z.


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


Mardin Eleditor


21 Informant


( Adgiress )


de betornae. St fr. Roxbury


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


(Signature of Agent of Board of Health or other)


Health Officer


Feb 5. 1963


...


(Registrar )|| (Official Designation)


(Date of Issue of Permit)


TV


A TRUE COPY ATTEST:


4


1963


(Year)


IHEREBY CERTIFY , That I attended deceased ,from


4


19.61


to


FEB


4


19.


I last saw h.// ... alive on


FEB3


4


death is said to


have occurred on the date stated above, at


DEATH WAS CAUSED BY: IMMEDIATE CAUSE


ACUTE MYOCARDIAL INFARCTION » (a)


INTERVAL BETWEEN ONSET AND DEATH 8 HRS.


ARTERIO- SCLEROTIC NENNT


(b)


2YRS


DISCIJI


Due To (c)


OTHER


SIGNIFICANT


CONDITIONS


Was autopsy performed?


What test confirmed diagnosis ?


CLINICAL


5 Was disease or injury in any way related to occupation of deceased 2 0 If so, specify


(Signature)


M. D.


MYRUNUN KING


...


(Print or Type_Name)


(Address) 222 PLANSINVI SI Date 2/4/0 63


Plade of Burial or Cremasony


(City or Town)


,63


DATE OF BURIAL


7 NAME OF


FUNERAL DIRECTORE


Chilena


ADDRESS


Received and filed


FEB 5-1963


19


(City or Town making this return)


No.


WinthropCommunity Hospital


Charles Gladstone


2 FULL NAME


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


MEDICAL CERTIFICATE OF DEATH


3 DATE OF


DEATH


FEB


(Month)


(Day)


10 SP.


... m.


PARENTS


-62-932382


Linthrop


SPACE FOR ADDITIONAL INFORMATION


DATE OF ENTERING MILITARY SERVICE.


DATE OF DISCHARGE


RANK, RATING


ORGANIZATION AND OUTFIT


SERVICE NUMBER


1.


-


FEB - 51963 FM


RULES OF PRACTICE


The fulfillment of the purpose of these laws calls for the observance of the following rules of practice: (1) Attending physicians will certify to such deaths only as those of persons to whom they have given bedside care during a last illness from disease un. related to any form of injury.


(2) Board of Health physicians will certify to such deaths only as those of persons who, though disabled by recognized disease unrelated to any form of injury, have died without recent medical attendance or whose physician is absent from home when the certificate of death is needed.


(3) Medical Examiners will investigate and certify to all deaths supposably due to injury. These include not only deaths caused directly or indirectly by traumatism (including resulting septicemia), and by the action of chemical (drugs or poisons), thermal, or electrical agents, and deaths following abortion, but also deaths froin disease resulting from injury or infection related to occu- pation, the sudden deaths of persons not disabled by recognized disease, and those of persons found dead.


Statement of Cause of Death .- Physicians: see explanatory instructions on face side of standard certificate of death.


Statement of Occupation .- Precise statement of occupation is very impor- tant, so that the relative healthfulnes's 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


....


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) ....


23


Registered No.


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


L. Joseph .Porcella


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


132 Crest Avenue


(a)


Residence. No ...


(Usual place of abode)


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


15


days. In place of residence 53.


... years .......... months ........


.. days.


MEDICAL CERTIFICATE OF DEATH


PERSONAL AND STATISTICAL PARTICULARS


8 SEX


9 COLOR


White


10 SINGLE


MARRIED


(write the word)


WIDOWED


DIVORCED Lundlowed


UNKNOWN


Il If married, widowed, or divorced F. Cnawara HUSBAND of


(Give maiden name of wife in full)


(or) WIFE of.


(Husband's name in full)


12


· AGE ..


8 % ears.


Months 25 Days


If under 24 hours


Hours


Minutes


13 Usual


Occupation :


RETired - Lawyer


(Kind of work done during most working life)


14 Industry


or Business:


1 month 15 Social Security No .......


012-16-4688


SIGNIFICANT


CONDITIONS


Resection of Bowel 1/31/63


Was autopsy performed?


No


What test confirmed diagnosis ?


Pathological ... Examination


5 Was diseaseor SP


Minuty In any way related to occupation of deceased ?


If so, specify ..... NO.


(Signature)


john 7 Collins moto


M. D.


John F. Collins, M.D.


(Print or Type Name)


27 ... Bennington ... S.t ..... Date ..


Feb. 6, 19 63


(Address)


PuriTAN LAWN


Peabody


6 .


Place of Burial or Cremation


(City or Town)


DATE OF BURIAL


2/8/63


19


7 NAME OF


FUNERAL DIRECTOR


ARTHUR S. PORcella


ADDRESS 876 win Throp ArC


Revere.


Received and filed FEB 6 1963 19


(Registrar)|


PARENTSO


18 BIRTHPLACE OF


FATHER (City)


(State or country)


ITALY


19 MAIDEN NAME


OF MOTHER


ANNA


ANSAlda


20 BIRTHPLACE OF


MOTHER (City)


(State or country)


ITALY


21 Informant


Mes Beatrice Collins


(Address) 134 CREST Are- Revere


I HEREBY CERTIFY that a satisfactory standard certificate of death was, filed with me BEFORE the burial or transit permit was issued: ralph 16 Lerianne


(Signature of Agent of Board of Health or other)


26auth offener


7.1- 6,1963


(Official Designation)


(Date of Issue of Permit)


X


(Month)


(Day)


(Year)


4 I HEREBY CERTIFY , That I attended deceased from


Feb ..... ],.


163


19 ..


63 ... , to .. Feb ...... 5,


I last saw h ...... alive on


Feb ....... 5.,


1.6 1963, death is said to


have occurred on the date stated above, at


7:15 Pm.


DEATH WAS CAUSED BY: IMMEDIATE CAUSE


(a) Coronary Thrombosis


INTERVAL BETWEEN ONSET AND DEATH 24 hrs


Due To (b)


Due To (c)


OTHER


Adenocarcinoma of Colon


16 BIRTHPLACE (City)


(State or country)


Mass


BOSTON


1


for burial permit ard of Health its Agent. RUCTIONS FOR CERTIFICATE


OR TYPE OR CAUSES DEATH not enter than one e for each (b) and (e)


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


62-932382


A TRUE COPY ATTEST:


PHYSICIAN - IMPORTANT


2 FULL NAME.


(Was deceased a


U. S. War Veteran,


(if so specify WAR).


No


Revere


Mass.


St


(If nonresident, give city or town and State)


3 DATE OF


DEATH


February


5,


1963


REVERZ 3- 7-63


(City or Town)


Winthrop Community Hospital


No.


ORM R-301


17 NAME OF


FATHER Stephen


PORcellA


MALE


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.


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.


FEB - 61963 CM


M R-303


for burial permit ard of Health ts Agent.


PLACE OF DEATH


SUFFOLK


(County)


WINTHROP


The Commonwealth of Massachusetts KEVIN H. WHITE SECRETARY OF THE COMMONWEALTH DIVISION OF VITAL STATISTICS MEDICAL EXAMINER'S CERTIFICATE OF DEATH


(City or Town making this return)


Registered No.


21


(City or Town) Bay View Nursing Home 41 Washington Avenue, Winthrop No.


JOHANNA


2 FULL NAME


(First Name)


(Middle Name)


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


PHYSICIAN - IMPORTANT


[ (Was deceased a


U. S. War Veteran,


(if so specify WAR)


no


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


31 Palmyra St., Winthrop


(a) Residence. No.


(L'sual place of abode)


4


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


February 6, 1963


(Month)


(Day)


(Year)


9 SEX


Female


10 COLOR


White


11 SINGLE


(write the word )


MARRIED


WIDOWEDWidowed


DIVORCED


UNKNOWN


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.


12 If married, widowed, or divorced


HUSBAND of


(or) WIFE of


Daniel


(Give maiden name of wife in full) Gallagher


(Husband's name in full)


13 DATE OF BIRTH


Sept 81


1878


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)


(How did injury occur ?)


Was autopsy Performed?NO.


.........


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


(Sin) Michael A. Luongo


(Print or Type Name)


2/7


63


19


7 Winthrop Cemetery


Winthrop


Place of Burial, or Cremation.


(City or Town)


DATE OF BURIAL February 9 19. 63


8 NAME OF


FUNERAL DIRECTOR


Arthur J. O' Maley Winthrop Mass


ADDRESS


Received and filed


FEB 7 1963


19


A TRUE COPY ATTEST:


(Registrar)


PARENTS


22 BIRTHPLACE OF


MOTHER (City)


(State or country)


Ireland


23 Lillian Abbott


Informant


(Address)


31 Palymra 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 offers


Zet. 7. 1963


(Official Designation) ( (Date of Issue of Permit)


If under 24 hours Hours ......... Minutes


15 Usual


Occupation


(Kind Ofwork done during most of working life)


16 Industry or Business ....


Own .... Home


17 Social Security No.


None


Hoboken


18 BIRTHPLACE (City)


(State or country)


New Jersey


19 NAME OF


FATHER


Michael Murphy


20 BIRTHPLACE OF FATHER (City) (State or country) Ireland


21 MAIDEN NAME OF MOTHER Mary Carmody


longo M. D.


Boston


Date


14 AGE .. 8.5Years .....


.Months ........... .Days


(If nonresident, give city or town and State)


28


St.


(Last Name)


3 DATE OF DEATH Manner of Nature of Injury If so, specify. (Address) DEATH in plain terms, so that it may be properly classified under the International Classification of Causes of Death. See reverse side for additional information. See also Chap. 38, §§ 6, 20; Chap. 46, §§ 9, 10; Chap. 114, Injury information should be carefully supplied. MEDICAL EXAMINERS should state CAUSE AND MANNER OF §§ 44-48. If deceased was a U. S. War Veteran, G.L. Chap. 46, Section 10, requires physicians to insert a recital to that effect. 50M-9-61-931348 N. B .- WRITE PLAINLY, WITH UNFADING BLACK INK-THIS IS A PERMANENT RECORD. Every item of While at work ?


X 1


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: FEB -71963 AM


(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."


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.)"


ORM R-301


for burial permit ard of Health ts Agent. TRUCTIONS FOR L CERTIFICATE


Expired


TOR TYPE OR CAUSES 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.




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