The volume, 1897–1899

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PHYSICIAN’S CERTIFICATE OF THE CAUSE OF DEATH.

The office of the Board of Health will he open for the granting of permits for burial, as follows: — Saturdays, 9 A. M. tlTI
3 P.M.; Sundays, 10 A.M. till 13 M.; Holidays, from lO A.M. till 12 M.; other days, from 9 A .M *JU 5 P.M.

—

UNDERTAKER’S RETURN.— B**en.

Date of dejrtfi^/ 181)^/^

Maiden name,* ^ Sex, Y^p. -

Married, simple, nr willow of wife of1 ^

Color, Age^t^ears, *>^inos., da)rs. Residence,

Place of death (8,J|Jbacnrd), q , ward

Place of birth Occupation,

Name of father Maiden name of mothei^-^^^^^

Birthplace of faChef^ f ^^t^^Birthpl ace of mother, Y&Zj.

Place of interment, f '//cYYs,

* If a married woman or a widow. * Give the name of the burial ground.

Signature of Undertaker :

RETURN OF A DEATH.

To the Clerk of the City or Town in which the Death occurred.

. x

tPMUcSUUM, Chapter 32, as amended by Acts of 18SS, Chapter 306 ; AcUoflSSS, Chapter 224; ActsoflSOS, Chapter 203.1

s% "r kvku^- ,oMmiih »«"•“* <» »«•*-

died, the duration of his last sickness and the date of hu H >,», ,L‘ L ’ ljC name °.f the deceased, his age, the disease of which lie
immediately thereafter, or at the birth of a stillborn child d a phy;sl<:lan "'ho bas attended at a birth of a child dying

stating to the best of his knowledg^^ fortlnV^h famish for registration a certificate^

lects or refuses to make a certificate as afo ^lt nr lt r . . d d,cd after b,rth fcr was born dead. If a physician neg-

flfty dollars. In case the deceased was a soldter’or a^ilnr -h* ^ there,ni *haI1 be Punished by a flne not exceeding

n,l tbo ™ ‘ ‘.1 “• Rician .hall give bolt

?•„“ W-T?! It a rera.es or «g,eS ,

! town in which he resides. j

“ n!m“ lerta'S " °r>" “f""" "““3 Ihe town l„ which he resides. ‘

clerk, as the case m«v hr. •. a..,, 0 Sl1?!’ ptrn,lt sba“ be issued until there has been delivered to such board, or a~ent or

recorded, togetlier with the certificate of thoattnuUn^^}^ c.ont!,.*'lln" thc fac,s required by this chapter to be returned and/
thereof a certificate as hereinafter provided If there”i/nnh!tta,1’iff ttll3u a? ,requlred b^ section three of this chapter, or in lieut
cannot be obtained for eo^ ^l suS^’rc^onL Jl attending physician, or if the certificate of the attending physician
physician employed by a ?cit? or to5 tl I n rl fortbe pulpose, the chairman of the board of health or any

required of the attending physician ; and in case of Xath bv vbde^e The°m8aifd }°ard’ “pCDt ?r5le,r-k’ make such certificate as is
When such satisfactory statement and certificate a/e delivered “ ^ '‘ l’ It r®que«tcd* make the same,

with countersign and transmit the same to the ^ ,s ag“nt- tbe board or agent shall forth,

shall t.hproflffor Aimtiai. : a t rcir for registration. The person to 'whom the permit is so given

shall thereafter famish for registration any otter InfS The person to whom the permit is so given

23S3SS" II io?u^

alt */*(? -* <7/

<*tr\

PHYSICIAN’S CERTIFICATE.

Name and Age of Deceased*

Jiafe and Place of Death, \ , died at y

SivMAMtd fioCcJ

Age, / ^ -J

189 ,

Disease or Cause of Death, - | of

\ ( Primary and Secondary .)J

! /Duration of Sickness, - - |

r* j N

I certify that the above is true , to th0ri>rstyt>f ffiy kiffudcdge and belief 7

and Residence of Certifying Physician , Led '

Date of Certificate,

•< T -’"A:

Ur bex of Infant (not named)* If stillborn so state. f If child died immediately after birth so state* I If a soldier or sailor who served in the War of the Rebellion.

Plate. Ed. October, 1895. — 5,UU0.

[Public Statutes, Chapter 32, as amended by Acts of 188S, Chapter 306 ; Acts of 2889, Chapter 224 ; Acts of 1S93, Chapter 2463."]

Section’ 3. A physician who has attended a person during his last illness shall, when requested, forthwith furnish for regis-
tration, a certificate stating, to the best of his knowledge and belief, the name of the deceased, his age, the disease of which he
died, the duration of his last sickness, and the date of his decease; and a physician who has attended at a birth of a child dying
immediately thereafter, of at the birtli of a stillborn child, shall, when requested, forthwith furnish for registration a certificate,
stating to the best of his knowledge and belief the fact that such a child died after birth or was born dead. If a physician neg-
lects or refuses to make a certificate as aforesaid, or makes a false statement therein, he shall be punished by a fine not exceeding
fifty dollars. In case the deceased was a soldier or a sailor who served in the war of the rebellion, the physician shall give both
the primary and the secondary -or immediate cause of death as nearly as he can state the same. If a physician refuses or neglects
to make such certificate he shall forfeit to the treasurer the sum of ten dollars for the use of the town in which he resides.

Section 5. No undertaker, sexton or other person shall bury in a city or town or remove therefrom a human body until he
has received a permit so to do from thqboard of health or its duly appointed agent, or, if there is no board of health in such city
or town, from the city or town clerk. No such permit shall be issued until there has been delivered to such board, or agent or
clerk, as the case may be, a satisfactory written statement containing the facts required by this chapter to be returned and
recorded, together with the certificate of the attending physician, if any, as required by section three of this chapter, or in lieu
thereof a certificate as hereinafter provided. If there is no attending physician, or if the certificate of the attending physician
cannot be obtained, for good and sufficient reasons, early enough for the purpose, the chairman of the board of health or any
physician employed by a city or town for the purpose shall, upon request of said board, agent or clerk, make such certificate as is
required of the attending physician; and in case of death by violence the medical examiner shall, if requested, make the same.
When such satisfactory statement and certificate are delivered to the board of health or to its agent, the board or agent shall forth-
with countersign and transmit the same to the clerk or registrar for registration. The person to whom the permit is so given
shall thereafter furnish for registration any other information as to the deceased or to the manner and cause of the death, as the
clerk or registrar may require. Any person violating any of the provisions of this section shall be punished by a fine not exceed-
ing fifty dollars.

-p

’■p

»^r

[ Public Statutes, Chapter 32, as ahiended by Acts of 18SS, Chapter 30G ; Acts of 1S89, Chapter 224 ; Acts of 1893, Chapter 263. j

Sioction 3. A physician wlii has attended a person daring his last illness shall, wlntn requested, forthwith furnish for regis-
tration, a certificate stating, to tile best of his knowledge and belief, the name of the deceased, his age, the disease of which he
died, the duration of his last sickness, and the date of his decease; and a physician who has attended at a birth of a child dying
immediately thereafter, or at thejbirth of a stillborn child, shall, when requested, forthwith furnish for registration a certificate,
stating to the best of his knowledge and belief the fact that such a child died after birth or was born dead. If a physician neg-
lects or refuses to make a certificate as aforesaid, or makes a false statement therein, liej shall be punished by a fine not exceeding
fifty dollars. In case the deceased was a soldier or a sailor who served in the war of the rebellion, the physician shall give both
the primary and the secondary or immediate cause of death as nearly as he can state the fame. If a physician refuses or neglects
to make such certificate he shall forfeit to the treasurer the. sum of ten dollars for the use of the town in which he resides.

Section 5. No undertaker, Sexton or other person shall bury in a city or town or femove therefrom a human body until he
has received a permit so to do frfjm the board of health or its duly appointed agent, or, if there is no board of health in such city
or town, from the city or town clerk. No such permit shall be issued until there has been delivered to such board, or agent or
clerk, as the case may be, a satisfactory written statement containing the facts required by this chapter to be returned and
recorded, together with the certificate of the attending physician, if any, as required by section three of this chapter, or in lieu
thereof a certificate as hereinafter provided. If there is no attending physician, or if the certificate of the attenamg physician
cannot be obtained, for good and sufficient reasons, early enough for the purpose, the chairman of the board of health or any
physician employed by a city or town for the purpose shall, upon request of said board, agent or clerk, make such certificate as is
required of the attending physician ; and in case of death by violence the medical examiner shall, if requested, make the same.
When such satisfactory statement and certificate are delivered to the board of health or tci its agent, the board or agent shall forth-
with countersign and transmit the same to the clerk or registrar for registration. The [ierson to whom the permit is so given
shall thereafter furnish for registration any other information as to the deceased or to tliie manner and cause of the death, as the
clerk or registrar may require. Any person violating any of the provisions of this section shall be punished by a fine not exceed'
ing fifty dollars. ■>. j IJS /J //

' ot the provisions of this sect

PHYSICIAN’S CERTIFICATE.

Name and Age of Deceased \*
Date and Place of Death ft -
l Disease or Cause of Death, -

{Primary and Si-ronda ry.ft

XDuration of Sickness,

\ge, (oO ''O’ 2-<T~

/O .189

I certify that the above is true , to the besj^f tnpkno uyfecjge ajfd belief.

Iw 'gnature and Residence of Certifying Physician ,

Off A-

Date of Certifn

ti fickle;

Ur Sex of Infant (not named). 11 stillborn so state. I If child died immediately after birth so state. I ICV stfdier or sailor who served in the War of the Rebellion.

Plate. Ed. October, 1895. — 5,0U0.

[Public Statutes, Chapter 32, as amended by Ads of 18SS, Chapter 30G ; Acts of 1889, Chapter 224; Acts oflS93, Chapter 2C3.]

tr&^nn^rortMra^Jt^ti cia“ wbo bas att®“ded a Person during his last illness shall, when requested, forthwith furnish for regis-
dted Vle best °£ !VS k,nowlcdge a,ld bclief> the name of the deceased, his age, the disease of which he

hmmed^atelv tK k ^ th®, date of,his decease; and a physician who has attended at a birtli of a child dying
statin- S* I?l.u tn 1 t^e.b'r h ^f.a,?tillb0r? child> shall> when requested, forthwith furnish for registration a certificate,

Statius to the best of his knowledge and belief the fact that such a child died after birth or was born dead. If a physician nee-

lftt dol l»?eSIn i.Zkii a certificate as aforesaid, or makes a false statement therein, lie shall be punished by a finenot exceeding
t h^nrinvfr^'nn1) th tb deceased was '? soldler or a sailor who served in the war of the rebellion, the physician shall give both
t « y f d l,b« stco,nda7 or ‘immediate cause of death as nearly as he can state the same. If a physician refuses or neglects

to make such certificate he shall forfeit to the treasurer the sum of ten dollars for the use of the town in which he resides. ~
w JNO undertaker, sexton or other person shall bury in a city or town or remove therefrom a human body until he

^town frnm o > S° l? d° fr?m, the board of health or its duly appointed agent, or, if there is no board of health in’ such city
,[om the Clt>' °.r town clerk. No such permit shall be issued until there has been delivered to such board, or agent or
Vi C,tSe a sat‘sfact0,7 written statement containing the facts required by this chapter to be returned and

thprpnf Wltb the. certificate of the attending physician, if any, as required by section three of this chapter, or in lieu

canno/he T hereiaafte,r Provided. If there is no attending physician, or if the certificate of the attending physician

bG btalned’ for go.od an(1 sufficient reasons, early enough for the purpose, the chairman of the board of health or any
remfi^d «?«?<!' * C\ty <?r.town for.the purpose shall, upon request of said board, agent or clerk, make such certificate as is
wi '„ed °l attending Pl'J'slcian 5 au(l In case of death by violence the medical examiner shall, if requested, make the same.
\\ lien such satisfactory statement and certificate are delivered to the board of health or to its agent, the board or agent shall forth!
«Vnii ®°unte^'ga and transmit the same to the clerk or registrar for registration. The person to whom the permit is so given
. hall thereafter ftirnish for registration any other information as to the deceased or to the manner and cause of the death as the
clei k or registrar may require. Any person violating any of the provisions of this section shall be punished by a line not exceed-

* If a Married Woman or Widow. J If a Soldier who served in the War of the Rebellion,
t If other than White. (M.) Mulatto. (X.) Indian. If of other Races, specify what.

[Be very particular to fill all Blanks.]

Plate. Ed. Dec., 1895.-5,000.

[Public Statutes, Chapter 32, as amended by Acts of 188S, Chapter 306 ; Acts of 1889, Chapter 224 ; Acts of 1S93, Chapter 263.]

Section 3. A physician who has attended a person during his last illness shall, when requested, forthwith furnish for regis-
tration, a certificate stating, to the best of his knowledge and belief, the name of the deceased, his age, the disease of which he
died, the duration of his last sickness, and the date of his decease; and a physician who has attended at a birth of a child dying
immediately thereafter, or at the birth of a stillborn child, shall, when requested, forthwith furnish for registration a certificate,
stating to the best of his knowledge and belief the fact that such a child died after birth or was born dead. If a physician neg-
lects or refuses to make a certificate as aforesaid, or makes a false statement therein, ne shall be punished by a fine not exceeding
fifty dollars. In case the deceased was a soldier or a sailor who served iu the war of the rebellion, the physician shall give both
the primary and the secondary or immediate cause of death as nearly as he can state the same. If a physician refuses or neglect^
to make such certificate he shall forfeit to the treasurer the sum of ten dollars for the use of the town in which he resides.

Section 5. No undertaker, sexton or other person shall bury in a city or town or remove therefrom a human body uutil he
has received a permit so to do from the board of health or its duly appointed agent, or, if there is no board of health iu such city ‘
or town, from the city or town clerk. No such permit shall be issued until there has been delivered to such board, or agent or
clerk, as the case may be, a satisfactory written statement containing the facts required by this chapter to be returned and
recorded, together with the certificate of the attending physician, if any, as required by section three of this chapter, or in lieu
thereof a certificate as hereinafter provided. If there is no attending physician, or if the certificate of the attending physician
cannot be obtained, for good and sufficient reasons, early enough for the purpose, the chairman of the board of health or any
physician employed by a city or town for the purpose shall, upon request of said board, agent or clerk, make such certificate as is
required of the attending physician; and in case of death by violence the medical examiner shall, if requested, make the same.
When such satisfactory statement and certificate are delivered to the board of health or to its agent, the board or agent shall forth-
with countersign and transmit the same to the clerk or registrar for registration. The person to whom the permit is so given
shall thereafter furnish for registration any other information as to the deceased or to the manner and cause of the death, as the
clerk or registrar may require. Any person violating any of the provisions of this section shall be punished by a fine not exceed-
ing fifty dollars.

PHYSICIAN’S CERTIFICATE

Name and Age of Deceased,*

Date and Place of Death f -
Disease or Cause of Death, -

( Primary and Secondary.) |

Duration of Sickness,

^Signature and Residence of Certifying

I certify that the above is true , to the best of my knowledge and belief ’

V Physic ran , ^ ......

Date of Certificate,

189.

* Or Sex of Infant (not named). If stillborn so state. f If child died immediately after birth so state. J If a soldier or sailor who served in the War of the Rebellion-

Plate. Ed. October, 1895. — 5,000.

[Public Statutes, Chapter 32, as amended by Acts of 1SSS, Chapter 30G ; Acts of 1889, Chapter 224; Acts of 1893, Chapter 2 G 3. j

Section' 3. A physician who has attended a person during his last illness shall, when requested, forthwith furnish for regis-
tration, a certificate stating, to the best of his knowledge and belief, the name of the deceased, his age, the disease of which he
died, the duration of his last sickness, and the date of his decease; and a physician who has attended at a birth of a child dying
immediately thereafter, or at the birth of a stillborn child, shall, when requested, forthwith furnish for registration a certificate,
stating to the best of his knowledge and belief the fact that such a child died after birth or was born dead. If a physician neg-
lects or refuses to make a certificate as aforesaid, or makes a false statement therein, he shall be punished by a fine n'otexceeding
fifty dollars. In case the deceased was a soldier or a sailor who served in the war of the rebellion, the physician shall give both
the primary and the secondary or immediate cause of death as nearly as he can state the same. If a physician refuses or neglects
to make such certificate lie shall forfeit to the treasurer the sum of ten dollars for the use of the town in which he resides.

Section 5. No undertaker, sexton or other person shall bury in a city or town or remove therefrom a human body until he
has received a permit so to do from the board of health or its duly appointed agent, or, if there is no board of health in such city
or town, from the city or town clerk. No such permit shall be issued until there has been delivered to such board, or agent or
clerk, as the case may be, a satisfactory written statement containing the facts required by this chapter to be returned and
recorded, together with the certificate of the attending physician, if any, as required by section three of this chapter, or in lieu
thereof a certificate ns hereinafter provided. If there is no attending physician, or if the certificate of the attending physician
cannot be obtained, for good and sufficient reasons, early enough for the purpose, the chairman of the board of health or any
physician employed by a city or town for the purpose shall, upon request of said board, agent or clerk, make such certificate as is
required of the attending physician ; and in case of death by violence the medical examiner shall, if requested, make the same.
When such satisfactory statement and certificate are delivered to the board of health or to its agent, the board or agent shall forth-
with countersign and transmit the same to the clerk or registrar for registration. The person to whom the permit is so given
shall thereafter furnish for registration any other information as to the deceased or to the manner and cause of the death, as the
clerk or registrar may require. Any person violating any of the provisions of this section Shall be punished by a fine not exceed-
ing fifty dollars.

PHYSICIAN’S CERTIFICATE

OF THE CAUSE OF DEATH.

Boston , .

189.../-

Name and age of deceased : <2f££&3idl?.. AgeM.f&...yr» mos dys.

f-S-

Date and place of death:
Disease or cause of death :

■ ^ OirArsJZr&ffrr: £..., ; ^VTV. .i. .

Duration of disease:* Ck.y & THtthS- £_ _

I certify that the above is true, to the best of my knowledge and belief ,

Name and residence ")
of physician. J

M. D.

* It is very desirable to be informed of the duration of the disease.

-he office of the Board of Health will he open for the granting of permits for burial, as follows : — Saturdays, 9 A.M. till
.M.; Sundays, lo A.M. till 12 M.; Holidays, from lO A. M. till 12 M.; other days, from 9 A.M. till 5 P. M.

Date of de athZZ .cf ..y.Znr. Z./. 189/ Name,..*. l/!. /&

Maiden narn^C Z. ....... (Z)Z:: X Sex,

c - . / y j x

Married, GHiglo^r widow of. „• rr .rrrrr^"""Wife

Color, .-Z AgeZ /years, — mos.,.-. ...days. ResidenceZ'-j^

/ Jy * s~~y< / y // // ( S-'Cr^ ^

Place of death (8tnr^a8nrd),Z^.^/..^.£Z § C ward ^

Place of birth, 1 Z....Z c J Occupation,! v,

Name of fathei^^^«^^ . . Maiden name of mother, c.-....: £ r^ZZ ^

Birthplace of father, Birthplace <5f mother,

Place of interment, f

* If a married woman or a widow. t Give the name of the burial ground.

Signature of Undertaker :

( /

Z ^..A:Zzx..£.

■

h S
£ p
3 •

O TJ
•-I M

c3 o
& *

[Public Statutes , Chapter 32 , as amended by Acts of 1888, Chapter 306 ; Acts of 1889 , Chapter 224 ; Acts of 1893, Chapter 263. ~\

Section 3. A physician who has attended a person during his last illness shall, when requested, forthwith furnish for regis-
tration, a certificate stating, to the best of his knowledge and belief, the name of the deceased, his age, the disease of which he
died, the duration of his last sickness, and the date of his decease; and a physician who has attended at a birth of a child dying
immediately thereafter, or at the birth of a stillborn child, shall, when requested, forthwith furnish for registration a certificate,
stating to the best of his knowledge and belief the fact that such a child died after birth or was born dead. If a physician neg-
lects or refuses to make a certificate as aforesaid, or makes a false statement therein, he shall be punished by a fine not exceeding
fifty dollars. In case the deceased was a soldier or a sailor who served in the war of the rebellion, the physician shall give both
the primary and the secondary or immediate cause of death as nearly as he can state the same. If a physician refuses or neglects
to make such certificate he shall forfeit to the treasurer the sum of ten dollars for the use of the town in which he resides.

Section 5. No undertaker, sexton or other person shall bury in a city or town or remove therefrom a human body until lie
has received a permit so to do from the board of health or its duly appointed agent, or, if there is no board of health in such city
or town, from the city or town clerk. No such permit shall be issued until there has been delivered to such board, or agent or
clerk, as the case may be, a satisfactory written statement containing the facts required by this chapter to be returned and
recorded, together with the certificate of the attending physician, if anv, as required by section three of this chapter, or in lieu
thereof a certificate as hereinafter provided. If there is no attending physician, or if the certificate of the attending physician
cannot be obtained, for good and sufficient reasons, early enough for the purpose, the chairmau of the board of health or any
phvsician employed by a city or town for the purpose shall, upon request of said board, agent or clerk, make such certificate as is
required of the attending physician ; and in case of death by violence the medical examiner shall, if requested, make the same.
When such satisfactory statement and certificate are delivered to the board of health or to its agent, the board or agent shall forth-
with countersign and transmit the same to the clerk or registrar for registration. The person to whom the permit is so given
shall thereafter furnish for registration any other information as to the deceased or to the manner and cause of the death, as the
clerk or registrar may require. Any person violating any of the provisions of this section shall be punished by a fine not exceed-
ing fifty dollars.

PHYSICIAN'S CERTIFICATE.

Name and Age of Deceased*

Date and Place of Deaths - died at

Please or Cause of Death, - [ 0f f__

(Primary and Secondary.)^

Duration of Sickness ,

4ge, /

I cet tify that the a hovels trite , to the best ofijny knowledge and belief.

Signature and Residence of Certifying Physician,

Date of Certificate,

^u..r. Z

* Or bex of Infant (not named). Inborn so s«a.e. , “ alidic7or saUor who served in the War of the Rebellion^

[Public Statutes, Chapter 32, as amende* by Acts of 1SSS, Chapter 30G ; Acts of 1889, Chapter 224; Acts of 1S93, Chapter 2(75.]
tration^a'cerUflca^e^staUn^'t^H^^fpaf^f1^0^8 PT^n duri“? his last illness sha11- "’hen requested, forthwith furnish for regis-

th%S?rTand“Kerona“^e? “**? soldlcr^ 'orVsilor who ^r^Ko'wnf’S ttcl3»mooj^^

« T* 0t d“ih ” «"» “ l'» «»" Mate the same. If i phjslcL refese” or^lccts

Sectiov r No u^dertnS fv treasurer ll!e of ten dollars for the use of the town in which he resides,

has received a permit soto^nfrnmth") Per?f°Kn sha11 ^l,r-v in a-city or towl1 or remove therefrom a human body until he

or town from the f ? , theJ?oard °f health or its duly appointed agent, or, if there Is no board of health In such city

clerk "as the else SK.Sf't S"t' permit sha11 be issued unliI there has been delivered to such board, or agent or
recorded tmrei her wf/h m ’ ^factory written statement containing the facts required by this chapter to he returned and
thereof a °f, *he a«e"ding Physician, if any, as required by section three of this chapter, or in lieu
cannot be offiS? tor S' FJm de*d‘ lf therc if! no lending physician, or if the certificate of the attending physician
n n l g ,?d and sufficient reasons, early enough for the purpose, the chairman of the board of health or anv

required of the' attendfnt purp°sf sh^V l,p?u, rc('ut'st ot' said board> agent or clerk, make such certificate as is

Whon ttnnh enti f P*J5slc,an> and *n case death by violence the medical examiner shall, if requested, make the same

« ™ * satisfactory statement and certificate are delivered to the board of health or to its agent the board or a-ent shall forth ’

SS ZSKmcW8"111 th,e sre t0 the clerk °r re"istrar for registration. The person to whom X permit is so gTven
derk oi^r e'ds tr a^m a v lsJratl 0 n any ot,‘er information as to the deceased or to the manner and cause of the death, as the

ing fifty dollars 7 q Any person violating any of the provisions of this section shall be punished by a fine not exceed-

u °

^ o

U .
c3 o
a ~

[Public Statutes, Chapter 32, as amended by Ads of 1S8S, Chapter 306 ; Ads of 1889, Chapter 224 • Acts of 1893 Chanter 9 fit V

- nf when requested, tothwi.h to „hh to regU.,

,he duration of his last sickness, and the date of ids rli>wK,.. • *P deceased, his age, the disease of which he

tration.

lectsOT refuses to make a certificate a^for^^id6^ makes “ Cwd ^ie<^ ^fter birth or was bom dea^ If a physiciim
fifty doiiars. In case the deceased was a soldier or a sailor who serSdKe^^f tf ^ w pllnjshe(' b-v a fluo not exceeding
^ J,rrarylaDd tbf sccondary or immiliate cause of death as nearly as he can statc°M £berebelbon> the physician shall give both
to make such certificate he shall forfeit to the treasurer the sum of ten doll^l f at,V samP;, I£ a Physician refuses or neglects
Section 5. No undertaker, sexton or other person shaft burv in » d l Z I the USC °f tbe ,town in which he asides,
has received a permit so to do from the board of health or if* rink* m • i or remove therefrom a human body until he

or town, from the city or town clerk. No such Verm sha ?be * *1? to "2 b°ard °f hpalth *» -Sb cl*

clerk, as the case may be, a satisfactory written statement conSn“thi tbe^e has been delivered to such board, or agent o'r
recorded, together with the certificate of the attendin'-- physician if ! f l! r?qaired by th's chapter to be returned and
thereof a certificate as hereinafter provided. If thereis no at te d L Z’ • ,required k section three of this chapter, or in lieu
cannot be obtained, for good and sufficient reasons earl 1 f ? Pksician, or / tbe certificate of the attending physician
physician employed by a city or town for the mi^nms^sliidl^^^^rpnneif-^f UI"^Sk’ chairman o£ the >^ard of health ’or any

wCn'f o£th«a«cnding physician ; and in case of^ a»eHt ^ ^ake such certificate as il

When such satisfactory statement and certificate are delivered to the"ho trd^>r h in -er sha *’ f recluested, make the same,
w'th countersign and transmit the same to the clerk or re-dstrar f^ 5ts agent’ the board or agent shall forth,

sh.all thereafter furnish for registration any other information tn tr t lV The Person to whom the permit is so given
clerk or registrar may require. Any persoii violatin'- anv offhfnmJi- d *s5,d. or to the manner and cause of the death, as the
ing fifty dollars. y P vioutina any of the provisions of this section shall be punished by a fine not exceed-

PHYSICIAN’S CERTIFICATE

Name and Age of Deceased ,*

'As'

..^r l89 '7 ’

d / y- /A / fcn* . ' fr

ti MuZs

I , '

\pate and Place of Death, t - died at

Disease or Cause of Death, - of

{Printary and Secondary .) +

Duration of Sickness, - -

I certify that the above is true , to the best of my knowledge and belief.

(1; OdfAHSA' \j\fir. .At't

signature and Residence of Certifying Physician, l (//*■

Date of Certificate, S7 PI

Age,

M.M

i*9 y

T. T.,J ,• A' Mk .IWUrth so state t If a soldier or sailor who served in the War of the Rebellion.

Or Sex of Infant (not named). If stillborn so state. t VdM

[Public Statutes, Chapter 32, as amended by Acts of IS 88, Chapter 30 G ; Acts of IS SO, Chapter 224 ; AclsoflS93, Chapter 203.]

Section 3. A physician who has attended a person during his last illness shall, when requested, forthwith furnish for regis-
tration, a certificate stating, to the best of his knowledge and belief, the name of the deceased, his age, the disease of which lie
died, the duration of his last sickness, and the date of his decease; and a physician who has attended at a birth of a child dying
immediately thereafter, or at the birth of a stillborn child, shall, when requested, forthwith furnish for registration a certificate^
stating to the best of his knowledge and belief the fact that such a child died after birth or was born dead. If a physician neg-
lects or refuses to make a certificate as aforesaid, or makes a false statement therein, he shall be punished by a fine not exceeding
fifty dollars. In case the deceased was a soldier or a sailor who served in the war of the rebellion, the physician shall give both
the primary and the secondary or immediate cause of death as nearly as lie can state the same. If a physician refuses or neglects
to make such certificate he shall forfeit to the treasurer the sum of ten dollars for the use of the town in which he resides.

Section 5. No undertaker, sexton or other person shall bury in a city or town or remove therefrom a human body until he
has received a permit so to do from the board of health or its duly appointed agent, or, if there is no board of health in such city
or town, from the city or town clerk. No such permit shall be issued until there has been delivered to such board, or agent or
clerk, as the case may be, a satisfactory written statement containing the facts required by this chapter to be returned and
recorded, together with the certificate of the attending physician, if any, as required by section three of this chapter, or in lieu
thereof a certificate as hereinafter provided. If there is no attending physician, or if the certificate of the attending physician
cannot be obtained, for good and sufficient reasons, early enough for the purpose, the chairman of the board of health or any
physician employed by a city or town for the purpose shall, upon request of said board, agent or clerk, make such certificate as is
required of the attending physician ; and in case of death by violence the medical examiner shall, if requested, make the same.
When such satisfactory statement and certificate are delivered to the board of health or to its agent, the board or agent shall forth-
with countersign and transmit the same to the clerk or registrar for registration. The person to whom the permit is so given
shall thereafter furnish for registration any other information as to the deceased or to the manner and cause of the death, as the
clerk or registrar may require. Any person violating any of the provisions of this section shall be punished by a fine not exceed'
ing fifty dollars.

RETURN OF A DEATH.

To the Clerk of the City or Town in which the Death occurred.

11. Name of Father.

[P«SIie ».», Ctaj.Kr &3, «, oiBeiJi «J AM »/ I««S. Chapter 306; AMoflSSO, Chaplir22t; AcU 0/1863, Chapter S63. ■

Section 3. A physician >vho ha. attended a person wte?E

tration, a certificate stating, to the besj ; of his ^“°w^dgf • and a physician who has attended at a birth of a child dying

died, the duration of his last sickness and thedateofhis d * ; , fortbwith furnish for registration a certificate,

immediately thereafter, or at the birth of a stillborn child, shall, w hen *vas born dead. If a physician nog-
stating to the best of his knowledge and belief the fact that s t thereln i,e shall be punished by a fine not exceeding

iects or refuses to make a certificate as aforesaid, or makes a false statement tnerem, ‘ physician shall give both

fif ty dollars. In case the deceased was a soldier or a sailor who served in the w ™ °* or neglects

tlm primary and the secondary or immediate cause of death as near ly as he can “™ihe^ffShlch he resides.

to make such certificate he shall forfeit to th®trea^er shaU bury in a city or town or remJve therefrom a human body until he
Section 5. No undertaker, sexton or other person shall bury in a city or tow m or feu board of health in such city

has received a permit so to do from the board of health ^^l^^Jcued until there has been delivered to such board, or agent or
or town, from the city or town clerk. jNo such peimit.hal ... ., f ts requjred by this chapter to be returned and

clerk, as the case may be, a satisfactory written statement cont.. «, • dqb secqpn three of this chapter, or in lieu

recorded, together with the certificate of the atte™bnS » physician, or if the certificate of the atteuumg physician

thereof a certificate as hereinafter provided. If ther® qI® the7 purpose the chairman of the board of health or any

cannot be obtained, for good and sufficient reasons, ea ^ eI) u» t l sJ]d byard a^ent or clerk, make such certificate as is

physician employed by a city or town for the P a rp°Sr? ® , ^-Vol Jn oeThc n edicaf c x^miner s?ml 1 , if requested, make the same.,

required of the attending physician; and m case of death ' ‘^le^e, , f h ,altb or to itsa<mnt, the board or agent shall fortli-

When such satisfactory statement and certificate are deln ei i cd to tl e ■ ^ person to whom the permit is so given

with countersign and transmit the same to the ejer h or and cause of the dealli, as the

this section shall be punished by a fine not exceed-
ing fifty dollars.

PHYSICIAN’S CERTIFICATE.

Name and Age of Deceased, *

Date and P/ace of Death, t - died at QjUiNff,

Disease or Cause of Death, of

^ {Primary and Secondary.) j

If nation of Sickness, - - j (' It fyutfcf fC}' X-'/-

I certify that the above is true, to the best of m y Jui o iNpiyefy n d beffef.

; gnature and Residence of Certifying Physician

Date of Certificate

,L-

* Or Sex of Infant (not named). If stillborn so state.

t If child died immediately after birth so state.

Plate. Ed. October, 1895.-5,000.

J If a soldier or sailor who served in the

irubhc Statutes, Chapter 32, as amended by Acts of 2888, Chapter 30G ; Acts of 1889, Chapter 224; Acts of 1893, Chapter 263.]

Section 3. A physician who has attended a person during his last illness shall, when requested forthwith furnish for rcric
lhe best oi; bis knowledge and belief, the name of the dece^ecl? his ag? the toe of whicdW.e'
!tdi m hls last sickness, and the date of his decease; and a physician who has attended at a birtli of a child dvin-

so.Hni tl l'i °f Ut tie1b,rth fl,a1?t! buorn chlld> sha11* when requested, forthwith furnish for registration a certificate”

. tatins to the best of his knowledge and belief the fact that such a child died after birth or was born dead. If a physician nec-

flftv do,irarfaUSeTn°r«pkth * °ertlflcate as af°resaid, or makes a false statement therein, he shall be punished by a fine not exceeding
111 case the deceased was a soldier or a sailor who served in the war of the rebellion, the physician shall give both
*be S 7 ,and V‘h s *co,ndary ornn mediate cause of death as nearly as he can state the same. If a physician refuses or neglects

to make such certificate lie shall forfeit to the treasurer the sum of ten dollars for the use of the town in which he resides. “

, ‘ 'C.II( ;* 1 undertaker, sexton or other person shall bury in a city or town or remove therefrom a human body until he

or town from S° d° f*?m, thek°ard ,of health or its duly appointed agent, or, if there is no board of health insuch cil v

eWtaa th ty °K t0"n ®.leFk\ such permit shall be issued until there lias been delivered to such board, or agent or
rieor’rWi ^ may a satisfactory written statement containing the facts required by this chapter to be returned and
thereof q’ tog?*:heF wlt1} th® certificate of the attending physician, if any, as required by section three of this chapter or in lieu
cannotfbe obtalne? Pr£v!ded- If there no attending physician, or if the certificate of the attending physician

nwwor ° 3tamed’ £or 8wd and sufficient reasons, early enough for the purpose, the chairman of the board of health or anv
physician employed by a city or town for the purpose shall, upon request of said board, agent or clerk, make such certificate as is

Whcnloh tb?5ffte“d,ng Fbysic5“ 5 aDd in.®ase of ^ by violence the medical examiner shall, if requested m^rthe same
AVhen such satisfactory statement and certificate are delivered to the board of health or to its agent, the board or agent shall forth

shall wnSmit thfe same t0 the1c,er.k or registrar for registration. The person to whom the permit is so given

shall thereafter furnish foi registration any other information as to the deceased or to the manner and cause of the death as the
i ^fifT- je^jStrar may require- Any Person violating any of the provisions of this section shall be punished by a fine not exceed'

PHYSICIAN'S CERTIFICATE OF THE CAUSE OF DEATH.

*ased,

Name of Deceased

Place and Date of Death : Died at e

Disease or cause of Death : f Primary,

Medfrml,

7 c^- Age, Sb Yrs., ^ Mos., 0^ Days.

^ Medford, 7^ x 80^

/. f.f*

/If a soldier who served in the War of the Rebellion, both \ * j q i

\ the primary and secondary causes of death must be given^ I ^cCOIKUliy,

fO V X* X j

Duration of Disease, t

Residence

I certify that the above is true, to the best of my knowledge and belief
Signature of Physician,

^ / 3 ^ ...... J '

(No.) Stn (Town or City.]

M.D.

*Acts of 1889, Chap. 224. f It is very desirable to be informed of the duration of the disease.

No. - — —

RETURN OF A DEATH.

To the Clerk of the City or Town in which the Death occurred,

3 'o'

«*-(

«4H

<4-H C

Q-i

o *5

£ a
£

r-J

* If a Married Woman or Widow. J If a Soldier who served in the War of the Rebellion.
t If other than White. (M.) Mulatto. (X.) Indian. If of other Races, specify what.

[Be very particular to fill all Blanks.]

l’late. Ed. Dec., 1895.-5,000.

[Public Statutes, Chapter 32, as amended by Acts of J.S8S, Chapter 306 ; Acts of 1SS9, Chapter 224 ; Acts'of 1S03, Chapter 263-']

Section 3. A physician who has attended a person during his last illness shall, when requested, forthwith furnish for regis-
tration, a certificate stating, to the best of his knowledge and belief, the name of the deceased, his age, the disease of which he
died, the duration of his last sickness, and the date of his decease; and a physician who has attended at a birth of a child dying
immediately thereafter, or at the birth of a stillborn child, shall, when requested, forthwith furnish for registration a certificate,
stating to the best of his knowledge and belief the fact that such a child died after birth or was iborn dead. If a physician neg-
lects or refuses to make a certificate as aforesaid, or makes a false statement therein, he shall be punished by a fine not exceeding
fifty dollars. In case the deceased was a soldier or a sailor who served in the war of the rebellibn, the physician shall give both
the primary and the secondary or immediate cause of death as nearly as he can state the same. If a physician refuses or neglects
to make such certificate he shall forfeit to the treasurer the sum of ten dollars for the use of the town in which he resides.

Section 5. No undertaker, sextoh or other person shall bury in a city or town or remove therefrom a human body until lie
has received a permit so to do from the board of health or its duly appointed agent, or, if there is no board of health in such city
or town, from the city or town clerk. No such permit shall be issued until there has been delivered to such board, or agent or
clerk, as the case may be, a satisfactory written statement containing the facts required by this chapter to be returned and
recorded, together with the certificate of the attending physician, if any, as required by section three of this chapter, or in lieu
thereof a certificate as hereinafter provided. If there is no attending physician, or if the certificate of the attending physician
cannot be obtained, for good and sufficient reasons, early enough for the purpose, the chairman of the board of health or anj
physician employed by a city or town fqr the purpose shall, upon request, of said board, agent or clerk, make such certificate as is
required of the attending physician ; and in case of death by violence the medical examiner shall, if requested, make the same.
When such satisfactory statement and Certificate are delivered to the board of health or to its agent, the board or agent sha.l forth-
with countersign and transmit the same to the clerk or registrar for registration. The person to whom the permit is so given
shall thereafter furnish for registration any other information as to the deceased or to the manner and cause of the death, as t.ie
clerk or registrar may require. Any person violating any of the provisions of this section shall be punished by a fine not exceed-
ing fifty dollars. ^

, . v. ' n

„ physicians certificate.

Name and Age of Deceased '* // '

nj/T '

Date and Place of Death ft - j died at % , ^ ff

, r~~. l89 7 ,

Disease or Cause of Death, -\ 0f It >

{.Primary and Secondary. )\ 1 '

Duration of Sickness, - - [

I certify that the above is true , to the best of my knowledge and belief.

Signature and Residence of Certifying Physician, v 'fr-C/ - ^ ^ ,

Date °f Certificate> L. ' / < ,/ /<?!?

* Or bex of Jnlant (not named). If stillborn so state ♦ if j- . _ •

* If a sailor who served in the War of the Rebellton.

[PxMte Smu**, avur 32, a , *ne*M * Ac tt o/ MS*. <**» «>«; -Ac «/ 1SS*. ^ 2« ;

Section 3. A physician who has attended a person during h.!s J^g^^gQf^h^dece^eiirhta age, the disease of which he
tration, a certificate stating, to the best of his k"?'yk^ w ho has attended at a birth of a child dying

died, the duration of his last sickness and the date of his decease , a 1 1 > ■ forthwlth furnish for registration a certificate,
immediately thereafter, or at the birth ofastdlbor^ ' or wag born dcad. If a physician in-

stating to the best of liis knowledge and belief the fact that such a child clieu « hc JaU ,je punished by a fine not exceeding
lects or refuses to make a certificate as aforesaid, or makes a false - t) rebellion, the physician shall give both

fifty dollars. In case the deceased was a soldier or a sai lor ™1 i the ’ phy8PicL refuses or neglects

the primary and the secondary or immediate cause of death as nearly ; as he ca o£ the town in whicli he resides,

to make such certificate he shall forfeit to the treasurer the sum of £ “Ifitlor town or remove therefrom a human body until lie

Section 5. No undertaker, sexton or other person shall bury in a city or j of health in such city

has received a permit so to do from the board of health or ts duly aP U tufro lias hcen deli verod to such board, or agent or
or town, from the city or town clerk. No such penult shall be mued until by thi3 chapter to be returned and

clerk, as the case may be, a satisfactory written statement contain acquired by section three of this chapter, or in lieu

recorded, together with the certificate of the atte inding P^s>cian, f any, asjcq ^ certjficate of the attending physician

thereof a certificate as hereinafter provided. If thei fls, for the3 purpose, the chairman of the board of health or any

cannot be obtained, for good and sufficient reasons, «“lJ. board, agent or clerk, make such certificate as is

physician employed by a city or town for the purpose s< , P tbe medical examiner shall, if requested, make the same,

required of the attending physician ; and in case of death by \ i s d of healtb or to its agent, the board or agent shall fortli-

When such satisfactory statement and certificate are del registration. The person to whom the permit is so given

with countersign and transmit the same to the clerk or « . • • the” deceased or to the manner and cause of the death, as the

shall thereafter furnish for registration any this section shall be punished by a fine not exceed-

clerk or registrar may require. Any person violating any ot tne pi o\ isio.i»

ing fifty dollars.

* If a Harried Woman or Widow, t If a Soldier who served in the War of the Rebellion,
f If other than White. (M.) Mulatto. (I.) Indian. If of other Races, specify what.

[Be very particular to fill all Blanks.]

l’late. Ed. Dec., 1895.-5,000.

[Public Statutes, Chapter 32, as amended by Acts of 1SS8, Chapter 306; Acts oflSS9, Chapter 224; Acts oflS93, Chapter 263.']

Section 3. A physician who has attended a person during his last illness shall, when requested, forthwith furnish for regis-
rat.on, a certificate stating, to the best of his knowledge and belief, the name of the deceased, his age, the disease of which he
died, the duration of his last sickness, and the date of his decease; and a physician who has attended at a birth of a child dying
immediately thereafter, or at the birth of a stillborn child, shall, when requested, forthwith furnish for registration a certificate,
stating to the best of his knowledge and belief the fact that such a child died after birth or >vas born dead. If a physician neg-
lects or refuses to make a certificate as aforesaid, or makes a false statement therein, he shall be punished by a fine not exceeding
iitty dollars. In case the deceased was a soldier or a sailor who served in the Avar of the rebellion, the plwsician shall give both
t le pr imary and the secondary or immediate cause of death as nearly as he can state the samb. If a physician refuses or neglects
to make such certificate he shall forfeit to the treasurer the sum of ten dollars for the use of the town in which he resides.

Section 5. No undertaker,! sexton or other person shali bury in a city or town or remo\’e therefrom a human body until lie
lias recen ed a permit so to do frbm the board of health or its duly appointed agent, or, if there is no board of health in such city
or town, from the city or town clerk. No such permit shall be issued until there has been delivered to such board, or agent or
cleik, as the case may be, a satisfactory written statement containing the facts required by this chapter to be returned and
recorded, together with the certificate of the attending physician, if any, as required by section three of this chapter, or in lieu
lereot a certificate as hereinafter provided. If there is no attending physician, or if the certificate of the attending physician
cannot be obtained, for good and sufficient reasons, early enough for the purpose, the chairman of the board of health or nnA'
physician employed by a city or town for the purpose shall, upon request of said board, agept or clerk, make such certificate as is
°u physician ; and in case of death by violence the medical examiner shall, if requested, make the same.

\v hen such satisfactory statement and certificate are delivered to the board of health or to its agent, the board or agent shall fortli-
Avith countersign and transmit thp same to t’ ~
shall thereafter furnish for registration any
clerk or registrar may require. Awy person
iug fifty dollars.

ue clerk or registrar for registration. The person to whom the permit is so given
other informatiop as to the deceased or to the manner and cause of the death, as the
violating, iiiij^f^^e provisions of this section shall be punished by a fine not exceed-

A ante and Age of Deceased,

PHYSICIAN’S CERTIFICATE.

' i Hqa * /(S/.

Date and Place of Death, f - j died at

bis,

ease or Cause of Death, - 0f

( Primary and Sccoudary.)\

u rati on of Sickness,

/ certify that t

Signature and Residence of Certifying Physic iant

Date of

* Ur be* of Infant (not named;. If stillborn so state. f If child died immediately after

Plate. Ed. October, 1895. — 5, DUO.

ff-

or bailor who served in the War of the/Kebellion

[Public Statutes, Chapter 32, as amended by Ads of IS SS, Chapter 30 G ; Acts of 1S89, Chapter 224; Acts of 1803, Chapter 263.]

Section 3. A physician who has attended a person during his last illness shall, when requested, forthwith furnish for regis-
tration, a certificate stating, to the best of his knowledge and belief, the name of the deceased, his age, the disease of which he
died, the duration of his last sickness, and the date of his decease; and a physician who has attended at a birth of a child dying
immediately thereafter, or at the birth of a stillborn child, shall, when requested, forthwith furnish for registration a certificate,
stating to the best of his knowledge and belief the fact that such a child died after birth or was born dead. If a physician neg-
lects or refuses to make a certificate as aforesaid, or makes a false statement therein, lie shall be punished by a fine not exceeding
fifty dollars. In case the deceased was a soldier or a sailor who served In the war of the rebellion, the physician shall give botli
the primary and the secondary or immediate cause of death as nearly as lie can state the same. If a physician refuses or neglects
to make such certificate he shall forfeit to the treasurer the sum of ten dollars for the use of the town in which he resides.

Section 5. No undertaker, sexton or other person shall bury in a city or town or remove therefrom a human body until he
has received a permit so to do from the board of health or its duly appointed agent, or, if there is no board of health in such city
or town, from the city or town clerk. No such permit shall be issued until there has been delivered to such board, or agent or
clerk, as the case may be, a satisfactory written statement containing the facts required by this chapter to be returned and
recorded, together with the certificate of the attending physician, if any, as required by section three of this chapter, or in lieu
thereof a certificate as hereinafter provided. If there is no attending physician, or if the certificate of the attending physician
cannot be obtained, for good and sufficient reasons, early enougli for the purpose, the chairman of the board of health or any
physician employed by a city or town for the purpose shall, upon request of said board, agent or clerk, make such certificate as is
required of the attending physician; and in case of death by violence the medical examiner shall, if requested, make the same.
When such satisfactory statement and certificate are delivered to the board of health or to its agent, the board or agent shall forth-
with countersign and transmit the same to the clerk or registrar for registration. The person to whom the permit is so given
shall thereafter furnish for registration any other information as to the deceased or to the manner and cause of the death, as the
clerk or registrar may require. An/person violating any of the provisions of this section shall be punished by a fine not exceed-
ing fifty dollars.

in Pi

* If a Married Woman or Widow. J If a Soldier who served in the War of the Rebellion,
t If other than White. (M.) Mulatto. (I.) Indian. If of other Races, specify what.

[Be very particular to fill all Blanks.]

Plate. Ed. Dec., 1895.-5,000.

(lie.l, the duration of his last sickness, and the date of his' decease lia.me .°.f the deceased. Ins age. the disease of which

Section 5. No undertaker, sexton or other person sha l bn rv i t Zl !°r the USe °f tl,e town 1,1 which he resides. °
has received a permit so to do from the hoard of health or its dulv annofniLo 7* °r F?TVe therefrorn a human body until 1

or town, from the city or town clerk. No such perm! sha be £0011^1 °r; lf thfre ls no board of health In such cit

clerk as the case maybe, a satisfactory written statement coihwl 1 there has been delivered to such board, or agent -
recorded, together with the certificate of the attendin *nhvL^n ^r g he faCts re(Julred h7 this chapter to be returned a

thereof a certificate as hereinafter provided If there^no ntton^ 7 a? .required b7 section three of this chapter or in ii

cannot be obtained, for good and sufficient reasons! ^ °rJf th ,e ?ertiflcate of the attending phvsic

physician employed by a city or town for the purpose shSl nn^ thf chairman of the board of health or ai

When®*1 of the attending physician; and in case of death by violence the Lprtii^0^ ' a*ent ?r Clerk’ make such certificate as
with^. t1 satisfactory statement and certificate are delivered to the board^h* 1 ,1exar"lt!er shall> lf requested, make the sain

<5{1!l'k anv'o^her'infor^ io^-^^The ^per^on^to^'w 'pern^it^is^'so ^givt

in^fty 3SST may require- Any PerSOU -V Of the pro visions o^this> section SKE SJfflPjJf

✓ rif

t v < . \J

PHYSICIAN’S CERTIFICATE

Name and Age of Deceased,*

rli

Age, / / s*>*srzS

Date and Place of Death, t - j died at ^ ^ ^ j y/'/ffca,r A, S' // ygg f ,

....:....l:^...^^^r^^. _

/ certify that the above is true , to the best of my knowledge and belief.

yy *■ yd f/f c/.Aef> > 4f>. y

3 erf

Disease or Cause of Death,

fc ( Primary and Secondary.) j

Duration of Sickness,

Signature and Residence of Certifying Physician,

Date of Certificate,

is9y

• Or Sex of Infant (not named). If stillborn so state. t If child died immediately after birth so state. t If a soldier or sailor who served in the War of the Rebellion.

Plate. Ed. October, 1895. — 5, out).

lP"hliC SlaluteS’ Chapter 32 ' as amended h,J Acls of 1888, Chapter 30G ; Acts of 1889, Chapter 224; Ads of 1893, Chapter 2 G3 ]

*»t ;«e!7i a'p,™,. „ S E3STJS SiF £fiUtt5£ SK SZ^Jra^SEA

«"."»; .STU.S ^SS5SS«”52

recoi ed, together with the certificate of the attending physician, if any, as required by section three of this chanter or in li n

cannot^ beobtainccf for ^SS If therc * no Ending physician1, or if /he SrtfflSS of the .SffiSS Sjllcta!

cannot he obtained, for good and sufficient reasons, early enough for the purpose, the chairman of the board of healfli or

renn/reil^f ?lPi !r a C‘ily °r.tovvn for.thc purpose shall, upon request of said board, agent or clerk, make such certificate as is

Wqhl i,r^ S?-’ *‘te?dmffP,»yslc»a°; a»d incase of death by violence the medical examiner shall, if requested, ^ mate tS gSie
with oonnl^r -1 f ^ and certificate are delivered to the board of health or to its agent, the board or a "cut shall fort li
H countersign and transmit the same to the clerk or registrar for registration. The person to whom the permit is so irivcn
. lall thereafter furnish for registration any other information as to the deceased or to the manner and cause of the deatii as the
lug fifty ddiar™ reqUire- Any person violatinS a»y of the provisions of this section shall be punished by a fine not exceed-

PHYSICIAN’S CERTIFICATE OF THE CAUSE OF DEATH

180.2

Name and age of deceased:' 1 ^ . . (-/—/

* J ^ .... Age.rx. yrs mos dys-.

Date and place of death : 3 -/$-?? !/,■■,

Disease or cause of death : L

Duration of disease :* ^ ^ 2 ~Z- C / C

I certify that the above is true, to the best of my knowledge and belief .

*It is very desirable to be informed of the duration of the disease.

The office of the ltoard of Health will be open for the granting of permits for burial, as follows Saturdays, 9 A. M. tffl
~ P.M., Sundays, 10 A.M. till 13 M.; Holidays, from lO A. M. till 13 otw.. .1,^

O 4 4-ill •?

Date of death, ^ \ £ 189/ Name,

31aiden name* ' geXj

Married, smgle^-or wieknrof <— w}fe 0f

Color, (Vl/ AgZ// years, mos., days. Residence, <5^ C' / f ^

Place of death (“'/), <y^^cxJZX « (5^^Z^^ward

Place of birth, ^ Occupation, . \Z

Name ol father, t c <?•■ >* <U Maiden name of mother, ' / Jz^zZc

Birthplace of father, ' Birthplace of mother, /^yt- ^

Place of interment,! /y^'^^L7 " L//Zsi_

‘ If a married woman or a widow. * Give the naaitfof the burial ground.

Signature of Undertaker :

— —

* If a Married Woman or Widow. J If aSoldier who served in the War of the Rebellion,
t If other than White. (M.) Mulatto. (I.) Indian. If of other Races, specify what.

[Be very particular to All all Blanks.]

Plate. Ed. Dec., 1895.-5,000.

[Public Statutes, Chapter 32, as amended by Acts of 188S, Chapter 306 ; Acts of 1889, Chapter 224; Acts oflS93, Chapter 263-2

Section 3. A physician who has attended a person during his last illness shall, when requested, forthwith furnish for regis-
t rat ion, a certificate stating, to the best of liis knowledge and belief, the name of the deceased, his age, the disease of which he
died, the duration of his last sickness, and the date of his decease; and a physician who has attended at a birth of a child dyin«*
immediately thereafter, or at the birth of a stillborn child, shall, when requested, forthwith furnish for registration a certificate'
stating to the best of his knowledge and belief the fact that such a child died after birth or was born dead. If a physician neg-
lects or refuses to make a certificate as aforesaid, or makes a false statement therein, ne shall be punished by a fine liotexceeding
fifty dollars. In case the deceased Vras a soldier or a sailor who served in the war of the rebellion, the physician shall give both
the primary and the secondary or immediate cause of death as nearly as he can state the same. If a physician refuses or neglects
to make such certificate he shall forfeit to the treasurer the sum of ten dollars for the use of the town in which he resides.

Section 5. No undertaker, sexton or other person shall bury in a city or town or remove therefrom a human body until he
has received a permit so to do from the boai'd of health or its duly appointed agent, or, if tjiere is no board of health in such citv
or town, from the city or town clerk. No such permit shall be issued until there lias been delivered to such board, or agent or
clerk, as the case may be, a satisfactory written statement containing the facts requirecj by this chapter to be returned and
recorded, together with the certificate of the attending physician, if any, as required by section three of this chapter, or in lieu
thereof a certificate as hereinafter provided. If there is no attending physician, or if the certificate of the attending physician
cannot be obtained, for good and sufficient reasons, early enough for the purpose, the chairman of the board of health or auv
physician employed by a city or town for the purpose shall, upon request of said board, agent or clerk, make such certificate as is
required of the attending physician ; and in case of death by violence the medical examiner shall, if requested, make the same.
When such satisfactory statement and certificate are delivered to the board of health or to its agent, the board or agent shall forth-
with countersign and transmit the same to the clerk or registrar for registration. The person to whom the permit Is so given
shall thereafter furnish for registration any other information as to the deceased or to the manner and cause of the death, as the
clerk or registrar may require. Any person violating any of the provisions of this section shall be punished by a fine not exceed-
ing fifty dollars.

Commonfoealtb of Passncbusetts.

* 1 f a Married Woman or Widow, t If a Soldier who served in the War of tire Rebellion,
t If other than White. (M.) Mulatto. (I.) Indian. If of other Races, specify what.

[Be very particular to fill all Blanks.]

Plate. Ed. Dec., 1895.-5,000.

0/1 „ , , r 7 Chapter 224 ; Acts of 1S93, Chapter 263.1

Section 5. No undertaker, sextan >r otl Jealth or its duly appointed agent, or, if ! there * d tQ such board, or agent or

S”'h pc™!t. be '?- """1 S r” SSa by Ills chapter. to, l.e .returned »m.

0t" . ’ Ko n sntisfae

has received a permit so to do from the board of 1 JJ until there has beer 'S ch ap e to ^returned and
S town, from the city or town containing the facts reqmred by 1 ^ ^chapte^ in Ucu

clerk, as the ceisc may be, a satisfactory ^lt di physiCian, if any, as required by sect n f the attending physician

recorded, together with the certificate of the *re°^n'0 attending physician, or if the cert Jc board of health or any

thereof a certificate as hereinafter P 0'1'1 early enough for the purpose, the chami in ke such certificate as is

cannot be obtained for good 8hJl, upon request of If requested, make the same,

nhvsician employed by a cit> or town P bv violence the medical ex* the board or agent shall forth-

- — d by 1 fl°° “* ““

iug fifty dollars.

Name and Age of Deceased*

Date and Place of Death, t - died at.

Disease or Cause of Death , - of

{Print ciry and Secondary.)^

Duration of Sickness ,

PHYSICIAN’S CERTIFICATE.

Age, pi/c

**9*7 ,

I certify that the above is true , to the best of >nx knowledge and belief.

Signature and Residence of Certifying Physician ,

'7U>£h

Date of Certificate

/Soj,

* Or Sex of Infant (not named). If stillborn so state. t If child died immediately after birth so state. t If a soldier or sailor who served in the War of t>f Rebellion.

Plate. Ed. October, 1895.-5,000.

ChajtorSOO; Mu./USH, <***224; AcUoflS93, <***223.1

(lied, the duratiou of Ins last sickness, and the date of his decease- AnJ n nW i > tlle1de9eased- hlf the disease of which lie
immediately thereafter, or at the birth of a stillborn rhiiri ’1 a a p ys ^ian wll° has attended at a birth of a child dvin"

stating to the best of his know^ forthwith furnish for registration a cerUfiX

lects or refuses to make a certificate as aforesaid or iLkes a false after.bir " °F born. dead- I f a physician negl

fifty dollars. In case the deceased was a soldier or a sailor who s 1 v. d in ti crein’ be sliaP 1,0 punished by a fine not exceeding
the primary and the secondary or immediate cause of death as neariv a^he nin Uo? °»fi thercbcll'°,n- t,lc physician shall give both
to make such certificate he shall forfeit to the trca° ^ state the same. If a physician refuses or neglects

Section 5. No undertaker, sexton or^tlier nerson shaU hn Z in n 'S?"8 {°r tLe Use of tl,e town in which he resides,
has received a permit so to do from the board of health nr it! , m a ? ty ?r towu or remove therefrom a human body until he
or town, from the city or town c°e?k No such ^nerm sha he y apPom^d+a?cnt, or, if there is no board of health in such city
clerk, as the case may be, a^toStoly^S^SSmSS conSn^the ^ beeadeli^d to such board, or agent or
recorded, togetlier with the certificate of the attending ohvsician if aife « r?q'nred b7 tins chapter to be returned and

thereof a certificate as liereinafter provided Tf therA*; ! V an\’ a? required by section three of this chapter, or in lieu

cannot be obtained, for good and sufficient reasons earlv enough fo? th^nn aD’ °r+lf th,e ?ertiflca^ of the attending physician
physician employed by a city or town for flip nnmnoo *1 oii * 1 ^ ie PulPOse, the chairman of the board of health or any

required of the attending physician ; and in case of death bv v?otenee Th °f ^ ^oard’ ageut °r clcrk> make such certificate as is
When such satisfactory statement and certiSe are dtltee^L e^C^CaLf Xamin-er shall> if ^quested, make the same,

with countersign and transmit the same to the clerk or ieglstear for ^£ 0^ ’ The Person8 1”1’ ‘t* b°^d °r aSent shall fortlu
sliall thereafter furnisli for registration anv other i n for mu i The person to whom the permit Is so given

clerk or registrar may require Any person violating „ the deceased or to tlie manner and cause of the death, as the

Ing fifty dollars. 7 P V1°ldting auy of the provisions of this section si, all be punished by a line not exceed?

RETURN OF A DEATH,
the Clerk of the City or Town in which the Death occurred.

, . * : = i <yS .

! : • : : ' Tf)

Disease or Cause of Death

(Primary aud Secondary), |

Duration of Sickness,

[■Public Statutes , Chapter 32. as amended bu A ct « ni 7 qqq ri* ,

Section 3. A physician who has attended a Derson ' 1 ^Jh- US 2 8S9, Chapter 22^/ Acts 0/ 1893, Chapter 263.}

!nT^rfCaV^ 10 the bestbf his knowled^ean^^elief athe1mmpS^t\^ when requested, forthwith furnish for regN-
ilieil, the duration of his last sickness, aud the date of his rierea ... o ^ name.°* the deceased, his age, the disea>e of which lu*
immediately thereafter, or at the birth df a stillborn child own T ’1 nd & P1^sl^lan " ho has attended at a birth of a child dvin<>-
stating to the best of his knowledge and belief the f-wt ,1 ’* t' hen requested, forthwith furnish for registration u eert! 0
lects or refuses to make a certificate a sifo «,a?d o mSo! f f ? 3 cthifld died after b*«h or was born

fifty dollars. In case the deceased was K sSer or a^Sor * Sta*e™e“t therel“. be shall be punished by a flnenof Seeding
the primary and the secondary or immediate cause of de-ith n a *( fne<^,lu * le war the rebellion, the physician shall #rive hot b
to make such certidcto he shall ««•«» **■»«• « i PHtScSJ SSVSSS

Section 5. No undertaker, sexto dor other person shafl llnrv fn 0 v’3 f°r the use o£ the to"'" hi which he resides
has received a permit so to do from thejboard of health or its dlbllT tovm °r remove therefrom a human body until he
ZTVD’ H°m the city or t0"n clerk. So such permft shaU be 1 dnSt^ °r| if tbere is 110 board health i /such city
deik as the case may be, a satisfactory written statement eont fining o * fe has b.een de,lvered to such board, or agent or
thpr^f^1* t0'’?^ller with the certificate of the attending physician if anv^s r®q,m'ud b^ this chapter to be returned and
thereof a certificate as hereinafter provided. If there'isno attending lK, ,recluired by section three of tiiis chapter, or in lieu
cannot be obtained, for good and sufficient or+f tbe certificate of the attending Physician

pli} sician employed by a city or town for the purpose shdl unon^SL^ th? chairman of the board of health or any

requited of the attending phj-sician ; and in case of death hv vininnea^ ° Sa,ld board> agent or clerk, make such certificate as is
hen such satisfactory statement and certificate are delivered t ti k he medical examiner shall, if requested, make the same
with countersign and transmit the same tto the clerk or registrar fv,r' ®rboard o£ healtb or 10 its agent, the board or agent shall forth*
rWt ‘hereafter furnish for registration any other inform^ The person to whom the permit is so gTven

Sf"Sr“arreqUire- Anr I^P01! violating any of the sectloa shpl^be puoishe^by a fine iwt exceed6

1 yyssa /

T*8/?-?zS' ■ '

PHYSICIAN’S CERTIFICATE.

Signature and Residence of Certifying Physician ,

I certify that the above is true , to the hist of my ftnow ledge and belief.

Date of Certificate, ~/8g y

* Or Sex of Infant (not named). If stillborn so state. T If child died immediately afterbirth so state. t If a soldier or sailor who served in the War of the Rebellion-

Plate. Ed. October, 1895. — 5,000.

[Public Statutes, Chapter 32, as amended by Ads of JSSS, Chapter 306; Acts of 1889, Chapter 224; Acts of 1893, Chapter 263 .]

Section 3. A physician who has attended a person during his last illness shall, when requested, forthwith furnish for regis-
tration, a certificate stating, to the best of his knowledge and belief, the name of the ctfeee&sed, his age, the disease of which he
died, the duration of his last sickness, and the date of his decease; and a physician who has attended at a birth of a child dyin"
immediately thereafter, or at the birth of a stillborn child, shall, when requested, forthwith furnish for registration a certificat<T
stating to the best of his knowledge and belief the fact that such a child died after birth of was born dead. If a physician neg-
lects or refuses to make a certificate as aforesaid, or makes a false statement therein, he shall be punished by a fine not exceeding
fifty dollars. In case the deceased was a soldier or a sailor who served in the war of the rebellion, the physician shall give both
the primary and the secondary or immediate cause of death as nearly as he can state the same. If a physician refuses or neglects
to make such certificate lie shall forfeit to the treasurer the sum of ten dollars for the use of the town in which he resides.

Section 5. No undertaker, sexton or other person shall bury in a city or town or renkove therefrom a human body until he
has received a permit so to do from the board of health or its duly appointed agent, or, if tjhere is no board of health in such city
or town, from the city or town clerk. No such permit shall be issued until there has been1 delivered to such board, or agent or
clerk, as the case may be, a satisfactory written statement containing the facts required by this chapter to be returned and
recorded, together with the certificate of the attending physician, if any, as required by section three of this chapter, or in lieu
thereof a certificate as hereinafter provided. If there is no attending physician, or if the certificate of the attending physician
cannot be obtained, for good and sufficient reasons, early enough for the purpose, the chairman of the board of health or any
physician employed by a city or town for the purpose shall, upon request of said board, agent or clerk, make such certificate as is
required of the.attending physician; and in case of death by violence the medical examiner shall, if requested, make the same.
When such satisfactory statement aiid certificate are delivered to the board of health or to its agent, the board or agent shall forth-
with countersign and transmit the same to the cleric or registrar for registration. The pcilson to whom the permit is so given
shall thereafter furnish for registration any other information as to the deceased or to the manner and cause of the death, as the
clerk or registrar may require. Any person violating any of the provisions of this section sfhall be punished by a fine not exceed-
ing fifty dollars.

Commonfocaltlj of Massachusetts.

kpH

Cfl

b£)

^■H

fee

/ Disease or Cause of Death

V (Primary and Secondary), f

(Duration of Sickness,

< V

«+-i

S O
fc £

»*= -+->

k-H

f=3

■

* If a Married Woman or Widow. J If aSoldier who served inthe War of the Rebellion,
t If other than White. (M.) Mulatto. (I.) Indian. If of other Races, specify what.

[Be very particular to fill all Blanks.]

Plate. Ed, l)ec., 1895. — 5,000.

r™“!' Tz<tLz:x^:::/T\c',Tso6: Ac“°/iss9- +*«»"• «**«*]

tration, a certificate stating, to the best of liis kmfwled^anlff ilIness sIlall> when requested, forthwith furnish for re"is

died, the duration of his l£t sickness, and the the deceased, his age, the disSSJS which^e

immediately thereafter, or at the birth of a stillborn child Physician who has attended at a birth of a child dvin-

stating to the best of his knowledge and belief the fact that such a child d!^d« ft fo,rth'vlth funilsh for registration a certificate”
lects or refuses to make a certificate as aforesaid or nnS °i born deild- If a physician neg-

fifty dollars. In case the deceased was a soldier or a Q..iior ^ L"t therein, he shall be punished bv a fine not exceeding

the primary and the secondary or immediate cause of death a ' i ° ' i ' ' ed ln 1 ie war of the rebellion, the physician shall give both
to make such certificate he slfall f <3$f to Wtl^f If a ^^-s or^Jlects

Section o. h.o undertaker, sexton or other person shall burv in a eite or t F tbe USe tbe .t0'vn in which he resides,
has received a permit so to do from the board of health or its dulv nnnoint' ** to"Ln or remove therefrom a human body until he
or town, from the city or town clerk. No such pemit shaS be °T\ lf th?re is no board of health in such city
clerk, as the case may be, a satisfactory written state™ „t Ilf”' “!■ there has been delivered to such board, or a^ent or
recorded, together with the certificate o/ the attendin^hvLian^fa1^ ‘G faCtS 1*9“ired bi' «»!■ chapter to be returned and
thereof a certificate as hereinafter provided. If thereof no attending nh’v«- .requ,red b£ section three of this chapter, or in lieu
cannot be obtained, for good andsnfficient reasons ^ eaidv enonX f J ’ °Mf the certjflcate of the attending physician

physician employed by a city or town for the purpose shall th? chairman of the b°ard of health or any
required of the attending physician ; and in case of death bv violence ^oard’ a"ent clerk, make such certificate as i's

When such satisfactory statement ahd certificate are delivered, to the hoard nf l.lca} exaaiin.er shall> if requested, make the same.

Sr«”srrn,vre<""r'' ^ ^

PHYSICIAN’S CERTIFICATE

Name and Age of Deceased,* * , ^4 A^O^hu-TeU

Date ami Place of Deaths died at ft A l J '/ pi, i: ■ \ ,pl .4 J H Jfa,, / ■*- • :-,y
bisease or Cause of Death> - of /tyfwj." *&2£g£ //UJyyfrjAy^ ^sJfUfA

{Primary aud Secondary.) J // ■*■

urution of Sickness, - -

/ certify that the above is true, to the best Jf my knowledge and belief.

Signature and Resilience of Certifying P/iysician, t/^

Date of Certificate, &. A/(* / cT~~ Tgg

• o, S- C — it— - —• t »«*

[Public SUOM. Chapter 32, a, amended h, Acs a/lSSS, Chapter 300; Act, of 1889, Chapter 224; AeU af 1893, Chapter 203 ]

tratio^aTrtL.t,' SnT‘t^ m"“s loqucstod, forthwith furntah for regia,

died, the duration of his l.% “icknesf aud thj date of i S*. T '1 the, <*““*»’. “s •*=• «“ diseaae which he

i=§§gPi^^

iug fifty dollars. ^ ' yl a > °latin0 any of the pro\ lsions of this section shall be punished by a fine not exceed-

(Commonfcocaltb of $|lassafl)us£tts.

* If a Married Woman or Widow. t If a Soldier who served in the War of the Rebellion,
t If other than White. (M.) Mulatto. (I.) Indian. If of other Races, specify what.

[Be very particular to fill all Blanks.]
l’latc. Ed Dec., 1895.-5,000.

IPublic Statutes, Chapter 32, as amended by Acts of 188S, Chapter 300 ; Acts of 18S9, Chapter 224; Acts of 1893, Chapter 263.]

Section 3. A physician who has attended a person during his last illness shall, when requested, forthwith furnish for regis-
tration, a certificate stating, to the best, of his knowledge and belief, the name of the deceased] his age, the disease of which he
died, the duration of his last sickness, and the date of his decease; and a physician who has attende.l at a birth of a child dying
immediately thereafter, or at tiie birth of a stillborn child, shall, when requested, forthwith furnish for registration a certificate,
stating to the best of his knowledge and belief the fact that such a child died after birth or was born dead. If a physician neg-
lects or refuses to make a certificate as aforesaid, or makes a false statement therein, he shall be punished by a fine notexceeding
fifty dollars. In case the deceased was a soldier or a sailor who served in the war of the rebellion, the physician shall give both
the primary and the secondary or immediate cause of death as nearly as he can state the same. If a physician refuses or neglects
to make such certificate he shall forfeit, to the treasurer the sum of ten dollars for the use of the town in which he resides.

Section 5. No undertaker, sextoii or other person shall bury in a city or town or remove [therefrom a human body until he
has received a permit so to do from the board of health or its duly appointed agent, or, if there is no board of health in such city
or town, from the city or town clerk. No such permit shall be issued until there has been delivered to such board, or agent or
clerk, as the case may be, a satisfactory written statement containing the facts required by this chapter to be returned and
recorded, together with the certificate of the attending physician, if any, as required by section three of this chapter, or in lieu
thereof a certificate as hereinafter provided. If there is no attending physician, or if the certificate of the attending physician
cannot be obtained, for good and sufficient reasons, early enough for the purpose, the chairman of the board of health or anyt
physician employed by a city or town for the purpose shall, upon request of said board, agent ot clerk, make such certificate as is
required of the attending physician ; and in case of death by violence the medical examiner shjall, if requested, make the same.
When such satisfactory statement and certificate are delivered to the board of health or to its agent, the board or agent shall forth-
with countersign and transmit the same to the clerk or registrar for registration. The person to whom the permit is so given
shall thereafter furnish for registration any other information as to the deceased or to the manner and cause of the death, as the
clerk or registrar may require. Any person violating any of the provisions of this section shall' be punished by a fine not exceed-
ing fifty dollars.

PHYSICIAN’S CERTIFICATE,

Name and Age of Deceased,*

Date and Place of Death, t - died at.. /,

Disease or Cause of Death, - of

{Primary and Secondary .){

Duration of Sickness, - - |

I certify that the above is true , to the best of my knowledge and belief.

N/S- ■

AsefSr--X^^
fudDd.: > ,

'tpj...~ds! - -

Signature and Residence of Certifying Physician,

£/■

Date dp Certificate ,

* Or Sex of Infant (not named) . If stillborn so state.

t I f child died immediately after birth so state . t 1 f a
Plate. Ed. October, 1895. — 5,000.

soldier or sailor who served in the War of the Rebellion.

[Public Statutes, Chapter 32, as amended by Acts of 1888 Chanter ?nr ■ a , , , OD„

Section 3. A physician who has attended a person ’durin- i • , of2S89’ ChaPter 224 Acts of 1893, Chapter 263.]

omm

mmm

189-2 "

PHYSICIAN’S CERTIFICATE OF THE CAUSE OF DEATH.

Duration of disease.*

/ certify that the above^true, to the best of my knowledge apft belief.

Name and residence )

of physician. J £

*It is very desirable to be informed of the duration of the disease.

M. D.

"* OM" EZSSSi X iem ?2S r —

J *“L±« M.i other days, from 9 A.M. till 5 P.M.

- ~~

■

Date of (leal h, . ..£2 189 % ;Name,.J?^

Maiden name,*. — -~~ " gex

single, er widow of- wife -of—

Color, Agejbt. years, cT^mos.,. /Jfdays. Kesidenee, ^

Place of death (•*£&“d), 2& &Z./&A' ward I/{_.

Place of birth, © Occupation,

Name of hither, Maiden name of ^wX\wv,(^fj^cU^^2:. ^

Bii thplace ot father, C 3^. Birthplace of mother, @jh-LA?fo)

Place of interment, f 2 !X//^ ^ ^ (

» If a married woman or a widow. + Give the name of the bnriai ground.

Signature of Undertaker :

[Public Statutes, Chapter 32, as amended by Acts of 188S, Chapter 30G ; Acts of 1889, Chapter 224; Acts of 1893, Chapter 263.]

Section 3. A physician who has attended a person during liis last illness shall, when requested, forthwith furnish for regis-
tration, a certificate stating to the best of his knowledge and belief, the name of the deceased, his age, the disease of which he
US last s.1.ck"«®s’ aa(1 the date of his decease; and a physician who has attended at a birth of a child dying
immediately thereafter, or at the birth ol a stillborn child, shall, when requested, forthwith furnish for registration a cert'floate
stating to the best of his knowledge and belief the fact that such a child died after birth or was born dead. If a physician ne~-
S* ?rnI'efusesT t0 mak® a certificate as aforesaid, or makes a false statement therein, he shall be punished by a fine not -xceedim-'
, l-v dollars. Iu case the deceased was a soldier or a sailor who served in the war of the rebellion, the physician shall give both
the primary and the secondary or immediate cause of death as nearly as he can state the same. If a physician refuses or neglects
to make such certificate he shall forfeit to the treasurer the sum of ten dollars for the use of the town in which he resides. °

section a. >io undertaker, sexton or other person shall bury in a city or town or remove therefrom a human body until he
has received a permit so to do from the board of health or its duly appointed agent, or, if there is no board of health in such citv
or tow n, from the city or town clerk. !No such permit shall be issued until there has been delivered to such board, or agent or
'i C'V9, ♦ C*lse a satisfactory written statement containing the facts required by this chapter to be returned and

ec rded, together with the certificate of the attending physician, if any, as required by section three of this chapter, or in lieu
thereof a certificate as hereinafter provided. If there is no attending physician, or if the certificate of the attending ohvsician
cannot be obtained, for good and sufficient reasons, early enough for the purpose, the chairman of the board of health or any
physician employed by a city or town for the purpose shall, upon request of said board, agent or clerk, make such certificate as is
requited of the attending physician; and in case of death by violence the medical examiner shall, if requested, make the same.

hen such satisfactory statement and certificate are delivered to the board of health or to its agent, the board or agent shall forth-
with countersign and transmit the same to the clerk or registrar for registration. The person to whom the permit is so given
snail thereafter furnish for registration any other information as to the deceased or to the manner and cause of the death as the
clerk or registrar may require. Any person violating any of the provisions of this section shall be punished by a fine not exceed-
ing fifty dollars.

PHYSICIAN’S CERTIFICATE.

Vame and Age of Deceased,* { f ~)JU UAA^fi.fR
Date and Place of Death ,t - died at.

n'-)\

Duration of Sickness,

f J r.\.ACAAfib

-fiXd/W

Disease or Cause of Death,

{Primary and Secondary. ) j

jOAOJaR

'j ,'ld< 1*^

Age, (obu-Kd
AqL 'A) 'L189' / ,

Signature and Residence 0/ Certifying Physician

I certify that the above is true , to the best of my knowledge an, Relief.

2t/. J?

U Z” i 89p .

Date of Certificate,

* Or Sex of Infant (not named). If stillborn so state. t

If child died immediately after birth so state. t If a soldier or sailor who served in the War of the Rebellion-

Plate. Ed. October, 1895. — 5,000.

[Public Statutes, Chapter 32, as amendedby Acts of 188S, Chapter 306 ; Actsofl889, Chapter 224; Actso/1893, Chapter 2 03 j

or town^'from thTc!^^ 7 52S!

recorded toS written Statement conffEg^the

thereof a’ cei7flcaL7s^ liorei ° 7 a“e”din= Physicia"* ?f any, as required by section three of this chapter or in lieu

sir

^s'doiir"”81

* If a Married Woman or Widow. t If a Soldier who served in the War of the Rebellion,
t If other than White. (M.) Mulatto. (I.) Indian. If of other Races, specify what.

[Be very particular to fill all Blanks.]

Plate. Ed. Dec., 1895. — 5,000.

[Public Statutes, Chapter 32, as amended by Acts of 1888, Chapter 306 ; Acts of 1S89, Chapter 224 ; Acts of 1S93, Chapter 263-1

Section 3. A physician who has attended a person during his last illness shall, when requested, forthwith furnish for regis-
tration, a certificate stating, to the best of his knowledge and belief, the name of the deceased, his age, the disease of which he
died, the duration of his last sickness, and the date of his decease; and a physician who has attended at a birth of a child dying
immediately thereafter, or at the birth of a stillborn child, shall, when requested, forthwith furnish for registration a certificate,
stating to the best of his knowledge and belief the fact that such a child died after birth or was born dead. If a physician neg-
lects or refuses to make a certificate as aforesaid, or makes a false statement therein, ne shall be punished by a fine not exceeding
fifty dollars. In case the deceased was a soldier or a sailor who served in the war of the rebellion, the physician shall give both
the primary and the secondary or immediate cause of death as nearly as he can state the same. If a physician refuses or neglects
to make such certificate he shall forfeit to the treasurer the sum of ten dollars for the use of the town in which he resides.

Section* 5. No undertaker, sexton or other person shall bury in a city or town or remove therefrom a human body until he
has received a permit so to do from the board of health or its duly appointed agent, or, if there is no board of health in such city
or town, from the city or town clerk. No such permit shall be issued until there has been delivered to such board, or agent or
clerk, as the case may be, a satisfactory written statement containing the facts required by this chapter to be returned and
recorded, together with the certificate of the attending physician, if any, as required by section three of this chapter, or in lieu
thereof a certificate as hereinafter provided. If there is no attending physician, or if the certificate of the attending physician
cannot be obtained, for good and sufficient reasons, early enough for the purpose, the chairman of the board of health or any
physician employed by a city or town for the purpose shall, upon request of said board, agent or clerk, make such certificate as is
required of the attending physician ; and in case of death by violence the medical examiner shall, if requested, make the same.
When such satisfactory statement and certificate are delivered to the board of health or to its agent, the board or agent shall forth-
with countersign and transmit the same to the clerk or registrar for registration. The person to whom the permit is so given
shall thereafter furnish for registration any other information as to the deceased or to the manner and cause of the death, as the
clerk or registrar may require. Any person violating any of the provisions of this section shall be punished by a fine not exceed-
ing fifty dollars.

PHYSICIAN’S CERTIFICATE.

Name and Age of Deceased,

' c <-< oA. * C ' <- /c

Age,

Da,t ru,u of Dea,U, t - | iUia.Nl UULpt^ifM -« /

Disease or Cause of Death, - of .

(Primary and Secondary. )\

Duration of Sickness,

/ certify that the above is true, to the best of my knowledge and belief. ^

1. Signature and residence of Certifying Physician, f /

Date of Certificate, . _y J, A

— — _ _ . , . , _ + If a soldier or sailor who served in the

if.u»b<,„„ ...... t '“uus^tKS£^!St-^

[Pu&ffc Statutes, Chapter 32, as amended by Acts of 18SS, Chapter 30G ; Acts of 1889, Chapter 224 ; Acts of 1S93, Chapter 2G3.]

Section 3. A physician who has attended a person during his last illness shall, when requested, forthwith furnish for regis-
tration, a certificate stating, to the best of his knowledge and belief, the name of the deceased, his age, the disease of which he
died, the duration of his last sickness, and the date of his decease; and a physician who has attended at a birth of a child dying
immediately thereafter, or at the birtli of a stillborn child, shall, when requested, forthwith furnish for registration a certificate,
stating to the best of his knowledge and belief the fact that such a child died after birth or was born dead. If a physician neg-
lects or refuses to make a certificate as aforesaid, or makes a false statement therein, he shall be punished by a fine not exceeding
fifty dollars. In case the deceased was a soldier or a sailor who served in the war of the rebellion, the physician shall give both
the primary and the secondary or immediate cause of death as nearly as he can state the same. If a physician refuses or neglects
to make such certificate he shall forfeit to the treasurer the sum of ten dollars for the use of the town in which he resides.

Section 5. No undertaker, sexton or other person shall bury in a city or town or remove therefrom a human body until he
has received a permit so to do from the board of health or its duly appointed agent, or, if there is no board of health in such city
or town, from the city or town clerk. No such permit shall be issued until there has been delivered to such board, or agent or
clerk, as the case may be, a satisfactory written statement containing the facts required by this chapter, to be returned and
recorded, together with the certificate of the attending physician, if any, as required by section three of this chapter, or in lieu
thereof a certificate as hereinafter provided. If there is no attending physician, or if the certificate of the attending physician
cannot be obtained, for good and sufficient reasons, early enough for the purpose, the chairman of the board of health or any
physician employed by a city or town for the purpose shall, upon request of said board, agent or clerk, make such certificate as is
required of the attending physician; and in case of death by violence the medical examiner shall, if requested, make the same.
When such satisfactory statement and certificate are delivered to the board of health or to its agent, the board or agent shall forth-
with countersign and transmit the same to the clerk or registrar for registration. The person to whom the permit is so given
shall thereafter furnish for registration any other information as to the deceased or to the manner and cause of the death, as the
clerk or registrar may require. Any person violating any of the provisions of this section shall be punished by a fine not exceed-
ing fifty dollars.

PHYSICIAN’S CERTIFICATE OF THE CAUSE OF DEATH

Duration of disease .

of physician

. I

r cer

i k

1 certify that the above is true, to the best of my knowledge and belief ,
Name and residence ' ' ~ 3s

45^>s—

* It is very desirable to be informed of the duration of the disease.

The office of the Board of Health will he open for the granting of permits for burial, as follows: — Saturdays, 9 A. M. till
2 P.M.; Sundays, It) A. M. till 12 M.j Holidays, from lO A. M. till 12 M.; other days, from 9 A.M. till 5 P.M.

I cnAA

UNDERTAKER’S RETURN.-dJsstae

Date of death, c . /j^ 189 Z. .....

Maiden name,* Sex, ^$...

Married, single, or widow of wife of

Color, w AgejlO years, 7 mos., ^Z.days. Residence, /C/ZStfj..

M Place of death (stnambaerd) ? ^^^^^yrard

Place of birth, . Occupati on(S ^ J/'f ff'T'C

Name of father, Maiden name of mother,

Birthplace of father, Birthplace of mother,

) Place of interment, f

* If a married woman or a widow. j Give the name of the burial ground.

Signature of Undertaker : ^ <:

yt>trZ4/2^ \

—

RETURN OF A DEATH.

To the Clerk of the City or Town in which the Death occurred.

* If a Married Woman or Widow. t If a Soldier who served in the War of the Rebellion,
t If other than White. (M.) Mulatto. (I.) Indian. If of other Races, specify what.

[Be very: particular to fill all Blanks.]

Plate. Ed. Dec., 1895.-5,000.

[ Public Statutes, Chapter 32, as amended bj Acts of 18SS, Chapter 306; Acts of 1889, Chapter 224; Acts of 1S93, Chapter 263.]

Section' 3. A physician who has attended a person during his last illness shall, when requested, forthwith furnish for regis-
tration, a certificate stating, to the best of his knowledge and belief, the name of the deceased, his age, the disease of which he
died, the duration of his last sickness, and the date of his decease; and a physician who has attended at a birth of a child dying
immediately thereafter, or at the birth of a stillborn child, shall, when requested, forthwith furnish for registration a certificate,
stating to the best of his knowledge and belief the fact that such a child died after birth or was born dead. If a physician neg-
lects or refuses to make a certificate as aforesaid, or makes a false statement thereiu, he shall be punished by a fine not exceeding
fifty dollars. In case the deceased was a soldier or a sailor who served in the war of the rebellion, the physician shall give both
the primary and the secondary or immediate cause of death as nearly as he can state the same. If a physician refuses or neglects
to make such certificate he shall forfeit to the treasurer the sum of ten dollars for the use of the town in which he resides.

Section 5. No undertaker, sexton or other person shall bury in a city or town or remove therefrom a human body until lie
has received a permit so to do from the board of health or its duly appointed agent, or, if there is no board of health in such city
or town, from the city or town clerk. No such permit shall be issued until there has been delivered to such board, or agent °''
clerk, as the case may be, a satisfactory written statement containing the facts required by this chapter to be returned and
recorded, together with the certificate of the attending physician, if any, as required by section three of tins chapter, or in lieu
thereof a certificate as hereinafter provided. If there is no attending physician, or if the certificate of the attending physician
cannot be obtained, for good and sufficient reasons, early enough for the purpose, the chairman of the board of health or any
physician employed by a city or town for the purpose shall, upon request of said board, agent or clerk, make such certificate as is
required of the attending physician; and in case of death by violence the medical examiner shall, if requested, make the same.
When such satisfactory statement and certificate are delivered to the board ot health or to its agent, the board or agent shall fortn-
with countersign and transmit the same to the clerk or registrar for registration. The person to whom the permit is so g'ven
shall thereafter furnish for registration any other information as to the deceased or to the manner and cause ot the death, as the

I’ofricfnor rr»o\r romiiPA Amr T\f»rcnn vinlflt.inof nnv nf nrnvisirtim of t.hlS SftCtioil Sllllll 1)6 DU0isll6Cl DV & fine llOt CXC6CU"

Name and Age of Deceased,

PHYSICIAN’S CERTIFICATE.

t Public Statutes, Chapter 32, as amended by Acts of 1888 , forthwith furnish for regies-

Section 3. A physician iwho and belief, the name of ^^.^“gttended^ dying

tration, a certificate stating, to md the date of his decease; and a physician w ho " . . for registration a certificate,

died, the duration of ins last oTa stdSorn ddld, shall, when requested f ^ L1 ^oVn JcucL l f a physician neg-

immediately thereafter, or at J,, belief the fact that such a child died after bn . ighed by a fine not exceeding

has received a permit so to do from permit shall be issued until there lias been chapter to be returned and

or town, from the city or town clerk. No such ^“tement containing the facts required by twsenap or in li(.u

clerk, as the case maybe, a satlsfactoij lending physician, if any, as required by section re ^ ^ attending physician
recorded, together with the cer ificate of ft « I , ,9^ attendlng physician, or t ( of thc board of health or any

thereof a certificate as hereinafter prov dea. u enough for the purpose, the chairman make such certificate as is

cannot be obtained, for good and sufflcie ' s)iall. npon re(iuest of said boaid, Wjt o 'requested, make the same,

physician employed by a city or town foi the the medical examiner shall, >* or a«ent shall forth-

shai1 be punished by a flne uot cxcecd*

ing fifty dollars.

(foTttmoivfornltb of ^iTssntbusrtts.

* If a Married Woman or Widow. J If a Soldier who served in the War of the Rebellion.
t If other than White. (M.) Mulatto. (I.) Indian. If of other Races, specify what.

[B© very particular to fill all Blanks.]

Plate. Ed. Dec., 1895.-5,000.

[Public Statutes, Chapter 32, as amended by Acts of 18SS, Chapter 306 ; Acts of 1889, Chapter 224; Acts oflS93, Chapter 263.]

Section 3. A physician who has attended a person during his last illness shall, when requested, forthwith furnish for regis-
tration, a certificate stating, to the best of his knowledge and belief, the name of the deceased, his age, the disease of which he
died, the duration of his last sickness, and the date of his decease; and a physician who has attended at a birth of a child dying
immediately thereafter, or at the birth of a stillborn child, shall, when requested, forthwith furnish for registration a certificate,
stating to the best of his knowledge and belief the fact that such a child died after birth or was born dead. If a physician neg-
lects or refuses to make a certificate as aforesaid, or makes a false statement therein, he shall be punished by a fine not exceeding
fifty dollars. In case the deceased was a soldier or a sailor who served in the war of the rebellion, the physician shall give both
the primary and the secondary or immediate cause of death as nearly as he can state the same. If a physician refuses or neglects
to make such certificate he shall forfeit to the treasurer the sum of ten dollars for the use of the town in which he resides.

Section 5. No undertaker, sexton or other person shall bury in a city or town or remove therefrom a human body until he
has received a permit so to do from the board of health or its duly appointed agent, or, if there is no board of health in such city
or town, from the city or town clerk. No such permit shall be issued until there has been delivered to such board, or agent or
clerk, as the case may be, a satisfactory written statement containing the facts required by this chapter to be returned and
recorded, together with the certificate of the attending physician, if any, as required by section three of this chapter, or in lieu
thereof a certificate as hereinafter provided. If there is no attending physician, or if the certificate of the attending physician
cannot be obtained, for good and sufficient reasons, early enough for the purpose, the chairman of the board of health or any
physician employed by a city or town for the purpose shall, upon request of said board, agent or clerk, make such certificate as is
required of the attending physician; and in case of death by violence the medical examiner shall, if requested, make the same.
When such satisfactory statement and certificate are delivered to the board of health or to its agent, the board or agent shall forth-
with countersign and transmit the same to the clerk or registrar for registration. The person to whom the permit is so given
shall thereafter furnish for registration any other information as to the deceased or tolhe manner and cause of the death, as the
clerk or registrar may require. Apy person violating any of the provisions of this section shall be punished by a fine not exceed-
ing fifty dollars.

•son violating any of the provisions of this septic

PHYSICIAN’S CERTIFICATE.

Name am/ Age of Deceased '*

Date and Place of Death,] - died at

f/JLou /&J ,

' J A.dt / o ( .

'JMd&i

Disease or Cause of Death, - of / /L^

{Primary und Secondary.)] * t\ /

v C

Duration of Sickness,

Cb-et ffi

t /

I certify that the above is true , A> the best of my knowledge and belief.

Signature a tut Residence of Certifying Physician ,

‘PD-N.

to the ties t oj mv Knowledge

YicdPi iL /

Date of Certificate, . ^ ^ C ’^/ / ^

189

* Or Sex of Infant (not named). Ifstillborn so state. t Ifchild died immediately after birth so state. \ If a soldier or sailorwho served in the War of the Rebellion.

Plate. Ed. October, 1895.-5,000.

[rvblic Statutes, Chapter 32, as amendedby AclsoflSSS, Chapter 306 ; ActsoflS89, Chapter 224; Actsofl893, Chapter 263.]
Section 3. A physician who has attended a person during his last illness shall, when requested fortlj\uth furn ish f or regis-

has received a pemit so to do f^m the board of health or or agent ^r

§§§^^

cannot be obtained, for good and sufficient reasons, JS

physician employed by a city or town for the PurP°s* if ’requested, make the same,
required of the attending physician ; and in case of death ^^1?“ ^ a„ent, the board or agent shall forth-

Whensuch satisfactory statement and certificate are delivered to .the ^ “ ,t Js ,0 given

with countersign and transmit the same to the clerk or registrai for r s < • manner and cause of the death, as the

sa s* * »->** * . *- « «— •

ing fifty dollars.

(Commonfocaltb of Hlassacjiusdts.

[Public Statutes, Chapter 32, as amended by Acts of 188S, Chapter 306 ; Acts of 1889, Chapter 224 : Acts of 1893, Chapter 263.]

Section’ 3. A physician who has attended a person during his last illness shall, when requested, forthwith furnish for regis-
tration, a certificate stating, to the best of his knowledge and belief, the name of the deceased, his age, the disease of which In-
died, the duration of his last sickness, and the date of his decease; and a physician who has attended at a birth of a child dyin^
immediately thereafter, or at tiie birth of a stillborn child, shall, when requested, forthwith furnish for registration a certificate,
stating to the best of his knowledge and belief the fact that such a child died after birth or was born dead. If a physician neg-
lects or refuses to make a certificate as aforesaid, or makes a false statement therein, he shall be punished by a fine uotexcceding
fifty dollars. In case the deceased was a soldier or a sailor who served in the war of the rebellion, the physician shall give both
the primary and the secondary or immediate cause of death as nearly as he can state the same. If a physician refuses or neglects
to make such certificate he shall forfeit to the treasurer the sum of ten dollars for the use of the town in which he resides.

Section 5. No undertaker, sexton or other person shall bury in a city or town or remove therefrom a human body until he
has received a permit so to do from the board of health or its duly appointed agent, or, if there is no board of health In such city
or town, from the city or town clerk. No such permit shall be issued until there has been delivered to such board, or agent or
clerk, as the case may be, a satisfactory written statement containing the facts required by this chapter to be returned and
recorded, together with the certificate of the attending physician, if any, as required by section three of this chapter, or in lieu
thereof a certificate as hereinafter provided. If there is no attending physician, or if the certificate of the attending physician
cannot be obtained, for good and sufficient reasons, early enough for the purpose, the chairman of the board of health or any
physician employed by a city or town for the purpose shall, upon request of said board, agent or clerk, make such certificate as is
required of the attending physician ; and in case of death by violence the medical examiner shall, if requested, make the same.
When such satisfactory statement and certificate are delivered to the board of health or to its agent, the board or agent shall forth-
with countersign and transmit the same to the clerk or registrar for registration. The person to whom the permit is so given
shall thereafter furnish for registration any other information as to the deceased or to the manner and cause of the death, as the
clerk or registrar may require. Any person violating any of the provisions of this section shall be punished by a fine not exceed-

(id <*,,

PHYSICIAN’S CERTIFICATE OF THE CAUSE OF DEATH

Boston, /....G. 189— /Z

ame and age of deceased : AtTL. Age.M*.. C?.. yrs.... mos,-(^rrr. dye

, .s-s (p >’ syry ~y

Date and place of death:

Disease or cause of death : . £:.

^ ^ ^

. mL

Duration of disease

Name and residence I
of physician. J

I certify that the above is true, to tlte best of my knowledge and belief.

(ft. . . .jbs*y*rwxei. >

M. D.

** ! 2> ' ^

[y .y' U^££ia^/,

It la very desirable to be informed of the duration of the disease.

return of a death.

To the Clerk of the City or Town in which the Death occurred.

.Disease or Cause of Death,

\ (Primary and Secondary), }

6- Duration of Sickness, .

By whom certified,
Residence,

1 r otheT than wiS' °'i m"V. If “,?°,ld,ie vWho serve(l *" tho War & the Rebellion.

(*1.) Mulatto. (I.) Indian. If of other Races, specify what,

I Be very particular to fill all Blanks.1

Pin In k\l T iuod = n,...

[Public Statutes, Chapter 32, as amended l>j Acts of 1S8S, Chapter 306 ; Acts of 1S89, Chapter 224 ; Arts of 1893, Chapter 2'

Section' 3. A physician who has attended a person during his last illness shall, when requested, forthwith furnish for r
tration, a certificate stating, to the best of his knowledge and belief, the name of the deceased, his age, the disease of whicl
died, the duration of his last sickness, and the date of his decease; and a physician who has attended at a birth of a child <
immediately thereafter, or at the birth of a stillborn child, shall, when requested, forthwith furnish for registration a certific
stating to the best of his knowledge and belief the fact that such a child died after birth or was born dead. If a physician n
lects or refuses to make a certificate as aforesaid, or makes a false statement therein, ne shall be punished by a fine notexceedir
fifty dollars. In case the deceased was a soldier or a sailor who served in the war of the rebellion, the physician shall give be
the primary and the secondary or immediate cause of death as nearly as he can state the same. If a physician refuses or ncgle
to make such certificate he shall forfeit to the treasurer the sum of ten dollars for the use of the town in which lie resides.

Section' 5. No undertaker, sexton or other person shall bury in a city or town or remove therefrom a human body until h
has received a permit so to do from the board of health or its duly appointed agent, or, if there is no board of health in such cit;
or town, from the city or town clerk. No such permit shall be issued until there has been delivered to such board, or agent <
clerk, as the case may be, a satisfactory written statement containing the facts required by this chapter to be returned a
recorded, together with the certificate of the attending physician, if any, as required by section three of this chapter, or in
•.hereof a certificate as hereinafter provided. If there is no attending physician, or if the certificate of the attending physic
cannot be obtained, for good and sufficient reasons, early enough for the purpose, the chairman of the board of health or
physician employed by a city or town for the purpose shall, upon request of said board, agent or clerk, make such certificate p
required of the attending physician; and in case of death by violence the medical examiner shall, if requested, make the s
When such satisfactory statement and certificate are delivered to the board of health or to its agent, the board or agent shai
with countersign and transmit the same to the clerk or registrar for registration. The person to whom the permit is so f.
'hall thereafter furnish for registration any other information as to the deceased or to the manner and cause of the death, a
clerk or registrar may require. Any person violating any of the provisions of this section shall be punished by a fine not excet
ing fifty dollars.

V.c

ri-

.•‘font' and Age of Deceased,

Date and Place of Death, \ - \ died at

r. JO

PHYSICIAN’S CERTIFICATE.

7fhi_ Tllasus ~7h

» $Tr±-T-

■/Disease or Cause of Death,

R, ( Primary and Secondary .)J

Deration of Sickness,

ZZ ~PuA<. JdA. L & a£j»9 y

Y&Jtd — - — iuf&fLJD*,

jjxSCuS>y^\}

liiK

bSl

J certify that the above is true , to the best of my knowledge and belief.

•s

iL p.j

ItQl'C IS It lie , IU LUC l test VJ K.n>V LUt'CU.gC UrUU. ^ f) C* / *\

7t &iu*k&y ...Si zfffz. *

Date of Certificate,

. Or bex of Infant (not named). If stillborn so state. T If child died immediately after birth so state. t If a soldier or sailor who served in the War of the Rebelhon.

Plate. Ed. October, 1895. — 5,000.

[Public Statutes, Chapter 32, as amended by Acts of 1888, Chapter 306 ; Acts of 1889, Chapter 224; Acts of 1893, Chapter 263.]
tratlon^^cwtfflcate^ta^’n^'^uTe^esfof durf? illness sha11' when ^quested, forthwith furnish for regis-

flfty dollars In case the <] Pl ori e as atOI<jsaid, OI makes a false statement therein, he shall be punished by a tine not exceedin''
the^rtolary and^h^seconda^^r fmmed?ate>Mnsp°o^ffa thF Wh° TVed iu lhe war of the hellion, the physician shall give* both
to make such certificate he shill f irTii f.i , f deat,h as nearly as he can state the same. If a physician refuses or neglects
Section 5 X undertakt SSl Z thfe, treasurer tbe of ten dollars for the use of the town in which he resides. b
has received a permit i P1^11 sha11 bury in a city or town or remove therefrom a human body until he

ortown, from the dty or town t v^,01 heal * °lr f8 daly appointed agent, or, if there is no board of health in such city
clerk as the case rniv he i ^ per™lt slia11 be ]ssue(1 until there has been delivered to such board, or agent or

recorded together with the cen m/n?t0'7 tx Tltt®n statement containing the facts required by this chapter to be returned and
thereof a certificate is lier^inio ^ f, the attending physician, if any, as required by section three of this chapter, or in lieu
cSot be obtained f m “ there 5f? no attendi»S physician, or if the certificate of the attending physician

physician employed bvVcitv oriL^nr^o, reasons> early enough for the purpose, the chairman of the board of health or any
required of the attend hi<» Purpose shall, upon request of said board, ageut or clerk, make such certificate as is

When such satisfactorv'stitemeiw llf-caSf °f de,a^1 by viokmce the medical examiner shall, if requested, make the same.

with countersign and transmit the sil. ti itt a[e deliv*r®d to_the board of health or 10 ’ ts aScnt> t,,e hoard or agent shall forth-
shall therea^r^rnish^or^eoSsfroM^^ ! the clerk or registrar for registration. The person to whom the permit is so given
clerk or registrar unv rennin-0 in! any °!;her informatlon as t0 the deceased or to the manner and cause of the death, as the
ing fifty dollars 7 Q Any P n Tlolat,nS any of the provisions of this section shall be punished by a fine not exceed-

* If a Married Woman or AVidow. f If a Soldier who served in the War of ^he llehellion.
t If other than White. (M.) Mulatto. (I.) Indian. If of other Races, specify what.

[Be very particular to fill all Blanks.]

1’lato.* Ed. Dec., 1895.-5,000.

[■ Public Statutes, Chapter 32, as amended by Acts of 1SSS, Chapter 306 ; Acts of 1SS9, Chapter 224 ; Acts of 1893, Chapter 263.]

Section 3. A physician who has attended a person during his last illness shall, when requested, forthwith furnish for regis-
tration, a certificate stating, to the best of his knowledge and belief, the name of the deceased, his age, the disease of which he
died, the duration of his last sickness, and the date of his decease; and a physician who has attended at a birth of a child dying
immediately thereafter, or at the birth of a stillborn child, shall, when requested, forthwith furnish for registration a certificate,
stating to the best of his knowledge and belief the fact that such a child died after birth or was born dead. If a physician neg-
lects or refuses to make a certificate as aforesaid, or makes a false statement therein, he shall be punished by a fine not exceeding
fifty dollars. In case the deceased was a soldier or a sailor who served in the war of the rebellion, the physician shall give both
the primary and the secondary or immediate cause of death as nearly as he can state the same. If a physician refuses or neglects
to make such certificate he shall forfeit to the treasurer the sum of ten dollars for tne use of the town in which he resides.

Section 5. No undertaker, sexton or other person shall bury in a city or town or remove therefrom a human body until he
has received a permit so to do from the board of health or its duly appointed agent, or, if there is no board of health In such city
or town, from the city or town clerk. No such permit shall be issued until there has been delivered to such board, or agent or
clerk, as the case may be, a satisfactory written statement containing the facts required by this chapter to be returned and
recorded, together with the certificate of the attending physician, if any, as required by section three of this chapter, or in lieu
thereof a certificate as hereinafter provided. If there is no attending physician, or if the certificate of the attending physician
cannot be obtained, for good and sufficient reasons, early enough for the purpose, the chairman of the board of health or any
physician employed by a city or town for the purpose shall, upon request of said board, agent or clerk, make such certificate as is
required of the attending physician ; and in case of death by violence the medical examiner shall, if requested, make the same.
When such satisfactory statement and certificate are delivered to the board of health or to its agent, the board or agent shall forth-
with countersign and transmit the same to the clerk or registrar for registration. The person to whom the permit is so given
shall thereafter furnish for registration any other information as to the deceased or to the manner and cause of the death, as the

PHYSICIAN’S CERTIFICATE

S' nature and Residence of Certifying Physician ,

I certify that the above is true , to the best of my knowledge and belief.

sLAl — v.

Date of Certificate,

189 J7 .

* Ur bex of Infant (not named). 11 stillborn so state.

t 1 f child died immediately after birth so state. t If a soldier or sailor who served in the War of the Rebellion-
Plate. Ed. October, 1895. — 5, UUO.

[ Public Statutes, Chapter 32, as amended by Acts of 18SS, Chapter 30G ; Acts of 1SS9, Chapter 224; Acts of 1S93, Chapter 263.]
Section 3. A physician who has attended a person during his last illness shall, when requested, ^nlsh for regis-

tration, a certificate stating, to the best of his knowledge and belief, the name of thcdec'^

died, the duration of his last sickness, and the date of his decease; and a physician who fended ^a , a ^birth of a enuu „
immediately thereafter, or at the birth of a stillborn child, shall, when requested, forthwith furnish for registration a certmeare,
stating to the best of his knowledge and belief the fact that such a child died after birth or was 1 born dead If l1
lects or refuses to make a certificate as aforesaid, or makes a false statement therein, he shall be pun slitd ® ®hdl ri^oth
fifty dollars. In case the deceased was a soldier or a sailor who served in the war of ^

the primary and the secondary or immediate cause of death as nearly as he can state the same “ 1 K“ ^h??SldOT
to make such certificate he shall forfeit to the treasurer the sum of ten dollars for the use of the “ ' " 11 ‘ hod v until lie

Section 5. No undertaker, sexton or other person shall bury in a city or town or remove therefrom a huma. bod} ntu lie
has received a permit so to do from the board of health or its duly appointed agent, or if there is no board ^ re lt (;r
ortovn, from the city or town clerk. No such permit shall be issued until there has been .deliver^ to

clerk, as the case may be, a satisfactory written statement containing the facts requne 3 of lhis cjlapter 0r in lieu

recorded, together with the certificate of the attending physician, if any, as required y. . ttcIKij„« physician

thereof a certificate as hereinafter provided. If there is no attending physician, or if the certificate of ° : t^,11'^,P Jor an
cannot be obtained, for good and sufficient reasons, early enough for the purpose the

physician employed by a city or town for the purpose shall, upon request ot said o. ’ Veouested make the same.

required of the attending physician ; and in case of death by violencct.lie ,,u'dlca P^a7n ^ went the board or a-ent shall forth-

When such satisfactory statement and certificate are delivered to the board of health or to its a e, «ermlt is so given

with countersign and transmit the same to the clerk or registrar for registration i. The .person to v 1 death as the
«!“» t'*reat*r any ^ Site SSVy » nJ not been,.

* If a Married Woman or Widow. J If a Soldier who served in the War of the Rebellion,
t If other than White. (M.) Mulatto. (I.) Indian. If of other Races, specify what.

[Be very particular to fill all Blanks.]

Plate. Ed. Dec., 1895.-5,000.

[ Public Statutes, Chapter 32, as amended by Ads of 188S, Chapter 306 ; Acts of 18S9, Chapter 224 ; Acts of 1S93, Chapter 263. ]

Section 3. A physician who has attended a person during his last illness shall, when requested, forthwith furnish for regis-
tration, a certificate stating, to the best of his knowledge and belief, the name of the deceased, his age, the disease of which 1
died, the duration of his last sickness, and the date of his decease; and a physician who has attended at a birth of a child dyi,
immediately thereafter, or at the birth of a stillborn child, shall, when requested, forthwith furnish for registration a certificat-
stating to the best of his knowledge) and belief the fact that such a child died after birth or was born dead. If a physician neg
lects or refuses to make a certificate as aforesaid, or makes a false statement therein, ne shall be punished by a flue not exceeding
fifty dollars. In case the deceased was a soldier or a sailor who served in the war of the rebellion, the physician shall give both
the primary and the secondary or immediate cause of death as nearly as he can state the same. If a physician refuses or neglects
to make such certificate he shall forfeit to the treasurer the sum of ten dollars for the use of the town in which he resides.

Section 5. No undertaker, sekton or other person shall bury in a city or town or remove therefrom a human body until he
has received a permit so to do from the board of health or its duly appointed agent, or, if there is no board of health in such city
or town, from the city or town clerk. No such permit shall be issued until there lias been delivered to such board, or agent or
clerk, as the case may be, a satisfactory written statement containing the facts required by this chapter to be returned and
recorded, together with the certificate of the attending physician, if any, as required by section three of this chapter, or in lieu
thereof a certificate as hereinafter provided. If there is no attending physician, or if the certificate of the attending physician
cannot be obtained, for good and sufficient reasons, early enough for the purpose, the chairman of the board of health or any
physician employed by a city or town for the purpose shall, upon request of said board, agent or clerk, make such certificate as is
required of the attending physician ; and in case of death by violence the medical examiner shall, if requested, make the same.
When such satisfactory statement and certificate are delivered to the board of health or to its agent, the board or agent shall forth-
with countersign and transmit the same to the clerk or registrar for registration. The person to whom the permit is so given
shall thereafter furnish for registration any other information as to the deceased or to the manner and cause of the death, as the
clerk or registrar may require. Any person violating any of the provisions of this section shall be punished by a fine not exceed'
ing fifty dollars.

PHYSICIAN’S CERTIFICATE.

seme and Age of Deceased,*

(JU£fa, Age,

Date and Place of Death, t - j died at. lO&zCk&h rfp'7 >

Disease or Cause of Death, of

• (Primary and Secondary.) ^

Duration of Sickness,

Signature ami Residence of Certifying Physician,

f -

• £T- t- WflMT— .. _^_w «L AWI^rid v

Hui,

I certify that the above is true , to the best of my knowledge and belief.

£■ *7 S*fk1r

Date of Certificate,

f:<L i:

/<?? 7

Or Sex of Infant (not named). If stillborn so state.

| If child died immediately after birth so state.

Plate. Ed. October, 1695. — 6,0U0.

| If a soldier or sailor who served in the War of the Rebellion.

I Public Statutes, Chapter 32, as amended by Acts of 1888, Chapter 30 G ; ActsoflSSQ, Chapter 224; Acts oflSD3, Chapter 263.-]

Section 3. A physician who has attended a person during his last illness shall, when requested forthwith furnish for rr<ri,
trat.on, a certificate stating to the best of his knowledge and belief, the name of the deceased? his age “the dlseUse of which^he'
died, the duration of his last sickness, and the date of his decease; and a physician who has attended at a birth of a child (ivin<r
tbereafte.r\ °f at birth of a stillborn child, shall, when requested, forthwith furnish for registration a certificate"
)CtSt 0f HS kD0\Vfld®e and bellef t,ie fact that such a child died after birth or was born dead? If a physician iic<>--
.,,cts , ,.refuse* to lna 'i<r a certificate as aforesaid, or makes a false statement therein, he shall be punished by a fine uot exceeding
fifty dollars. In case the deceased was a sol, her or a sailor who served in the war of the rebellioh ' the ^DhyJicdan shad ulvfSh
he primary and the secondary or immediate cause of death as nearly as he can state the same. If a physician refuses or’iie<dects

"section1 rrtNoumlertakaPT ^tl^ th« treas,,rer t!!0 f.u'n (,f tea d°l>ars for the use of the town in which he resides. °

* ction o. b o undertaker, sexton or other person shall bury in a city or town or remove therefrom a human bodv until ho
has received a permit so to do from the board of health or its duly appointed agent, or, if there is no board of health in such c\tv
from the city or town clerk. No such permit shall be issued until there has been deliyered to such board ir iment or
eih, as the case maybe, a satisfactory written statement containing the facts required by this chapter to be returned mid
Jhnronf1 ’et0f«hef "'“t the ce,rtiflcat‘; of the a^”dins Phelan, if any, as requLd ^section ?! ree of This chaJtTr orTn be

cannotf be^btaineef K therC ^ no attendi"S P^ian* or if the certificate of the aSdlng ^ sician

cannot be obtained, for good and sufficient reasons, early enough for the purpose, the chairman of the board of health or «»v

Muire“ofS2teid5i- nhvs^cian^^mnn’e purPf sf s,.\a11,’ l,pon. rcflucs.t of said board> a^nt or clerk, make such certificate as i's
ml Li! uie attending physician; and in case of death by violence the medical examiner shall, if requested, make the same

with sa.tlsfact?r/ statement and certificate are delivered to the board of health orto its agent, the board or a^ent shall forth

sha therenftifftfrnf Jfansmifc *h.e same to the clerk or registrar for registration. The person to whom the permit is so given
C erk l i nn!1 for registration any other information as to the deceased or to the manner and cause of the death, as the
ing fifty d<fi lars 7 qU're‘ Any person violating any of the provisions of this section shall be punished by a fine not exceed-

PHYSICIAN’S CERTIFICATE OF THE CAUSE OF DEATH

Duration of disease ;*■■

I certify that the above is true, to floe best of my knowledge and belief.

Name and residence' J
of physician. J

if. D.

* It la very desirable to be informed of the duration of the disease.

The office of the Board of Health will be open for the granting of permits for bnrial, as foUows : - Satnrdays, 9 A. M. till
2 P.M.; Sundays, 10 A.M. till 12 M.; Holidays, from lO A.M. till 12 M.; other days, from 9 A.M. till 5 P.M.

^ 1

UNDER I AKLU is KUUKN.-UosW

Date of death,., 189,2 A

Maiden name* ; — Sex> A±0

Mamed, single, er--wkknv of ~~ ; wjfe 0f

Color, :1V Age, years, mos., //.days. Residence. I A/'

Place of death ("iSw4),/i 6. Mf..‘ >■//? '-"'X y / • ')/• ” < ^ 4uaT ^

N Place of birth, tVynr«i™, ^

JZ,

Li. -L-

Name of father, , (V' ti... Maiden name of mother, . . ^ J fa ^ ^

Birthplace of mother, . .

Birthplace of father,
Place of interment, f

♦ If a married woman or a widow. f Give tie name of the burial ground.

Signature of Undertaker :

Commonforalilr of Passaclnisctts.

X
X
X
h
, W
X

c/5

* If a Married Woman or Widow, 1 If a Soldier who served in the War of the Rebellion,
t If other than White. (M.) Mulatto. (I.) Indian. If of other Races, specify what.

[Be very particular to fill all Blanks.]
l’late. Ed. Dec., 1895.-6,000.

[ Public Statutes, Chapter 32, as amended by Acts of 188S, Chapter 306 ; Acts of 18S9, Chapter 224 ; Acts of 1S93, Chapter 263.']

Section 3. A physician who has attended a person during his last illness shall, when requested, forthwith furnish for regis-
tration, a certificate stating, to the best of his knowledge and belief, the name of the deceasedt his age, the disease of which he
died, the duration of his last sickness, and the date of his decease; and a physician who has attended at a birth of a child dying
immediately thereafter, or at the birth of a stillborn child, shall, -when requested, forthwith furnish for registration a certificate,
stating to the best of his knowledge and belief the fact that such a child died after birth or was born dead. If a physician neg-
lects or refuses to make a certificate as aforesaid, or makes a false statement therein, he shall be punished by a fine not exceeding
fifty dollars. In case the deceased was a soldier or a sailor who served in the war of the rebellion, the physician shall give both
the primary and the secondary or immediate cause of death as nearly as he can state the same. If a physician refuses or neglects
to make such certificate he shall forfeit to the treasurer the sum of ten dollars for the use of the town in which he resides.

Section 5. No undertaker, sexton or other person shall bury in a city or town or remove therefrom a human body until lie
has received a permit so to do from the board of health or its duly appointed agent, or, if there is no board of health in such city
or town, from the city or town clerk. No such permit shall be issued until there has been delivered to such board, or agent or
clerk, as the case may be, a satisfactory written statement containing the facts required by this chapter to be returned and
recorded, together with the certificate of the attending physician, if any, as required by section three of this chapter, or in lieu
thereof a certificate as hereinafter provided. If there is no attending physician, or if the certificate of the attending physician
cannot be obtained, for good and sufficient reasons, early enough for the purpose, the chairman of the board of health or any
physician employed by a city or town for the purpose shall, upon request of said board, agent or clerk, make such certificate as '
required of the attending physician ; and in case of death by violence the medical examiner sliall, if requested, make the sai
When such satisfactory statement and certificate are delivered to the board of health or to its agent, the board or agent shall for
with countersign and transmit the same to the clerk or registrar for registration. The person to whom the permit is so g
shall thereafter furnish for registration any other information as to the deceased or to the manlier and cause of the death, as
clerk or registrar may require. Any person violating any of the provisions of this section shall be punished by a fine not ex<

ing fifty dollars.

PHYSICIANS CERTIFICATE.

Name and Age - / Deceased,* Age, (q

Date and Place of Death, t - died at )k~AlP^ Mloki (lolijjLhv..) 9-4 up is9^,

Disease or Cause of Death, - of OdufAM : „ ^

(Primary and Secondary. )|

Duration of Sickness, - - yf

I certify that the above is true, to the best of my hifavleffe and belief.

fMkture and Residence of Certifying Physician ,

•jm ' / .

A Date of Certificate, 'i /<?p *> .

1 Sex of Infant (not named). If stillborn so state. t If child died immediately afterbirth so state. t If a soldier or sailor who served in the War of the Rebellion.

Plate. Ed. October, 1895. — 5, uuO.

/OcU

[Public Statutes, Chapter 32, as amended by Acts of 1SSS, Chapter 30G ; Ads oflSSO, Chapter 224; Ads oflS93, Chapter 2G3.]

Section- 3. A physician who has attended a person during his last illness shall, when requested, forthwith furnish for reeis-
tration, a certificate stating, to the best of his knowledge and belief, the name of the deceased, his age, the disease of which lie
died, the duration of his last sickness, and the date of his decease; and a physician who has attended at a birth of a child dying
immediately thereafter, or at the birth of a stillborn child, shall, when requested, forthwith furnish for registration a certificate'
stating to the best of his knowledge and belief the fact that such a child died after birth or was born dead. If a physician ne"-
lects or refuses to make a certificate as aforesaid, or makes a false statement therein, he shall be punished by a fine not exceedin’"
lift} dollars. In case the deceased was a soldier or a sailor who served in the war of the rebellion, the physician shall give both
the primary and the secondary or immediate cause of death as nearly as he can state the same. If a physician refuses or neglects
to make such certificate he shall forfeit to the treasurer the sum of ten dollars for the use of the town in which he resides. °

Section 5. No undertaker, sexton or other person shall bury in a city or town or remove therefrom a human body until lie
has received a permit so to do from the board of health or its duly appointed agent, or, if there is no board of health in such city
or town, fiom the city or town clerk. No such permit shall be issued until there has been delivered to such board, or a,rent or
clerk, as the case may be, a satisfactory written statement containing the facts required by this chapter to be returned and
recorded, together with the certificate of the attending physician, if any, as required by section three of this chapter, or in lieu
thereof a certificate as hereinafter provided. If there is no attending physician, or if the certificate of the attending physician
cannot be obtained, for good and sufficient reasons, early enough for the purpose, the chairman of the board of health or any
physician employed by a city or town for.the purpose shall, upon request of said board, agent or clerk, make such certificate as is
required o. the attending physician; and in case of death by violence the medical examiner shall, if requested, make the same.
When such satisfactory statement and certificate are delivered to the board of health or to its agent, the board or agent shall fortli-
"iii countersign and transmit the same to the clerk or registrar for registration. The person to whom the permit is so given
shall thereafter furnish for registration any other information as to the deceased or to the manner and cause of the death as the
clerk or registrar may require. Any person violating any of the provisions of this section shall be punished by a fine not exceed'
ing fifty dollars.

* If a Married Woman or Widow. 1 If a Soldier who served in the War of the Rebellion,
t If other than White. (M.) Mulatto. (I.) Indian. If of other Races, specify what.

[Be very particular to fill all Blanks.]

Plate. Ed. Dec., 1895.-5,000.

—

f 4'L zxt;

[Public Statutes, Chapter 32, as amended by Acts of 1888, Chapter 306 ; Acts of 1SS9, Chapter 224; Acts of 1S93, Chapter 263.']

Skctiox 3. A physician who has attended a yetson daring h!^ tasilllness shall, when requested, forthwith furnish for regis-
tration, a certificate stating, to the best of his knowledge and belief, the name of the deceased, his age, the disease of which he
died, the duration of his last sickness, and the date of his decease; and a physician who has attended at a birth of a child dying
immediately thereafter, or at the birth of a stillborn child, shall, when requested, forthwith furnish for registration a certificate,
stating to the best of his knowledge and belief the fact that such a child died after birth or was born dead. If a physician neg-
lects or refuses to make a certificate as aforesaid, or makes a false statement therein, he shall be punished by a fine not exceeding
fifty dollars. In case the deceased was a soldier or a sailor who served in the war of the rebellion, the physician shall give both
the primary and the secondary or immediate cause of death as nearly as he can state the same. If a physician refuses or neglects
to make such certificate he shall forfeit to the treasurer the sum of ten dollars for the use of the town in which he resides.

Section 5. No undertaker, sexton or other person shall bury in a city or town or remove therefrom a human body until he
has received a permit so to do from the board of health or its duly appointed agent, or, if there is no board of health in such city
or town, from the city or town clerk. No such permit shall be issued until there has been delivered to such board, or agent or
clerk, as the case may be, a satisfactory written statement containing the facts required by this chapter to be returned and
recorded, together with the certificate of the attending physician, if any, as required by section three of this chapter, or in lieu
thereof a certificate as hereinafter provided. If there is no attending physician, or if the certificate of the attending physician
cannot be obtained, for good and sufficient reasons, early enough for the purpose, the chairman of the board of health or any
physician employed by a city or town for the purpose shall, upon request of said board, agent or clerk, make such certificate as is
required of the attending physician ; and in case of death by violence the medical examiner shall, if requested, make the same.
When such satisfactory statement and certificate are delivered to the board of health or to its agent, the board or agent shall forth-
with countersign and transmit the same to the clerk or registrar for registration. The person to whom the permit is so given
shall thereafter furnish for registration any other information as to the deceased or to the manner and cause of the death, as the
clerk or registrar may require. Any person violating any of the provisions of this section shall be punished by a fine not exceed-
ing fifty dollars.

« •

1*.

PHYSICIAN’S CERTIFICATE.

Name and Age of Deceased ,* 'O*-' jQ(Jj(X ^ ^ >i,- ■■ Age ,

Date and Place of Death ,t - died at ^ AN / f8g ' ^ ,

Disease or Cause of Death, - of . ....__,

{Primary and Secondary.)^ y / ' f / A

Duration of Sickness , - - ^ N _

I certify that the above is true , to the best of my knowledge and befief.

, .. T'f ft 3- .

Signature ami Result tire of Certifying Physician , ^

Date of Certificate, fp....i8gf .

* Or Sex of Infant (not named). If stillborn so state. t If child died immediately after birth so state. t If a soldier or sailor who served in the War of the Rebellion.

Plate. Kd. October, lsyS. — o.uuO.

[Pullic Statutes, Chapter 32, as amended h>j Acts of 1S8S, Chapter 30G ; Acts oflS89, Chapter 224; Acts oflS93, Chapter 2G3.]

Section 3. A physician who has attended a person during his last illness shall, when requested, forthwith furnish for regis-
t ration, a certificate stating, to the best of his knowledge and belief, the name of the deceased, his age, the disease of which he
died, the duration of his last sickness, and the date of his decease; and a physician who has attended at a birth of a child dyiti"
immediately thereafter, or at the birth ot a stillborn child, shall, when requested, forthwith furnish for registration a certificate
stating to the best of his knowledge and belief the fact that such a child died after birth or was born dead. If a physician neg-
lects or lei uses to make a certificate as aforesaid, or makes a false statement therein, he shall be punished bv a fine not exceedin*1*
fifty dollars. In case the deceased was a soldier or a sailor who served in the war of the rebellion, the physician shall give both
the primary and the secondary or immediate cause of death as nearly as he can state the same. If a physician refuses or neglects
to make such certificate he shall forfeit to the treasurer the sum of ten dollars for the use of the town in which he resides.

Section .». No undertaker, sexton or other person shall bury in a city or town or remove therefrom a human body until he
has received a permit so to do from the board of health or its duly appointed agent, or, if there is no board of health in such city
or town, from the city or town clerk. No such permit shall be issued until there lias been delivered to such board, or agent or
clerk, as the case may be, a satisfactory written statement containing the facts required by this chapter to be returned and
recorded, together with the certificate of the attending physician, if any, as required by section three of this chapter, or in lieu
thereof a certificate as hereinafter provided. If there is no attending physician, or if the certificate of the attending physician
cannot be obtained, for good and sufficient reasons, early enough for the purpose, the chairman of the board of health or any
physician employed by a city or town for the purpose shall, upon request of said board, agent or clerk, make such certificate as is
required of the attending physician ; and in case of death by violence the medical examiner shall, if requested, make the same.
When such satisfactory statement and certificate are delivered to the board of health or to its agent, the board or agent shall forth-
with countersign and transmit the same to the clerk or registrar for registration. The person to ■whom the permit is so given
shall thereafter furnish for registration any other information as to the deceased or to the manner and cause of the death, as the
clerk or registrar may require. Any person violating any of the provisions of this section shall be punished by a fine not exceed'
ing fifty dollars.

RETURN OF THE DEATH

/o 3> /BzeM^

at . / ■ aiM )icr(

Date, ^^bd.ed/UL
Filed, t'P1’’ f k

[Extracts from Chapter 29, Revised Laws.]

Section G. Every householder in whose house a death occurs and the oldest next of kin of a deceased person in the
or town in which the death occurs, shall, within five days thereafter, cause notice thereof to be given to the board of health
o the town clerk.

Section 7. The commanding officer of a vessel shall give notice of the death of any person under his charge to the
rd of health or to the clerk of the city or town within the Commonwealth at which his vessel first arrives after such death.
Section 8. Penalty for neglect to comply with the requirements of sections 6 and 7, five dollars.

Section 10. A physician shall forthwith after the death of a person whom he has attended during his last illness, at the
.lest of an undertaker or other authorized person or of any member of the family of the deceased, furnish for registration
irtificate setting forth the required facts.

Section 11. If the deceased was a soldier or sailor who served in the war. of the rebellion, give both the primary and
secondary or immediate cause of death as nearly as he can state the same. Penalty for refusal or neglect, ten dollars.

Section 12. Every undertaker or other person who lias charge of a funeral, shall forthwith obtain the physician’s cer-
ate required by section 10, enter thereon the facts required by section 1, and return it to the board of health or to the clerk
he city or town in which the death occurred. The person making such return shall receive from the city or town a fee of
nty-five cents.

[Extracts from Chapter 78, Revised Laws.]

Section 38. No undertaker or other person shall bury a human body in a city, or town or remove therefrom a human
y which has not been buried, until a permit from the board of health or its agent has been received. No such permit shall

a ' 11 f/ tlic_Ju£ts required by laic , with a

/Disease or Cause of Death,

\ (Primary and Secondary),!

0. Duration of Sickness, .

I ffl

[Public Statutes , Chapter 32, as amended b>j Ads of 18SS, Chapter 30G ; Ads of 1889, Chapter 224; Acts of 1893, Chapter 203.]

Section 3.^ A physician who has attended a person during his last illness shall, when requested, forthwith furnish for regis-
trat.on, a certificate stating, to the best of his knowledge and belief, the name of the deceased, his age, the disease of which he
died, the duration of Ins last sickness, and the date of his decease; and a physician who has attended at a birth of a child dying
immediately thereafter, or at the birth of a stillborn child, shall, when requested, forthwith furnish for registration a certificate,
stating to the best of his knowledge and belief the fact that such a child died after birth or was born dead. If a physician neg-
Iects or refuses to make a certificate as aforesaid, or makes a false statement therein, he shall be punished by a fine not exceeding
fifty dollars. In case the deceased was a soldier or a sailor who served in the war of the rebellion, the physician shall give both
the primary and the secondary or immediate cause of deatli as nearly as he can state the same. If a physician refuses or neglects
to make such certificate he shall forfeit tp the treasurer the sura of ten dollars for the use of the town in which he resides.

Section 5. No undertaker, sexton or other person shall t ury in a city or town or remove therefrom a human body until lie
lias received a permit so to do from the board of health or its duly appointed agent, or, if there is no board of health in such city
or town, from the city or town clerk. No such permit shall be issued until there has been delivered to such board, or agent or
clerk, as the case may be, a satisfactory written statement containing the facts required by this chapter to be returned and
recorded, together with the certificate of the attending physician, if any, as required by section three of tills chapter, or in lieu
thereof a certificate as hereinafter provided. If there is no attending physician, or if the certificate of the attending physician
cannot be obtained, for good and sufficient reasons, early enough for the purpose, the chairman of the board of health or any
physician employed by a city or.town for the purpose shall, upon request of said board, agent or clerk, make such certificate as is
required of the attending physician; and in case of death by violence the medical examiner shall, if requested, make the same
hen such satisfactory statement and certificate are delivered to the board of health or to its agent, the board or agent shall fortl
w ith countersign and transmit the same to the clerk or registrar for registration. The person to whom the permit is so giv<
-hall thereafter furnish for registration any other information as to the deceased or to the manner and cause of the death, as t
clerk or registrar may require. ' , punished by a fine not cxcec

mg fiftv dollars.

TUTU TF f/etr/c

PHYSICIAN’S CERTIFICATE,

Name and Age of Deceased,*

Dale and Place of Death; j- - died at

fliAAN> ^ Age, £ (O,

UAAJL 16 " ./«p7,

J /A <k\N;Podtk

Disease or Cause of Death, -

{Primary and Secondary.)^

Duration of Sickness,

I certify that the above is true, to the best of my knowledge and belief.

J^! nalut

and Residence of Certifying Physician,

Date of Certificate,

189

* u7bex of Infant (not named). If s.tllborn so state. t Kehdd

t If a soldier or sailor who served in the War of the Rebellion.

[Public Statutes, Chapter 32, as amended by Acts of 1S8S, Chapter 30G ; Acts of 1SS9, Chapter 224, Acts of 1S93, Chapter 2G3 ]

q„,rTlnv 3 a nhvsician who has attended a person during his last illness shall, when requested, forthwith furnish for ™gis-
to toe to. of his knowledge end W the .nme of the decetod, hi. _y., the Jch.l.c

died, the duration of his last sickness, and the date of his decease; and a physicii an who has .^te^ed at a^b.rUi^
immediately thereafter, or at the birth of a stillborn child, shall, when requested, forthwith funi sh 1 > » • . . . _

staTing to the best of his knowledge and belief the fact that such a child died after birth or fln^^SceeSing

lects or refuses to make a certificate as aforesaid, or makes a false statement therein, lie P nhvsician shall give botli

fifty dollars. In case the deceased was a soldier or a sailor who served in the war of the rebellion

the^primary and the secondary or immediate cause of death as nearly as he can state the same. I l ‘ h resjdcs. °
to make such certificate he shall forfeit to the treasurer the sum o£ .te" ^ojlare a luunan body until he

Sfction 5. No undertaker, sexton or other person shall bury in a cit} or to\Mi or le , , * ^ 0«nh in mirh rit.v

has received a permit so to do from the board of health or its duly appointed agent, or, 1 , to such board or a,rent or

» tow (tom 'the city or town clerk. No tael, permit stall be «-i ch.ptot to taiSmed n„"

clerk, as the case may be, a satisfactory written statement containing the acts required y eg o{. thls clmptcri or in neu
recorded, together with the certificate of the attending physician, if any, 1 • f f>t.rtiiicatc of the attending physician

thereof a certificate as hereinafter provided. If there is no attending /tfo'ehaTrma.i of the board of health or any

cannot be obtained, for good and sufficient reasons, early enough f<> P P > , or c]crv make such certificate as is

physician employed by a city or town for the purpose shall, upon icq 1 . • , ’ .* shn.ll if requested, make the same,

required of the attending physician ; and in case of death by v r to its a^ent the biardor agent shall forth-

When such satisfactory statement and certificate are delivered to the boaid loflicatn 1 to 1 _ = ’ the permit is so given

with countersign and transmit the same to the clerk or registrar for registration. P • and (.!Ulse of the death, as the

shall thereafter furnish for registration any other information as to the t'wn shall be minislied by a fine not exceed-
clerk or registrar may require. Any person violating any of the provisions of tins section sli p i

ing fifty dollars.

Disease or Cause of Death
(Primary and Secondary), J

Duration of Sickness,

! °^)VY\VV; * If a ?oldter "ho “erveid the War of the Rebellion,

t If other than White. (M.) Mulatto. (I.) Indian. If of other Races, specify what.

[Be very particular to fill all Blanks.]

Plate. Ed. Dec., 1895.-5,000.

tration, a certificate stating, to the best of his kno'' -« »e dec°ase* and a physician who has attended at a birth of a child dyin0
died, the duration of his last sickness and the fate of his deceas e,^ P ^ forthwith furuish for registration a certificate,
immediately thereafter, or at the birth of a s , ’ l child died after birth or was born dead. If a physician neg-

stating to the best of his knowledge and behef the fact that s a thereillf ae shall be punished by a fine not exceeding

lects or refuses to make a certificate as aforesaid, or makes a st te the rebellion, the physician shall give both

fifty dollars. In case the deceased can state the same. If a physician refuses or neglects

the primary and the secondary or immediate cause of d®a.t.^^"eanriyt(rl dollars for the use of the town in which he resides,
to make such certificate he shall forfeit to the tT^Z ^JlTin in a city or town or remove therefrom a human body until he
Section 5. No undertaker, sexton or other person bm iut'ed ao-ent, or, if there is no board of health in such city

has received a permit so to do from the board of h^th or Js d PP 1 tdth”re has beCn delivered to such board, or agent or
or town, from the city or town clerk. No such permit shall be issue ^ required by this chapter to be returned and

clerk, as the case may be, a satisf: actory w: ri^te“ j ian"if anv as required by section three of this chapter, or in 1 eU

recorded together with the certificate of the attending physician, n a y, 4 certificate of the attending physician

thereof a certificate as hereinafter provided. If there is no attending of the board of health or any

cannot be obtained, for good and sufficient reasons, ear y » t Gf said boavd agent or clerk, make such certificate as is

physician employed by a city or town for the PurP°B«^^ examiner shall, if requested, make the same,

required of the attending physician ; and in case of ^ ^ v J d to the board 0f health or to its agent, the board or agent shall forth-

— «f s“l bc — d by ‘ - “ot

ing fifty dollars.

PHYSICIAN’S CERTIFICATE.

Age,

Name and Age of Deceased*

Date and Place of Death, t
Disease or Cause of Death,

{Primary and Secondary .) |

Duration of Sickness,

I certify that the above is triM, to the-j>est ofniy knowledge and belief a _

Signature and Residence of Certifying Physician , ^ ^ . f V 2z^t ix.

* Or Sex of Infant (not named). If stillborn so state.

Date of Certificate,

i If child died immediately after birth so state.

Plate. Ed. October, 1895.-5,000.

Ad — x

a soldier or sailor who served in the War of the

[ Public Statutes, Chapter 32, as amended by Acts of 1S83, Chapter 306 ; Acts of 1889, Chapter 224 ; Acts of 1893, Chapter 2 63. ]

Section 3. A physician who has attended a person during his last illness shall, when requested, forthwith furnish for regis-
tration, a certificate stating, to the best of his knowledge and belief, the name of the deceased, his age, the disease of which he
died, the duration of his last sickness, and the date of his decease; and a physician who has attended at a birth of a child dying
immediately thereafter, or at the birth of a stillborn child, shall, when requested, forthwith furnish for registration a certificate,
stating to the best of his knowledge and belief the fact that such a child died after birth or was born dead. If a physician neg-
lects or refuses to make a certificate as aforesaid, or makes a false statement therein, lie shall be punished by a fine not exceeding
fifty dollars. In case the deceased was a soldier or a sailor who served in the war of the rebellion, the physician shall give both
the primary and the secondary or immediate cause of death as nearly as he can state the same. If a physician refuses or neglects
to make such certificate he shall forfeit to the treasurer the sum of ten dollars for the use of the town in which he resides.

Section 5. No undertaker, sexton or other person shall bury in a city or town or remove therefrom a human body until he
has received a permit so to do from the board of health or its duly appointed agent, or, if there is no board of health in such city
or town, from the city or town clerk. No such permit shall be issued until there has been delivered to such board, or agent or
clerk, as the case may be, a satisfactory written statement containing the facts required by this chapter to be returned and
recorded, together with the certificate of the attending physician, if any, as required by section three of this chapter, or in lieu
thereof a certificate as hereinafter provided. If there is no attending physician, or if the certificate of the attending physician
cannot be obtained, for good and sufficient reasons, early enough for the purpose, the chairman of the board of health or any
physician employed by a city or towrn for the purpose shall, upon request of said board, agent or clerk, make such certificate as is
required of the attending physician ; and in case of death by violence the medical examiner shall, if requested, make the same.
When such satisfactory statement and certificate are delivered to the board of health or to its agent, the board or agent shall forth-
with countersign and transmit the same to the clerk or registrar for registration. The person to whom the permit is so given
shall thereafter furnish for registration any other information as to the deceased or to the manner and cause of the death, as the
clerk or registrar may require. Any person violating any of the provisions of this section shall be punished by a fine not exceed-
ing fifty dollars.

* w aginssncirusms.

[Public Statutes, Chapter 32, as amended by Acts of 188S, Chapter 306 ; Acts of 1889, Chapter 224; Acts of 1893, Chapter 263.

Section 3. A physician who has attended a person during his last illness shall, when requested, forthwith furnish for regis-
tration, a certificate stating, to the best of his knowledge and belief, the name of the deceased, his age, the disease of which he
died, the duration of his last sickness, and the date of his decease ; and a physician who has attended at a birth of a child dying
immediately thereafter, or at the birth of a stillborn child, shall, when requested, forthwith furnish for registration a certificate,
stating to the best of his knowledge and belief the fact that such a child died after birth or was born dead. If a physician neg-
lects or refuses to make a certificate as aforesaid, or makes a false statement therein, he shall be punished by a fine not exceeding
fifty dollars. In case the deceased was a soldier or a sailor who served in the war of the rebellion, the physician shall give both
the primary and the secondary or immediate cause of death as nearly as he can state the same. If a physician refuses or neglects
to make such certificate he shall forfeit to the treasurer the sum of ten dollars for the use of the town in which he resides.

Section 5. No undertaker, sexton or other person shall bury in a city or towii or remove therefrom a human body until he
has received a permit so to do from the board of health or its duly appointed agent, or, if there is no board of health in such city
or town, from the city or town clerk. No such permit shall be issued until there has been delivered to such board, or agent or
clerk, as the case may be, a satisfactory written statement containing the facts required by this chapter to be returned and
recorded, together with the certificate of the attending physician, if any, as required by section three of this chapter, or in lieu
thereof a certificate as hereinafter provided. If there is no attending physician, or if the certificate of the attending physician
cannot be obtained, for good and sufficient reasons, early enough for the purpose, the chairman of the board of health or an\r
physician employed by a city or town for the purpose shall, upon request of said board, agent or clerk, make such certificate as is
required of the attending physician ; and in case of death by violence the medical examiner shall, if requested, make the same.
When such satisfactory statement and certificate are delivered to the board of health or to its agent, the board or agent shall forth-
with countersign and transmit the same to the clerk or registrar for registration. The person to whom the permit is so given
shall thereafter furnish for registration any other information as to the deceased or to the manner and cause of the death, as the
clerk or registrar may require. Any person violating any of the provisions of this section shall be punished by a fine not exceed-
ing fifty dollars.

PHYSICIAN’S CERTIFICATE.

Name and Age of Deceased *

Date and Place of Death, t - died at
Disease or Cause of Death, - of

( Primary and Secondary .) J

Diuation of Sickness,

(h Ha /f) Agef

I certify that the above is true , to the best of my knowledge and belief.

Signature and Residence of Certifying Physi

Date of Certificate ,

* Or Sex of Infant (not named). Jf stillborn so state. f If child died immediately after birth so state. J If a soldier or sailor who served in the War of the Rebellion-

Plate. F.d. December, 1896. — 5,000.

[ Public Statutes, Chapter 32, as amended b'j Acts of 1SSS, Chapter 300 ; A' ls of 1SS9, Chapter 221 ; -lets of J SOS, Chapter 203.]

Section 3. A physician who has attended a person during his last illness shall, when requested, forthwith furnish for regis-
tration, a certificate stating, to the best of his knowledge and belief, the name of the deceased, his age, the disease of which he
died, the duration of his last sickness, and the date of his decease; and a physician who has attended at a birth of a child dying
immediately thereafter, or at the birth of a stillborn child, shall, when requested, forthwith furnish for registration a certificate,
stating to the best of his knowledge and belief the fact that such a child died after birth or was born dead. If a physician neg-
lects or refuses to make a certificate as aforesaid, or makes a false statement therein, he shall be punished by a fine not exceeding
fifty dollars. In case the deceased was a soldier or a sailor who served in the war of the rebellion, the physician shall give botli
the primary and the secondary or immediate cause of death as nearly as he can state the same. If a physician refuses or neglects
to make such certificate he shall forfeit to the treasurer the sum of ten dollars for the use of the town in which he resides.

Section 5. No undertaker, sexton or other person shall bury in a city or town or remove therefrom a human body until lie
has received a permit so to do from the board of health or its duly appointed agent, or, if there is no board of health in such city
or town, from the city or town clerk. No such permit shall be issued until there has been delivered to such board, or agent or
clerk, as the case may be, a satisfactory written statement containing the facts required by this chapter to be returned and
recorded, together with the certificate of the attending physician, if any, as required by section three of this chapter, or in lieu
thereof a certificate as hereinafter provided. If there is no attending physician, or if the certificate of the attending physician
cannot be obtained, for good and sufficient reasons, early enough for the purpose, the chairman of the board of health or any
physician employed by a city or town for the purpose shall, upon request of said board, agent or clerk, make such certificate as is
required of the attending physician ; and in case of death by violence the medical examiner shall, if requested, make the same.
When such satisfactory statement and certificate are delivered to the board of health or to its agent, the board or agent shall forth-
with countersign and transmit the same to the clerk or registrar for registration. The person to whom the permit is so given
shall thereafter furnish for registration any other information as to the deceased or to the manner and cause of the death, as the
clerk or registrar may require. Any person violating any of the provisions of this section shall be punished by a fine not exceed-
ing fifty dollars.

<T onrmonforaltlT of pnssntpsdk

/Disease or Cause of Death

\ (Primary and Secondary), {

C>. Duration of Sickness, .

ao ;

* If a Married Woman or Widow, t If afioldier who served in the War of the Rebellion,
t i other tlinn \\ hite. (M.) Mulatto. (I.) Indian. If of other Races, specify whai.

[Bo very particular to fill all Blanks.]

[ Public Statutes, Chapter 32, as amended by Acts of 18SS, Chapter 30G ; Acts of 1S89, Chapter 224; Acts of 1893, Chapter 263.]

Section 3. A physician who has attended a person during his last illness shall, when requested, forthwith furnish for regis-
tration, a certificate stating, to the best of his knowledge and belief, the name of the deceased, his age, the disease of which In-
died, the duration of his last sickness, aiid the date of his decease; and a physician who has attended at a birth of a child dying
immediately thereafter, or at the birth of a stillborn child, shall, when requested, forthwith furnish for registration a certificate,
stating to the best of his knowledge and belief the fact that such a child died after birth or was born dead. If a physician neg-
lects or refuses to make a certificate as aforesaid, or makes a false statement therein, he shall be punished by a fine not exceeding
fifty dollars. In case the deceased was a soldier or a sailor who served in the war of the rebellion, the physician shall give both
the primary and the secondary or immediate cause of death as nearly as he can state the same. If a physician refuses or neglects
to make such certificate he shall forfeit to the treasurer the sum of ten dollars for the use of th<j town in which he resides.

Section 5. No undertaker, sexton pr other person shall bury in a city or town or remove therefrom a human body until he
has received a permit so to do from the board of health or its duly appointed agent, or, if there is no board of health in such city
or town, from the city or town clerk. No such permit shall be issued until there has been delivered to such board, or agent or
clerk, as the case may be, a satisfactory written statement containing the facts required by this chapter to be returned and
recorded, together with the certificate of the attending physician, if any, as required by section three of this chapter, or in lieu
thereof a certificate as hereinafter provided. If there is no attending physician, or if the certificate of the attending physician
cannot be obtained, for good and sufficient reasons, early enough for the purpose, the chairman of the board of health or any
physician employed by a city or town for the purpose shall, upon request of said board, agent or clerk, make such certificate as is
required of the attending physician ; and in case of death by violence the medical examiner shall, If requested, make the same.
When such satisfactory statement and certificate are delivered to the board of health or to its agent, the board or agent shall forth-
with countersign and transmit the same to the clerk or registrar for registration. The person J.o whom the permit is so given
-liall thereafter furnish for registration any other information as to the deceased or to the manner and cause of the death, as the
clerk or registrar may require. Any person violating any of the provisions of this section shall be punished by a fine not exceed-
ing fifty dollars.

—

" :0«£ ‘ r

PHYSICIAN’S CERTIFICATE.

Name and Age of Deceased,

Date and Place of Death ,t - died at.

Disease or Cause of Death,

(.Primary arid Secondary. ) J

Duration of Sickness,

Age,

189

I certify that the above is true , to the best of my knowledge and belief.

Signature amt Residence 0/ Certifying

fyhtg Physician, ' Z J%j yJd f .

t* 'J 2 ’ df

Date of Certificate,

* Or Sex of Infant (not named). If stillborn so state. f If child died immediately after birth so state. | If a soldier or sailorwho served in the War of the Rebellion-

Plate. Ed. October, 1895.-5,000.

[Public Statutes, Chapter 32, as amended by Acts of 1888, Chapter 306 ; Acts of 1889, Chapter 224 ; Acts of 1893, Chapter 263.}

Section 3. A physician who has attended a person during his last illness sliall, when requested, forthwith furnish for regis-
tration, a certiflcate stating, to the best of his knowledge and belief, the name of the deceased, his age, the disease of which he
died, the duration of his last sickness, and the date of his decease; and a physician who has attended at a birth of a child dying
immediately thereafter, or at the birth of a stillborn child, shall, when requested, forthwith furnish for registration a certiflcate,
statin" to the best of his knowledge and belief the fact that such a child died after birth or was born dead. If a physician neg-
lects or refuses to make a certiflcate as aforesaid, or makes a false statement therein, he shall be punished by a fine notexceeding
fifty dollars. In case the deceased was a soldier or a sailor who served in the war of the rebellion, the physician shall give both
the primary and the secondary or immediate cause of death as nearly as he can state the same. If a physician refuses or neglects
to make such certificate he shall forfeit to the treasurer the sum of ten dollars for the use of the town in which he resides.

Section 5. No undertaker, sexton or other person shall bury in a city or town or remove therefrom a human body until he
has received a permit so to do from the board of health or its duly appointed agent, or, if there is no boaid of health in such city
or town, from the city or town clerk. No such permit shall be issued until there has been delivered to such board, or agent or
clerk, as the case may be, a satisfactory written statement containing the facts required by this chapter to be returned and
recorded, together with the certiflcate of the attending physician, if any, as required by section three of this chapter, or in lieu
thereof a certiflcate as hereinafter provided. If there is no attending physician, or if the certificate of the attending physician
cannot be obtained, for good and sufficient reasons, early enough for the purpose, the chairman of the board of health or any
physician employed by a city or town for the purpose shall, upon request of said board, agent or clerk, make such certiflcate as is
required of the attending physician ; and in case of death by violence the medical examiner shall, if requested, make the same.
When such satisfactory statement and certificate are delivered to t he board of health or to its agent, the board or agent shall forth-
with countersign and transmit the same to the clerk or registrar for registration. The person to whom the permit Is so gn en
shall thereafter furnish for registration any other information as to the deceased or to the manner and cause of the death, as the
clerk or registrar may require. Any person violating any of the provisions of this section shall be punished by a fine not exceed-
ing fifty dollars.

PHYSICIAN’S CERTIFICATE OF THE CAUSE OF DEATH

Boston ,

Name and age of deceased : S Age. 3. .a — yrs....

Date and place of death: 0 <ZJ)....^ ■ o*LJ.

Disease or cause of death

c£)rL<a-LuZA^...s.

Duration of disease :* 'f ..r.lsi?

I ^\£AJruc:b^L. . . . . ..4~,

I certify that the above is true, to the best of my knowledge and belief.

Name and residence 1
of physician. )

> /

**/■?/ GnjuZ ±

M. D

•It is very desirable to be informed of the duration of the disease.

The office of the Board of Health will be open for the granting of permits for burial, as follows: — Saturdays, 9 A. M. till
2 P. 31.; Sundays, 10 A.M. till 12 M.; Holidays, from IQ A. M. till 12 M.; other days, from 9 A.M. till 5 P. M.

UNDERTAKER’S RETURN -Boston.

Date of death, 189^' Nam

Maiden n ame,* . C.ir.:. Sex,

Married, single; or widow- of wife

Co\ort\ky Age, Jf.^.years, mos., days. Residence, <J£.. . ,^./^7.....

Place of death (8£Smb£d) ward

Place of birth,.... Occupation, ,.c:

Name of father, Maiden name of moliierjV^^k^ •

Birthplace of father, Birthplace of mother, .< ■'

Place of interment, f /.,...

• If a married woman or a widow. t Give the name of the burial ground.

Signature of Undertaker :

RETURN OF A DEATH.

To the Clerk of the City or Town in which the Death occurred.

* 1 f ii Married Woman or Widow. J If a Soldier who servfetfm the War yl Ihe Rebellion,
t If other than White. (M.) Mulatto. (I.) Indian. If of other ltacea, specify what.

[Be very particular to fill all Blanks.]

t-rUh y

[ Public Statutes, Chapter 32, as amended Id Acts of 1SSS, Chapiter 306 ; Arts of 1S89, Chapter 2‘^^-Aets of 1893, Chapter 263.]

Section 3. A physician who has attended a person during his last illness shall, when requested, forthwith furnish for regi--
tration, a certificate stating, to the best of his knowledge and belief, the name of the deceased, his age, the disease of which In-
died, the duration of his last sickness, and the date of his decease; and a physician who has attended at a birth of a child dying
immediately thereafter, or at the birth of a stillborn child, shall, when requested, forthwith furnish for registration a certificate,
stating to the best of his knowledge and belief the fact that such a child died after birth or was born dead. If a physician neg-
lects or refuses to make a certificate as aforesaid, or makes a false statement therein, he shall be punished by a fine not exceeding
fifty dollars. In case the deceased was a soldier or a sailor who served in the war of the rebellion, the physician shall give both
the primary and the secondary or immediate cause of death as nearly as he can state the same. If a physician refuses or neglects
to make such certificate he shall forfeit to the treasurer the sum of ten dollars for the use of the town in which he resides.

Section 5. No undertaker, sexton or other person shall bury in a city or town or remove therefrom a human body until he
has received a permit so to do from the board of health or its duly appointed agent, or, if there is no board of health in such city
or town, from the city or town clerk. No such permit shall be issued until there has been delivered to such board, or agent or
clerk, as the case ma}' lie, a satisfactory written statement containing the facts required by this chapter to be returned and
recorded, together with the certificate of the attending physician, if any, as required by section three of this chapter, or in lieu
thereof a certificate as hereinafter provided. If there is no attending physician, or if the certificate of the attending physician
cannot be obtained, for good and sufficient reasons, early enough for the purpose, the chairman of the board of health or any
physician employed by a city or town for the purpose shall, upon request of said board, agent or clerk, make such certificate a> i*
required of the attending physician ; and in case of death by violence the medical examiner shall, if requested, make the same.
When such satisfactory statement and certificate are delivered to the board of health or to its agent, the board or agent shall forth

The text goes on. The rest is in the file.