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