The volume, 1886–1892
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(Jfommontoealtlj of JJflassadjuartts.
10. Place of Birth,
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If u Married Woman or Widow.
[ Public Statutes , Chap. 32. Sect. S-~\ . , lcrk or
No human body shall be buried or removed from any ^ ^ ^
registrar to the undertaker, sexton, or other person performing ^ ^ such certificate or bunal perm.t until t e
required by this chapter have been returned and recorded; ,f ^ in attendance at the last sickness of the deceased, and
certificate of the cause of death has been obtained from P ^ ^ ^ boardS of health, the certificate of the cause o
placed in the hands of said clerk or registrar; and m cities ^ r fey lhe registrar or clerk. Upon application, the chairman
death shall also be approved by such board before a perm. 0 such purpose, shall sign the certificate of the cause o < ea
of the board of health, or any physician employed by any ci y He shall also sign such certificate, upon apphc. ■
{
dollars.
PHYSICIAN’S CERTIFICATE.
Name of Deceased * -
Date and Place of Death , -
Disease or Cause of Death , -
* $ rf /fid. "d/
died at '
fAlo/ {nu/lr'f
188 .
of
s\/
Duration of Sickness / t d ...
Name and Residence of Certifying Physician,
1 certify that the above is true, to the best of my knowledge and belief.
, £c //.. Zd // H fdL
Date o,
/ n
f Certificate,, 188 .
'Or R»*x of Infant (not named).
[ Extracts from Chapter 32 of the Public Statutes .]
1 u- Uot ;iinKc shall when requested within fifteen days after the decease
“ Sf.ct. 3- A physician who has attend a person during h,s last Huess , J „,e disease of which the person die.l,
of ,»ch person, forthwith furnish for registration tt certihcatc of .he duratmn ^ ^ ^ ^ ^ ^ ^ cettifate, he shall
and the dale of his decease, as nearly as he can state the same. • 1 >
forfeit ten dollars to the use of the town in which he resides.’ certificate has been given by the clerk
“ Sect. 5. No human body shall be buried or removed from any city or to, n un P P that the
registrar to the undertaker, seston, o, Cher perse, performing the bun.l or removing the hoO,.^ ^uch ^ ^ ^ ^
facts required by this chapter have been returned and recorded, and no cler « I ^ ^ of lhe deceased, and
the certificate of the cause of death has been obtained from the phys.ctan, ,f any , . , ^ ,he certi6cate „f lhe cause of
placed in the hands of said clerk or registrar; and in cities and towns mere ere are “ ’ application, the chairman
death .bail a„o be approved by such board before a permit to bury » g™ by of the cause of death
„f ,„e board of health, or an, physician employed by any city or town for such purpose g
„,e best of hi, knowledge and beiief, if there ha, been no physician attendance He " physician ca for
,i„„, in case of death by dangerous ^ shai, the
person violating the provisions of this section shall be punished by fine not exceeding twenty-five dollars.”
Duration of Sickness,
By whom certified, .
Place of Death,
* If a Married Woman or Widow.
t i t oilier than White. (M.) Mulatto. (I.) Indian. If of other Karen, specify what.
[Be very particular to fill all Blanks.]
[. Public Statutes, Chap. 32 , Sect. J . J
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. Sucl^ 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 thf last sickness of the deceased, and
placed in the hands of said clerk or registrar; and in cities and towns where there are boards of health, the certificate of the cause of
death shall also be approved by such board before a permit to bury is given by the registrar or clerk. Upon application, the chairman
of the 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, if there has been no physician in attendance. lie shall also sign such certificate, upon applica-
tion, 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. In case of death by violence, the medical examiner attending shall furnish the
requisite medical certificate. Any person violating the provisions of this section shall be punished by fine not exceeding twenty-live
dollars.
PHYSICIAN’S CERTIFICATE.
Tame of Deceased,* -
Kite and r/ace of Death, -
V sense or Cause of Death, -
.QdMSLfa'
died at .
of Duration of Sickness
time and Residence of Certifying Physician
1 certify that the above is true, to the best of my knowledge and belief.
,.y /is . ( ■ i ' r<'C i L //-t 7 i.
yf
Date of Certificate, f OA ■' t r.
i8s£
♦Or Suit of Infant (not named).
[Extracts from Chapter 32 of the Public Statutes.]
“ Sf.ct. 3. A physician who has attended a person during his last illness shall, when requested within fifteen days after the decease
itrn;rr furnish "ation a cer,ir,cate °f the °r the - *• of w*! the Per j
, the date of his decease, as nearly as he can state the same. If a physician refuses or neglects to make such certificate he shall
forfeit ten dollars to the use of the town in which he resides.”
“ 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 reg,s rar to the undertaker sexton, or other person performing the burial or removing the body. Such certificate shall state that the
. reqmred 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
, > " , " " regiStrar; an<1 " CUieS and t0"'nS "’here thCre are 1>0ardS °f health> the certificate of the cauie of
d ath shall also be approved by such board before a permit to bury is given by the registrar or clerk. Upon application, the chairman
the board of health, 0, any p ysician employed by any city or town for such purpose, shall sign the certificate of the .use of death
i ' cl f d thT ^ ^ ,here haS bCen "° PhySida" !n a“eniIanCe- HC Sha11 a,S° SUch certificate, upon app.ica- 1
.ton 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. In case of death by violence, the medical examiner attending shall furnish the
requisite medical certificate. Any person violating the provisions of this section shall be punished by fine not exceeding twenty-five dollars
.>>
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[. Public Statutes, Chap. 32, Sect. 5 . J
No human body shall be buried or removed from any city or town until a proper certificate lias 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 and in cities and towns wliere there are boards of health, the certificate of the cause of
death shall also be approved by such boarttLefore a permit to bury is given by the registrar or clerk. Upon application, the chairman
of the board of health, or any physician l^Htaycd 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, if j|^has been no physician in attendance, lie shall also sign such certificate, upon applica-
tion, 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. In case of death by violence, the medical examiner attending shall furnish the
requisite medical certificate. Any person violating the provisions of this section shall be punished by fine not exceeding twenty-li\ e
dollars.
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vyTWiuy
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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, . . .
Name, Professional Title , and Residence,
I certify that the above is a true Return , to the best of my recollection and belief.
<£ (f. 2 fXPNZr’J)
Dated at... isrc
.Be 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 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
state the same.— [Extract from Chapter 21 of 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.
UP3 Physicians may obtain Blank Certificates from the Town Clerk
or Registrar.
I3P 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.
©
v
[Be very particular to fill all Blanks, j
fc-W-
[Public Statutes, Chap. 32, Sect, jr.]
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 acts
required by this chapter have been returned and recorded; and no clerk or registrar shall give such cert.ficate or buna! perrn.t unt.l the
certificate of the cause of death has beep obtained from the physician, if any, in attendance at the last s.ckness of the decease. , an.
placed in the hands of said clerk or registrar; and in cities and towns where there are boards of health, the cert.ficate of the cause o
death shall also be approved by such board before a permit to bury is given by the registrar or clerk. Upon appl.cat.on, the chairman
of the board of health, or any physician employed by any city or town for such purpose, shall sign the cert.ficate of the cause of death
to the best of his knowledge and belief, if there has been no physician in attendance. He shall also sign such cert.ficate, upon applica-
tion, in case of death by dangerous contagious disease, or in any other event when the certificate of the attendmg phys.c.an canno or
„ood and sufficient reasons be early enough obtained. In case of death by violence, the medical exam.ner attendmg shall furn.s .
requisite medical certificate. Any persjn violating the provisions of this section shall be punished by fine not exceed.ng twenty- .
dollars.
<35
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PHYSICIAN’S CERTIFICATE.
Name of Deceased * -
Dale and Place of Death,
Disease or Cause of Death, -
dczc //d 188 f
< &L Duration of Sickness Cc. -c^e^/(
I certify that the above is true, to the best of my knowledge and belief.
Wayne and Residence of Certifying Physician , i '
Date of Certificate,
188 £.
*Or Sox of Infant (not named).
[Extracts from Chapter 32 of the Public Statutes. ]
“ 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. If a physician refuses or neglects to make such certificate, he shall
forfeit ten dollars to the use of the town in which he resides.”
“ 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 t lie deceased, and
placed in the hands of said clerk or registrar; and in cities and towns where there are boards of health, the certificate of the cause of
death shall also be approved by such board before a permit to bury is given by the registrar or clerk. Upon application, the chairman
of the 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, if there has been no physician in attendance. He shall also sign such certificate, upon applica-
tion, 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. In case of death by violence, the medical examiner attending shall furnish the
requisite medical certificate. Any person violating the provisions of this section shall be punished by fine not exceeding twenty-five dollars.'’
Duration of Sickness
By whom certified,
* If a Married Woman or Widow.
t If other than White. (M.) Mulatto. (I.) Indian. If of other Races, specify what.
[Be very particular to fill all Blanks 1
\_Public Statutes , Chap. 32, Sect. J-]
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 tl;e
certificate of the cause of death has been obtained from the physician, if any, in attendance at the last sickness of the deceased, an
placed in the hands of said clerk or registrar; and in cities and towns where there are boards of health, the certificate of the cause o
death shall also be approved by such board before a permit to bury is given by the registrar or clerk. Upon application, the chairman
of the 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, if there has been no physician in attendance. He shall also sign such certificate, upon app .ca-
tion, in case of death by dangerous contagious disease, or in any other event when the certificate of the attending physician cannot
good and sufficient reasons be early enough obtained. In case of death by violence, the medical examiner attending sh ill furnish he
requisite medical certificate. Any person violating the provisions at thijj^ection .shall be punched by hue not exceec ing tucnn
1 11 f * /+ *^4-' 7. P- /t'As/'
dollars. 6 x f / j • l
— c - • ^
n C~> • /
RETURN OF A DEATH.
To the Clerk of the Town in which the Death occurred.
tty whom certified.
X
.>»
If a Marrird Woman or Widow.
[• Public Statutes, Chap, jj. Sect. /.]
No human body shall he buried or removed from any city or town until a proper certificate has been given by the clerk or
1 ed by this chapter have been returned and recorded; and no clerk or registrar shall give such certificate or burial permit until the
d t°/ . 7"? °f 7ath HaS bCCn °btained frul“ the Physician, if any, in attendance at the last sickness of the decease,., and
Lt n ■ , . °VCgiStrar; and " dtiCS and t,WnS WhCre there are boardS °r health’ lhe certificate of the cause of
i : : ;r hy Z ”“d ***>“ a ^ to by the registrar or dlerk. Upon application, the chairman
to the besfof hs t i 7 "r" emPl°'Ved ^ any Cit>’ °r t0"n f°r SUCh P“rP°Se- Sha11 «« certificate of the cause of death
tion in ca f 1 \hh 'T “ ’ ™ ^hysidan in ^tendance. lie shall also sign such certificate, upon applica-
and ufhe t dangerous contagious disease, or in any other event when the certificate of the attending physician cannot for
'enuisite n • V '7 ^ 7' * en°Ugh obtalned- In case of death by violence, the medical examiner attending shall furnish the
ilo.lars “ ‘Ca LCr ny PCrSOn V,°lating lhe Prov’sions of this section shall be punished by line not exceeding twenty-five
* I f !l Married Woman or Widow. 7*
t other than White. (M.) Mulutto. (I.) Indian. If of other Races, specify what.
[Be very particular to All all Blanks.]
/JL
[^W/V Statutes , Chap. J2, Sect, j ]
No human body shall be buried or removed from any city or town until a proper certificate has been
registrar to the undertaker, sexton, or other person performing the burial or removing the lmdy. uo certl ca eJ u untU the
required by this chapter have been returned and recorded; and no clerk or registrar shall *ve sue tee '-a deceased and
certificate of the cause of death has been obtained from the physician, if any in attendance at of
placed in the halids of said clerk or registrar; and in cities and towns where there are >oar ’ ^ thfi chairman
death shall also be approved by such board before a permit to bury is given by the reg.strai or cle, . , PP death
of the board of health, or any physician employed by any city or town for such purpose shal s.gn <b ^ 1 « applica.
to the best of his knowledge and belief, if there has been no physician in attendance H j shal 4 «J£ for
tion, in case of death by dangerous contagious disease, or in any other event when t re cer “ * °i attetKu„g shall furnish the
good and sufficient reasons be early enough obtained. In case of death by violence t e medical tUmth g ^
requisite medical certificate. Any person violating the provisions of this section shall be pun.sned by fine
dollars.
(
* If a Married Woman or Widow.
t If other than White. (M.) Mulatto. (I.) Indian. If of other Races, specify what.
fBe very particular to fill all Blanks.!
required by this chapter
No human body I hall be buried or removed from any city
Lpstrar to the undertak
[■ Public Statutes, Chap. j2 , Sect. j.J
■ ' >r t°'vn until a proper certificate has been given by the clerk or
:r, sexton, or other person performing the hi rial or removing the body. Such certificate shall state that the facts
lave been returned and recorded; and no c^erk or registrar shall give such certificate or burial permit until the
f I 1 1 h/W* l\AAM - - 1. _ " 1 r .1 t •• mm
I ' e> fa**'- wiuiitait yji uuiiai jjcium uimi me
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 sajjd clerk or registrar; and in cities and towns where there are boards of health, the certificate of the cause of
ueath shall also be approved by such board before a permit to btWf’fgiven by the registrar or clerk. Upon application, the chairman
of the board of health, ct any physician employed by any city or tewn for such purpose, shall sign the certificate of the cause of death
to the best of his knowledge and belief, if there has been no physici in in attendance. lie shall also sign such certificate, upon applica-
tion, in case of death by dangerous contagious disease, or in any oth *r event when the certificate of the attending physician cannot for
OTind and cnffiriAnf t . . • i - ..
good and sufficient reasons be early enough obtained. In case of
leath by violence, the medical examiner attending shall furnish the
‘ J * mv. iiiv.uiv.ai t.vauiiiici clllCIlUIIlg Mia.ll lUrillMl lilt
requisite medical certificate. Any person violating the provisions of this section shall be punished by line not exceeding twenty-five
dollars.
* Vo
gif* The Undertaker, or other informant, is requested to report the facls — together with the
Physician’s Certificate of the Causes of Death — to the Town Clerk, before the interment.
gif' 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.
gif Blank forms for Returns of Deaths may be obtained from the Town Clerk.
,. oo
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TTVZ~n ^ ■
PHYSICIAN’S CERTIFICATE.
C. l i.y d /■’, / Cj < ' cc
fl/" Deceased* - - - Cf^s/ .
r)n/e and Place of Death , - died at //ft
disease or Cause of Death, . of Duration of Sicknat
I certify that the above is true , to the best of my knowledge and belief,
ame and Residence of Certifying Physician, [r ft t/h-fn I'Cltt, l// Jf
J -Jdfnft/tC/ Pdf a DP- Date of Certificate, . W Its i e^jP J
188 L
*Or Sex of Infant (not ■flamed).
88 C
[Extracts from Chapter 32 of the Public Statutes."]
“ Sect. 3. A physician who has attended a person during his last illness shall, when requested within hftecn da\s 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. If a physician refuses or neglects to make such certificate, he shall
forfeit ten dollars to the use of the town in which he resides.”
“ 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 certilicate 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; and in cities and towns where there are boards of health, the certilicate of the cause of
death shall also be approved by such board before a permit to bury is given by the registrar or clerk. Upon application, the chairman I
of the board of health, or any physician employed by any city or town for such purpose, shall sign the certilicate of the cause of death |
to the best of his knowledge and belief, if there has been no physician in attendance. lie shall also sign such certificate, upon applica- >
tion, 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. In case of death by violence, the medical examiner attending shall furnish the
requisite medical certilicate. Any person violating the provisions of this section shall be punished by fine not exceeding twenty-five dollars.” I
RETURN OP A DEATH.
To the Clerk of the Town in which the Death occurred.
u^- The o,
physician’s Certificate of the Causes of eat 1 Certificate of Registry of the Clerk of the
©- Iu case of an interment taking place, wtt ‘o« » fir8t been obtained, the person
“'d
Clerk. Penalty for neglect, twenty dollais. — •
rt _ f' u T") A*m>n Q of T) paths
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.
gif" 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.
gif' Blank forms for Returus of Deaths may be obtained from the Town Clerk.
Vame of Deceased ,* -
"fate and P/ace of Death,
Disease or Cause of Death,
PHYSICIAN’S CERTIFICATE.
w c4 'L irrzjd
leU
r
died at
Q
of \d g
%
188 &
*x>
77 s
//fczyfo
n . . { *£< ,
Duration of Sickness 7 O-yc-t) yC~f exc^d
/ certify that the above is true, to the best of my knowledge and belie'.
awe amt Residence of Certifying Physician, ~ U^TneS. ^ VCiftt
Date of Certify
ificate, ty-i
cu/ dLl
*Or Sox of Infant (not. named).
t-
[ Extracts from Chapter 32 of the Public Statutes . ]
“ 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. If a physician refuses or neglects to make such certificate, he shall
forfeit ten dollars to the use of the town in which he resides.”
“ 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; and in cities and towns where there are boards of health, the certificate of the cause of
death shall also be approved by such board before a permit to bury is given by the registrar or clerk. Upon application, the chairman
of the 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, if there has been no physician in attendance. He shall also sign such certificate, upon applica-
tion, 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. In case of death by violence, the medical examiner attending shall furnish the
requisite medical certificate. Any person violating the provisions of this section shall be punished by fine not exceeding twenty-five dollars.”
RETURN OF DEATH TO THE CITY REGISTRAR. ,
OVbb CITY HALL, BOSTON.
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JOS. S. WATERMAN & SON,
UNDERTAKERS.
Cl)is Certifies, ^
c/m/ on t/o
c/ind.
rikXjL-——-- apec/
T
ys ^ / vyrccdut
CAUSE OF | Primary , SCCUc^C^'L C f Fzff/l C Duration/
DEATH. f Secondary, pc Duration/
J *z£n~- T/~+ — y <? -rf -> C'K-Q~< ACsL4~-4. C~/~£<-A~
IruA- c< *&-
7 /l
Physician.
(/
RETURN OF A DEATH.
To the Clerk of the Town in which the Death occurred.
* If a Married Woman or Widow.
t If other than white. (A.) African ; (M.) Mulatto; (I.) Indian. If of other Races, specify what.
[Be very particular to fill all Blanks.]
/j "
4^9 <& «.
^ ^ ■:>
&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.
fcg* 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 Iuterment must FORTn with give notice thereof — or report these facts — to said
Clerk. Penalty for neglect, twenty dollars.
tgg’ Blank forms for Returns of Deaths may be obtained from the Town Clerk.
PHYSICIAN’S CERTIFICATE.
e °f Deceased* .
and Place of Death,
** * y / ™TT
rc --■“•■*. . Sfif '
' /" U^£Ddnation of Sickness ..
taH® *• <*"”'£ >r«', kaizr,
"t-^‘-fc,rl,y„U!P, fTf? , ° "•’ hm/f mitoUf.
y
°- Sex of Infant fnot
'tamed).
Any Physician having attended a person during his last illness, shall — when requested within fifteen days after the decease of I
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, /Sjg.]
Without repealing the foregoing requirements of the General Statutes, the recent “ Act to provide for the more Accurate Registri
of Vital Statistics,” passed April 23, 1S78, provides that “ no human body shall be buried, or removed from any city or tow
proper Certificate has been given by the clerk or local registrar of statistics, to the Undertaker or Sexton, or person performi
burial or removing the body. This certificate shall state that the facts required by chap. 21 of the General Statutes have
returned and recorded; and no clerk or local registrar shall give such certificate or burial permit until the Certificate of the Cau
Death has been obtained, (from the Physician, if any, in attendance at the last sickness of the deceased), and placed in the hands
clerk or local registrar.”
ui, iiq
■mind
lave I
If there has been no Physician in attendance, or in case of death by dangerous contagious disease, or in any other event whei
certificate of the attending Physician cannot, for good and sufficient reasons, be early enough obtained, the chairman of the local HoB
Health, or any Physician employed by any city or town for such purpose, shall sign the Certificate of the Cause of Death, to the tfl
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.
10. Place of Birth,
* If a Married Woman or Widow. „ t , .
t If other than White. (M.) Mulatto. (I.) Indian. If of other Races, specify what.
[B© very particular to fill all Blanks. j
[. Public Statutes, Chap. 32 , Sect. 5.]
No human body shall be buried or removed from any city or town until a proper certificate t^t delete
registrar to the undertaker, sexton, or other person ^ r^Z^J. tfvc suTce^Lte or burial permit until the
placed in the hands of said clerk or registrar; and in cities and towns where there are boar s ° • * ,,ication> the chairnlan
death shall also be approved by such hoard before a permit to bury is given by the registrar or c ei - ^ death
of the board of health, o, any physician employed by an, city « «n. for sad, purpose shal « .the » ^ ,pp,iea-
,0 the best of his knowledge and belief, if there has been no physician in attendance^ He shall a g ' fot
lion, in case of death by dangerous contagious disease, or in an, other event » en I te cer . tea f„nish ,he
good and sufficient reasons be early enough obtained. In case of death by violence .wentvd.ve
recpiisite medical certfficate. Any person violating the provision, of this section shall be punished by One ». .
dollars.
A
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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 Flace of Death , .
Disease , f p-irsi Qr primary
pr Cause <
of Death, Secondary, • • •
SXC...
X
9 dtt
X
2 >2^-^
Duration of* ^
Duration of.
Vtrtne, Professional Title , and Residence ,
I certify that the above^is a true Return, to the best of my recollection and belief
[Be very particular to fill all Elank3.]
Dated at •» '£ /^fc 1 fylitdriL/ Z 4- f f £*
* Ileckoned to the time of death.
Any rhyslcian having attended a person during his last illness, shall — when requested within fifteen
days after the decease of swell person —forthwith ltirnisli 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 us he can
state the same.— [Extract from Chapter 21 of the General Statutes, 1 8o9. ]
I^Tho 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.
Ep3 Physicians may obtain Blank Certificates from the Town Clerk
or Registrar.
£5P Copies of the Statistical Nosology, adopted for the purposes
of Registration, may be obtained on application to the Secretary of the
Commonwealth .
9. Occupation,
If a Married Woman or Widow.
[. Public Statutes , Chap. 32, Sect. 3.]
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, an
placed in the hands of said clerk or registrar; and in cities and towns where there are boards of health, the certificate of the cause ol
death shall also be approved by such board before a permit to bury is given by the registrar or clerk. Upon application, the chairman
of the 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, if there has been no physician in attendance. He shall also sign such certificate, upon applica- ^
tion, 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. In case of death by violence, the medical examiner attending shall furnish the
requisite medical certificate. Any person violating the provisions of this section shall be punished by fine not exceeding twenty-live '
dollars.
CI)is Certifies, WZat. l\x
Vo i Ha^Uh
Primary,
Sccondan
Duration
Duration
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ondition,
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•JJ.I9J3 MI.) uiojj paurejqo oq Ajuu ‘sajuoijijjaj s(umoisA'qj pm? ‘siunjaj jo suuoj 3pre[g
•sjepop iqiiaAvj ‘^oa^Sau joj Xjpiuaj ‘q-i9l3 pies oj —
sqouj gsgqj piodaj jo — joaaaqj aoixox 3aio hxiavhxjicm ?sn«i juauuajui qons jo aSjtjqo StiiAnq uos.iad
aqj ‘pamujqo U99q js.tij SuiA'Bq (pgpisg.i pasnooop aqj jo) pgjjnooo qpsap aqj qoupvv ui uayox jo jCjij 1
aqj jo qtsjQ 9qi jo XjisiSojj jo ajuopijJOQ aqj jnoqjm 80«jd Smqi;j juauuajaj m? jo 9sx?o
•apaui U99q si?q ujujoj 9qj ^«qj 9j'BoqijJ9^) s^JQlQ oqj 9AI909J
pm; ‘XN3KH3XKI 3HX aaoaaa ‘q-^IO AlO 8qj oj — qji;9(j jo 9sm?3 oqj jo 9ji;oxjijj93 spnuoisjCqj
aqj qjiAY jaqjaSoj — sjovj aqj jjodgj oj pgjsonbaj si ‘jmjuuojin xaqjo jo ‘J9qi;jJ9purj aqx^^J
PHYSICIAN’S CERTIFICATE.
To tile Clerk of lJl«* City of
ceased D .
Cause of (Death,
y
Place of (Death , . . . died at
, . . of(SaU«A* , (Duration of Sickness
188 ^
certify that the abovejl true, {^tftTtesi^) know ledge and belief.
°L , Z&z'...,
ulence of Certifying Physician
(Date of Certificate
■l /3%_ rnfi
* Or Sex of infant (not named).
A physician who h.. oUhe of which the person hied, and 3
Seeiion 4 of ,h« „ chapfer prorides -no h.nnan
has been given by the clerk or registrar to the undertaker or se. , nQ Qr registrar sha„ give su«
sr ^^-r^rr:rLrr^-- — * - — - •
tificate of the attending physician cannot, foi Oood a shali sign the certificate of the cause of death, to the best
“rsr ■
i
§
s
r-H
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3
0
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<s
1
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n
The Undertaker, or other informant, is requested to report the facts — together with t
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 t
Town in which the Death occurred (or the deceased resided) having first been obtained, the pers
having charge of such Interment must forthwith give notice thereof — or report these facts — to sai
Clerk. Penally for neglect, twenty dollars.
tjgl’ Blank forms for Returns of Deaths may be obtained from the Town Clerk.
P of Deceased*
land Place of Death , .
jp Cause of Death ,
PHYSICIAN’S CER^bBCA|£,
To the Clerk of the-Clty-of Cambridge^
Zb,
died at
f A '' l88 ^
°f ^^t^Duration of Sickness $
I certify that the a\oveJs true , to the best of my knowledge and belief.
1 *"**"« of Certifying Physician icL * ^}f
Date of Certificate
Or Sex of infant (not named).
X"
188 c
* * l*"°n durins hi! illn'“ shall when requested within fifteen d.,s after the decease of
XT.fhfT ” “u ” ‘ “rti"C“ °f ‘h° dUr*“0n °f ,he,*“ *• <"•“* which the person die,,
of In, decease, a. nearly as he can state the same.-[&, root /row C/«.pter32 of the Public SlatuM Section 3 ]
ha. berXen t e eWk ” h *** ** '* ^ «- -J or town, trttti, , proper e.rti,
eertitol lhleXX h IV “ °th» *"» P"*™* the bnria, or removing the hod,, I
or Tar * *“• *■*•' ''*™ "turned and recorded ; and no dark or registrar shall L Lit
*- — - - *-* --------
certifilrteof the Xendim T* ” '* ^ ^ ^ contagion, diseases, or in any other event whetj
h It “ X?„h“ d n^ 7 -J—n »nnot, for good and snfhcien, reasons, he eariy enough obtained, the chairman of the ioea, ho,
knowledge and h "’V X *"J' ” — f” *«" P“r~. ** -«• «» of the eanse of the best
knowledge and belief. In ease of death by violence, the medical examiner shall furnish the certificate
03 X
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° O
03 •*“«
£
S3
Q
T3
<D
cp
a
o
pa
£
CG
o3
Q
If a Married Woman or Widow.
[ Public Statutes, Chap. 32, Sect. 3. J
„ ^7“ ';°"Vh*11 ~ f'»” «*«*« «n,il a prop,, certificate has given by the clerk o,
° J' h , T"’ or Mh" per“n pe^f“r,ni,,8 “* ”“rial « "~™2 ^ w* **
certificate e et 1' I tlTh "7^ 7 r“°r"! “d "° ” "«“» sh“'> -ch certificate or l.uria, permit the
p,erii :ir:; “hif 7 in “ *■ ^ - — - - — -
death shall also be approved by such hoard before >t heallh’ lhe eertifieate of the came of
of the board of health I • peran o ury is given by the registrar or derk. Upon application, the chairman
,0 ,he be,', of hi, k J I , by "y CUy ” f” ”Ch I,nrP°"’ Sh,l‘ S‘g" *h' «*“«« <* th' «*~ •» death
don „ c L f c h 7 PhySiCi“ ^ a‘"n<1*n"' ,,e *ha" *» *<“* eertilicatc, upon applic
gj -a : y dil"SCr0"; “n,!,S'“"S di”asc- ” “*• ™“ »■"“ ">d certificate of the attending physician cannot for
fe^she I"! T TT " r '”“S “b,ainCd' ““ °f d'a"' by attending shall furnish the
dollar, P"S°n 2 ‘he P'“V“i0nS °f ,h“ Shal‘ U l»,’“h'd '>>’ exceeding tiventy-five
7/P '*■
~-r~v? tnf~7 ■^S/q -ce
le of Deceased * -
’ and Place of Death, - died a*
pse or Cause of Death, - of
PHYSICIAN’S CERTIFICATE.
< s,. Cct i ■/ e £
</
>
O'
i.cy.z... ’Sitdt-.g..
h. <&+. PDu ra tio n of Sickness. . . v
I cettify that the above is true, to the best of my knowledge and belief.
and Residence of Certifying Physician
Date of 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 o
person —forthwith furnish for registration a certificate of the duration of the last sickness, the disease of which the person died, a;
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 Regis
of Vital Statistics,” passed April 23, 1878, provides that “no human body shall be buried, or removed from any city or town,
proper Certificate has been given by the clerk or local registrar of statistics, to the Undertaker or Sexton, or person performii
burial or removing the body. This certificate shall state that the facts required by chap. 21 of the General Statutes have
returned and recorded; and no clerk or local registrar shall give such certificate or burial permit until the Certificate of the Ca1
Death has been obtained, (from the Physician, if any, in attendance at the last sickness of the deceased), and placed in the hands 1
clerk or local registrar.”
j
If there has been no Physician in attendance, or in case of death by dangerous contagious disease, or in any other event wha
certificate of the attending Physician cannot, for good and sufficient reasons, be early enough obtained, the chairman of the local B<
Health, or any Physician employed by any city or town for such purpose, shall sign the Certificate of the Cause of Death, to the 1
his knowledge and belief. In case of death by violence, the medical examiner shall furnish the certificate.
w
1 ^
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Q
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I 121
Ph
P
E-«
I H
1
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£
c/T
£
oT
bio
<
*o
Duration of Sickness,
By whom certified,
<a
O
+-»
Sh
3
o
<rt
ft
If a Married Woman or Widow.
[. Public Statutes , Chap. 32, Sect. /-.J
No human body shall be buried or removed from any city or town until a proper certificate has been given by the clerk or fj
registrar to the undertaker, sexton, or other person performing the burial or removing the body. Such certificate shall state that the facts i
required by this chapter have been returned and recorded; and no clerk or registrar shall give such certilicate 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 1
placed in the hands of said clerk or registrar; and in cities and towns where there are boards of health, the certificate of the cause of I
death shall also be approved by such board before a permit to bury is given by the registrar or clerk. Upon application, the chairman 1
of the board of health, or any physician employed by any city or town for such purpose, shall sign the certificate of the cause of death I
to the best of his knowledge and belief, if there has been no physician in attendance. He shall also sign such certificate, upon applica- f
tion, 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. In case of death by violence, the medical examiner attending shall furnish the
requisite medical certificate. Any person violating the provisions of this section shall be punished by fine not exceeding t\\ent\ -live ^
dollars.
Deceased -
Place of Death, -
r Cause of Death, -
1 certify
Residence of Certifying Physician ,
led at sdcA- /CtjSsC
f 7K* CfCp&t*.
/ eT
'$>’ that the above is true, to the best of my knowledge and belief. ' /
C’C fffc f4u^i
.&■ P/L3t~. mc
Dale of Certificate ,
kOr Sex of infant (not named).
I
[. Extracts from Chapter 32 of the Public Statutes. ]
“ Sect. 3. A physician who has attended a person during his last illness shall, when requested within fifteen days after t'
of such person, forthwith furnish for registration a certificate of the duration of the last sickness, the disease of which the pe
and the date of his decease, as nearly as he can state the same. If a physician refuses or neglects to make such certificat
forfeit ten dollars to the use of the town in which he resides.”
“ SeC£. 5. No human body shall be buried or removed from any city or town until a proper certificate has been given bj
or registrar to the undertaker, sexton, or other person performing the burial or removing the body. Such certificate shall stat<
/acts required by this chapter have been returned and recorded; and no clerk or registrar shall give such certificate or burial pi
the certificate of the cause of death has been obtained from the physician, if any, in attendance at the last sickness of the dec«
placed in the hands of said clerk or registrar; and in cities and towns where there are boards of health, the certificate of the
death shall also be approved by such board before a permit to bury is given by the registrar or clerk. Upon application, the
of the board of health, or any physician employed by any city or town for such purpose, shall sign the certificate of the cause
to the best of his knowledge and belief, if there has been no physician in attendance. lie shall also sign such certificate, upo
tion, in case of death by dangerous contagious disease, or in any other event when the certificate of the attending physician c
good and sufficient reasons be early enough obtained. In case of death by violence, the medical examiner attending shall fi
requisite medical certificate. Any person violating the provisions of this section shall be punished by fine not exceeding twenty-fivi
1
; Stfrasl WMte? °(H0 M°Jatto. (I.) Indian. If of other Races, specify wh«t
[Be very particular to fill all Blanks.]
[Public Statutes, Chap, jj. Sect, j.]
, X“ h"*-> J from any city or „,„il a proper certi6catc h„ been hv
4” ° 4 cht'rrT"'0' M"rm p"f“'minE ,l,e buriai °r remotin‘ ,h' s“h m — «* .-a me,
«La,e f ” a«« 7 ’7 "h ! "“rdedi ““ ” »“ »«* certificate on burin! perntit the
Placed il ,he Tj, , 7 "h'”""1 fr0”' ph>'““"' if >">'• >" a. ,h= las, sickness of ,be deceased, and
d a h b , , 7 ' ” r'g,!tr“r; and in Ci,i" “d •»»“ .bene a,, boards of health, the cerlificate of ,h. can e of
“7717 "y 7h '“rd 7°re * b>' - - clerk. Upon apphcarion, ^
to .he beTof h 7 l "”y 7T'a" 'mP ^ "y d,y “ " «* *“h — *« .he certificate of the cause of .lea,!,
tion in case of ,7th I "7 “ ’ h*‘ b"" "0 Ph>,”Cia'' «c shall also sign such certificate, upon applied-
good and „7 , 7 7 “ «* °>h" >»« certificate of the attending physician for
,1 ,e ! , TT I" ' '"“Sh °b,ai”d' ““ <>f d“‘h LP ™‘““' •>" «»— « attending" shall the
X Any P"“" *• of ■>■« I .hall he punished by fine no, luenlylive
tl Hi-tfliru. l) . /gsb
Cljis Certifies, ?%at QUflu IVfAz |
c/eee/on //ie 1 1 t/cy 0/ t./tfStfa j (7^0(/ — ■■.
5
???on
//u.
7
WWMj 1
CA U SE OF | Primary, 3- UU/\
EE A TIT. j i^^TTTyr^n 1 — — — — — rVvT^rrtT —
l^,
Physician.
RETURN OF A DEATH.
To the Clerk of the Town in which the Death occurred.
. Place of Death,
* If a Married Woman or Widow. , .
| If other than White. (M.) Mulatto. (I.) Indian. If of other Races, specify what.
[Be very particular to fill all Blanks.]
n,. />
$ /le*Q, - r}
uUU
, J
[. Public Statutes, Chap. J2 , Sect, j.]
Xo 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 h^s been obtained from the physician, if any, in attendance at the last sickness of the deceased, and
placed in the hands of said clerk of registrar; and in cities and towns where there are boards of health, the certificate of the cause of
death shall also be approved by such board before a permit to bury is given by the registrar or clerk. Upon application, the chairman
of the 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, if there has been no physician in attendance. He shall also sign such certificate, upon applica-
tion, 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. In case of death by violence, the medical examiner attending shall furnish the
requisite medical certificate. Any person violating the provisions of this section shall be punished by fine not exceeding twenty-five
dollars.
■
-
/
/ > - ■ 0 <T j
;|
PHYSICIAN’S CERTIFICATE OF THE CAUSE OF DEATH.
To the Clerk or Registrar of the Town or City in which the Death occurred .
I certify that the above is a true Return , to the best of my recollection and belief.
o/essiotial TiiUt and Residence, -
Dated at
/r- ,tfc
•y 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 of the General Statutes, 1859.]
[J^’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.
EiP 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.
\_Public Statutes, Chap. 32, Sect, j.]
No human body shall bd buried or removed from any city or town until a proper certificate has been given by the clerk <
registrar to the undertaker, sexton, or other person performing the burial or removing the body. Such certificate shall state that the fac
required by this chapter have been returned and recorded; and no clerk or registrar shall give such certificate or burial permit until tb
certificate of the cause of death has been obtained from the physician, if any, in attendance at the last sickness of the deceased, an
placed in the hands of said clerk or registrar; and in cities and towns where there are boards of health, the certificate of the cause <
death shall also be approved by such board before a permit to bury is given by the registrar or clerk. Upon application, the chairms
of the board of health, or any physician employed by any city or town for such purpose, shall sign the certificate of the cause of deal
to the best of his knowledge and belief, if there has been no physician in attendance. lie shall also sign such certificate, upon applies
tion, in case of death by dangerous contagious disease, or in any other event when the certificate of the attending physician cannot fl
good and sufficient reasons be early enough obtained. In case of death by violence, the medical examiner attending shall furnish tl
requisite medical certificate. Any person violating the provisions of this section shall be punished by line not exceeding twenty lb
dollars.
'
PHYSICIAN’S CERTIFICATE.
Name of Deceased ,* - -
Date and Place of Death,
Disease or Cause of Death,
J Duration of Sickness.
Na?ne and Residence of Certifying Physicia
I certify that the above is true, to the best of my knowledge and belief
Date of Certificate, r £
cLs...
c
x8$7p.
* 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 22 of the General Statutes, fSjg.}
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. I his 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.
* If a Married Woman or Widow.
t If other than white. (A..) African ; (M.) Mulatto ; (I.) Indian. If of other Races, specify what,
[Be very particular to fill all Blanks.]
<j!§^ 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.
gr la 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) haviug 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.
f Deceased* - -
| id Place of Death,
or Cause of Death,
died at ' Cy
of C'/pCP./tPl**- ssf^Dtiration of Sickness
I certify that the above is true, to the best of my knowledge and belief.
///> f s
Residence of Certifying Physician ' . 7/ C,. \ ^
Date of 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
person— forthwith furnish for registration a certificate of the duration of the last sickness, the disease of which the person died, i
date of his decease, as nearly as he can state the same. — \Extract from Chapter 21 of the General Statutes, /Sjq.]
Without repealing the foregoing requirements of the General Statutes, the recent “ Act to provide for the more Accurate Regl
of Vital Statistics,” passed April 23, 1S7S, provides that “no human body shall be buried, or removed from any city or towr
proper Certificate has been given by the clerk or local registrar of statistics, to the Undertaker or Sexton, or person perforni
burial or removing the body. This certificate shall state that the facts required by chap. 21 of the General Statutes ha|
returned and recorded; and no clerk or local registrar shall give such certificate or burial permit until the Certificate of the
Death has been obtained, (from the Physician, if an)-, in attendance at the last sickness of the deceased), and placed in the handal
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 wB
certificate of the attending Physician cannot, for good and sufficient reasons, be early enough obtained, the chairman of the local
Health, or any Physician employed by any city or town for such purpose, shall sign the Certificate of the Cause of Death, to thef
his knowledge and belief. In case of death by violence, the medical examiner shall furnish the certificate.
12. Name of Mothei
* If a Married Woman or Widow.
[■ Public Statutes , Chap. 33, Sect, j . j
N° human body sha11 l,e buried or removed from any city or town until a proper certificate has been given by the clerk t
registrar to the undertaker, sexton, or other person performing the burial or removing the body. Such certilicatc shall state that the faj
required by this chapter have been returned and recorded; and no clerk or registrar shall give such certificate or burial permit until th
certificate of the cause of death has been obtained from the physician, if any, in attendance at the last sickness of the deceased, an
placed in the hands of said clerk or registrar; and in cities and towns where there are boards of health, the certificate of the cause c
death shall also be approved by such board before a permit to bury is given by the registrar or clerk. Upon application, the chair.na
of the board of health, or any physician employed by any city or town for such purpose, shall sign the certificate of the cause of deat
to the best of his knowledge and belief, if there has been no physician in attendance. He shall also sign such certificate, upon applies
tion, in case of death by dangerous contagious disease, or in any other event when the certificate of the attending physician cannot fa
good and sufficient reasons be early enough obtained. In case of death by violence, the medical examiner attending shall furnish thi
requisite medical certificate. Any person violating the provisions of this section shall be punished by fine not exceeding twenty-iiv
dollars.
[Extracts from Chapter 32 of the Public Statutes.^
“ Sect. 3. A physician who has attended a person during his last illness shall, when requested within fifteen da\s aft
of such person, forthwith furnish for registration a certilicate of the duration of the last sickness, the disease of "hich the I
and the date of his decease, as nearly as he can state the same. If a physician refuses or neglects to make such cert it
forfeit ten dollars to the use of the town in which he resides.”
“ Sect. 5. No human body shall be buried or removed from any city or town until a proper certilicate has been gi'ei |
or registrar to the undertaker, sexton, or other person performing the burial or removing the body. Such certilicate shall
facts required by this chapter have been returned and recorded; and no clerk or registrar shall give such certificate or buria 1
the certificate of the cause of death has been obtained from the physician, if any, in attendance at the last sickness of the 1 |
placed in the hands of said clerk or registrar; and in cities and towns where there are boards of health, the certificate of J
death shall also be approved by such board before a permit to bury is given by the registrar or clerk. Upon application, ^
of the board of health, or any physician employed by any city or town for such purpose, shall sign the certilicate of the c: I
to the best of his knowledge and belief, if there has been no physician in attendance. lie shall also sign such certificate,,
tion, in case of death by dangerous contagious disease, or in any other event when the certificate of the attending physicm j
good and sufficient reasons be early enough obtained. In case of death by violence, the medical examiner attending sha j
requisite medical certificate. Any person violating the provisions of this section shall lie punished by fine not exceeding twenty j
The Undertaker, or other informant, is requested to report the fact, -together with the
Phystcan a Cert, tide of the Causes of Death-, o the Town Clerk, before the interment
6T In case of an interment taking place, without the Certificate of Registry of the Clerk of the
hXcl "h,CV , T (°r l"e de“““d ■“"*» «* heenyoh,ained, the person
Clerk" P 1, f I,°tome°t must POBIawIIa O'™ »°™E thereof — or report these facte -to said
Llerk. Renal ty for neglect, twenty dollars.
• Blank forms for Returns of Deaths may be obtained from the Town Clerk.
i f
£l)is Certifies,
<^A</ o?? //e ? i
^ MO
CAUSE OF 1 Primary,
DEATH. \ Second an,
)/ ,y.,/ /7>
t/rtyj.
4/CtHd,
Duration
ura t ion
D
' ' AT*h ysician.
RETURN OF A DEATH.
To the Clerk of the Town in which the Death occurred.
The Undertaker, or other informant, is requested to report the facts — toget -cr w,n
Physician^ 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 o tie cr o ic
Town kTwhich the Death occurred (or the deceased resided) having first been obtained the perso
having chaTge of such Interment must forthwith oive 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.
UK
y
me °f deceased* -
C and P/ace of DeatJi,
ase or Cause of Death -
PHYSICIAN’S CERTIFICATE.
L ^ v
ofsUU's, djUc^^,
1 certi/y //,«/ tjle a/l .
/ * *£" « ”'y w
- ^ ^ ^ A
belief.
*°r Se* of infant
(not named).
/" ti/, f/y. (///
Da,‘ * Certify jff/l /
[. Extracts front Chapter 32 of the Public Statutes .]
“ Sect. 3. A physician who has attended a person during his last illness shall, when requested within fifteen days after the deceasi
of such person, forthwith furnish for registration a certificate of the duration of the last sickness, the disease of which the person diet
and the date of his decease, as nearly as he can state the same. If a physician refuses or neglects to make such certificate, he sha
forfeit ten dollars to the use of the town in which he resides.”
“ Sect. 5. No human body shall be buried or removed from any city or town until a proper certificate has been given by the del
or registrar to the undertaker, sexton, or other person performing the burial or removing the body. Such certificate shall state that tl
facts required by this chapter have been returned and recorded; and no clerk or registrar shall give such certificate or burial permit uii
the certificate of the cause of death has been obtained from the physician, if any, in attendance at the last sickness of the deceased, a|
placed in the hands of said clerk or registrar; and in cities and towns where there are boards of health, the certificate of the cause I
death shall also be approved by such board before a permit to bury is given by the registrar or clerk. Upon application, the chairnl
of the board of health, or any physician employed by any city or town for such purpose, shall sign the certificate of the cause of del
to the best of his knowledge and belief, if there has been no physician in attendance. lie shall also sign such certificate, upon appll
tion, in case of death by dangerous contagious disease, or in any other event when the certificate of the attending physician cannot I
good and sufficient reasons be early enough obtained. In case of death by violence, the medical examiner attending shall furnish!
requisite medical certificate. Any person violating the provisions of this section shall be punished by fine not exceeding twenty-five dolls
RETURN OF A DEATH.
To the Clerk of the Town in which the Death occurred.
CO
00
xh
<4
v
c
o
>
o t
s 2
° 3
? &
a
ca
3
3
o
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ca
3
o
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u
ca
ft
©
>
CD
pq
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 fact9 — to said
Clerk. Pennlty for neglect, twenty dollars.
63T Blank forms for Returns of Deaths may be obtained from the Town Clerk.
c
/ 4 y
t/
1
* If a Married Woman or Widow.
| If other than White. (M.) Mulatto. (I.) Indian. If of other Races, specify what.
[Be very particular to All all Blanks.]
[. Public Statutes , Chap. 32, Sect. J.]
No human body shall be buried or removed from any city or town until a proper certificate has been given by the clerk
registrar to the undertaker, sexton, or other person performing the burial or removing the body. Such certiticate shall state that the fac
required by this chapter have been returned and recorded; and no clerk or registrar shall give such certiticate or burial permit until tb
certificate of the cause of death has been obtained from the physician, if any, in attendance at the last sickness of the deceased, at|
placed in the hands of said clerk or registrar; and in cities and towns where there are boards of health, the certiticate of the cause oM
death shall also be approved by such board before a permit to bury is given by the registrar or clerk. Upon application, the chamn a|
of the board of health, or any physician employed by any city or town for such purpose, shall sign the certiticate of the cause of deaj
to the best of his knowledge and belief, if there has been no physician in attendance. He shall also sign such certificate, upon applicj
tion, in case of death by dangerous contagious disease, or in any other event when the certificate of the attending physician cannot &
good and sufficient reasons be early enough obtained. In case of death by violence, the medical examiner attending shall furnish tW|
requisite medical certificate. Any person violating the provisions of this section shall be punished by fine not exceeding tuentx liW
dollars.
PHYSICIAN’S CERTIFICATE.
•’used* - -
re of Death , -
nise of Death, -
Duration of Sickness
I certify that the above yer^ruc, to
,-ncc of Certifying Physician ,
the best of my knowledge and belief ■
(ylfr^cc^
Date of Certificate ,
j88Q,
ex of Infant (not named).
{^Extracts from Chapter 32 of the Public Statutes. ]
“Sect. 3. A physician who has attended a person during his last illness shall, when requested within fifteen days aft
of such person, forthwith furnish for registration a certificate of the duration of the last sickness, the disease of which the
and the date of his decease, as nearly as he can state the same. If a physician refuses or neglects to make such certili
forfeit ten dollars to the use of the town in which he resides.”
“ Sect. 5. No human body shall be buried or removed from any city or town until a proper certificate has been given
or registrar to the undertaker, sexton, or other person performing the burial or removing the body. Such certificate shall s
facts required by this chapter have been returned and recorded; and no clerk or registrar shall give such certificate or burial
the certificate of the cause of death has been obtained from the physician, if any, in attendance at the last sickness of the d
placed in the hands of said clerk or registrar; and in cities and towns where there are boards of health, the certificate of
death shall also be approved by such board before a permit to bury is given by the registrar or clerk. Upon application, t
of the board of health, or any physician employed by any city or town for such purpose, shall sign the certificate of the ca
to the best of his knowledge and belief, if there has been no physician in attendance. He shall also sign such certificate, 1
tion, in case of death by dangerous contagious disease, or in any other event when the certificate of the attending physicia
good and sufficient reasons be early enough obtained. In case of death by violence, the medical examiner attending shall
requisite medical certificate. Any person violating the provisions of this section shall be punished by fine not exceeding twenty-:
1
To the Clerk of the Town ijj which the Death occurred.
If a Married Woman or Widow.
*2 ' c$.
7
j/^/,
a
[. Public Statutes, Chap / J2, Sect. J. ]
Xo human body shall be juried or removed from any city or town until a proper certificate has been given by the clerk
registrar to the undertaker, sexton,; or other person performing the burial or removing the body. Such cerlilicate shall state that the fact
required by this chapter have been! returned and recorded; and no clerk or registrar shall give sue! 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 < r registrar; and in cities and towns where there are boards of health, the certificate of the cause of|
death shall also be approved by su:h board before a permit to bury is given by the registrar or clerk. Upon application, the chairman
of the board of health, or any physician employed by any city or town for such purpose, shall sign the certificate of the cause of deatW
to the best of fts knowledge and belief, if there has been no physician in attendance. He shall also sign such certificate, upon apphea-j
non, in case of death by dangerous contagious disease, or in any other event when the certificate of the attending physician cannot tod
good and sufficient reasons be early enough obtained. In case of death by violence, the medical examiner attending shall furnish the
requisite medical certificate. Any person violating the provisions of this section shall be punished by fine not exceeding twenty-livf
dollars.
PHYSICIAN’S CERTIFICATE.
1 certify that the above is true to the best of my knowledge and belief .
me and Residence of Certifying Physician , tefc srfr cf J.
Date of Certificate , ffif
*Or Sex of Infant (not named).
[. Extracts from Chapter J3 of the Public Statutes. ]
“ 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. If a physician refuses or neglects to make such certificate, he shall
forfeit ten dollars to the use of the town in which he resides.”
“ 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; and in cities and towns where there are boards of health, the certificate of the cause of
death shall also be approved by such board before a permit to bury is given by the registrar or clerk. Upon application, the chairman
of the 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, if there has been no physician in attendance. lie shall also sign such certificate, upon applica-
tion, 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. In case of death by violence, the medical examiner attending shall furnish the
requisite medical certificate. Any person violating the provisions of this section shall be punished by fine not exceeding twenty-five dollars.”
| 'Public Statutes , Chap. 32 , 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 certiiicate shal state t
required by this chapter ha,, been returned and recorded; and no clerk or registrar ah.ll give such certificate or hurt. pen,,,, an d the
certiiicate of the cau.e of death ha. been obtained from the physician, if any, in attendance at the last stclne.s of the decease , .
placed in the hand, of said clerk or registrar; and in cities and towns where there are boards of health, the cert. Scute
death shall also be approved by such board before a permit to bury is given by the registrar or clerk. I p.m app tea ion, e
of the board of health, or any physician employed by any city or town for such purpose, shall sign the certificate of the cause of fl
the best of hi. knowledge and belief, if there ha, been no physician in attendance, lie shall also sign such cer.tfica.e upon appia
ti„n, in case of death by dangerous contagious disease, o, in any other even, when the certificate of the ntten.h.g phys, man an,
.ood and sufficient reason, be early enough obtained. In case of death by violence, the medic., .summer attending shall nm h «
requisite medical certificate. An, person violating the provision, of this section shall be punished by fine no, exceeding twent.-fi
dollars.
Deceased* -
PHYSICIAN’S CERTIFICATE.
I
/ Place- of Death, - | died a( /^2^c
Duration of Sickness
J certify that the
Kesid,nce °S Certifying PkysUian,
■ '77~r
dge amt belief.
>r tie* of iijfau
t ( not named).
Date of Certificate, / 2-
[. Extracts from Chapter of the Public Statutes. ]
“ Sect. 3. A physician who has attended a person during his last illness shall, when requested within fifteen days after the df
of such person, forthwith furnish for registration a certificate of the duration of the last sickness, the disease of which the pcrsoiT
and the date of his decease, as nearly as he can state the same. If a physician refuses or neglects to make such certif ltc, K
forfeit ten dollars to the use of the town in which he resides.”
“ Sect. 5. No human body shall be buried or removed from any city or town until a proper certificate has been given by tl
or registrar to the undertaker, sexton, or other person performing the burial or removing the body. Such certificate shall state
facts required by this chapter have been returned and recorded; and no clerk or registrar shall give such certificate or burial per
the certificate of the cause of death has been obtained from the physician, if any, in attendance at the last sickness of the decea
placed in the hands of said clerk or registrar; and in cities and towns where there are boards of health, the certificate of the
death shall also be approved by such board before a permit to bury is given by the registrar or clerk. Upon application, the <
of the board of health, or any physician employed by any city or town for such purpose, shall sign the certificate of the cause
to the best of his knowledge and belief, if there has been no physician in attendance. lie shall also sign such certificate, upon
tion, in case of death by dangerous contagious disease, or in any other event when the certificate of the attending physician ca
good and sufficient reasons be early enough obtained. In case of death by violence, the medical examiner attending shall fur
requisite medical certificate. Any person violating the provisions of this section shall be punished by fine not exceeding twenty-five
* If a Married Woman or Widow. ~~ “
t If other than whi&WA.) African; (M.)Mnlatto; (I.) Indian. If of other Races, specify what.
[Be very particular to fill all Blacks.]
L-A y
? /
u
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. Penally for neglect, tweuty dollars.
Blank forms for Returns of Deaths may be obtained from the Town Clerk.
\
* If a Married Woman or Widow.
f II other than White. (M.) Mulatto. (I.) Indian. If of other Races, specify what.
fBe very particular to fill all Blanks.]
[ Public Statutes , Chap. 32, Sect. 5-J b y the clerk or
=s=s=siis=Iss
»' ,h' ““ ”f ' 1 lira,; and in chics and ,o»;ns where .h« a,, hoard. » ^ „cltion, the chair, nan
srir
, 1 c i.ooHV, or any physician employed by any ci y aiso g such certificate, up rr
of the board of • ^ .f there has been no physician in attendan . ^ ^ attending physician cannot or
to the best of his knowledg . in any other event when the certiti . hall furnish the
requisite medical certificate. Any person
dollars. • ]
une of Deceased* -
ite and Place of Death, -
PHYSICIAN’S CERTIFICATE.
sense or Cause of Death, - \ of
e I '
died at
Duration of Sickness /
188&
ie and Residence of Certifying Physician
*Or Sox of Infant (not named).
/ certify that the above is true , to tJie best of viy knowledge and belief.
. ;Ur dy
Date of Certificate,
188 C,
[ErWrfr frm 3* °f S'M'^ ,
1 hi. last illness shall, whan requested within fifteen day. after the decease
“ Sect. 3. A physician who has attended a person during h.s last illness s « ‘ - " disease of which the person died,
of such person, forthwith * — — * — ’ * “
and the date of his decease, as nearly a. he ean state the sa,„e. If
forfeit ten dollars to the ».« of the town m which he resides. , certificate has been given by the clerk
..Srcr c. No human body shall be boned or removed from any e,ty Such certificate shall state that tlj
O, registrar to the undertaher, ser.on, or other person perfornfing the ^ . «„ certificate or burial perm
facts required by this chapter have been returned and recorded, a ^ at the last sickness of the deceased, am
the certificate of the cause of death ha. been obtained » 4 , ^ .« boards of health, the certificate of the can* o
placed in the hand, of said cleric o, registrar-, and ,n ctt.es nd . ^ ^ Upo„ .ppfatfttn, the eha„„„i
death shall also be approved by such board be ore a perm. fot ^ putp0Mi .hall ,ign the certificate of the cause of deal
of the hoard of health, or any physician employed >y an> c. , ^ attendance. He shall also sign such certificate, upon appl.ci
to the best of his knowledge and belief, if there has >een no P when the certificate of the attending physician cannot fc
.ion, in case of death by dangerous contagious d.sease, or ^ Y ^ ^ ^ ^ attending shall furms
e-Th. Under,.!-, or ,
fa i
- *—- rep"fa
C,eA' ulZsVZ* s «, b. ^ T°"'tt C'e,k' I
Name of Deceased '* - .
Da/e and P/acc of Death,
Khseasc or Cause of Death,
/ cer
'n"’C an* *«U«ue of Certifying
*°r 8t'x of Jnfant (not n«
PHYSICIAN’S CERTIFICATE.
fcA/~ S/
of
I
tfy ‘hat the above
yf
P hysician,
Duration of Sick
6
imed).
S tn<e, to ,he best of my knowledge and belie'.
^ £ * .Ma36*^
.. DlUr °f Certificate, fSV/£/-
[ Extracts from Chapter 32 of the Public Statutes. ]
“ 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. If a physician refuses or neglects to make such certificate, he shall
forfeit ten dollars to the use of the town in which he resides.”
“ 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; and in cities and towns where there are boards of. health, the certificate of the cause of
death shall also be approved by such board before a permit to bury is given by the registrar or clerk. Upon application, the chairman
of the board of health, or any physician employed by any city or town for such purpose, shall sign the certificate of the cause of dead
to the best of his knowledge and belief, if there has been no physician in attendance. He shall also sign such certificate, upon applica
tion, in case of death by dangerous contagious disease, or in any other event when the certificate of the attending physician cannot fo
good and sufficient reasons be early enough obtained. In case of death by violence, the medical examiner attending shall furnish f
requisite medical certificate. Any person violating the provisions of this section shall be punished by fine not exceeding twenty-five dollars
RETURN OF DEATH TO THE
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Cl)is Certifies, -gT
^ yeaif.
Me ^
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/& $£> _, eyee/
e/aye.
The Undertaker, or other informant, is requested to report the facts — together with the
Physician’s Certificate of the Causes of Death — to the iovvo Clerk, before the intebment.
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.
ggf* Blauk forms for Returns of Deaths may be obtained from the I own Clerk.
O '(V
/
V f'
{Extracts from Chapter 32 of the Public Statutes. ]
“ Sect. 3. A physician who has attended a person during his last illness shall, when requested within fifteen days after the decea:
of such person, forthwith furnish for registration a certificate of the duration of the last sickness, the disease of which the person die
and the date of his decease, as nearly as he can state the same. If a physician refuses or neglects to make such certificate, he shal
forfeit ten dollars to the use of the town in which he resides.”
“ Sect. 5. No human body shall be buried or removed from any city or town until a proper certificate has been given by the clcr
or registrar to the undertaker, sexton, or other person performing the burial or removing the body. Such certificate shall state that ....
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, an.
placed in the hands of said clerk or registrar; and in cities and towns where there are boards of health, the certificate of the cause o
death shall also be approved by such board before a permit to bury is given by the registrar or clerk. Upon application, the chairma
of the board of health, or any physician employed by any city or town for such purpose, shall sign the certificate of the cause of deat
to the best of his knowledge and belief, if there has been no physician in attendance. He shall also sign such certificate, upon applies
tion, in case of death by dangerous contagious disease, or in any other event when the certificate of the attending physician cannot fo
good and sufficient reasons be early enough obtained. In case of death by violence, the medical examiner attending shall furnish th
requisite medical certificate. Any person violating the provisions of this section shall be punished by fine not exceeding twenty-five dollars
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 thtl
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* Blauk forms for Returns of Deaths may be obtained from the Town Clerk.
/J/ - /c)%.
/ S Sy& , aper/ / ^
>//aj
r/r/ ^4.
CAUSE OF | Primary, O £**s^*^Y ' Duration
DEATH. J Secondary, Duration
, Physician
RETURN OF DEATH TO THE CITY REGISTRAR.
8^-* Insert Town and State. tSfafe whether white oc'black.
N
1 rt
> . . , ' ! w :
* 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 ol
person— forthwith furnish for registration a certificate of the duration of the last sickness, the disease of which the person died,
date of his decease, as nearly as he can st?le the same. — [ Extract from 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 Regis)
of Vital Statistics,” passed April 23, 1878, provides that “no human body shall be buried, or removed from any city or town, uti
proper Certificate has been given by the clerk or local registrar of statistics, to the Undertaker or Sexton, or person performii
burial or removing the body. This certificate shall state that the facts required by chap. 21 of the General Statutes have]
returned and recorded; and no clerk or local registrar shall give such certificate or burial permit until the Certificate of the Caustt
Death has been obtained, (from the Physician, if any, in attendance at the last sickness of the deceased), and placed in the hands ofl/'
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
certificate of the attending Physician cannot, for good and sufficient reasons, be early enough obtained, the chairman of the local Bq
Health, or any Physician employed by any city or town for such purpose, shall sign the Certificate of the Cause of Death, to the 1
his knowledge and belief. In case of death by violence, the medical examiner shall furnish the certificate.
CO
M
a
03
r— H
m
cm
o
-M
cd
H
P
©
03
ft
If a Married Woman or Widow.
The Undertaker, or other informant, is requested to report the fae'.s — 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.
\e of Deceased * -
1 and P/ace of Death,
'se or Cause of Death,
died at / Ph/fTs
^ <-/,yf/ fi."> ]88£
Duration of Sickness
of
1 Ctrtify th,U the abT isAU‘> ** "f W bonded
'”** Residence of Certifying Physician,
*Or Sex of Infant (not named'
dge and he lief.
Date of Certificate, K £/ $ " /<?<? £
r Extracts from Chapter 32 of the Public Statutes.']
, . Wc ,„t ;iiness shall, when requested within fifteen days after the deceit
“ Sect. 3. A physician who has attended a person < unng > ^ ^ sickness, the disease of which the person did
of such person, forthwith furnish for registration a certificate o t e “r { or neglects to make such certificate, he shj
and the date of his decease, as nearly as he can state the same. If a physic.
forfeit ten dollars to the use of the town in which he resides tQWn unlil a pr0per certificate has been given by the cl
“Sect. 5. No human body shall be buried or remo\ei rom™ or removing the body. Such certificate shall state that til
()r registrar to the undertaker, sexton, or other person per fornaing^ e mm ^ ^ ^ giye such certir,catc or burial permit until
facts required by this chapter have been returned am reenre e< ^ ,f any> ,n attendance at the last sickness of the deceased, J
the certificate of the cause of death has been obtained from P ’ f health> the certificate of the cause of
placed in the hands of said clerk or registrar; and in cities and towns where ^e are bo^ ^ ^ ^ the chain J
death shall also be approved by such board before a permit o mry purpose shall sign the certificate of the cause of deal,
of the board of health, or any physician employed by any city orow * & He shall also sign such certificate, upon applkl
:r.r
$3T The Undertaker, or other informant, is requested to report the facts together vith the
Physician’s Certificate of the Causes of Death — to the Town Clerk, before the interment.
*3* In case of an interment taking place, without the Certificate of Registry of the Clerk of the^
Town in which the Death occurred (or the deceased resided) having first been obtained the person
having charge of such Interment must forthwith give notice thereof— or report these ac s
Clerk. Penalty for neglect, twenty dollars.
• Blank forms for Returns of Deaths may be obtained from the Town Clerk.
PHYSICIAN’S CERTIFICATE.
me of Deceased,* - -
te and Place of Death,
sease or Cause of Death,
.. ): .p
died at j8$^-
of. . Duration of Sickness 2
>te and Residence of Certifying Physicia
I certify that the above is true, to the best of my knowledge and belief *
„ ff.
Date of Certificate, D’cdpy.
• 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 s ,
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, i8j;q.]
Without repealing the foregoing requirements of the General Statutes, the recent “Act to provide for the more Accurate Registra
of Vital Statistics,” passed April 23, ' 1S78, provides that “no human body shall be buried, or removed from any city or town, uni
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 body. This certificate shall state that the facts required by chap. 21 of the General Statutes have b‘
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 sf
clerk or local registrar.”
If there has bedn no Physician in attendance, or in case of death by dangerous contagious disease, or in any other event where
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 best |
his knowledge and belief. In case of death by violence, the medical examiner shall furnish the certificate.
be reported before inte.
Sex, whether single, married, or widowed
Occupation,
UNDERTAKER,
NO. 251 1 REMONT ST.,
Insert Town and State. 30S F' j N M A SS ^tate whether white or black.
Printing Department, Deer Island, Boston Harbor.
CO AN
7* >*
!
I?
n
It!
Cl)i0 Certifies,
x^>r/ ^
Z2'
^ ^FcPrf ^ x/^/x/ yeaic,
c/a
v/y4.
?Wv
i If
ff
CAUSE OF | Primary, ^ ^c/^C'CAoioic/y
DEATH. | Secondary, tp/f
Duration
\
He
Benj. F. Smith,
UNDERTAKER,
0.251 TREMONT ^T.,
BOSTON, MASS.
Duration //
Physician .
< ~
fa .E
t
c
&
Place of Death,
The Undertaker, or other informant, is reque,'
Physician’s Certificate of the Causes of Death — to the Town
iSiT In case of an interment takiug place, without th
I own in which the Death occurred (or the deceased res
having charge of such Interment must forthwith give no'
Clerk. Penalty for neglect, twenty dollars.
£aT Blank forms for Returns of Deaths may be obtaii
tomtit
[Extracts from Chapter 32 of the Public Statutes. ]
“ Sect. 3. A physician who has attended a person during his last illness shall, when requested witliirt fifteen days after th
of such person, forthwith furnish for registration a certificate of the duration of the last sickness, the disease of which the per
and the date of his decease, as nearly as he can state the same. If a physician refuses or neglects to make such certificate^
forfeit ten dollars to the use of the town in which he resides.”
“ Sect. 5. No human body shall be buried or removed from any city or town until a proper certificate has been given byj
or registrar to the undertaker, sexton, or other person performing the burial or removing the body. Such certificate shall state ;
facts required by this chapter have been returned and recorded; and no clerk or registrar shall give such certificate or burial p
the certificate of the cause of death has been obtained from the physician, if any, in attendance at the last sickness of the decc
placed in the hands of said clerk or registrar; and in cities and towns where there are boards of health, the certificate of the I
death shall also be approved by such board before a permit to bury is given by the registrar or clerk. Upon application, the
of the board of health, or any physician employed by any city or town for such purpose, shall sign the certificate of the cause!
to the best of bis knowledge and belief, if there has been no physician in attendance. lie shall also sign such certificate, upof
tion, in case of death by dangerous contagious disease, or in any other event when the certificate of the attending physician o
good and sufficient reasons be early enough obtained. In case of death by violence, the medical examiner attending shall fiV
requisite medical certificate. Any person violating the provisions of this section shall be punished by fine not exceeding twenty-fiv
10. Place of Birth,
* 11 a Married Woman or Widow. f (
{ 11 utbei than White. (M.) Mulatto. (I.) Indian. If of other Races, specify what.
LB© very particular to till all Blanks. j
\_Public Statutes , Chap. 33, Sect. j.j ^ !
Xo human body shall be buried or removed from any city or town until a proper certificate ha^^en given by the elcrl
registrar to the undertaker, sexton, or other person performing the burial or removing the body. Such certificate shall state that the I
required by this chapter have been returned and recorded; and no clerk or registrar shall give such certificate or burial permit untij
certificate of the cause of death has been obtained from the physician, if any, in attendance at the last sickness of the deceased,
placed in the hands of said clerk or registrar; and in cities and towns where there are boards of health, the certificate of the caul
death shall also be approved by such board before a permit to bury is given by the registrar or clerk. Upon application, the chait
of the board of health, or any physician employed by any city or town for such purpose, shall sign the certificate of the cause of d
to the best of his knowledge and belief, if there has been no physician in attendance. He shall also sign such certificate, upon ap|
tion, in case of death by dangerous contagious disease, or in any other event when the certificate of the attending physician cannol
good and sufficient reasons be early enough obtained. In case of death by violence, the medical examiner attending shall furnisl
requisite medical certificate. Any person violating the provisions of this section shall be punished by fine not exceeding tuenM
dollars.
-
f*e of Deceased* -
r and Place of Death, -
wase or Cause of Death,
PHYSICIAN’S CERTIFICATE.
ITf^ (
died at / / fadt
ofCyt^na^^uyO
Q
i88p.
and Residence of Certifying P/tysi,
Duration of Sickness ~£ofi
/ certify that the above is true, to the best of my knowledge and belief.
, £ /kc /ea.acty
Or Sex of Infant (not named).
Date of Certificate ,
*. k
i88f.
[. Extracts from Chapter 33 of the Public Statutes.]
U sECT. 3. A physician who has attended a person during his last illness shall, when requested within fifteen days after the dece,
„f such person, forthwith furnish for registration a certificate of the duration of the last sickness, the disease of which the person dr
and the date of his decease, as nearly as he can state the same. If a physician refuses or neglects .0 make such certificate, he si
forfeit ten dollars to the use of the town in which he resides.”
« Sect. 5. No human body shall he buried or removed from any city or town until a proper certificate has been given by the cM
or registrar to the undertaker, sexton, or other person performing the burial or removing the body. Such certificate shall state that j
facts 'required by this chapter have been returned and recorded; and no clerk or registrar shall give such certificate or burial pernut uj
the certificate of the cause of death has been obtained from the physician, if any, in attendance at the last sickness of the deceased, *
placed in the hands of said clerk or registrar; and in cities and towns where there are boards of health, the certificate of the cause*
death shall also be approved by such board before a permit to bury is given by the registrar or clerk. Upon application, the cha.rrj
of the board of health, or any physician employed by any city or town for such purpose, shall sign the certificate of the cause of d*
to ,he best of his knowledge and belief, if there has been no physician in attendance. He shall also sign such cert.ficate, upon app.,1
tion in case of death by dangerous contagious disease, or in any other event when the certificate of the attending physician cannot
a„od and sufficient reasons be early enough obtained. In case of death by violence, the medical examiner attendmg shall furnish
requisite medical certificate. Any person violating the provisions of this section shall be punished by fine not exceed, ng twenty-five doll*
KKTUKN OF A DEATH.
To the Clerk of the Town in which the Death occurred.
» If a Married Woman or Widow.
t If other than white. (A.) African ; (M.) Mulatto; (1.) Indian. If of other Races, specify what.
[Be very particular to fill all Blanks.]
rrc
D
f
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.
i In case of an interment taking place, without the Certificate of Registry of the Clerk of th
Town in which the Death occurred (or the deceased resided) having first been obtained, the perse
having charge of such Interment must forthwith give notice thereof — or report these facts — to sai.
Clerk. Penalty for neglect, twenty dollars.
Blank forms for Returns of Deaths may be obtained from the Town Clerk.
T
/
17
— *<&.
/ '.<*•
PHYSICIAN'S CERTIFICATE
’/ Deceased * .
d Place of Death, -
] °r Cause °f Death, -
1 eem/y ,/iat the
p,m^
Duration oj Sic/mtss
'-■now/, edge a ad belief.
,r Spi of J„fant
(not named ).
Dad Pf_ Certificate,
[Extracts from Chapter 32 of the Public Statutes. ]
“ Sect. 3. A physician who has attended a person during his last illness shall, when requested within fifteen clays 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. If a physician refuses or neglects to make such certificate, he shall
forfeit ten dollars to the use of the town in which he resides.”
« 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 tfl
facts required by this chapter have been returned and recorded; and no clerk or registrar shall give such certificate or burial permit unfl t|
the certificate of the cause of death has been obtained from the physician, if any, in attendance at the last sickness of the deceased, afl
placed in the hands of said clerk or registrar; and in cities and towns where there are boards of health, the certificate of the cause H
death shall also be approved by such board before a permit to bury is given by the registrar or clerk. Upon application, the chairman f
of the board of health, or any physician employed by any city or town for such purpose, shall sign the certificate of the cause of d^H
to the best of his knowledge and belief, if there has been no physician in attendance. lie shall also sign such certificate, upon applies-®
tion, in case of death by dangerous contagious disease, or in any other event when the certificate of the attending physician cannot
good and sufficient reasons be early enough obtained. In case of death by violence, the medical examiner attending shall furnish the
requisite medical certificate. Any person violating the provisions of this section shall be punished by tine not exceeding twenty-live dollai^H
If a Married Woman or Widow.
[. Public Statutes , Chap. 32 , Sect. 5. J
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 iH
certificate of the cause of death has heen obtained from the physician, if any, in attendance at the last sickness of the deceased,
placed in the hands of said clerk or registrar; and in cities and towns where there are boards of health, the certificate of the cause of
death shall also be approved by such board before a permit to bury is given by the registrar or clerk. Upon application, the chairman
of the board of health, or any physician employed by any city or town for such purpose, shall sign the certificate of the cause of
to the best of his knowledge and belief, if there has been no physician in attendance. He shall also sign such certificate, upon applica-
tion, in case of death by dangerous contagious disease, or in any other event when the certificate of the attending physician cannot ft
good and sufficient reasons be early enough obtained. In case of death by violence, the medical examiner attending shall furnish the
requisite medical certificate. Any person violating the provisions of this section shall be punished by fine not exceeding tuenty-M
dollars.
[Extracts from Chapter 32 of the Public Statutes. ]
“ Sect. 3. A physician who has attended a person during his last illness shall, when requested within fifteen days after the dec
of such person, forthwith furnish for registration a certificate of the duration of the last sickness, the disease of which the person d
and the date of his decease, as nearly as he can state the same. If a physician refuses or neglects to make such certificate, he s
forfeit ten dollars to the use of the town in which he resides.”
“ Sect. 5. No human body shall be buried or removed from any city or town until a proper certificate has been given by the d
or registrar to the undertaker, sexton, or other person performing the burial or removing the body. Such certificate shall state that
facts required by this chapter have been returned and recorded; and no clerk or registrar shall give such certificate or burial permit
the certificate of the cause of death has been obtained from the physician, if any, in attendance at the last sickness of the deceased,
placed in the hands of said clerk or registrar; and in cities and towns where there are boards of health, the certificate of the caus
death shall also be approved by such board before a permit to bury is given by the registrar or clerk. Upon application, the chair
of the board of health, or any physician employed by any city or town for such purpose, shall sign the certificate of the cause of d
to the best of his knowledge and belief, if there has been no physician in attendance. lie shall also sign such certificate, upon appl
tion, in case of death by dangerous contagious disease, or in any other event when the certificate of the attending physician cannot
good and sufficient reasons be early enough obtained. In case of death by violence, the medical examiner attending shall furnish
requisite medical certificate. Any person violating the provisions of this section shall be punished by fine not exceeding twenty-five dolla
t i^thlrihanmue? ?M™M°Uatto. (I.) Indian. If of other Eacea, specify what.
[Be very particular to fill all Blanks 1
[. Public Statutes, Chap. J2, Sect. 5.]
No human body shall he buried of removed from any city or town until a proper certificate has been given by the clerk I
registrar to the undertaker, sexton, or othe^ person performing the burial or removing the body. Such certificate shall state that the fad
required by this chapter have been returned and recorded; and no clerk or registrar shall give such certificate or burial permit until th
certificate of the cause of death has been^ obtained from the physician, if any, in attendance at the last sickness of the deceased,
placed in the hands of said clerk or registrar; and in cities and towns where there are boards oj health, the certificate of the caus
death shall also be approved by such board before a permit to bury is given by the registrar or clerli. Upon application, the chair
of the board of health, or any physician employed by any city or town for such purpose, shall sign the certificate of the cause of dea
to the best of his knowledge and belief, if there has been no physician in attendance. lie shall als»j> sign such .certificate, upon applic
tion, in case of death by dangerous contagious disease, or in any other event when the certificate of the attending physician cannot u
good and sufficient reasons be early enough obtained. In case of death by violence, the medical examiner attending shall furnish j
requisite medical certificate. Any persoty violating the provisions of this section shall be punished by fine not exceeding twenty-fi
dollars
&
-'H
j
-J-
_a_ l j
[. Extracts front Chapter 32 of the Public Statutes. ]
“ Sf.CT. 3. A physician who has attended a person during his last illness shall, when requested within fifteen days after the deck
of such person, forthwith furnish for registration a certificate of the duration of the last sickness, the disease of which the person <
and the date of his decease, as nearly as he can state the same. If a physician refuses or neglects to make such certificate, he 1
forfeit ten dollars to the use of the town in which he resides.”
“ Sect. 5. No human body shall be buried or removed from any city or town until a proper certificate has been given by the d
or registrar to the undertaker, sexton, or other person performing the burial or removing the body. Such certificate shall state than
facts required by this chapter have been returned and recorded; and no clerk or registrar shall give such certificate or burial permit 1
the certificate of the cause of death has been obtained from the physician, if any, in attendance at the last sickness of the deceased,]
placed in the hands of said clerk or registrar; and in cities and towns where there are boards of health, the certificate of the cans]
death shall also be approved by such board before a permit to bury is given by the registrar or clerk. Upon application, the chair]
of the board of health, or any physician employed by any city or town for such purpose, shall sign the certificate of the cause of d]
to the best of his knowledge and belief, if there has been no physician in attendance. lie shall also sign such certificate, upon appl
tion, in case of death by dangerous contagious disease, or in any other event when the certificate of the attending physician cannotl
good and sufficient reasons be early enough obtained. In case of death by violence, the medical examiner attending shall furnish
requisite medical certificate. Any person violating the provisions of this section shall be punished by fine not exceeding twenty-five dolla
To the Clerk of the Town in which the Death occurred.
If a Married Woman or Widow.
If other than White. (M.) Mulatto. (I.) Indian. If of other Races, specify what.
[Be very particular to fill all Blanks .1
[■ Public Statutes, Chap. J2, Sect. j.J
Xo human body shall be buried or removed from any city or town until a proper certificate has been given by the clerkir
registrar to the undertaker, sexton, or other person performing the burial or removing the body. Such certificate shall state that the fact-
required by this chapter have been returned and recorded; and no clerk or registrar shall give such certificate or burial permit untilL I
certificate of the cause of death has been obtained from the physician, if any, in attendance at the last sickness of the deceased, L
placed in the hands of said clerk or registrar; and in cities and towns where there are boards of health, the certificate of the cauiofl
eath shall also be approved by such board before a permit to bury is given by the registrar or clerk. Upon application, the chairlJ
o t e oard of health, or any physician employed by any city or town for such purpose, shall sign the certificate of the cause of datlu
to the best of his knowledge and belief, if there has been no physician in attendance. He shall also sign such certificate, upon appL I
tion, in case of death by dangerous contagious disease, or in any other event when the certificate of the attending physician cannot}.: i
good and sufficient reasons be early enough obtained. In case of death by violence, the medical examiner attending shall furnishL I
requisite medical certificate. Any person violating the provisions of this section shall be punished by fine not exceeding twentyire
dollars
PHYSICIAN’S CERTIFICATE.
of Deceased,* -
nd Place of Death,
e or Cause of Death
died at
\.Q.f V fa. >/* 1
fftdcttif, fk. 6 C ■ /»>
t -%f=~ DTzmtmi-uf-Sukncss
J/y£-r (? fdAz.D /? //£' 1 *-/
/ certify that the above is irf/e, to the best of my knowledge and belief.
„.4c0. P
' jss y
nd Residence of Certify ins; Physician ,
£W<‘’ of Certificate , / '
*0r Sox of Infant (not named).
[Extracts from Chapter 32 of the Public Statutes. ]
“ Sect. 3. A physician who has attended a person during his last illness shall, when requested within fifteen days after the dec
of such person, forthwith furnish for registration a certificate of the duration of the last sickness, the disease of which the person di
and the date of his decease, as nearly as he can state the same. If a physician refuses or neglects to make such certificate, he s>
forfeit ten dollars to the use of the town in which he resides.”
« Sect. 5. No human body shall be buried or removed from any city or town until a proper certificate has been given by the cl
or registrar to the undertaker, sexton, or other person performing the burial or removing the body. Such certificate shall state that j
facts required by this chapter have been returned and recorded; and no clerk or registrar shall give such certificate or burial permit uL
the certificate of the cause of death has been obtained from the physician, if any, in attendance at the last sickness of the deceased, i
placed in the hands of said clerk or registrar; and in cities and towns where there are boards of health, the certificate of the cause j"
death shall also be approved by such board before a permit to bury is given by the registrar or clerk. Upon application, the chairn
of the board of health, or any physician employed by any city or town for such purpose, shall sign the certificate of the cause of del
to the best of his knowledge and belief, if there has been no physician in attendance. lie shall also sign such certificate, upon appll
tion, in case of death by dangerous contagious disease, or in any other event when the certificate of the attending physician cannot ,
good and sufficient reasons be early enough obtained. In case of death by violence, the medical examiner attending shall furnish t
requisite medical certificate. Any person violating the provisions of this section shall be punished by tine not exceeding twenty-five dollaj
j.v “ ”7^" TT Z7~Z rTTTTT:
To the Clerk of the Town in which the Death occurred.
* If a Married Woman or Widow.
f If other than White. (M.) Mulatto. (I.) Indian. If of other Iiaces, specify what.
[Be very particular to fill all Blanks.]
[. Public Statutes , Chap. J2. 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 c (
registrar to the undertaker, sexton, or other person performing the burial or removing the body. Such certificate shall state that the £m j
required by this chapter have been returned and recorded; and no clerk or registrar shall give such certificate or burial permit untilfh
certificate of the cause of death has been obtained from the physician, if any, in attendance at the last sickness of the deceased, 11
placed in the hands of said clerk or registrar; and in cities and towns where there are boards of health, the certificate of the cauH
death shall also be approved by such board before a permit to bury is given by the registrar or clerk. Upon application, the chairm
of the board of health, or any physician employed by any city or town for such purpose, shall sign the certificate of the cause of da
>o the best of his knowledge and belief, if there has been no physician in attendance. He shall also sign such certificate, upon appli.
iion, in case of death by dangerous contagious disease, or in any other event when the certificate of the attending physician cannojlj
good and sufficient reasons be early enough obtained. In case of death by violence, the medical examiner attending shall furmaj^l
requisite medical certificate. Any person violating the pro^iqnp o^.tfiis.^ecti^n^ha^^e^unished by fine not exceeding twenty
/ i
dollars.
v
e of Deceased * -
and Place of Death ,
PHYSICIAN’S CERTIFICATE.
* y y^fcU^C^f
C^y Duration of Sickness
■““’Causeof Death,.- of
/ certify that the above is true, ia, „f my k„0wlldgt a,ul ^
ivd Residence of Certifying Physician , ^ -.Up-d -
*Or Sex of Infant (not named).
Date of Certificate , 2 f £>
188
188
[. Extracts from Chapter 32 of the Public Statutes.]
1 • 1 • illness chill when requested within fifteen days after the dccea^H
■■ Sect 3. A physician who has attended a person dunng his last illness shall, reque j
, . nf thf duration of the last sickness, the disease of which the person t>lcWl
of such person, forthwith furnish for registration a cert.I.cate or neolects to maUc such certificate, he >hai I
and the date of his decease, as nearly as he can state the same. a p i)si .
or registrar to the undertaker, sexton, or other person performing the burial or removing the body Sue , certihca 1 e . « * - I
facts required by this chapter have been returned and recorded; and no clerk or register of ,hc (le eased, □
the certificate of the cause of death has been obtained from the physician, if any, » * enda < at h as ^ck ess ■
placed in the hands of said clerk or registrar; and in cities and towns where there are boards *^*-*~^ ,he
death shall also be approved by such board before a permit to bury is given by the regist a « ' J J ■
of the board of health, or any physician employed by any city or town for such purpose, ^ g he W
* If a Married Woman or Widow.
t If other than White. (M.) Mulatto. (I.) Indian. If of other Races, specify what.
LBe very particular to till all Blanks. j
\_Public Statutes , Chap. j>, Sect. j.J
Xo human body shall be buried or removed from any city or town until a proper certificate has been given by the clerk ot
registrar to the undertaker, sexton, or other person performing the burial or removing the body. Such certificate shall state that the l.ict-
required by this chapter have been returned and recorded; and no clerk or registrar shall give such certificate or burial permit untilH
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; and in cities and towns where there are boards of health, the certificate of the causn
death shall also be approved by such board before a permit to bury is given by the registrar or clerk. Upon application, the chairing
of the board of health, or any physician employed by any city or town for such purpose, shall sign the certificate of the cause of deal
to the best of his knowledge arid belief, if there has been no physician in attendance. He shall also sign such certificate, upon applitt
tion, in case of death by dangerous contagious disease, or in any other event when the certificate of the attending physician cannot f<*
good and sufficient reasons be early enough obtained. In case of death by violence, the medical examiner attending shall furnisIMJ
requisite medical certificate. Any person violating the provisions of this section shall be punished by fine not exceeding twent®*
dollars.
m
* II a Married Woman or Widow.
t If other than White. (M.) Mulatto. (I.) Indian. If of other Races, specify what.
[Be very particular to fill all Blanks.]
/U-
=cu&~
\_Fublic Statutes, Chap. 32, Sect. /.]
No human body shall be buried or removed from any city or town until a proper certificate has been given by the clerk ot
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, an.
placed in the hands of said clerk or registrar; and in cities and towns w here there are boards of health, the certificate of the cause of J
death shall also be approved by such board before a permit to bury is given by the registrar or clerk. Upon application, the chairman j
of the board of health, or any physician employed by any city or town for such purpose, shall sign the certificate of the cause of deat I
>0 the best of his knowledge and belief, if there has been no physician in attendance. He shall also sign such certificate, upon applies- |
non, in case of death by dangerous contagious disease, or in any other event when the certificate of the attending physician cannot I ' I
good and sufficient reasons be early enough obtained. In case of death by violence, the medical examiner attending shall furnish the I
requisite medical certificate. Any person violating the provisions of this section shall be punished by tine not exceeding twenty-five
dollars.
PHYSICIAN’S CERTIFICATE.
" of Deceased,* -
ind Place of Death,
\C or Cause of Death,
died at
a4-
of
L cs'/fptd c/t ffr
Duration of Sickness — -
188 /
I certify that the above is true, to the best of my knowledge and belief.
vd Residence of Certify bio; Physician ,
Date of Certificate, . ^ 2U£^A mf
*Or 8(*x of Infant (not named).
[Extracts from Chapter 32 of the Public Statutes. ]
“ 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. If a physician refuses or neglects to make such certificate, he shall
forfeit ten dollars to the use of the town in which he resides.”
“ Sect. 5. No human body shall he 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; and in cities and towns where there are boards of health, the certificate of the cause of
death shall also be approved by such board before a permit to bury is given by the registrar or clerk. Upon application, the chairman
of the board of health, or any physician employed by any city or town for, such purpos^, shall sign the certificate of the cause of death
to the best of his knowledge and belief, if there has been no physician in attendance. lie shall also sign such certificate, updn applicaJ
tion, 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. In case of death by violence, the medical examiner attending shall furnish the
requisite medical certificate. Any person violating the provisions of this section shall be punished by fine not exceeding twenty-five dollars.”
* If a Married Woman or Widow. (/
t If Other than White. (M.) Mulatto. (I.) Indian. If of other RaceS; specify what.
[Be very particular to fill all Blanks.]
[ Public Statutes , Chap. 32 , Sw*. J-]
No human body shall bo buried or removed from any city or .own until a proper certificate ha, been ^
registrar to the undertaker, sexton, or other person performing the burial or removing the body. Such certthc.e s ^
required b, this chapter have been returned and recorded; and no clerk or registrar shall give such certificate or P
certificate 'of the cause o, death ha, been obtained from the physician, if any, in attendance a the ... «ck. re s < >f be <1 c
placed in ,h. hands of said clerk or registrar; and in cities and towns where there are board, of health, the cert heat, of the cause of
Lath shall also be approved by such board before a permit to bury is given by the registrar or clerk. Upon application, .hr ; ch>, ■
~r lhe hoard of health or any physician employed by any city or town for such purpose, shall sign the cert, heat, of the cause of d ad,
the best of hi. knowledge and belief, if there has been no physician in attendance. He shall also sign such certificate, upon ap|
don, in case of death by dangerous contagious disease, or in an, other even, when the certificate of the
good and sufficient reason, be early enough obtained. In case of death by violence the medical ekamine, g
requisite medical certificate. Any person violating the provisions of this section shall be punished by
dollars. , -i
'A
W(!2
jj
t
J-<r
. ^b or
W -J-H i c<
(Mp W/2^^ ? t- ^
tpj Olfm yj. ’ i"~i- \X^- &j Jp; ; t - ,
f Qui ^y** * o* '' •. A
hteet/fe t>~ C& - &{ . J|
' ^ , yV-^^-c bdcc^ ^
//vusj
P :', |
RETURN OF DEATH TO THE CITY REGISTRAR.
15
a
t
t
a
$>
Q)
a
$>
s:
a
c:
RETURN OF A DEATH.
To the Clerk of the Town in which the Death occurred.
* If a Married Woman or Widow.
t If other than White. (H.) Mulatto. (I.) Indian. If of other Races, specify what.
[Be very particular to till all Blanks. j
\Public Statutes, Chap. 32 , Sect. J-J lhc clerk or
No human body shall be buried or removed from any cit) ^ ^ untd a certifieate .hall tbe fact,
registrar to the under, alto, , setton, or Cher person performing he bun.l « ” J certificate or burial permit until the
required b, this chapter hare been returned and recorded, -I - „ ,hc siehne.s of the deceased, and
certificate of ,he cause of death ha, been obtained from the ph «m», ^ ^ ^ ^ ,he certificate of the cause of
placed in the hands of said clerk or registrar, and m cute, and t ^ ^ ^ „ d„t. Upon application, the charrma
death shall also be approved by such board be ore a penm ^ ^ purpose> shaU sign the certificate of the cause o c ea
of the board of health, or any physician employed by any y ice He shall also sign such certificate, upon apphc
— eo
dollars.
K; | <
" T' ;'&/
®I)is Certifies, AI'Auoas.
7 </■ , a^aLSA. jeau.
:. dap<f.
CAUSE OF ) Primary,
DE A TIL ) Secondary ,
(P IM^vlvO // J&
£^'6tC'lA v - /
Duration
Duration
fMJU Phys ician.
t '
>
T3
CD
f-H
j
• o
X §
y :
h ^
Xi
j cS
< ®
W 0,
Q £
< £
• A
£
N!>!
k .5
-4 i
0 ii
£ ^
i N
£ 1
P ^
H i— d
W ®
£ °
CD
c;
c o
O
Eh
5 £
73 c5
G £
*-« oi
CO TjH
«r
<y
03
CD
<!
jrV$
;\ /I
t4
«o|
* If a Married Woman or Widow. ~ (/
f If other than White. (M.) Mulatto. (I.) Indian. If of other Races, specify what.
[Be very particular to fill all Blanks.]
[. Public Statutes, Chap. 32, Sect, j.]
Xo human body shall be buried or removed from any city or town until a proper certificate has been given by the clerk or registr;
to the undertaker, sexton, or other person performing the burial or removing the body. Such certificate shall state that the facts req firt
by this chapter have been returned and recorded; and no clerk or registrar shall give such certificate or burial permit until the certificate ,
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 ham
of said clerk or registrar; and in cities and towns where there are boards of health, the certificate of the cause of death shall also I
approved by such board before a permit to bury is given by the registrar or clerk. Upon application, the chairman of the board of healt
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 knowled
and belief, if there has been no physician in attendance. He shall also sign such certificate, upon application, in case of death by dangr
ous contagious disease, or in any other event when the certificate of the attending physician cannot for good and sufficient reasons be ea
enough obtained. In case of death by violence, the medical examiner attending shall furnish the requisite medical certificate. Any pers
violating the provisions of this section shall be punished by fine not exceeding twenty-five dollars.
[Acts of 1887, Chap. 202, Sect. J.]
Section one of chapter thirty-two of the Public Statutes is hereby amended by inserting after the word “burial” in the twentl
line of said section the words : — if the deceased was a married woman the name of her husband.
[. Extracts from Chapter 32 of the Public Statutes. ]
“ Sect. 3. A physician who has attended a person during his last illness shall, when requested within fifteen days after the de
of such person, forthwith furnish for registration a certificate of the duration of the last sickness, the disease of which the person die
and the date of his decease, as nearly as he can state the same. If a physician refuses or neglects to make such certificate, he shall!
forfeit ten dollars to the use of the town in which he resides.”
“ SECT. 5. No human body shall be buried or removed from any city or town until a proper certificate has been given by the 1
or registrar to the undertaker, sexton, or other person performing the burial or removing the body. Such certificate shall state thatl
facts required by this chapter have been returned and recorded; and no clerk or registrar shall give such certificate or burial permit 1
the certificate of the cause of death has been obtained from the physician, if any, in attendance at the last sickness of the deceased,!
placed in the hands of said clerk or registrar; and in cities and towns where there are boards of health, the certificate of the causl
death shall also be approved by such board before a permit to bury is given by the registrar or clerk. Upon application, the chaid
of the board of health, or any physician employed by any city or town for such purpose, shall sign the certificate of the cause of
to the best of his knowledge and belief, if there has been no physician in attendance, lie shall also sign such certificate, upon apd
tion, in case of death by dangerous contagious disease, or in any other event when the certificate of the attending physician cannot
good and sufficient reasons be early enough obtained. In case of death by violence, the medical examiner attending shall furnish
>62
Cp r r
/a.
&V'
/crr? *-t# 1
, ,?/, ^
~tr~*-»'
\
'^2^1,
[jP«Mf Statutes , Chap. 32 , 5<f<r/. J.j
No human body shall he 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 acts
required by this chapter have been returned and recorded; and no clerk or registrar shall give such certihcate or bunal pernnt until the
certificate of the cause of death has been obtained from the physician, if any, in attendance at the last sickness of the decease. , an
placed in the hands of said clerk or registrar; and in cities and towns where there are boards of health, the certificate of the cause o
death shall also be approved by such board before a permit to bury is given by the registrar or clerk. Upon application, the chairman
of the board of health, or any physician employed by any city or town for such purpose, shall sign the certificate of the cause of deal ,
to the best of his knowledge and belief, if there has been no physician in attendance. He shall also sign such certificate, upon applica-
tion, 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. . In case of death by violence, the medical examiner attending shall urru h
requisite medical certificate. Any person violating the provisions of this section shall be punished by fine not exceeding fentyfi*.
dollars.
^ir |L
©)is Certifies, 5^/
£*44
s/t'cc/ on t/ie %L ’/— s/ay cy/..*//z<*An'y.... / '$8^7, ayes/ V (3
awn
aa?/4.
CA USE OF ) Primary +si 64 cfc° Duration OUyy
DEATH. ) Secondary, Duration
Physician.
* If Married Woman or Widow.
f If other than White. (M.) Mulatto. (I.) Indian. If of other ltacea, specify what.
[Be very particular to fill all Blanks.]
[Public Statutes, Chap. 32, 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 require !
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; and in cities and towns where there are boards of health, the certificate of the cause of death shall also be
approved by such board before a permit 'to bury is given by the registrar or clerk. Upon application, the chairman of the board of health,
or any phvsician 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 if there has been no phvsician in attendance. lie shall also sign such certificate, upon application, in case of death by danger-
ous contagious disease, or in any other event when the certificate of the attending physician cannot for good and sufficient reasons be early
enough obtained. In case of death by violence, the medical examiner attending shall furnish the requisite medical certificate. Any person
violating the provisions of this section shall be punished by fine not exceeding twenty-five dollars.
[Acts of 1887, Chap. 202, Sect, j.]
Section one of chapter thirty-two of the Public Statutes is hereby amended by inserting after the word “burial ” m the twentieth
line of said section the words: — if the deceased was a married woman the name of her husband.
’ante of Deceased '*
PHYSICIAN’S CERTIFICATE.
ate and Place of Death, - died at
1
is ease or Cause of Death, - | 0f Uj
** w ^uf.
rod.
Duration of Sickness
a’Ul of Certifying Physician,
’Or Sex of Infant (not named).
Date of Certificate, 188^
[ Extracts from Chapter 32 of the Public Statutes. ]
“ Sect. 3. A physician who has 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. If a physician refuses or neglects to make such certificate, he shall
forfeit ten dollars to the use of the town in which he resides.”
“ Sect. 5. No human body shall be buried or removed from any city or town until a proper ccrtilicate 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; and in cities and towns where there are boards of health, the certificate of the cause of
death shall also be approved by such board before a permit to bury is given by the registrar or clerk. Upon application, the chairman
of the 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, if there has been no physician in attendance. He shall also sign such certificate, upon applica-
tion, 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. In case of death by violence, the medical examiner attending shall furnish the
requisite medical certificate. Any person violating the provisions of this section shall be punished by fine not exceeding twenty-five dollars.”
RETURN OF DEATH TO THE CITY REGISTRAR.
! Varne of Deceased * -
date and Place of Death , -
disease or Cause of Death , -
PHYSICIAN’S CERTIFICATE.
I certify that the above is true, to the best of my knowledge and belief.
Jed—- J ^9 rfl y
ame amt Residence of Certifying Physician , t
Date of Certificate,
It f/
JeUJd
9 0
1 88 .
/
*Or Sex of Infant (not named).
/
“ Sect.
\_Extracts from Chapter 32 of the Public Statutes. ]
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. If a physician refuses or neglects to make such certificate, he shall
forfeit ten dollars to the use of the town in which he resides.”
“ 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; and in cities and towns where there are boards of health, the certificate of the cause of
death shall also be approved by such board before a permit to bury is given by the registrar or clerk. Upon application, the chairman
of the 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, if there has been no physician in attendance. He shall also sign such certificate, upon applica-
tion, 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. In case of death by violence, the medical examiner attending shall furnish the
requisite medical certificate. Any person violating the provisions of this section shall be punished by fine not exceeding twenty-five dollars.”
Disease or Cause of Death
Duration of Sickness,
J
2+2* y^t'=^*^~
[. Public Statutes, Chap. 32 , Sect, j.]
Xo human body shall be buried or removed from any city or town until a proper certificate has been given by the clerk 01
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 thel,
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; and in cities and towns where there are boards of health, the certificate of the cause ofj
death shall also be approved by such board before a permit to bury is given by the registrar cr clerk. Upon application, the chairman
of the board of health, or any physician employed by any city or town for such purpose, shall sign the certificate of the cause of death
'0 the best of his knowledge and belief, if there has been no physician in attendance. He shall also sign such certificate, upon applicw
tion, in case of death by dangerous contagious disease, or in any other event when the certificate of the attending physician cannot f»
good and sufficient reasons be early enough obtained. In case of death by violence, the medical examiner attending shall furnish t
requisite medical certificate. Any person violating the provisions of this section shall be punished by fine not exceeding twenty-rt
dollars.
Co
PHYSICIAN’S CERTIFICATE.
AWzw^,.. .j
Oatc ami Place of Dea/h, ,ia, a, ^
c**“ *■&**, - o/ L /. - . / i t ] /: ,/f
f'Z'SJ&Mration of Sick
ness
1 "* "M "f * «y w* w ,M>,
■— — 4. U '
- _ Date of Certificate,. f
*Or Sex of Infant (not named).
r Extracts from Chapter 32 of the Public Statutes .]
« Sfct. 3- A physician who ha, attended a person during his last
of such person, forthwith furnish for registration a certificate of the « »™ _ or negleets to make such certificate, he sha.l
and the date of his decease, as nearly as he can state the sanae. If Ph>«
forfeit ten dollars to the use of the town m which he resades until a pr„per certillcate has been given by the clerk
« sect. 5. No human body shall be buried or removed from any y Such certir,Cate shall state that the
or registrar tothe undertaker, se.on, or other person performmg the ^ ^ ^ ^ or burial permit until
facts required by this chapter have been returned am rcc n in attendance at the last sickness of the deceased, am
the certificate of the cause of death has been obtained from the phys , ^ ^ ^ of health, the certificate of the cause of
placed in the hands of said clerk or registrar; and m ct.es and to ^ istrar or derk. Upon application, the cha.rman
death shall also be approved by such board before a permit to ^ ^ purpose, shall sign the certificate of the cause of death
of the board of health, or any physician employed by any ci y , lie shall also sign such certificate, upon apphea-
' RETURN OF A DEATH.
To the Clerk of the Town in which the Death occurred.
[Public Statutes, Chap. J-’, Sect. J-J ^ he derk or
No human body shall be buried or removed from any city or town u,Ull a Such cerlificate shall state that the facts
to the undertaker, sexton, o, other person performing the buml .egistramhall give such certificate o, bum. permit «»'«
d by this chapter have boon returned a„d t.ootdodt and no deck o teg*- ^ ^ o( the deceased, and
certificate of the cause of death has been obtained from .be bo„ds o( hea.th, the certificate of the cause of I
placed in the hands of said clerk or registrar! and in cues an or „ cUrW. Upon application, the chairman,
death shall also be approved by such board before a pernn. to IW ^ ^ ,.g„ lhe certificate of the cause of death
of the board of health, or any physician employed by any city He shall also sign such certificate, upon appK
to ,he best of hi. knowledge and belief, if there has been no physic,. ^ ^ o( ,he ...ending physician cannot fo
.ion, in case of death by dangeroos contagions disease, or ,n an, „,dic.l examiner attending shad ««*
dollars.
Name of Deceased * -
Dale and Place of Death ,
'disease or Cause of Death, - J of
PHYSICIAN’S CERTIFICATE.
l”" a”d »/ Certify!. ug Physician,
/ certify that the above is true to the he / f
’ t0 the best °f ”>y knowledge and belief.
‘Or Sex of Infant
(not named).
Date of Certificate ,
A 7^
lSS 7-.
[ Extracts front Chapter 33 of the Public Statutes. ]
“ 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. If a physician refuses or neglects to make such certificate, he shall
forfeit ten dollars to the use of the town in which he resides.”
“ 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; and in cities and towns where there are boards of health, the certificate of the cause of
death shall also be approved by such board before a permit to bury is given by the registrar or clerk. Upon application, the chairman!
of the 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, if there has been no physician in attendance. He shall also sign such certificate, upon applica-
tion, 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. In case of death by violence, the medical examiner attending shall furnish the
requisite medical certificate. Any person violating the provisions of this section shall be punished by fine not exceeding twenty-five dollars.”
* If a Married Woman or Widow.
\ If other than White. (M.) Mulatto. (I.) Indian. If of other Races, specify wliat.
[Be very particular to fill all Blanks 1
[ Public Statutes, Chap. 32 , Sect. 5.]
No human M,- - — - — T —
registrar to the undertaker, sexton, or other person performing the una 01 r certificate or burial permit until the
required by this chapter have been returned and recorded; and no clerk or register ^ of the deceased, and
certificate of the cause of death has been obtained from the p >siuan 1 a , ds of health> the certificate of the cause of
placed in the hands of said clerk or registrar; and in cities and towns where the application, the chairman
death shall also be approved by such board before a permit to bury is given ^ re^or ^ _ of death
of the board of health, or any physician employed by any city or own P ^ ^ also sjgn such certificate, upon appl.ca- .
to the best of his knowledge and belief, if there has been no physician in ~ ‘f the attending ohysician cannot for
tion, in case of death by dangerous contagious disease, or in any the medical examiner attending shall furnish the
good and sufficient reasons be early enough obtained In case o - fine nQt exceeding twentyhve
requisite medical certificate. Any person violating the provisions of this section P
dollars
7 QZp
V> T ‘ "'Ij
PHYSICIAN’S CERTIFICATE.
va»ie of Decease*/* - .
)a/e and P/ace of Dead/,
'isease or Cause of Dca/h, -
n,‘d d Certifying PhysScia,,
■'/.ala, jf
L'/.dfUz •/■; . .
/ uration of Sickness
1 ceriify Mat the dove Z true to / ~4 ,
fjf /j> ’ ' est y v,y knowledge and belief
. -/i, Z ' '/ . , /
*Or Bex of Infant
(»»ot named).
Date of Certificate,
,, Public Statutes .]
fr*. W- 3- f ^ ^ fin„„ days after .he deoe.se
. JZ'J the undertaker, sea, on, o, other person P— «• ^ sha„ give ,«h certiheate or hurkd - J
RETURN OF A DEATH.
To the Clerk of the Town in which the Death occurred.
If a Married Woman or Widow.
[. Public Statutes , Chap. 32, Sect. p.J
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; and in cities and towns where there are boards of health, the certificate of the cause of
death shall also be approved by such board before a permit to bury is given by the registrar or clerk. Upon application, the chairman
of the 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, if there has been no physician in attendance. He shall also sign such certificate, upon applica-
tion, in case of death by dangerous contagious disease, or in any other event when the certificate of the attending physician cannot fot >
good and sufficient reasons be early enough obtained. In case of death by violence, the medical examiner attending shall furnish the
requisite medical certificate. Any person violating the provisions of this section shall be punished by fine not exceeding twenty-five
dollars. »
PHYSICIAN’S CERTIFICATE.
fame of Deceased,* -
?a/e and Place of Death,
e* l c.
died at
/
'/sense or Cause of Death, - | of
cdfxd 4sL
<etC
188
/ certify that the above is true, to the best of my knowledge and belief.
”e ami Residence of Certifying Physician,
°f Certificate, t^Lc £ 7y$ V
*0r Sex ,.f Infant (not named). e* — _ — Z.
...6'Jt.dL^Ji.
[. Extracts from Chapter 32 of the Public Statutes. ]
“ 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. If a physician refuses or neglects to make such certificate, he shall
forfeit ten dollars to the use of the town in which he resides.”
“ 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; and in cities and towns where there are boards of health, the certificate of the cause of
death shall also be approved by such board before a permit to bury is given by the registrar or clerk. Upon application, the chairman
of the 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, if there has been no physician in attendance. lie shall also sign such certificate, upon applica-
tion, 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. In case of death by violence, the medical examiner attending shall furnish the
requisite medical certificate. Any person violating the provisions of this section shall be punished by fine not exceeding twenty-five dollars.”
w
-H
<1
[ Public Statutes , Chap. 32 , Sect. 5.]
be b— o,
registrar to the undertaker, sexton, or other person performing the buna or re ^ giye such certificate or burial permit until t
required by this chapter have been returned and recorder ; an no c ■ er °” aUendanCe at the last sickness of the deceased, a
certificate of the cause of death has been obtained rom t e p >SKia ^ ^ are boards of health, the certificate of the cause
placed in the hands of said clerk or registrar; an in cities an own • t or clerk. Upon application, the chairn
death shall also be approved by such board before a permit to bury is given * ^ ^ of the cause of de
of the board of health, or any physician employed by any city or town or ^ He shaU als0 sign such certificate, upon appl
to the best of his knowledge and belkf, if there has been no p >s.cian m ^ ^ certificate of the attending physician cannot
tion, in case of death by dangerous Antag.ous disease, or in any o e ^ ^ medical examiner attending shall furnish
good and sufficient reasons be early enough obtained In case o ea ^ punished by fine not exceeding twenty
requisite medical certificate. Any person violating the provisions of this section P
dollars
-&1- S- £= &- „.b, C
PHYSICIAN’S CERTIFICATE.
[Extracts from Chapter 32 of the Public Statutes. ~\
“Sect. 3. £ 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. If a physician refuses or neglects to make such certificate, he shall
forfeit ten dollars to the use of the town in which he resides.’'
“ 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; and in cities and towns where there are boards of health, the certificate of the cause of
death shall also be approved by such board before a permit to bury is given by the registrar or clerk. Upon application, the chairman
of the Uoard 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, if there has been no physician in attendance. lie shall also sign such certificate, upon applica-
tion, 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. In case of death by violence, the medical examiner attending shall furnish the
requisite medical certificate. Any person violating the provisions of this section shall be punished by fine not exceeding twenty-five dollars.”
RETURN OF A DEATH.
To the Clerk of the Town in which the Death occurred.
£
<
[. Public Statutes , Chap. 32, Sect. 5-J*
^ « — — -- «*
registrar to the undertaker, sexton, or other person P6^0™1"®^ ^ “™ °”egistfar shall give such certificate or burial permit until the
required by this chapter have been returned and recorc e , an n attendance at the last sickness of the deceased, and
certificate of the cause of death has been obtained from the phystcan tf any m attendance ^ ^ ^ Qf thc cause of
placed in the hands of said clerk or registrar; and in cities and towns where th* ^ ^ Upon application, the chairman
death shall also be approved by such board before a permit to ur> is gn en ghall sign the certificate of the cause of death
of the board of health, or any physician employed by any city or town or ’ shall also sign such certificate, upon applica-
to the best of his knowledge and belief, if there has been no physician ,n M ^ ^ ^ attending physician cannot for
tion, in case of death by dangerous contagious disease, or in any od« eve ^ medical examiner attending shall furnish the
good and sufficient reasons be early enough obtame . n case . sh aU be punished by fine not exceeding twenty-live
requisite medical certificate. Any person violating the provisions of this section
dollars
2
iW of Deceased,* -
ate ami Place of Death,
?. sease or Cause of Death,
PHYSICIAN’S CERTIFICATE.
.Qh£. v. 188 J
*2 G^Gk^t^eO
died at
of
lAeL^M^X Duration of Sickness
■tie and Residence of Certifying Physician ,
1 certify that the a hove is true, to the best of my knowledge and belief.
Qt C ^0% S*~UA Ufca,ScF ^ * -
■ u*'.
Date of Certificate,
188
»0r ties of infant (not named).
[Extracts from Chapter 32 of the Public Statutes. ]
“ 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, I
and the date of his decease, as nearly as he can state the same. If a physician refuses or neglects to make such certificate, he shall!
forfeit ten dollars to the use of the town in which he resides.”
“ 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; and in cities and towns where there are boards of health, the certificate of the cause ofl
death shall also be approved by such board before a permit to bury is given by the registrar or clerk. Upon application, the chairman
of the 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 • es* ' h' nowledge and belief, if there has been no physician in attendance. lie shall also sign such certificate, upon applica-
tion, \&i e 1 by dangerous contagious disease, or in any other event when the certificate of the attending physician cannot for
good ah ' „nt reasons be early enough obtained. In case of death by violence, the medical examiner attending shall furnish the
requisite meciical certificate. Any person violating the provisions of this section shall be punished by fine not exceeding twenty-five dollars.”
RETURN OF A DEATH.
To the Clerk of the Town in which the Death occurred,
f If othJr than White? . ito. (I.) Indian. If of other Races, specify what.
[Be very particular to fill all Blanks.]
[. Public Statutes, Chap. 32, Sect, j.]
No human body shall be buried or removed from any city or town until a proper certificate has been given by the clerk or re;
to the undertaker, sexton, or other person performing the burial or removing the body. Such certificate shall state that the facts rec
by this chapter have been returned and recorded; and no clerk or registrar shall give such certificate or burial permit until the certific 1
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
of said clerk or registrar; and in cities and towns where there are boards of health, the certificate of the cause of death shall a '
approved by such board before a permit to bury is given by the registrar or clerk. Upon application, the chairman of the board of 1
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 kno\ ^
and belief, if there has been no physician in attendance. He shall also sign such certificate, upon application, in case of death by d :
ous contagious disease, or in any other event when the certificate of the attending physician cannot for good and sufficient reasons bt
enough obtained. In case of death by violence, the medical examiner attending shall furnish the requisite medical certificate. Any 1
violating the provisions of this section shall be punished by fine not exceeding twenty-five dollars.
[Jets of 1887, Chap. 202, Sect. 5.]
Section one of chapter thirty-two of the Public Statutes is hereby amended by inserting after the word “burial” in the tv n
line of said section the words: — if the deceased was a married woman the name of her husband.
[Ex tracts from Chapter 32 of the l'ublic Statutes. ]
“ 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. If a physician refuses or neglects to make such certificate, he shall
forfeit ten dollars to the use of the town in which he resides.”
“ 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 requiretl 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; and in cities and towns where there are boards of health, the certificate of the cause of
death shall also be approved by such board before a permit to bury is given by the registrar or clerk. Upon application, the chairman
of the 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, if there has been no physician in attendance. lie shall also sign such certificate, upon applica-
tion, 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. In case of death by violence, the medical examiner attending shall furnish the
requisite medical certificate. Any person violating the provisions of this section shall be punished by fine not exceeding twenty-five dollars.”
RETURN OF A DEATH.
To the Clerk of the Town in which the Death occurred.
[ Public Statutes , Chap. 32 , Sect. 5.]
Xo human body shall be buried or removed from any city or town until a proper certificate has been given by the clerk c
registrar to the undertaker, sexton, or other person performing the burial or removing the body. Such certihcate shall state that the ac
required by this chapter have been returned and recorded; and no clerk or registrar shall give such cert.hcate or bunal permit unt,
certificate of the cause of death has been obtained from the physician, if any, in attendance at the last sickness of the deceased, a,
placed in the hands of said clerk or registrar; and in cities and towns where there are boards of health, the cert.ficate of the cause
death shall also be approved by such board before a permit to bury is given by the registrar or clerk. Upon appl.cat.on, the cha.rm
of the board of health, or any physician employed by any city or town for such purpose, shall sign the certificate of the cause of de;
to the best of his knowledge and belief, if there has been no physician in attendance. He shall also sign such certificate, upon appli-
don, in case of death by dangerous contagious disease, or in any other event when the certificate of the attending physician cannot
good and sufficient reasons be early enough obtained. In case of death by violence, the medical examiner attending shall urms
requisite medical certificate. Any person violating the provisions of this section shall be punished by hne not excee. mg «en
dollars.
\
[. Extracts from Chapter 32 of the Public Statutes. ]
“ Sect. 3. A ,M*. ~ ~
„,SUc„ p„™, forthwith furnish for V— . » — ~>> - -
and the date of his decease, .as nearly as he can state the same. If a physician
“t _ »«, . p7: * r r
or registrar to the undertaker. sev.on, or other person performing tite harm! — - , “^hcate or permit -
facts required by this chapter have been returned and recorded; and no cle k registrar g „
the certificate o, the ct.se of death has been obtained front the phystcan, tf any, tn of the cause o
placed in the hand, of said cleric or registrar; and in cities and towns where the, ' ,„e ell!linn,
death shall also be approved by such board before a permit to bur, given by ^ ^ of de,
of the board of health, or any physician employed by any city or town for - m* * „„ c„tific„e, up„„ applic
the best of his knowledge and belie,, if there has been no phyrtctan ^ ^ o[ .Jat, ending physician canuo, ,
„on, in case death by dangerous ««£- ^ ^ ^ ^ ^ inline, attending sh.,1 furnish ,
r;:."ri:r:iz
RETURN OF A DEATH.
To the Clerk of the Town in which the Death occurred.
By whom certified.
If a Married Woman or Widow.
9
[. Public Statutes , Chap. 32 , .SV<r/. 5 . J
No human body shall be buried or removed from any city or town until a proper certificate has been given by the clerk or I
registrar to the undertaker, sexton, or other person performing the burial or removing the body. Such certificate shall state that the lactsl
required by this chapter have been returned and recorded; and no clerk or registrar shall give such certificate or burial permit until the J
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; and in cities and towns where there are boards of health, the certificate of the cause offl
death shall also be approved by such board before a permit to bury is given by the registrar or clerk. Upon application, the chairman*
of the 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, if there has been no physician in attendance. He shall also sign such certificate, upon applica-J
lion, 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. In case of death by violence, the medical examiner attending shall furnish the 1
requisite medical certificate. Any person violating the provisions of this section shall be punished by fine not exceeding tuent)-fi\e«
dollars.
RETURN OF A DEATH.
To the Clerk of the Town in which the Death occurred.
iry particular to till all Blanks.]
[. Public Statutes, Chap. 32, Sect, j.]
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, anc
placed in the hands of said clerk or registrar; and in cities and towns where there are boards of health, the certificate of the cause o
death shall also be approved by such board before a permit to bury is given by the registrar or clerk. Upon application, the chairma
of the board of health, or any physician employed by any city or town for such purpose, shall sign the certificate of the cause of deat
to the best of his knowledge and belief, if there has been no physician in attendance. He shall also sign such certificate, upon applies
iion, in case of death by dangerous contagious disease, or in any other event when the certificate of the attending physician cannot fc
good and sufficient reasons be early enough obtained. In case of death by violence, the medical examiner attending shall furnish tl
requisite medical certificate. Any person violating the provisions of this section shall be punished by fine not exceeding twenty-fi 1
dollars.
Vame of Deceased* - -
?ate and Place of Death,
PHYSICIAN’S CERTIFICATE
^ ^ /2e6f/f~ 1 88 y.
disease or Cause of Death , - 0f
fu-iuci fit 8.
*""'*" */ Certifying Physician,
Or Sex of Infant (not named).
ZW/’ (3/ Certificate,
[. Extracts from Chapter 32 of the Public Statutes. ]
“ Sect. 3. A physician who has attended a person durijig'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. If a physician refuses or neglects to make such certificate, he shall
forfeit ten dollars to the use of the town in which he resides.”
“ 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 a 1 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; and in cities and towns where there are boards of health, the certificate of the cause ofj
death shall also be approved by such board before a permit to bury is given by the registrar or clerk. Upon application, the chairman j
of the board of health, or any physician employed by any city or town for such purpose, shall sjgn the certificate of the cause of death
to the best of his knowledge and belief, if there has been no physician in attendance. lie shall also sign such certificate, upon applica
tion, in case of death by dangerous contagious disease, or in any other event when the certificate of the attending physician cannot fo
good and sufficient reasons be early enough obtained. In case of death by violence, the medical examiner attending shall furnish tlv
requisite medical certificate. Any person violating the provisions of this section shall be punished by fine not exceeding twenty-five dollars.’
m
[. Public Statutes, Chap. 32 , Sect. 5-]
No-human body shall be buried or removed from any city or town ^td a s^^erdficate shill state that the fact,
registrar to the undertaker, sexton, or other person performing the° ^ ”™trar shail give such certificate or burial permit until the
required by this chapter have been returned and recorder ; an no attendance at the last sickness of the deceased, anc
certificate of the cause of death has been obtained from t 6 P th’ere are boards of health, the certificate of the cause o
placed in The text goes on. The rest is in the file.