The volume, 1925–1927
Town Clerk, Winthrop · from the Internet Archive · 1338 pages · 135.7 MB
open the file ↗ · original at the source ↗
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FORM R-301
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OFFICE OF THE SECRETARY
DIVISION OF VITAL STATISTICS
I PLACE OF DEATH
County
i
STAND
City or Town
2 FULL NAME!
(a) Residence. No..
(Usual place of abode)
Length of residence in city or town where death occurred
years
PERSONAL AND STATISTICAL PARTICULARS
5a It weorriad, widowwd ui diyumJCT
mt3&AND uf-
log \AOF£_of
If STILLBORN, enter that fact here
7 OCCUPATION OF DECEASED
(a) Trade, profession, or CM7-
particular kind of work '
(b) Name of employer
8 BIRTHPLACE (City) 3' •’
(State or country)
9 NAME OF Q
FATHER C
lO BIRTHPLACE OF
FATHER (City)
(State or country)
11 MAIDEN NAME
OF MOTHER
12 BIRTH PLACE-OF/
MOTHER leftyK
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(City or town)
• _Registered No..
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ed States, give rank, organization, etc.)
ion-resident give city or town and state)
years months days
3 SEX
4 COLOR OR RACE
5 SINGLE, MARRIED, WIDOWED, OR
15
DIVORCED (write the word)
16
13
Informant
(Address) X J~
14
Filed feWY 'V. \r\ 2- V
i(Month) (Day) (Year)
Registrar
MEDICAL CERTIFICATE OF DEATH
IS DATE OF DEATH.
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(Month)
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(Day)
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(Year)
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HEREBY CERTIFY, That I attended deceased from
19
that I last saw h -&A/ alive on
and that death occurred, on the date stated above, at.
The CAUSE OF DEATH was as follows:
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CONTRIBUTORY.
(secondary)
(duration) 4 yrs..
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ds.
(duration)
_yrs._
17 Where was disease contracted
if not at place of death?
.ds
Did an operation precede death?
Was there an autopsy?
What test confirmed
.Date of„
iSt confirmed diagnosis? . a >
(Signed). \) 'VaMAfif0^
' (Address). vlnWt 0
M, 0.
Date.
CAAs-
(Month)
JZ
(Day)
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(Year)
1 8 PLACE Of BURIAt, CREMATION OR REMOVAL
(Cemetery) (City or town)
DATE OF BURIAL
19 UNDERTAKER
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ADDRESS
20 I HEREBY CERTIFY that a satisfactory stan-
dard certificate of death was tiled with me
BEFORE the burial or transit permit was issued
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OFFICE OF THE SECRETARY
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I PLACE OF DEATH
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State
(City or town)
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2 FULL NAME.
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C^cs-TTk^
(a) Residence. No
(Usual place ot abode)
length of residence in city or town where death occurred
f S
(If in the Army or Navy of the United States, give rank, organization, etc.)
St., Ward
years
2- months J2
days.
(If non-resident give city or town and state)
How long in U. $., 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 'worried, widowed ui lii'iuiUJlf-'
HUSBAND uf
(OXL WiF£_flf
c -
It STILLBORN, enter that fact here
7 OCCUPATION OF DECEASED^,
(a) Trade, profession, or
particular hind of work,
(b) Name of employer
8 BIRTHPLACE (City)
(State or country)
9 NAME OF Q
FATHER q/7 <
lO BIRTHPLACE OF
FATHER (City)
(State or country)
11 MAIDEN NAME
OF MOTHER
12 birthplac&Of/
MOTHER (CityK
(State or country)
13
Informant
(Address) / J~
si' 2<
14
Filed
i
((Month) (Day) (Year)
Registrar
MEDICAL CERTIFICATE OF DEATH
15 DATE OF DEATH
GiM .
(Month)
(Day)
Jjzf
(Year)
16
HEREBY CERTIFY, That I attended deceased from
■ J C iQ/iy , to ^ A»-v ,19^4.,
, 19<£^
that I last saw h •AA' alive on .
and that death occurred, on the dWte stated above, at.
The CAUSE OF DEATH was as follows:
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CONTRIBUTORY.
(secondary)
(duration) L yrs.
yrs._
Ixr
ds.
(duration)
17 Where was disease contracted
if not at place of death?
4
.ds
Did an operation precede death?
Was there an autopsy?
What test confirmed
(Signed)
.Date of.
confirmed diagnosis? — ~
(Address).
Date.
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(Month)
(Day)
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18 PLACE Of BDRlAt, CREMATION OR REMOVAL
(Cemetery) (City or town)
19 UNDERTAKER^-,
DATE OF BURIAL
1 V <n-~
ADDRESS
2 O I HEREBY CERTIFY that a satisfactory stan-
dard certificate of death was filed with me
BEFORE the burial a transit permit was issued.
Dale of
issue . / / - .
of permits 3 ,
/ Permit
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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.
O 2
STfjr (Comma nmpaltlj of fHaaaarijuBetta
STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH
County —
8 208
BOSTON
(City or town)
Registered No.
Suffolk
State .
Massachusetts
(Place of death)
Registered No._
Boston
(Place of residence)
City or town
2 full name Robert Somerville
Mfrfrs.Eye & Ear Infirmary St>> Ward
(If death occurred in a hospital or institution, give its name instead of street and number)
(a) Residence. State_
(Usual place of abode)
Length of residence m city or town where death occurred
Ma s s
year*
City or
months days.
(If in the Army or Navy of the United States, give rank, organization, etc.)
Wi vs+Vr-yrt-rs. w_ Of
No.-
How long in U. S„ if of foreign birth?
months
days
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
M
4 COLOR OR RACE
w
5 SINGLE, MARRIED, WIDOWED, OR
DIVORCED (write the word)
Single
5a If married, widowed, or divorced
HUSBAND of
(or) WIFE of
6 AGE Years
3
Months
Days
4
If LESS than
1 day, hr*.
If STILLBORN, enter that fact here
MEDICAL CERTIFICATE OF DEATH
15 DATE OF DEATH-
Jan 6
1925
(Month)
(Day)
(Year)
16
HEREBY CERTIF Y, That I attended deceased from
Jan 4 „ Jan 6 1>25 __
that I last saw h_
ali
Jan 6
1925
and that death occurred, on the dated stated above, at
The CAUSE OF DEATH was as follows:
Fibrinous Faclieitis and Bronchi ti s
Broncho .Pneumonia.
7 OCCUPATION OF DECEASED
(a) Trade, profession, or
particular kind of worh
(b) Name of employer
(durationl-
yr*.
do.
Boston
(State or country)
Mass
9 NAME OF _
FATHER
Somerville
0)
H-
10 BIRTHPLACE OF
Winthr op
z
111
X
<
(State or country)
11 MAIDEN NAME - , . , _
of mother Martha Forest
contributory Edema of larynx^
(secondary)
-(duration)-
_yTs.
— ds*
17 Where was disease contracted
if not at place of death?
Did an operation precede death?-
Was there an autopsy?
y 6S Date of-
yes
What test confirmed diagnosis?
(Signed) J E Quincy
, M. D.
12 BIRTHPLACE OF
MOTHER (city or town) .
(State or country)
-Boslon.
(Address) _
Mass a Eye & Ear Infirmary
Mass
Date-
13
Informant.
Rae Somerville.
( Addresses Prescott St Winthr
18 PLACE OF BURIAL CREMATION, OR REMOVAL
Winthr op , W in thr op
14
Filed.
Filed.
Jan 1 0^25
ifL 1925
St flinthroi)
(Cemetery)
( City or town)
DATE OF BURIAL
Jan 8
, 1925
Registrar of city or town where death occurred
19 UNDERTAKER
Frank E Brown
Registrar of city or town where deceased resided
ADDRESS
E. Boston
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N. B.-WRITE PLAINLY, WITH UNFADING BLACK 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 and extracts from the laws on back of certificate.
A R - 30 I
00,000. 3567.
3 SEX
5 SINGLE, MARRIED, WIDOWED, OR
DIVORCED ( write the word)
OFFICE OF THE SECRETARY
DIVISION OF VITAL STATISTICS
1 PLACE OF DEATH
County
<2tjp (Eontnunuupaltfy of fHasBartjuapttB
STANDARD CERTIFICATE OF DEATH
/ ' (City or town )
-"f j State ki^^^......,.. Registered No.
City or T own No St., Ward
/ (If death occurred in a hospital or institution, give its^AMB instead of street and number)
~7 . /> . f J J
2 full name yUA/ut/
r , 7 . (If in the Army 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 of town where death occurred years months days. Bow long in U. S., if of foreign birth ? years mon'hs days
PERSONAL AND STATISTICAL PARTICULARS
5a If married, widowed, or divorced
HUSBAND of
(or) WIFE of ~-t , ,
/
6 AGE
Years
Months
Days .
If LESS than
1 day, hrs.
If STILLBORN, eater that fact here
7 OCCUPATION OF DECEASED
(a) Trade, profession, or ,
particular kind of work
(b) Name of employer
8 BIRTHPLACE (City)
(State or country
10 BIRTHPLACE OF
FATHER (City)
(State or country)
11 MAIDEN NAME .,
OF MOTHER
12 BIRTHPLACE OF J . t * /
MOTHER (City) (J '/...it.. '. 4. KKl
(State or country)
Informant ..../.
(Address)
Filed
i.y.Lfc’^yl.
(Month) (Bay) (Year)
Registrar
MEDICAL CERTIFICATE OF DEATH
15 DATE OF DEATH
/'fafSSthf' ( Tfay )
16 (
I HEREBY CERTIFY, That I attended deceased from
,.LLiU**rx. / to f.. ,19 ^ ,
that 1 {pdt saw hrrr<-^.. . alive on y?T , 19 ^ (?'
and that death occurred, on the date stated above, at cr'T m.
The/CAijUg OS DEATH was as fol^rws : / /I
(duration) yrs. mos. ds.
Date of
CONTRIBUTORY
(secondary)
(duration) yrs..
17 Where was disease contracted “ — *
if not at place of death?
Did an operation precede death?
Was there an autopsy? l/ —
What test confirmed diagnosis?
(Signed)
(Address)
Date
(Month^
ds.
%J..
, M.D.
( Day)
lS^PLA^E OF BURIAL, CREMATION, OR REMOVAL
(Cemetery) / (City or town)
AKER
19 UNDENT
-/ f /sOt/
'1A
DATE OF BURIAL
20 I HEREBY CERTIFY that a satisfactory stan-
dard certificate of d«th was filed with me
BEFORE the burial or transit permit was issued
Date Permit /
tr.. of permit 1/L/jUa£L*.
ADDRESS
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•o O
OFFICE OF THE SECRETARY
DIVISION OF VITAL STATISTICS
I PLACE OF DEATH
County.
©1]? (Eotmmmmpaltlj of fSaHaarhoHettB
City or Town
STANDARD CERTIFICATE OF DEATH
(City or tow
.Registered No..
2 FULL NAME.
(a) Residence. No.
.Ward
(If death occurred in a hospital or institution, give its NAME instead of street and number)
(j^fn the Army or Navy of the United States, give rank, organization, etc.)
.Ward.
(Usual place of abode)
Length of residence in city 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
C/5
£ E
5 >-
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
4 COLOR OR RACE
5 SINGLE, MARRIED. WIDOWED. OR
__ DIVORCED (write the word)
IS DATE OF DEATH
16
5a If married, widowed or divorced
HUSBAND of _______
(or) WIFE of
I H E R E B
(Day)
(Year)
6 AGE
Years
Months
Days
6
CD
o
V"
V-
that I last saw h .
iERTIFY, That I attended deceased from
_, 19 to ,19 ,
.alive on , 19 ,
and that death occurred, on the date stated above, at.
The CAUSE OF £1EATH was asJollofWs:
_m.
If STILLDORN, enter that fact hare
7 OCCUPATION OF DECEASED
(a) Trade, profession, or
(articular kind of work.
(b) Name of employer
S BIRTHPLACE (City)
(State or countfy)
CONTRIBUTORY.
(secondary)
(duration)
yrs._
17 Where was disease contracted
if not at place of death?
(State or country)
Did an operation precede death? ** °Uate of.
Was there an autopsy? .
11 MAIDEN NAME
OF MOTHER
What test confj,
(Signed) _
12 BIRTHPLACE OF
MOTHER (City)
(Addri
M. 0.
(State or country)
Date.
(Year)
£3-100.000
13
Informant
(Address) / *
18 PLACLOf BURIAL, CREMAI10NJR REMOVAL
(Cemetery)
(City or town)
14
Filed VOvy I (/' / f) iZ*
1 i If--/.
(Month) (Day) (Year)
Registrar
19 UNDERTAKER
<2
ADDRESS
20 I HEREBY CERTIFY that a satisfactory stan-
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Official
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-WRITE PLAINLY, WITH UNFADING BLACK 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 and extracts from the laws on back of certificate.
>RM R-301
co
z
JUM.
13-100,000
OFFICE OF THE SECRETARY
DIVISION OF VITAL STATISTICS
PLACE OF DEATH
County
©If* (Eommnmttraltb of JHaHHarijnHrttB
STANDARD CERTIFICATE OF DEATH
state Massachusetts
Suffolk
i'l/ Vi .^VL Lryj
(City or town)
Registered No._
City or Town.
14*
.No.
Ward
2 FULL NAMEL
(If death occurrgd-K) a hospital or institution, give its NAME instead of street and number)
(a) Residence. No._
33
(Usual place of abode)
Length of residence in city nr town where death occurred
(If in the Army or Navy of the United States, give rank, organization, etc.)
_ St. , Wa rd
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
uy
5 SINGLE. MARRIED, WIDOWED. OR
DIVORCED (write the word)
15 DATE OF DEATH
MEDICAL^jCERTIFICATE OF DEATH
~77=I~~7^CJ-
( Month),
£
(Day)
(Year)
5a If married, widowed or divorce*
HtrgBAtitP-Bf
(or) WIFE of
16
I HEREBY CERTIFY, That I attended deceased Juju i
6 AGE
Y'ars
Months
Days
If LESS than
1 day hrs.
or min.
and that death occurred, on the date stated above, at'
The CAUSE OF DEATH was as follows:
If STILLBORN, enter that fact lure
7 OCCUPATION OF DECEASED
(a) Trade, profession, or
particular kind of work
(b) Name ef employer
CEASED • n
J\ f
8 BIRTHPLACE (City)
(State or country)
C.
o
--^7
(duratinnt
yrs. mos. rls.
CONTRIBUTORY
— C — -
(secondary)
L_ yfc.jL=?. mos. ds
17 Where was disease contracted
if not at place of death?.
Filed.
ionth) (DaW (Year)
20 I HEREBY CERTIFY that a satisfactory sten
dard certificate ef dath was filtd with
BEE ORE the burial or transit permit waa issued
Z ’j4— Q- ~J
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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.
3 0 2
(Hummmuopaltlj of MaaaartyttBrttH
STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH
County Suffolk
347
BOSTON
(City or town)
Registered No.
City or town
Boston
State Massachusetts
No. Mass Homoeo Hosp
(Place of death)
Registered No.
(Place of residence)
St.,
Ward
(If death occurred in a hospital or institution, give its name instead of street and number)
2 FULL NAME Donald Hfl.ru i 1 t.nn
(a) Residence. State ^<*3.8 8
(Usual place of abode)
Length of residence m city or town where death occurred jean
(If in the Army or Navy of the United States, give rank, organization, etc.)
-City or Town thr Op No 68 HotPijQr V 1 6Y7 AStC
months
days.
How long in 0. S., if of foreigo birth?
months
days
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
M
4 COLOR OR RACE
w
5 SINGLE, MARRIED, WIDOWED, OR
DIVORCED (write the word)
Single
5a If married, widowed, or divorced
HUSBAND of
(or) WIFE of
6 AGE «Yeaxs
Months
Days
If LESS than
1 day, brs.
1
2
28
or min.
If STILLBORN, enter that fact here
7 OCCUPATION OF DECEASED
(a) Trade, profession, or
particular kind of worh
(h) Name of employer
8 BIRTHPLACE (city or town) .
(State or country)
Everett
Ka.
9 NAME OF
FATHER Harold
E Hamilton
10 BIRTHPLACE OF
Dallas
(State or country)
Texas
11 MAIDEN NAME
OF MOTHER ,
Evelyn M Hick er son
12 BIRTHPLACE OF
MOTHER (city or town) __
Chela »a
(State or country)
Mas 8
15 DATE OF DEATH
MEDICAL CERTIFICATE OF DEATH
Jan 11
1925
(Month)
(Day)
(Year)
16
HEREBY CERTIF Y, That I attended deceased from
Dec 25 . iq 24 ^ Jan 11
1925 ,
that I last saw hilH— ali
Jan IX
,1925 ,
and that death occurred, on the dated stated above, at- 9 a — m.
The CAUSE OF DEATH was as follows:
Ulcerative laryngitis*
_(durationl_
18
ds.
CONTRIBUTOR Y_
(secondary)
Broncho Pneumonia
-(duration X-
IQ,.
17 Where was disease contracted
if not at place of death?
Did an operation precede death? — y
Was there an autopsy?
m Data of—
^Trache
What test confirmed diagnosis?
(Signed) F E Cruff
M. D
Dote
(Address) 296 -All s ton St Brighton
Jan -11 1925
13
Inf.
(Addrcs.)
Evelyn M Hamilton
Win thr op
14
Filed.
Jan 1,4>25
18 PLACf OF BURIAL CREMATION. OR REMOVAL
^lenwood, Everett
(City or town)
(Cemetery)
Registrar of city or town where death occurred
1925
19 UNDERTAKER
Frank D Sweeney
Rogistnr of city or towi where deceased resided
DATE OF BURIAL
Jan 12
, 1925
ADDRESS
Everett
*4—50,000
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MARGIN RESERVED FOR BINDING
WRITE PLAINLY, WITH UNFADING BLACK INK-THIS IS A PERMANENT RECORD. Every item of information
should be carefully supplied. MEDICAL EXAMINERS should state CAUSE AND MANNER OF DEATH in plain terms,
so that it may be properly classified under the International Classification of Causes of Death. See reverse side
for extracts from the laws relative to the return of certificates of death.
RM
R-303
OFFICE OF THE SECRETARY
DIVISION OF VITAL STATISTICS
(Eommomuraltlj of MasBarijttBftta
1 PLACE OF DEATH
County
City or Town
2 FULL NAME
MEDICAL EXAMINER’S CERTIFICATE OF DEATH
(Issued under the Provisions of General Laws, Chapter 38)
|f^ State Z
(City or town) /
Registered No.
No. hr , - 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.)
« f / (If in the Army or Navy ot
(a) Residence. No. VJ , 4 dT~ St., Ward
(Usual place of abode) * (If non-resident give city or town and State)
Length of residence in city or town where death occurred years months days How long in U. S., if of foreign hirth? years months days
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
lt
co
3 SEX
4 COLOR OR RACE j 5 SINGLE, MARRIED, WIDOWED OR
q7 j LUYORCCD {Write the word)
_ 14/ nitf
15 DATE OF DEATH
16
(M^ntji)'
l z
(Day) (Year)
<lht
5a If married, widowed^or divorced
HUSBAND of
(or) WIFE of
6 AGE
Years
Months
Days
If LESS than
\o 1
//
V
1 day, brs.
or min.
I HEREBY CERTIFY that I have investigated the
death of the person above-named and that the CAUSE AND MANNER
thereof are as follows :
~
If STILLBORN, enter that fact here
7 OCCUPATION OF DECEASED
(a) Trade, profession, or
particular kind of work
(b) Name of employer
8 BIRTHPLACE (City)
(State or country)
9 NAME OF
FATHER
10 BIRTHPLACE OF
FATHER (City)
(State or country)
(See reverse side for description for unknown person)
a
11 MAIDEN NAME / « /
OF MOTHER /
12 BIRTHPLACE OF /j s6D
MOTHER (City)
(State or country)
17 Where was injury sustained
if not at place of dea
. y. t*\
(Signed)'
, M.D.
Dale
(Address) .J
Medical Examiner for..
t'y.
13
Informant
(Mr
(Day)
( Year)
14
(Address)
18 PLACE OF BURIAL, CREMATION, or REMOVAL
(City or town)
is r i nr. ur Durum, enci
(Cemetery) /
Filed /S.
(Mouth) (Day) (Year)
19^NDERTAKER
DATE OF BURIAL
onth) (Dayy(Yeai)
ADDRESS
Registrar
20 Burial permit
issued by
\rzBir&rljZ (5*
» gSSag as •*- . ■ - ^
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. 46.
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, he
shall forthwith go to the place where the body lies and take
charge of the same. . . . Gen. Lavis, Chap. 88, 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.
88, 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 are 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 an®sthetic.” “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)
(
f
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. — General Laws, Chap. 38, Sect. 14.
THIS CERTIFICATE CONSTITUTES SUCH PERMIT
4? I
-WRITE PLAINLY, WITH UNFADING BLACK 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 and extracts from the laws on back of certificate.
)RM R-301
CD
23 100.000
OFFICE OF THE SECRETARY
DIVISION OF VITAL STATISTICS
I PLACE OF DEATH
County
(Commornttpalth of fHasBarboaPtts
STANDARD CERTIFICATE OF DEATH
State
I AINUAKL)
City or Town,
2 FULL NAME_
(a) Residence. No.-<>~^
CL
(City or town)
-Registered No
St.( _Ward
(If death occurred in a hospital or in/ritution, give its NAM E instead of street and number)
(Usual place of abode)
length of residence in city or town where death occurred
-st.,
i the Army or Navy of the United States, give rank, organization, etc.)
-Ward
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 v
4 COLOR OR RACE
or > uivukulu (write tne wo
5 SINGLE, MARRIED, WIDOWED. OR
DIVORCED (write the word)
5a If married, widowed or divorced
-HtEStfANtTof
(or) WIFE of
6 AGE Years
/ft onths
Days
If LESS than
//
1 day, hrs.
or min.
If STILLBORN, enter that fact hare
7 OCCUPATION OF DECEASE
(a) Trade, profession, or
particular kind of work
(b) Name of employer
8 BIRTHPLACE (City),
(State or country)
9 NAME OF
FATHER Z'
lO BIRTHPLACE OL^ — » V , '
FATHER (Citv) '
(Stale or country)
i=Z2t
11 MAIDEN NAME
OF MOTHER-
12 BIRTHPLACE OF
MOTHER (City)-
(State or country)
^
Informan
(Addres;) —
14
/
Filed A'-1 X , ; ■ I 7 ^
(Month) (Day) (Year)
Registrar
MEDICAL CERTIFICATE OF DEATH
IS DATE OF DEATH
16
(Month)
(Day)
(Year)
I HEREBY CERTIFY, That I attended deceased from
i- /f , 19^.$^ to * /JL llJLST
that I last saw h _P^3 ~ alive on / / , 19^Lt£T
and that death occurred, on the date^fated above, at f. m.
The CAUSE OF DEATH was as follows:
(duration)
_yrs.
ds.
CONTRIBUTORY-
(secondary)
(duration)
_yrs._
-ds
17 Where was disease contracted
if not at place of death?
Did an operation precede death? -Date of ~
Was there an autopsy?
What test confirrrj^ri diagnosis?
(Signed) ^ . M.
(Address) iT
Date
/TxA- *
(Year)
18 PLAST Of BURIAL, CREMATION OR REMOVAL J
DATE OF BURIAL
(Semetery)
(City or town)
19 UNDERTAKER
/vf /^LT
20 I HEREBY CERTIFY that a satisfactory stan-
dard cartificate of death was filad with me
BEFORE the burial or transit permit was issued
ifa/AXi-T .&£?
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CQ
100,000. 3567.
6 AGE Years
Months
Days
1 If LESS than
n
/
(3
1 day, hrs.
or min.
OFFICE OF THE SECRETARY
DIVISION OF VITAL STATISTICS
1 PLACE OF DEAT
County
CitforTown
(Sljp C£mtuiumun,alilj of fUaeaarbuapita
DARD
CERTIFICATE
2 FULL NAME
TH 0
*?Ll ,
Jt y \aa ucawi UV/tUUCU ,
Appudi dl QaMZcAs
{ fit /) . 1 (Ifi
DEATH
(City or town)'
Registered No.
!3U. St., I./-. Ward
(If death occurred in jj, hospital cjrTnstitution, give its NAjqt instea<yof street and number)
(a) Residence. No.
(Usual place of abode)
Length of residence in city or town where death occurred
- luM-A
months
Army or Navy of the United States, give rank, organization, etc.)
/ Ward
(If non-resident give city or town and State)
How long in U. S., if of foreign birth ? years monihs 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
If STILLBORN, enter that fed here
7 OCCUPATION OF DECEASED
(a) Trade, profession, or
particnlar kind of work
(b) Name of employer
8 BIRTHPLACE (City)
(State or country
9 NAME OF ff f) (Tf ('} DU /
FATHER JnojJL .
W
10 BIRTHPLACE OF
FATHER (City)
/ ' x £ r
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11 MAIDEN NAME
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Odl
a
12 BIRTHPLACE OF ■p'
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(State or country) v.
13
Informant W
(Address) AA '• 'JA> '
14
Filed t 1.1
(Month) (Day) (Year)
Registrar
20 I 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
15 DATE OF DEATH n ./±*a
(J (Month) (Day) (Year)
16
HEREBY CERTIFY, That I attended deceased from
"V ?r..3 19^-^, to f ( , 19
...SLa&isesT. } !). 19 Hh. A
date stated
that I last saw hjtr*r* alive on
and that death occurred, on the
The CAUSE OF DEATH was as follows:
above, at.. *?'/
CONTRIBUTORY
(secondary)
(duration) yrs.
17 Where was disease contracted
if not at
..ds.
/as disease contracted , A— f) J
place of death?
Did an operation precede death? Date of *2* 7*“. .^ 7 AU.^T
Was there an autopsy?
What test confiri
(Signed)
(Address)
Date
Official
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WRITE PLAINLY, WITH UNFADING BLACK INK-THIS IS A PERMANENT RECORD. Every item of information
should be carefully supplied. MEDICAL EXAMINERS should state CAUSE AND MANNER OF DEATH in plain terms,
so that it may be properly classified under the International Classification of Causes of Death. See reverse side
for extracts from the laws relative to the return of certificates of death.
3RM
R-303
OFFICE OF THE SECRETARY
DIVISION OF VITAL STATISTICS
(Smnmomnralih of fHaaaarljuaptta
(City or town)
State Registered No.
MEDICAL EXAMINER’S CERTIFICATE OF DEATH
»»» „(I8SUED UNDER THE PROVISIONS OF GENERAL LAWS, CHAPTER 38)
_
* St- Ward
■ * (If deatj occurred m a hospital or inst|fution, gilrelts name instead of street and number)
2 FULL NAME \ Z.
1 S- s~\ ilf >n the Army or Navy of the United States, give rank, organization, etc.)
(a) Residence. No OULAAA-' — d} St., Ward
(Usual place of aboder (If non-resident give city or town and State)
Length of residence in city or town where death occurred years months days How long in U. S., if of foreign birth? years months days
1 PLACE OF DEATH
County
r
City or T own
I.
m
z
PERSONAL AND STATISTICAL PARTICULARS
3 SEX - 4 COLOR OR RACE 5 SINGLE, MARRIED. WIDOWED OR
. » fl 'H — ' anpRCED ttt’WWthe word)
5a If married, widowed, or divorced
HUSBAND of
(or) WIFE of
6 AGE
Years
iir
Months
I o
Days
II
If LESS than
1 day, hrs.
or min.
If STILLBORN, enter that fact here
7 OCCUPATION OF DECEASED
(a) Trade, profession, or A
particular kind of work rvATVVAJO
(b) Name of employer
8 BIRTHPLACE (City)
(State or country)
9 NAME OF
FATHER
10 BIRTHPLACE OF
W FATHER (City)
Z (State or country)
“ 11 MAIDEN NAM1
< OF MOTHER
A
17 Where was injury sustained
if not at place of deaths
(Signed)
(Address)
MEDICAL CERTIFICATE OF DEATH
15 DATE OF DEATH
t
(Moiith)]
7<5r
(Day)
,tiu
(Year)
IaT
16
I HEREBY CERTIFY lhat I have investigated the
death of the person above-named and that the CAUSE AND MANNER
thereof are as follows:
'<^{ , GvatK <?vaAa-^_
ClA JL ,
"tL t/v ctwi oJL
HllwctJlX
(Sec reverse side for description for unknown person)
f
Medical Examiner for
(Md^th) (
I4ZSI
(\ ear)
Filed
(Month) (Day) (Year)
REGISTRAR
20 Burial
issued
19 UNDERTAKER . Q ADDRESS
Id bpyermit._..:^^: C-, 21 of 4 ,/zrSr*
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. 45.
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, he
shall forthwith go to the place where the body lies and take
charge of the same. . . . Gen. Laws, Chap. 88, 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.
88, 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 are 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 anaesthetic.” “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)
I-
i iCE TO UNDERTAKERS: No embalming fluid, or any substitute therefor, shall be injected into the
~uy person supposed to have met his death by violence, until a permit, signed by the Medical
Examiner, has first been obtained. — General Laws, Chap. 38, Sect. 14.
THIS CERTIFICATE CONSTITUTES SUCH PERMIT
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OFFICE OF THE SECRETARY
DIVISION OF VITAL STATISTICS
1 PLACE OF DEATH
County
GJammmtuiraltlj of fSassarljUHCtta
STANDARD CERTIFICATE OF DEATH
Suffolk
_ Massachusetts _ .
State Registered No*
BOSTON
(City or town)
City or Town
2 FULL NAME
,(jf
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 occnrred SJD years
(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 monihs days
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
4 COLOR OR RACE
th\ Qjr
5 SINGLE, MARRIED. WIDOWED. OR
DIVORCED ( write the word)
Qi/^U<rXASZA
5a If married, widowed, or divorced
HUSBAND of
(or) WIFE of
If STILLBORN, eoler that fact here
7 OCCUPATION OF DECEASED
(a) Trade, profession, or
particular kind of work
(b) Name of employer
t
(State or country
9 NAME OF /7
FATHER / /
</)
10 birthplac^SSf
FATHER (USV)
Fr
z
• (State.or country)
EE
<
11 MAIDEN NAME - ' »
OF MOTHER y
SL
12 birthpCace of
MOTHER (City)
(State or country)
13
(Address) / ^
14
2- J
(Month) (Day) (A
ear) Registrar
MEDICAL CERTIFICATE OF DEATH
15 DATE OF DEATH
(Month)
Z o
(Day)
2. £.
(Year)
REBY CERTIFY, That I attended deceased from
Z£....,19*r.2.,to ... ~ ^ ,19 ^ /
last saw h alive on ^CJ . \9 A J,
and that death occurred, on the datev&t^ited above,
The C AAttfi OF DEATH was as follows
.A?. (duration)
UTOft| y. //
CONTRIB
(secondary)
(duration) tL.....yrs,.
17 Where was disease contracted
if not at place of death? FOR- WH-AT Y
Did an operation precede death ? “T^fcrDate of
Was there an autopsy?
What test confirsned diagnosis?
( Signed
(AdHs)
Date ’*£4 jLj%L J
18 PLAC1
BURJAL, CREMATION. OR REMOVAL
C^}lu£^€»1
(City or town) _J
I DATE OF BURJAL
ADDRESS
20 I HEREBY CERTIFY that a satisfactory stan-
dard certificate of death was filed with me
BEFORE the burial or transit permit was issued
/ . Permit
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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.
•3 0 2
1 PLACE OF DEATH
NORFOLK
County-
City or town
2 FULL NAME
BROOKLINE
Qftfp (Emtummmealtli of JfflaoaarffnBrtto
STANDARD CERTIFICATE OF DEATH
. state MASSACHUSETTS
BROOKS HOSPITAL
BROOKLINE
(City or town)
Registered No._ ^7
(Place of death)
Registered No.
(Place of residence)
No.
St.,
-Ward
(If death occurred in a hospital or institution, give its name instead of street and number)
James Brown
k
(If in the Army or Navy of the United States, give rank, organization, etc.)
(a) Residence. S S a CilUS 0 t t S City or Town W ~1 T~1 tlTl r Op No. ^ 1 Off t) 1 C A V eat.
(Usual place of abode)
Lmgth of residence in dty or town where death occorred fears months days. How long in U. S., if of foreign birth? fears months days
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
3 SEX
Male
4 COLOR OR RACE
White
5 SINGLE, MARRIED, WIDOWED, OR
DIVORCED (write the word)
Vri dower
'• ' ' ■_ .-c
is date of nr atm January
(Month)
23,
(Day)
1925.
(Year)
16
5a If married, widowed, or divorced
HUSBAND of
(or) WIFE of
6 AGE Years
74
Months
1
Days
15
If LESS than
1 day, hrs.
If STILLBORN, enter that fact here
I HEREBY CERTIFY, That I attended deceased from
-P-C t . 18, „ ia_24 tn Jan. 25, , ia£5..
that I last saw Alive on -Jan a 22,
and that death occurred, on the dated stated above, at_
The CAUSE OF DEATH was as follows:
Carcinoma of Pros hate.
7 OCCUPATION OF DECEASED
u) Trade, profess*™, or Retired: Master Mariner
particular land of work
(h) Name of employer
Red
Beach
(State or country)
Maine
9 NAME OF
father (Cannot be
learned)
</)
1-
10 BIRTHPLACE OF
I Pcmn Af >vch ^
2
Id
X
<
(State or country)
11 MAIDEN NAME
OF mother (Cannot
be learned)
CONTRIBUTOR Y_
(secondary)
JL
-(duration) SSTS&T Q-H —
-(duration),
L
_ds.
17 Where was disease contracted]
if not at place of death? -^QiIaO »
12 BIRTHPLACE OF
mother (city or town) - ( Canno-t — he — learned )
(State or country)
Did an operation precede dwtW S_a _ Date of U (
igtal Prostatectomy ror
Was there an autopsy ?j-N VZ-# Ql f 3T* O S ~&8. b ^
What test confirmed diagnosis? _
m George Gilbert Smith
( Address) 7 — M&r
Dale January
, M. D.
s
-23,,
1925.
13
Informant..
Charles A^Colton
14
45 At 1 ant
Mm
Wlnthrop' Man
18 PUCE OF BURIAL CREMATION, OR REMOVAL
Winthr op
g (Cemetery)
Mas
(City erf town)
pi ud Jan. 23^ 23
Registnr of dty or lowi where death occurred
Filed
19
19 UNDERTAKER
C R Bennison
Registrar of dty or tow* where deceased resided
DATE OF,BURIAL
3l/g^/'1925
ADDRESS
Winthr op Ma
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-WRITE PLAINLY WITH UNFADING BLACK INK-THIS IS A PERMANENT RECORD. Every item of information
should be carefully supplied. AGE should be stated EXACTLY. See reverse side for affidavit.
>RM R-306
1 PLACE OF DEATH
QJIje (Eomutomm'aUh of Maaaarffusptta
AFFIDAVIT AND CORRECTION OF A RECORD OF DEATH
47
OFFICE OF THE SECRETARY
DIVISION OF VITAL STATISTICS
Registered No. Deposition No
City or Town BROOK LI NE No EBOOKS HOSPITAL Stf Ward
__ _ (If death occurred in a hospital or institution, give its name instead of street’and number)
2 FULL NAME .JAMES. II BROWN
(If in the Army or Navy of the United States, give rank, organization, etc.)
(a) Residence. No .4.5.... ATLANTIC. St„ Ward -WINTHKOP MASS
(Usual place of abode) (if non-resident give city or town and State)
Length of residence in city or town where death occurrcj years months dag Howjongjn D. S.. if of foreign birth? years mM1ths &js
CO
z
3 SEX
Male
4 COLOR OR RACE
White
5 SINGLE, MARRIED. WIDOWED OR
DIVORCED t write the word)
mnrried
5a If married, widowed, or divorced
HUSBAND of , .
(or) wife of Cascelia E
6 DATE OF BIRTH
Tiiionth)
(Day)
(Year;
7 AGE Yeai-6
74
If STILLBORN, enter that fact here
Months
1 15
Days
If LESS than
1 day, hrs.
or min.
8 OCCUPATION OF DECEASED
(a) Trade, profession, or
particular land of work -R© t IP GCL St^P MaplUW
(b) General nature chndostry,
business, or establishment in
which emoloved (or enmlover)
(c) Name of employer
9 BIRTHPLACE (City) Red. Beach
(State or country)
44a ine —
14
10 NAME OF ,
father (Cannot be learned)
1 1 birthplace of
father (city) {G&nnot he learned )
(State or country)
12 MAIDEN NAME / ~ , \
of mother (Cannot be learned)
13 BIRTHPLACE OF ,
mother (City) (fjann ot he learned )
(State or country)
informant Ch.s.r.le-s A C 0-1 t on
(Addres*) 4r; API nntl P. ft ~
is date of death Janimr.y. ...23..* 19.2.5 at 4A M.
(Month) * (Day) r (Year)
16 CAUSE OF DEATH
- Ca.r.c.inoma of Prostate.
CONTRIBUTORY
(SECONDARY) ....
17 Where was disease contracted
if not at place of death?
Home .
(Signed) Goor pe Gilbert Smith m.d.
(Address) 7 Marlboro St B.os.ton. Ilu,s.s
D»te January. ...25.., 192=5...
(Month) (Daj) (Year)
18 PLACE OF BURIAL, CREMATION, or REMOVAL
Lin thr op , V. inthr op Map 3
(Cemetery) (City or town)
DATE OF BURIAL
(Month) (Day) ( Year)
19 Date original certificate of death was filed by city or town clerk
JANUARY 23, 1925
20 The above correction* with reference to the statement on the back of this blank have been entered upon the death record, of the Tnwn
vjp r, av' Tin, , (i- ity or Town)
°f (SameofcUy 'orpwot~‘ In accordonce with the provisions of Revised Laws, Chap. 29, Sec. 14, this 30 til day
A.PIK' J. 19 , and a
~WAou^
copy of these corrections and affidavit has been transmitted to the Secretary of the Commonwealth
— 1| — WEOisr
DEPOSITION
WRITE LEGIBLY WITH DURABLE BLACK INK
The Commonwealth of Massachusetts)
County of )
The undersigned, being duly sworn, depose and say that the record relating to the death of
JAMES BROWN
in the Town Gf Brookline ,
(Give name of decedent exactly as recorded on the original record) (City or town) (Name of city or town )
does not fully and correctly state all the facts relating to said death, and that the true statement
of facts omitted or incorrectly stated in said record has been supplied by liep .on the form of
(Him or her)
certificate on the other side of this blank.
SIGNATURE
Hattie E Colton
RESIDENCE
(City or town, Btreet and iramlier, If any)
45 Atlantic St
V.'inthrop
Relation to decedent,
if awy
Daughter
Date, April 23, 1926... F
Then personally appeared before me the person whose signature appear above and made
oath that the statements subscribed to by llO.P are true.
Name ,C.fo.E£.l.©..S. H.....C..0.1.t0H
V*
Vi
•*1
( ) Official designation iQ.tarj. ic Co mm* -ynipo!! t: opt/
(City or town clerk or assistant clerk, notary public,
or other officer authorized to administer oaths for
general purposes)
MARGIN RESERVED FOR BINDING
•WRITE PLAINLY, WITH UNFADING BLACK 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 and extracts from the laws on back of certificate.
RM R-301
I.
cb
OFFICE OF THE SECRETARY
DIVISION OF VITAL STATISTICS
I PLACE OF DEATH
County
Uflja Gmmttummmtlf of MaaaartfttBrttB
STANDARD CERTIFICATE OF DEATH
OF FOU< State
Ulk
1/1/ TfJlFoP*
City or Town.
W / nt htrror
No./ a? , f-ferTMO/v
(City or town)
.Registered No
St.,
.Ward
(If death occurred in a hospital or institution, give its NAME instead of street and number)
2 FULL NAME.
William Mot?6an
(a) Residence. No L 3Z I-Ierman
(Usual place of abode)
Length of residence in city or town where death occurred years months
(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 I). S., if of foreign birth? years months days
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
Male
4 COLOR OR RACE
Wl-llTf
5 SINGLE, MARRIED, WIDOWED. OR
DIVORCED (write the word)
Married
5a If married, widowed or divorced
HUSBAND of - ~
(or) WIFE of
6 AGE
Years
78
>rcea
Elleh
Months
Days
If LESS than
1 day, hrs.
or min.
K STILLBORN, enter that fact hare
7 OCCUPATION OF DECEASED
(a) Trade, prnfession, or
particular kind of wort(_
(b) Name of employer
~T)jza in EAyefT
8 BIRTHPLACE (City)
(State or country)
CV
R D IFF
9 NAME OF/t _ .
FATHER U(\NNOT <3 £ BFARNEP
lO BIRTHPLACE OF
FATHER (City)
Carpi ff
(State or country)
Wales
11 MAIDEN NAME
OF MOTHER
Thompson
12 BIRTHPLACE OF
MOTHER (City)
Cardiff
(State or country)
Wales
13
Informant.
(Address)
A 'BETH Mq-RGA /V.
±l3i // BR MQ /V
14
Filed , . l — 1. :/ 2-8 —
(Month) (Day) (Year)
k>
Registrar
MEDICAL
:ertificate of death
IS DATE OF DEATH.
BIBO
33
(Month)
(Day)
16
I HEREBY CERTIFY, That I attended deceased from
/ ~ LF , 194JL, to /-Z-3
that I last saw h.
.alive on
and that death occurred, on the date stated above, at.
The CAUSE OF DEATH was as follows:
CONTRIBUTORY.
(secondary)
(duration)
(duration)
_yrs._
_ds.
ds
17 Where was disease contracted
if not at place of death?
Did an operation precede death?
Was there an autopsy?
What test confirmed dj^gnosis?
(Signed) _
(Address)
Date
(Month)
.Date of.
M. D.
18 PUCE Of BURIAL. CREMATION OR REMOVAL
WlM TH EOF W INTM R°r
(Cemetery) (City or town)
NDERTAKER
20 I HEREBY CERTIFY that a satisfactory stan
ted cartificata of death was filed with
HffOSE the burial • transit perm.l was issued
-/■ (0 k
DATE OF BURIAL
Jam
'Official ,
position
Dete of
issue
/
permit
ADDRESS ,
Permit
NO.
100.000
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.100,000.
OFFICE OF THE SECRETARY
DIVISION OF VITAL STATISTICS
1 PLACE OF DEAT
County
5Jl]p (Eammonuivalily of iStaaaartjUBPtta
RD CERTIFICATE OF DEATH
City or Town,
2 FULL NAME
n
r
* / ^ (City or town)
Registered No. !.
St., Ward
spital or institution, give its name instead of street and number)
(a) Residence. No. <3
(UsuaA 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. .
(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
RACE
5 SINGLE, MARRIED, WIDOWED, OR
DIVORCED (wrije the word)
5a If married, widowed, or divorced
HUSBAND of
(or) WIFE of
A.
6 AGE
yj
Months
Dt
f /T
If LESS than
1 day, hrs.
If STILLBORN, enter that fact here
7 OCCUPATION OF DECEASED
(a) Trade, profession, or
particolar kind of work
(b) Name of employer
8 BIRTHPLACE (City)
(State or country
9 NAME OF
FATHER
11 MAIDEN NAM
OF MOTHER
12 BIRTHPLA
MOTHER
(State or country)
Fil.d ... . <..! I J ... I
(Month) (Day) (Year)
MEDICAL CERTIFICATE OF DEATH
15 DATE OF DEATH 'Si X.5 / f ..? A
p/onth) (Day) (Year)
16
I HEREBY CERTIFY, TJjat I attended deceased from
aL .. s> , 19oLe>. ., to
OLAao 5^ jg
that'l last VsWw Yi.rO^?.... alive on M .... 19
and that death occurred, on the dare stated above
The CAUSE OF DEATH was as follows:
:.i j:zz
CONTRIBUTORY '-LA i <T I
(duration) yrs.
. ds.
(secondary)
4
yrs
(duration)
17 Where was disease contracted , — — •
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• 1 J" t}
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NA o
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(Signed)
(Address)
Date ° LAA.y
diagnosis/ | (\ fT>
QAAnM \ > ' \nm>uuA^ ■ K)
~7 4 *
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2
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Exact statement of OCCUPATION is very important. See instructions on back of certificate.
3 0 2
Sty* (E0mmxmtopaltlj of iHIaaoarljttBrttB
STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH
County Suffolk
Registered No.
BOSTON
(City or town)
822
. State
Massachusetts
(Place of death)
City or town
2 FULL NAME
Boston
N„ MASS , HOMEO , HQSPT,
Registered No. _
(Place of residence)
St.,_
Ward
SUMNER GREENBERG
(If death occurred in a hospital or institution, give its name instead of street and number)
(a) Residence. State M A S S ,
(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.)
_City or Town W I N TH R QP No. 5-3 T R J 0 E.NT ABE, St.
months
days.
How long in U. S„ if of foreign birth?
months
days
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
M
4 COLOR OR RACE
w
5 SINGLE, MARRIED, WIDOWED, OR
DIVORCED (write the word)
s
5a If married, widowed, or divorced
HUSBAND of
(or) WIFE of
6 AGE
Years
Months
1 1
Days
H LESS than
1 day, hrs.
H STILLBORN, ester that fact here
MEDICAL CERTIFICATE OF DEATH
JAN . 2q~
15 DATE OF DEATH-
JL5£5_
(Month)
(Day)
(Year)
16
1 HEREBY CERTIFY, That I attended
JAN 15 JAN. 26
deceased from
ia25 ,
JAN .26
, 19 25
and that death occurred, on the dated stated above, at
The CAUSE OF DEATH wan an follows:
AC, LARYNGEAL S TEN OS 1 S ( PR OB
3>3QA_.m.
. 1 N-
fluenzal)
14 .4.
rnNTBiRirrnRY BRONCHO — PNEU ' Q N 1 A
(secondary)
(duration X
yrs.
mos. — da.
7 OCCUPATION OF DECEASED
(a) Trade, profession, or
partknlaj kind of work
(k) Name of employer
8 BIRTHPLACE (city or town) -
(State or country)
W| NTHROP
9 NAME OF
FATHER
PHILIP GREENBERG
10 BIRTHPLACE OF
(State or country)
RUSS 1 A
11 MAIDEN NAME
OF MOTHER
_ ANNIF GRFFM
12 BIRTHPLACE OF
MOTHER (citv or town) —
(State or country)
RUSS 1 A
Informant _
EAT-HEfi .
17 Where was disease contracted
if not at place of death?
Did an operation precede death?-
Was there an autopsy?
.Date of-
What test confirmed diagnosis?
(Signed) F t E » C_R U F F
, M. D.
(Address)
Date
JAN .26
1925
■24—50.000
13
18 PLACE OF BURIAL CREMATION. OR REMOVAL
CHEVRA THILIM
14
Filed
JAN .28
,19 25
(Cemetery)
(City or town)
Filed
nH-
1925
fik
Registrar a f dly or town
rs
19 UNDERTAKER
MANUEL STANETSKY
Registrar ef dty or tow* where deceased
DATE OF BURIAL
JAN, 26
, IS 25
ADDRESS
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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.
•3 0 2
1 PLACE OF DEATH
County Suffolk
(Emnmnmiiraltl) of fRasHarljuarttB
STANDARD CERTIFICATE OF DEATH
Massachusetts
State
BOSTON
(City or town)
Registered No. 347
(Place of death)
Registered No.-
City or town
2 FULL NAME
Boston
MATTHEW L. MC DONALD
_ _ (Place of residence)
Nr. MASS. CHAR, EYE & EAR INF, St>> Ward
(If death occurred in a hospital or institution, give its name instead of street and number)
(a) Residence. State-
MASS,
(Usual place of abode)
Leagth of residence '■ city or tows where death occurred
(If in the Army or Navy of the United States, give rank, organization, etc.)
-City or Town W I NTH RQ E No H N S3 N A V E . -St.
days.
How long in I). S., if of foreign birth?
months
days
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
U
4 COLOR OR RACE
W
5 SINGLE, MARRIED, WIDOWED, OR
DIVORCED (write the word)
5a If married, widowed, or divorced
HUSBAND of
(or) WIFE of
6 AGE
Years
Months
Days
If LESS than
12
3
20
1 day, hrs.
tf STILLBORN, enter that fad here
7 OCCUPATION OF DECEASED
(a) Trade, profession, or
particular kind of worh
SCHOOLBOY
(h) Name of employer
8 BIRTHPLACE (city or town) -
(State or country)
BOSTON
9 NAME OF
FATHER
MATTHEW L.
tf)
t-
10 BIRTHPLACE OF
BOSTON (EAST)
z
Ld
(State or country)
X
<
11 MAIDEN NAME
OF MOTHER
MARY A.SHAUGHNESS
0.
12 BIRTHPLACE OF
MOTHER (city or town)
BOSTON
(State or country)
13
Informant
FATHER
(Addrrn)
14
Filed ^ ^ • 3 * ,1925
Fiud 1 M Ay Ibj f 192R
r\ Registrar of city orjown when death ece>rred
I
Registrar ef city or town where deceased .nesided
15 DATE OF DEATH
MEDICAL CERTIFICATE OF DEATH
~JAN.28
1925
(Month)
(Day)
(Year)
16
HEREBY CERTIFY, That I attended deceased from
jam ,28 , 192&. .
... JAN .28
that I last saw h LB 0 alive on
1925
and that death occurred, on the dated stated above, at- -5-.-35P
The CAUSE OF DEATH was as follows:
MASTO ID ITIS ,AC.SHPP11RATI VF ,RT-,-
S I NUS THRO MB OS I S
“ J ~ ~ ” ' 1 t ‘ — i- !=. u ~ ~
CONTRIBUTORY
AC. SUP .MEN 1 NG ITIS
(secondary)
(duration). _ yrs. mos. _
A.
17 Where was disease contracted
if not at place of death?
Did an operation precede death?
Was there an autopsy?
What test confirmed diagnosis?
Y (Signed) H » 6 . TO BEY
-Date of
, M. D.
(Address)
Dite
1925
I
ad
z
•'34—50,000
18 PLACE OF BURIAL CREMATION, OR REMOVAL
y^or tcsU?i) ^
19 UNDERTAKER
J .F . 0 ’MALEY
DATE OF BURIAL
ADDRESS
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OFFICE OF THE SECRETARY
DIVISION OF VITAL STATISTICS
I PLACE OF DEATH
Co u nty *_jsut
®lT* OInmtmmmpalth of maHsarhttaptta
STANDARD CERTIFICATE OF DEATH
\ State^^
(City or tovm)
.Registered No.
City or Town
_No.Z
s
2 FULL NAME
.Ward
(If death occurred in a hqgpftal 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 occurred / 5 years
J* /-
(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
y*
4 COLOR OR RACE
^tC: He
5 SINGLE. MARRIED. WIDOWED. OR
DIVORCED (write the word)
5a If married, widowed or divorced
HUSBAND of
(or) WIFE of
If LESS than
1 day, his.
or min.
If STILLBORN, enter that fact here
7 OCCUPATION OF DECEASED
(a) Trade, profession, or ^
particular kind of work,
(h) Name of employer
15 DATE OF DEATH
// (Month)
^ 9 « r £
(□ay) (Year)
16 (/
1 HEfiEBY*CERTIFY,
<7vUr'/t isUy.t n.
aThat 1 attended deceased from
that f la^t <;aw h alivp on
- L £ 19 lS
and that death occurred, on the d^te
The CAUSE^OF D£AXHjwas as follows:
r-' A
stated above, at ^ ' m.
8 BIRTHPLACE (City)
(State or country)
9 NAME OF
FATHER
lO BIRTHPLACE OF
FATHER (City)
(State or country)
11 MAIDEN NAME
OF MOTHER
VUc
12 BIRTHPLACE OF
MOTHER (City)
(State or country)
13
Informant • SJ? • ■/
(M*^) ) /S' JV
14
Filed
(Month) (Day)1 (Year)
zl
Registrar
MEDICAL CERTIFICATE OF DEATH
(duration)
_yi s. .
ds.
CONTRIBUTORY.
(secondary)
(duration)
_yrs..
ds
17 Where was disease contracted
if not at place of death?.
Did an operation precede death?
Was there an autopsy?
What test confjfiyed'^i,
(Signed)
Date of.
(Month)
C 7\ S
(Year)
SlZ
M. D.
1 8 PUCE Of WRIAL. CREMATION OR REMOVAL
S/C -yot+~C hj
(Cemetery) (City or Town)
19 UNDERTAKER
DATE OF BURIAL
f T'
ADDRESS
20 I HEREBY CERTIFY that i satisfactory stan
M cartificale of death was filed with
BET ORE the burial or transit permit was issued
2 k • 0
Official
position
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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
(Emmmmmpaltl! of MaHHarffttarttB
STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH
County Suffolk
BOSTON
(City or town)
Registered No. I 0 8 0
. State _
Massachusetts
City or town
2 FULL NAME
Boston
No.
INFANTS HOSPT.
Registered No.
(Place of death)
(Place of residence)
St.,
-Ward
(If death occurred in a hospital or institution, give its name instead of street and number)
PATRICK F. SULLIVAN
(a) Residence. State-
MASS.
(Usual place of abode)
logth of residence in city or tows where death occurred
(If in the Army or Navy of the United States, give rank, organization, etc.)
.City o. Town WINTHROP N„, 77 BARTLFTT R0«4
months
days.
How long in D. S., if of foreign birth?
months
days
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
3 SEX
M
4 COLOR OR RACE
W
5 SINGLE, MARRIED, WIDOWED, OR
DIVORCED (write the word)
15 DATE OF DEATH-
(Month)
FEB. I
(Day)
1925-
(Year)
5a If married, widowed, or divorced
HUSBAND of
(or) WIFE of
6 AGE
Years
I I
Months
l
Days
If LESS than
1 day, hrs.
H STILLBORN, ester that fact here
16
I HEREBY CERTIFY, That I attended deceased from
_^T20 19 ^4 { . lft25 .
that I last saw h — I M alive on ,1925—,
and that death occurred, on the dated stated above, at 4 * I 0 A m.
The CAUSE OF DEATH wan as follows:
CHR.VALV. HEART DISEASE
7 OCCUPATION OF DECEASED
(a) Trade, profession, or
particular kind of work
(b) Name of employer
(duration)-
15
_ds.
8 BIRTHPLACE (city or town) .
(State or country)
CAMBRIDGE
CONTRIBUTOR Y_
(secondary)
-RHEUMATIC FE VER_
p
(duration)—
_yr 8.
- ds.
9 NAME OF
FATHER
JOHN D.
10 BIRTHPLACE OF
FATHER (citvor town)
IRELAND
(State or country)
11 MAIDEN NAME
OF MOTHER
MARGARET SULLIVAN
12 BIRTHPLACE OF
MOTHER (eitv or town!
(State or country)
1 RELAND
17 Where was disease contracted
if not at place of death?
Did an operation precede death?-
Was there an autopsy?
-Date of-
What test confirmed diagnosis?
<*■*> J.H. JOHNSTON
, M. D.
(Address)
Dale
FEB. |
1925
13
Informant-
MOTHER
14
Filed FEB, 3 ,1» 25
PParL ) L 1925
18 PLACE OF BURIAL CREMATION. OR REMOVAL
MALD EN (HOLY CROSS)
(City or town)
(Cemetery)
r Registrar o( dty or tm where death occarred
19 UNDERTAKER
J.J. KELLEY &
SON
Refistnr of dty or tm where deceased redded"- '
DATE OF BURIAL
FEB. 3
, 1925
ADDRESS
CAMB .
->24— 50.000
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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.
RM R-301
co
z
3 S^x
OFFICE OF THE SECRETARY
DIVISION OF VITAL STATISTICS
I PLACE OF DEATH
County
QJIjp (Eommumrrpalth of fHaaflarbnaptts
STANDARD CERTIFICATE OF DEATH
City or Town
2 FULL NAME.
(City or to\j
Registered No..
^St.,_
.Ward
(If death occurred in a hospital or institution, give its NAME instead of street and number)
(a) Residence.
(Usual place ot abode)
Length of residence in city nr town where death occurred
v
years
V
months
(If in the Army or Navy of the United States, give rank, organization, etc.)
_St., Ward.
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
4. COLOR OR RACE
SINGLE, MARRIED, WIDOWED, OR
DIVORCED (write the word)
5a If married, widowed or divorced
HUSBAND of
(or) WIFE of -
6 AGE
V
Years
Months
Days
If LESS than
1 day, hrs.
or min.
If STILLBORN, enter that fact hare
7 OCCUPATION OF DECEASED
(a) Trade, profession, or
particular kind of work
(b) Name of employer
8 BIRTHPLACE (City)
(State or country)
9 NAME OF
FATHER
lO BIRTHPLAC
FATHER (City)
(State or country)
11 MAIDEN NAM
OF MOTHE- '
9- ^
12 BIRTHPLACE OF
MOTHER (City)
(State or country)
13
Informant-
(Address)
14
Filed k J. I i > 3
(Month) (Day) (Year)
Registrar
MEDICAL CERTIFICATE OF DEATH
IS DATE OF DEATH.
J?
(Month)
(Day)
(Year)
16
I HEREBY CERTIFY, That I attended deceased from
1 19^~ , to -hU, =2 igL'S~ ,
that I last saw h.
alive on .
■Q-l/q
11
and that death occurred, on the date stated above, at
The CAUSE OF DEATH was as follows:
£D~e~*<L, J)
, 19gJ>_,
A m.
A
(TVv-v
(duration)
5. -J. ds.
CONTRIBUTORY.
(secondary)
(duration)
-yrs._
ds
17 Where was disease contracted
if not at place of death?
Did an operation precede death?.
Was there an autopsy?
.Date of-
Whattest confirmed diagnosis
(Signed) ^ <J
(Address) ' A
Data
nJL ( oAn
18 PUCE Of BURIAL CREMATION OR REMOVAL
(Cemetery)
JlSUu&&*r/
(City or tovVn)
19 UNDERTAKER
DATE OF BURIAL
ADDRESS
20 I HEREBY CERIIFY tint I satisfactory stan-
dard certificate of death was filed with me
BEFORE the burial a transit permit was issued
JT
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issue £
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OFFICE OF THE SECRETARY
DIVISION OF VITAL STATISTICS
1 PLACE OF DEATH
County
City or Town
OH?* (Eommomupaltti of Utaoaarfyu grits
STANDARD CERTIFICATE OF DEATH
(City or town)
State . Registered No*
No. k.\ St., Ward
(If death 'occurred in a hospital or institution, give its name instead of street and number)
2 FULL NAME
(a) Residence. No.
(Usual place of abosle)
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
'.!f/WI/bL
4 COLOR OR RACE
fljJ -/>
5 SINGLE, MARRIED, WIDOWED, OR
i DIVORCED t write the word)
5a. If married, widowed, or divorced
HUSBAND of
<”)WIF£°t /rWs^Z/
MEDICAL CERTIFICATE t>F DEATH
15 DATE OF DEATH
JL
(Month)
hi
(Day)
JJ-
(Yearj
16
6 AGE
Years
yo
Months
Days
If LESS than
1 day, hrs.
or min.
If STILLBORN, enter that Fact here
. I HEREBY CERTIFY, That I attended deceased from
iMheCe*. A...#. .19 ^ , to ,f?. ,19 A t
'that I last saw h..^Tjr.... alive on ^ ... 19
and that death occurred, on the date stated above, at..
The^*CAUSE OF DEATH w|ls as follows : / / ^
Gdik j //^jy
7 OCCUPATION OF DECEASED /}>-
(a) Trade, profession, or t A)L7j j Y n - j.
particular kind of work y / ..
(b) Name of employer
8 BIRTHPLACE (City)
(State or country
.'CZW
<o
9 NAME OF
FATHER
10 BIRTHPLACE OF
FATHER (CitV)
(State or country)
11 MAIDEN NAME/?
OF MOTHER /s
/vwAjI i/td . (
12 BIRTHPLACE OF
MOTHER (City)
(State or country)
Filed
(Month) (Day) (Year)
/
Registrar
(duration)
'yrs.. mos.
CONTRIBUTORY1
(secondary)
(duration) yrs.
17 Where was disease contracted
if not at place of death?..
ds.
Did an operation precede death?
Was there an autopsy?...
What test confirmed /diagnosis ?
(Signed)
(Address)' JL C/~~*cS
Dale Jrrrrr.. $
(Month)
18 PLACE OF BURIAL, CREMATION, OR REMOVAL
- . y\jrX^J
(yeinetjiryj (City or town)
(Day)
19 UNDERTAKER
A
20 I HEREBY CERTIFY that a satisfactory stan-
dard crrtiheale of death was hied with me
BEFORE the banal or transit permit was issued
■ J-L,
> V / u dhl
Official
position
gLL
Date of / . / Permit _ / /
Ujmjl, SUt Uk/XS s-t*J
/ /
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®ljp <2Imnm0ttuu>alttf of iMaaoarljuaptta
STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH
Lynn
(City or town)
Registered No. 1.64
(Place of death)
County ESSfiX State Ma.S.S.. Registered No.
(Place of residence)
City or Town JiX.fl.li No. ....Lfl.3,.On. ...Lo SP i t ell St., Ward
(If death occurred in a hospital or institution, give its name instead of street and number)
2 full name ..Gertrude W, Mer r i l l
(If in the Army or Navy of the United States, give rank, organization, etc.)
(a) Residence. State MS.S.S.* City or Town....^?.i..U.t jjr.Q.P No. 78. Centre St.
(Usual place of abode)
Length of residence m city or town where death occnrred years months XU days. 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
W
5 SINGLE, HARRIED, WIDOWED, OR
DIVORCED ( write the word)
is date of death February 6, 1935
(Month) (Day) (Year)
Divorced
5a If married, widowed, or divorced
HUSBAND of _ , , ,,
(or) wife of Scott Merrill
6 AGE Years
Months
Days
K LESS than
1 day, hrs.
58
5
or min.
If STILLBORN, enter tint fad here
16
I HEREBY CERTIFY, That I attended deceased from
Jan,. 8 ,isS.d to Feb. 6 19...35..
that I last saw h Q.T.. alive on F..Q.TD.<. 8 19 3.0. ,
and that death occurred, on the date stated above, at..Vr?...». 30.....P.*.
The CAUSE OF DEATH was at follows:
General Par.alys.i.s
7 OCCUPATION OF DECEASED
S.o.b.Q.o.1 teacher.
(b) Name of employer
8 BIRTHPLACE (city or town).
(State or country)
(duration) yrs. 3 mos do.
Mass
9 NAME OF
father Alexander ,t7ebber
CONTRIBUTORY
(secondary)
(duration) yrs.
ds.
10 BIRTHPLACE OF
FATHF.R (citv or town} OnciT^XGXSn *
(State or country)
Me.
11 MAIDEN NAME
OF MOTHER
Nancy P. Allen
17 Where was disease contracted
if not at place of death ?
12 BIRTHPLACE OF Qhunloi jh
MOTHER (city or town) Xg lglij
(State or country) Me . 0u
Did an operation precede death 7 Date of
Wm there an autopsy?.
What test confirmed diagnosis?
(si**d) Geo, C. Par oher
^/2t>9 (Addw) Sa fflL3 , Mass.
I.D.
Weber
18 PLACE OF BURIAL. CREHATION, OR REMOVAL
'vinthrop, Mass.
DATE OF BURIAL
Feb.S, 19 25
Fa.d Mar .
Filed)V\J,V ! % .19*
rar of dty or town
Krrntnr of city or town where deceased resided
>9 UNDERTAKER
Jas. M. Blaisdell S
ADDRESS
on Lynn
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Fvery item of information should bo carefully supplied. AGE should be stated EXACTLY. PHYSICICMS should state
CRUSE 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.
i PLACE OF DEATH
County .-Suff olk.......
Township .uS±n_thr.ap*
Department of Commerce
BUREAU OF THE CENSUS
Village
STANDARD CERTIFICATE OF DEATH
Massachusetts .
Registered No.
State of.
or T?n-r»-l- 3 v-iV [If death occurred In
city — ;UCK2
of street and number.]
2 FULL NAME Jt.Qui.s9..Ferr_ant •_
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
Female.
4 COLOR OR RACE
White.
5 SINGLE,
MARRIED,
WIDOWED,
?'Y?RCE£ Mar r i e d <
( Write the word)
6 DATE OF BIRTH
3_e_pt.e_m.bar_ _6th, 1.85.8..
(Month) (Day) (Year)
7 AGE
2.6....
yrs.
..5.
s. 2— ds.
If LESS than
1 dev, hrs.
or min. 7
8 OCCUPATION
(a) Trade, profession, or TT . _
particular kind of work
(b) General nature of Industry,
business, or establishment In
which employed (or employer) ._
9 BIRTHPLACE
(State or country)
Germany
10 NAME OF
FATHER
Joseph Rebhan,
11 BIRTHPLACE
OF FATHER
(State or country)
Germany.
12 MAIDEN NAME
OF MOTHER
Unknown.
13 BIRTHPLACE
OF MOTHER
(State or country)
Germany.
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant) CpL._..J__Qja eph. .F: er r aii_t_
(Address) Fog-t. 5knks.,..l;.asjajL
15
Filed .
-. — , 1 9 p. .y: —
Registrar
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
17
I HEREBY CERTIFY, i hat I attended deceased from
..?e^arx_8th, 19i£5, t0 .£ebruary...8.t^i9i.^
that I last saw h.Qr. alive on -F-ei).rJJ4i.r-y-8-"bh— > 191-2-5
and that death occurred, on the date stated above, at7*X>„?m.
The CAUSE OF DEATH* was as follows:
...Shock and, hemorrhage from ruptured
...eat op i.a . . pr agnanay ..
oiHouus .
(Duration) yrs.
contributory- Sc-tQpija.-P-r-agna&G®^
(Secondary) ^
-J-- (Duration) yrs. !L mos. ds.
(Signed! ^ajor, M. D.
, 19(25 (Address) ..Ft.? Si^Llk&-,-._Li£tS-S-«---
* State the Disease Causing Death, or, in deaths from Violent Causes, state
(1) Means or Injuey ; and (2) whether Accidental, Suicidal, or Homicidal.
18 LENGTH OF RESIDENCE (For Hospitals, Institutions, Transients,
or Recent Residents)
At place -1 a pi In the a 0
death rtr. yrs. .!?. mos. .w.-i-.ds. State A. yrs. ...ifc-- mos. .Aa-JL ds.
of oeatn yrs
Where was disease contracted,
If not at place of death ?
Former or — , ,, _
usual residence.— JO-OiC-t ii.CXQ.Yen.S^...Gj9.A
19 PLACE OF BURIAL OR REMOVAL
-H-
'&1/L
y
* :
20 IjNDERTAKER
■ • *
DATE OF BURIAL
..sL/M- . 1 a&a"
11—3184
ADDRESS
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WRITE PLAINLY, WITH UNFADING BLACK 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 and extracts from the laws on back of certificate. f\
)RM R-301
(dmnmumnealth of mJaBaarfyuartta
I
m
• 23 100.000
5a If married, widowed or divorced , r-,
HUSPAK&Tjf^— -r ^7 / \V (I A
(or) WIFE of T fUL-CXjUlXcJjZ, V W
tXjuLOJtJi
6 AGE Years
n
Months
/
Days
/ 3
If LESS then
1 day, hrs.
or min.
OFFICE OF THE SECRETARY
DIVISION OF VITAL STATISTICS
1 PLACE OF DEATH
County Pv
STANDARD CERTIFICATE OF DEATH
: olJe. Sta ClAjA) »
City orTown_
JJL
No
. <2 /, /
(City or town) |
.Registered No.
.Ward
2 FULL NAME.
(If deattvoCcprred in a hospital pr institution, give its NAME instead of street and number)
CUXL I /CiLAylXClA^/
A / 1
(Usual place of abode) j
Length of residence in city or town where death occurred years L >
(a) Residence. No..
(If in the Army or Navy of the United States, give rank, organization, etc.)
St.r Ward
months
days.
(If non-resident give city or town and state)
How long in U. $., if of foreign birth? years months days
PERSONAL AND STATISTICAL PARTICULARS
4 COLOR OR RACE
5 SINGLE, MARRIED. WIDOWED, OR
If STILLBORN, enter that fact here
7 OCCUPATION OF DECEASED
(a) Trade, profession, or
particular kind of work
(b) Name of employer
-3^6-
b-ijuUi -
8 BIRTHPLACE (City)
(State or country)
z£h
lO BIRTHPLACE OF
FATHER (City)
(State or country)
11 MAIDEN NAME
OF MOTHER
^ C-
12 BIRTHPLACE OF
MOTHER (City)
(State or country)
13
(Address) _2£I
('~ C.n^U.ouudf
Informant'
14
ICLA U ~fl
\D X
UH; O
Filed
(Month) (Day) (Year)
Registrar
MEDICAL CERTIFICATE OF DEATH
15 DATE OF DEATH
' (Month)
/ O /
(Day)
(Year)
16
HEREBY CERTIFY, Jhat I attended d
to V-O- u)
|W I n L n L
j
that I last saw h
- 19k£S^r
.alive on j ~ ^ *~
hat I attended deceased from
u~
<£-
_, 19.
. , 19
and that death occurred, on the date stated above, at. JLA
The CAUSE OF DEAi H was as follows:
_m.
(duration)
yrs..
ds.
17 Where was disease contracted
if not at place of death?.
Did an operation precede death?
Was there an autopsy?
What test confirrppd dj. gnosis?
(Signed)
\^<=X
Date of
(Address)
Dele.
3 £ G>
7Tj
' (Month)
(Day)
lA Mr
(Year)
418.PIACE Of BURIAL. MEMATION OR REMOVAL
I V i-
(Cemetery) (City or town)
mRJV iJ
lOOAtLA) U [• {JujjAAA^A
xtrc/M
-t
DATE
fLb
EOF BURIAL
17. _
I 9 2A>
20 I HEREBY CLRIlfV that e satisfactory stM- , / ^
dad certiticate el death ms tiled with me - — 7
ILL ORE the burial ■ transit pam.t was issued
Hr-
Official Y
position
Date of
issue J?
t ol permit VAj.
AiDDRE?
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23 100 000
OFFICE OF THE SECRETARY
DIVISION OF VITAL STATISTICS
©tj* (Eommimmealth nf fflJaaaarljttarttH
1 PLACE OF DEATH 'O
County r\ i V-
jX-fa -
City or Town
VPriX No. £ /,
cxA/o
2 FULL NAME-
TVi
gjx^i
XXJUU (_
(City or town) |
.Registered No.
-rStr,.
.Ward
(If deatfverCcOrred in a hospital br institution, give its NAME instead of street and number)
(a) Residence. No._ £ ; ' lda{ (Ui)
(Usual place of abode) /
U months
Length of residence in city or town where death occulted
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)
days. How long in U. S„ if of foreign birth? years months days
PERSONAL AND STATISTICAL PARTICULARS
4 COLOR OR RACE
5 SINGLE. MARRIED. WIDOWED. OR
0 r\ C (l . DIVORCED (write the word)
oJu
5a If married, widowed or cjjvorced
(or) WIFE of tfULCULA
6 AGE
Years
Months
Days
If LESS then
u
/
/ 3
1 day, hrs.
or min.
If STILLBORN, enter that fact hare
7 OCCUPATION OF DECEASED
(a) Trade, profession, or
particular kind of work
Cxt ^6-
chjlaJL -
(b) Name of employer
8 BIRTHPLACE (City)
(State or country)
^>a /*J .
9 fatherF (yj^o-^a^ ~7 YaXqMx
lO BIRTHPLACE OF 1
FATHER (City) „ /i
(State or country)
11 MAIDEN NAME
OF MOTHER .
HlJxul <Alcc ly&Cz ■
12 BIRTHPLACE OF
MOTHER (City)
(State or country)
Cy cxflc VAxd
13
Informant' JLLk
(Address) f~ )
14
o
±_
Filed
(Month) (Day) (Year)
Registrar
MEDICAL CERTIFICATE OF DEATH
15 DATE OF DEATH
• (Month)
/O /7LjN
(Day)
(Year)
16
x I HERE
HEREBY CERTIFY, .That I attended deceased from
u~
i9kt,to JrxA^XJXL
.alive on /
that I last saw h
and that death occurred, on the date stated above, at iA
The CAUSE OF DEATH was as follows:
19_
., 19lrQ_,
(duration)
17 Where was disease contracted
if not at place of death?.
Did an operation precede death?
Was there an autopsy?
What test confirrppad
(Signed)
-1/4— C3
Date of_
REMATION OR REMOVAL
(Cemetery)
(sWa JCtk:
(City or town)
mXhvo 1) [• (joCc la>u>
DATE of burial
■fLU' /
i 9
20 I HEREBY CERTIFY that e alisfidory stan-
dard certificate pf death was filed with me
BEFORE the burial or transit parm.t was issued
ADDRE
/tw
Official
position.
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