The volume, 1853–1885
Town Clerk, Winthrop · from the Internet Archive · 588 pages · 14.1 MB
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RETURN OF A DEATH.
%
Itrtkj
Crrtiftj,
as
I am
informed,
that on the
c/YC A. D. 18 St
r r/Y/
aged
'years, ^ months, /# days, in
Stiipet. Said person was a
/-//'.S?r S/, f A.AAt day of
^///7V/ died,
at No.
and, by occupation, a
was born in <■ ' and was the ^ /ii' of c
The disease, or cause of death, was
interred, or to be interred, in % //,
f-&y#iLSs& / A/ '/
7y // the J S' day of ^r/s//a/Jf A. D. 18-1/
Informant.
Dated, at
RETURN OF A DEATH.
% Jkltluj ‘lUllfl], as I am informed, that on the
A. D. 18 ££_
zu
^
/
day
of
M died,
^ aged f years, /f months, { - days, in Jk y/ y y'/ at No.
g.
r
//ft LtZiL .Street.
Said person was
a
t,<^ovn.
■
and,
by
occupation,
a
was born m cl, and was the t : t;.a ///a of /// ‘ '
born
m
.
<3^
and was the (£/&.
rytJiJsOii
Is' '
Sj/Cj
JC
>4/^
f
The disease, or eausc of death, was JL w ^
)[ interred, or to be interred, in
' e~~7~
- £/?
XZ, t^y.
//SI' Informant.
3
RETURN OP A DEATH.
3
Jjmhtj Certify
as
I
am
informed,
that on
the
zz
/-
A. D. 18 4 /
day o*
died,
A. D.
aged V / years, J* months, days, in at No.
. Street. Said person was a c u-rts and, by occupation, a
was born in IS' and was the z^z z*/ fr/r s^red ,
1
^ /
Z' /
z
v
^ zZ^zz Zzzzz z^6 Jrz. z> The disease, or cause of death, was
interred, or to be interred, in
'JsU*
Dated, at
f Informant.
'€’*'/•/?' day of
<<
a. D. V66f
RETURN OP A DEATH.
3
jtoflnj
Cnlifij,
as
I am
informed,
that on the
JL dlLCi . A. D. 18^/ A
///
'// 61,/^'^
aged A years, 6 months, days, in . at No.
Street. Said person was a i£at*v and, by occupation, a
was horn in /fal'A'/ and -was the ^ hr of %£ ' //a?/;
\A
The disease, or cause of death, was
interred, or to be interred, in ' /
Dated, at /Cuan. &. the
V'/y s -/ cs
day of
died,
a$r
ft //
/c+Z/ '/* tp/s Informant.
s ^u // day of ' A. D. 18jA
RETURN OF A DEATH.
y as I am informed, that on the '7/fft // /// t // £ day of
/
i>
aged / y years, / months, days, in // ' " fft s i /&>
f-Kx+y
a. D.
18
Si ofar,
7
/ti.s
__ '"/
died,
at No.
I was horn in £/.
Street. Said person was^x JU*6 and, by occupation, a
^
and was
the ^rxcr^/y
/ah-
of ^Y///Ct J
^
^cyx^ry'-^.
The disease, or cause of death, was ./X / (/ //
j|
interred, or to be interred,
in
//
rf- $-
. £M Mr, Informant,
''/sfh/r/t the jjy' day of M c C A. D. 18 S-4
Dated, at
RETURN OF A DEATH.
in
-
,
.
\
3
3BfrElll]
(Ctrfifl|?
a3
I
am
informed,
that on
the
y^/j-,
/
(
setkStj/./
day
of
/24*U
A.
D.
yf(/i*
j
*'J
y
yJs/r/sss
died,
y/'tspt /// r/o at No.
and, by occupation, a
■was born in v */’ As y><u and was the of /^v/. //uj a- y&tiJ* /y^'/^y
j/ /y /.
The
disease,
or
cause of death,
was
/tst-L'' / L
c 6-
f
interred, or to be interred, in ///ti /fo/ s/i* (
/ fi//o y/eji y Informant.
Dated, at " tfo* t/t the Jy day of f A. v. 18
aged y years, V months, V days, i
o,/,
7 Street. Said person was a
Lf/f
RETURN OF A DEATH
day of
died,
3
JSmlnj
Cwtifij,
as
I am
informed,
that on
the
,
/y
/
/
/'
/V
' D. 18^ j2v<^vv/
aged
years,
J. months,
days,
in
y
/y
//
////
at
No. <2i'
/t-
Street. Said
person was
|r-
and,
by
occupation,
a
was born in & /t£ /M and was the / of /' -/sy <
i
v--. /
The disease, or cause of death, was ^ fy-Y^/C-SC ^
interred, or to be interred, in S/ / / 1 Y /if/ Y,
<////' f I the
£: day of
/c
//
/ <
■./////
Informant.
f/' £ <Y A. D. 18 ff/ Dated, at
RETURN OF A DEATH
e^r zbc
% Certify as I am informed, that on the .Arsf/br?/? 'b/<'
bbyyfj't A. D. 18^ * A'- //y / , /'/ ■ z/z /
aged ■’) / years, months, ^ days, in
*
V
/ /. Street. Said person was a
was born in C / sz ZiS zt a and was the
|
The disease, or cause of death, was
interred, or to be interred, in /Aiu //zz z/ez
b/ ' / / ///yb at No.
and, by occupation, a
!/V ' y /fci . ^J/ti i / z/- 3c /sib/y
/ / /Z/LS
ff/'-zzW.
<A>z-
<
day o*
died,
CO
///, Z' /z/e/ct\\G
£
// zz /,/;,/ Informant.
day of/ JA/O A. 1). 18^/ Dated, at
RETURN OP A DEATH.
I
% jjjert'hlj CnliflJ, as I am informed, that on the
Jl-?
A. D. 18
o#
(h/y
< W&evM / ■ /V / a. D. 18 54 Wc A; a / • Jt. / y ,
igcd»
years,
ff
months,
days,
in
/Z'
6-S
t/zz
at
No
'//
'
*f-
Street, Said
person was
a
,
and; by
occupation,
a
day of
died,
was born in / /// / / //w o/t and was the c/t / o
of
*
y
AfA/u ;i .AtJzt/t- * 'J" y-y'A/o
The disease, or cause of death, was . C ' Lc/ / -(J / / /ttjJ
interred, or to be interred, in AA/./r, A Af,/c/ ^
rfAr/t
sz
-
e/lps
,
Informant.
Dated, at A. c //(rtyt- the A. y day of Aff C ' A. D. 18 4
day of
died,
%
J3mhl) Certify
as
I am
informed,
that on the
tf.ArZ. A. D. 18^.
V
/
/
' y , A f>/ J '• ' i r fj
%
j/l
*
/-
/
iaged years, J months, days, in a , y yyl
at No.
Street. Said person was a . >, a and, by occupation, a
was born in v ■ /- and was the
The disease, or cause of death, was
interred, or to be interred, in
///
V A,
of ' ' ' .
7
j' s
// ■? y
st/.
sf
~
■
s r
/
■
'
yyy
^ i Informant.
Dated, at 4 the y / day of A. D. 18 /}/
RETURN OF A DEATH.
/A ■ /Af,' y / ?./j / day of
died.
3
3l<5
B rB
b
t|
as
I am
informed,
that on the
A. D.
18
6>
Sfsy
y,
...
,
>
And ^ years, / months, days, in at No.
Street. Said person was a . ^.^ ^..^ ^ and, by occupation, a
was bom in and was the of ,
f
•
^ .// / IS/ I-
interred, or to be interred, in
The disease, or cause of death, was //. 4
-
ft"'' ^ Informant.
the A ■■ y day of , ■ ■ • y A. D. 18 <■ '
Dated, at
--
*
Return of a death.
3 it .. as I am informed, that on the
/ //&»&£ A. I). 18 >!
fifi// /fit. day of
{/
/
/
u
/'
/
/>
.
died,
,Sed ./
years, months,
days,
in
at
No.
^
Street.
Said person was
a
and,
by occupation,
a
as
born in dz-abccy *. / u iaj- and was the //'S/ c of /fi-C .
J/Cfi // 1?
The disease, or cause of death, was
iterred, or to be interred, in (///r „ fi.fi y
cfij *’ // css-yy- ->
/f
y
day of _ A. D. 18 ■
.
/f
—
cfi
Informant.
''/f/fi /// r/ the eJ
L Z
Dated, at
1
. 5
!
1
RETURN
OF
A
DEATH.
5
limbi] Certify
as
I am
informed,
that
on
the
^
:/s;^£
A&z*
/A . > ' - / / si
a -e
/y )C A. D. 18 O /Jezz^/z, c L A/? .
;ed ^ years, A months,
/J ZZ'Z-zZ
days, in
Street. Said person was a
born in e. Aul/z- Is// / // and was the
day of
died,
at No
and, by occupation, a
Of %.Az. cxfg J'Z'Ls
JL
The
disease,
or
cause of death,
was
AAv*zji+s*t
A
/zAzcs
iterred, or to be interred,
in
i
’//
t
jfo,
->
'
“
^ +AA &
I-/
Informant
.
>'■/*/
the day of
‘
'
A
9
*/■*-&' A. D. 18 ' £■ Dated, at
k
RETURN OF A DEATH.
3 ISmlnj iertiftj, as I am informed, that on the /y j ^
A. D.
18
v/,.
A W.
>
'
/7T
.
ffZ years, months, / days, in • at No.
Street. Said person was a and, by occupation, a
f / - // 9 //-
tS/y-j -ts ot Li-' f- ct/ z>
t
The disease, or cause of death, was e , , f z.. c x*
day of
died,
is born in £ z.C't^ and was the
terred, or to be interred, in ^ r*. ,/
^ 'x 7
^ ^ *"
' ‘ *
Informant
.
Dated, at // ^// //tz-j/z the c / day o £/ A. D. 18 d £
RETURN OP A DEATH.
3
iSmiuj
Crrfifi),
as
I am
informed,
that on the
& A *.
at No.
and, by occupation, a
t/J- istnu’-e'* ■> A. D. 18 >/ > / / i/
;ed
*//
years,
/#
months,
y
days,
in
day of
died,
Street. Said person was a
as
born
in
^
and was
the^t
;<c<
4/1
ft
>■
°f
*
^
'
v/
<.
,
t
The disease, or cause of death, was
iterred, or to be interred, in
6
* y<- *t
i
v the
/< f/fj 'o C? s’ ***■ f "t r i/
/ yy <
day 'of 'A. D. 18/^
Informant.
r
Dated, at
RETURN OF A DHBHATH.
4 Hereby Certify , aslam a that on the
ve
day of
died,
Informant.
%
J
Ie? A.D. 184 Vf , Ptah wT ™ &
ced years, /é months, 7/2 days, in at No.
Street. Said person was a and, by occupation, a
Pp ty iP ’
as born in rl med 7A and was the |. -17/ we, of : " —
a
The disease, or cause of death, was an
erred, or to be interred, in aap &y eae: a
ws é fobe . a é
—_— ‘ yr ” ;
Daten, at 7 Zee ns fe the ‘ —_— of A.D. 18 4
RETURN OF A DEATH.
p.-- : 7 / s
3 Jimlnj Certifij, as I am informed, that on the - ' . L ■ / // / day of
A. D. 18 i? / .✓.Si' died,
;erred, or to be interred, in
jd years, months, / days, in <7 o at No.
Street. Said person was a
s bom in and was the
The disease, or cause of death, was
'j
-Z.-id.fi Ltr j c C't-K
7V//i . i z %yi Ks Informant. C' S' +■ * l' *■ ' J.
Dated, at y/x the day of A. D. /
RETURN OF A DHATH.
Hereby Certify, as I am informed, ah a I eee
Berek A.D. 1862 —— Mies = Mijoe (austin, : died,
Wl years, months, ame; in ae at No.
oJ Said person was a ___.and, by occupation, a
es. and was the ye of £YA Tiyan coos:
The disease, or cause of death, was 2a ered tigife a
ed, or to be interred, in Sina Shire Gauges ofe
a == = Lok Informant.
Daren, at Worm lag wwe /? eve day of “/An— A.D. 1808
*
RETURN
OF
A
DEATH.
S Certify, as I am informed, that on the ^2 v * / /^' ^y?ct
& A. D. 18 A l £JLX^
;ed ff " years, // mnnt,lia)
as born in
/ ^ y'C^C- C- (4,
days', in at
No Street.
Said person was
a
_
and,
by
occupation,
a
of
day of
died,
A*
and was
the
+/*-/
1
The disease, or cause of death, was
terred, or to be interred, in
,
A <2r
-C.jfr'/' ('& Y\
1
Informant.
Dated, at the day <oy
‘
A. D. 18
*
RETURN
OF
A
DEATH.
S iknl\l\ Certify as I am informed, that on the
. D. 18 <Tt
-*^a£L
A
daj of
died,
ed
//
years,
//
months, (/
days,
in
at
No.
Street.
Said person was
a
— and,
by occupation,
a
;is
born
in //
Sff/
&A
and was
the
of
O7
cfut-co/
a.
o
The disease, or cause of death, was
terred, or to be interred, in
j/ - n y Informant .
Dated, at the /* ^ day of /-o-' A. D. 18 6$
RETURN OF A DEATH.
^ jtoehj Certify, as I am informed, that on the ^ day of
A. D.
18^2
r^/zsi't
r
‘//c
/■
/
c
jy
(^e(j)
-
—
ay
;ed yj.._ years, 6 months, days, in
/ Street. Said person was a
at No.
and, by occupation, a
is born in
v/^/iv
t
/v
an(j
was
the of y&> fa-si y z l
The disease, or cause of death, was — ZJc /e-/~
terred, or to be interred, in & t'f'Z €
'
X? XX
.
/
^X. ,/7
‘
y
e-vi s e t L cy
<-
C Informant.
RETURN OF A DHATH.
4 Hereby Certify, as I am informed, that on the ____ Perit day of
Body A.D. 1862 om ye wa wae died,
4 EE. years, /2 months, days, in at No.
Street. Said person was a and, by occupation, &
ls born in @. Mb bhillia and was the oa of 6a = hsm
The disease, or cause of death, was Cz tee dense, uae
rred, or to be interred, in Yi teat, Jian ae le ef ia
f Ol eat Ahoy cel Informant.
Phesnilioah he ne Z lm A. D. 18024
Daten, at -
RETURN
OF
A
DEATH.
3 Certify as I am informed, that on the t
I uv-J' A. D. 18tfe
;d jjt? years, months,
00-*.
@
0C
days, in
/ Street. Said person was a
s bom in ^ ^ and was the #L
The disease, or cause of death, was
day of
c?s2,
died,
at No.
and, by occupation, a 7
O-
j-t
erred, or to be interred, in
Informant .
Dated, at
— I — — —
Z RETURN OF A DEATH.
yet
48 Hereby Certify, as I am informed, that on > eo . Lyfe ee iis day of
elo B, A. D. igo ¢ - Doadhast e zy. é ve = died,
d JF years, - A months, days, in at No.
, Street. Said person was a and, by or & ,
3 born in Mau lhief and was the a/teceyde lor SPY a G Ma ali U 3iplehir
Pj j Pp ial
The disease, or cause of death, was Pa . (2A ee EGE SS
rred, or to be interred, in W virbiivisd Crags olen =" g
Goin. é Ag eye Informant.
Daren, at Bailing. a the /“ May of je A. D187
RETURN OF A DEATH.
Street. Said person was a
i born in and was the // f
% 2^ErEtll| (CnlifiJ, as I am informed, that on the fyfjes*/ Sfr. day of
r ./ C ffl*3' /
jL&'t-Mt A. D. 18 5 J « wini lC J ?t /<fj c-f / r died,
/ J~2 ye airs, JL months, days, in
at No.
The disease, or cause of death, was
rnred, or to be interred, in ^//fat ^ /
and, by occupation, a . y
s/ £// t , , /
of
Jr^ ^
1
^
c-
&
*
t*
/<U
(C/
‘
L/(^)
/// r ?e-s 1 ( f
Dated, at 7'fl
<- y /s & / / / ^ j s'? (' /x.
7r/j'/C Informant .
t the /^ day of J J £ ^ A •
RETURN OP A DEATH.
3 IWlllJ (livBrtiflJ, as I am informed, that on the .c/cec ^* day of
A. D.
1805
•
died,
'd
years, months,
days,
in
at
No.
Street.
Said person was
a
and,
by
occupation,
a
born in and was the of
■
-"r
The disease, or cause of death, was J
jrred, or to be interred, in
Dated, at JPLdL/ the 4 day of
' ^ //■ Informant .
A. D. 18^5
YEARS MISSING
ON
i
ON
1 oo
NO
1 lr\
l
Ni-
1 i 1
co
CN.
on
i 1 i
o-
NO
CM
ON
1 1 1 | NO ITN f— 1
cc
1 1 1 1 lr\ o
CN.
Irv NO
O-
o~
00 00 co CO
iH rH rH rH
i
oj co
CO
n
£j
f— \
o
o
o
To the Clerk
of the Town
in which the Death occurred. /
I oT
Cause
of
Secondary,
fs
W
9
a
a
o
3
Pi
>»
•5JJ9I3 UAU\L 0,U maU panjejqo gq jCeui suxnpjj jo siuxoj quiqg
•sxrqjop a)uoa\j ‘pajgau
.iqj jC}}'cuo<j -q.1013 PIys 0} — spuj osaqi ixodox .10 — joaxoqi aoixoN saio hxiavhxhoa isruu luanixoiuj qons
jo oSxeqo SaiAraq uosxad oqi ‘paunqqo uaoq jsxij SuiAoq (‘papisax pastsaoap 9qi .10) ‘paxxnooo qiooQ oqi qonpv
m uavoj, 9qi jo qxo[Q oqi jo jf.ijsiSgjj jo opogp-iaQ oqi inoqqAV ‘ooiqd guppq juauixoiu; ui? jo osno u[
•XX3KH3XKI anx aaoxaa ‘qxojQ tuiox oqi 0} — qitioQ jo sasnoQ aqi jo oiaogijxa;}
s.trcpis.Cqj aqi qit.u xoqiaSoi — ?ioty aqi ixodox oi pajsonbax si ‘itreraxojot xaqio xo ‘xaqpixapiqx oqx .JS?
'10 the Clerk of the Town
in which the Death occurred.
•jtjojq
uavox
oqi
iuojj
pooreiqo oq
Xrmi
sinniog
jo soijoj
qmqg
J5S
.
•
-fjBqop
Xjua.vvj
‘poiSon
jci
/qt?noj
-qjaTq)
pres
oj—
siorq
asoqi
uodox
jo—
joo.ioqi
aoiiOK haid HXiAVHxaoa
isntu
juanuajuj
qans
jo
pSxTjqo
SuiABq
uosxod
oqi
‘poupnqo
uooq
i&iy
SuiABq
(‘popisox
posuooop
oqi
.10)
‘po.unooo qjt?9Q
oqi
m
UAiox
oqi
jo
qioyQ
atP J°
-folsiSog;
jo
oiBogtuoQ
oqi
inoqq.vv ‘ooiqd
Suiqc) luouuoiui
uu
jo
uj
•XNaKaaxNj hhx
aaoxaa
‘qxoyQ
n.\\oj_
oqi
01
—
qino(T jo sostibq
oqi
jo
oitroiqi-n^
s/creioi=.(qcT
oqi qiiM
joqioSo;— spry
oqi liodoi
Ol
poisonbox
si
‘lUBtnxojni xoqio JO
‘jospqJOpuQ oqX
^
EETURN OF A DEATH,
To the Clerk
of
the
Town
in
which
the
Death
occurred.
D
I
)isc;ise
or
C
First
or
Primary,
Cause
of
■{
Secondary,
(if
any,)
4
*3J8D tmol, oiojj paorejqo aq Iot sujrqajj jo saxioj qtrejg jg£
•sjupop /pia.ui ‘pa[3aa
joj Xqmiag ‘qxaiQ pres oj — sjdbj asaqj podax jo — -joaxaq} aoixoN 3Aio hxiaihxhoa istuu luauuajuj ipns
jo aSxijqa StiiABq nosxad aqj ‘paurejqo uaaq •jsjg Sauuq (‘papisaj pasuaaap aqj jo) ‘pojjnaoo qp:aQ aqj qaiqAi
m uaioj, oqi jo qx9[3 aqj jo jfjjsiSajj jo apjagijja^ aqj ■jnoqjiAi ‘aatqd Sungq luarajajui in: jo asua uj
•XN3KH3XNI 3Hx aaoAaa ‘qiajQ uaiox aqi oj — tpaaQ jo sasrreQ aq) jo ajuarjnjaQ
s.nBioia/fqj aqj qjui xaqjaSoj — spqj aqj ^jodaj oj pajsanbax si ‘jtrenuqjai jaqjo jo ‘jaqcjjapix^ aqj,
USHUBIE Te IF 0} relNosed A10A og]
(Ww OTA CME
“AOPIAA UO UBUIOAY PIVABPL B JI «
-qoqss Astoods ‘soowy 10990 Jo JI “UMDTASY PUL ONAL DO:
. ge —«—€ a Sipe ug ay HCLT ye ae
a a ,
EZ. f? y Sanjay,
| [) Suryeur uosted JOP
10 JayRElopuy] Jo aanyousig
\ we ae a a ae —_
Og Si —— em J “yoy Jo sorjdiparg, eT
|__— <i an | q + Gapoyy Jo omBNy “PT
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DEATH.
1
Second,
Duration,*
Duration,
0?-tZAau^) Diwern * Reckoned to the time of dentil.
Physicians’ Certificates can he obtained on application at the City Registrar’s Office, No. 0 City Hall Avenue.
RETURN OF A DEATH.
To the Clerk
of
the
Town
in
which
the Death occurred.
-
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RETURN OF A DEATH.
To the Clerk
of
the
Town
in
which
the
Death occurred.
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RETURN OF A DEATH.
To the Clerk
of
the
Town
in
which
the
Death occurred.
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To the Clerk
of the Town
in which
the Death occurred.
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a
a.
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s.treroTsXqj oqi qiiAi xaqjoSo} — spry oqi jxodox 0; pajsonbai si ‘ureuxiojni joqio jo ‘joqrnJoptQ oqx <i§&
RETURN OF A DEATH.
To the Clerk
of
the
Town
in
which
the Death occurred.
y*
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•sjcqop X)U3av; ‘joajSan
joj jfqanag 'q^IO pres oj — s;aqj asaq; ;jodaj jo — joajaq; hoixon aAio hiuihisoj ;snui xuanuajuj qans
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ni umoj, aqj jo >[xa[Q oqi jo XxjsiSajj jo oreotji)x,)3 oqj inoqipw ‘aaBpI Suiqej juaraxajui ire jo ossa uj .jS&
•XNaKaauq aHX aaoaaa ‘qxajQ tuvox aqi 01 — qjaaQ jo sasrreQ aqj jo ajBagijxaQ
s.ireTOTsXqj aqj qjm xoipaSoi — spbj aqj ixodax 01 pajsanbax si ‘jtremxojni xaqjo xo ‘xaqBjxapnfi aqx
RETURN OF A DEATH.
To the Clerk
of
the
Town
in
which
the
Death occurred.
7
^
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•satipop Xjua.w; ‘pajgaa
joj XqL’aaj 'qJ8I3 pp33 °J — SJORJ asaqj qaodaa ao — -joaxaqi aoixoN aAio nxiAVHxaoa isnui uianiaajuj ipns
jo aSaaqo SuiABq nosxad atp ‘paunqqo uaaq ?say SniAuq (‘papisaa pasaaaap aqi ao) ‘paaanoao qp?aQ aqj ipiqii
or uavox aqi jo qaajQ aq) jo iajsiSajj jo apaypaa^ aq) inoqjyw ‘aoiqd Suppy luauuaju; u»: jo asBD nj
'XN3KH3XKJ anx aaoaaa ‘qaaj^ imox aqi oj — qmaQ jo sasntQ aqi jo aiBayriaaQ
s^xotsXqj aqj qjt.w aaqjagoi — spry aqj jaodea oj pajsanbaa si ‘junraaojui aaqjo ao ‘aaqiqaapuQ aqx Jgj?
RETURN OF A DEATH.
To the Clerk
of
the
Town
in
which
the Death occurred.
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PHYSICIAN’S CERTIFICATE OF THE CAUSE OF DEATH. To the Clerk or Ttegistrar of the Town or City in which the Death occurred.
Name and Sex of Deceased .
Date and Place of Death , .
Disease,
or Cause <
of Death,
First or Primary,
Secondary, . .
/ P7\ * / / ,/Y „ • tJUMZijelrtZdue.
L Duration of j ~*t r <- f , i
I certify that the above is a true Return, to the best of my recollection and belief.
Name, Professional Title, and Residence,
we is a true dieiurn, w me ocsi oj my rccouecuon ana ueu
ft.
Dated 18 f
[Be very particular to fill all Blanks.] * Reckoned to the lime of death.
Any Physician having attended a person during his last illness, shall— when requested within fifteen
days after the decease of such person— forthwith furnish for registration a certificate of the duration of
the last sickness, the disease of which the person died, and the date of his decease, as nearly as he can
state the same. — [Extract from Chapter 21 of the General Statutes, 1859.]
E^The attending Physician is requested to make out bis Certificate as
promptly as possible, for the information and use of the Undertaker, or
other person making return of the case to the Town Clerk.
EP* Physicians may obtain Blank Certificates from the Town Clerk
or Registrar.
ly’ Copies of the Statistical Nosology, adopted for the purposes
of Registration, majr be obtained on application to the Secretary of the
Commonwealth.
RETURN
OF DEATH
TO THE CITY REG
CITY HALL, BOSTON.
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, CA USE OF yUriiwu'ij, TJ/ d, ' cc^AU%f^<Dicration.
DEA EjD. ’Secondary, t Duration.
S^mt^^TU^vIUau-j |1l^>1 'Physician.
Sd,
ek
Nace
ers, 122 Washington St.
CR AR RNR aa aa Bae
ockwell & Churchill, City Print
r
Ags
Sad oI
29 SAIC
ERE,
Pe
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Boston,
Chis Gertifies, “ar He
a
aed on the SES day i ply
2 Jt
months,
CAUSE OF Primary,
DEATH. ) Secondary,
th
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Chelona Aafleslain Duration.
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The Undertaker, or other informant, is requested to report the facts — together with the
Physician’s Certificate of the Causes of Death — to the Town Clerk, before the interment.
(&T In case of an interment taking place, -without the Certificate of Registry of the Clerk of the
Town in which the Death occurred (or the deceased resided) having first been obtained, the person
having charge of such Interment must forthwith give notice thereof — or report these facts — to said I
Clerk. Penalty for neglect, twenty dollars.
Blank forms for Returns of Deaths may be obtained from the Town Clerk.
Ben 090, we ; Et Lau s VA |
Chis Gertifies, hc “eZ Kallag ler
did on the 27° day of ( fe & 180, aged... yoats,
ce month, detifd |
CAUSE Af mi 7 é dirt Jay Secrntalemme Dustin.
DEATH. 3 Secondary,............ Duration. |
= . : f
C dud Tato cars, ww Physician.
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The
Undertaker,
or other informant,
is
requested
to
report
the
facts
—
together
with
tl|
Physician’s
Certificate
of
the
Causes
of
Death
—
to
the
Town
Clerk,
before the interment.
la case
of
an interment taking
place, without the
Certificate of
Registry
of the Clerk
rfij
Town
in
which
the
Death occurred (or the
deceased resided) having
first
been obtained,
the^^B
having charge
of such
Interment must
forthwith
give notice thereof—
or report these
facts
—
to
n
'
Clerk.
Penalty
for
neglect,
twenty
dollars.
Blank forms
for
Returns
of
Deaths may
be obtained from
the
Town
Clerk.
I
- as Carle)
Phe:
fo My Bie
Yileh
Ql Is fo |
1 Prat xe
7
be)
Rockwell & Churchill, City Printers, 122 Washington St.
ra,
EG a TED
ee
mes
ae
ni?
linn, the
8
CAUSE OF
DEATH.
—
RE
a Du ST. (ry Vhaw, Mub + Physician.
ji a Se — 15355
Chis Gertifies, Hoc (Lune Soclyn WLet
ei] day of. Mg . ISK 80, aged. ysis
monthé, | ut dey :
Primary, Wretes fe ] Duration. | Ww
Secondary, ? YWRAAMAOVLA ¥ Fiawknn Duration. ‘LW
PHYSICIAN’S CERTIFICATE OF THE CAUSE OF DEATH. To the Cleric or Registrar of the Town or City in which the Death occurred .
Any Physician having attended a person during his last illness, shall — when requested within fifteen
days after the decease of such person— forthwith furnish for registration a certificate of the duration of
the last sickness, the disease of which the person died, and the date of Ilia decease, as nearly as ho can
state the same. — [Extract from Chapter 21 of the Generae Statutes, 1859.]
jt^The attending Phj-sician is requested to make out his Certificate as
promptly as possible, for the information and use of the Undertaker, or
other person making return of the case to the Town Clerk.
UP"1 Physicians may obtain Blank Certificates from the Town Clerk
or Registrar.
Copies of the Statistical Nosology, adopted for the purposes
of Registration, maj’- be obtained on application to the Secretary of the
Commonwealth .
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{ | The Undertaker, or other informant, is requested to report the facts — together
Physician’s Certificate of the Causes of Death — to the Town Clerk, before the interment.
with the
In case of an interment taking place, without the Certificate of Registry of the Clerk of the
Town in which the Death occurred (or the deceased resided) having first been obtained, the person
having charge of such Interment must forthwith give notice thereof — or report these facts' — to said
Clerk. Penalty for neglect, twenty dollars.
Blank forms for Returns of Deaths may be obtained from the Town Clerk.
;
Bue
ae
2
on Bt.
FA
SE gett
+39 SR
c=
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Rockwell & Churchill, City Printers, 122 Washingt:
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Chis Gertifies, “av Ht. Vie C-ime.cll|
deed on the 6a day g~ Supt: 186 O , aged. — / . = Yeas, |
_ month, ee a
CAUSE i — Y, Chiu. ales in Duration. so dh
DEATH. ) Seeei PY; Z Duration—— |
Sd A TW lerne Mprinicion |
\ \
I -
PHYSICIAN’S CERTIFICATE OF THE CAUSE OF DEATH. To the Clcrl: or Deyistrar of the Town or City in which the Death occurred.
Name and Sex of Deceased, .
Date and Place of Death, . .
Disease, f .
’
Pirst
or
Primary,
s>r Cause -[
of
Death,
[
Se™ndary,
■
•
•
c A, 7/ ty __= .
Yc-A / / ^ c / yy / < < A * ** c y / d*
’....!2LdL Duration of,* / 6 L
/t<_ j L Cl )
Duration of,
I certify that the above is a true Return, to the best of my recollection and belief
Name, Professional Title , and Residence,
[Bo very particular to fill all Blanks.] * Reckoned to the time of death.
Any rhysician having attended n person during his last illness, shall — when requested within fifteen
days after liic decease of such person —forthwith luruish for registration a certificate of the duration of
the last sickness, the disease of which the person died, and the date of his decease, as nearly as ho cuu
6 Late the same.— [Extract from Chapter 21 of tiie General Statutes, 1859.]
[^The attending Physician is requested to make out liis Certificate as
promptly as possible, for the information and use of the Undertaker, or
other person making return of the case to the Town Clerk.
SEP3 Physicians may obtain Blank Certificates from the Town Clerk
or Registrar.
Copies of the Statistical Nosology, adopted for the purposes
of Registration, ma}r be obtained on application to the Secretary of the
Commonwealth .
(‘sqUBla IIB 11g 07 retnoysed £104 og]
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“pauung00 yjyeeg ou? YdI
c™"
“
i
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I* T,
r^-.f£r=J2
having charge
of each Intermen. must
FOUTUvn™
c.vo »OT.CE .hereof-
or re,o,t
Clerk. Penally
for neglect,
twenty
dollars.
•
Blank forms for Returns
of
Deaths may
be obtained from the
Town
Cle.k,
PHYSICIAN'S CERTIFICATE OF THE CAUSE OF DEATH.
'ex of Deceased, .
ace of Death,
.. ^
.(../..d.L^.Ak. /.k.
Disease or )
cause of Death, ) Axf.it a, .CSKL/ffe: J. . . Duration of; ..A.<M....y.z£.Q.L.
Y certify that the above is true to the best of my recollection and belief
ional Titley and Residence^
Dated at
' above is true to the vest of my recollection and belief
L J /i.c ‘tiu/iti is \-n£
particular to fill all Blanks.} * Reckoned to the time of death.
[‘sxUB[E 118 ITY 07 aelnoNzed £104 og]
sqeqar Ajrools *sooey some jo gy “uu*pUT CT) Soret CI) SueoTyy CV) certs uREa seMI0 IT
Baio! SMOPTM 10 URUIOM POLIVIY U Jy «
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= : Fors ss Lo10g “F
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le jf mn sods JoyIaYA puB ‘xog “¢
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“pouamoo0 weed eu) Holm _uI-ap4 =r
^
The Undertaker, or other informant,
is
requested
to
report
the
facts
together
with
Physician’s
Certificate
of
the
Causes
of
Death—
to the
Town
Clerk,
BEFORE
tiie
interment.
gg-
la case
of
an interment taking place, without the Certificate of
Registry of the
Clerk
of thel
Town
in
which
the
Death occurred (or the deceased
res'fded)
having
first
been obtained, the persouj having charge of such Interment must
forthwith
give notice thereof—
or report these
facts
—
to said
Clerk. Penalty
for neglect,
twenty
dollars.
Blank forms for Returns
of Deat hs
may
be obtained from the
Town
Cleric.
PHYSICIAN’S CERTIFICATE OF THE CAUSE OF DEATH.
Name* Professional Title , and Residence ,
/ certify that the above is true to the best of my recollection and belief
tdence ,
.£ is Dated at fk.1L
[Be very particular to fill all Blanks.] * Reckoned to the time of death.
R
u
0 0
c?
Ci
3 dS
V 3 Ci
CO
0 Q
5
Secondary
(if
any)
Residence
d
A
>
co
-
V
ci
£
u
<3
£4
The Undertaker, or other informant, is requested to report the fatfts — together with the
Fhysiciau’s Certificate of the Causes of Death — to the Town Clerk, before the interment.
In case of an interment taking place, without the Certificate of Registry of the Clerk of the
Town in which the Death occurred (or the deceased resided) having first been obtained, the person
having charge of such Interment must forthwith give notice thereof — or report these facts — to said
Clerk. Penalty for neglect, twenty dollars.
l£if" Blank forms for Returns of Deaths may be obtained from the Town Clerk.
RETURN OF A DEATH.
To the Clerk of the
Town
in which
the Death occurred.
a
03
0 n
■
S
«
S 3
... o
1 8
| 9
„ o
C3
P.
<j£ST The Undertaker, or other informant, is requested to report the facts — together with the
Physician’s Certificate of the Causes of Death — to the Town Clerk, before the interment.
In case of an interment taking place, without the Certificate of Registry of the Clerk of the
Town in which the Death occurred (or the deceased resided) having first been obtained, the person
having charge of such Interment must forth with give notice thereof — or report these facts — to said
Clerk. Penalty for neglect, twenty dollars.
Blank forms for Returns of Deaths may be obtained from the Town Clerk.
v
PHYSICIAN’S CERTIFICATE
Name and Residence of Certifying Physician
I certify that the above is true , to the best of my knowledge and belief \
n. & ^ /f
Date of Certificate, .. j87 /
* Or Sex of Infant (not named).
Any Physician having attended a person during his last illness, shall — when requested within fifteen days after the decease of such
person— -forthwith furnish for registration a certificate of the duration of the last sickness, the disease of which the person died, and the
date of his decease, as nearly as he can state the same. — [Extract from Chapter si of the General Statutes, /8jg.]
Without repealing the foregoing requirements of the General Statutes, the recent “Act to provide for the more Accurate Registration
of Vital Statistics,” passed April 23, 1878, provides that “no human body shall be buried, or removed from any city or town, until a
proper Certificate has been given by the clerk or local registrar of statistics, to the Undertaker or Sexton, or person performing the
burial or removing the body. This certificate shall state that the facts required by chap. 21 of the General Statutes have been
returned and recorded; and no clerk or local registrar shall give such certificate or burial permit until the Certificate of the Cause of
Death has been obtained, (from the Physician, if any, in attendance at the last sickness of the deceased), and placed in the hands of said
clerk or local registrar.”
If there has been no Physician in attendance, or in case of death by dangerous contagious disease, or in any other event where the
certificate of the attending Physician cannot, for good ant] sufficient reasons, be early enough obtained, the chairman of the local Board of
Health, or any Physician employed by any city or town for such purpose, shall sign the Certificate of the Cause of Death, to the best of
his knowledge and belief. In case of death by violence, the medical examiner shall furnish the certificate.
Commonwealth; of l^litssitchtrs
3
e
£
o
u
E
t-
o
o
CO
eS
a?
CO
s
Cause
of
-j
Secondary
(if
any)
Death,
[
By
whom
certifie
d
X.
V
o
a
^3
« Ph O Pn
oo
d
J
_
The Undertaker,
or other informant,
is
requested
to
report
the
facts
-together wit
t
>e
PhvsicWs
Certificate
of
the
Causes
of
Dcath-to
the
Town
Clerk,
befobe the ^tebmeet.
In case of
an interment taking
place, without the
Certificate of Eogi. rj of
tie
u
o
ic
Town "which
.he
Death occurred (or the deceased resided)
havin^rst
having charge
of such
Interment must FOBTiiwiTn give notice
thereof oin.p
Clerk.
Penalty
for neglect,
twenty
dollars.
Blank forms for Returns
of
Deaths may
be obtained from
the
Town
Clerk.
rites alee Seayr ieee.
| a
| mae
Name of Deceased* - - - | atl D4 POOL tl .
»
Ulin ae. iil Bhi 9 Phahh ~ BA
Nate and Place of Death,
—
é Duration of Sickness 2.
asease or Cause of Death,
|
t certify that the above ts true, to the best of my knowledge and belief.
* sy) o
Ho
Name and Residence of Certifying Physician 4 4 zs ¢ <<... af -f: 7
‘
Date of Certificate, .. “¥ £
* Or Sex of Infant (not named).
187
Any Physician having attended a person during his last illness, shall — when requested within fifteen days after the decease of such
person— -forthwith furnish for registration a certificate of the duration of the last sickness, the disease of which the person died, and the
date of his decease, as nearly as he can state the same. — [Extract from Chapter 21 of the General Statutes, /8jg.]
Without repealing the foregoing requirements of the General Statutes, the recent “Act to provide for the more Accurate Registration
of Vital Statistics,” passed April 23, 1878, provides that “no human body shall be buried, or removed from any city or town, until a
proper Certificate has been given by the clerk or local registrar of statistics, to the Undertaker or Sexton, or person performing the
burial or removing the body. This certificate shall state that the facts required by chap. 21 of the General Statutes have been
returned and recorded; and no clerk or local registrar shall give such certificate or burial permit until the Certificate of the Cause of
Death has been obtained, (from the Physician, if any, in attendance at the last sickness of the deceased), and placed in the hands of said
clerk or local registrar.”
If there has been no Physician in attendance, or in case of death by dangerous contagious disease, or in any other event where the
certificate of the attending Physician cannot, for good and sufficient reasons, be early enough obtained, the chairman of the local Board of
Health, or any Physician employed by any city or town for such purpose, shall sign the Certificate of the Cause of Death, to the best of
his knowledge and belief. In case of death by violence, the medical examiner shall furnish the certificate.
[SRAVLA 18 ITY 03 Te[noyaed A10A og]
*yeqar Ajroods ‘saony 19yzo Jo JT “uBIpay (Cy) Posey CW) SU ,
ia at "2? ae wo
“AINA WRIT] O|O JT +
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1
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‘HLVAG V dO NYNLAY
Fam
OgF The Undertaker, or other informant, is requested to report the facts — together with the
Physician’s Certificate of the Causes of Death — to the Town Clerk, before the interment.
er In case of an interment taking place, without the Certificate of Registry of the Clerk of the
Town in which the Death occurred (or the deceased resided) having first been obtained, the person
having charge of such Interment must forthwith give notice thereof — or report these facts — to said
Clerk. Penalty for neglect, twenty dollars.
tjgf* Blauk forms for Returns of Deaths may be obtained from the Town Clerk.
PHYSICIAN’S CERTIFICATE
* Or Sex of Infant (not named).
Any Physician having attended a person daring his last illness, shall — when requested within fifteen days after the decease of such
person— -forthwith furnish for registration a certificate of the duration of the last sickness, the disease of which the person died, and the
date of his decease, as nearly as he can state the same. — \Extracl from Chapter 21 of the General Statutes, /Spg.]
Without repealing the foregoing requirements of the General Statutes, the recent “Act to provide for the more Accurate Registration
of Vital Statistics,” passed April 23, 1878, provides that “no human body shall be buried, or removed from any city or town, until a
proper Certificate has been given by the clerk or local registrar of statistics, to the Undertaker or Sexton, or person performing the
burial or removing the body. This certificate shall state that the facts required by chap. 21 of the General Statutes have been
returned and recorded; and no clerk or local registrar shall give such certificate or burial permit until the Certificate of the Cause of
Death has been obtained, (from the Physician, if any, in attendance at the last sickness of the deceased), and placed in the hands of said
clerk or local registrar.”
If there has been no Physician in attendance, or in case of death by dangerous contagious disease, or in any other event where the
certificate of the attending Physician cannot, for good and sufficient reasons, be early enough obtained, the chairman of the local Board of
Health, or any Physician employed by any city or town for such purpose, shall sign the Certificate of the Cause of Death, to the best of
his knowledge and belief. In case of death by violence, the medical examiner shall furnish the certificate.
iE ela (J uw gi zemonied £104 eal
+ anja oy?
op) fo aangouiig
ws
ig “rm * SLaTpOPT Jo aoupd yg, FL
rs ae _— TF
G
lat vy Ate fc "+ Saueg jo aourdyaig? “ET
os
6 z) tt SaIpOyY Jo ow OT
ms i: %,
wy Lz, ty 4, : EN CLL
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gyre iu
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CALLY re D yore 8 Gauapisoyy “2
paynaa moyn Ag “yaad
) Aavpuooag ¢ JO BSR, y
—_s hy yee =
pas UU ») we sopsats sons rk 7
++ yf(oureny capreyy)
——~—__
“AWAY, PO) JN 4 . SRS 800000 50
V5) a LouD P + + SypyRaq Jo amd “1
‘paaunoo0 ‘ured eu) yorum { UMO] 94) JO 4219) out OL
‘HLVGd V dO NYOLTY 7
mae
* ewes
7 /)U
The Uudertaker, or other informant, is requested to report the facts — together with the
Physician’s Certificate of the Causes of Death — to the Towu Clerk, before the interment.
In case of an interment taking place, without the Certificate of Registry of the Clerk of the
Town in which (lie Death occurred (or the deceased resided) having first been obtained, the person
having charge of such Interment must forthwith give notice thereof — or report these facts — to said
Clerk. Penalty for neglect, twenty dollars.
t^“ Blank forms for Returns of Deaths may be obtained from the Town Clerk.
PHYSICIAN’S CERTIFICATE.
I certify that the above is true, to the best of my knowledge and belief.
Name and Residence of Certifying Physician Sj’, f) d fte Da“ ‘t cemfeatt,.
v
'■ t '"•*
>‘-.f ✓ * Or Sox of Infant (not named).
Any Physician having attended a person during his last illness, shall — when requested within fifteen days after the decease of such
person— -forthwith furnish for registration a certificate of the duration of the last sickness, the disease of which the person died, and the
date of his decease, as nearly as he can state the same. — [Extract from Chapter 21 of the General Statutes, 1839.]
Without repealing the foregoing requirements of the General Statutes, the recent “Act to provide for the more Accurate Registration
of Vital Statistics,” passed April 23, 1S78, provides that “no human body shall be buried, or removed from any city or town, until a
proper Certificate has been given by the clerk or local registrar of statistics, to the Undertaker or Sexton, or person performing the
burial or removing the body. This certificate shall state that the facts required by chap. 21 of the General Statutes have been
returned and recorded; and no clerk or local registrar shall give such certificate or burial permit until the Certificate of the Cause of
Death has been obtained, (from the Physician, if any, in attendance at the last sickness of the deceased), and placed in the hands of said
clerk or local registrar.”
If there has been no Physician in attendance, or in case of death by dangerous contagious disease, or in any other event where the
certificate of the attending Physician cannot, for good and sufficient reasons, be early enough obtained, the chairman of the local Board of
Health, or any Physician employed by any city or town for such purpose, shall sign the Certificate of the Cause of Death, to the best of
his knowledge and belief. In case of death by violence, the medical examiner shall furnish the certificate.
CommomucattTt of Ittassachusct
o
U
o
<D
CO
c3
a
CO
5
clUSe
of
•<
Secondary
(if
any)
certified
The Undertaker, or other informant, is requested to report the facts — together with t lie
Physician’s Certificate of the Causes of Death — to the Town Clerk, before the interment.
In case of an interment taking place, without the Certificate of Registry of the Clerk of (lie
Town in which the Death occurred (or the deceased resided) having first been obtained, the person
having charge of such Interment must FORTIIWITII give notice thereof — or report these facts — to said
Clerk. Penally for neglect, twenty dollars.
fggT Blank forms for Returns of Deaths may be obtained from the Town Clerk.
PHYSICIAN’S CERTIFICATE.
a ] a =
Name of Deceased,*
if é
Date and Place of Death, -| died at . ay TEAS.
Oo “J . A ll / - i
| 7 é . 3 -
Disease or Cause of Death, -| of “Ax OSH Cremer of Sickness... LAUL WA Let 7
| 7
T certify that a
( =a a Z
A Z a + laf ¥
Name and Residence of Certifying Physician &é ) LSP» %, po Peek klet SOE AM
; -
= —
Date of Certificate, A » 8D)
* Or Sex of Infant (not named). :
4
Oe “a
Any Physician having attended a person during his last illness, shall — when requested within fifteen days after the decease of such
person— -forthwith furnish for registration a certificate of the duration of the last sickness, the disease of which the person died, and the
date of his decease, as nearly as he can state the same. — \Extract from Chapter 21 of the General Statutes, /8j<?.]
Without repealing the foregoing requirements of the General Statutes, the recent “Act to provide for the more Accurate Registration
of Vital Statistics,” passed April 23, 1878, provides that “no human body shall be buried, or removed from any city or town, until a
proper Certificate has been given by the clerk or local registrar of statistics, to the Undertaker or Sexton, or person performing the
burial or removing the body. This certificate shall state that the facts required by chap. 21 of the General Statutes have been
returned and recorded; and no clerk or local registrar shall give such certificate or burial permit until the Certificate of the Cause of
Death has been obtained, (from the Physician, if any, in attendance at the last sickness of the deceased), and placed in the hands of said
clerk or local registrar.”
If there has been no Physician in attendance, or in case of death by dangerous contagious disease, or in any other event where the
certificate of the attending Physician cannot, for good and sufficient reasons, be early enough obtained, the chairman of the local Board of
Health, or any Physician employed by any city or town for such purpose, shall sign the Certificate of the Cause of Death, to the best of
his knowledge and belief. In case of death by violence, the medical examiner shall furnish the certificate.
{‘S4Ue1E 18 ITE 0} AeMonsIed Ar904 og]
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A A ome OS ————
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‘HLVad V dO NYOLaY
—
———— )
giT The Undertaker, or other informant, is requested to report the facts — together with the
Physician’s Certificate of the Causes of Death — to the Town Clerk, before the interment.
In case of an interment taking place, without the Certificate of Registry of the Clerk of the
Town in which the Death occurred (or the deceased resided) having first been obtaiued, the person
having charge of such Interment must forthwith give notice thereof — or report these facts — to said
Clerk. Penalty for neglect, twenty dollars.
Blank forms for Returns of Deaths may be obtained from the Town Clerk.
PHYSICIAN’S CERTIFICATE
I certify that the above is true , to the best of my knowledge and belief.
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The Undertaker, or other informant, is requested to report the facts — together with the
Physieiau’s Certificate of the Causes of Death — to the Town Clerk, before the interment.
er in case of an interment taking place, without the Certificate of Registry of the Clerk of the
Town in which the Death occurred (or the deceased resided) having first "been obtaiued, the person
having charge of such Interment must forthwith gia7e notice thereof — or report these facts — to said
Clerk. Peualty for neglect, twenty dollars.
tjgT Blank forms for Returns of Deaths may be obtained from the Town Clerk.
PHYSICIAN’S CERTIFICATE
I
certify
that the
above
is
true, to
the best
of
my
knowledge and
belief.
Name and Residence of Certifying Physician Z., ///, s^c
J
/J
V
Date of
Certificate,
L
j8^
/
*
Or Sex
of
Infant
(not
named).
Any Physician having attended a person during his last illness, shall — when requested within fifteen days after the decease of such
person —forthwith furnish for registration a certificate of the duration of the last sickness, the disease of which the person died, and the
date of his decease, as nearly as he can state the same. — [. Extract from Chapter 21 of the General Statutes , i8pg.]
Without repealing the foregoing requirements of the General Statutes, the recent “Act to provide for the more Accurate Registration
of Vital Statistics,” passed April 23, 1878, provides that “no human body shall be buried, or removed from any city or town, until a
proper Certificate has been given by the clerk or local registrar of statistics, to the Undertaker or Sexton, or person performing the
burial or removing the body. This certificate shall state that the facts required by chap. 21 of the General Statutes have been
returned and recorded; and no clerk or local registrar shall give such certificate or burial permit until the Certificate of the Cause of
Death has been obtained, (from the Physician, if any, in attendance at the last sickness of the deceased), and placed in the hands of said
clerk or local registrar.”
If there has been no Physician in attendance, or in case of death by dangerous contagious disease, or in any other event where the
certificate of the attending Physician cannot, for good and sufficient reasons, be early enough obtained, the chairman of the local Board of
Health, or any Physician employed by any city or town for such purpose, shall sign the Certificate of the Cause of Death, to the best of
his knowledge and belief. In case of death by violence, th^ medical examiner shall furnish the certificate.
[‘s¥av1q ITB 11D 07 tetnoNIed Lr0A og]
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Van teal)
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The Undertaker,! or other informant, is requested to report t lie facts — together with the
Physician’s Certificate of the Causes of Death — to the Town Clerk, before tub interment.
tgf In case of an interment taking place, without the Certificate of Registry of the Clerk of the
Town in which the Death occurred (or the deceased resided) having first bf e n obtained, the person
having charge of such Interment must forthwith give notice thereof — or report these facts — to said j
Clerk. Penalty for neglect, twenty dollars.
C#T* Blank forms for Returns of Deaths may be obtained from tbc Town Clerk.
V
4
ee ws ee CATE.
a ae
lame of Deceased,* - - - ~ LM ice
ve and Place of Death, - | died at . . . os 187
tsease or Cause of Death, - | of. eS See prt wf eeDuration of Sickness
I certify that the above is true, to the best of my knowledge and belief.
pme and Residence of Certifying
ig Physician
Date of Certificat ; 187
* Or Sex of Infant (not named),
Any
Physician having attended
a
person during
his
last
illness, shall
— when
requested
within
fifteen
days
after
the
decease
of
such
person
—forthwith
furnish
for
registration
a
certificate
of
the
duration
of
the
last
sickness, the disease
of
which
the
person
died,
and
the
date
of his
decease,
as
nearly
as
he can
state
the
same.
—
{Extract
from
Chapter
21
of the
General
Statutes,
sSjg.]
W
ithout
repealing
the
foregoing
requirements
of
the
General
Statutes,
the
recent
“Act
to
provide
for
the
more Accurate
Registration
of
\
ital
Statistics,”
passed
April
23,
1S78,
provides
that
“no
human
body
shall
be
buried,
or
removed
from any
city
or
town,
until
a
proper
Certificate has
been given
by
the
clerk
or local
registrar
of
statistics,
to
the
Undertaker
or Sexton,
or
person
performing
the
burial
or
removing
the
body.
This
certificate
shall state
that the
facts
required by
chap.
21
of the
General
Statutes have
been
returned and recorded;
and
no clerk
or local
registrar shall give
such
certificate or
burial
permit
until
the Certificate
of
the
Cause
of
Death
has
been obtained,
(from
the
Physician,
if
any,
in
attendance
at
the
last
sickness
of the
deceased),
and placed
in
the
hands
of
said
clerk
or local
registrar.”
If
there has
been no Physician
in
attendance,
or in
case of
death by
dangerous
contagious
disease, or
in
any other event
where
the
certificate
of
the
attending Physician cannot,
for
good
and
sufficient
reasons, be early
enough
obtained,
the
chairman
of the local
Board
of
Health,
or
any Physician
employed
by
any
city or
town
for
such purpose,
shall sign the
Certificate of the
Cause
of
Death,
to
the
best
of his
knowledge
and belief.
In case
of
death by
violence, the
medical examiner
shall
furnish
the certificate.
8GP*Fill out in
ink.
When married, erase "single” and "widow”; when widowed,
erase
"single” d
ed."
la) vet
Pos, ZAWGA.. R. ABBU
pL, Chen:
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Chis Certifies, GWor..arve Vakleag,
8
Po
$
2 pordpaes ee te atic e
= oy
e Vey)
CITY
Ord ES
27 a
Ve at one vena!
ORD DAY aL erie a aL.
$f
2 Peat eaten tay
§ cli om the 0. day of. fing 188! , aged .— ~~ ..yeats,
i /
=
t
' month, ee
| CAUSE Don Cholewa Iuffeac leceaDuraton |
DEATH.
Secondary, 00... ... Duration ......... me
. (Steg! L MW bceclicced Physivian.
Olu,
i
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‘SPPISNYIVSSUBE JO WyRaaommosgy
V
•
r
w
is
remiestcd
to
report
the
facts
—
together with
the
M*
The
Undertaker,
01
ot
iel
^
ll)e
Towu
Clerk,
before
the interment.
Physician’s
Certificate
of
the
Causes
ot
Pe
Pc-iistry of the
Clerk
of
the
gg- In case of an interment taking place, cvillioiit lit u ' ic r obtained, the person
Town fwhich the Den,., oceurred (or the " rjpor. these faets- to -d
having charge
of
such
Interment most
FO.tr,
.wm.
o,v B
»OT,cn
Clerk.
Penalty
for
neglect,
twenty
dollars.
i
hi.
Town
Clerk
gg- Blank forms
for
Returns
of
Deaths
may
he
obtamed
from the
loan
Clot*
/■Si/ > ft
VI/ yi
PHYSICIAN’S CERTIFICATE OF THE CAUSE OF DEATH. To the Cleric or Registrar of the Town or City in which the Death occurred .
Name and Sex of Deceased , .
Date and Place of Death , .
First or Primary ,
Secondary, .
Disease,
or Cause
of Death,
C/..L < /JPN JN
(iyfyy //^‘ /DY/ _
y t Duration of * O 7^-c-
Duration of,* ' &
Duration of, D
I certify that the above is a true Return, to the best of my recollection and belief
Name, Professional Title , and Residence , CffCi j ' l( 7 flf/ edf s'/ / f f*
Dated at 'fl.
sir/.
[Be very particular to fill all Blanks.] * Reckoned to the lime of death.
Any rbvsicinn having attended a person during his last illness, shall— when requested within fifteen
days after the decease of such person— forthwith lurnish for registration a certificate of the duration of
the last sickness, the disease of which the person died, and the date of his decease, as nearly as he can
slate the same.— [Extract from Chapter til of hie General Statutes, 1809.]
attending Physician is requested to make out his Certificate as
promptly as possible, for the information and use of the Undertaker, or
other person making return of the case to the Town Clerk.
OP Physicians may obtain Blank Certificates from the Town Clerk
or Registrar.
Copies of the Statistical Nosology, adopted for the purposes
of Registration, may be obtained on application to the Secretary of the
Commonwealth.
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uosjad aqj ‘paunqqo uaaq jsjg Sui^Bq (‘papisaj passaoap aqj jo) ‘pajjnooo qpzaa aqj qoiqxi ui umox
aqj jo qaaio aqj jo ijjsigajj jo ajBagipia3 aq} jnoqqxv ‘aoBgl guppjj juauxiajui ub jo 9sbo uj
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aq} qjiAv jaqjaSo} — sjobj aq} jjodaj oj pajsanbax si ‘jubuijojui jaq}0 jo ‘jaqujjapufl aqi .=<£3
- \
PHYSICIAN’S CERTIFICATE OF THE CAUSE OF DEATH. To the Clerk or Registrar of the Town or City in which the Death occurred .
Name and Sex of Deceased , .
Date and Place of Death. . / 2— /'f/c'l e/^.x
Disease , First or Primary ,
Secondary , .
// /? /fs1~£L 'f fsOCsLdXs Duration off
or Cause - 12 ~ ' // *
Duration of,
of Death ,
Name, Professional Title, and Residence,
I certify that the above is a true Return , to the best of my recollection and belief.
Dated at. .
1 8<T/.
[Be very particular to fill all Blanks.] • Reckoned to tho time of destU.
Any Physician having attended a person during his last illness, shall— when requested within fifteen
days after the decease of such person — •forthwith furnish for registration a certificate of the duration of
the last sickness, the disease of which the person died, and the date of his decease, as nearly as he can
state the same.— [Extract from Chapter 21 of the General Statutes, 1859.]
fc^’The attending Physician is requested to make out his Certificate as
promptly as possible, for the information and use of the Undertaker, or
other person making return of the case to the Town Clerk.
Physicians may obtain Blank Certificates from the Town Clerk
or Registrar.
Copies of the Statistical Nosology, adopted for the purposes
of Registration, may be obtained on application to the Secretary of the
Common we a lth .
a
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+-> O'-
*
\
2 }
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■C <V
03
\
£
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\
ggT The Undertaker, or other informant, is requested to report the facts — together with the
Physician's Certificate of the Causes of Death — to the Town Clerk, before tiie interment.
Ogr I'1 case of an interment taking place, without the Certificate of Registry of the Clerk of the
Town in which the Death occurred (or the deceased resided) having first been obtaiued, the person
having charge of such Interment must forthwith give notice thereof — or report these facts — to said
Clerk. Peualty for neglect, twenty dollars.
fjjr Blank forms for Returns of Deaths may be obtained from the Town Clerk.
[ow Ss _-ellhhinaitlldac
Name of Deceased* - - - Gifu & iy yes, Mo
c a
Date and Place of Death, - | died’ al bor PP asus - p o ie Vy,
oe B/S 1669 ,
Disease or Cause of Death, -\ of a lj Duration of Sickness
i
I certify that the above is true, to the best of my knowledge and belief.
/ tA C
_ ; ,
Name and Residence of Certifying Physician Patil b Calemale jl oy - “LE ate
Date of Certificate, (0 ¢e SF 18% /.
* Or Sex of Infant (not named).
pc
r
s
o
i
'i—forf/t
with
furnSf^^
requested
within
fifteen
days
after
the
decease
of
such date
of hts
decease,
as
near.y
as
he can
state
the
sanre.-^^
^
^
of Vital Statistics,”
passed
^^3^
'^uman
\odv
b
'V'
‘T0™'6
f°r
the
more Accurate
Registration
proper
Certificate has
been given by
the
clerk
or local registrar
oHtatistics
to
the
IT
T’
l"
rem°Ved
fr°m
dty
°r
t0Wn-
until
a
banal
or
removing
the
body.
This
certificate
shall
stafe
that
1 I
Undertaker
or Sexton,
or
person performing
the
returned and recorded; and no clerk or local registrar shall trivl , I faCtfSfirequ,redl hy chaP- 21 <* ‘he General Statutes have been
Death has been obtained, (from the Physician, if any, in attendance at S'* °J l’T?* the Certificate of the Cause of
clerk or local registrar.” " ’ a,tendance at ‘he last stekness of the deceased), and placed in the hands of said
certificate of
dm
a"end"ng^^^^^^
contagious
disease, or in
any other event
where
the Health, or any Physician employed by any city or town for surh 7 . y enouSh obtained, the chairman of the local Board of
his knowledge and belief. li case of deadly vTo one e *" J'5" <* lh' Cause »' Death, to the bj o
am
oy violence, the
medical examiner
shall
furnish the
certificate.
o
to
*
S
*
G
O
a e
o
o
cc
d
o
G
G
co
G
a a
o
c3
3
£
rO
£
o3
-»->
U2
PHYSICIAN’S CERTIFICATE
Name of Deceased * - - -
Date and Place of Death,
Disease or Cause of Death, -
died at
of. . (^/l'lSr^Ms,L £f &4ntion of Sickness
I certify that the above is true, to the best of my knowledge and belief.
Name
and Residence
of Certifying
Physician
.
> / /
♦ Or Sex of Infant (not named).
Date of Certificate,. ed^fr*~^...S4....
.
person-
-forthwith
furnish6
for
reg^raboTa
'certificate
of
'the
d"T’
"'l'6"
re<|UCS,ecl
wilhiu
fifteen
(la>s
after
the
decease
of
such
o,
,o
provw'
for
*■
—
*«■»«
**«*.
proper Certificaf. has been given by the clerk or local resist ar ,r°m city or town, until a
burial or removing the body. This ce ificate shaH JZT* t ‘° Undertaker °r Sexton, or person performing the
returned and recorded; and no clerk or S ^ ^ ” °f ^ Statutes havetaen
Death has been obtained, (from the Physician ffany in ^ ^ ^ Ccrtificate of the Cause of
clerk or local registrar.” ' nCe 3 t le ast Slckness of the deceased), and placed in the hands of said
certificate of the attending Physic^'I^^^o^^an^uffideT^ ^ dan,ger°US contaSious disease, or in any other event where the
Health, or any Physician employed by any city or town for surh'6*1 *!? Carly enOUgh obtained> the chairman of the local Board of
hie
knowledge
end
beiief.
cL
^
^
-
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tA't'i)
2
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The
Undertaker,
or other informant,
is
requested
to
report
the
facts
—
together with
the
Physicians
Certificate
of
the
Causes
of
Death-to
the
Town
Clerk,
before the intekmekt.
la case of
an interment
taking
place, without the
Certificate of
Registry
of the
Clerk
o
le
Town
if
which
the
Death occurred (or the
deceased resided) having
first
been obtained,
^person
having charge
of
such Interment must
forthwith
give notice
thereof
01 repoit
t
ese
ac
s
Clerk.
Penalty
for
neglect,
twenty
dollars.
Blank forms
for
Returns
of
Deaths may
be obtained from
the
Town
Clerk.
Mevtc Bevox
Boston, Mag, £2 18R4
Chis Certifies, “7 Me than Lh ot
did on the ~<f day Sf , lip re SEL J aged ~~ yeais,
|
L |
| . WOLttk months, z= MAYS,
|
|
i
CAUSE OF ) Primary, = 2 neZz. Suc Cle Ua nde Duration € 2c oe
DEATH. ) Secondary. Duration
CuATr Wilany Wo « Physician.
[‘sHUBI_ 118 119 03 ZelNoNAVd A104 og]
“geqan Aproads ‘soouy royye Jo FE MPU CT) four CN) fWeopyy CP) cayMTA weNy Jeyy ITE
“MOPIM JO UNION POLIUN UIT «
LR ex goty, G uo ‘ yy Ww aaLvqd
a "7 = ls
pA nuvi . meeayous i
a Oe | tayrsopugy —— aunqoubry
‘+ wangoyy 2y)
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ee “‘ompoyy Jo ooujdquarg: “pT
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‘HLVGG V dO NYoLay
Cy ON
c
Sun
d,,,
^_>rsy
,,,
. .
,
^'Ie Undertaker, or other informant,
is
requested
to
report
the
facts
—
together with
tl.e
»)
aic.an
s
Certificate
of
the
Causes
of
Death—
to the
Town
Clerk,
before the interment. In case
of
an
interment taking place, without the Certificate of
Registry
of the
Clerk
of
the
Towa
,»
which
the
Death occurred (or the deceased resided) havipg
ficst be,
/obtained
the
Persia
elk pT„Sh ,“,CrmC“t «■« -“"OB thereof — or report these f.«, said
t-lcrk. Penalty
for neglect, twenty
dollars.
CT Blank forms for Returns
of
Deaths may
be obtained from the
Town
Clerk.
___ PHYSICIAN'S CERTIFICATE.
® of Deceased* - |Rbob. Mx hes. Lede. thar,
Date and Place of Death, -| died at Py, iy , Mutha, Ape, o?; Spoleto.
y..MeothA - Duration of Sickness 7
Disease or Cause of Death,
J certify that the above ts Wa to the, best of my knowledse anit belich,
p Z —
‘ y f
Name and Residence of Certifying Physician’ Sp Wee =, ' or F La: da Udes.
uy — 4 Hl ,
epbatrr fo Date of Certificate, i 7 AL . 8K,
Any Physician having attended a person during his last illness, shall — when requested within fifteen days after the decease of such
person —forthwith furnish for registration a certificate of the duration of the last sickness, the disease of which the person died, and the
date of his decease, as nearly as he can state the same. — [Extract from Chapter 21 of the General Statutes,
Without repealing the foregoing requirements of the General Statutes, the recent “Act to provide for the more Accurate Registration
of Vital Statistics,” passed April 23, 1S7S, provides that “no human body shall be buried, or removed from any city or town, until a
proper Certificate has been given by the clerk or local registrar of statistics, to the Undertaker or Sexton, or person performing the
burial or removing the body. This certificate shall state that the facts required by chap. 21 of the General Statutes have been
returned and recorded; and no clerk or local registrar shall give such certificate or burial permit until the Certificate of the Cause of
Death has been obtained, (from the Physician, if any, in attendance at the last sickness of the deceased), and placed in the hands of said
clerk or local registrar.”
If there has been no Physician in attendance, or in case of death by dangerous contagious disease, or in any other event where the
certificate of the attending Physician cannot, for good and sufficient reasons, be early enough obtained, the chairman of the local Board of
Health, or any Physician employed by any city or town for such purpose, shall sign the Certificate of the Cause of Death, to the best of
his knowledge and belief. In case of death by violence, the medical examiner shall furnish the certificate.
[sxueia
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Ip pe gbny Joy
et a “uangay aut
bo 4 buyow wosatmmpee
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ve wns. MW) a7, * Gaya jo aoudyqarg,
=e Maj of ny + + Atoipoyy Jo ouuyy
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=... br tlie OG | + aig, jo oul g
7 + Qanoptseyy
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‘HLVGG V dO NYOLaY
ye
™
Ttie
Undertaker,
or other informant,
is
requested
to
report
the
facts
topetl.cr
with
the
Physicist
Certitatte
of
to
Causes
of
Death-.
o
the
Town
Clerk,
status
ms
™K*.
<3-
I"
'”se
«f
“
'mmM
'f "g
^
'"'"hT^X^
^eeoyobtatod,
to
person
Clerk.
Peualty
for
neglect,
twenty
dollars.
•
TtlonU
forms
for
Returns
of
Deaths
may
be
obtained from the
1
own
Clerk.
sw
7 Auf, £ 3 JS'p/
fa
Cl)is Certifies, ^
o/eet/
on
Mo
-3
■->"
s/ay,
/fic^
/tf/T
/
Cl*
aaec/ v/eaD,
men
<di,
c/nnj. 7Vd
CAUSE OF | Primary, k /cc /fcltZ A lu_ Duration
DEATH. \ Secondary , Duration
1hy sic ion .
[‘SUB[E 118 11 07 AeynoWIed Ar0A og]
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“MOPEAL 40 HINO AL POHTIEN ¥ IT «
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fa
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. ‘TOYO JO OWBN “ZT
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|
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{
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yowapouaeny Payap ey) + + some
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‘HLVaG V dO NYOLTY
' co
™ SJLISMALILSSLBE JO YWIwenMOWUOD
gg3 The Undertaker, or other informant, is requested to report the facts — together with the
Physician’s Certificate of the Causes of Deatli — to the Town Clerk, before the interment.
In case of an interment taking place, without the Certificate of Registry of the Clerk of the
Town in which the Death occurred (or the deceased resided) having first been obtained, the person
having charge of such Interment must forthwith give notice thereof — or report these facts — to said
Clerk. Penalty for neglect, twenty dollars.
Blank forms for Returns of Deaths may be obtained from the Town Clerk.
(X j?
/ .$'7 T? -Y 0 * ' o 6 (j
m/Yi
,
cfi
Ci)is Certifies,
tAat
//a ^
iy
/ttyi e tc
&
d
c/cet/ on Me 3,3 r/ay e^ M<-iy {cr>f /$ft / , ayec/ ~~ yeaM,
«F£F^€
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me
n
Me
j
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ye.
CAUSE OF j Primary , t /e( /c l <£y <VZ<M/eZs jf/ct/c Duration
DEATH. ) Secondary, Duration
^cU*/ LT
•
^hMjtciiu^ Huf), Physician.
(SXUV_ I 1B 07 te[nNoWAed Area og]
“yey Ayroods ‘soouzy soyzo Jo JT ‘uerpuy (1) comeing (WY) “OIIT AA URI Jom JT }
“AOPLAL IO UBWOM POLE © FT «
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40
apucy fo aunpoubig
* QuouldoyUy JO soB[q ‘GL
+ STaqoY Jo oovydipag “PE
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(Aww 5) Arepuoaag JO BSN,
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ene... =... ‘poamopt A 10 ‘paler
ie aaa li og fe ‘g[Sus Joujoyr puw'xeg -g
mrerrmrcetnmann «6 onreny UspIO HD)
S(p Pe ypereses |: + + + oung -g
ry eee + + + Smog Jo atq ‘1
“Pedino00 YyyVag ey} YOIYM UT UMO] 94) JO Ysa) OY) OL
HLVAd V ao NYOLGa
“syssnhusseys yo Gyyeaguommop
•JJJ9I0 uavoj, oq; uiojj pauit?;qo oq A'bui sujn;a;i jo buuoj >gn?ig <^3
•sjnpop A;uaAi; kjooi§eu joj Aquuaj -qjai^ pitta
o; — s;oaj asaq; jjodaj jo — joajaq; aoixos aAio hxiavhxhoj ;snui ;aaaija;uj qons jo aSjtjqa SutAttq
nosaad aq; ‘paait?;qo uaaq ;sjy SuiAtjq (‘papisa.t past?aoap aq; jo) 'pajjnooo q;naQ aq; qoiqM ui umoj,
aq; jo qjai3 aq; jo Aj;stSaji jo ajtjatjtjja^ aq; ;noq;;.\i. ‘ao^jd Supp?; ;uauua;ui at? jo asao nj jFI
•xsareaaxxi anx aaoaan ‘qxa[3 uavoj, aq; o; — q;t?aQ jo sasnt?f) aq; jo ajaogijjaQ s^toisiq^
aq; q;iAv jaq;a2o; — s;ot?j aq; ;xodax o; pa;saabax st ';uuuijojui jaq;o jo ‘jaqt?;japu{} aqj
PHYSICIAN’S
CERTIFICATE OF
THE CAUSE OF
DEATH. To the Clerk or Registrar of the Town or City in twhich the Iteath occurred •
Name and Sex of Deceased ,
Date and Place of Death , .
Disease, [ ^ . ,, .
first or Primary,
or Cause of
Death,
[
S^mtdaey,
■
•
•
An# Uj /uZl tyy?
£.17 ArAx (Afl (Nt~» ^
A^J>tiftf /d -6- 1 df? SpzfjA Duration of,* Z/drAjeet,
<
Duration
of,
^
Xante, Professional Title , and Residence ,
/ certify that the above is a true Return, to the best of my recollection and belief.
Ck ^ '■/ AfP2 Z't-e-AAPN > Jd. JP.
Dated at -/sfk.rA...
1 85/ .
[Be very particular to fill all Blanks.] * Reckoned to the time of death.
8tate lhe Bame. [Extract from Chapter 21 of thegenerL! ^aTATME^lS^]’ a8 “ hu u"“
f^The
attending
Physician
is
requested
to
make
out
his
Certificate
as
promptly
as possible,
for
the
information and
use
of the
Undertaker,
or
other
person
making
return of the case
to
the
Town
Clerk.
Physicians may
obtain
Blank
Certificates from
the
Town
Clerk
or
Registrar.
t
Copies
of the Statistical Nosology, adopted
for
the purposes of
Registration,
may
be
obtained
on
application
to the
Secretary
of the
Commonwealth
.
EY} LOUMIO JT £
poe UIT e
caer Aploads ‘soouy 294
a beriiyg lis Ay
WW daivgd
. “wanjagy oy}
plop monn 5 Ue a
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p aay wag dy vei
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Vet ‘Loop Jo vovpdyuug “pT
s Ye 4 AL. 15 ,
“ef Myr * * Saul jo saytdqiaig “ey,
4 AS
OV fF a7) Pouvey 7 8 Sampoyy Jo ourwny “ZT
egnly ag i? L . “roy Vy JO omeNT “TT
y Aa? il SS 8 Sayer 7
oy We 7 |
SoG tp geoukatye | *“qutIg Jo 00% “OT
ee * + ‘onvdnssg “6
fev * “‘pweq jo eoxg *g
“Y G8 i oi : “+ Souepisayy +,
omoqn kt) Bay
|( ue jr) Saepuosag - asneg
\aewmizg 30 vn Jo osuasiq( -9
yea , 4 ‘sq moyy, SSIMOE te ‘aBy -¢
—— “PNY, sot ts ss Log -F
Pte PPOMOPLAA 10 ‘porsaeyy
: GOL MA, “(Burs Joyaya puw ‘xeg +g
# eT —.. a. ‘Sasa
a “4 ie “+ {peag: jo ama“
CLG oS
“padinooo yyeog ey) YyoryAL “ul waen ay} JO yey) oy) oF
‘HLVaG V dO NYOLTY
of
The Undertaker, or other informant, is requested to report ;the facts — together with the
Physician’s Certificate of the Causes of Death — to the Town Clerk, befoke the interment.
tjif In case of an interment taking place, without the Certificate of. Registry of the Clerk of the
Town in which the Death occurred (or the deceased resided) having firfet been obtained, the persou
having charge of such Interment must forthwith give notice thereof — or report these facts — to said
Clerk. Penalty for neglect, twenty dollars.
CiT’ Blank forms for Returns of Deaths may be obtained from the Town Clerk.
y
PHYSICIAN’S CERTIFICATE.
Name and Residence of Certifying Physician
I certify that the above is true, to the best of my knowledge and belief.
* Or Sex of Infant (not named).
Any Physician having attended a person during his last illness, shall — when requested within fifteen days after the decease of such
person— -forthwith furnish for registration a certificate of the duration of the last sickness, the disease of which the person died, and the
date of his decease, as nearly as he can state the same. — [. Extract from Chapter 21 of the General Statutes,
Without repealing the foregoing requirements of the General Statutes, the recent “ Act to provide for the more Accurate Registration
of \ ital Statistics,” passed April 23, 1S78, provides that “no human body shall be buried, or removed from any city or town, until a
proper Certificate has been given by the clerk or local registrar of statistics, to the Undertaker or Sexton, or person performing the
burial or removing the body. This certificate shall state that the facts required by chap. 21 of the General Statutes ha've been
returned and recorded; and no clerk or local registrar shall give such certificate or burial permit until the Certificate of the Cause of
Death has been obtained, (from the Physician, if any, in attendance at the last sickness of the deceased), and placed in the hands of said
clerk or local registrar.”
If there has been no Physician in attendance, or in case of death by dangerous contagious disease, or in any other event where the
certificate of the attending Physician cannot, for good and sufficient reasons, be early enough obtained, the chairman of the local Board of
Health, or any Physician employed by any city or town for such purpose, shall sign the Certificate of the Cause of Death, to the best of
his knowledge and belief. In case of death by violence, the medical examiner shall furnish the certificate.
OU spony If
>
BG G7" E oi &
“Would TO YM seyzeqA opeIg, ‘oqwig pUL UMOT, WosUT, .e%4
Pre g
‘yueaojuy Io Joyt}opuy)
““BAOWOY, IO JUSUAOJUT JO oye
-)
Ss
nF ‘yuouLIEJU] Jo soul
sa BF Sap ‘uolRing Gai, ae ht / ‘favpuooag qwoqd
‘uornRing . ‘Arvuurtg € jo osntg
ep)
wv . , Tayop, Jo sox dyyarg
—, oe oy Slay gy jo soxupdyyarg
PEL iey r po TOYOTA JO OULBNT
a : . ““ToyRYL JO ove Ny
JO MOPIL AA? A we ee peo y, ovpdqarg
JO_OFEM SS ya o = toredns09,
oumamya oo Sg Su es “6
—PoLanyy apsulg y xeg”” ps "Ze Vie Ps i ooUOpISozy
‘ON pur yaei}g
ywog Jo su, g
GuYM ‘>% Yous 9
sAup ; p yuou re geen a Bir
a roe SURAT
8L, 7° ; AANtES, 7) cateog jo oeq
v7 ‘ : = Ae
7
"NOLSOS ‘“ITVH ALIO
AVULSIOTY ALIN FHL OL HLVIC JO NUALTY
POI, PUB oT FUI8,,
08819 ‘POMOPIM UOT M {,,MOPIM,, PUL ,,e[SUIS,, osBiO ‘porleM TOT ‘HUI UL yno [TT e5¢
oe a. * bsg
This Certifies, H-
Pa.
ie
i,
cA
| | ded on the f> day of : ASSIS, aged. a €. yen,
‘ ee month, ; _ days.
g Se.
ye || CAUSE OF) Primary, . Duration
DEATH. Secondary, Cen jeern f ae | o-— ae Oe pes
®
4
ee 1,
A Pate hg cut 4 Z Physician.
10;
te
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.
^
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■mon, aaiid.
CAUSE OF ) Primary ,
DEATH.
t/id, actpi
VVUViuAj^
Duration .A
...\\I.CL\Ca
Secondary , Duration
\j
iV G
I V.
..
1
Phy sician.
“HO 10 opty Toqzeys 030994 - Pa puv Yyuog, OST], 4
—————
P fo
eae ra ‘queALIOJUT IO 1oye}LOpuy)
z- tt wcmmang 10 JUOUTADIUT JO oye
29 Lor AA ‘qudULIOjU] JO 908] qT
5 a Si: OT, ;
Ivpuos0g yyeod
mee" trorRIng ~
‘uonring a ‘ ~ ‘Kavuntag ( Jo osneg
—— — — soopeg - spree oo LONIOW jo sovpdyyaig
— ee oe apy ayy Mae . sls il {TY JO sovpdyqaigy
safe ercttetes go et wee alt Zl ~-o¢gayJOPY JO OUBNT
poet UL Prag sop yo OMEN
Prt. - se pray PAD —
~toredna99,
‘age FO 7 ae By ORHAN
7 Ԥ
poruepy copBerg ~ Va ; KOS ILE YEA, -
AAG 7 ‘ooUopIsyy
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sup Set... ..-aae ampere... qyuou a savas Ye -a8y
z S
Jp (tae NORCOEMITVH ALTO
UVULSINTY ALIO HL OL HLVAC 40 NUALTY
(cPOLLIVML,, PU ,,o] SUIS,
osula ‘POMOPI Toy f,,AOPIM, PUB ,,O[ SUIS, oselo ‘pelien TOY ‘YU UL yn [Jee
pomopra Toy PIs, P Yeahs Pe 40.2} Tl.
ide. Ste
ad
desea =
Eva
an
id we
oe )
>
ap.
Spratt a+ DR pear ateaodt »
d
pS
ta
oz
ate ede ea GY BS
Fea erate CS Goore
A
oun, = Cay a LA 4 ASSL
This Certifies, Hac areh JM Ciasah
s
died on the 20" dey. Qzr 18S, aged BE ais
CAUSE OF
DEATH.
month,
Secondary,
eee Ec dry 3. |
|
vv i i
5 \ " , \ +H
Primary,.... \.W° RAs ek. Uv. Duration .1\.Nox vu my
we. Duration |
ee a ens Physician.
{
(SHAVE T1® IIT 07 zejno4azed AroA og]
“qeqa Aytoads ‘saany 10T]}0 Jo JT “UBIPUT CT) PoyLpNIY (
CK? ape COIAN Li Oe
>
wopug fo aanpoubry
eo Z|
vi oe UY 4 ») ry lea 2. “Sao Jo sovpdyiug pT
wa cnglrbdy ~* ypoprrt ys + Stout Jo outa ugT “ET
bay $ ee > ans aay a ec
4 KI p IPS q
i.
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+ ‘oF a is “@ ; 0 | 0 aS ‘aorednso9 6
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— g> | pagnaas < “pea
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wml
|
‘skuq- geen UB nit @ LP . coy Ge,
-_ —, abs nm [ sorts sf ojog “F
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ace “pemoplLAy to ‘paruypy
OV"! hig ee = doyyoya pur ‘xeg -¢
a “y A Yf, y) ghey p tthe aA * *yuaUIdayOT Jo avv[q “GT
ey jo owen LL
“UME JO ULE “OL
Savunsg 20 ysayt | to
ros *9
+ {Cowen uopreyy)
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si AiG, Ba r a4 ' - qmeq jo amd “T
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‘HLVGdG V dO NYOLGH
oe
u J QJ Csi
CW
2,9
'iy
t>
O'
The
Undertaker,
or other
informant,
is
requested
to
report
the
facts
—
together with
the
Physician’s
Certificate
of
the
Causes
of
Death
—
to
the
Town
Clerk,
before
tiie
interment.
65“
In
case
of
an
interment
taking
place, without the
Certificate of
Registry
of the
Clerk
of
the
Town
in
which
the
Death
occurred (or
the
deceased resided)
having
fifst
been obtained, the
person
having charge
of
such
Iuterment
must
forthwith
give notice
thereof
—
or report these
facts
—
to said
Clerk.
Penalty
for
neglect,
twenty
dollars.
65“ Blank forms
for
Returns
of
Deaths
may
be
obtained from
the
Town
Clerk.
CHAS. G, BROOKS, M.D,
| SARATOGA PLACE
EAST ot
it, Abram KA lf
G alow ADV ws
Vis aio UA
[SXUBLEL T1B ITF 03 ZB NoWAEd A190 og)
sqeqat Apioods ‘soovy 10mjo Jo FT MUIPUT CT) POMUENTY CW) FBvoLY Cy)
“MOPEM 40
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ett TOI0 IT
pu ——— odnpoubry
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aie me nei “Bl
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» £pLBOIGY, 6 0 tg jo ort “OL
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Lit va $7 Ve
|poynteo moun dg | SIRO
ae ePULDIG = asneg
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sheq——— Ssynoyy ~ fseo ‘wy G
ner 2 + \ a ae ‘pamopt Ay 40 ‘poravyy
a f ) bie ey od ‘apouis datpaya puy “Neg “¢g
nn 7,
| + f(oue NT Dopleyy)
—
+ SOUURNT °S
2 (Ss o e ways + “pmaq jo ord ‘1
“padanooo ures oy) yoIUM UL UMOY ey) yo aquer) au) ol
‘HLVad V dO NYONLAY
= vs Ve ton
ss yasmapessey 10 yusarnowmog
do osvasig °9
The
Undertaker,
or other informant,
is
requested
to
report
the
facts
together with
the
Phygiciau’s
Certificate
of
the
Causes
of
Death
—
to
the
Town
Clerk,
before the interment.
gg-
In case
of
an interment taking
place, without the
Certificate of
Registry
of the
Clerk
of
the
Town
in
which
the
Death occurred (or the
deceased resided) having
first
been obtained, the person
bavin- char-e
of
such
Interment must
forthwith
give notice thereof—
or report these
facts
—
to said
Clerk.
Penalty
for neglect,
twenty
dollars.
Blank forms for Returns
of
Deaths may
be obtained from the
Town
Clerk.
PHYSICIAN’S CERTIFICATE.
a me of Deceased - -
Date
arid
Place
of
Death,
Disease or
Cause
of
Death,
died at
of
Duration of Sickness
I
certify that the
above
is true, to
the best
of
my knowledge and
belief.
Tame and Residence
of
Certifying Physician
/
r.
Date of Certificate,
*
Or Sex of Infant (not named).
persoii^^/v^wV^Hfunii^rfor^eg^ratiw^
ce^^cate1
of^e
dm^don^of
'^e
l'ast
h
'T
^
^
*'*
^
deCtaSe
of
su‘h
date
of h,s
decease,
as
nearly
as
he
can
state
the
sante.-^^
^
^
’
“d
of
Vita!
Statistics,”
p^ed^^
Statutes
the
recent
“Act
to
provide
for
the
more Accurate
Registration
proper
Certificate
has
been given
by
the
clerk
or local registrar
oHtTtistS"
to
t
h
removed
from
any
city
or
town,
until
a
bunal
or
removing
the
body.
This
certificate
shall
stafd
that the
f'e
a k
‘
°r SeXton>
°r
Person Performing
the
returned and recorded; and no clerk or local registrar shall rive the faCts recluired hV chap. 21 of the General Statutes have been
Death
has
been obtained,
(from
the
Physician,
ff
any,
i„
attendance^
ThelT’
v
l
‘T™*
Unti‘
the Ccr,ificate
°l
‘he
Cause
of
clerk
or local
registrar.”
y’
attendance
at
‘he
last
sickness of the
deceased), and placed
in
the
hands
of
said
certificate
the
contagious
disease, or
in
any other event
where
the
Health, or any Physician employed by any city of town for such m rn K u Y T™8 °b‘ained’ the Chairman of the local Board of
hts knowledge and belief. In case of deafh byy C““ * ^ * ** -
(‘SHOVIE I18 ITg 09 qelnotIed Ara ag]
CD fonemiy CH
syeqar Ayroods ‘saouy sayy Jo jr cuy
— a ae. % - WuamMayay Jo vv[g CL
oni ne
Vda) 7 A
i sp
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ie re : , § {A dN N ‘Gl
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{ ¢ 7 y Pr
geass if ai, » ST 8 MT Jo D0NLT “OT
* Tonednoog -%
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Savpuooes Fo osnvy
‘semua 10 asm} uo asvasiqy “9
sea 47 “yra0yy a7 OX" 8g St nn 8 8 taB ye ag
> 0- 30-5 BY D U1)
Tee oa cme - ._ M to ‘paraueyy
yo Sen” 2 es Heya puv sxag -¢
' i A “+ (@ureyy wopieyy)
“al niet aan ihe es wh A St ss eae =z
‘ 73 SiS wy wi + Sprrag: jo omg “1
paaanoo0 y weed eu) YoIUM uF UMOL 24) Jo yaa]) 94) ol
‘HLVaGd V ado NYOALAY _
SHON
j
The
Undertaker,
or other informant,
is
requested
to
report
the;
facts
—
together with
t lie
Physician’s
Certificate
of
the
Causes
of
Death
—
to
the
Town
Clerk,
before the interment.
In case of
au interment
taking
place, without the
Certificate of
Registry
of the
Clerk
of
the
Town
in
which
the
Death
occurred (or the
deceased resided)
liaviug
first
been obtained, the person
having charge
of such
Interment must
FORTHWITH
give notice
thereof
—
or report these
facts
—
to said
Clerk.
Penalty
for
neglect,
twenty
dollars.
Blank forms for Returns of Deaths may be obtained from the Town Clerk.
PHYSICIAN’S CERTIFICATE.
Name of Deceased ,* -
Date and Place of Death,
Disease or Cause of Death,
....
died at.
of Cl:
<L
Duration of Sickness
I
certify that the
above
is true, to the best
of
my knowledge and
belief.
Name
and Residence
of
Certifying Physician
Date of Certificate, ..
JCCZff-
*
Or Sex of Infant (not named).
ot ™ f,u"s; ,h; t:'." Aa ,o provi<" •*• *“»»« ***~*»
proper
Certificate has
been given
bv
the
cleVk
or
teal
t ^
7
7
shal>
be
buried-
°r
amoved
from any
city
or
toun,
until
a
burial or
removing
the
bodv.
This
certificate
shall
staf^th^t
°tl
StatlS‘,CS’
t0.t
®
Undertaker
or Sexton,
or
person performing
the
returned and recorded-
and
no clerk
or
locall
Tn
t ^
by
Chap‘
21
°f the
General
Statutes have
b«"
Death
has
been
obtained (from
he
Phvsician
ff
anT
n
"
certificate or
burial
permit
until
the Certificate
of
the
Cause
of
clerk
or local
registrar.”
7
’
7’
“ aUendance
at
the
last
s>ckness
of the
deceased), and placed
in
the
hands
of
said
certificate
of
the
attending Physician
canno^f
ore
oo'd'"
T*
ffi death
^
dangerous contag>ous
disease, or
in
any other event
where
the
Health,
or
anv Physician
employed
bv
anv
cit
&
t
1
l'6"1
reasons> be early
enough
obtained,
the
chairman
of the local
Board
of
his
knowledge
and
belief
"n
cLe
of
del
T
T" Z
^ ^
^
Certificate °f the
CaUSe
of
Death-
t0
the
be^
of
n
CaSe
0f
death by
V10lence, the
medical examiner
shall
furnish the
certificate.
-Wtnmouwealtlt of Massachus
clUSC
of
Secondary
(if
any)
The Undertaker, or other informant, is requested to report dhe facts — together with the
Physician’s Certificate of the Causes of Death — to the Town Clerk, before tiie interment.
In case of an interment taking place, without the Certificate of Registry of the Clerk of the
Town in which the Death occurred (or the deceased resided) having fir^t been obtained, the persou
having charge of such Interment must forthwith give notice thereof — otr report these facts — to said
Clerk. Penalty for neglect, twenty dollars.
Blank forms for Returns of Deaths may be obtained from the Town Clerk.
PHYSICIAN’S CERTIFICATE
Name
of
Deceased,*
-
-
-
Date and Place of Death,
Disease or Cause of Death, - of.. irnCM MAmeZz.. Duration of Sick ness... fiCpp/r.. //..£
Name and Residence of Certifying Physician
I certify that the above is true, to the best of my knowledge and belief.
t. , $
Date of Certificate, .1 /l
<*&/■
Or Sex of Infant (not named >.
Any Physician having attended a person during his last illness, shall — when requested within fifteen days after the decease of such
person—; forthwith furnish for registration a certificate of the duration of the last sickness, the disease of which the person died, and the
date of his decease, as nearly as he can state the same. — [Extract from Chapter 21 of the General Statutes, /Sjg.]
Without repealing the foregoing requirements of the General Statutes, the recent “ Act to provide for the more Accurate Registration
of Vital Statistics,” passed April 23, 1S78, provides that “no human body shall be buried, or removed from any city or town, until a
proper Certificate has been given by the clerk or local registrar of statistics, to the Undertaker or Sexton, or person performing the
burial or removing the body. This certificate shall state that the facts required by chap. 21 of the General Statutes have been
returned and recorded; and no clerk or local registrar shall give such certificate or burial permit until the Certificate of the Cause of
Death has been obtained, (from the Physician, if any, in attendance at the last sickness of the deceased), and placed in the hands of said
clerk or local registrar.”
If there has been no Physician in attendance, or in case of death by dangerous contagious disease, or in any other event where the
certificate of the attending Physician cannot, for good and sufficient reasons, be early enough obtained, the chairman of the local Board of
Health, or any Physician employed by any city or town for such purpose, shall sign the Certificate of the Cause of Death, to the best of
his knowledge and belief. In case of death by violence, the medical examiner shall furnish the certificate.
RETURN
OF
DEATH
TO
THE CITY
REGISTR
Ph
>
CHU MN
CLM! Eb 7 ig?
3 )
Cl)is Certifies,
//iat
Zrr /<?<?/
c/('ec/en
t/te
c/au
f
,
aae</
won aai/j.
CAUSE OF IPrimary^J^^A. Ui^/i&ifOuration
DEATH, j Secondary , \Jlfe^
$£?... Duration
Physician.
[sxUe lg Te 11g 07 ReTRounEd AI9A oa]
O3T
Gps te <9 meet) uo
“i — ‘wanjoy ou?
ei ja) oo ML IALAD DD + YOU reese RO
il (O , ( coypjaapug fo asnqoubruy
_—— ~ é
Ya 6 maid Of
¢
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cL ettar VAD ee 1 CTA b/
tet a2) ?
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i Te nee KA soe “aye Jo oueyy IL
ome” A fe “wy fs "WHET Jo 99vfq “OT
‘uonednsa9 *¢
5 vp de im 4 7 7 ynwaE Jo soe[q °g
fs <1 a it :
(A Pept, )Peippenag ¢, rome 2
eo monn kg) St mod
3!) Axepuooag b 50 SND)
| Savanig 20 ysang | 10 asvasiq “9
VOT — se eee * &8y -¢
- . . . . . 4 “1010; sd
NT fog 4 2
she yy ‘squoyy ba
PRD 7) brig ca
a + 4{(aunsy caprapg)
pina MO ROY? + somone g
-MOPLAL 10 ‘pare
oSUIs JOyIOYM puy ‘xag -¢
a A
OI ug A fy | “mer oowa
‘padinoo0 yyeaq ey) Yom uF “imo ‘om JO y49]) Oy} OF
‘HLVad V dO Nanay /
9g °K
me.
m
,
I’'6 UuJer'aker’
or other
iu
formant,
is
requested
to
report
the
facts
—
together with
the
I
hysician
s
Certificate
of
the
Causes
of
Death—
to
the
Town
Clerk,
before
the interment.
^
In case
of
an
interment
taking
place, without the
Certificate of
Registry
of the
Clerk
of
the
,
in
which
the
Death occurred (or
the
deceased resided) having
first
been obtained, the person
having charge
of such
Interment
must
forthwith
give notice
thereof—
or report these
facts
—
to said
Ucrk.
Penalty
for
neglect,
twenty
dollars.
Blank forms
for
Returns
of
Deaths
may
be
obtained from
the
Town
Clerk.
PHYSICIAN’S CERTIFICATE
Name of Deceased ,* -
Date and Place of Death,
I
certify that the
above
is true, to the best
of
my knowledge and
belief.
Name
and Residence
of Certifying Physician
. .
.
jffl
.
.
M^lf.
Date of Certificate, . DC 37 j8^/ .
* Or Sex of Infant (not named).
person— for//i7tn/A furnislf fo^regbtratfoi^a certificate ^ dumion^of 'th'' ]16^ 'vkhin f,fteen da>'s ^ the decease of such
date
of his
decease,
as
near*
as
he can
state
the
same.-f^/row
^
™d
of
to
provide
for
the
more Accurate
Hegistration
proper
Certificate has
been given by
the
clerk
or local registrar of
statistic/
to
n
?
’>
°r
rem°Ved
from a"X
«%
or
town,
until
a
burnl
or
removing
the
body.
This
certificate
shall state
that the
fac
I
r’el!
’
H
,
!
°r Sexton-
or
Per*°" performing
the
returned and recorded; and no clerk or local registrar shall eive s I fi q d, by Chap' 21 °f the Ge,u'ral Statutes have been
Death has been obtained, (from the Physician, if any, in attendance at S las't^ V !?"?* Certificate °f tbe Cause of
clerk
or local
registrar.”
'
6 at
,he
Iast
slckness of the
decea^l), and placed
in the
hands
of said
certificate of the attending^^ contagious disease, or in any other event where the
Health, or any Physician employed by any city or town for such i n ^ 7 en0Ugh obtained- the chairman of the local Board of
hi.
—ledge
and
belief.
cane of dead, by violence,
the £££?,
Z ^ °'
“
““
*
% ■
Vi
[SHUBIE 118 IG 0} uelnowsed A104 og]
CD forempy (iy) Surowyy CF) ‘ous wey. deTI0 IT 4
*MOPIA\ IO URMOAL POLICHE UIT «
Ze SP Ley po YO G 5”
sqeqm Ayroads ‘savvy 10730 JO JT “Ww
ae BEL “- < WW asivg
Zz ( [, : oe ay?
eZ Any) ) Suyow eset cope
= i aig ( | caynpropt Q fo asnpoubry
|
‘yaoUayay jo oo[q “CT
|; -‘taqnoyy yo coud
a Se baageenees 2 |
VVZCOGE ) —— i
ff ei / ron Ds Al
aan ns —— A ©C > - AIRE oRSeNT SOT
+ ‘nonednoag °6
Yuva? Vai “+ “vag: jo vRq *g
i yong rors + + Gonapisayy *y
|paynava moqa Sg ‘yivaqd
ee Arepuoseg jo osney
"| saempcg 10 ang | so asvasiq, “9
‘shaq LP aang ssn gy" tote ts fey cg
— yy ott sf Mt0j0Q "%
‘pamopr ad 10 “paraavyy
-— FLO =— ‘ajDUIS JOYIOYA pu 'xeg “g
yy Fiiaa = ‘(oulwNr uapieyq)
— —_ * 7 N wopiuyy
‘OF oa SOUIUNT *S
“podansoo yieed 94t yorum Oy umol oY} JO Hse) 84} OL
‘HLVad V dO NYOLGa
) a “mag jo ord T
pgp ON
The Undertaker, or other informant, is requested to report the facts — together with the
Physician's Certificate of the Causes of Death — to the Town Clerk, before Tiie interment.
giP In case of an interment taking place, without the Certificate of Registry of the Clerk of the
Town in which the Death occurred (or the deceased resided) having first been obtained, the person
having charge of such Interment must forthwith give notice thereof — or report these facts — to said
Clerk. Penally for neglect, twenty dollars.
6^ Blank forms for Returns of Deaths may be obtained from the Town Clerk.
[‘SHUBTE 118 ITE 0} eno1ed As0A og]
WC CIK) Suvopyy (CF) *OIt{A weqy remo IT +
*MOPEM IO TRUTO AL POLIT UIT +
7 ecingnyy ayy
wayppopuy fo aunjoubry
|
) ‘yuautlejuy Jo wrt “CT
J -“ |
- i wie) | *ToToyy J
gg)
oo ai + + + ‘gay Op JO OWUNT “ZT
“2ayyey JO OMBNT “LT
+ Wig, jo etd “OT
+ ‘aonvdnoa9 *6
“Req jo avg “g
+ Souapriseay “2
payhses moyn Sy *qreoqd
(Sut jt) Aaepuosag fy osneD
Saempig 30 3st] 10 osvost(y °9
+ + + 2 By -g
sie ig 7 “sumo eg at
—-- Tiesseceennvonseneeeenussscensnsssaemgngsagciges er: I sot os tt L Mtopog “%
Reems ey paMmopraAy to “parauyy
rf. Ke Pl ‘Q[BUIS LayOYM PUL ‘xeg *g
«(oweN vopIyy{)
SouIUN, *S
‘yyeog jo ard ‘T
“pouanoo0 Yee OY) YORYM UT UMOL OY} JO Y4o}) ey} OL
‘HLVEG V dO NUNLaa
Kjgf* The Undertaker, or other informant, is requested to report the facts — together with the
Physician’s Certificate of the Causes of Death — to the Town Clerk, before THE interment.
In case of an interment taking place, without the Certificate of Registry of the Clerk of the
Town in which the .Death occurred (or tile deceased resided) having first been obtained, the person
having charge of such Interment must forthwith give notice thereof — or report these facts — to said
Clerk, Penalty for neglect, twenty dollars.
Igg’ Blank forms for Returns of Deaths may be obtained from the Town Clerk.
PHYSICIAN’S CERTIFICATE OF THE CAUSE OF DEATH. To the Clcrh or Registrar of the Town or City in which the Death occurred .
Name and Sex of Deceased , .
Date and Place of Death , . .
Disease ,
or Cause <
of Death,
1CLc..P.I£.n. ^
ItfJ -$f ffV 3 , k/.l.fiN.6L..
.f. Duration off /Id lL / c P C /f First or Primary ,
Secondary, . . .
Duration of,
Name, Professional Title f and Residence,
I certify that the above is a true Return, to the best of my recollection and belief.
Dated at
[Be very particular to fill all Blanks.]
M..DU-L A. i8^5.
* Reckoned to Ike time of death.
Any rbysicirm having attended a person during: his last illness, shall — when requested within fifteen
days after the decease or such person— forthwith furnish for registration a certificate of the duration of
the last sickness, the disease of which the person died, and the date of his decease, as nearly as he can
state the same. — [Extract from Chapteu 21 of the Genekal Statutes, 1809.]
fi^Tke attending Physician is requested to make out his Certificate as
promptly as possible, for the information and use of the Undertaker, or
other person making return of the case to the Town Clerk.
Physicians may obtain Blank Certificates from the Town Clerk
or Registrar.
[^"Copies of the Statistical Nosology, adopted for the purposes
of Registration, may be obtained on application to the Secretary of the
Commonwealth.
TTo,
1W’
RETURN OF A DEATH.
To the Clerk
of the
Town
in
which
the Death occurred.
ggP The Undertaker, or other informant, is requested to report the facts — together with the
Physician’s Certificate of the Causes of Death — to the Town Clerk, before tiie interment.
In case of an interment taking place, without the Certificate of Registry of the Clerk of the
Town in which the Death occurred (or the deceased resided) having first been obtained, the person
having charge of such Interment must forthwith give notice thereof — or report these facts — to said
Clerk. Penalty for neglect, twenty dollars.
Blank forms for Returns of Deaths may be obtained from the Town Clerk.
PHYSICIAN’S CERTIFICATE
Name and Residence of Certifying Physicia
I certify that the above is true, to the best of my knowledge and belief.
ician L. {/.Kelt.
Date of Certificate, 187 ■
* Or Sex of Infant (not named).
Any Physician having attended a person during his last illness, shall — when requested within fifteen days after the decease of such
person —forthwith furnish for registration a certificate of the duration of the last sickness, the disease of which the person died, and the
date of his decease, as nearly as he can state the same. — [Extract from Chapter 21 of the General Statutes, tSjg.]
Without repealing the foregoing requirements of the General Statutes, the recent “ Act to provide for the more Accurate Registration
of Vital Statistics,” passed April 23, 1878, provides that “no human body shall be buried, or removed from any city or town, until a
proper Certificate has been given by the clerk or local registrar of statistics, to the Undertaker or Sexton, or person performing the
burial or removing the body. This certificate shall state that the facts required by chap. 21 of the General Statutes have been
returned and recorded; and no clerk or local registrar shall give such certificate or burial pern''', until the Certificate of the Cause of
Death has been obtained, (from the Physician, if any, in attendance at the last sickness of the deceased), and placed in the hands of said
clerk or local registrar.”
If there has been no Physician in attendance, or in case of death by dangerous contagious disease, or in any other event where the
certificate of the attending Physician cannot, for good and sufficient reasons, be early enough obtained, the chairman of the local Board of
Health, or any Physician employed by any city or town for such purpose, shall sign the Certificate of the Cause of Death, to the best of
his knowledge and belief. In case of death by violence, the medical examiner shall furnish the certificate.
RETURN OF A DEATH.
To the c,erk
of th3
Town
in
which
Ihe Death occurred.
^
The
Undertaker,
or other
informant,
is
requested
to
report
the
facts
—
together with
the
Physician’s
Certificate
of
the
Causes
of
Death
—
to
the
Town
Clerk,
before
the interment.
gST
In case
of
an
interment
taking
place, without the
Certificate of
Registiy
of the
Cleik
of
the
Town
in
ttrhich
the
Death bccurre^fSr
the
cfcceiTScd
resided)
having
first
been obtained, the person
having charge
of
such
Interment
must
forthwith
give notice
thereof—
or report these
facts
—
to said
Clerk.
Penalty
for
neglect,
twenty
dollars.
gg" Blank forms
for
Returns
of
Deaths
may
be
obtained from
the
Town
Clerk.
S3
PHYSICIAN’S CERTIFICATE.
Name
of
Deceased ,*
-
-
Date and Place of Death,
Disease or Cause of Death,
j.
fL..
L
LLS..L-
/J.OL.
died
>
mtLL:
<r
>
Duration
of
Sickness.
1
certify that the
above
is
true, to
the best
of
my knowledge and
belief.
Jf A?
.<
J
.
■//.<.
(J
/L
*
2.
1
yA
z
sj
C_
*
,.. I La. l.. .M. iS7'’ j?-
Or Sex of Infant (not named).
Anv
Phvsician having attended
a
person
during
his
ias.
shal.-jhen
iT^tson
died,
and
the
XZSZ.
same.
[Extract
from
CUpur
„
<*.
«—
'
»*
,
7777.
Act
to
provide
for
the
more Accurate
Registration
Without repealing the — tU" >*„ *« >»f* “ *
^ in
>ald
SS
">min"
sh>n
turaish
,he
'
I
RETURN
OF A DEATH.
To the Clerk
of the
Town
in
which
the Death occurred.
$
w
Q
o
V
to »o
Place
of
Death,
igUT
The Undertaker,
or other
informant,
is
requested
to
report
the
facts
—
together with
the
Physician's
Certificate
of
the
Causes
of
Death
—
to
the
Town
Clerk,
before the interment.
In case
of
an
interment
taking
place, without the Certificate of
Registry
of the
Clerk
of
the
I
own
in
which
the
Death occurred (or the
deceased resided) having
first
been obtained, the person
having charge
of such
Interment must
forthwith
give notice
thereof
—
or report these
facts
—
to said
Clerk.
Penally
for neglect,
twenty
dollars.
Blauk forms for
Returns
of
Deaths may
be obtained from
the
Town
Clerk.
r
// /
PHYSICIAN’S
CERTIFICATE OF THE CAUSE OF
DEATH. To the Cleric or Registrar of the Town or City in which the Death occurred •
/h. , , Tzr ' '/// • cj/
and Sex of Deceased , .
\e and Place of Death , . .
Se'
First or
Primary
,
1
use
<
lath,
Secondary>
•
• •
f^t-r
t
Duration
off
i
Duration of, i.
I certify that the above is a true Return , to the best of my recollection and belief. ~P
Professional Title, and Residence,-
• me aoove is a irue eteiurn, to me oesi oj my rccoueciion ana oeuej.
„f Ik.
"22t
isy^.
\ ry particular to fill all Blanks.]
Nil
* Reckoned to the time of death.
Any Physician having attended a person during his last illness, shall — when requested within fifteen
days after the decease oi such person — forth with lurnish for registration a certificate of the duration of
the last sickness, the disease of which the person died, and the date of his decease, as nearly as he can
6tatc the Bame. — [Extract from Chapter 21 of tiie General Statutes, 1859.]
UP^The attending Phj’sician is requested to make out his Certificate as
promptly as possible, for the information and use of the Undertaker, or
other person making return of the case to the Town Clerk.
UIP Physicians ma}r obtain Blank Certificates from the Town Clerk
or Registrar.
ESP Copies of the Statistical Nosology, adopted for the purposes
of Registration, may be obtained on application to the Secretary of the
Commonwealth .
TT VEY, Oe / A Se — aa _
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1
6ST The -Undertaker, or other informant, is requested to report the facts — together with the
Physician’s Certificate of the Causes ofT)cath — to the Town Clerk, before tiie interment.
&!T
In case of
an interment taking place, without the Certificate of
Registry
of the
Clerk
of the
lown
in
which
the
Death occurred (or the deceased resided) having
first
been obtained, the person
having charge of such Iuterment must
forthwith give notice thereof
—
or report these
facts
—
to said
Clerk. Penalty
for neglect, twenty
dollars.
6^* Blank forms for Returns
of Deaths may be obtained from the
Town Clerk.
PHYSICIAN’S CERTIFICATE.
Name
of
Deceased
*
-
-
- DZ.l.i r t t < A. / £
{ d nx/t ) £•/ l
Date and Place of Death, died at
..//... c./D {J/lN./.o/. L . . d/.Cffj.
Disease or Cause of Death, - of Duration of Sickness...
/ certify that the above is true, to the best of my knowledge and belief.
Name and Residence of Certifying Physician ±. ...Aaj /
Date of Certificate, c/a... /sA. jsgy.
Or Sex of Infant (not named).
Any Physician having attended a person during his last illness, shall — when requested within fifteen days after the decease of such
person —forthwith furnish for registration a certificate of the duration of the last sickness, the disease of which the person died, and the
date of his decease, as nearly as he can state the same. — [Extract from Chapter 21 of the General Statutes, s8jp.]
Without repealing the foregoing requirements of the General Statutes, the recent “Act to provide for the more Accurate Registration
•” of Vital Statistics,” passed April 23, 1S78, provides that “no human body shall be buried, or removed from any city or town, until a
+ proper Certificate has been given by the clerk or local registrar of statistics, to the Undertaker or Sexton, or person performing the
burial or removing the body. This certificate shall state that the facts required by chap. 21 of the General Statutes have been
returned and recorded; and no clerk or local registrar shall give such certificate or burial permit until the Certificate of the Cause of
Death has been obtained, (from the Physician, if any, in attendance at the last sickness of the deceased), and placed in the hands of said
clerk or local registrar.”
If there has been no Physician in attendance, or in case of death by dangerous contagious disease, or in any other event where the
certificate of the attending Physician cannot, for good and sufficient reasons, be early enough obtained, the chairman of the local Board of
Health, or any Physician employed by any city or town for such purpose, shall sign the Certificate of the Cause of Death, to the best of
his knowledge and belief. In case of death by violence, the medical examiner shall furnish the certificate.
1
(SxUBTg Te IIE 03 aelMoNIed £194 og]
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HIvad V Jo NuoLaa
eg ye
Physician’s Certifica^of^h'e Causes'of Dead!— to tl^eTowiTcierk0 7* the together with the fCf, Tn‘ „ . 1 e Ao"u tlcik, BEFORE TIIE INTERMENT.
-Towaia a^ch^lll llle'd °f Refstl7 of Clerk of the
having charge of such Interment must forthwith^give IT ^ ^ ***“ °b,aiucd' tlie Persou
Clerk. Penalty
for neglect,
twenty
dollars.
'
°TICE thereof—
or reP°rt these
facts
—
to said
‘
•
Blank forms for Returns
of
Deaths may
be obtained from the
Town
Clerk.
PHYSICIAN’S CERTIFICATE.
Navte and Residence of Certifying Physician
I certify that the above is true, to the best of my knowledge and belief.
ician . . . J,. .. rff.cez, c. . {.f-. /fri. fydf /* i Date of
Certificate, 4
* Or Sex of Infant (not named).
^rsan—fori/iwiz/i f^ii'^for1
regi^rati^n^ ce^t^cat^
of^e
d^rTdon^of^e
^ast
^.e^uestcd 1"*tj.in
fifteen
da>'s
**
the
decease
of
such
date
of
his
decease,
as
nearly
as
he
can
state
the
*“«
^
a"d
*■
of
Vital
Statistics,”
pass'elT^
Statutes
the
recent
“Act
to
provide
for
the
more Accurate
Registration
proper
Certificate has
been given
by
the
clerk
or local registrar of
“Ttisti^
be
baried>
or
rem°ved
from any
city
or
town,
until
a
bunal
or
removing
the
body.
This
certificate
shall
stafe
that the
f
?
,Undertaker
or Sexton,
or
person
performing
the
returned and recorded; and no clerk or local registrar shall S the required by chap. « of the General Statutes have been
Death
has been obtained,
(from
the
Physician,
ff
any
in
attendancet
TfT*
°J
!
^
the
Certificate
'he
Cause
of
clerk
or local
registrar.”
Y>
attendan«
at
the
last
sickness of
the
deceased),
and placed
in
the
hands
of said
dTrOUJ
COntagiOUS
diSeaSe’ °r
in
**
where
the
Health, or any Physician employed by any city of town for such mim h ^ 7 r°“gh °btained> the chai™an of the local Board of
3nd b£lief-
^ ““
°£
deatb
^
viOence,
the
^ ^
*°
^
beSt
°f
RETURN OF A DEATH.
To the Clerk
of the
Town in/w^ich
the Death occurred.
P1
•
^he
Un^rtaker
or other
informant,
is
requested
to
report
the
facts
-together
with
the
Physician
s
Certificate
of
the
Causes
ofDeath-to
the
Town
Clerk,
before tub interment.
«r
In
case
>
of
an
interment taking
place, without the
Certificate of
Registry
of the
Clerk
of
the
rown
m winch
the Deatlu
occurred (or the
deceased resided) having
first
been' obtained, the person
fl pr°7?U
DterMt
must
forthwith
give NOTICE
thereof-
or report these
facts
-
to said l
lerk. Penalty
for
neglect,
twenty
dollars.
Blauk forms for
Returns
of
Deaths may
be
obtained from
the
Town
Clerk.
PHYSICIAN’S CERTIFICATE.
I
certify that the
above
is true
,
to
the best
of
my knowledge and
belief
A awe and Residence
of
Certifying Physician Vt* i( lefic i <l. A. f a ,
Date of Certificate
,
'i/.c
c
-/
* Or Sex of Infant (not named).
Any Physician having attended a person during his last illness, shall — when requested within fifteen days after the decease of such
person— -forthwith furnish for registration a certificate of the duration of the last sickness, the disease of which the person died, and the
date of his decease, as nearly as he can state the same. — [Extract from Chapter 21 of the General Statutes,
Without repealing the foregoing requirements of the General Statutes, the recent “Act to provide for the more Accurate Registration
of Vital Statistics,” passed April 23, 1S78, provides that “no human body shall be buried, or removed from any city or town, until a
proper Certificate has been given by the clerk or local registrar of statistics, to the Undertaker or Sexton, or person performing the
burial or removing the body. This certificate shall state that the facts required by chap. 21 of the General Statutes have been
returned and recorded; and no clerk or local registrar shall give such certificate or burial permit until the Certificate of the Cause of
Death has been obtained, (from the Physician, if any, in attendance at the last sickness of the deceased), and placed in the hands of said
clerk or local registrar.”
If there has been no Physician in attendance, or in case of death by dangerous contagious disease, or in any other event where the
certificate of the attending Physician cannot, for good and sufficient reasons, be early enough obtained, the chairman of the local Board of
Health, or any Physician employed by any city or town for such purpose, shall sign the Certificate of the Cause of Death, to the best of
his knowledge and belief. In case of death by violence, the medical examiner shall furnish the certificate.
■a
u
K
3)
S?
i
I
a*
Cause
of-j
Secondary
(if
any)
The Undertaker, or other informant, is requested to report the facts — together "with the
Physician’s Certificate of the Causes of Death — to the Town Clerk, before the interment.
In case of an interment taking place, without the Certificate of Registry of the Clerk of the
Town in which the Death occurred (or the deceased resided) having first been obtained^ the_ person
having charge of such Interment must forthwith give notice thereof — or report these facts — to said
Clerk. Penalty for neglect, twenty dollars.
IgU* Blank forms for Returns of Deaths may be obtained from the Town Clerk.
PHYSICIAN’S CERTIFICATE
I certify that the above is true, to the best of my knowledge and belief.
i'ie and Residence of Certifying Physician jSf, flU /
Date of Certificate , . tjf^c.^ .T.TrdL.. i&.
* Or Sex of Infant (not named).
Any
Phvsician having attended
a
person during
his
last
illness, shall
— when
requested
within
fifteen
days
after
the
decease
o
person
—forthwith
furnish
for
registration
a
certificate
of
the
duration
of
the
last
sickness, the disease
of
which
the
person
died,
an
tip
date
of his
decease,
as
nearly
as
he can
state
the
same.
—
{Extract
from
Chapter
21
of the
General
Statutes,
1859.]
Without
repealing
the
foregoing
requirements
of
the
General
Statutes,
the
recent
“Act
to
provide
for
the
more Accurate
Registratij
of
Vital Statistics,”
passed
April
23,
1878,
provides
that
“no
human
body
shall
be
buried,
or
removed
from any
city or
town,
lihtij
proper
Certificate has
been given
by
the
clerk
or local registrar of
statistics,
to
the
Undertaker
or Sexton,
or
person performing
t
burial
or
removing
the
body.
This
certificate
shall state
that the
facts
required by
chap.
21
of the
General
Statutes have
be
returned and recorded;
and
no clerk
or local
registrar shall
give
such
certificate or
burial
permit
until
the Certificate
of
the
Cause
Death
has
been obtained,
(from
the
Physician,
if
any,
in
attendance
at
the
last
sickness
of
the
deceased),
and
placed
in
the
hands
of
s-i
clerk
or local
registrar.”
If
there has
been
no Physician
in
attendance,
or
in
case of
death by
dangerous contagious
disease, or in
any other event
where
tl
certificate of the
attending Physician cannot,
for
good
and
sufficient
reasons, be early
enough
obtained,
the
chairman
of the local
Boar
|
Health,
or
any Physician
employed
by any
city or
town
for
such purpose,
shall sign
the
Certificate of the
Cause
of
Death,
to
the est
^
his
knowledge
and belief.
In case
of
death by
violence, the
medical examiner
shall
furnish the certificate.
RETURN OF A DEATH.
To the Clerk
of the
Town in^which
the Death occurred.
61P The Undertaker, or other informant, is requested to report the facts — together wiRj. the
Physician’s Certificate of the Causes of Dejrth — to the Town Clerk, before tub- interment.
In case of an interment takiug’^lacc, without the Certificate of Registry of the Clerk of the
Town in which the Death occurred (or thej (fecen^ed resided) having first been obtained, the. person
having charge of such Iuteruient must forthwith give notice thereof — or report these facts — to said
Clerk. Penalty for neglect, twenty dollars.
fisT" Blank forms for Returns of Deaths may be obtained from the Town Clerk.
PHYSICIAN’S CERTIFICATE OF THE CAUSE OF DEATH. To the Clerk or Registrar of the Town or City in which the Death occurred.
Name and Sex of Deceased , .
Date and Flace of Death , .
Disease , f ^ r, .
j Dirst or Dr unary,
or Cause -j of
Death,
[
Si«mdaryt
. .
.
StLw
(if
3
4T
Su*s
S&Jv
C l4in*dL,
Duration
of,*
^
.ifCU^L Duration of,
I certify that the above is a true Return, to the best of my recollection and belief.
^ K uk-r-'Miih 'Li.^ <1na//n.. f H ante, Professional Titles and Residence,
very particular to fill all Blanks.]
C i3 53 .
* lieckoucil to the lime of death.
Any Physician having attended n person during his last illness, shall — when requested within fifteen
days after the decease of 6uch person— forthwith furnish for registration a certificate of the duration of
the last sickness, the disease of which the person died, and the date of his decease, as nearly as he can
state the 6aiuc.— [Extract moM Chapter 21 or the General Statutes, 1809.]
E^Thc attending Physician is requested to make out his Certificate as
promptly as possible, for the information and use of the Undertaker, or
other person making return of the case to the Town Clerk.
(3F* Pli3'sicians may obtain Blank Certificates from the Town Clerk
or Registrar.
Copies of the Statistical Nosology, adopted for the purposes
of Registration, majr be obtained on application to the Secretary of tiie
Commonwealth .
ry 0 of gL IO yornss Yyvi,
7 L “Uy ee 4 amma
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‘HLVdd V dO NHOLAD
the
ci:?: nt\z2 ,;:ezrct: zi ™ ™,r l,cr "i"'
To.. f^rr zrzzfz ,he °r,in“,e -f ^ <** .f
having charge of such Interment must forthwith give notice il ' " T ^ °btamed’ ,lie Persou-
Clerk. Penalty for neglect, twenty dollars. ' * theieof— or report these facts — to said
Blank
forms for
Returns
of
Deaths
may
be
obtained from
the
Town
Clerk.
Gal 4 1483
ye) ~~? o a Way Ji . ~~
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ee heel, CGorscer
| DB Wa Read ff dey ,” thre deb Cet fe eee 0 be Bag,
| a aN os 2
RETURN
OP
DEATH
TO THE
CITY REGI
.
CITY HALL,
BOSTON.
<D
co
o3
Ped
Czy
ne
ail
if ii
HELE
ty
see
PROCy
BRD...
Se “REPS ees
—
ASE UO
Ns, ‘
SRrat-wale vara QE
(Pa eee ere aes A,
Rockwell & Churchill, City Printers, 39 Areh Street, Boston.
gle
PM
aa On Ea re
oh
GN Sea ites os -
Ge
Chis Certifies, Sted 1
ded on the
Miihe ¥, by
cell month,
CAUSE OF
DEATH.
Primary, . ly
Secondary,
JI dey
Ltt am
cd GF
L bowls |
4. A JS Z aged years,
“~~ Duration
Duration
Physician.
»
'
■
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ssduqu
avip saat:
7 made
Pit An
. S ai
I
1 (Sue 51) —
a
-
}
BGs
TT JO ¢
‘reyie yy JO ouvpy *
. “UMig, jo wor” ‘
wo jo svg
‘aouap!sayy
payyass wos
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+L s0jog -
+((oungy vepreyy)
SouIVANT +
“wag jo ang °
10 osvasiq *
“pouanooo yieveg eur yoiymet umoy cu) JO Ysaq) 9G} OL
‘HLVad V dO NYOLaY
lgg“ The Undertaker, or other informant, is requested l6 report the facts — together with the
Physician’s Certificate of the Causes of Death — to the Town Clerk, before the interment.
In case of an interment taking place, without the Certificate of Registry of the Clerk of the
Town in which the Death occurred (or the deceased resided) having first been obtained, the person
having charge of such Interment must forthwith give NOTICE thereof — or report these facts — to said
Clerk. Penalty for neglect, twenty dollars.
Blank forms for Returns of Deaths may be obtained from the Town Clerk.
PHYSICIAN’S
CERTIFICATE OF
THE CAUSE OF DEATH. To the ClcrJc or Registrar of the Town or City in which the Death occurred.
Name and Sex of Deceased , .
Date and Flace of Death , . .
Disease ,
pr Cause
of Death,
First or Frimary,
Secondary, . l
ha*
2. 0
Duration off _
Duration
of, _
I certify that the above is a true Return, to the best of my recollection and belief.
kVi4Aa^aLl^| 1/IM) ' L ^ VV-. Dated at jjLsjjy. %dL i8&3 .
■ a me, Professional Title, and Residence ,
le very particular to fill all Blanks.] * Reckoned to tlie lime of death.
Any Physician having attended a person during his last illness, shall — when requested within fifteen
days after the decease nr such person —forthicith lurulsh for registration a certificate of the duration of
the last sickness, the di-case of which the person died, anil the date of his decease, as nearly as he can
6tatc the same.— [Extract from Chapter 21 of the General Statutes, 1859.]
|^=The attending Physician is requested to make out his Certificate as
promptly as possible, for the information and use of the Undertaker, or
other person making return of the case to the Town Clerk.
UJp Physicians may obtain Blank Certificates from the Town Clerk
or Registrar.
Copies of the Statistical Nosology, adopted for the purposes
of Registration, may be obtained on application to the Secretary of the
Commonwealth .
03
M
a
e3
3
cS
• 4
3
<3
a
>»
fh
CD
>
©
n
The
Undertaker,
or other
informant
,
,
Physicim/s
Certificate
of
the
Causes
of
Death
-to
the
^
x®
wi,hr
,l,e,
srtiflcwe
or
<** -
...
having charge of such Interment must FOBlHWnlT^ a"' b““ "1<i l“r““
Clerk.
Penalty
for neglect,
twenty
dollars.
tick
t
teteo
or report these
facts
—
to said
'
Blank forms for
Belarus
of
Deaths may
be
obtained from
the
Town
Clerk.
PHYSICIAN’S CERTIFICATE.
I certify that the above is true , to the best of my knowledge and belief.
Any Physician having attended a person during his last illness, shall — when requested within fifteen days after the decease of such
person —forthwith furnish for registration a certificate of the duration of the last sickness, the disease of which the person died, and the
date of his decease, as nearly as he can state the same. — [Extract from Chapter 21 of the General Statutes, sSpg.]
Without repealing the foregoing requirements of the General Statutes, the recent “Act to provide for the more Accurate Registration
of Vital Statistics,” passed April 23, 1878, provides that “no human body shall be buried, or removed from any city or town, until a
proper Certificate has been given by the clerk or local registrar of statistics, to the Undertaker or Sexton, or person performing the
burial or removing the body. This certificate shall state that the facts required by chap. 21 of the General Statutes have been
returned and recorded; and no clerk or local registrar shall give such certificate or burial permit until the Certificate of the Cause of
Death has been obtained, (from the Physician, if any, in attendance at the last sickness of the deceased), and placed in the hands of said
clerk or local registrar.”
If there has been no Physician in attendance, or in case of death by dangerous contagious disease, or in any other event w'here the
certificate of the attending Physician cannot, for good and sufficient reasons, be early enough obtained, the chairman of the local Board of
Health, or any Physician employed by any city or town for such purpose, shall sign the Certificate of the Cause of Death, to the best of
his knowledge and belief. In case of death by violence, the medical examiner shall furnish the certificate.
emer Tre TIE oF as 4104 og]
oe S O19 or uo ‘ PLE WwW ds maa
£ Awiipy ey}
Lb Bat mmOTTOe
apug fo asnyoubry
Ate Ss te
eS say
wt eI ISA ape roypuar) ~ Syuouliajyuy Jo dV[q “GT
ana 3 vy, 73 eit i72 |
- By nae "Y esa | "5 Stoipoyy Jo OUUNT “ST
‘¥ sme ain 4) : [jo own *
5
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Raaeeee jc“ —
COU 6 Le ++ Sonapisoyt “2
a ; hd o. [ <r | ‘ywoq
Tn Ku 51) Saupuoaay | JO VSNVD
Savant 40 | do osvasiq, *9
Prt ac “anon b.. ‘sana yen Fo 8 BBY og
Serer Care ae
ay ti,
shat <4
«(OWEN UdpIyyy)
i,
Gory manepiigo sr 8 SURAT 7S
eit 4 Oy yop 7 Sea 0 oma 7
“‘pauuno00 yyeed ou) YOIYM UL UMO] cy} JO KAZI) Ou} OL
‘HLVad V dO NYNLaY
The Undertaker, or other informant, is requested to report the facts — together with the
Physician’s Certificate of the Causes of Death — to the Town Clerk,, before the interment.
In case of an interment taking place, without the Certificate of Registry of the Clerk of the
Town in which the Death occurred (or the deceased resided) having first been obtained, the person
having charge of such Interment must forthwith give notice thereof — or report these facts — to said
Clerk. Penalty for neglect, twenty dollars.
Blank forms for Returns of Deaths may be obtained from the Town Clerk.
PHYSICIAN’S
CERTIFICATE OF
THE CAUSE OF
DEATH. To the Cleric or Registrar of the Town or City in which the Death occurred.
Name and Sex of Deceased , .
Date and Place of Death , . .
First or Primary,
Secondary, . . .
Disease,
or Cause <
of Death,
S&LcuJfe _ t QjJr.
1*1“ ciJ"" .. *c Ur
ir
Shf** A*i»t W*
Duration of,*
Duration of,
I certify that the above is a true Return, to the best of my recollection and belief.
'ante, Professional Title , a>id Residence ,
Dated at.
3e very particular to fill all Blanks.]
A. ha.^, HM? . 123. % ^ fry. & HiU f
I8t3 .
* Reckoned to the time of death.
Any Tbysicinn having attended a person daring his last illness, shall — when requested within fifteen
days after t lie decease of such person —forthwith tarnish for registration a certificate of the duration of
the last sickness, the disease of which the person died, and the date of his decease, as nearly as he cun
state the same.— [Extract from Chapter 21 of tiie General Statutes, 1859.]
OP The attending Physician is requested to make out his Certificate as
promptly as possible, for the information and use of the Undertaker, or
other person making return of the case to the Town Clerk.
UP" Physicians may obtain Blank Certificates from the Town Clerk
or Registrar.
Copies of the Statistical Nosology, adopted for the purposes
of Registration, may be obtained on application to the Secretary of the
Commonwealth.
[('SeYUsl_ [1% 11H 01 elNoWIvd Area OG)
CA UBT 9M TTL
UWOS POLATIQ UST «
squat Aypoads ‘soauyy aero jo JL “umgpuy C1) *
© gps . . ur : 2 ye GaALvG
Vee a
ee *
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{ NY JOT JO oUIUN ET
‘au j
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oN
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oe Epa Bvt J «L
“padanooo yyeog 94) YOIYM UI UMO] IY} JO Ysa) BY) OL
HALVEHdGC V AO NXNLAA
M
er
The
Undertaker,
or
other infonoaot.
is
:«l
""
Physiol's
Certificate of the
Cause,
of
Death
-
.»
the
^
^
~
^
of
go In ease of an interment tnk.ug place, nuliout t n ' "' -j, , j^,„ Stained, the person
Town iTwhich
the Death oecurreth (or the
deceased
these
facts
-to having charge
of
such Interment must
forthwith
fot.cs.
said
Clerk. Penalty
for
neglect,
twenty
dollars.
•
ty. Blank forms of
Returns may
he obtained from
the
Town
Clerk.
>
IC rt oe
we:
| . ;
- Woman Ker 4 Bbryrerrec OY ‘
Phe,
leg weasetes §
1
hte <G9/ 4. 6-2 Vb. Vo - 4
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yn -
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Keston, ee gm) 1833
Chis Certifies, That lar. hea Measreh Worcou)
\ en a
heed on the , ae day of eg. 1883 , aged. Pe i Y yous,
month, A, ry.
DEATH.
8
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CAUSE OF) Primary,{/ & ~~ ace, iC y Duration
Secondary, Lorrcseemy Duration
-4
Cipaccees Al atte? Ph ysician. |
ee. Lect | be |
ae
RETURN OF A DEATH.
To the Clerk
of the
Town
in
which
the Death occurred.
g§T The Undertaker, or other informant,
is
requested
to
report the
facts
—
together with
the
Physician’s
Certificate of the
Causes
of
Death
—
to the
Town
Clerk,
before the interment. &T
In case of
an irfferment
takiug place, without the Certificate of
Registry of the Clerk
of the
lown
in
which
the
Death occurred (or the deceased resided) having
first
been obtained, the person
having charge of such Interment
mirft
forthwith give notice thereof
—
or report these facts
—
to said
Clerk. Penalty for neglecti^twenty dollars.
Blank forms for Returns of Deaths may be obtained from thVTovtm Clerk.
PHYSICIAN’S CERTIFICATE.
Name of Deceased* - - - la!fir, J/.1 L fk
Date and Place of Death, died at /f . .
Disease or Cause of Death, - of ldl£c. C. Duration of Sickness
/
/ certify that the above is true , to the best of my knowledge and belief.
Name and Residence of Certifying Physician i L( Xfilfi i
/ ' r C_
Date of Certificate,
.t,.. 187
•
* Or Sex of Infant (not named).
Any Physician having attended a person during his last illness, shall — when requested within fifteen days after the decease of such
person —forthwith furnish for registration a certificate of the duration of the last sickness, the disease of which the person died, and the
date of his decease, as nearly as he can state the same. — {Extract from Chapter 21 of the General Statutes , 1859.]
Without repealing the foregoing requirements of the General Statutes, the recent “ Act to provide for the more Accurate Registration
of Vital Statistics,” passed April 23, 1878, provides that “no human body shall be buried, or removed from any city or town, until a
proper Certificate has been given by the clerk or local registrar of statistics, to the Undertaker or Sexton, or person performing the
burial or removing the body. This certificate shall state that the facts required by chap. 21 of the General Statutes have been
returned and recorded; and no clerk or local registrar shall give such certificate or burial permit until the Certificate of the Cause of
Death has been obtained, (from the Physician, if any, in attendance at the last sickness of the deceased), and placed in the hands of said
clerk or local registrar.”
If there has been no Physician in attendance, or in case of death by dangerous contagious disease, or in any other event where the
certificate of the attending Physician cannot, for good and sufficient reasons, be early enough obtained, the chairman of the local Board of
Health, or any Physician employed by any city or tow'n for such purpose, shall sign the Certificate of the Cause of Death, to the best of
his knowledge and belief. In case of death by violence, the medical examiner shall furnish the certificate.
[SUVIE 118 ITY 07 eMosed Area og}
qe Sypads ‘soowyz s0720 JOT “WUPUT (1) LowetANC CI) SuwoHEY CF) “outta ue TOMO ITF
‘mop AL do TMMTO.M POLI IT
7 RST 5 . uo ww ad? ALY,
£48 I ap boyy a Via
——— ae
7 Suny an)
ae eT | | | ea ee
sommepn fo asnpoubry
mde 4 Vane Ter 'W Syuotutayny Jo vvxjq “CT
‘40 jo ooudyuig “FT
evs eo me Lik WZ, VL} rato JO 9 qu,
mIevIffy arg + aan Jo 9
ae A WED,
79) yp ep 5 | - + Gaye jo omen CLT
* on “g _—_ “a “yng, jo out “OT
soe ee + Go judnsag *
Wig “gl
ye ne ‘OOTY Jo OUNN “ST
6
‘qywoqd jo woul 8S
i
- + Souoprsay *
See ee
ST ae emg fl... (NEG
on Pi emo ay U5 | s+ + bMojog “F
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f sapbuls aaa pau "Xeg “g °
eve) L |"
A. ae: + f(ounge uopeny)
YTD IGS. ~~
08 oe ie | — “wag jo ard ‘T
*poduno90 uneed au) yorum BeUMmoL sy) Jo yas] OG) OL
qv dO NUN.
era-
The
Undertaker,
or other informant,
is
requested
to
report the
facts
together with
the
Physicians
Certificate
of
the
Causes
of
Dea,l,-to
the
Town
Clerk,
beeoee tue .interment.
fof
In case
of
an interment
taking
place, without the
Certificate of
Regtstiy
o t
te
■
'
'
"
'1
Town fwhich
the
Death occurred (or the
deceased resided) havtng «rst-heen
having charge
of such
Interment must
FOETBW.TH
GIVE XOT.CE
thereof-
or report these
fact,
-to
satd
Clerk.
Penalty
for
neglect,
twenty
dollars.
Blank forms for
Returns
of
Deaths may
he obtained from
the
Town
Clerk.
/
PHYSICIAN’S CERTIFICATE OF THE CAUSE OF DEATH. To the Clerk or Registrar of the Town or City in which the Death occurred.
Name and Sex of Deceased,
Date and Place of Death
Disease,
i /V? U * 'N 7
2l£efi
?r Cause <
tf/" Death,
First or Primary,
Secondary, .
Pi 1 Duration of* //
_ Duration of,
I certify that the above is a true Return, to the best of my recollection and belief.
Any rhysician having attended a person during his last illness, shall — when requested within fifteen
days after the decease of such person —forthwith luroish for registration a certificate of the duration of
the last sickness, the disease of which the person died, and the date of his decease, as nearly as he can
state the 6ame.— [Extract from Chapter 21 of the General Statutes, 1859.]
ISP The attending Physician is requested to make out his Certificate as
promptly as possible, for the information and use of the Undertaker, or
other person making return of the case to the Town Clerk. \
Physicians may obtain Blank Certificates from the Town Clerk
or Registrar.
Copies of the Statistical Nosology, adopted for the purposes
of Registration, ma}T be obtained on application to the Secretary of the
Commonwealth.
PHYSICIAN’S CERTIFICATE OF THE CAUSE OF DEATH. To the Clerli or Registrar of the Town or City in which the Death occurred.
Name and Sex of Deceased ’ . j . CUUJ.1 .44
Date and Place of Death , . . ; “if- ^3 /V..3?...*?...^
Disease , | pirst or Primary, \ V "'V A Duration off .
of
Death
[
Secondary,
.
. .
j
Qj/yy^d^CdL.
Duration of~.
cuhl
I certify that the above is a true Return , to the best of my recollection and belief.
Name,
Pre/css,
cal
Title,
and
Residence,
^ X U ^ ^
~
(
0>AU
4*4^
I*
,
^
Dated at is?j .
[Be very particular to fill all Blanks.] * Reckoned to the timo of death.
Any Fhysician having attended a person during his last illness, shall — when requested within fifteen
days after the decease of such person— forthwith turuish for registration a certificate of the duration of
the last sickness, the disease of which the person died, and the date of his decease, as nearly as he can
state the same.— [Extract from Chapter 21 of the General Statutes, 1859.]
E^’Tlie attending Physician is requested to make out bis Certificate as
promptly as possible, for the information and use of the Undertaker, or
other person making return of the case to the Town Clerk.
U1P Physicians may obtain Blank Certificates from the Town Clerk
or Registrar.
Copies of the Statistical Nosology, adopted for the purposes
of Registration, may be obtained on application to the Secretary of the
Commonwealth .
RETURN OF A DEATH.
To the Clerk
of the
Town
in
which
the Death occurred.
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3
o
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TO
£ 5
<-< <£>
^ ,£J
«
p.
.
.
,
The
Undertaker,
or other
informant,
is
requested
to
report
the
facts
—
together with
the
Physician
s
Certificate
of
the
Causes
of
Death
—
to
the
Town
Clerk,
before the interment.
In
case
of
an
interment
taking
place, without the
Certificate of
Registry
of the
Clerk
of
the
wl,,ch the
Death
occurred
(or
the
deceased resided) having
first
been obtained, the
person
Clerk” P I, rS ,Dterment mUSt F0RTUWITn GIVE NOTICE thereof- or report these facts - to said tleik. 1 enalty for neglect, twenty dollars.
Blank
forms
for
Returns
of
Deaths
may
be
obtained from
the
Town
Clerk.
A
(M CO rj* id
X)
a
o
u
H
a
a
A
>
>»
«
o
ft
1/2
cn
M
P
C3
3
a
o
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CD
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ffl
°c>
V
p
3
o
\ \
v
S'
A
ph“
i
srctr
r*
,w
**
,„.
Iq case Of an i
ferment lakin.
„|L
”
.,7
T
C!>'rlt’
B"°“
™E "*******■
Town
in
winch
,he
Death occurred (o'r
L
dece led rl 'd dlT'”'0
°f
°f "'e
CkA
°f
Py.ng
charge of such Interment must
fouthw™ 1“E
"
1 \
,
7
firSt
bcCD
lh« Person
eik. Penalty for neglect, t\v enty dollars1!'11^711 ^ N°TICE thereof-°r report these facts_to said
Blank forms for Returns of Deaths he obtained from the Town Cork.
jamin F. Smith
Undertaker
31 Tremont St PHYSICIAN’S CERTIFICATE.
Any Physician having attended a person during his last illness, shall — when requested within fifteen days after the decease of such
person—; forthwith furnish for registration a certificate of the duration of the last sickness, the disease of which the person died, and the
date of his decease, as nearly as he can state the same. — [Extract from Chapter 21 of the General Statutes, s8pg.]
Without repealing the foregoing requirements of the General Statutes, the recent “ Act to provide for the more Accurate Registration
of Vital Statistics,” passed April 23, 1878, provides that “ no human body shall be buried, or removed from any city or town, until a
proper Certificate has been given by the clerk or local registrar of statistics, to the Undertaker or Sexton, or person performing the
burial or removing the body. This certificate shall state that the facts required by chap. 21 of the General Statutes have been
returned and recorded; and no clerk or local registrar shall give such certificate or burial permit until the Certificate of the Cause of
Death has been obtained, (from the Physician, if any, in attendance at the last sickness of the deceased), and placed in the hands of said
clerk or local registrar.”
If there has been no Physician in attendance, or in case of death by dangerous contagious disease, or in any other event where the
certificate of the attending Physician cannot, for good and sufficient reasons, be early enough obtained, the chairman of the local Board of
Health, or any Physician employed by any city or town for such purpose, shall sign the Certificate of the Cause of Death, to the best of
his knowledge and belief. In case of death by violence, the medical examiner shall furnish the certificate.
[SHABIE 118 IIB 0} teINOAed A104 og]
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AL 10 WRUIO AL WUgle
syeqm Sytoods ‘saowy seqyo Jo JT “uRIpuy (7) foxemp CW) ft
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is + ‘wanpay ayr
2H WP. ge KG S\ ) Sm uosiad 12Y70 40 7
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| * Gayo JO av
[) * fsayyeg jo savyd
Or aha pigs
Q EaTy \ * ‘rayjoyy Jo sweN “ZT
mfroy — o * Gayrey Jo omun “LL
ome ua) ~~ | "+ Wt Jo PvE “OL
noredns0Q 6
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come pop + + Souepisayy ‘2
a0 moyM Kg ‘yivaq
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|
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Y |
aR cee Fen eee Leolog “F
—/TY
ji + ,{(aureyy cepreyy)
me ewe [ . nC CING i
” aie a | (neaq jo —_ T
a =
“paaunooo yyeeg ey) yorum Ur umol oy) Jo yor) ou) OL
‘“HLVaG V dO NYOLAE |
“on
The Undertaker, or other informant, is requested to report the facts — together with the
Physician’s Certificate of the Causes of Death — to the Town Clerk, before the interment.
In case of an interment taking place, without the Certificate of Registry of the Clerk of the
Town in which the Death occurred (or the deceased resided) having first been obtained, the person
having charge of such Interment must forthwith give notice thereof — or report these facts — to said
Clerk. Penalty for neglect, twenty dollars.
Blank forms for Returns of Deaths may be obtained from the Town Clerk.
>a
F. Smitn
.ertaker
■ernont St
>n Mass PHYSICIAN’S CERTIFICATE.
\e of
Deceased
,*
\and
Place
of
Death,
-
died
at
Lr or Cause of Death,
I
certify that the
above
is true, to the best
of
my knowledge and
belief.
_
KU ..
^
,
m
Residence
of Certifying Physician
Date of Certificate,
CLieCf.,. 2.2. is$y. M
n| Or Sex of Infant (not named). T
Any Physician having attended a person during his last U'ness ^ Jj“ ^XTi^thTdiTeateoT which the person died, and
.
.
_
.
Cf,fnfpc
the
recent
“
Act
to
provide
for
the
more Accurate
Registra
Without repealing the foregoing requirements of the General Sta , J removed from any city or town, un
of Vital Statistics,” passed April a3, .878, provides that / ttIL Undertaker or Sexton, or person performing
proper Certificate has been given by the clerk or local registrar of stab Uc h V ^ the General statutes have 1
burial or removing the body. This certificate shall state that the f ^ ^ thc Certificate of the Cans
returned and recorded; and no clerk or local registrar fha £>' sickness of the deceased), and placed in the hands of
Death
has
been obtained,
(from the Physician,
if
any,
in
attendance
at
the
last
clerk
or local
registrar.”
Phy^n
in
»
in
—
n.
dca.h
certificate of the attending Physician cannot for good and JD0Se shall sign the Certificate of the Cause of Death, to the b*
[SHUBI IIB 11y 0} aBINOTIIed Ar98A oa]
qe Asroeds ‘soorzy royqo Jo yy curipur (1) foyeyy Cy) fu 7H) wey] 19T0 IT +
MOPIA\ IO Uw poraeyy vo yy «
Em pe “pg perOryy pap, we daLY(y
i? lee oe *. Waa
winzoy ayp
vhoge HZ THE Dl IED ¥ a — orosroteretms
layppapug fo aanpoubry
“—_ ae, poy YO
TOR VCY Nai ye / vz OP 2D *‘gampoyy Jo aovpdqiaig “FT
FOR?) tA COLT t > a Ws ( HOO * Gaye jo sovdipng “ET
Aivisy eC Wye? Pm Ap} ‘is ,, iG "7 + SHOPOTY JO OUR “GT
PE YN 7, 7> aig | "+ Aroyregy Jo ommeN LT
SASF ae 6 7 1 UT Jo ov “OL
a eee pod Ls. ;
7p f ee 2 Af jprbypice + °) TRBGRCIeaRe iS
» Lema yf A pms (8 J ‘+ + Ganaptsayy ‘2
‘aonvdnsgQ -¢
oo ao moun dg] SyvOC,
(uv 3) Kavpuooag JO asN¥D
trem 10 ysuyt J LO osvasI(y “9
as
+ £40109 “F
SpeaMOpL A Jo ‘parreyy
IS day puV ‘xeg “¢
ere pa q xf (ureNT aapinyy)
A YP YPE'D) aA _}-
yy ve pembngy |) wmasoena
“‘Ppadanooo yWeoq OY} YOIYM Ul UMO]L Sy) JO YueT) oY} OL
‘Hivad V do NUQIgu
ar
1A” he amw 140%
Iggf’ Tiie Undertaker, or other informant, is requested to report the facts — together -with the
Physician’s Certificate of the Causes of Death — to the Town Clerk, before the interment.
In case of an interment taking place, without the Certificate of Registry of the Clerk of the
Town iu which the Death occurred, (or the deceased resided) having first been obtained, the person
having charge of such Interment must forthwith give notice thereof — or report these facts — to said
Clerk. Penalty for neglect, twenty dollars.
Blank forms for Returns of Deaths may be obtained from the Town Clerk.
Gv yO 1)
f
“Oran wp : ror
emeayeslag ‘yon bam hag
ESS yo
ft
YO my po
V9) Ads a Vans ”) mene i 4
_
RETURN OP A DEATH.
To the Clerk
of the
Town
in
which
the Death occurred.
£ £
e ^
t S
£
i
>>
3
>
©
fl
t- oo ci o
^iT
The
Undertaker,
or other
informant,
is
requested
to
report
the
facts
—
together with
the
Physician’s
Certificate
of
the
Causes
of
Death—
to
the
Town
Clerk,
before
tiie
interment.
In case
of an
interment taking
place, without the
Certificate of
Registry
of the
Clerk
of
the
Town
in
which
the
Death occurred (or the deceased resided) having
first
been obtained, the person
having charge
of such
Interment must
forthwith
give notice thereof—
or report these
facts
—
to said
Clerk.
Penalty
for neglect,
twenty
dollars.
Blank forms for
Returns
of
Deaths may
be obtained from
the
Town
Clerk.
PHYSICIAN’S CERTIFICATE OF THE CAUSE OF DEATH. To the Clerk or Registrar of the Town or City in which the Death occurred.
Name anil Sex of Deceased,
Date, and Place of Death , .
Disease ,
or Cause
of Death ,
First or Primary,
Secondary, . . .
C&JLS 4U*Jr:.. yj
If .jSfe.
uration of,* * cTl~-LvI<L,
Duration of, __
I Name, Professional Title , arid, Residence ,
I
certify that the
above
is a
true
Return,
to the best
of
my
recollection
and
belief
-
*
jwsr
Dated at ^ P
U\
Be very particular to fill all Blanks.] * Reckoned to Ike time of dentil.
^tC
thC
B^-LEXTRACT
FROM
CUAPTEU
21
OF
THE
GENERAL
STATUTES,
18,9.] jr^=Thc
attending
Physician
is
requested
to
make
out
liis
Certificate
as
promptly
as possible,
for
the
information and
use of the
Undertaker,
or
other
person
making
return of the case
to
the
Town
Clerk.
Physicians may
obtain
Blank
Certificates from
the
Town
Cleik
or
Registrar.
Copies
of the Statistical
Nosologt, adopted
for
the purposes of
Registration,
may
be
obtained
on
application to
the
Secretary
of the
Commonwealth.
RETURN OF A DEATH.
To the Clerk
of the
Town ip^vhich
the Death occurred.
<D T3
To
>
a >
£ >
<o
CO
•5
M
O — £
Cu_ c*_
o 0 O 0
Q a
0 » 2
G>
0
c«-i
c*_
c—
O 0
c O 0 0
pG
Cu
0
0
S«
O
O
<1?
G
0 Oh
Ch
•*
S 5 3 u
P-l O
P-t
£ s s
00
C5
0
1-i
<N
CO
The Undertaker, or other informant, is requested to report the facts — together with the
Physician’s Certificate of the Causes of Death — to the Town Clerk, before tiie interment.
In case of an interment taking place, without the Certificate of Registry of the Clerk of the
Town in which the Death occurred (or the deceased resided) having first been obtained, the person
having charge of such Interment must Forthwith give notice thereof — or report these facts — to said
Clerk. Penalty for neglect, twenty dollars.
Blank forms for Returns of Deaths may be obtained from the Town Clerk.
bd Aeon } CERTIFICATE. |
Vame of Deceased,* - at (e KA...
Date and Place of Death, -| died at Leff 8
Disease or Cause of Death, -| of
L certify that the above is joie to the best of my knowledge and belief.
4 (- Aa” Z "
Were and Residence of Certifying Physician “7 1” “a ‘7 6 cw :
Duration of Sickness |... xs
Date of Certificate, OS 4 ‘ 1
\ * OF Sex of Infant (not named),
Auv Physician having attended a person during his last illness, sl"|' disuse ot which the person died, and tin
v,
nt
Art
to
provide
for
the
more Accurate
Registratioi
Without
repealing
the
foregoing
requirements
of
the
General
Statute5, the
tec J
frQm any
city or
town,
until
of Vital Statistics,” passed April * ^ P-tdes 0 L Undertaker or Sexton, or person performing th
proper Certificate has been given by the clerk or local reg requited by chap, *i of the General Statutes have bee
burial or removing the body. This certificate shall state that the s fac req ^ ^ Certificatc 0f the Cause
returned and recorded ; and no clerk or local registrar shall g.ve such cert fica P deceased)) and placed in the hands of sa
Death
has
been obtained,
(from
the
Phystc.an,
if
any,
in
attendance
at
the
last
clerk
or local
registrar.”
disease
or
in
any
other event
where
til
If there has been no Physician in attendance, or in case of death ^ns^Tarty^nough obtained, the chairman of the local Board I
certificate of the attending Physician cannot for good and sufficien , • Certificate of the Cause of Death, to the best
[‘sqas1q IIe ITF 039 zemonaed Ar08A A off]
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‘HiVad V 40 NUQiga a“
me
TT ts SeuTeAT °Z
a ie —
giT
The
Undertaker,
or other informant,
is
requested
to
report the
facts
together with
the
Physician’s
Certificate
of
the
Causes
of
Death—
to
the
Town
Clerk,
before the interment.
In case
of
an interment taking
place, without the
Certificate of
Registry
of the
Clerk
of
the
Town
in
which
the
Death occurred (or the deceased resided) having
first
been obtained, the person
having charge
of such Interment must
forthwith
give notice thereof—
or report these
facts
—
to said
Clerk. Penally
for
neglect,
twenty
dollars.
(g- Blauk forms for Returus
of
Deaths may
bo obtained from the
Town
Clerk.
PHYSICIAN’S CERTIFICATE
Name of Deceased,* -
Date and Place of Death,
Disease or Cause of Death,
I
certify that the
above
is true, to the best of
my knowledge and
belief.
frame and Residence
of Certifying
Physician ftd. f.
iiNffpfZdL
...
/
n ' e_
Date of Certificate,
.
'{-£.
/ rff l8^f.
Or Sex of Infant (not named).
person-^^^a^nfum/^£o^regU^rati^nSa ce^tificat^of^he dliradoa^of^th'' ]161! f'fteen days after the decease of such
date
of his
decease,
as
near.y
as
he can
state
the
sa.e-t^^
CkapUr^}
Te'^rTZl^^
^
^
'
““
**
of
"«'*«
to
provide
for
the
more Accurate
Relation
proper Certificate has been given by the clerk or local registrar of statistic/ to „ °r removed froin any city or town, until a
burial or removing the body. This certificate shall state thit- ti f ■ j Undertaker or Sexton, or person performing the
returned and recorded; and no clerk or local registrar shall give such certVir h 7 ” °f ^ Gencral StatUtes have been
Death has been obtained, (from the Physician, ffany in attendance ni T\ T J PermU Untl’ the Ccrtificate of the Cause of
clerk or local registrar.” * J’ attendance at ,he la^ sickness of the deceased), and placed in the hands of said
certificate of the attending^^ by danSerous contagious disease, or in any other event where the
Health, or any Physician employed by any city or town for such n , ^ 7 °btained’ the chairman of the local Board of
H,s
knowledge
„d
U*.
case
Jt
Jh
*
”
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6sT The Undertaker, or other informant, is requested to report the facts — together with the
Physician’s Certificate of the Causes of Death — to the Town Clerk, before the interment.
&T In case of an interment taking place, without the Certificate of Registry of the Clerk of the
Town in which the Death occurred (or the deceased resided) having first been obtained, the person
having charge of such Interment must forthwith give notice thereof — or report these facts — to said
Clerk. Penalty for neglect, twenty dollars.
Blauk forms for Returns of Deaths may be obtained from the Town Clerk.
PHYSICIAN’S
CERTIFICATE OF THE CAUSE OF DEATH. To the Cleric or Registrar of the Town or City in which the Death occurred.
Name and Sex of Deceased , .
Date
and Place of
Death
,
.
Disease
,
f
p-rst or
primary
}
sr
Cause
<
of
Death,
[
Se™ndaD,
.
•
.
Duration of, *
Duration of, f ^
I certify that the above is a true Return, to the best of my recollection and belief.
Name , Professional Title, and Residence , — •
Dated at.. iS ^3 .
Be very particular to fill all Blanks.] * Reckoned to the time of death.
AnT
rhyrician
having
attended
|
daya
aftvW
&S.
pen-n
!«•]
"« CHAPT
.
tQ
mdk0
out his Certificate
as
^The
attenmng^ysi^^qu-
^
^
of
tb0
Undertaker,
or
promptly
as
possible,
io
^
^
^
to
tUc
Town
Clerk.
other person -ung^ ^ Certificates from the Town Clerk
physicians maj
or Registrar. Rented for the purposes
f tv.e Statistical Nosology, . P cfCRETary of the
C°T J,v be obtained on application to to SECttoan
of Registration, maj oe
Commonwealth.
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ee neon) V9 wprihp i I -ajBars sya PUY “KES “S
7
yo + yfCaureyt doplsyd)
The
Undertaker,
or other
informant,
is
requested
to
report
the
facts
—
together
with, the
Physician
s
Certificate
of
the
Causes
of
Death
—
to
the
Town
Clerk,
before the interment.
In case
of
an
interment
taking
place, without the
Certificate of
Registry
of the
Clerk
of
the
T%wa
iu
which
lhe
Death
occurred (or the
deceased resided)
having
first
been obtained, the
person
having charge
of
such
Interment
must i-'OGtHjvith
give notice
thereof
—
or report these
facts to* said
Clerk.
Penalty
for
neglect,
twenty
dollars.
GiT Blank forms
for
Returns
of
Deaths
may
be
obtained from
the
Town
Clerk.
Cljis Certifies,
F/ia/
</eec/ on //io /S' o/ay of ../$$ 3 , otyoo/ ,'r^/j?,}* yeaid.
mon//id,
CAUSE OF |Primary , Jfi/,
(/apJ.
^
Duration /
£
DEATH. j
Secondary,
/
Duration
Physician.
[‘SHUVIE T18 IIT 03 Tetnonzed A704 og]
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‘podanooo yieeg 4 Ul UMOL CY} JO yseqD cu OL
’ ‘HLVGd V dO NYQigu
The
Under. a!:
,
o
other
informant,
is
requested
to
report
the
facts
—
together
with- the
•J
hy sician
s
Certificate
Mthe
C
uses
of
Death—
-to
tlie
Town
Clerk,
BEFOKE the
interment
^
#
^
*
^
Iu case
of
p
intern. cut
taking place, without the
Certificate of
Registry
of the
Clerk
of
the
I°"a
'u
which
the
1
4&th occurred (or
tlie
deceased resided) haviug
first
been obtained, the person
having charge
of
such
Interna-
it
must
forthwith
give notice
thereof-}- or report these
facts
—
to said
Clerk.
Penally
for
negle
uty
dollars.
4aT Blank forn.ybr
T turns of
Deaths
ifiay
be obtained from the
Town
Clerk.
PHYSICIAN’S CERTIFICATE.
Name
of
Deceased,*
-
-
-
Date and Place of Death,
Disease or Cause of Death, -
died at
/
T- -Z-
of-
M'u A ZZtepy. Duration of Sickness
Name and Residence of Certifying P hysttxa
I
certify that the
above
is true, to the best
of
my knowledge and
belief.
r
n
f/e(
. . .
irPPrd..
(.£
//..X.
.
x.
.
>.
f A
%-
^
-
of Certificate, ..J...
..
.
■
V: J8fr^ Date
* Or Sex of Infant (not named).
Anv
Phvsician having attended
a
person
during
his
last
illness,
shall-when
requested
within
fifteen
days
after
the
decease
of
such
person
-forthwith
furnish
for
registration
a
certificate
of
the
duration
of the
last
sickness,
the
disease
of
which
the
person
died,
and
date
of his
decease,
as
nearly
as
he can
state
the
same.—
{Extract
from
Chapter
21
of the
General
Statutes, jSpg.\
Without
repealing
the
foregoing
requirements
of
the
General
Statutes,
the
recent
“
Act
to
provide
for
the
more Accurate
Registration
of
Vital
Statistics,”
passed
April
23,
1878,
provides
that
“no
human
body
shall
be
buried,
or
removed
front
any aty
or
town,
until a
proper
Certificate has
been
given by
the
clerk
or local registrar
of
statistics,
to
the
Undertaker
or Sexton,
or
person performing
burial
or
removing
the
bodv.
This
certificate
shall state
that the
facts
required by
chap.
21
of the
General
Statutes have be
n
returned and recorded; and no clerk or local registrar shall give such certificate or burial permit Untl1 thc C*j^^ the tand.T«aid
Death has been obtained, (from the Physician, if any, in attendance at the last sickness of the deceased), and placed in the hands of .aid
clerk
or
local
registrar.”
*
'
If
there has
been
no
Physician
in
attendance,
or
in
case of
death by
dangerous
contagious disease, or
in
any
other
event
‘he
certificate of
the
attending Physician
cannot,
for
good
and
sufficient
reasons, be early
enough
obtained,
the
c
airm
n
Health,
or
any Physician
employed
by. any
city or
town
for
such purpose,
shall sign the
Certificate^
the
Cause
of
Death,
to
the
best
of his
knowledge
and belief.
In case
of
death by
violence, the
medical examiner
shall
furnish
the
certificate.
Disease
or
f
First
or
Primary
Cause
of
-f
Secondary
(if
any)
to
M
a
a
3
3
o
3
o
oi
&
S»
©
>
©
m
CiT
The
Undertaker,
or other
informant,
is
requested
to
report
the
facts
—
together with
the
Physician’s
Certificate
of
the
Causes
of
Death
—
to
the
Towu
Clerk,
before the interment.
In case
of
an
interment taking
place, without the
Certificate of
Registry
of the
Clerk
of
the
Town
in
which
the
Death occurred (or the
deceased resided) having
first
been obtained, the person
having charge
of
such
Interment
must
forthwith
give notice
thereof
—
or report these
facts
—
to said
Clerk.
Penalty
for
neglect,
twenty
dollars.
Blank forms for
Returns
of
Deaths may
be obtained from
the
Town
Clerk.
PHYSICIAN’S CERTIFICATE.
h
Name
of
Deceased
*
-
-
Date and Place of Death,
\Disease or Cause of Death,
I
. . sjffLty. Oc£ . Cc C
died ae fl . fief Xf
of . PrKf. *. ?jf. . . Du ra tio n of
i
Sickness
I certify that the above is true, to the best of my knowledge and belief, j
Name
and Residence
of Certifying
Physician
£
££pi
c/c
/i
t *
tf/A
1
*
Date of Certificate,
.
,t££££? 187 y.
* Or Sex of Infant (not named).
Any Physician having attended a person during his last illness, shall — when requested within fifteen days after the decease of such
person— -forthwith furnish for registration a certificate of the duration of the last sickness, the disease of which the person died, and the
date of his decease, as nearly as he can state the same. — [Extract from Chapter 21 of the General Statutes, 1 8ji?.]
Without repealing the foregoing requirements of the General Statutes, the recent “Act to provide for the more Accurate Registration^
of Vital Statistics,” passed April 23, 1878, provides that “no human body shall be buried, or removed from any city or town, until a
proper Certificate has been given by the clerk or local registrar of statistics, to the Undertaker or Sexton, or person performing the
burial or removing the body. This certificate shall state that the facts required by chap. 21 of the General Statutes have been
returned and recorded; and no clerk or local registrar shall give such certificate or burial permit until the Certificate of the Cause of
Death has been obtained, (from the Physician, if any, in attendance at the last sickness of the deceased), and placed in the hands of said
clerk or local registrar.”
If there has been no Physician in attendance, or in case of death by dangerous contagious disease, or in any other event where the
certificate of the attending Physician cannot, for good and sufficient reasons, be early enough obtained, the chairman of the local Board of
Health, or any Physician employed by any city or town for such purpose, shall sign the Certificate of the Cause of Death, to the best of
his knowledge and belief. In case of death by violence, the medical examiner shall furnish the certificate.
w
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Disease
or
f
First
or
Primary
^3^*
The
Undertaker,
or other
informant
ic
j
Physician’s Certificate of the Causes of Death — to the TqUeSn l° the ^cts — together with the
.
i^eatn—
to
the
down
Clerk,
before
the interment.
Town £ciwi'h:,,he,“s «**** °f "■* ^
having charge of such Interment must forthwith^ve n^iL tl^'T ^ °btamed’ the Persou
Clerk. Penalty for neglect, twenty dollars. thereof — or report these facts — to said
'Blank
forms
for
Returns
of
Deaths
may
be
obtained from
the
Town
Clerk.
RETURN
OF A DEATH.
To the Clerk
of the
Town
in
which
the Death occurred.
$
!>i I ^
K
4, :
"H
i %! * ^
$ \
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of-i Secondary
(if
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«•>. .. r a
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/
physicS
?q“^1
r
repo,t
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*-—«■*•
»<* «-
I
-Ucatli
to
the
Town
Clerk,
before
the interment.
!f,ce;
'vi",out
,ue
cer,ini'a,e °f
****
«
«»
«•*
»f
«*
having char-c
of
smh
Iut,L.T
/
r“i<lo,,)
hlrin*
fir8t
bccn <*'”■>«<), the person
cert
peU:,,
f:;tgtir:;r,rrHW,ia
g,ve kot,cb
,hereof-w
"*«*- *«-
*
-
•
Blank forms
for
Returns
of
Deaths
may
be obtained from
the
Town
Clerk.
PHYSICIAN’S CERTIFICATE
Name of Deceased* - - -
Date and Place of Death,
Disease or Cause of Death, -
/(&..{&.
died a» //. fif ft, <fC *1 ,
ffi.Z...£C fb<Ck?CCiii.ii)uration of Sickness
of
ante
and Residence of Certifying PJtysicia
* Or Sex of Infant (not named).
/ certify that the above is true, to the best of my knowledge and belief,
ician /L ...V 's.f&./l..:. Date of
Certificate,
18ft
^
r
^
a
PCrSOn
g
*
laSt
illneSS>
sha^
when
requested
within
fifteen
days
after
the
decease
of
such
P1S°"
/°
!
UmiSh
f°r
reg‘Stratl0n
a
ccrt,ficate
of
lhe
duration
of
the
last
sickness, the disease of
which
the
person
died,
and
the
date
of h.s
decease,
as
nearly
as
he can
state
the sam
^.-[Extract
from Chafer
2, of the
General
Statutes,
,8J9.]
nf
'Y/'jT
trepeal:,ng
the
[°^o[ng
requirements
of
the
General
Statutes,
the
recent
“Act
to
provide
for
the
more Accurate
Registration
-f
\.tal
Statistics passed
April
23,
1S78,
provides
that
“no
human
body
shall
be
buried,
or
removed
from any
city
or
towm
until
a
proper Ceruficate
has,
been given
.by
the
clerk
or local registrar
of
statistics,
to
the
Undertaker
or Sexton,
or
person
performing
lhe
burial
or
removing
the
body.
This
certificate
shall state
that the
facts
required by
chap.
2I
of the
General
Statutes have
“been
returned and recorded;
and
no
clerk
or local
registrar shall give
such
certificate or
burial
permit
until
the Certificate
of
the
Cause
of
PhySiCian’
if
any’
in
attendance
at
the
laSt
SickneSS
0f the
deceased),
and
placed
in
the
hands
of
sah!
certificate6 oflhe attendance’ or in case of death by dangerous contagious disease, or in any other event where the
Health or anv Phvsici "g >’s,clan cannot- for Sood and sufficient reasons, be early enough obtained, the chairman of the local Board of
his'know" d "eandZS T " 7/77 °- I0"'" ** PUrP°Se’ Sha" sig" the Certificate of the Cause Death, *o the best of
his
knowledge
and belief.
In case
of
death by
violence, the
medical examiner
shall
furnish the
certificate.
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gem Ayrood. ‘sooey roy Jo JT ‘uvipuy (1) foyepyy CK)
“ARs
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re | san aao on ‘yiwaq
“eanpoy ay)
DU Oto oreo
‘royWyy Jo
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(Aue p) Saepuoaag + JO osnNg,
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+ Sty 4
* dfaojop -
Opt AA to ‘porraeyy
x{(owey: wopiryy)
‘ywaq jo omg ~
+ Goyey jo sordyug +
“tayoyy Jo oweyy +
Na
UNG jo wu *
* ‘uorywdnv0Q *
‘Qouoptsayy *
Joyo puv *xeg *
Soumuny *
“Podinooo Yee GY YOIYAA Ul UMO CUI JO ydaI) ou} CL
‘HLVad V JO NYOLaa
cree
‘SIPISMAIUSSLYE Jo yYRannou.8
The Undertaker, or other informant, is requested to report the facts — together with the
Physician’s Certificate of the Causes of Death — to the Town Clerk, before the interment.
In case of an interment taking place, without the Certificate of Registry of the Clerk of the
Town in which the Death occurred (or the deceased resided) having first been obtained, the person
having charge of sucli Interment must forthwith give notice thereof — or report these facts — to said
Clerk. Peualty for neglect, twenty dollars.
Blank forms for Returus of Deaths may be obtained from the Town Clerk.
PHYSICIAN’S CERTIFICATE.
* Or Sex of Infant (not named).
Any Physician having attended a person during his last illness, shall — when requested within fifteen days after the decease of such
person—; forthwith furnish for registration a certificate of the duration of the last sickness, the disease of which the person died, and the
date of his decease, as nearly as he can state the same. — [Extract front Chapter 21 of the General Statutes, i8pgl\
Without repealing the foregoing requirements of the General Statutes, the recent “Act to provide for the more Accurate Registration
of Vital Statistics,” passed April 23, 1S78, provides that “no human body shall be buried, or removed from any city or town, until a
proper Certificate has been given by the clerk or local registrar of statistics, to the Undertaker or Sexton, or person performing the
burial or removing the body. This certificate shall state that the facts required by chap. 21 of the General Statutes have been
returned and recorded; and no clerk or local registrar shall give such certificate or burial permit until the Certificate of the Cause of
Death has been obtained, (from the Physician, if any, in attendance at the last sickness of the deceased), and placed in the hands of said
clerk or local registrar.”
If there has been no Physician in attendance, or in case of death by dangerous contagious disease, or in any other event where the
certificate of the attending Physician cannot, for good and sufficient reasons, be early enough obtained, the chairman of the local Board of
Health, or any Physician employed by any city or towrn for such purpose, shall sign the Certificate of the Cause of Death, to the best of
his knowledge and belief. In case of death by violence, the medical examiner shall furnish the certificate.
^rnurnmnumm of |t*assachxisc
I
-a
CD
S-
S~ 3
O
O
o
<D
s:
o
}
One /Z iUAoT&l
x/
I
/fn /« / !
ggp The Undertaker, or other informant,
is
requested
to
report the
facts
—
together with
the
Physician’s
Certificate
of
the
Causes
of
Death—
to the
Town
Clerk,
before the interment.
{&“
In case
of
an interment taking place, without the Certificate of Registry of the Clerk
of the
Town
in
which
the
Death occurred (or the deceased resided) having
first
been obtained, the person
having charge of such Interment must
forthwith give notice thereof
—
or report these facts
—
to said
Clerk. Penalty
for neglect, twenty
dollars.
{ £ 3^ Blank forms for Returns of Deaths may be obtained from the
Town Clerk.
PHYSICIAN’S
CERTIFICATE OF
THE CAUSE OF
DEATH.
— To the Clerk or Jtegistrar of the Town or City in which the Death occurred •
me and Sex of Deceased ,
date and Place of Death , .
Disease,
r Cause
Death ,
First or Primary ,
Secondary, . . .
B>- yjhrtfirre -
hufjJuZbCr
y2z..dDZr.L...
Duration
of* 7^
L C ^ <pytrtr^£s)--. fln-m/
I Certify that she above is a true Return, to the best of my recollection
Duration of*
Duration of,
>dSU
'■f-
a}>u} Professional Title , and Residence ,
and belief.
-trLJ- D . A. f. tyteAtutfor,
Dated- <z/~ Of-DOL iff.
very particular to fill all Blanks.] * Reckoned to the time of death.
Any Physician having attended a person during his last illness, shall — when requested within fifteen
days after the decease of such person— forthwith furnish for registration a certificate of the duration of
the last sickness, the disease of which the person died, and the date of his decease, as nearly as he can
state the same.— [Extract from Chapter 21 or the General Statutes, 1859.]
E^The attending Physician is requested to make out his Certificate as
promptly as possible, for the information and use of the Undertaker, or
other person making return of the case to the Town Clerk.
Physicians may obtain Blank Certificates from the Town Clerk
or Registrar.
Copies of the Statistical Nosology, adopted for the purposes
of Registration, may be obtained on application to the Secretary of the
Commonwealth.
[sqUeIE 118 11g 09 nee £70 oa!
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EY] 1OYIO JT 4
HIVE Y IT «
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lg jo wg *
* ‘onyvdns9Q *¢
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ao MONA Mg PLT @ §
(Aue 31) dapuooos $ JO OsNVA
em Sareea 40 - do osvasiqy
3S
f'0}09
-|pamopray Jo ‘partaryy
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SoUUNT *Z
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=—
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Vv
*
The Undertaker, or other informant, is requested to report the facts — together with the
Physician's Certificate of the Causes of Death — to the Town Clerk, before the interment.
t^ * In case of an interment taking place, without the Certificate of Registry of the Clerk of the
Town in which the Death occurred (or the deceased resided) having first been obtained, the person
having charge of such Interment must forthwith give notice thereof — or report these facts — to said
Clerk. Penalty for neglect, twenty dollars.
Blank forms for Returns of Deaths may be obtained from the Town Clerk.
I
PHYSICIAN’S
CERTIFICATE OF THE CAUSE OF DEATH. To the Clerk or Registrar of the Town or City in which the Death occurred •
Name and Sex of Deceased , .
Date and Place of Death , . .
Disease ,
or Cause <
of Death,
First or Primary,
Secondary, . . .
J
/7
y
v
y
yf-
/ ( C
Celt L j l i c (li e
frnTtibiarb
• PDdmtion off / f / X ^
__ Duration of,
/ certify that the pbove is, a true Return, to the best of yty recollection find belief.
Xante, Pro/essiofuil Title , and Residence ,
Keturn , to tne vest of my recollection find oeliej .
/// ^ yv/ (</ c} / 4* j /°s * —
ed at hf ( c //f 1 8 S
Dated
ie very particular to fill all Blanks.] * iieckoued to the time of death.
A
tc
llic
same. —
[lahiawi
~
grThc
attending
Physician
is
requested
to
make
“^Una^
“
promptly
as possible,
for
the
information and
use
of
the
Undertaker,
other'
person
making
return
of the case
to
the
Town
Clerk.
ET
Physicians may
obtain
Br-anit
Cnn-rmCATES
from
the
Town
Clerk
or
Registrar.
r^Conies
of the Statistical Nosology, adopted
for
the purposes
of
Strata
may
be
obtained
on application to the
Srcnnranr
or run
Commonwealth.
[S3IUBT_ Ile ITE 03 te~nomsred A100 oa]
rrCD) fouepnyy Cy
“gern Ajjoad , ‘saoey tomo Jo JT uv
M0 UEMAIO.K P JIU 8 BT
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pest 7 ‘swap _ —_ | ff
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[Diu UestEd—IN OO
yoyapugQ fo poubuy
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* Gey Jo sovdyuig, “gy
{UT JO omen “TT
1° Oona OT
* ‘gonudusg9 +6
‘Wyvog Jo WIT “gs
‘Qouopisay "2
ao mound) ¢ vod
“1 (Rue jy) Saepuosag Jo osnuy
faemig 410 ysang | 10 esuosiq “9
. sy G
7 + LMtojog -y
TAY to ‘paramyy
[POIs Jouayar puy ‘xeg *¢
* yf(eurexy uapmyy)
* SOUR °%
Pog JO ONG ‘T
“pedanooo Yiveq oy) YoIYM UI UMOL oY) Jo yuaID ou) ol
‘HLVdd V dO NYOLaY
oy ae
‘S]PSNYIUWSSLAE Jo yNanuoumog?
i —,
33T The Undertaker, or other informaut,
is
requested
to
report the
facts
—
together with
the
I hysician
s
Certificate
ot the
Causes
of
Death
—
to
the
Town
Clerk,
before the interment.
gif In case of
an interment takiug place, without the Certificate of Registry of the Clerk of the
Town
in
which the
Dea^h occurred (or the deceased resided) having
first
been obtained, the person
having charge of such Interment must forthwith give notice thereof
—
or report these facts to said
Clerk. Penalty for negleqt, twenty dollars.
@sT Blank forms for Returns of Deaths may be obtaiued from the Town Clerk.
PHYSICIAN’S CERTIFICATE.
Name
of
ceased* *
-
- -
Date and Place of Death,
Disease or Cause of Death, -
I
certify that the
above
is
true, to the best
of
my knowledge and
belief.
Name
and Residence
of Certifying Physician
.
'
•••>•
.
L.y/'.t..
Date of Certificate, ..jf.. 187
* Or Sex of Infant (not named).
An,
Physician having
Coded
a
person
dte
~Twh4
.he
person
died,
and
.he
S^t^e"
"t”.":
same.
[Extract
fr°"‘ Chapter
si
of
the
«—
—
*
T
Art
to
provide
for
the
more Accurate
Registration
Without
repealing
the
foregoing
requirements
of
the
General
Statutes,
,
t
>
*«
•
J
or
removed
from
any
city
or
twn,
until
a
of
W
Statistics,”
passed
April
a3> tS7S,
provides
that
/
no
or Sexton,
or
person
performing
he
Portifirate
has
been
given
bv
the
clerk
or
local registrar
of
statistics,
to
General
Statutes have been
clerk or local registrar. , • us d;sease, or in any other event where the
If
there has
been no Physician
in
attendance,
or
in
case of
death
i
by
enQU|h
obtained,
the
chairman
of the local
board
of
certificate of the
attending Physician
cannot,
for
good
and
suffic’e^
’
b
.
Ythe
Certificate of
the
Cause
of
Death,
to
the best
sisid-ifhSrzrdS
[SYUSl_ 118 11g 07 BlNoWIed LacA eq]
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“MOPIAL JO TRUIOAY POLLIUTY VIL +
Ww aaLyg
‘jnautiejuy jo OV GI
* PompoTY Jo avy
POT JO oWVNT “ET
LT JO OWEN “LT
“MMT JO NIT “OT
* fuonudussg °¢
“WWwaq jo vxq “g
‘souapisayy *y
{° jpeynseo moun dg) SBA’
(Kue 51) Savpuooag |
rjo esuuy
oy ac
* LStojog
AA 10 ‘poraeyy
pra S 1oqjayay pay *X8g "$
+ wy uopreyy)
7 SamENT °Z
“Wivog, jo arg ‘Tt
*Pazanooo yyeeq eYyr YIYM UL UMOY ay} Jo MAS} Oy} OL
‘HLVadG V JO NYNLaYy
— +e
‘s]yIsnyay:
The
Undertaker,
or other
informant,
is
requested
to
report
tlie
facts
—
together with
the
Physician’s
Certificate
of
the
Causes
of
Death
—
to
the
Town
Clerk,
before
the interment.
In case
of
an
interment
taking
place, without the
Certificate of
Registry
of the
Clerk
of
the
Town
in
which
the
Death
occurred
(or the
deceased resided) having
first
been obtained, the persou
having charge
of
such
Interment
must
forthwith
give notice
thereof
—
or
report these
facts
—
to said
Clerk.
Penalty
for
neglect,
twenty
dollars.
Blank forms for Returns of Deaths may be obtained from the Town Clerk.
43
Mee
ok)
6.
m4
ee on eee
S
NARA
Py
&
Scan
CAD De®
su
eile a OG
STD rh tea,
ae
othe *
a
eee
|
SR
J
la
=
Keston, a a isiy | |
Chis Certifies, M7 Marevcacl "diate
died on the y day of, pom SISY, caged be". yews,
Z ments,
CAUSE OF een bE fe Ce Pay Duration
Scoondaryyds 7 (Harwell maui on
Seat ese~ Ga
Tora
\eS eaten ay =
3s
a Heys
6
on
Mal SAUNT
«eter yo
ee
ease S
DEATH.
Printing Pepartment, Deer Island, Boston Harbor.
ead ah wat,
nae
es
wy ’ A@
s> La eto’ 446 2 Lie 7 Physician.
as
[(SHUBIG 118 119 03 IetnoW1ed Ar0A og]
"MODEL 10
2.
ATA UV] LOMO JT 4
MOM POLAVIC VIL «
| i Ww daLyg
Pye Meanjpoy ay?
BUIYDUE Ue ahebhmabde TOO
doyppopug fo vinjoubry
1
* ‘yuattajuy jo oxy
“Moo Jo oovpdyargye
+ Soya jo oovjdqyargy
“LOOT JO OLUU NT
“QV WT JO ourvyy
“EE BROT
* ‘uoneduos¢
“yywaq Jo soupy
‘auoprsoyy
paynaao wor ke
‘imag.
(hue 3p Saupaosag $0 asNBD
favang 10 4847 | 10 osvasiq
ss ee 9 taser
of
>» [paMOpLAy to ‘patsy
*OPSAIs LOA puv *xeg
‘I0[09
‘4 {(ouey, cepieyy)
SOUR NT
‘ywag jo arg
a
“podunooo yyeeq ey} YOIyYM UI UMO]L 84} JO Yaoqy O42 OL
‘HLVad V dO NYOLay ©
(VON
:
j
Jl 7
gg” The Undertaker, or other informant, is requested to report the facts — together with the
Physician’s Certificate of the Causes of Death — to the Town Clerk, before tue interment.
In case of an interment taking place, without the Certificate of Registry of the Clerk of the
Town in which the Death occurred (or the deceased resided) having first been obtained, the person
having charge of such Interment must forthwith give notice thereof — or report these facts — to said
Clerk. Penalty for neglect, twenty dollars.
Blauk forms for Returns of Deaths may bo obtained from the Town Clerk.
PHYSICIAN’S
CERTIFICATE OF
THE CAUSE OF DEATH.
To the
Clerk,
or
Registrar
of the
Town
or City in
which
the
Death
occurred.
T Name
and Sex
of
Deceased
,
.
Date
and Place of
Death,
.
Disease, f , _ .
Pirst or
Primary,
or Cause <
of
Death,
Second*ry,
• •
■
C7 i'VaMj)
j..uu.uu.Ji /y ? /-
.
Duration off
ItJz. Duration of, f ,c/<. Cl. id •
I
certify that the
above
is
a true
Return,
to the best
of
my
recollection
and
belief.
, 3 ^ it ■ J/pfdl 1 -
Dated
at.Jfil±o^led.r
Name, Professional Title, and Residence,
[Be very particular to fill all Blanks.] * Iicckoued to the lime of death.
Any Physician having attended a person during: his last illness, shall — when requested within fifteen
days after the decease of such person—; forthwith furnish for registration a certificate of the duration of
tile last sickness, the disease of which the person died, and the date of his decease, as nearly as he can
state the same.— [Extract from Chapter 21 of the General Statutes, 1859.]
C^Tlie attending Physician is requested to make out liis Certificate as
promptly as possible, for the information and use of the Undertaker, or
other person making return of the case to the Town Clerk.
Physicians may obtain Blank Certificates from the Town Clerk
or Registrar.
Copies of the Statistical Nosology, adopted for the purposes
of Registration, may be obtained on application to the Secretary of the
Commonwealth.
(SRHUSIA 11% [1g 07 TeINo41eAa Atos ogy
XT
sony “ET
URN CZ
POW.
MOYPLP JO oN "TT
[Jo 99td “0T
opis “L
+ 5 spoynod utorat ‘a)
| + -ssauypry jo u
rai 9
‘yyeag jo asneg 10 a
“seq ‘SIMO TT a ey Oo Oe ‘BY ce
.
“M0JO,) "Ff
IN
Xow
“yaracT JO oN, “TL
“passno00 yyeeq ay) YOIUM UI UMO] oY} JO Yo] OU} OL
HALVYdG V dO NUNLaa
The
Undertaker,
or
other informant,
is
requested
to
report the
facts
—
together with
the
Physician’s
Certificate of the
Causes
of
Death
—
to the
Town
Clerk,
before the interment.
in case of an
interment taking
place,
without
the Certificate of
Registry
of the
Clerk
of the
Town
in
which
the
Death
occurred, (or
the
deceased
resided,)
having
first
been
obtained, the person
having charge
of
such Interment must
forthwith
give notice
thereof—
or
report these
facts
—
to
said
Clerk.
Penalty
for
leglect,
twenty
dollars.
Ufp Blank
forms
of
Returns
may
be
obtained from
the
Town
Clerk.
yus/i
I i_ .
PHYSICIAN’S CERTIFICATE.
Name
of
Deceased
*
-
-
-
Date and Place of Death , - died at mL %rr.. *. .188
Disease or Cause of Death, - of (JyC<.. 6^.rz*c<L.tC.Act ./'/is. ter .7.Jt Z/tsDuration of Sickness //.hi //. d
J certify that the above is true, to the best of my knowledge and belief.
Name and Residence of Certifying Physician, 'a. .. d/ e e < < e /. f N 1 7 - fr. / h/z......r
vS
Date of Certificate, J2L-& 188 - .
*Or Sex of Infant (not named).
[Extracts from Chapter 32 of the Public Statutes, 1SS2.]
“ Sect. 3. — A Physician who has attended a person during his last illness, shall, when requested within fifteen days after the decease
of such person, forthwith furnish for registration a certificate of the duration of the last sickness, the disease of which the person died,
and the date of his decease, as nearly as he can state the same.”
“Sect. 5. — No human body shall be buried, or removed from any city or town, until a proper certificate has been given, by the
clerk or registrar, to the undertaker, sexton, or other person performing the burial or removing the body. Such certificate shall state
that the facts required by this chapter have been returned and recorded; and no clerk or registrar shall give such certificate or burial
permit until the certificate of the cause of death has been obtained from the Physician, if any, in attendance at the last sickness of the
deceased, and placed in the hands of said clerk or registrar.”
[If there has been no physician in attendance, or in case of death by dangerous contagious disease, or in any other event when the
certificate of the attending physician cannot, for good and sufficient reasons, be early enough obtained, the chairman of the Board of
Health, or any physician employed by any city or town for such purpose, shall, upon application, sign the certificate of the cause of death,
to the best of his knowledge and belief. In case of death by violence, the medical examiner attending shall furnish the requisite
certificate.]
[SHUBIG 113 ITE 07 WeTMoNIed A104 og]
syeqa Ayroods ‘soovy 10yj0 Jo JT “uMIpUT CD fovEpNTY (rg) {ueoL :
—— 7
Ju oy
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‘aPOPY JO OBA, “ZT
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Ly
al geese FG i 7 5 2 8 + Gouaprisesy *y
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shu ath ~‘Ssyuoyy re ‘savoX hl
ee ee f >
<< HYPYA puu ‘xag ©
— SPP = : wry * (owen uopmyq)
ae | it
jo asnuy
|
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‘_— 40 qarg | IO asvasiqy “9
‘apou
/ eo3 “mag jo2rd ‘T
“pauino00 YEG EY) YOIYM Ul UMO] OY) JO yJE]) eYI OL
‘HLVGG V dO NYNLaAY
cota ye
)
(jgl’ The Undertaker, or other informant, is requested to report the facts — together with the
Physician’s Certificate of the Causes of Death — to the Town Clerk, before the interment.
In case of an interment taking place, without the Certificate of Registry _of the-Glerk of the'
Town in which the Death occurred (or the deceased resided) having first been obtained, the person
having charge of such Interment must forthwith give notice thereof — or report these facts — to said
Clerk. Penalty for neglect, twenty dollars.
Blank forms for Returns of Deaths may be obtained from the Town Clerk,
[‘SHUVIE [18 IG 09 Aelnowred L104 og}
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a ie 7 he a >) | buryor womted—oerte
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a8
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‘HLVad V dO NuQuay fa
‘aUIUN °Z
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SiT
The
Undertaker,
or other informant,
is
requested
to
report
the
facts
—
together with
the
Physician's
Certificate
of
the
Causes
of
Death
—
to
the
Town
Clerk,
before
the interment.
651“
In
case
of
an
interment
taking
place, without the
Certificate of
Registry
of the
Clerk
of
the
Town
in
which
the
Death
occurred (or
the
deceased resided) having
first
been obtained, the
persou
having charge
of
such
Interment
must
forthwith
give notice
thereof
—
or report these
facts
—
to said
Clerk.
Penalty
for
neglect,
twenty
dollars.
Blank forms for Returns of Deaths may be obtained from the Town Clerk.
PHYSICIAN’S CERTIFICATE
Name
of
Deceased*
-
-
Date arid Place of Death,
Disease or Cause of Death
I certify that the above is true, to the best of my knowledge and belief.
■ v , / e
A" a vie and Residence of Certifying Physician
fd te .
Date of Certificate,
/Ll.fD/s.± ■Z..
sf
r 187 .
* Or Sex of Infant (not named).
Any
Physician having attended
a
person during
his
last
illness,
shall-when
requested
within
fifteen
days
after
the
decease
of
such
person
-forthwith
furnish
for
registration
a
certificate
of
the
duration
of
the
last
sickness,
the
disease
of
which
the
person
died,
and
the
date
of his
decease,
as
nearly
as
he can
state
the
same.—
{Extract
from
Chapter
21
of
the
General
Statutes,
iSjg.]
Without
repealing
the
foregoing
requirements
of
the
General
Statutes,
the
recent
“Act
to
provide
for
the
more Accurate
Registration
of
Vital
Statistics,”
passed
April
23,
1878,
provides
that
“no
human
body
shall
be
buried,
or
removed
from any
city or
town,
until
a
proper
Certificate has
been given by
the
clerk or
local
registrar
of
statistics,
to
the
Undertaker
or Sexton,
or
person performing
tic-
burial
or
removing
the
body.
This
certificate
shall state
that the
facts
required by
chap.
21
of the
General
Statutes have
been
returned and recorded;
and
no clerk
or local
registrar shall give
such
certificate or
burial
permit
until
the Certificate
of
the
Cause
o
Death
has
been obtained,
(from
the
Physician,
if
any,
in
attendance
at
the
last
sickness
of the
deceased),
and placed
in
the
hands
of
san
clerk
or local
registrar.”
If
there has
been
no
Physician
in
attendance,
or
in
case of
death by
dangerous contagious
disease,
or
in
any other event
where
the
certificate of the
attending Physician
cannot,
for
good
and
sufficient
reasons, be early
enough
obtained,
the
chairman
of the
loca
Boar
o
Health,
or
any Physician
employed
by any
city or
town
for
such purpose,
shall sign
the
Certificate of the
Cause
of
Death,
to
t
ie jest
o
his
knowledge
and belief.
In case
of
death by
violence,
the
medical examiner
shall
furnish
the
certificate.
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we > & ai ‘gouaptsayy 2
7 OF 7)
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(Sun 4p) Saepuooes + Jo asned,
eee Caen 30 ysart | £0 asvasig, “9
Toth ts 2 By og
“PEMOPLAL 10 “partnyy
‘g[5uIs wayjoym pur txeg -g
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7 + Saurmny °%
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‘HLVGdG V dO NYNLAY ;
ay —— fe
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11
1^* The Undertaker, or other informant, is requested to report the facts — together with the
Physician’s Certificate of the Causes of Death — to the Town Clerk, before the interment.
In case of an interment taking place, without the Certificate of Registry of the Clerk of the
Town in which the Death occurred (or the deceased resided) having first been obtained, the person
having charge of such Interment must forthwith give notice thereof — or report these facts — to 6aid
Clerk. Penulty for neglect, twenty dollars.
Blank forms for Returns of Deaths may be obtained from the Town Clerk.
PHYSICIAN’S
CERTIFICATE OF
THE CAUSE OF DEATH. To the Cleric or Registrar of the Town or City in which the Death occurred.
Name and Sex of Deceased , .
Date and Place of Death , . .
disease,
. Cause
f Death,
First or Primary,
Secondary, . . .
0
(^VuaaTC
Sul. hif\UA~ . ^
— Duration off 3^u~4ry .
hpc&pfiXe . Duration of,
I certify that the above is a true Return , to the best of my recollection and belief.
ame, Professional Title, and Residence,— ^ /'| l (W|y|ilAA^i^ ^Cr^L ^ f ^At (?CL
~
'
Dated at..
Se very particular to fill all Blanks.] * Ueckoned to the lime of death.
Any rhysician having attended a person during his last illness, shall — when requested within fifteen
days after the decease of such person— forthwith furnish for registration a certificate of the duration of
the last sickness, the disease of which the person died, and the date of his decease, as nearly as he can
state the same.- [liXTRACT from Chapter 21 of the General Statutes, 1859.]
f^The attending Pi^sician is requested to make out his Certificate as
promptly as possible, for the information and use of the Undertaker, or
other person making return of the case to the Town Clerk.
ISP" Physicians may obtain Blank Certificates from the Town Clerk
or Registrar.
Copies of the Statistical Nosology, adopted for the purposes
of Registration, may be obtained on application to the Secretary of the
Commonwealth.
teTFill out in
ink. When married erase “single” and “widow”; when widowed, erase
“single" and “married." RETURN
OF
DEATH
TO
THE
CITY
REGISTRAR.
o
qS
£
£
c3
*->
02
03
o3
02
T3
fl o3
SS a |i
f Bern, LS bgp, G2 1894
. : = Ne, , Oe
Chis Certifies, Tia Mepifee AM Vii hon
A Ca.
Va Lomtthe 2 hay otic. 1892 apd '
he Ch Wu w Uy S ca a yeild,
x ment , G drys.
7.
CAUSE OF) Primary, —% ah ' ‘Duration
DEATH. Secondary, _ Duration
Printing Department, Deer Island, Boston Harbor.
Physician.
RETURN OF A DEATH.
To the Clerk
of the
Town
in
which
the Daath occurred.
J
The
Undertaker,
or other informant,
is
requested
to
report
the
facts
together "»th
the
Physician’s
Certificate
of
the
Causes
of
Death
—
to
the
Town
Clerk,
before the interment. In case
of
an interment taking place, without the
Certificate of
Registry
of the
Clerk
o
Me
Town
f
which
the
Death occurred (or the deceased resided) having
first
heen
obtatned
tlm person
having charge of such
Interment must
forthwith
give notice thereof—
01
repoi
tese
Clerk.
Penalty
for neglect,
twenty
dollars.
Blank forms for
Returns
of
Deaths may
be obtained from the
Town
Clerk.
r
PHYSICIAN’S
CERTIFICATE OF
THE CAUSE OF DEATH.
To
the Clerk
or
Registrar
of
the
Town
or City in
which
the
Death
occurred.
e and Sex of Deceased ’ .
Date
and Place of
Death,
.
Disease,
f
p-rs( Qr
primary^
pr
Cause
<
of
Death,
[
Secondary,
.
.
.
&d^cufL
(hfldr.
Sul, Mutu~ huUf A
JdkasuC yfrlMfZM-
Duration
off
_
3
jhurt.
H _ Duration of,
I certify that the above is a true Return, to the best of my recollection and belief
Name , Professional Title f and Residence , f/U<T;'.T—hAU<l
Dated at i3t¥.
~
A
[Bo very particular to fill all Blanks.] * lleckoued to the time of death.
Any Physician having attended a person during his last illness, shall — when requested within fifteen
days after t ho decease of such person —forthwith tnniish for registration a certificate of the duration of
the last sickness, the disease of which the person died, and the date of his decease, us nearly os he can
6tato the same.— [Extract from Chapter 21 of the General Statutes, 1859.]
E^Tlie attending Physician is requested to make out his Certificate as
promptly as possible, for the information and use of the Undertaker, or
other person making return of the case to the Town Clerk.
£3?^ Ph}'sicians may obtain Blank Certificates from the Town Clerk
or Registrar.
I3P1 Copies of the Statistical Nosology, adopted for the purposes
of Registration, majr be obtained on application to the Secretary of the
Commonwealth.
RETURN
OF
DEATH
TO
THE CITY REGIST
CITY HALL, BOSTON.
CLu
'j
/£-
■>>
#3
eh A AS
Sf
rae)
XY Yast ana han Kee. Sys
ee De ye,
4 i
: Eiesten, lia ihre ASSL
Chis Certifies, That Quit p Tle oct
did on the wer May G j less 158 ¢.caged py ym |
ARR
eee
df’ months, LO .htys.
inting Department, Deer Island, Boston Harbor.
_—
aaa fl
3
we
3
Gea eRe OG
5S,
Re
CAUSH OF) Primary, * OS hl * Duration |
Secondary, Cory edleon Cevrburation F obey d ;
ua a’
va AL fin Physician.
DEATH.
AAR:
aS
BRD arate Gh
qT
yy
2 CP
toy
3
2
EPI
= hae
—
=
{
b3
i9
k
. 1}
(Gettoumny? *
RETURN OF A DEATH.
To the Clerk
of the
Town
in
which
the Death occurred.
Disease
or
f
First
or
Primary]
The
Undertaker,
or other
informant,
is
requested
to
report
the
facts
—
together with
the
Physician’s
Certificate
of
the
Causes
of
Death
—
to
the
Town
Clerk,
before
the interment.
In
case
of
an
interment
takiug
place,
without the
Certificate
of
Registry
of the
Clerk
of
the
Town
in
which
the
Death
occurred (or
the
deceased resided)
having
first
been obtained, the person
having charge
of
such
Interment
must
forthwith
give notice
thereof—
or report these
facts
—
to said
Clerk.
Penally
for
neglect,
twenty
dollars.
gg* Blank
forms
for
Returns
of
Deaths
may
be
obtained from
the
Town
C.eik.
PHYSICIAN’S CERTIFICATE.
Vame of Deceased* - - -
|. ¢ :
Date and Place of Death, - | died at , f ay
Bease or Cause of Death, of. ¢ ware Ahwvation of Sickness...
I certify that the above is true, to the best of my knowledge and belief.
re" 7
be and Residence of Certifying Physician an
Date of Certificate,... ... ; A 187
* Or Sex of Infant (not named).
Any Physician having attended a person doting his last illness, shall “l'“ di'Lse oTrvhich the person died, and he
Without
repealing
the
foregoing
requirements
of
the
General Statutes^rte
recent
to
jtrovulejor
dty
or
town,
until
a
Vital Statistics.” passed April 2J ** 5 «*« h““" ^ undertake or Sexton, or person performing , .
proper Certihcat. has been given by the clerk or local «f £lap. a. of the General Statute, have been
burial or removing the body. This certificate shall state tha q Qr buJal it until the Certificate of the Cause of
returned and recorded; and no clerk or local registrar shall give sue sickness of he deceased), and placed in the hands of said
Death
has
been obtained, (from
the
Physician,
if
any,
in
attendance
at
the
last
sickness
Cle“r::no
Physician
in
attendance,
or
in
case of
death
by
of
certificate of the attending Physician cannot, for good and sufficient reasons> J y Certificate of the Cause of Death, to the best of
Health or any Physician employed by any city or town for such purpose, shall sign the Certificate ot
S knowledge and belief. In else of death by violence, the medical examiner shall furnish the certificate.
RETURN OF A DEATH.
To the Clerk
of the
Town
in
which
the Death occurred.
Cause
of
"i
Secondary
(if
any)
S
a>
r>«j
; a> s £ o
w-H
a
a
s t§
ef
.2 M
cS
[iiThe text goes on. The rest is in the file.