The volume, 1922–1924
Town Clerk, Winthrop · from the Internet Archive · 1200 pages · 119.9 MB
open the file ↗ · original at the source ↗
I
J. L FAIRBANKS & CO.
Stationers
43 FRANKLIN STREET
—BOSTON—
uni i c rLniiiL i , vvi i n unrnuiuu ulhvi\ mix i iiio ig n r tnmni\tu i ntuunu, Lvcrjf i lem ui imurmauuii
should be carefully supplied. AGE should be slated EXACTLY. PHYSICIANS should state CAUSE OF DEATH
in plain terms, so that it maybe properly classified. Exact statement of OCCUPATION is very important. See
instructions and extracts from the laws on back of certificate.
M R-301
)0,000
OFFICE OF THE SECRETARY
DIVISION OF VITAL STATISTICS
iHlje GJommnmuruttlj of fHassarliuavt
1 PLACE OF D1
Count;
STANDARD CERTIFICATE
City or Town.
(City or Town)
Registered No,...„ /
No.Z.^...,.Cfc^ St. Ward
(If de^tli occurred in a hospital or institution, give its name instead of street and number)
2 FULL NAME
(a) Residence. No
(Usual place of abode)
Length of residence in city or town where death occurred
years
_ (If in the Army or Navy of the United States, give rank, organization, etc.)
St., Ward.
(If non-resident give city or town and State)
months days. How long in U. S., if of foreign birth ? years months days
PERSONAL AND STATISTICAL PARTICULARS
4 COLOR ^R RACE
S' SINGLE, MARRIED, WIDOWED. OR
f DIVORCED ( write the word)
(Day) (Year)
7 AGE
Years
Months
Days
or mm.
If STILLBORN, enter that fact here
8 OCCUPATION OF DECEASE
(a) Trade, profession, or
particular kind of work
(b) Name of employer
9 BIRTHPLACE (City)
(State or country)
Filed v
(Month
(Day) (Yrear)
Registrar
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH .
...x
(Day) (Year)
IREBY CERTIFY,
L 19.J«.
that I last saw h on
t I attended deceased from
19
2. L-
.... 19
2- 1-
and that death occurred, on the/^late stated above, at m.
The CAUSE OF DEATH was as follows:
..(duration) yrs mos. d9.
CONTRIBUTORY.
(secondary)
(duration) yrs„..
18 Where was disease contracted
if not at place of death?
U — o
Did an operation precede death? Date of.
Was there an autopsy?
What test cojtf|rn<ed diagnosis?
(Signed ) . . */. M . D.
(Addres*) 3..^ (a..
Date .
21 I HEREBY CERTIFY that a satisfactory stan-
dard certificate of death was filed with me
BEFORE the burial or transit permit was isi
( Month)
19 PLdfCE 0F XUR1AL, CREATION, OR REMOVAL:
TCemetejffiy (City or town)
DATE OF BURIAL
AKER ^7
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of certificate,
(Comaummeatti! of fHassarhusrtfs
I'town)
Registered No S?<L.
(Place of death)
Registered No 7&—
~ residence)
STANDARD CERTIFICATE OF DEATH
1 PLACE OF/tfEA
County
City or Town.i^!^^: .£L<-:7. ... .y«^2y-No. '..:£. Ward
^ y /> /(If death, occurred in a hospital or institution, give its name instead of street and number)
2 FULL NAME . . #
' y /// / (If in thp Jenny or Maw of the United States, give rank, organization, etc.l
City or Town.. Cjt^W/Hrd' /c2; \ d/ ■£€.,
years j months J days How long io U. S., ifof foreign birth? c?3 years
a. Registered INo. p
— ' / — P- / (Placeof resic
\
(a) Residence. State
(Usual place of abode)
Length cf residence in city or town where death occurred
months
St.
days
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
^/'CaJ'-c.y
4 COLOR OR RACE
5 SINGLE, MARRIED, WIDOWED, OR
DIVORCED {tvrite the word)
'VC
■'v/-
g-L : : — ^ ^ —
5a If married, widowed, or divorced 1/
(oVf vvife of . t
Km ‘ 7
6 DATE OF BIRTH (month, day, and year)
7 AGE <3 3f~ Years
v* Months
j! j Days
If LESS than
1 day, hrs.
or min.
If STILLBORN, enter that fact here
8 OCCUPATION OF DECEASED
(») Trade, profession, or /
particnlai kind of work
7LL7L7d.....
(b) Name of employer
9 BIRTHPLACE (city or townb
(State or country)
10 NAME OF FATHER
a j
/ y t
11 BIRTHPLACE OF FATHER (city 99 town) /
(State or country) Q^/ / r?;. .
12 MAIDEN NAME OF MOTHER
13 BIRTHPLACE OF MOTHER (city or tetWnT
(State or country)
or t^ yfln) ./£.
y. /, -itt.
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH (month, day, and year) 7/- 19°5
17
I HEREBY CERTIFY, That I attended deceased from
19 .0.1... , 19.^.^
&&' k
(7 v ri • 'T .
that I last saw .l.r^Vsdi ve on J....
(c-30 _
w m.
19..
and that death occurred, on the date stated above, at
The CAUSE OF DEATH* was as follows:
/7 /?
CONTRIBUTORY.
(secondary)
...(duraticiri). Id . yrs. mos.
ztyyL^::.
. ds.
18 Where was disease contracted
if not at place of death?
Did an operation precede death?.^..^£..... Date of
Was there an autopsy? Jd e> >
yy , 77
What test confirmed diagnosis?..., ' S"»- ' 7y> f a v ;
j (Signed) .1.—.
^Y^^9^^^Address)
confirmed dia
7.7... f.
14
Informant .
(Address)
L
19 PLACE OF BURIAL, CREMATION, OR REMOVAL
15 Filed y.Gu*.U,...^/:fi 1 9 .1^ ' £^. . . .4: 'K7 /....
Registrar of city or town where death occnfred
FiIe<f^:c.J^..\..0... , 19 ■L.-lArf
<DE
Registrar of city or town where deceased resided
7t
20 UNDERTAKER
f' 1 J
DATE OF BURIAL
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STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH
County Suffolk State
Massachusetts
BOSTON
(City or town)
Registered No I. .4.1
(Place of deathL ,
Registered No. <s*fe£T.s 5.... I
(Place of residence)
St., ...Ward
City or Town BOStOfl No HA RT H.Q..S.ET..,.
(If death occurred in a hospital or institution, give its namb instead of street and number)
o ct ,t y Ki a ivyvir MARGARET HYNES
2 FULL NAME ••••• ■■•••
(If in the Army or Navy of the United States, give rank, organization, etc.)
(a) Residence. State MASS.., City or Town W.J...NT..H..RQfto 28 — P-£A ftL — AVE St.
(Usual place of abode)
Length of residence in city or town where death occurred years months days How long in 1). S., if of foreign birth? years months days
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
4 COLOR OR RACE
5 SINGLE, MARRIED, WIDOWED, OR
16
DIVORCED ( write the word)
F
w
SIN.
17
5a If married, widowed, or divorced
HUSBAND of
(or) WIFE of
6 DATE OF BIRTH (month, day, and year)
7 AGE Years
'8
Months
5
Days
1 3
If LESS than
1 day, hrs.
or min.
If STILLBORN, enter that fact here
8 OCCUPATION OF DECEASED
(t) Trade, profession, or
particular kind of work..
CLERK
(b) Name of employer TW | N yilTlIAl INS
9 BIRTHPLACE (city or town) B O ST O N
(State or country)
10 NAME OF FATHER
EDWARD J.
11 BIRTHPLACE OF FATHER (city or town)....
(State or country) I RFl AMD
12 MAIDEN NAME OF MOTHER MARGARET CRAVEN
13 BIRTHPLACE OF MOTHER (city or town)
(State or country) I R E L A N D
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH (month, day, and year) J A N , 5 19 22
I HEREBY CERTIFY, That I attended deceased from
19 to 19. W ,
that I last saw h alive on 19.. s?.? ,
and that death occurred, on the date stated above, at m.
The CAUSE OF DEATH* was as follows: »
ACUTE GENERAL “PERITONITIS FOL *
ABORT! ON
..(duration) yrs.
. de.
CONTRIBUTORY
(secondary)
(duration) _ yrs. mos. ds.
18 Where was disease contracted
if not at place of death ?
Did an operation precede death? Date of.
Was there an autopsy?^.
What test confirmed diagnosis?
TIMOTHY1 LEARY MED. EX,
(Signed) ..
, 19 22 (Address)
J A N , 5
... M.D.
14
Informant ..
(Address)
JOSEPH P, HYNES
19 PLACE OF BURIAL, CREMATION, OR REMOVAL
CALVARY l NEW)
15 Filed. ...l...A...'l*..5...„ 19 22
File '2rUA:JS.... 19?4._..
Registrar of dty or town where death occurred
Registrar of dty or town where deceased resided
20 UNDERTAKER
P .J. BRADY
DATE OF BURIAL
J A N . 7
19 22
ADDRESS
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-WRITE PLAINLY, Wl I H UNrALilNu t>L auk ink — i ms lo a rtniYiAiM i ntuumj. tvery item or iniormaiion
should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state CAUSE OF DEATH
in plain terms, so that it may be properly classified. Exact statement of OCCUPATION is very important. See
instructions and extracts from the laws on back of certificate.
M R
00
Z
: oo.ooo
301
OFFICE OF THE SECRETARY
DIVISION OF VITAL STATISTICS
1 PLACE OF DEAT
County.
Uljp (Emmnmtutpalllj of iHasaacljuartta
STANDARD CERTIFICATE OF DEATH
.U '
State
(City or Town)
.Registered No.
City or Town No. A. St Ward
y ' ' (If death occurred in a hospital or institution, give its name instead of street and number)
Residence. 4^.
< Usual olar.fi of aborlei ^7 ^
Q years
(Usual place of abode)
Length of residence in city or town where death occurred
(If in the Army or Navy of the United States, give rank, organization, etc.)
.St., Ward.
months
(if non-resident give city or town and State)
days. How long in U. S., if of foreign birth? years months days
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
uJZ^
4 COLOR OR RACE
5 SINGLE, MARRIED, WIDOWED, OR
DIVORCED (write the word)
5a if married, wdrrWCttyyjrinWfCtd
HUSBAND of /y . y
(or) wife of y~iL
6 DATE OF BIRTH.
( Month) (bay)
(Year)
7 AGE
Years
7V
Months
Days
If LESS than
1 day, his.
or min.
If STILLBORN, enter that fact here
8 OCCUPATION OF DECEASED
(a) Trade, profession, or ^
particular kind of work
(b) Name of employer
-c. -^*
9
BIRTHPLACE (City)
(State or country)
5**^=;
10 NAME OF
FATHER /
'ey
</)
[-
11 BIRTHPLACE OF / * ■
FATHER (Citv) >*■*-» Pits'*- — — *—
Z
UJ
a.
<
(State or country) /
4, h* **
12 MAIDEN NAME
OF MOTHER A
** *■ - •
0.
13 BIRTHPLACE OF
MOTHER (City)
,
(State or country) ,
-
14
I nf o r ma n t 22 . . f^r. . . ..
(Address )
Ay
16 DATE OF DE
MEDICAL CERTIFICATE OF DEATH
ATIT~7^
(Month)
17
I HEREBY CERTIF
19?^
/'7=7 ,/?*?> r.
(Day) (Year)
I attended^leceased from
* Sm / ^ , 1 9 r?.
that I last saw WiC4iulj.. alive o ^ , 19..??..?!*,
and that death occurred, on the date stated above, at /~'2>CZr m.
The CAUSE OF DEATH was as follows :
***..-. ...d!£^
.....vX»rr
CONTRIBUTORY
(SpCONDARY^
(duration) yrs......#
mos. ds.
(duration) yrs* mos* ds.
18 Whergrwas disease contracted . —
if notrat place, of death ?
Did an operation precede death Date of
Was there an autopsy?
What test confirmed diag
(Signed)
(Address)
UL
/' At
( M ont\Ar ( Da v ) ( Y ear)
M.D.
19 PLACE OF BURIAL, CREMATION, OR REMOVAL
(Cemetery) Iri (City or town)
DATE OF BURIAL
/X -Il-
ls
Filed 1 .Lfo,A4..“l-.l3,..
(Month) (Day) (Year)
21 I HEREBY CERTIFY that a satisfactory stan-
dard certificate o f death was filed with me
BEFORE the burial or transit permit was issued
20 UNDERTAKER
cTVf v d.
ADDRESS
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2
OFFICE OF THE SECRETARY
DIVISION OF VITAL STATISTICS
®t?r (Stmtmottuirallb nf HlaHBariiuBrtts
1 PLACE OF DEATH
County
City or Town
2 FULL NAME Sr;
MEDICAL EXAMINER’S CERTIFICATE OF DEATH
(Issued under thb Provisions op General Laws, Chapter 38)
ll^ State
Nojun
(City or town)
Registered No. „:>wL...
n
(If deatli occ
(XsVUL
(a) Residence. No.
(Usual place of abode)
Length of residence in city or town where death occurred
St., Ward
occurred in a hospital or institution, gitfe its name instead of street and number)
(If in the Army or Navy of the United States, give rank, organization, etc.)
St., Ward.
(If non-resident give city or town and State)
days How long in U. S., if oi foreign birth? years months days
3 SEX
PERSONAL AND STATISTICAL PARTICULARS
| 4 COLOR OR RACE
5 SINGLE, MARRIED, WIDOWED OR
DIVORCED ( write the word)
| , y / \ wtrauu twun iuc wi
[ft 1 )/£/ IsC&stAAud,
5a If married, widowed, or divorced
HUSBAND of
(or) WIFE of
6 DATE OF BIRTH
( Month)
(Day)
7 AGE
YearB
73
Months I
Days
3
// 1
If LESS than
1 day, hrs.
or min.
if STILLBORN, enter that fact here
8 OCCUPATION OF DECEASED
(a) Trade, profession, or
particular kind of work
(b) Name of employer
9 BIRTHPLACE (City)
(State or country)
11 BIRTHPLACE OF
FATHER (City)
(State or country)
12 MAIDEN NAME
OF MOTHER
7
13 BIRTHPLACE OF (/
MOTHER (City )
(State or country)
14
Informant.
(Address)
1£-
15
Filed 3. !
(Month) (Day) ( Year)'
registrar
MEDICAL CERTIFICATE OF DEATH
IS DATE OF DEATH.
17
Xoaa-u. ..... 19 '^'2.
(MoflthjV (Wty) (Year)
I HEREBY CERTIFY that I have investigated the
death of the person above-named and that the CAUSE AND MANNER
'thereof are as follows:
ckwj'O-.
JL
( 3u^jUu ^ SuJjCL)
(See reverse side for description for unknown person)
18 Where was injury sustainei
if not at place of death?
(Signed)
Date.
Medical Examiner for.-^a T
2. 4 (4 —
(Monti?) (Day)^ (Yftir)
19 PLACE OF mm., CREM
?/}i (luiuw*
DATE OF BURIAL
(Cemetery)
i 1C l..lr
Month) (Day) (Year)
21
Burial permit
issued by
Official
position.
20 UNDERTAKER
L&JL
' 22 Date of
issue ,
EXTRACTS
FROM THE LAWS OF THE
COMMONWEALTH OF MASSACHUSETTS
GOVERNING THE
RETURN OF CERTIFICATES OF DEATH
A physician or registered hospital medical officer shall
forthwith, after the death of a person whom he has attended
during his last illness, at the request of an undertaker or
other authorized person or of any member of the family of
the deceased, furnish for registration a standard certificate
of death, stating to the best of his knowledge and belief the
name of the deceased, his supposed age, the disease of which
he died (defined so that it can be classified under the inter-
national classification of causes of death), where same was
contracted, the duration of his last illness, when last seen
alive by the physician or officer and the date of his death. . . .
— General Laws, Chapter 46, Section 9.
No undertaker or other person shall bury a human body
.... until he has received a permit from the board of health
or its agent . . . or . . . from the clerk of the town where
the person died; ... no such permit shall be issued
until there shall have been delivered to such board,
agent or clerk, ... a satisfactory written statement
containing the facts required by law to be returned
and recorded, which shall be accompanied ... by a satis-
factory certificate of the attending physician, if any, as re-
quired by law, or in lieu thereof a certificate as hereinafter
provided' If there is no attending physician, or if, for
sufficient reasons, his certificate cannot be obtained
early enough for the purpose, or is insufficient, a phy-
sician who is a member of the board of health, or em-
ployed by it or by the selectmen for the purpose, shall
upon application make the certificate required of the
attending physician. If death is caused by violence,
the medical examiner shall make such certificate . . .
The person to whom the permit is so given and the physician
certifying the cause of death shall thereafter furnish for regis-
tration any other necessary information which can be obtained
as to the deceased, or as to the manner or cause of the death,
which the clerk or registrar may require. — General Laws,
Chap. 114, Sec. 4&-
Medical examiners shall make examination upon the view
of the dead bodies of only such persons as are supposed to
have died by violence. If a medical examiner has notice
that there is within his county the body of such a person, lie
shall forthwith go to the place where the body lies and take
charge of the same. . . . Gen. Laws, Chap. 38, Sec. 6.
• . . He shall in all cases certify to the town clerk or regis-
trar in the place where the deceased died his name and resi-
dence, if known; otherwise a description as full as may be,
with the cause and manner of death. — General Laws, Chap.
38, Sec. 7.
RULES OF PRACTICE
The fulfilment of the purpose of these laws calls for the
observance of the following rules of practice:
(1) Attending physicians will certify to such deaths
only as those of persons to whom they have given bedside
care during a last illness from disease unrelated to any form
of injury.
(2) Board of Health physicians will certify to such
deaths only as those of persons who, though disabled by
recognized disease unrelated to any form of injury, have
died without recent medical attendance or whose physician
is absent from home when the certificate of death is needed.
(3) Medical Examiners will investigate and certify to all
deaths supposably due to injury. These include not only
deaths caused directly or indirectly by traumatism (including
resulting septicemia), and by the action of chemical (drugs
or poisons), thermal, or electrical agents, and deaths following
abortion, but also deaths from disease resulting from in-
jury or infection related to occupation, the sudden
deaths of persons not disabled by recognized disease,
and those of persons found dead.
STATEMENT OF CAUSE OF DEATH
Medical Examiners in certifying to a death will state the
cause and manner thereof, and will specify: (1) Under
cause, the nature of an injury and of its consequences; and
(2) under manner, the mode of its production together
with the circumstances when these arc known. For example:
“Compound fracture of the femur with ensuing septicemia
(gas bacillus) caused by a steam railway accident.” “Pistol
shot wound of the chest with associated hemorrhage, homi-
cidal.” “Asphyxiation by suspension, suicidal.” “Syn-
cope while under the influence of ether administered as a
surgical ansesthetic.” “Fracture of the skull with associated
internal injury sustained under circumstances unknown.”
If investigation shows the death to have been due to dis-
ease, specify: (1) Under cause, its known or presumable
nature; and (2) under manner, indicate the circumstances
leading to medico-legal inquiry. For example: “Hemorrhage
spontaneous, of the brain (basal ganglia) (found dead in
bed).” “Heart disease, presumably coronary sclerosis.
(Sudden death.)”
DESCRIPTION (for unknown person)
%
-C
5
NOTICE TO UNDERTAKERS: No embalming fluid, or any substitute therefor, shall be injected into the
body of any person supposed to have met his death by violence, until a permit, signed by the Medical Examiner,
has first been obtained. — Gen. Laws, Chap, 38, Sec. !4.
THIS CERTIFICATE CONSTITUTES SUCH PERMIT
should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state CAUSE OF DEATH
in plain terms, so that it may be properly classified. Exact statement of OCCUPATION is very important. See
instructions and extracts from the laws on back of certificate.
I R-301
20,000.
KXM.
OFFICE OF THE SECRETARY
DIVISION OF VITAL STATISTICS
1 PLACE OF DEATH
©fje (fommmtniTalllj of iHassarljusetta
STANDARD CERTIFICATE OF DEATH
Massachusetts
City or Town...
2 FULL NAME ...
(a) Residence. No. / C5
( Usual place of abode)
Length of residence in city or town where death occurred
Bostorl
No
(If death
— ? ( y — c/ st.,
occurred in aJroapitul or institution, give its name instead of street a
BOSTON
(City or Town)
Registered No. ^
;..Ward
and number)
(If in the Army or Navy of the United States, give rank, organization, etc.)
St„ Ward. ,1
(If non-resident give city or town and State)
How long in U. S., if of foreign birth? years cioithr days
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
^ ‘
7 AGE
5a If married, widowed
HUSBAND of
(or) WIFE of
6 DATE OF BIRT
5 SINGLE, MARRIED, WIDOWED. OR
DIVORCED ( write the word)
±r? L
( Yean
If LESS than
1 day, his.
If STILLBORN, enter that fact here
8 OCCUPATION OF DECEASED
(a) Trade, profession, or / *
particular kind c I work K
(b) Name of employer
9 BIRTHPLACE (City)
(State or country)
^IT
MAIDEN NAME Of)/) r* /) /)
OF MOTHER (°
'
13 BIRTHPLACE OF
MOTHER (City)
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
17
✓*/(Month)
_ . /_ sja
(Month) (Day) (Year)
I HEREBY CERTIFY, That I attended deceased from
..h&r&f , 1
that I last saw h alive on
and that death occurred, on the date stated above, at
The CAUSE OF DEATH was as follows :
, 19 /f
O ,19 X
/ m.
CONTRIBUTORY
(secondary)
(duration) yrs mos* ds.
18 Where was disease contracted
if not at place of death?
FOR WHAT?
Did an operation precede death?. ^ Date of ?T. . Z
Was there an autopsy ? --
What test confirmed diagnosis ?
(Signed)
(Address).
onfirmed diagnosis
ddress) . Q~~U
, Md).
21 1 HEREBY CERTIFY that a satisfactory stan-
dard certi6cate of death was filed with me
BEFORE the burial or transit permit was issued
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N. B.— WRITE PLAINLY, WITH UNFADING BLAUK INK- 1 mis is A rt.niviAiNfc.ix l KtuuKD. tvery item or information
should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state CAUSE OF DEATH
in plain terms, so that it may be properly classified. Exact statement of OCCUPATION is very important. See
instructions and extracts from the laws on back of certificate.
M R-301
OFFICE OF THE SECRETARY
DIVISION OF VIJALSTAIHICS
PLACE dF Q.
County...^*
©If? (HontnumujeaUIj of fHasaarljoaptta
(City or Town)
Registered No.
_ St, Ward
(Jf/featY occurred in A hospital or institution, give its name instead of street and number)
("Month) (Day) (Year)
7 AGE Tears
Months
Days
/ ot;
If LESS than
1 day his.
or min.
, 19 -... ,i
that I last saw alive
and that death occurred, date stated above, at m.
The CAUSE OF DEATH was as follows s
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-WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD. Every item of information should be
carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state CAUSE OF DEATH in plain terms,
so that it may be properly classified. Exact statement of OCCUPATION is very important. See instructions on back
of certificate.
R-302
©tje (Comma mctfaUfy of iftassarljuspfta
STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH
County llorfolk State
Foxco rough
(City or town)
Registered No..
•BLSrSS,"
(Place o£ death)
City or Town F..Q.Xj3.0..CQ.U.gll No. ...St.®
,rf *«««. — — «" “ : titution, give its namjs instead of street and number)
lace <
Registered No. Jb__
(Place of residence)
St.. w»k1
(If death occurred in a hospital or institut: — -r— *•* ■ *’
2 FULL NAME An.B.S..t.a.S.i J • . .M.C.C..Q.ril.a.Ck
(If in the Army or Navy of the United States, give rank, organization, etc.)
(a) Residence. State M.S,.S .*■?...• City or Town.r/.i.n.th.iC.Q.p. No. St.
(Usual place of abode)
Length of residence in city or town where dealt occurred *7 years 1 months *7 Jays How long in D. S., if of foreign birth? year; months days
20,000
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
F
4 COLOR OR RACE
w
5 SINGLE, MARRIED, WIDOWED, OR
DIVORCED ( write the word)
Mar.
5a If married, widowed, or divorced
HUSBAND of
(or) WIFE of . , . _ .. _ ,
Austin J . Me C o rma ck
6 DATE OF BIRTH (month, day, and year) 19 ,
1368
7 AGE Years
Months
Days
If LESS than
5.3
s
12
1 day, hrs.
or min.
If STILLBORN, enter that fact here
8 OCCUPATION OF DECEASED
Housewife
(b) Name of employer
9 BIRTHPLACE (city or town) JB.O.S tl 0 H
(State or country) ■, - - , ^
10 NAME OF FATHER
J oim. Kirby
11 BIRTHPLACE OF FATHER (city or town)
(State or country) Ireland
14
12 MAIDEN NAME OF MOTHER Bridget F .POWH S
2Z
13 BIRTHPLACE OF MOTHER (city or town)
(State or country) X lS HCL
informant.Record.s.Fax'bjo.r.Q S.±.a..tfi
(Address) HO STli tal \
15
Filed .2/1/22 t 19 ^ ^ j - - 7
^ 'sN*i . Registrar of city or town where death occorred
Filed 7. , 19 -
Registrar of city or town where deceased resided
,i.i— i i , a ..=====
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH (month, day, and year)
Jan. 31f 1925*
17
I HEREBY CERTIFY, That I attended deceased from
•••April 15.., 19 .2.0 to...j-n..3.1., , 19 22,
that I Ia6t saw h..^!.r alive on 19 22
and that death occurred, on the date stated above, at 3.QU m.
The CAUSE OF DEATH* was as follows :
Acute entero-coli tie
(duration) yrs. mos._ ds,
coNTRiBUTOR'v^.P.^..']:.® i? ^ heme n ti a 5c val~
(secondary) vuTa’r heart' disease
(duration) ... JLD— yrs. mos ds.
18 Where was disease contracted
if not at place of death?
Did an operation precede death?J53 Date of.
Was there an autopsy?
What test confirmed diagnosis?
(signed ) C. .X . .'.5. c ho. r er
7239 (Afess) Foxboro State Hospital
19 PLACE OF BURIAL, CREMATION, OR REMOVAL
... M.D.
-Holy Cross*
ic.e:
20 UNDERTAKER
Richard C. Kirby
DATE OF BURIAL
2/3/22
19
ADDRESS
R. Boston
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should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state CAUSE OF DEATH
in plain terms, so that it may be properly classified. Exact statement of OCCUPATION is very important. See
instructions and extracts from the laws on back of certificate.
1 R-301
0,000
(EomntmuttraWj of iHaosarljuaftta
STANDARD CERTIFICATE OF DEATH
* (City or Tdwn)
State..
.Registered No.
f
OFFICE OF THE SECRETARY
DIVISION OF VITAL STATISTICS
1 PLACE OF DEATH
County
City or Town No Z-jf - St., Ward
' (If death occurred in a liospital or institution, give its name instead of street and number)
2 FULL NAME cJ...
(If in tbe^Yrmy or Navy of the United States, give rank, organization, etc.)
(a) Residence. No. . . . St.,. Ward.
(Usual place of abode) (If non-resident give city or town and State)
Length of residence in city or lows where death occurred years months days. How long in U. S., il of foreign birth? years months days
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
4 COLOR OR RACE
S SINGLE, MARRIED. WIDOWED, OR
DIVORCED (write the word)
5a Ifmnarried, widowed, oc divorced
WJ&BAMP PT YP .
(or) WIFE of
6 DATE OF BIRTH
,f *
/xv#
(Month)
(bay)
(Tear)
7 AGE ^7 ^ Years
Months
Days
If LESS than
/
X l
1 day, hrs.
or min.
If STILLBORN, enter that fact here
8 OCCUPATION OF DECEASED y
(a) Trade, profession, or xPf ✓ .a 4
particular hind of work
(h) Name of employer
9 BIRTHPLACE (City)
(State or country)
10 NAME OF
11 BIRTHPLACE OF
FATHER (City)
(State or country)
P A
12 MAIDEN NAME
OF MOTHER
ij: . ./„• $
13 BIRTHPLACE OF
MOTHER (City)...
(State or country)
Filed 3r .l^A X.
(Month) (Day) (Year)
Registrar
19 PLACE OF BURIAL, CREMATION. OR REMOVAL
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATf
Month)
■J/
(Day)
/ 9^
(Year)
17
I HEREBY CERTIFY, That I attended deceased from
£ , to. ,
that I last saw h..&^r. alive on . PrFr^rrr. ,
/SL O
..r.
The CAUSE OF DEATH was as follows:
..(duration) yrs..
ds.
CONTRIBUTORY
(secondary)
(duration) yrs....
18 Where was disease contracted
if not at place of death? ,—r — —
ds.
id an operation precede death? Date of
'cdt** ~d i
Was there an autopsy ?
What test confirmed diagnosis ?
(Signed)
Date..
(Address)
Vy._,
f^Honth)
DATE OF BURIAL
2-
20 UNDERTAKER
(5
21 1 HEREBY CERTIFY that a satisfactory stan-
dard certificate of death was filed with me
BEFORE the burial or transit permit was issued
Date of
Official Health Officer issue
.position.. of permit
p,nni' « / -
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should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state CAUSE OF DEATH
in plain terms, so that it may be properly classified. Exact statement of OCCUPATION is very important. See
instructions and extracts from the laws on back of certificate.
M R-301
a
2
19. 50,000.
OFFICE OF THE SECRETARY
DIVISION OF VITAL STATISTICS
PLACE OF
County-*
City or Town
2tljp (Somatmtuu'aUfj of ilassarljusrttB
STANDARD CERTIFICATE OF DEATH
2 FULL NAME
(a) Residence. No,
(Usual place of aboct
Length of residence in city or town where death occoned
(City or Town)
Registered No. ~i...
St., Ward
give its name instead of street and number)
(If in the Army or Navy of the United States, give rank, organization, etc.)
St,. Ward
(If non-resident give city or town and State)
days. How long in U. S., if of foreign birth ? years months days
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
a
4 COLOR OR RACE
5 SINGLE, MARRIED. WIDOWED. OR
DIVORCED ( write the word)
16 DATE OF DEATH
(Month)
(Day)
Ci ) y
(Year)
17
5a If married, widowed, or divorced
HUSBAND of - _
(or) WIFE of A. ~~r~
6 DATE OF BIRTH
J
(Month)
(Day)
(Year)
7 AGE Years
Months
Days
If LESS than
1 ■day,.V...hrs.
—
—
"
or min.
HEREBY CERTIFY, That I attended deceased from
, 19.?....*=., to. , 19...1" V
that I last saw h..^rinr alive on ... i , 19....?. V
and that death occurred, on the date stated above, at. t..A m.
The CAUSE OF DEATH was as follows:
If STILLBORN, enter that fact here
8 OCCUPATION OF DECEASED
(a) Trade, profession, or
particular kind of work.
(b) Name of employer
(XS
(duration) yrs....
ds.
9 BIRTHPLACE (City)
(State or country)
CONTRIBUTORY
(secondary)
(duration) yrs....
18 Where was disease contracted
if not at place of death?
ds.
Did an operation precede death? Date of..
O
Was there an autopsy ?
What test confirmed diagnosis ?
(Signed)
(Address).
Date.
Ot 6 ~2i> — L
\^0 3 c£..x
(Month)
(Year)
Filed mJi
(Month) (Day)
21 I HEREBY CERTIFY that a satisfactory stan-
dard certificate of death was filed with me
BEFORE the burial or transit permit was
stan-
L:
iURIAL
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should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state CAUSE OF DEATH
in plain terms, so that it may be properly classified. Exact statement of OCCUPATION is very important. See
instructions and extracts from the laws on back of certificate.
1 R-301
10.000
OFFICE OF THE SECRETARY
DIVISION OF VITAL STATISTICS
STIjp (Eommonuij'aUfj of fHassadjusptta
STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH // J/ * (City or To<fn)
County State ^ Registered No. \...G -
Town ' No.*L. .. St.,.™ Ward
City or
(If death occurred iu a hospital or institution, give its nasi e instead of street and number)
2 FULL NAME
(a) Residence. No
( Usual place of abode)
Length of residence in city or town where death occurred
in the Army or Navy of the United States, give rank, organization, etc.)
St., Ward. .
years
months
days.
(If non-resident give city or town and State)
How tong in U. S., if of foreign birth ? years months days
PERSONAL AND STATISTICAL PARTICULARS
4 COLORPR R^CE
3 SEX 4 COLORpR R£C
5 SINGLE, MARRIED, WIDOWED, OR
DIVORCED (write the word)
5a If married, widowed, or divorced
HUSBAND of
(or) WIFE of
»r aiv<
J.
6 DATE OF BIRTH .
( Month)
tz.
"(bay)'
(Year)
7 AGE
7^L
Years
Months
/d
Days
17
If LESS than
1 day, his.
or min.
If STILLBORN, enter that fact here
8 OCCUPATION OF DECEASED
(a) Trade, profession, or
particular kind of work
(b) Name of employer
9 BIRTHPLACE (City)
(State or country)
10 NAME OF
FATHER
11 BIRTHPLACE OI
FATHER (City)....
“L
(State or country
12 MAIDEN NAME
OF MOTHER
13 BIRTHPLACE Of
MOTHER ( Citv)
(State or country) ,
14
Informant
(Address)
15
xi
^ t~u
Filed 'tgJa. , \A.r.\%. J- y~:
(Month) (Day) (Year)
Registrar
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
3
"(Day)'
v?a.l
(Year)
17
I HEREBY CERTIFY, That I attended deceased from
7bs^SsJL.^.M , to 19X2^.
that I last saw h./V^Y..... alive on » 19>rTr*,
and that death occurred, on the date stated above, m.
The CAUSE OFL DEATH was as follows:
(duration)' yrs
CONTRIBUTORY —
(secondary) f
(duration) > yrSw
18 Where was disease contracted
if not at place of death ?
Did an operation precede death?. 7^....
ds.
ds.
Date of...
Was there an autopsy ?
What test confirmed diagnosis?
(Signed)
(Address)
Date
19 PLACE OF BURIAL, CREMATION, OR REMOVAL
(Cemetery) 7_ (City or town)
20 UNDERTAKER
DATE OF BURIAL
ie.J 9 Z 2-
ADDRESS y y
21
I HEREBY CERTIFY that a satisfactory stan-
dard certificate of death was bled with me , / / '77 ■>, y . a_ y
BEFORE the burial or transit permit was issued. 2
Official
...position/, fcr
Date of
issue
i permit..
Permit
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of certificate,
(Eomnumaii’aUl} of Hasoarljua^tfa
STANDARD CERTIFICATE OF DEATH aaS.XON
1 PLACE OF DEATH Rep.ter«d No. LL4S.
Suffolk state Massachusetts r ^uul^T
. _ _ ,1-. (Place or re
cZ"I t„:: 1 Boston _ No MASS , HOMEO » HOS PT ,
(If death occurred in a hospital or institution, give its namb instead of street and number)
2 FULL NAME MARY. .J..»..B RQYYN
(If in the Army or Navy of the United States, give rank, organization, etc.)
MASS. city „ Town WINTHItOP No. 59 QUINCY AVE ■ s.
(a) Residence. State
(Usual place of abode)
Length of residence in at? or town where death occurred
months
days
How long in 0. S., if of foreign birth?
months
days
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
4 COLOR OR RACE
w
5 SINGLE, MARRIED, WIDOWED, OR
DIVORCED (write the word)
WIO.
5a If married, widowed, or divorced
HUSBAND of ia/.« u
(or) WIFE of WM.n
a
6 DATE OF BIRTH (month, day, and year) — — — — —
| 7 AGE Years
70
Months
Days
If LESS than
1 day, hrs.
or min.
If STILLBORN, enter that fact here
| 8 OCCUPATION OF DECEASED
(t) Trade, professien, or
particular kind of work
NO ME
(b) Name of employer
9 BIRTHPLACE (city or town) P I C T O L)
(State or country) [jtgt
10 NAME OF FATHER
11 BIRTHPLACE OF FATHER (city or town).
(State or country)
P I CTO U
N.S.
12 MAIDEN NAME OF MOTHER ELIZABETH GRANT
13 BIRTHPLACE OF MOTHER (city or town) p 4CT0U —
(State or country) N.S,
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH (month, day, and year) F E B , 4 • 1922
17
I HEREBY CERTIFY, That I attended deceased from
jLSJL3-Q- 19.2.2., to E.E.B.a4.a 19 22 ,
that I last saw h ER alive on E.-EB..*.^.#. gv 19.22 ,
) # ( 5^
and that death occurred, on the date stated above, at m.
The CAUSE OF DEATH* was as follows: ,
BR0NCH0-PNEUMONI A
..(duration) yrs. mos.
d«.
CONTRIBUTORY.
(secondary)
.(duration) yrs mos.
.ds.
ALEXANDER CAMPBEU® Where was disease contracted
if not at place of death 7
Did an operation precede death?..
Was there an autopsy?
.Date of
What test confirmed diagnosis?
(Signed) H.M, POLLOCK
, 19 22 (Address)
... M.D.
EEB-,5,
14
Informant .
(Address)
15
Filed. F6&,
jXUUt-
,<892j
19 PLACE OF BURIAL, CREMATION, OR REMOVAL
FOREST HILLS
Filed
l, 19
Registrar of city or town where death occurred
Registrar of city or town where deceased resided
20 UNDERTAKER
J.S. WATERMAN k SONS
DATE OF BURIAL
FEB. 79 22
ADDRESS
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1
-WRITE PLAINLY, WITH UNFADING INK — THIS IS A PERMANENT RECORD. Every item of information should be
carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state CAUSE OF DEATH in plain terms,
so that it may be properly classified. Exact statement of OCCUPATION is very important. See instructions on back
of certificate. (
(CommmutieaUl! of Massachusetts
BOARD OF HEALTH PHYSICIAN’S CERTIFICATE OF DEATH
OFFICE OF THE SECRETARY
DIVISION OF VITAL STATISTICS
To be used only in case there is no attending physician or if for sufficient reason the attending physician’s certificate cannot
1 PLACE OF DEATH be obtained early enough for the purpose of granting a burial per mit , as provided by Revised Taws, Chapter 78, Section 88.
. Ndr^C / J r St., Ward
(If death occurred in a hqpwtal or Institution, give its name instead of street and number)
Registered No. l.i
2 FULL NAME
(a) Residence. No
(Usual place of abode)
Length of residence in city or town where death occurred
months
tlie Army or Navy of the United States, give rank, organization, etc.)
St., Ward.
(If non-resideDt give city or town and State)
How long in U. S., if of foreign birth? years months days
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
3 SEX
4 COLOR OR RACE
5 SINGLE. MARRIED, WIDOWED, OR
DIVORCED (icrite th^word)
5a If married, widowed, or divorced
HUSBAND of
(or) WIFE of
16 DATE OF DEATH 6
(Month) (Day) (Year)
17
6 DATE OF BIRTH (month, day, and year) ^ f %
I HEREBY CERTIFY, That I have ascertained the
nature of the disease from which the person above-named died, and that
the CAUSE OF DEATH* was as follows:
7 AGE
\3 lcars
If STILLBORN, enter that fact here
Months
Days
If LESS than
1 day, hrs.
or. min.
•State the Disease Causing Death. (See reverse side for additional
space and instructions.)
8 OCCUPATION OF DECEASED
(a) Trade, profession, or
particular kind of work
(b) General nature of industry,
business, or establishment in
which employed (or employer)..
(c) Name of employer
. (duration) mos.
/O
. ds.
9 BIRTHPLACE (city or tow
(State or country)
CONTRIBUTORY
(secondary)
(duration) yrs
18 Where was disease contracted /*• /. I _
if not at place of death?
ds.
10 NAME OF FATHER
11 BIRTHPLACE OF FATHER (city or town)
(State or country)
12 MAIDEN NAME OF MOTHER^^^? p_(
13 BIRTHPLACE OF MOTHER (city or town)
(State or country)
Did an operation precede death?..
Was there an autopsy?
;?| lC
. Date of..
What test ed diagnosis?.
(Signed)
Date..
(Address) / V f C T~ 1/*^
7 .1922^
(Month) (Day) (Year)<L. . J* . s y.
14
15
Informan*^^^^'. .
■ ~Q ? j- ^
19 PLACE OF BURIAL, CREMATION, OR REMOVAL
(Address)
. /f
DATE OF BURIAL
19 2.Z_
FUed / ( , 19 L
(Month) (Day) (Year)
Registrar
20 UNDERTAKER /
ADDRESS
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instructions and extracts from the laws on back of certificate.
R-301
OFFICE OF THE SECRETARY
DIVISION OF VITAL STATISTICS
1 PLACE OF DEAT;
County
©If* GJommmmiratiij of fSassadfusrtta
City or T own
2 FULL NAME J
STANDARD CERTIFICATE OF DEATH
5
(City or Town)
Registered No.
C- No st. ward
(If death occurred in a hospital or institution, give its name instead of street and number)
7 ' (If in the Army orXajyrtef the United States, give ra:
/ 3
(a) Residence. No. ......
(Usual place of abode) r\ / /
length of resilience in city or town where death occurred 0 '
(If in the Army oymoxfot the United States, give rank, organization, etc.)
St.,_ f^V^ard.
months
days.
(If non-resident give city or town and State)
How long in U. S., if of foreign birth ? years months days
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
hr /<rz-^
(Day) (Tear)
4 COLOR OR RACE
24/-yUr6e7
5 SINGLE, MARRIED. WIDOWED, OR
DIVORCED ( write the word)
16 DATE OF DEATH
17
(Month)
5a If matrifid, widowed, or drvTJYc^d
HUSBAND af-
tor) WIFE
J?\ £ r
6 DATE OF BIRTH
'2-J
/ 83 y
( Month)
(’Day)
(Year)
7 AGE Years
Months
Days
If LESS then
c1^
/
/ <o
1 day, his.
or min.
1 HEREBY CERTIFY, That I attended deceased from
L laZ^to is
'that I hr^t saw alive on , „ 19
and that death occurred, on the date stated above, at
The CAUSE OF DEATH was as follows :
If STILLBORN, enter that fact here
8 OCCUPATION OF DECEASED
(») Trade, profession, or ^
.....(duration) ...^^.....yrs )C, mos,...^ ds.
cu^< J 'y-
_<■. yrs mos. lil^ds.
rlicpncA rnntra rfpd *
Did an operation precede death? Ju Date of
2u
particular hind ol work
(h) Name of employer
CONTRIBUTORY
(secondary)
9 BIRTHPLACE (City)
(State or country)
10 NAME OF
FATHER
11 BIRTHPLACE OF
FATHER (City)
9 f ^ — y —
(State or country)
jj / ^ >
12 MAIDEN NAME /? * , / , r- /
OF MOTHER T7^L . . .Hc&C
13 BIRTHPLACE OF
MOTHER (City)
(State or country)
■/ c_y r
18 Where was disease contracted
if not at place of death?
Was there an autopsy?
What test confirmed diagnosis?..
(Signed)..
M.D.
(Address) .
MtJkJL y /£.£.zZL.
/ (Month) (Day) (Year) jr
14
Informant
19 PLACE OF BURIAL, CREMATION. OR REMOVAL
(Cemetery’) ((.'itv or town)
DATE OF BURIAL
'
/ "/ J. L
15
Filed
(Month)
d'd - I
. I. l%z i
(Day) (Tear)
Registrar
20 UNDERTAKER
/&L.
ADDRESS
— T. —
3.000
21 1 HEREBY CERTIFY that a satisfactory stan-
dard certificate of death was filed with me
BEFORE the burial or transit permit was issued .:
j (
W-7
sssU
Date of
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in plain terms, so that it may be properly classified. Exact statement of OCCUPATION is very important. See
instructions and extracts from the laws on back of certificate.
A R-301
i
9. 50,000.
OFFICE OF THE SECRETARY
DIVISION OF VITAL STATISTICS
1 PLACE OF
Count
City or Town.
Sty* (Eomnumujrattlj of iHasoarljusctta
>F DEATH
STANDARD CERTIFICATE
ICity or Town)
J. Registered No. I ^3
2 FULL NAME
(a) Residence. No.
(Usual place of abode)
Length of residence in city or town where death occurred
euL No st Ward
(If death occurred in a hospital or institution, give its name instead of street and number)
( If in the Army or Navy of the United States, give rank, organization, etc.)
3t^ Ward.
months
(If non-resident give city or town and State)
days. How long in U. S., if of foreign birth ? years months days
PERSONAL AND STATISTICAL PARTICULARS
SEX
4 COLOR OR RACE
5a If married, widowed, or divorced
HUSBAND of
(or) WIFE of
5 SINGCE, MARRIED, WIDOWED. OR
DIVORCED (write Uie word)
7 AGE Years
Months
Days
If LESS than
C?o
F
jy
1 day, hrs.
or min.
If STILLBORN, enter that fact here
8 OCCUPATION OF DECEASED ,
(a) Trade, profession, or / /} i
particular kind of work JAJiL/
(b) Name of employer
9 BIRTHPLACE (City)
(State or country)
10 NAME OF,
FATHER f
11 BIRTHPLACE OF
FATHER (City)
(State or country)
12 MAIDEN NAM1
OF MOTHER
13 BIRTHPLACE OF
MOTHER (City) ^
(State or country)
16 DATE OF DEATH
MEDICAL CERTIFICATE OF DEATH
„ '.Su..
(Month)
%
ay)
J.x.X'.y...
(Ye "
fear)
17
I HEREBY CERTIFY, That I attended deceased from
j: , i9. v h, to 9 19
that I last saw h....?r^^alive on , 19..M.C*,
and that death occurred, on the date stated above, at m.
The CAUSE OF DEATH was as follows :
(duration) yrs mo8«...**$ ds,
CONTRIBUTORY
(secondary) U
(duration) / yrs„ raos ds.
18 Where was disease contracted
if not at place of death?
Did an operation precede death? Date of
Was there an autopsy?
What test confirmed diagnosis ?
(Signed) M.D.
1 ^
(Month)
(Day)
(Year)
14
Informant
(Address) /
19 PLACE Of BURIAL, CRE.
(Cemetery) //
DATE OF BURIAL
// 19 22.
15
Filed _
(Month) (Day) (
) (Day) (Year)
21 I HEREBY CERTIFY that a satisfactory stan-
dard certificate of death was filed with me
dard certificate of death was filed with me
BEFORE the burial or transit permit was
et 1 «
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should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state CAUSE OF DEATH
in plain terms, so that it may be properly classified. Exact statement of OCCUPATION is very important. See
instructions and extracts from the laws on back of certificate.
R-301
OFFICE OF THE SECRETARY
DIVISION OF VITAL STATISTICS
Sllje (EomuumuiraUIf of iHaasarlmsrtJs
OF
Registered No.
STANDARD CERTIFICATE OF DEATH ~ v...,
1 PLACE OF DEATH ^ ~ (City or Town)
County.
City or Town No £.<? - - St.. Ward
(If death occurred in a hospital or institution, give its name instead of street and number)
State
li.
(If in the Arntj^yr Navy of the United States,
2 FULL NAME
(a) Residence. No ^ —
(Usual place of abode) . .
Length of residence in city or town where death occurred / ■ jears months
give rauk, organization, etc.)
St., Ward.
(if non-resident give city or town and State)
days.
How loDg in U. S., if of foreign birth ?
years months
days
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
OF DEATH Z&JkzZ
(Month) (Day) (Year)
3 SEX 4 COLOR OR RACE
5 SINGLE, MARRIED. WIDOWED, OR
DIVORCED (write th^ word)
16 DATE
-c
17
5a If married, widowed, or divorced-
(or) WIFE of ^
4 ✓ f £jP
(Month) (Day) (Year)
6 DATE OF BIRTH.
I HEREBY CERTIFY, That I attended deceased from
,19 , 19.i?^2^
that I last saw alive on t 19
7 AGE
Years
Months
Days
If LESS than
u
c
XT
1 day, hrs.
or min.
and that death occurred, on the date stated above, at
The CAUSE JDF DEATH was
II STILLBORN, enter that fact here
8 OCCUPATION OF DECEASED
(a) Trade, profession, or
particnlar kind ol work
(b) Name of employer
wAUSE^QF^ DEATH was as follows : jj
d oration ) yrs mos. ds.
tkkJtO
9 BIRTHPLACE (City)
(State or country)
10 NAME OF
FATHER
Y7Z&
^7° / - i/
CONTRIBUTORY
(secondary)
(duration) yrs„..
18 Where was disease contracted
if not at place of death ?
ds.
11 BIRTHPLACE OF , // ^
FATHER (City) k^.. *//£....”. zZZZ
(State or country) u/
Did an operation precede death? 'fylL/O. ... Date of
12 MAIDEN NAME
OF MOTHER
13 BIRTHPLACE OF
MOTHER (City)
(State or country)
Was there an autopsy?
What test confirmed diagnosis ?
(Signed) cuz . ,, „ .
(Address)
//ay)"
... M.D.
u
Date
( Month)
(Year)
14
Informant X-,...
(Address) 1' <3
19 PLACE OF BURIAL, CREN
MOVAL,
((’eincteryp (Pity or town)"
DATE OF BURIAL
^-//S ~Z1-
15
Filed Jj Jo A3 . lx 2^
(Month) (Day n (Year)
Registrar
20 UNDERTAKER
<g /£
ADDRESS
),000
21 I HEREBY CERTIFY that a satisfactory stan- y /Zi
dard certificate o( death was filed with me /f „ ‘ .W’wyy/Z. y
BEFORE the burial or transit permit was issued .....X^Z...’ /Z.
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in plain terms, so that it may be properly classified. Exact statement of OCCUPATION is very important. See
instructions and extracts from the laws on back of certificate.
M R-301
OFFICE OF THE SECRETARY
DIVISION OF VITAL
1 PLACE OF
County.
City or Town
©ommmtuH'aUlj of iflassarijusrtla ^ __
STANDARD CERTIFICATE OF DEATH 1 J\X\sJUL^
(City or Town#
S%tCte/s'.'..s - - , j Registered No. J. S
N o. S t., W ard
ath occurred in a hospitrd'or institution, give its name instead of street and number)
2 FULL NAME I
(a) Residence. No
(Usual place of abodi
Length of residence in city or town where death occurred
PERSONAL AND STATISTICAL PARTICULARS
(If in the Army or Navy of the United States, give rank, organization, etc.)
St.,. Ward.
R RACE
5 SIMILE. MARRIED. WIDOWED, OR
Dj/ORCEDJ,!c.ri(^tfie word)
5a If married, widowed, or divorced
HUSBAND of
(or) WIFE of j /
6 DATE OF BIRTH
y<s~
/?0J
(Month)
(Day)
(Year)
7 AGE Years
/ Months
Days
If LESS than
eSc
/c
oS 7
1 day, hrs.
or min.
If STILLBORN, enter that fact here
8 OCCUPATION OF DECEASED
(a) Trade, profession, or
particular kind of work
(b) Name of employer
(If non-resident give city or town and State)
How long in U. S., if of foreip birth ? years months days
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH Z..& ....
' (Month) Day) '(Year)
17
I HEREBY CERTIFY, That I attended deceased from
^ , 19* A, to / 7- , 19 77~f
that I last saw h.Arr?:..... alive on ....frr. .., 19.^ 2-
and that death occurred, on the date stated above, at ../....Q.. ...(ff,. ..m.
The CAUSE OF DEATH was as follows s
DATE QF BURIAL
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instructions and extracts from the laws on back of certificate.
R-301
OFFICE OF THE SECRETARY
DIVISION OF VITAL STATISTICS
1 PLACE OF DEATH
County
©I i* (Eomutotiuu'uUlj of fHassuchuortta
y (City or Town)
- > / / State Registered No. / ...(p
City or Town. No St. Ward
STANDARD CERTIFICATE OF DEATH
.Registered No.
(If death occurred iu a hospital or institution, give its name instead of street and number)
2 FULL NAME
(a) Residence. No.
(Usual place of abode)
Length of residence in citj or town where death occurred
(If in the Army or Navy of the United States, give rank, organization, etc.)
St., Ward. .
months
days.
(If non-resident give city or town and State)
How long in U. S., if of foreign birth? years months days
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
3 SEX
4 COLOR OR RACE
5 SINGLE, MARRIED. WIDOWED, OR
DIVORCED (write the word)
16
17
DATE OF DEATH...X^.*^Z: ../.‘/‘A A..
(Month)/
(Day)
(Year)
5a If mMavnd, widow«dy«*Ji*wi^wF -
HUSBAND of — / /Z
Ur) WIFE— at, Y ' £r-L*~****^~%,
I HEREBY CERTIFY, That 1 attended deceased from
... 19-
6 DATE OF BIRTH.
// /fj V
(Month) (Day) (Year)
7 AGE
Years
$rY
Months
/ o
Days
s
If LESS than
1 day, hrs.
or min.
- to
that I last saw h.^^W..... alive on 19...^rrr.!^T
and that death occurred, on the date stated above, at..
The CAUSE OF DEATH was as follows: ^
II STILLBORN, enter that fact here
8 OCCUPATION OF DECEASED
(a) Trade, profession, or *,
particular kind ol work 7
(duration) yrs..
do.
(b) Name of employer
9 BIRTHPLACE (City)
(State or country)
10 NAME OF
FATHER
CONTRIBUTORY.
(secondary)
(duration) yrs,.
18 Where was disease contracted
if not at place of death ? 7 :: . '
ds.
11 BIRTHPLACE OF 7/ -7
FATHER (City) Z.
! (City)
(State or country)
Did an operation precede death?
Was there an autopsy ? iZZY..
What test confirmed diagnosis?...
Date of.
12 MAIDEN NAME
OF MOTHER
13 BIRTHPLACE OF
MOTHER (City)
(State or country)
(Signed).
Date
14
e-
si#
19 PLACE OF BURIAL. CREMATION, OR REMOVAL
(Cemetery)
(City or town)
15
Filed C \ ...
(Month) (Day) (Year)
Registrar
20 UNDERTAKER
&sf- 6
DATE OF BURIAL
JL
ADDRESS
,000
21 1 HEREBY CERTIFY that a satisfactory stan-
dard certificate of death was filed with me
BEFORE the burial or transit permit was issued
Date of Permit
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should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state CAUSE OF DEATH
in plain terms, so that it may be properly classified. Exact statement of OCCUPATION is very important. See
instructions and extracts from the laws on back of certificate.
R-301
OFFICE OF THE SECRETARY
DIVISION OF VITAL STATISTICS
1 PLACE OF DEATH
County.
City or Town....,
2 FULL NAME
(a) Residence. No,
( Usual place of abode)
Length of residence in city or town where death occorred
Stye (EommmtroeaUIj of fUassadjusrtJa
STANDARD CERTIFICATE OF DEATH
State yjZ
NoTr^^H _
(If death oecurred'Tn a
Registered No. L.| .
St., ...Ward
or institution, give its name instead of street and number)
(If in the Army or Navy of the United States, give rank, organization, etc.)
St.,. Ward.
months
(If non-resident give city or town and State)
How long in U. S., if of foreign birth ? years months days
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH .
jU rf /pA-
(Month) (Day) (Year)
4 COLOR
>R^t
5 SINGLE, MARRIED. WIDOWED, OR
DIVORCED (write the woyd)
3 SEX 4 COLOR OR RACE 5 SINGLE, MARRIED. WIDOWED, OR
,) y , . DIVORCED (write the wo^d)
16 DATE OF DEATH .
5a If married, widowed, or divorced /? , SL '
HUSBAND of A
(or) WIFE of „ / 0 /7
6 DATE OF BIRTH.
' /ftyD
(Month) (Day) (Year)
7 AGE
Years
?/
Months
ff
Days
If LESS than
1 day, hrs.
or min.
EREBY CERTIFY^ That 1/ attended deceased from
/V-
that \ last saw h./..f^.. alive on , 19.^..!?.,
and that death occurred, on the date stated above, at m.
The CAUSE OF DEATH was as follows:
If STILLBORN, enter that fact here
8 OCCUPATION OF DECEASED
(a) Trade, profession, or
particular kind ot work
(b) Name of employer
Icjyy't- V kj'c
..(duration) yrs r?T... mos, .
.ds.
CONTRIBUTORY
(secondary)
(duration) yrs,..
18 Where was disease contracted
if not at place of death ?
f . >
Did an operation precede death? Date of
ds.
Was there an autopsy?
What test confirmed diagnosis? r.....rr....^cg3r...
^
( M until )
(Address).....
Dale
( Day)
Informant
(Address)/^
Filed . JJUfo.: , ^,3...)„G\..2:..2. ...
(Month) (Day) (Year)
13 PLACE- QF BURjAL, CREMATION, OR REM0.VAI
'(Cemetery) (City or to
20 UNDERTAKER
Registrar
, / j Date of Permit
21 1 HEREBY CERTIFY that a satisfactory stan-
dard certificate of death was filed with me
BEFORE the burial or transit permit was issued .
Date of
issue JJ j
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’19-XXM.)
OFFICE OF THE SECRETARY
DIVISION OF VITAL STATISTICS
1 PLACE OF DEATH
STANDARD CERTIFICATE OF DEATH
County. S LI ffol |k State MaSSacHu S fitts Registered No. t ^
City or Town. ...l PQ ST O fM No.^,/..^
\-x . -rjr 4 ilf death occurred in a hospital or institution, give i
Vf
2 FULL NAME yirfZvk* ^W- , W,
St Ward
its name instead of street and number)
(Usual place of abode)
Length of residence in city or town where death occurred years
’ *
Dt*
(Ian the At
y% t j otn me Army or Navy of the United States, give rank, organization, etc.)
(a) Residence. No. \J. C^L l >... St.,. Ward.
(if non-resident give city or town and State)
months days. How long in U. S., if of foreign birth ? years months days
?•*»
21 I HEREBY CERTIFY that a satisfactory stan-
dard certificate of death was filed with me
BEFORE the burial or transit permit was issued
tssoe
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R-301
OFFICE OF THE SECRETARY
DIVISION OF VITAL STATISTICS
1 PLACE OF DEATH ^
tftyp (EomttumttmtUfj of fflassarljuartta
STANDARD CERTIFICATE OF DEATH
^ ^ - (7 / ,
State .
St. Ward
(If death occurred iu a hospital or institution, give its name instead of street and number)
County ._.
City or Town. No 77. 1 — 2* t
(If death occurred in a ' — 5 — — -1 — "
2 FULL NAME
S npTr iti
/ 7 .
^ years
(City or Town)
Registered No. IJ-j
(a) Residence. No.
(Usual place of abode)
Length of residence in city or town where death occorred
r ^ ' -V
the Army or Navy of the United States, give rank, organization, etc.)
St.,. Ward.
/ V
I months days.
(If non-resident give city or town and State)
How long in U. S., if of foreign birth? So years months Nr days
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
. CERT1F
/(Month)
3 SEX
4 COLOR OR RACE
5 SINGLE, MARRIED. WIDOWED, OR
DIVORCED ( write the word)
16 DATE OF DEATH
7'.^ c\
lee
(Day)
(Year)
17
5a If married, widowed, or divorced
HUSBAND of
(or) WIFE of
6 DATE OF BIRTH.
7
[EREBY CERTIFY, That I attended deceased from
t
( Mont,
(Day)
(Year)
7 AGE
Years
Months
i
Days
19,'k.'^. to 19.,
that I last saw h alive on Lt , 19...^..V,
I JK
and that death occurred, on the date stated above, at i m.
If LESS than
1 day, bs.
or min.
The CAUSE OF DEATH was as follows:
It STILLBORN, enter that fact here
PATION OF DECEASED sr ^ / / J)
!, profession, or , f'V, / I C I
kind of work tzTzfi.6. \.
(b) Name of employer //j/c 7- / 7*/ ^ ^ ^ z * z.
8 OCCUPATION
(a) Trade,
particular
(duration) yrs..
9 BIRTHPLACE (City)
(State or country)
10 NAME OF
FATHER
CONTRIBUTORY
(Secondary)
(duration) yrs mos. ds.
18 Where was disease contracted
if not at place of death ?
11 BIRTHPLACE OF
FATHER (City)
* l
y
(State or country)
V
<-
12 MAIDEN NAME
OF MOTHER
V
J
13 BIRTHPLACE OF
MOTHER (City)
*
‘r
, /
(State or country)
Did an operation precede death? Date of
Was there an autopsy? .... LArrrrr. CS.
What test confirmed diagnosis?
(Signed)..
iddress) .T?..
Date
14
Informant....^!^.^^^1^. </«
JIAddress)^
19 PLACE OF BURIAL, CREMATION, OH REMOVAL
//C> C 7 C C ^ < 'r2- — ■ —
(Cemetery) c (City or town)
DATE OF BURIAL
15
20 UNDERTAKER
ADDRESS
Filed v..£_fo . X3> .
(Month) (Day) (Year) > ^
registrar
77 7 Y J *-
■#s<>
,000
21 1 HEREBY CERTIFY that a satisfactory stan-
dard certificate of death was filed with me
BEFORE the burial or transit permit was issued G
Permit
nit... SI±
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should be carefully supplied. AUt should be stated tXAU l LY. PHYSICIANS should state UAUSt UP utA l H
in plain terms, so that it may be properly classified. Exact statement of OCCUPATION is very important. See
instructions and extracts from the laws on back of certificate.
R-301
000
OFFICE OF THE SECRETARY
DIVISION OF VITAL STATISTICS
1 PLACE OF DEATH
County
Stye (EommmutiraUh of iJSassadjusetta
OF
CERTIFICATE OF DEATH
STANDARD
TH / / J * f
City or Town No
i ocpfirretj/iu a hospital or institution, give its name instead of street and number)
(City or Town)
Registered No. c2<LO - -
st w^d
2 FULL NAME ^
(a) Residence. No.
(Usual place of abode)
Length of residence in city or town where death occom
3 SEX
PERSONAL AND STATISTICAL PARTICULARS
4 COLOR OR RACE
5 SINGLE, MARRIED. WIDOWED. OR
DIVORCED (write the word)
^ / . y DIVORCED (write tue worn)
5a If married, widowed, or divorced
HUSBAND of
(or) WIFE of /^7,
6 DATE OF BIRTH.
( i\Tbuth)^^^/ y (fbiy^ ^ Vfear)
7 AGE Tears
Months
Days
If LESS than
J
c
1 day, his.
or min.
If STILLBORN, eoter that fact here
10 NAME OF //
FATHER i
11 BIRTHPLACE OF ^ ,
FATHER (Citv)
(State or country)
12 MAIDEN NAME--'?
OF MOTHER 777^^7 /!,
13 BIRTHPLACE OF . / A. ^
MOTHER (Citv) \ 7
(State or country) >
Filed , 2 J Z3.
(Month) (Day) (Tear)'
21 I HEREBY CERTIFY that a satisfactory stan-
dard certificate o f death was filed with me
BEFORE the burial or transit permit was issued
I HEREBY CERTIFY, That I attended deceased from
, , i9.*r/....., njQyi.
that I last saw h.. alive on , 19 .2-'
and that death occurred, on the date stated above, at.....y£.. ^r/. ^ /$m.
The CAUSE OF DEAJH was as follows:
(duration) <yr§v
L.ds.
. ds.
CONTRIBUTORY
(secondary)
(duration) yrs...
18 Where was disease contracted
if not at place of death ?
Did an operation precede death? Date of
Was there an autopsy? ... T-o „
What test confirmed diagnosis?
(Signed) f - M.D.
(Address) 11 $ * ,./}nb
19 PLACE OF BUJJAL, CREMATION, OR REMOVAL
(Cemetery) (City or town!
DATE OF BURIAL
<yy<3L y y
ADDRESS
Date of Permit
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©ottutumun'altlj of fHaBsarffunrftfl
1 PLACE OF DEATH
County
BOSTON
(City or to\jTg ^
STANDARD CERTIFICATE OF DEATH
Re
Suffolk State Mas.sachusetts Regiitered
(Place of residence)
City or Town BOStOfl No. f St., Ward
(If death occurred in a hospital or institution, give its name instead of street and number)
2 FULL NAME
L I BB I E ROSENBERG
(If in the Army or Navy of the United States, give rank, organization, etc.)
(a) Residence. State City or Town .W..I...N..T.H.R..Q.P. No 1 ,P4 E-A..U1 LN.E St.
years months days How long in U. S., if of (oreign birth? years months days
(Usual place of abode)
Length of residence in city or town where death panned
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
4 COLOR OR RACE
w
5 SINGLE, MARRIED, WIDOWED, OR
DIVORCED (write the word)
WID.
5a IP married, widowed, or divorced
HUSBAND of
(or) WIFE of HARRY
6 DATE OF BIRTH (month, day, and year)
7 AGE Years
82
Months
Days
If LESS than
1 day, brs.
or min.
If STILLBORN, eater that fact here
8 OCCUPATION OF DECEASED
(a) Trade, profession, or
particolai kind of work
NONE
(h) Name of employer
9 BIRTHPLACE (city or town) R U S S I A
(State or country)
10 NAME OF FATHER LOUIS MARCUS
11 BIRTHPLACE OF FATHER (city or town)...
(State or country) RUSS I A
12 MAIDEN NAME OF MOTHERE STHER
13 BIRTHPLACE OF MOTHER (city _or town)
(State or country) r \ U O O I A
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH (month, day, and year) F E B » 2 0 19 22
17
I HEREBY CERTIFY, That I attended deceased from
F.E.B.,J.„9. 19.2.2 ., to E£B ,2 0 ,9 ....
that I last saw h I...M alive on 19 .22. ..,
and that death occurred, on the date stated above, at A.*AQ £. m.
The CAUSE OF DEATH* was as follows: ,
CERE. HEMORRHAGE r * *
I
ds.
(duration) yrs. m
ARTERI O-SCLEROS I S
CONTRIBUTORY „
(secondary)
(du ration) y rs. mos. ds
18 Where was disease contracted
if not at place of death?
Did an operation precede death? Date of..
Was there an autopsy?
What test confirmed diagnosis?
(Signed) -...F......S..,.L.A.R.S..Q..N.S m.d.
, 19 22 (Address) F EB ,2 I
14
Informant .
(Address)
S. ROBERTS
19 PLACE OF BURIAL, CREMATION, OR REMOVAL
WOBURN (BETH JOSEPH)
DATE OF BURIAL
FEB . 2 I i9 22
15
FUed E E B w 2-4 . 19 n
< Registrar of city or town where death occurred
Filed^/^L-^wC, 19 wLi
20 UNDERTAKER
MANUEL STANETSKV
ADDRESS
Registrar of city or town where deceased resided
rj- *1 tS4 w Oq
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-WRIIfc rLAINLT, Wlln urvrALMiNU iimiv— imo 10 n rtmnnincii i nm/unu, every nem o> imurmatiun snouia De
carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state CAUSE OF DEATH in plain terms,
so that it may be properly classified. Exact statement of OCCUPATION is very important. See instructions oil back
of certificate.
I
©lie GJommoratipattli of iHassarljitsrtta
CERTIFICATE OF DEATH OF NON-RESIDENT <ci
1 PLACE OF DEATH Registered No
Count, Hampden s».. . Mass. n..
Springfield N„. 45 North Hain
City or Town
2 full name J ohn W» Swin.t
No.
(If death occurred in a hospital or institution, give its name instead of street and number)
(If in the Army or Navy of the United States, give rank, organization, etc.)
(a) Residence. State City or Town ,W.i.n..t.h.r.Q..P. _...No 81 Qtl S St.
(Us ual place of abode) _
Length of residence in city or town where death occorreJ
months
18da,
How long in U. S., if of foreign birth?
months
days
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
Male
4 COLOR OR RACE
White
5 SINGLE, MARRIED, WIDOWED, OR
DIVORCED {rorite the word)
Married
5a If married, widowed, or divorced
HUSBAND of - . -> • i ,
(oH.w4FB.f- Delia Richardson
6 DATE OF BIRTH (month, day, and year) J ' e b T U ar y 2 1 8 £ B
7 AGE _ Years
70
Months
19
Days
If STILLBORN, enter that fad here
If LESS than
1 day hrs.
8 OCCUPATION OF DECEASED
(a) Trade, profession, or
particular kind
72C _EaJtax - I
(b) General nature of industry,
business, or establishment in
which employed (or employer)
(c) Name of employer
9 BIRTHPLACE (city or town)_... S JT a C U S e
(State or country) fleW York
10 NAME OF FATHER <JOiln W. Swint
11 BIRTHPLACE OF FATHER (city or town)Yfo.KllS..
(State or country)
Germany
12 maiden name of mother Margaret Matzen-
13 BIRTHPLACE OF MOTHER (ci^OT?own)^
(State or country) Germany
bacnei
Feb
14
Informant ... Dr.,.. A* Lfimla
(Address) ■>1Tq
15
raJeb 24 .,, 22
Alii., in gif i pi
•Ife'S'S".
Filed. 19
Registrar of city or town where death occnrred
Registrar of city or town where deceased resided
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH (month, day, and 2 119 O O
17
I HEREBY CERTIFY, That I attended deceased from
Deo.. — 3 isg-1 to .Ee-b-. ~-2.l- w 22
that I last saw h .it. Hi. alive on .i}. ebu 2J 19 22
■'and that death occurred, on the date stated above, at
The CAUSE OF DEATH* was as follows:
2 P.
* State the Disease Causing Death, or in death s from Violent Causes,
state (1) Means and Nature of Injury, and (2) whether Accidental,
Suicidal, or Homicidal. (See reverse side for additional space.)
Angina Pectoris
- (duration) yr»...“r.Sn mos. ds.
10
CONTRIBUTORY.
(secondary)
_ (duration) _
..ds.
18 Where was disease contracted-* —
if not at place of death ? .
Did an operation precede death?-
Was there an autopsy?
No
.Date of _
No
What test confirmed diagnosis?. Clinical
(Signed) _...S.e_tb A* Lewl-S
23 192 3 Add^) 45 No, Main
M.D.
19 PLACE OF BURIAL, CREMATION, OR REMOVAL
Woodlawn , Everett
i.
20 UNDERTAKER
Cheney D. Washburn Springfield
date of Burial
Feb 24 19 22
address
Mass =
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-WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD. Every item of information should be
carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state CAUSE OF DEATH in plain terms,
so that it may be properly classified. Exact statement of OCCUPATION is very important. See instructions on back
of certificate.
(y i l/ 1/ o
5a If married, widowed, or divorced
HUSBAND of /
(or) WIFE of r A
is*'
//
LZI LSV
6 DATE OF BIRTH (month, day, and year)
VUUUJL-
3.
7 AGE (g £ Years p1 Months /
yj Days
I( LESS than
1 day, hrs.
If STILLBORN, enter that fact here
©[}? (Eommnnmraltlj of iHassarhusrtta
BOARD OF HEALTH PHYSICIAN’S CERTIFICATE OF DEATH
OFFICE OF THE SECRETARY
DIVISION OF VITAL STATISTICS
1 PLACE OF DEATH ,
To be used only in case there is no attending physician or if for sufficient reason the attending physician's certificate cannot
be obtjtinyl early enffajhfor the purpose of granting a buriaUpermit, as provided by Revised Laws, Chapter 78, Section 38.
County State Registered No.
i buriuLinermit , as prpvidec
City
2 FULL NAME
No. , St., Ward
eatli occurred in a hospital or institution, give its name instead of street and number)
s—f — — /j // Army or^^o^t>e United States, give rank, organization, etc.)
(a) Residence. No J... 'Z^St., Ward?
(Usual ]>lace of abode) “ / (If non-resident give city or town and State)
Length of residence in cily or town where death occurred Q years months days How long in U. S„ if of foreign birth? years months days
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
JL.A „
/TZ
4 COLOR OR RACE
5 SINGLE, MARRIED, WIDOWED, OR
DIVORCED (i write the word).
8 OCCUPATION OF DECEASED
(a) Trade, profession, or
particular kind of work
(b) General nature of industry,
business, or establishment in
which employed (or employer)..
(c) Name of employer
9 BIRTHPLACE (city or town)
(State or country)
10
NAME OF FATHER
(0
1-
n
BIRTHPLACE OF FATHER (city or town; ...
l t
z
u
(State or country)
K
<
12
MAIDEN NAME OF MOTHER
n
a
13
BIRTHPLACE OF MOTHER (citv or town).. .
i
(State or country)
Informant
(Address)
15
Filed J A?...:. .^3 19X\
(Month) (Day) (Year)
Registrar
J' i
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH ?*..%. 19^» X
(Month) (Day) (Year)
17
I HEREBY CERTIFY, That I have ascertained the
nature of the disease from which the person above-named died, and that
/ the CAUSE OF DEATH* was as follows:
•State the Disease Causing Death. (See reverse side for additional
space and instructions.)
/ C -f
(duration) /..$» yrs.
. ds.
CONTRIBUTORY.
(secondary)
,ds.
18 Where was disease contracted
if not at place of death?
(duration) yrs.
"1
Did an operation precede death?...^^^. Date of
*
Was there an autopsy? ^.$1 _A.
fi? *
What test confirmed diagnosis ?.! .t
(Avc r« O
(Signed) .
(Address) ...
Dale
... M.D.
(Month)
Z3 .19
(Day) (Year)
19 -FLAW 0PT0IR1AL, CREMATION, OR REMOVAL
ftfiVkL
20 UNDERTAKER
DATE OF BURIAL
*2-
ADDRESS
SL >-'4 '
should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state CAUSF OF DEATH
in plain terms, so that it may be properly classified. Exact statement of OCCUPATION is very important. See
instructions and extracts from the laws on back of certificate.
1 R-301
50,001
OFFICE OF THE SECRETARY
DIVISION OF VITAL STATISTICS
1 PLACE
(Eommmum'aUlj of HJaBsarljusrtlfi
STANDARD
LACE OF DEATH f y / S y? S
County
City or Town ...
3L N
CERTIFICATE OF DEATH
(City or Town)
State - Registered No. ''.K u)
V7/v_
St., Ward
in aliospitai or institution, give/tsAtAME instead of street and number)
2 FULL NAME.......
(a) Residence. No. './.Z
( Usual place of abode) / / . - ' /
Length of residence in city or town where death occurred / years fa
(If In/tbe Army or Nayy of the United States, give rank, organization, etc.)
,(2tfc€L«Ward.
months
(If non-resident give city or town and State)
How long in U. S., if of foreign birth ? years months days
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
4 COLOR OR RACE
-j / J t DIVORCED {write the w
5 SINGLE, MARRIED. WIDOWED. OR
DIVORCED ( write tlie word)
5a If married, widowe
HUSBAND of
(or) WIFE of
6 DATE OF BIRT
^.MZzL
(Day) (Year)
7 AGE
Years
Months
Days
ZZ
If LESS than
1 day, his.
If STILLBORN, enter that fact here
8 OCCUPATION OF DECEASED.
(a) Trade, profession, or
particular kind ol work
(b) Name of employer
9 BIRTHPLACE (City)
( State or country)
10 NAME OF
FATHER
11 BIRTHPLACE OF
FATHER (City)
(State or country)
12 MAIDEN NAME
OF MOTHER
13 BIRTHPLACE OF
MOTHER (City)
(State or country)
Filed ,
(Mon£fi) (Day) (Year)
211 HEREBY CERTIFY that a satisfactory stan-
dard certificate of death was filed with me
BEFORE the burial or transit permit was issued^
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
(Month)
(Day)
/?2s^
(Year)
17
I HEREBY CERTIFY, That I attended deceased from
J...?-r... , 19.2'?:. , to .^f '3 , 19 '}?**'. ,
it I last saw alive on . * oL J. , 19 .£•>-:
and that death occurred, on the date stated above, at..../...^.. m.
The CAUSE OF DEATH was as follows :
*
JO
(duration) yrs mos. jT*. ds.
CONTRIBUTORY
(secondary)
(duration) ... sT
yrs ...mosw..
ds.
18 Where was disease contracted
if not at place of death? .K....
Did an operation precede death? LArJ? Date of
Was there an autopsy ? * t
What test confirmed diagnosis? QJL*
(Signed)
(Address),
Date
lfirmed diagnosis? "S-r
ss)
1 I
(Month)
M.D.
^ /f7r>-
(Day) (Year)
19 PLACE OF BURIAL, CREMMJON, OR REMOVAL
Yh
(Cemetery)
20 UNDERTAKER
4,
(City
wn)
DATE OF BURIAL
19^_±_
ADDRESS
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should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state CAUSE OF DEATH
in plain terms, so that it may be properly classified. Exact statement of OCCUPATION is very important. See
instructions and extracts from the laws on back of certificate.
R-301
000
OFFICE OF THE SECRETARY
DIVISION OF VITAL STATISTICS
1 PLACE OF DEATH
County.
dlje (EomuumniraUlj of fHassarljuartta
STANDARD CERTIFICATE OF DEATH
No 7
(If death oecurreoini'a hospital or institution, give its name instead <jt street and number)
(City or To»n)
Registered No
St., Ward
2 FULL NAM
(a) Residence. No.
(Usual place of abode)
(If in the Army or Navy of the United States, give rank, organization, etc.)
St., Ward.
L uouai [Mace ui. duuuci ;
Length of residence in city or Iowa where death occurred p years ^ months 1 1 days.
(If non-resident give city or town and State)
How long in U. S., if of foreign birth ? years months days
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
4 COLOR OR RACE
5 SINGLE. MARRIED, WIDOWED, OR
DIVORCED ( write the word)
5a If married, widowed, or divorced
HUSBAND of '"7 jT .
(or) WIFE of
b. (Ld
X/, 1^*4^
( Month)
(bay)
(Year)
7 AGE Y'ears
Months
Days
If LESS than
72.
3
3
1 day, his.
or min.
If STILLBORN, enter that fact here
8 OCCUPATION OF DECEASED
(a) Trade, profession, or
particular kind of work
(b) Name of employer
9 BIRTHPLACE (City)
l State or country)
22
10 NAME OF
FATHER
11 BIRTHPLACE OF
FATHER (City)
i,OF
(State or country)
12 MAIDEN NAME"
OF MOTHER
cJtJLl
13 BIRTHPLACE OF
MOTHER (City)
(State or country)
/ MM*
l
14
15
Informant Q&U. A:
(Address)-* f' ^ 7^/7+*
Filed lo. 2.
(Month) (Day) (Year)
Registrar
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH .....^
(Month)
23
(Day)
CYearj
17
I HEREBY CERTIFY, That I attended deceased from
’JA'kfAA, 19..*4.,to .ry^iot , 19. Ss.2:
that I last saw h..- >.... alive on . 3^Ss4lJL JU n2xJz
and that death occurred, on the date stated above, at m.
The C/
IV _ H 4 — - (1 L .
f±SL
:AUSE OF DEATH was as follows:
j %.m l^^?^
CONTRIBUTORY
(secondary)
........ .?( duration) ..yrs mos ds.
(duration) yrs.. mos. .’*? ds.
18 Where was disease contracted
if not at place of death ?
Did an operation precede death?.. /.IT..P Date of
Was there an autopsy ? ... jHJl
What test confirmed diagnosis?
Itt Li)
(Signed)..
(Address)
Date
(Mo
19 PLACE OF BURIAL, CREMATION, OR REMOVAL
fa ?***-<>
(Cemetery) v (City or town)
20 UNDERTAKER
£5L/e /&
DATE OF BURIAL
J-<* J-2-
ADDRESS
21 I HEREBY CERTIFY that a satisfactory stan-
dard certificate of death was filed *hb me
BEFORE the burial cr transit permit was issued ..
Official
..position
Permit
Date of p. i tiiui.
issue
of permit
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1
REVISED UNITED STATES STANDARD CERTIFICATE OF DEATH EXTRACTS
* FROM THE LAWS OF THE
(Approved by 0. S. Censu anJ American Public Heallh Associalionl COMMONWEALTH OF MASSACHUSETTS
should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state CAUSE OF DEATH
in plain terms, so that it may be properly classified. Exact statement of OCCUPATION is very important. See
instructions and extracts from the laws on back of certificate.
R-301
000
OFFICE OF THE SECRETARY
DIVISION OF VITAL STATISTICS
1 PLACE OF DEAT
County
Sty? (Etmmumuit'aliit of ifiasoarlfasrtta
City or Town
2 FULL NAME
STANDARD CERTIFICATE OF DEATH
/ (City or Town)
Registered No. Jy
St Ward
or institution, give its name insteador street and number)
No $0, Sc
(If death occurred yr a hOBH
(a) Residence. No
(Usual place of abl
Length of residence in tin or town where death occurred
(If in the Army or Navy of the United States, give rank, organization, etc.)
St., Ward.
months
PERSONAL AND STATISTICAL PARTICULARS
(If non-resident give city or town and State)
days. How long in U. S„ if of foreign birth? years months days
MEDICAL CERTIFICATE OF DEATH
3 SE
4 COLOR.OR RACE
5a If married, widowed, or divorced
HUSBAND of
(or) WIFE of
5 SINGLE, MARRIED, WIDOWED, OR
DIVORCED, (write the word)
ilVORCEQ. (write the word)
6 DATE OF BIRTH
( Month)
(bay)
(Year)
7 AGE 1 curs
Months
Days
If LESS than
//
6
1 day his.
or min.
If STILLBORN, enter that fact here
8 OCCUPATION OF DECEASED
(a) Trade, profession, or
particular kind of work.
(b) Name of employer
9 BIRTHPLACE (City)
(State or country)
10 NAME OF
FATHER
11 BIRTHPLACE OF
FATHER (City)
(State or country)
12 MAIDEN NAME
OF MOTHER
13 BIRTHPLACE OF
MOTHER (City)
(State or country)
Filed
(Month) (Day) (Year)
Registrar
16 DATE OF DEATH..
(Day)
' (Year)
17
HEREBY CERTIFY* That I attended deceased from
6 19^-Zt. to s
that I last saw alive on /
... 19
..... 19
sS~
i-Z.
and that death occurred, on the date stated above, at GLm.
The CAUSE OF DEATH was as follows:
) yrs. mos. ... A ..da.
CONTRIBUTORY
secondary)
..(duration)
18 Where was disease contracted
if not at place of death ?
ds.
Did an operation precede death? .. Date of
Was there an autopsy ? .. yy
What test confirmed diagnosis
(Signed)c2^^<^.
(Address)
■2^’'^'..... / <P ^ t,
pVIoiith) ( Day) (Year)
Date .
19 PLAfE OF BURIAL, CREMATION, OR REMOVAL
(Cemetery) (City or town)
DR REMOVAL
20
UNDERTAKE
DATE OF BURIAL
ADDRESS
21 1 HEREBY CERTIFY that a satisfactory stan-
dard certificate of death was filed with me
BEFORE the burial or transit permit was issued .
Date of
issue
of permit
Permit
B
& o ®
ffl
_ *0
^ M O 5' & rt-
2 . g ET 0
o ® S § I' s &
8 P 6 g-
.8*fi s ti
p B B O- p. &
3 ” S'
“ 3 55 <*• a P.
B g cr
, D O- ®
snuuiu ue uareiuiiy suppneu. nut snuuiu ue siaitru LAni»iLi. rmoivmi^o snuuiu state lhuol ur utMin
in plain terms, so that it may be properly classified. Exact statement of OCCUPATION is very important. See
instructions and extracts from the laws on back of certificate.
R-301
wo
OFFICE OF THE SECRETARY
DIVISION OF VITAL STATISTICS
1 PLACE OF DEATH
County
Etyp (EommxuunraUh of iRasEadjusrtta
TANDARD CERTIFICATE OF DEATH
)//.
City or Town.
2 FULL NAME
(a) Residence. No
( Usual place of abode)
Length of residence in at? or town where death occurred
(City or Town
_ Registered No.
State
No , St., Ward
tlf death occurred in a hospital or institution, give its name instead of street and number)
Q>c
(If in the Army or Navy of the United States, give rank, organization, etc.)
St.,. Ward.
months
days.
(If non-resident give city or town and State)
How long in U. S., if of foreign birth? years months days
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
4 COLOR OR RACE
5 SINGLE, MARRIED. WIDOWED. OR
DIVORCED (write the word)
5a If married, widowed, or divorced
HUSBAND of
(or) WIFE of
6 DATE OF BIRTH.
A ? LlAAz...
(Month) (Day) (Year)
7 AGE
Years
Months
Days
If LESS than
1 day, hrs.
or min.
If STILLBORN, enter that fact here
8 OCCUPATION OF DEC1
(a) Trade, profession, or
particular kind of work
(b) Name of employer
9 BIRTHPLACE (City)
(State or country)
10 NAME OF
FATHER
''AAA
12 MAIDEN NAME
OF MOTHER
13 BIRTHPLACE OF
MOTHER (City)
(State or country)
14
Informant A/«
(Address) ^7
, 1
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH . ....B-AA.. A2 /L±
(Month) (Day) (Year)
17
1 HEREBY CERTIFY, That I attended deceased from
.../AAf...
... 19
L L-
, to b l 19.
z- Z_
that I last saw h alive on 19 ,
and that death occurred, on the date stated above, at m.
The CAUSE OF DEATH was as follows:
AAM.,
..(duration) yrs mos.
ds.
CONTRIBUTORY
(secondary)
(duration) A. yrs„ mos. ..........ds.
18 Where was disease contracted
if not at place of death ?
Did an operation precede death? Date of
Was there an autopsy?
What test confirmed diagnosis ?
(Signed)
(Address)
M.D.
Dale JhxZdtS... “2.
19 PLACE OF BURIAL, CREMATION, OR REMOVAL
(Cemetery) ^ (City or tbwn)
DATE OF BURIAL
21 1 HEREBY CERTIFY that a satisfactory stan-
dard certificate of death was filed with me
BEFORE the burial or transit permit was issued
a :® a
E. 00
& ? a-
?•§. a
p 7
■ o' -
a *■» ©
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carefully supplied. AGE should be staled EXACTLY. PHYSICIANS should state CAUSE OF DEATH in plain terms,
so that it may be properly classified. Exact statement of OCCUPATION is very important. See instructions on back
of certificate.
1
-302
GJouuiumuicaUf] of iUacaarljua^tta
Mas:
fz
; ct deat]
Danvers
(City or town}
Registered No..
(Place tff death)
Registered No.
ci* „ Town Danvers N„.ranyer?
(if death occurred in a hospital or institution, give its name instead of street and number)
2 FULL NAME Daniel Thurston
(If in the Army or Navy of the United States, give rani, organization, etc.)
(a) Residence. State I -h? ‘3 • City or Town V‘In.tfcX.O.P No
(Usual place of abode) __
mnnths -L«3 Jays
STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH
County State
Danvers
Length of resilience in city or town where death occurred
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
| 4 COLOR OR RACE
5 SINGLE, fdARRIED, WIDOWED, OR
16
male
| white
DIVORCED ( write the word)
widowed
17
How long in U. S., if of foreign birth?
months
__St.
days
>0,000
5a If married, widowed, or divorced
HUSBAND of
(or) wife of Cannot be learned
6 DATE OF BIRTH (month, day, ."(s&IiilUD t be 1 e
amed
7 AGE nr7 Years
(O
Slonths
Days
If LESS than
1 day hrs.
or min.
If STILLBORN, eDter that fact here
8 OCCUPATION OF DECEASED
Sailor
(•) Trade, profession, or
particolar kind of work...
(b) Name of employer
9 BIRTHPLACE (city or town)..
(State or country)
North Haven
he.
io name of father Solataon iharston
11 BIRTHPLACE OF FATHER (city or towrJpaiTl.d.en
(State or country) j, j g
14
12 maiden name of motherJ a ne Cal d er wo o d
13 BIRTHPLACE OF MOTHER (city or to^n? L
hk.
(State or country)
i.<.,™.. 5L?ti.|_Hoeh
(Address) natn orne, Mass .
15 Filed .3-5- , ig22 LJ/
Filed 'V\\o>^- , 19 ^
Registrar of city or town where death occurred
Registrar of city or town where deceased resided
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH (month, day, and year) J O 0 . 2 8, 19
I HEREBY CERTIFY, That I attended deceased from
?eb. 15, 1922 to jj’eb, 28, 1922
that I last saw h .1??. alive on A®1?.* 28y ^ ig 22 ^
and that death occurred, on the date stated above, at .1.2’.
.. 11 ^ a".£r 1 mrz"_
CONTRIBUTORY.
(secondary)
..(duration) yrs. mos.^ ds.
.(duration)... yrs. mos. ds.
18 Where was disease contracted
if not at place of death?
Did an operation precede death? H.Q Date of.
Was there an autopsy?.. _
What test confirmed diagnosis 4
. (Signed) ^ .?*. .... A4. .• /Cl 11. S
/l/ 19 2 2 Address) 11 a th o rn e Lf ass.
... M.D.
19 PLACE OF BURIAL, CREMATION, OR REMOVAL
'■•'oodlawn Rverett
20 UNDERTAKER
D. R. Benson
DATE OF BURIAL
3/2 1922
ADDRESS
• 'lnthroT)
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R-301
300
OFFICE OF THE SECRETARY
DIVISION OF VITAL STATISTICS
1 PLACE OF DEATH
County
..M
SJlj* (EommxmmfaUI? uf Massariftiartta
City or Town..
STANDARD CERTIFICATE
DEATH
State ....
(City or Town)/
.Registered No
No. GJZ. £ St., Ward
llf death occurred in a hospital or institution, give its name instead of street and number)
2 FULL NAME
. - - — — — -r* — o* ' v * — “ —
.».
^ ' (If in the Army or Navy of the ynited States, give rank, org;
S>P /
(a) Residence. No.
( Usual place of abode)
Length of resilience in city or town where death occurred
s*
organization, etc.)
years
months
St.,. Ward
(If non-resident give city or town and State)
days. How long in U. S., if of foreign birth? years months days
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
4 COLOR OR RACE
5 SINGLE, MARRIED, WIDOWED. OR
DIVORCED (write the word)
(or) WIFE of *
6 DATE OF BIRTH
(Month)
(bay)
(Year)
7 AGE Y ears
Months
Days
If LESS than
1 day, hrs.
or min.
If STILLBORN, enter that fact here
8 OCCUPATION OF DECEASED
(a) Trade, profession, or sL S'
-nr *
particular kind of work
(b) Name of employer
9 BIRTHPLACE (City)
(State or country)
10 NAME OF SZ’ ' // /O /
FATHER
0)
t-
11 BIRTHPLACE OF
FATHER (City)
§ V-5U, . .
Z
UJ
cc
<
(State or country)
-
12 MAIDEN NAME C\
OF MOTHER
/ 1/^jC
Q.
13 BIRTHPLACE OF
r\ •-i — — rj r
MOTHER (City).
(State or country)
14
Informant
(Address)
t
£ * jt 'Z
15
Filed^l ItA1
(Month) (Day) (Year)
21 1 HEREBY CERTIFY that a satisfactory stan-
dard certificate of death was filed with me
BEFORE the burial or transit permit was issued
-
registrar
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH iEO-t
(Month)
2,F
(Day)
(Year)
17
I HEREBY CERTIFY, That I attended deceased from
2. Or. , 19.?.1.„, to. .sb-Ct %r. ...3c". 19 *V...
that I last saw h.^rr. ajive on . .3^ , is m.
and that death occurred, on the date stated above, at..../.5 m
The CAUSE OF DEATH was as follows: t
w. 4-
CONTRIBUTORY
(secondary)
p&l.
(duration) ....../ yrs 4..
ds.
(duration) yrs„
18 Where was disease contracted /*» pl *
' T ds.
if not at place of death ?
/lc& .
Did an operation precede death ?...TjRP. •. ' Date of...
/I
Was there an autopsy? r*ri? t
is? .(^^^iWiy.o./-
What test confirm^i4iagn)
(Signed)
(Address)
Date
19 PLACE OF BURIAL, CREMATION, OR REMOVAL
(Cemetery)
(City or town)
20 UNDERTAKE]
DATE OF BURIAL
3
ADDRESS
Official
position
Date of
issue
of permit.
Permit
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carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state CAUSE OF DEATH in plain terms,
so that it may be properly classified. Exact statement of OCCUPATION is very important. See instructions on back
of certificate.
1
*02
(Hommmmiraltlj of iflassarhusctta
STANDARD CERTIFICATE OF DEATH
BOSTON
(City or town)
Registered No ,?..?..3J?...
(Place of death
County
City or Town
1 PLACE OF DEATH .. .
Suffolk Massachusetts
State Registered No Jtr&T.'..
, (Place of residence)
Boston No MASS .H3ME3.H0SPT. s, w„d
(If death occurred in a hospital or institution, give its name instead of street and number)
SAMUEL NATH
2 FULL NAME
(If in the Army or Navy of the United States, give rank, organization, etc.)
e MASS. T WlNTHROP N 4o flAWThCTRNE »
(a) Residence. State * City or Town No._ “ -S
(Usual place of abode)
I A nr tnwn where death occurred years months days How long in U. S., if of foreign birth? years months days
St
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
M
4 COLOR OR RACE
w
5 SINGLE, MARRIED, WIDOWED, OR
DIVORCED ( write the word)
MAR .
5a If married, widowed, or divorced
HUSBAND of
(or) WIFE of
JENN 1 E
6 DATE OF BIRTH (month, day, and year) — — — — —
20,000,
7 AGE Years
&0
Months
Days
If LESS than
1 day, hrs.
or. min.
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH (month, day, and year) p p g 2 8' 19
22
If STILLBORN, enter that fact here
8 OCCUPATION OF DECEASED
(l) Trade, profession, or
particalnt kind of work
FRUIT DEALER
(b) Name of employer
9 BIRTHPLACE (city or town) A-UST R l A
(State or country)
10 NAME OF FATHER
SIMON
11 BIRTHPLACE OF FATHER (city or to^J [■■■£■■
(State or country)
12 MAIDEN NAME OF MOTHER ROSE
13 BIRTHPLACE OF MOTHER (city or town)
(State or country) A U o I it I A
14
Informant
(Address)
i.'i A i< , 2 ,
J , STENGEL
15 22
Filed. , 19
Registrar of city or town where death occurred
Filed lfl^L
Registrar of city or town where deceased resided
17
I HEREBY CERTIFY, That I attended deceased from
FEB. 21 i9...?..?, to Eli .•.?! 19“
that I last saw h I.M aUve on L33...T.3J... 19...“
and that death occurred, on the date stated above, at 4.JJP m.
The CAUSE OF DEATH* was as follows : ,
CARCINOMA OF RECTUM
..(duration) yrs. mos.
d«.
CONTRIBUTORY
(secondary)
.(duration) —
ds.
18 Where was disease contracted
if not at place of death?
Did an operation precede death? I.. ......r.. Date of 3 « ^
Was there an autopsy?^.
What test confirmed diagnosis?
H.M. POLLOCK
(Signed)
, 19 (Address)
... M.D.
<-> 0
— —
19 PLACE OF BURIAL. CREMATION, OR REMOVAL
WOBURN (AUSTRI AN C EM j
20 UNDERTAKER
MANUEL ST A NET SKY
DATE OF BURIAL
FEB. 28
19
22
ADDRESS
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should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state CAUSE OF DEATH
in plain terms, so that it may be properly classified. Exact statement of OCCUPATION is very important. See
instructions and extracts from the laws on back of certificate.
R-301
OFFICE OF THE SECRETARY
DIVISION OF VITAL STATISTICS
1 PLACE OF DEATH
County.
/JM
Sffjp GJommmuuraUlj of fHassarifusttta
City or Town
IDARD CERTIFICATE QF DEATH
State ...
No. 2?*^*
2 FULL NAME
(City or Town)
Registered No.
St Ward
(If death occurred in a hospital or institution, give its name instead of street and number)
(a) Residence. No,
(Usual place of abode)
Length of residence in city or town where death occnm
Z.£
(If in the Army or Navy of the United States, give rank, organization, etc.)
3%
years
months
days.
St,. Ward.
■ (If non-resident give city or town and State)
How long in U. S., if of foreign birth? years months days (V /
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
4 COLOR OR RACE
5 SINGLE, MARRIED, WIDOWED, OR
DIVORCED ( write the word)
16 DATE OF DEATH
/ Zlt...
(Month) (Day) (Year)
V
5a If married, widowed, or divorced
HUSBAND of
(or) WIFE of
HEREBY CERTIFY* That I attended deceased from ^
S DATE OF BIRTH
A v<
/9U2-
(Month)
(Day)
(Year)
7 AGE Years
Months
Days
If LESS than
<
i
1 day, hrs.
or min.
If STILLBORN, enter that fact here
—
that I last saw hA*r. . alive on f. 19. £•£...., <j>
and that death occurred, on the date stated above, at. ..if*..'. m.
The CAUSE OF DEATH was as follows:
0
8 OCCUPATION OF DECEASED
(a) Trade, profession, or
particular kind of work
(b) Name of employer
(duration) yrs..
ds.
10 NAME OF
FATHER
11 BIRTHPLACE OF
FATHER (City)
CONTRIBUTORY..
(secondary)
(duration) yrs .. mos,...^..,
18 Where was disease contracted
if not at place of death ?
ds.
(State or country)
12
MAIDEN NAME S? » x
OF MOTHER
Vi
Did an operation precede death? Date of
Was there an autopsy ?
What test confirmed diagnosis ?..
(Signed)
13 BIRTHPLACE OF
MOTHER (City).
(State or country)
A. . JLstr-V 1
M.D.
Dale .
(Address)
/f?±
(Month)
(Year)
14
Informant
(Address ) -Jd
15
19 PLACE OF, BURIAL, CREMATION, OR REMOVAL
jUm JO&sfz ujl^JLL
(Cemetery) / (City or towiy)
Filed/TMf
(Month) (Day) (Year)
20 UNDERTAKER
Registrar
DATE OF BURIAL
yV/ ^
ADDRESS
21 I HEREBY CERTIFY that a satisfactory stan-
dard certificate of death was filed with me
BEFORE the burial or transit permit was issued ....
Official
. position .
Date of
issue
■oT permit.
Permit
1 V No Lf (ry..
000
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carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state CAUSE OF DEATH in plain terms,
so that it may be properly classified. Exact statement of OCCUPATION is very important. See instructions on back
of certificate.
-302
50,000.
Styf (Eommmtou'alifj of tfHassarljuspflfl
STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH
County.. hU.f . State
Che lues
(City or town)
Registered No 1.29
I » (Place of dentil j
..M*L£i.S.n Registered No.
(Place of residence)
City or Town .G.h.6.1 S.QS No....Xl£.£^ J£®-fcL6i HQ.8„pi„u||..X St, Ward
(If death occurred in a hospital or institution, give its name instead of street and number)
2 full name Grover H«. ...C.i.llis
(If in the Army or Navy of the United States, give rank, organization, etc.)
(a) Residence. State Ks ES. City or Town No 432 RfiVftrft
(Usual place of abode)
Length of residence in city or town where death occurred years months Jays How long in U. S., if of foreign birth? years months days
St.
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
I.T
4 COLOR OR RACE
w
5 SINGLE, MARRIED, WIDOWED, OR
DIVORCED {.write the word)
**g rr led
5a If married, widowed, or divorced
HUSBAND of
(or) WIFE of
6 DATE OF BIRTH (month, day, and yeaj) q q # 2 1888
7 AGE
Years
33
Months
Days
1
if LESS than
1 day, hrs.
If STILLBORN, enter that fact here
8 OCCUPATION OF DECEASED
(■) Trade, profession, or w 4. ■» %
particular kind of work M.E..15.6.n«JEUj2.l>.Q 3T...
(b) Name of employer
9 BIRTHPLACE (city or town) Y/t UCjke t ,
(State or country) ^ j ^
10 NAME OF FATHER ftp ft R rt Q i H j R
11 BIRTHPLACE OF FATHER (city or town)
(State or country) .
lb,
12 MAIDEN NAME OF MOTHER nnje PerkiHS
14
13 BIRTHPLACE OF MOTHER (city or town)
(State or country) S-pV j y, g-p -j c 1 H TJ V . . .
Informant ...Ho.b.el?..!/. .01111.^.
(Ad,lftss) V/iiLtfafaop
15 Filed ?>, 19 2
Filed 19 2-X
lr-£-
-2
Registrar of city or towo where death occurred
Registrar of city or towo where deceased resided
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH (month, day, and year) li£ T . 3
19
22
17
I tiERESV CERTIFY, That I attended deceased from
Feb. 1Q9 2£0 tor.
that I last saw h Ijllive on - ^ • 3
19
i9 22
and that death occurred, on the date stated above, at 2 » 3Qj5"_ •
The CAUSE OF DEATH* was as follows :
jo btr Pneu mortis
. (duration) yrs mos.
. ds.
CONTRIBUTORY _
(secondary)
(duration) yrs mos. ds.
18 Where was disease contracted
if not at place of death?
■jq r*» IT Q
'©Wan operation precede death? Date of
Was there an autopsy?. No
What test confirmed diagnosis?
(Signed) John H. Dorsn M D
r . 3 19 ng*”* u9 Q lr oe d . . t y . Che Ifc e£
19 PLACE OF BURIAL, CREMATION, OR REMOVAL
V/intrhop , Winthrop
20 UNDERTAKER
G.H.F£UnC)
DATE OF BURIAL
19
ADDRESS
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in plain terms, so that it may be properly classified. Exact statement of OCCUPATION is very important. See
instructions and extracts from the laws on back of certificate.
R-301
OFFICE OF THE SECRETARY
DIVISION OF VITAL STATISTICS
1 PLACE OF DE
County
City or Town..
Stye (ttmnmomnjraUlj of ittassadjuurKai
DEATH
STANDARD CERTIFICATE
State .Begi
No. / & frr
(City or Town)
.egistered No. JZ
Ward
(If death occurred m u "hospital or institution, give its name instead of street and number)
2 FULL NAME
. . ^lf in the Army-m^Iavy of the CtajtedSOites,
(a) Residence. No. ZrA _
give rank, organization, etc.)
(Usual place of abode) , .
Length of residence incity or town where death occurred years months^ days.
(If non-resident give city or town and State)
How long in U. S., if of foreign birth ? years months days
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
4 COLOR OR RACE
5 SINGLE, MARRIED. WIDOWED. OR
DIVORCED (.write the ward)
5a If married, lallbifhd, or divorced
HUSBAND of ' '
(wirl WiFF of.
35
P7JL
7/ ( Month)
(Day)
(Year)
7 AGE Years
// 6
Months
/
Days
0
If LESS than
1 day, hrs.
or min.
If STILLBORN, enter that fact here
1ASED S
8 OCCUPATION OF DECEASED
(a) Trade, profession, or
particular kind of work wr ...
(b) Name of employer \ -Z. . /&
9 BIRTHPLACE (City)
(State or country)
10 NAME OF
FATHER
C7'
11 BIRTHPLACE OF '7
FATHER (City )
l (City)
(State or country)
12 MAIDEN NAM
OF MOTHER
13 BIRTHPLACE OF
MOTHER (City)
HF ^ aO
(State or country)
■
14
. r ... ~ ' ,
Informa
^(Address^^^^^^^
15
(Month) (Day) (Year)
Registrar
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH..
(Month)
& —
"(Day)"
/ftt.
(Year)
17
I HEREBY CERTIFY, That I attended deceased from
_ , 19.fi/. to. . . ^..r. , 19.
that I last saw alive on , 19 .^./?.,
aThe text goes on. The rest is in the file.