The volume, 1928–1930
Town Clerk, Winthrop · from the Internet Archive · 1294 pages · 116.6 MB
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PHYSICIANS should stato
AGE should be stated EXACTLY. 3
Exact statemont of OCCUPATION is very
item of information should be carefull
properly classified.
be
at
ysup
tific
» SO that it
n plain terms
See instructions on back of certi
OF DEATH
r
CAUS!
important.
1PLACE OF DEATH
County Suffolk
Township __“inthro 42h ae / G $2 ¥,
DEPARTMENT OF COMMERCE
BUREAU OF THE CENSUS
STANDARD CERTIFICATE OF DEATH
State of _.MASSACEUSETTS
or ']
Village Registered No.-----/.). L
ae - . Me nae occurred in
. eti Jospital,.F fanics. Mas a hospital or institution
ste ES I I te (Nomtetion Eospital,Ft Banks, Masme, Ward) Sivo its NAME tnetond
j of street and number. j
PULL SAMS ree reel A ee
PERSCNAL AND STA/SISTICAL PARTICULARS MEDICAL CERTIFICATE OF DEATH
3SEX 4COLOR OR RACE | °SINGLE, 16 DATE OF DEATH
MARRIED, T 7 28
* WAP LIS es avtedia: Liao oe & Stee ooo Bess TTL YoY Jae eta in, ee en 19 £8.
Male White on pvorcen = Angle Afonth) METI
6DATE OF BIRTH oS | HEREBY CERTIFY, That | attended deceased from
oe Unione cS ye ee 7. | December (2), |, 10127,t0. Jamuary* (5, tom
(Month ) (Day) Se (Year) “
7 AGE If LESS than || tat! last saw h.2M. alive on-Janueary....H5 -.., it8 ,
21 1 day,----hrs+ || and that death occurred, on the date stated above, at 1229
aE eae Tigi iy ee ay ay Ser f ; be
PEPSI ATION The CAUSE OF DEATH® was as follows: |
(a) Trade, profession, or Soldier.U.S.Armv Thrombrosis,of richt s matic
particular kind of wk... Soldier, U.S. Army. Hie | gt ae ae a
(b) General nature of industry, Wea Menent. Oner ative. 60°... 6.) Sie) alee en
business, or establishment in :
UCumUIN LOVORAKON SIMPIOVEN ieee ee eat Oh
9 BIRTHPLACE A
(State or aege G: 1lty » Unkn OWN 6
Massachusetts
10 NAME OF
FATHER
Unknown
® | 11 BIRTHPLACE : (Si =
OF FATHER igned) .,_@7 2 Ol €-e << Bie aoe = aoe » M.D,
E (State or country) Uninown he ML ° a eLurner,v apt. tebeVe oe Ariy °
ul = VANUATY 2, 19198 (Address) Fort Banks, Masse
oe | eer “ae * State the D Cc D deaths f
MOTHER 2 tate the Disease Causina DEATH, or, in deaths from VIOLENT CAUSES, stat
a é Unknown (1) Means or Insury; and (2) whether Roceiarerie: Ronee, or Hawranoiin, ae
13 BIRTHPLACE A 18LENGTH OF RESIDENCE (For HospitaALs, INSTITUTIONS, TRANSIENTS,
OF MOTHER Unknown OR RECENT RESIDENTS) 3
(State or country) At place in the
of death ______ Soa mos. ©! ds State ___ Unknown 1lO$e! 2s ds.
14THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE Where was disease contracted) ms nya 9
im Re ire Wace
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informant) + eRecords U.%.Armve Former or a, aol: ee ea
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19
ee foe oe ee 8 Oe PLACE oy. OR ao ee DATE OF BURIAL
is Merwetw Tee | fee . , 19se8!
tw C— 20UNDERTAKER . ADDRESS
Ub 0s Bas ci 2, i ae hae aa a | f2.
{ REGISTRAR wth
113184
ae Vi, } vi {0 / + }
fi the fo’? 4eee
fialt
C Fe ‘. ©
ee ee ee —_— | #4 I
ittfiar>s 11 / 1 BYS
REVISED UNITE
_ [Approved by U. 8. Census and American Public Health Association]
ae
ee Statement of occupation.—Precise statement of occupation
is very important, so that the relative healthfulness of
various pursuits can be known. The question applies to
each and every person, irrespective of age. For many
occupations a single word or term on the first line will be
sufficient, e. g., Farmer or Planier, Physician, Compos-
itor, Architect, Locomotive engineer, Civil engineer, Stationary
fireman, etc. But in many cases, especially in industrial
employments, it is necessary to know (a) the kind of
work and also (b) the nature of the business or industry,
and therefore an additional line is provided for the latter
statement; it should be used only when needed. As
examples: (a) Spinner, (b) Cotton mill; (a) Salesman, (b)
Grocery; (a) Foreman, (b) Automobile factory. The ma-
terial worked on may form part of the second statement.’
Never return ‘‘Laborer,” ‘‘Foreman,’’ *‘Manager,”
“Dealer,” etc., without more precise specification, as
Day laborer, Farm laborer, Laborer—Coal mine, etc.
Women at home, who are engaged in the duties of the
household only (not paid Housekeepers who receive a)
definite salary), may be entered as Housewife, Housework,
or At home, and children, not gainfully employed, as At
school or At home.. Care should be taken to report spe-
cifically the occupations of persons engaged in domestic
service for wages, as#ervant, Cook, Tousemaid, ete. If the
occupation has beent changed or given up on account of
the pISBASE CAUSING DEATH, state occupation at beginning
of illness. Ef retired from business, that fact may be indi-
cated thus: Farmer (retired, 6 yrs.). For persons who
have no occhpation whatever, write None.
Statement of ‘cguse of death.—Name, first, the DISEASE CAUS-
ina pratH (the primary affection with respect to time
and causation), using always the same accepted term for
thesame disease. Examples: Cerebrospinal fever (the only
definite synonym is ‘‘Epidemic cerebrospinal menin-
gitis’’?); Diphtheria (avoid use of “‘Croup’’); Typhoid fever
(never report ‘Typhoid pneumonia”); Lobar pneumonia;
Bronchopneumonia (‘*Pneumonia,”’ unqualified, is indefi-
nite); Tuberculosis of lungs, meninges, peritonaeum, etc., Car-
cinoma, Sarcoma, etc., of ...-.--------- (name origin; “‘Can-
cer’ is less definite; avoid use of ‘‘ Tumor” for malignant
neoplasms); Measles; W. hooping cough; Chronic valvular
heart disease; Chronic interstitial nephritis, etc. The con-
tributory (secondary or intercurrent) affection need not
be stated unless important. Example: Measles (disease
causing death), 29 ds.; Bronchopnewjnonia (secondary),
10 ds. Never report mere symptoms or terminal eondi-
tions, such as ‘t.\sthenia,”’ “‘4naemia’’ (merely symptom-
atic), ‘Atrophy,’ ‘‘Collapse,”’ “Coma,’’ “Convulsions,”
“Debility”’ (‘ Congenital,’’ “Senile,” etc.), “ Dropsy,”
‘‘Exhaustion,”’ ‘Heart failure,’’ “ Haemorrhage,”’ ‘‘ Inani-
tion,” ‘‘Marasmus,”’ “Old age,’”’ ‘‘Shock,”’ “Uraemia,’’
“Weakness,” etc., when a definite disease can be ascer-
tained as the cause. Always qualify all diseases result-
ing from childbirtin or miscarriage, as ‘* PUERPERAL septi-
chaemia,” ‘Purreurat peritonitis,” etc. State cause for
which surgical operation was undertaken., For VIOLENT
DEATHS state MEANS OF INJURY and qualify a3 ACCIDENTAL,
SUICIDAL, OF HOMICIDAL, or as probably such, if impossible
to determine definitely. xamples: Accidental drowning;
Struck by railway train—accident; Revolver wound of head—
homicide; Poisoned by carbolic acid—probably suicide. The
nature of the injury, as fracture of skull, and consequences
(e. g., sepsis, tetanus) may be stated under the head of
“Contributory.’’? (Reconimendations on’ statement of
cause of death approved by Committee on Nomenclature
of the American Medical Association. )
Nore.—Individual offices may add to above list of undesirable terms and
refuse to accept certificates containing them. Thus the form in use in New
York City states: ‘Certificates will be returned for additional information
which give any of the following diseases, without explanation, as the sole
cause of death: Abortion, cellulitis, childbirth, conyuls:ons, haemorrhage,
gangrene, gastritis, erysipelas, meningitis, miscarriage, necrosis, peritonitis,
phlebitis, pyaemia, septichaomia, tetanus.” But general adoption of the
minimum list suggested will work vast improvement, and its scope can be
extended at a later date.
11—3184
+3
EVOL Y PRtle WF TEP UNE Pe bea une
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
“IN. DB. WALT C PLAINLY, WIth UINFAUIING DLAUIN TININ TPO FO FAP EENIVIFLIN EINE ENE IN
instructions and extracts from the laws on back of certificate.
00,000
ee——E———— SS es Pe
t
wo
¢
OFFICE OF THE SECRETARY The Commonmealth of Massachusetts -
DIVISION OF VITAL STATISTICS aka Thay) Wye OF DEATH mS 85
1 PLACE OF DEATH BEY: {City or town) 5
County. State Massachusetts Registered No. |
meyemnitun. sce eee ee SS ed Boston 167 “revente Qye St., Ward
ne d ath Jb} in a hospital or institution, give its NAME instead of street and number)
2 FULL NAM
(If in the Army or Navy of the United States, give rank, organization, etc.)
(a) Residence. No. Que. ee, Ward.
(Usual place of abo (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
MEDICAL CERTIFICATE OF DEATH
4 COLOR OR RACE 5 SINGLE, MARRIED, WIDOWED, OR ~ 47
DIVORCED (write the word) 15 DATE OF DEATH pe St (02
Us e ( Month). (Day) (Year)
I HEREBY CERTIFY, That | attended deceased irexn
yA. ib , 19d, Ce 1925,
4hat | last saw h_=~ __alive qiaks I> 2 ee pote 2
and that death occurred, on the date stated above, at AO On,
The CAUSE OF DEATH was as follows:
ne tate et fack fees Ons ei ee Nh we he
(duration) wt _yrs. mos. ds.
& BIRTHPLACE (City) J ] CONTRIBUTORY 244i 92 ee ae eyo
ti t (SECONDARY) , f He Se
Retain ecuritry) (duration) yrs. mos. ds
4 17 Where was disease contracted | ae
SHH OD dda, Lath nnn | Meee oe ee ee
’ 1,
EI NAS ea aes £0 2,
: er a
10 BIRTHPLACE OF « , + ah Ht, Did an operation precede death i=. Date of
FATHER (City) Seamed Lieto eA doth A Me LO
-~ Was there an autopsy?
(State or country) psy
PARENTS
\
- fir d di 7? ee PP .
71. MAIDEN NAM / : a a What test con irmes i ii —
OF MOTHER aa ey m- oO " J (Signed) j if : yl. Oru je EBS
12 BIRTHPLACE OF Sa AT At Address ie tA? eon 2
MOTHER (City) _})4 CL KA Ko a 4 ve o~
Dati } A - 2
(State or'country) wD f,___ (Month) (Day) (Year) __
REE 18 PLACE OF BOR CREMATION OR REMOVAL — DATE OF BURIAL
AA al,
CSc slates le er JO Mh Pees
HAKPG ENS (Cemetery) (City ort or — ) , 19 x
14 19 UNDERTAKER ADDRESS |
Filed.) Lit &/ 74 y 9 : ( | wl
{fMonth) (Day) (Year) BESaIpsr “O\- ATO fa ote tT ey Mad 6
ZO | Hey CERTIFY that a satisfactory stan- ) / \ ff 7 5
certificate of death was filed with me ~ Ve.
SETORE te bers tons pce a WY? AN! | AG AAL KK
Permit
na_ZLi7 AT
REVISED UNITED ‘STATES STANDARD CERTIFICATE OF DEATH
(Approved by U. S. Census and American Public Health Association)
Statement of occupation.—Precise statement of occupation is
very important, so that the relative healthfulness of various pursuits
can be known. The question applies to each and every person, irre-
spective of age. For many occupations a single word or term on the
first line will be sufficient, e. g., Farmer or Planter, Physician, Com-
positor, Architect, Locomotive engineer, Civil engineer, Stationary fire-
man, etc. But in many cases, especially in industrial employments,
it is necessary to know (a) the kind of work and also (b) the nature of
the business or industry, and therefore an additional line is provided
for the latter statement; it should be used only when needed. As
examples: (a) Spinner, (b) Cotton mill; (a) Salesman, (b) Grocery;
(a) Foreman, (b) Automobile factory. The material worked on may
form part of the second statement. Never return “Laborer,” ‘‘Fore-
man,” ‘Manager,’ ‘‘Dealer,”’ etc., without more precise specification,
as Day laborer, Farm laborer, Laborer—Coal mine, etc. Women at
home, who are engaged in the duties of the household only (not paid
Housekeepers who receive a definite salary), may be entered as House-
wife, Housework, or At home, and children, not gainfully employed, as
At school or At home. Care should be taken to report specifically the
occupations of persons engaged in domestic service for wages, as
Servant, Cook, Housemaid, etc. If the occupation has been changed
or given up on account of the DISHASD CAUSING DDATH, state occupa-
tion at beginning of illness. If retired from business, that fact may
be indicated thus: Farmer (retired, 6 yrs.). For persons who have
no occupation whatever, write None.
Statement of cause of death.—Name, first, the D1ismASH CAUSING
ppatH (the primary affection with respect to time and causation),
using always the same accepted term for the same disease. Exam-
ples: Cerebrospinal fever (the only definite synonym is ‘‘Epidemic
cerebrospinal meningitis’); Diphtheria (avoid use of ‘“Croup’’);
Typhoid fever (never report ‘‘Typhoid pneumonia’); Lobar pneu-
monia; Bronchopneumonia (‘‘Pneumonia,” unqualified, is indefinite) ;
Tuberculosis of lungs, meninges, peritoneum, etc., Carcinoma, Sarcoma,
Bree Gl pak cunecew try (name origin; ‘‘Cancer”’ is less definite; avoid use
of ‘‘Tumor” for malignant neoplasms); Measles; Whooping cough;
Chronic valvular heart disease; Chronic interstitial nephritis, etc. The
contributory (secondary or intercurrent) affection need not be stated
unless important. Example: Measles (disease causing death),
29 ds.; Bronchopneumonia (secondary), 10 ds. Never report mere
symptoms or terminal conditions, such as ‘‘Asthenia,” “‘Anemia”’
(merely symptomatic), ‘‘Atrophy,” “Collapse,” ‘‘Coma,” ‘‘Convul-
sions,” ‘‘Debility’”’ (‘‘Congenital,”’ ‘‘Senile,’’ etc.), “‘Dropsy,’’ ‘‘Ex-
haustion,” ‘‘Heart failure,’ ‘‘Hemorrhage," “‘Inanition,’’ ‘‘Maras-
mus,”’ ‘Old age,” ‘“‘Shock,’’ ‘‘Uremia,”, ‘‘Weakness,” etc., when a
definite disease can be ascertained as the cause. Always qualify all
diseases resulting from childbirth or miscarriage, as ‘‘PUbRPPRAL
septicemia,” ‘“‘PUERPERAL peritonitis,”’ ete.
State cause for which surgical operation was undertaken.
(Recommendations on statement of cause of death approved by Com-
mittee on Nomenclature of the American Medical Association.)
Bronchopneumonia: If primary cause, write the word
‘‘primary’’; if secondary, give primary cause.
Certificates will be returned for additional information
which give any of the following diseases, without explanation,
as the sole cause of death: Abortion, cellulitis, childbirth,
convulsions, hemorrhage, gangrene, gastritis, erysipelas,
meningitis, miscarriage, necrosis, peritonitis, phlebitis,
pyemia, septicemia, tetanus.
EXTRACTS
FROM THE LAWS OF THE
COMMONWEALTH OF MASSACHUSETTS
GOVERNING THE
RETURN OF CERTIFICATES OF DEATH
A physician or registered hospital medical officer shall forth-
with, 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 registra-
tion a standard certificate of death, stating to the best of his knowl-
edge and belief the name of the deceased, his supposed age, the disease
of which he died, defined as required by section one, 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. ...—Gen. Laws, Chap.
46, Sec. 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 con-
taining the facts required by law to be returned and recorded,
which shall be accompanied, in case of an original interment, by a
satisfactory certificate of the attending physician, if any, as required
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 pur-
pose, or is insufficient, a physician who is a member of the
board of health, or employed 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 registration 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 re-
quire —Gen. 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.—Gen. Laws, Chap. 38, Sec. 6.
_..He shall in all cases certify to the town clerk or registrar in the
place where the deceased died his name and residence, if known;
otherwise a description as full as may be, with the cause and manner
of death.—Gen. 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 uure-
lated to any form of injury, have died without recent medical at-
tendance 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 injury or infection related to occupation, the
sudden deaths of persons not disabled by recognized disease,
and those of persons found dead.
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH
ya an
(Place of residence’
St.2 Ward
State Registered No.
*
2 FULL NAME
(If i e Army orgNavy of the United States, give rank, opfanizatj etc.)
(a) Residence. State City or Town 0. 30 tt.
(Usual place of abode)
Length of residence in city or town where death occurred years months a days. How long in U. S., if of foreign birth? years months dayz
PERSONAL AND STATISTICAL PARTICULARS MEDICAL CERTIFICATE OF DEATH
15 DATE OF DEATH s :
3 SEX 4 COLOR OR RACE 5 SINGLE, MARRIED, WIDOWED, OR
x DIVORCED (write the word).
16 I EREBY
5a If scvapeatat ia le divorced 2 p, i V4 (]
Name of } (tr) WIFE Gr Gabe 3 a -
{7 4
If LESS that that Kast saw h_&2**slive o
1day,....hrs. and that death occurred, on the stated above, a‘ ‘ Fi aL, B.
Ae - min. The CAUSE OF DEATH was as follows: (State fully)
If STILLBORN. enter that fact here Z : ==
ee
le, profession, or
particular kind of work
(b) Name of employer
6 AGE iz G Years Months Days
ds.
CONTRIBUTORY
(SECONDARY)
8 BIRTHPLACE (city or town)
(State or country) 17 Where was disease contracted
9 NAME OF if not at place of deat
eee ifr ae Did an operation precede death / 77 Ror what fe tie Reb ae
10 BIRTHPLACE OF
FATHER (city or town)
(State or country) ‘SY EPS:
11 MAIDEN NAME
OF MOTHER
12 BIRTHPLACE OF
MOTHER (city or iad ie Ce 2 ey aap
(State or country)
E OF BURIAL
Informant
(Address)
9 2
“4 [
Filea 7 Ct. 19 UNDERTAKER ADDRESS
hk wae 16 wrk : CH Ce. ey ae bs Uf relae
(duration)__yrs. mos. ds.
Date of operation
s there an eye 2
What test confirmegMiagnosis CO
(Signed) —_—“~>-2BAe A Chg y 7a? OM. =
(Addves) OZ) V3 4 LZ
PL
Date ws ° 2. “GE. 74 aae
PY BURIAL, CREMATION,
PARENTS
fully 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.
No. 4812
ie
D
ray
°
a ee ee ae a
plied. AGE should be stated EXACTLY. PHYSICIANS should state CAUSE OF DEATH in plain terms, so that it may be properly classified"
See instructions and extracts from the laws on back of certificate.
Exact statement of OCCUPATION is very important.
200,000. 9-26. NO. 6373 —
OFFICE OF THE SECRETARY Che Commonmealth of Massachusetts
DIVISION OF VITAL STATISTICS Va) ANDARD CERTIFICATE OF DEATH
f
1PLACE OF DEATH f
County____ AA a4 fe th State
City or Town WS WpAAMVit A Sa No.
i Ly , (lf death occurred in a hospital
2FULL NAME_g’ fee SAS
/ BY, (if U. S. War Veteran, specify WAR)
a) Residence? Noa Vrre til ah a LL- St, Ward, a t
(Usual place of abode) (lf non-resident give city or town and state)
Length of residence in city or town where death occyfyed years months days. How long in U. S., if of foreign birth? years months days.
PERSONAL AND STATISTICAL PARTICULARS MEDICAL CERTIFICATE OF DEATH
15 oreo opal G i eee
" (Month) (Day) (Year)
i6 | HEREBY CE 1 F Y , That! attended deceased from
ES: Pe ae 192d to 6 pA go
that | last saw h__Zesasalive on
and that death occurred, on the daté.stated above, a = TY a m.
The CAUSE OF DEATH was as follows: (State fully)
fo32 LEE = ere oF
3 SEX 4 COLOR QR RACE | 5 SINGLE, MARRIED, WIDOWED, OR
; : | NMjde (write the word)
[J é f
5a If married, widowed or divorced iD
HUSBAND of ot Etta
(or) WIFE of
6 AGE Years | Months | Days | IF LESS than
| | | 1 day,........Ars.
{0 | / a ood f | On Sac min.
IF STILLBORN, enter that fact here
T OCCUPATION OF DECEASED
(a) Trade, profession, or
particular kind of work
(b) Name of employer,
CRO Se MW i NPR 9 Ts, = = mos. 7 ds.
EE ERE, Seer ey NPD age re
(Secon ary) Yanda)
a ebeonr, (du
17 Where was disease contracted
if not at place of death
& BIRTHPLACE (City)
(State orcountry)
SS ey
9 NAME OF
Z
FATHER Did an operation precede death_<-€® __For what nd
7] 1O BIRTHPLACE OF Date of operation Fee al & ‘
: FATHER (City) ¥
a ZO
z (State or country) Was there an autopsy ee - =
7 11 MAIDEN NA What test confirmed diagnosis Cit Pet TE ee
OF MOTHER
. "War cine) (Oreeli, Se. Lewtden La wi. M.D.
1 2 BIRTHPLACE OF > (2-3 of Miisg,
MOTHER ¢City). A _-- (Address). a 7
(State or country) Z Y 4 A> Date / 2, a LP ZL a wp f tite 4ea- J
Fa
13 " 3 8 PLACE OF BU AL, CREMATION, OR REMOVAL, | DATE rs Syl
Informant | AYY/LWw ALM {4 _. NTX VE a7. = 3
19 UNDERTAKER } 2
famk © Yprcn
y Date of
ies positc lL LA Af fee 2 Fee Li, —— fy,
eee — re
20 | HEREBY CERTIFY that a satisfactory stan-
dard certificate of death was filed with me
BEFORE the burial or transit permit was issued
ITEDSTATESSTANDARD CERTIFICATE OF DEATH
(Approved by U. S. Census and Arherican Public Health Association)
Statement of occupation.—Precise statement of occupation is
very important, so that the relative healthfulness of various pursuits
ean be known. The question applies to each and every person, irre-
spective of age. For many occupations a single word or term on the
first line will be sufficient, e. g., Farmer or Planter, Physician, Com-
positor, Architect, Locomotive engincer, Civil engineer, Stationary fire-
man, ete. But in many cases, especially in industrial employments,
it is necessary to know (a) the kind of work and also (b) the nature of
the business or industry, and therefore an additional line is provided
for the latter statement; it should be used only when needed. As
examples: (a) Spinner, (b) Cotton mill; (a) Salesman, (b) Grocery;
(a) Foreman, (b) Automobile factory. The material worked on may
form part of the second statement. Never return “Laborer,” ‘‘Fore-
man,” 'Manager,”’ ‘‘Dealer,” etc., without more precise specification,
as Day laborer, Farm laborer, Laborer—Coal mine, etc. Women at
home, who are engaged in the duties of the household ony (not paid
Housekeepers who receive a definite salary), may be entered as House-
wife, Housework, or At home, and children, not gainfully employed, as
‘At school or At home. Care should be taken to report specificaily the
oceupations of persons engaged in domestic service for wages, as
Servant, Cook, Housemaid, ete. If the occupation has been changed
or given up on account of the DISEASE CAUSING DRATH, state occupa-
tion at beginning of illness. If retired from business, that fact may
be indicated thus: Farmer (retired, 6 yrs.). For persons who have
no oceupation whatever, write None.
Statement of cause of death.—Name, first, the Disease Causing
Death (the primary affection with respect to time and causation),
using always the same accepted term for the same disease, Ixam-
ples: Cerebrospinal fever (the only definite synonym is “Epidemic
cerebrospinal meningitis’); Diphtheria (avoid use of “Croup”);
Typhoid fever (never report “Typhoid pneumonia’); Lobar pneu-
monia; Bronchopneumonia (“Pneumonia,” unqualified, is indefinite) ;
Tuberculosis of lungs, meninges, peritoneum, etc., Carcinoma, Sarcoma,
BEOs ee Lecueee tis ocche--s (name origin; ‘‘Cancer’”’ is less definite; avoid use
of “Tumor” for malignant neoplasms); Measles; Whooping cough;
Chronic valvular heart disease; Chronic interstitial nephritis, ete. The
contributory (secondary or intercurrent) affection need not be stated
unless important. Example: Measles (disease causing death), 29 ds.;
Bronchopnewmonia (secondary), 10 ds. Never report mere symptoms
or terminal conditions, such as ‘‘Asthenia,” “Anemia” (merely symp-
tomatic), ‘Atrophy,’ “‘Collapse,”’ “Coma,” “Convulsions,” ‘Debility”’
(‘‘Congenital,”” ‘‘Senile,’’ ete.), “Dropsy,” ‘Exhaustion,’ “Heart
failure,’ “Hemorrhage,” “Tnanition,”’ ‘Marasmus,”’ ‘Old age,”
“Shock,’’ ‘Uremia,” ‘Weakness,’ etc., when a definite disease
can be ascertained as the cause.
from childbirth or miscarriage, as “PUERPERAL septicemia,
peritonitis,” ete.
Always qualify all diseases resulting
’“ PUDBRPERAL
State cause for which surgical operation was undertaken.
(Recommendations on statement of cause of death approved by Com-
mittee on Nomenclature of the American Medical Association.)
Bronchopneumonia: If primary cause, write the word
‘‘primary’’; if secondary, givo primary cause.
Certificates will be returned for additional information
which give any of the following diseases, without explanation,
ag the sole causo of death: Abortion, cellulitis, childbirth,
convulsions, hemorrhage, gangrene, gastritis, erysipelas, menin-
gitis, miscarriago, necrosis, peritonitis, phlebitis, pyemia,
sopticemia, tetanus,
EXTRACTS
FROM THE LAWS OF THE
COMMONWEALTH OF MASSACHUSETTS
GOVERNING THE
RETURN OF CERTIFICATES OF DEATH
A physician or registered hospital medical officer shall forth-
with, 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 registra-
tion a standard certificate of death, stating to the best of his knowl-
edge and belief the name of the deceased, his supposed age, the disease
of which he died, defined as required by section one, 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.....den. Laws, Chap. 46,
Sec. 9.
No undertaker or other person shall bury or otherwise dispose of a
human body in a town, or remove therefrom a human body which has
not been buried, until he has received a permit from the board of
health or its agent appointed to issue such permits, or if there is no
such board, from the clerk of the town where the person died; and no
undertaker or other person shall exhume a human body and remove
it from a town, or from one cemetery to another, until he has received
a permit from the board of health or its agent aforesaid or from the
clerk of the town where the body is buried. No such permit shall be
issued until there shall have been delivered to such board, agent or
clerk, as the case may be, a satisfactory written statement containing
the facts required by law to be returned and recorded, which shall be
accompanied, in case of an original interment, by a satisfactory certi-
ficate of the attending physician, if any, a3 required by law, or in lieu
thereof certificate as hereinafter provided. If there is no attending
physician, or if, for sufficient reasons, his certificate cannot be ob-
tained early enough for the purpose, or is insufficient, a physician
who is a member of the board of health, or employed 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. If the death certi-
ficate contains a recital, as required by section ten of chapter forty-six,
that the deceased served in the army, navy or marine corps of the
United States in any war in which it has been engaged, such recital
shall appear upon the permit. The board of health or its agent,
upon receipt of such statement and certificate, shall forthwith counter-
sign it and transmit it to the clerk of the town for registration. ‘The
person to whom the permit is’ so given and the physician certifying
the cause of death shall thereafter furnish for registration 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.—Chap, 114, Sec. 45, G. L., as amended,
Medical examiners shall make examination upon the view of the
dead bodies of only such persons as are supposed to have died by
violence.—Gen. Laws, Chap. 38, Sec. 6.
He shall in all cases certify to the town clerk or registrar in the
place where the deceased died his name and residenee, if known;
otherwise a deseription as full as may be, with the cause and manner
of death —Gen. Laws, Chap. 28, Sec. 7.
No undertaker or other person shall bury a human body or the
ashes thereof which have been brought into the commonwealth until
he has received a permit so to do from the board of health or its agent
appointed to issue such permits, or if there is no such board, from the
clerk of the town where the body is to be buried or the funeral is to
be held, or from a person appointed to have the care of the cemetery
or burial ground in which the interment is made.—Chap. 114, Sec. 46,
G, L., as amended.
nu
®
é Wir Le of
OFFICE GF THE SECRETARY Che Gomuonmealih of Massachusetis
Rg
S| bvisiod OF viTaL stanistics STANDARD CERTIFICATE OF DEATH
oO
z}i1PLACE OF DEATH (City or town)
g Smyrna t= eG ee Ser Holk State______ Massachusetts Registered Set tee
$ City or Town GAS vid |
= irred in a hospital or institution, give its NAME instead of street and number)
N
2FULL NAME__ )
(if U. S. War Veteran, specify WAR)
a) Residence. ANE ee ee s
(Usual place of abode) S (If non-resident give city or town and state)
Length of residence in city or town where death occurre years months days. How long in U. S., if of foreign birth? years months
PERSONAL AND STATISTICAL PARTICULARS MEDICAL CERTIFICATE OF DEATH i
SEX 4 COLOR QAHRACE {<-5 SINGLE, MARRIED, WIDOWED, OR “
‘ DIVORCED (wute the word) 15 DATE OF DEATH AA : 4 fj $2
(Month) (Day) (Year)
ale if i anne 16 yi HER
Vi c ERTI That | attended deceased from
5a if pao, wiaeued or divorced vA 19 24
AND oc ,
os ; zs Lg
— taat | last saw h_=S== alive on = ae [Qs
6 AGE Years IF LESS than |
stated above, at_
s: (State fully)
|
and that death occurred, on ihe
| 1 daYronw-RIS. The CAUSE OF DEATH was as f
62 |
IF STILLBORN, enter that fact here
T OCCUPAT:ON OF DECEASED
(a) Trade, profession, or
particular ind of work
u
(b) Name of empicyer WME Ty rie moss ds
= CONTRIBUTORY Es ari - =
i @ _ A3a were
& BIRTHPLACE (City) pret 3 cei hal we, (duration). yrs. mos. ds.
See instructions and extracts from the laws on back of certificate.
17 Where was disease contracted
if not at place of death =
(State or country)
2 RATHER Did an operation precede death For what_ J
10 BIRTHPLACE OF Date of operation Se Pe A
FATHER (City)
Was there an autopsy = see
f under ons year, was Infant Breast Fed 2oo.c....ccccc..ccceccscscscsccsssccsscscseesessseseese
ae test confirmed diagnosi
(State or country)
11 MAIDEN NAME
OF MOTHER CLL
12 BIRTHPLACE OF
MOTHER (City)
Guns or Econety)
M.D.
PARENTS
(Signed)
Be dE : 5
CREMATION, DATE OF BURIAL
LY flten jG
plied. 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.
oy 0 town)
| ADDRESS
REGISTRAR Be bat te me Clark
20 BUEREBY CERTIFY that a satisfactory stan y/ = Wi ‘4 ne
° ard certificate of death was filed with me SA / ci / ermi
BEFORE the burial or transit permit was issued = Chdlddttae Se tof permit ag Ret L3S 2
4S
oe ae m 4
(Address) es hea "i
N. B.—WRITE PLAINLY, WITH UNFADING BLACK INK—THIS IS A PERMANENT RECORD. Every item of information should be carefully sup- —
:
S
=
“Ls | - hah ko a
REVISED UNEPED STATESSTANDARD CERTIFICATE OF DEATH
(Approved by U. S. Census and American Public Health Association)
Statement of occupation.—Precise statement of occupation is
yery important, so that the relative healthfulness of various pursuits
can be known. The question applies to each and every person, irre-
spective of age. For many occupations a single word or term on the
first line will be sufficient, e. g., Farmer or Planter, Physician, Com-
positor, Architect, Locomotive engineer, Civil engineer, Stationary fire-
man, etc. But in many cases, especially in industrial employments,
it is necessary to know (a) the kind of work and also (b) the nature of
the business or industry, and therefore an additional line is provided
for the latter statement; it should be used only when needed. As
examples: (a) Spinner, (b) Cotton mill; (a) Salesman, (b) Grocery;
(a) Foreman, (b) Automobile factory. The material worked on may
form part of the second statement. Never return “Laborer,” ‘‘Fore-
man,” ‘Manager,’ “Dealer,” etc., without more precise specification,
as Day laborer, Farm laborer, Laborer—Coal mine, etc. Women at
home, who are engaged in the duties of the household onty (not paid
Housekeepers who receive a definite salary), may be entered as House-
wife, Housework, or At home, and children, not gainfully employed, as
At school or At home. Care should be taken to report specificaily the
occupations of persons engaged in domestic service for wages, aS
Servant, Cook, Housemaid, ete. If the occupation has been changed
or given up on account of the DISEASE CAUSING DEATH, state occupa-
tion at beginning of illness. If retired from business, that fact may
be indicated thus: Farmer (retired, 6 yrs.). For persons who have
no occupation whatever, write None.
Statement of cause of death.—Name, first, the Discase Causing
Death (the primary affection with respect to time and causation),
using always the same accepted term for the same disease. Exam-
ples: Cerebrospinal fever (the only definite synonym is “Epidemic
cerebrospinal meningitis”); Diphtheria (avoid use of “Croup’’);
Typhoid fever (never report “Typhoid pneumonia’’); Lobar pneu-
monia; Bronchopneumonia (‘‘Pneumonia,”’ unqualified, is indefinite);
Tuberculosis of lungs, meninges, peritoneum, etc., Carcinoma, Sarcoma,
PPL (oy ieee ah ee (name origin; “Cancer” is less definite; avoid use
of “Tumor’ for malignant neoplasms); Measles; Whooping cough;
Chronic valvular heart disease; Chronic interstitial nephritis, ete. The
contributory (secondary or intercurrent) affection need not be stated
unless important. Example: Measles (disease causing death), 29 ds.;
Bronchopnewmonia (secondary), 10 ds. Never report mere symptoms
or terminal conditions, such as “Asthenia,” ‘Anemia’? (merely symp-
tomatic), “Atrophy,” “Collapse,”’ ‘‘Coma,”’ “Convulsions,” ‘‘Debility”’
(‘Congenital,” “Senile,” etc.), “Dropsy,” “xhaustion,” “Heart
failure,” ‘‘Hemorrhage,”’ “Tnanition,” ‘Marasmus,’’ “Old age,”
“Shock,” ‘‘Uremia,” “Weakness,” etc., when a definite disease
can be ascertained as the cause. Always qualify all diseases resulting
from childbirth or miscarriage, as “ pUBRPERAL septicemia,”’ ‘PUERPERAL
peritonitis,” ete.
State cause for which surgical operation was undertaken.
(Recommendations on statement of cause of death approved by Com-
mittee on Nomenclature of the American Medical Association.)
Bronchopneumonia: If primary cause, write the word
‘‘primary’’; if secondary, give primary cause.
Certificates will be returned for additional information
which give any of the following diseases, without explanation,
as the sole cause of death: Abortion, cellulitis, childbirth,
convulsions, hemorrhage, gangrene, gastritis, erysipelas, menin-
gitis, miscarriage, necrosis, peritonitis, phlebitis, pyemia,
septicemia, tetanus,
ro" EXTRACTS
FROM THE LAWS OF THE
COMMONWEALTH OF MASSACHUSETTS
GOVERNING THE
RETURN OF CERTIFICATES OF DEATH
A physician or registered hospital medical officer shall forth-
with, 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 registra-
tion a standard certificate of death, stating to the best of his knowl-
edge and belief the name of the deceased, his supposed age, the disease
of which he died, defined as required by section one, 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.....@en. Laws, Chap. 48,
Sec. 9.
No undertaker or other person shall bury or otherwise dispose of a
human body in a town, or remove therefrom a human body which has
not been buried, until he has received a permit from the board of
health or its agent appointed to issue such permits, or if there is no
such board, from the clerk of the town where the person died; and no
undertaker or other person shall exhume a human body and remove
it from a town, or from one cemetery to another, until he has received
a permit from the board of health or its agent aforesaid or from the
clerk of the town where the body is buried. No such permit shall be
issued until there shall have been delivered to such board, agent or
clerk, as the case may be, a satisfactory written statement containing
the facts required by law to be returned and recorded, which shall be
accompanied, in case of an original interment, by a satisfactory certi-
ficate of the attending physician, if any, as required 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 ob-
tained early enough for the purpose, or is insufficient, a physician
who is a member of the board of health, or employed 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. If the death certi-
ficate contains a recital, as required by section ten of chapter forty-six,
that the deceased served in the army, navy or marine corps of the
United States in any war in which it has been engaged, such recital
shall appear upon the permit. The board of health or its agent,
upon receipt of such statement and certificate, shall forthwith counter-
sign it and transmit it to the clerk of the town for registration. The
person to whom the permit is so given and the physician certifying
the cause of death shall thereafter furnish for registration 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.—Chap. 114, Sec. 45, G. L., as amended.
Medical examiners shall make examination upon the view of the
dead bodies of only such persons as are supposed to have died by
violence.—Gen. Laws, Chap. 38, Sec. 6.
He shall in all cases certify to the town clerk or registrar in the
place where the deceased died his name and residence, if known;
otherwise a description as full as may be, with the cause and manner
of death —Gen. Laws, Chap. 38, Sec. 7.
No undertaker or other person shall bury a human body or the
ashes thereof which have been brought into the commonwealth until
he has received a permit so to do from the board of health or its agent
appointed to issue such permits, or if there is no such board, from the
clerk of the town where the body is to be buried or the funeral is to
be held, or from a person appointed to have the care of the cemetery
or burial ground in which the interment is made.—Chap. 114, Sec. 46,
G.L., as amended.
(a) Residence.
(Usual place of abode)
Length of residence in city or town where death occurred
St. ; Ward.
A R-301 OFFICE OF THE SECRETARY Che Commonmealth of Massachusetts (Gea
yo] _DMSION OF WraL stanismis STANDARD CERTIFICATE OF DEATH
) 4 || 1 PLACE OF DEATH ir 5 ae or town)
é einiy Suffolk Stata Massachusetts pesistered No. pest Se
i ey (If death occurred in a hgspital or institution, give its NAME instead of street and number)
QE o
S 2 FULL NAM
q = (If in the Army or Navy of the United States, give rank, organization, etc.)
“. oO
: Nu
>
J
(If non-resident give city or town and state)
How long in U. S., if of foreign birth? years
MEDICAL CERTIFICATE OF DEATH
15 DATE OF DEATH = 19 p5
16
(Month)
Qn 1 HEREBY CERTIFY, That! attended deceased from
FRA 3 - ist _, o Nan Ff,
| that | last saw hn alive on yi 7 1925,
and that death occurred, on the date stated above, at/& fe _m.
The CAUSE OF DEATH was as follows:
days. months days
5 SINGLE, MARRIED, WIDOWED, OR
DIVORCED (write the word)
(Day) (Year)
7 OCCUPATION OF DECEASED
satour tial a = AAAMMALI HAL A
haath! ray (duration) yrs. hese ds.
8 BIRTHPLACE (City) CONTRIBUTORY
asa feo ee (d¥ration) yrs. mos. J ds
17 Where was disease contracted
9 NAME OF
should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state CAUSE OF DEATH a
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.
FATHER f if not at place of death?
| 10 BIRTHPI Ac “OF I< Sr. Did an operation precede AAG ake oft 2 Sn Se3.
F y 7 i = a, “| Was there an autopsy? AA
4 (State or country) Yu AL A if under ong-yerx, was infa . eee AY Pe rr Oe ee ae
$A _o_O_Ov_O_O_————————Oe —]] What test Ad di A :
@/ 11 MAIDEN NAME ZZ i . 4
< OF MOTHER ; (Signed)
a - EC ELD 7. “v1 2ELAV.
12 BIRTHPLACE OF “hy
MOTHER (City) AD tye .
(State or country) Date "i ty 19 2°.
~ (Month) (Day) (Year)
Lian, Drapoam. Baya FEED, BURIAL,» CREMATION OR REMOVAI~7 DATE OF BURIAL
z haw LADY fA ‘ VA y/ 9
CAL Viaw.//,
(Cemetery) _ (City or town) 7
19 UNDERTAKER / ope
VERS. SS Hid
a a 7G
Filed
‘: onth Da (Year) REGISTRAR
20 | HE EREBY CERTIFY that a satisfactory stan-
ee EN Eee UREN S Be S Ee REECE Eg UPC CPS GMUCR SESE CeN Sas weer e RCTS = See eee pee ee ee
dard certificate of death was filed with me LL oie Len “aie Permit
SUSE yar Ol Ldun position CL GEnX of permit _% / Lipa ey LISS | 33
r-
ne Ag) Leen ee
REVISED ane STATES STANDARD CERTIFICATE OF DEATH
(Approved by U. S. Census and American Public Health Assocation)
Statement of occupation.—Precise statement of occupation is
very important, 80 that the relative healthfulness of various pursuits
can be known. The question applies to each and every person, irre-
spective of age. For many occupations a single word or term on the
first line will be sufficient, e. g., Farmer or Planter, Physician, Com-
positor, Architect, Locomotive engineer, Civil engineer, Stationary fire-
man, etc. But in many cases, especially in industrial employments,
it is necessary to know (a) the kind of work and also (b) the nature of
the business or industry, and therefore an additional line is provided
for the latter statement; it should be used only when needed. As
examples: (a) Spinner, (b) Cotton mill; (a) Salesman, (b) Grocery;
(a) Foreman, (b) Automobile factory. The material worked on may
form part of the second statement. Never return “Laborer,” ‘‘Fore-
man,” ‘‘Manager,” “Dealer,” etc., without more precise specification,
as Day laborer, Farm laborer, Laborer—Coal mine, etc. Women at
home, who are engaged in the duties of the household only (not paid
Housekeepers who receive a definite salary), may be entered as House-
wife, Housework, or At home, and children, not gainfully employed, as
At school or At home. Care should be taken to report specifically the
occupations of persons engaged in domestic service for wages, a8
Servant, Cook, H ousemaid, ete. If the occupation has been changed
or given up on account of the DISBASH CAUSING DEATH, state occupa-
tion at beginning of illness. If retired from business, that fact may
be indicated thus: Farmer (retired, 6 yrs.)- For persons who have
no occupation whatever, write None.
~~ statement of cause of death.—Name, first, the DISHASH CAUSING
ppaTH (the primary affection with respect to time and causation),
using always the same accepted term for the same disease. Exam-
ples: Cerebrospinal fever (the only definite synonym is ““Bpidemic
cerebrospinal meningitis’’) ; Diphtheria (avoid use of “Croup”’);
Typhoid fever (never report ‘Typhoid pneumonia”); Lobar pneu-
monia; Bronchopneumonia (‘‘Pneumonia,”’ unqualified, is indefinite);
Tuberculosis of lungs, meninges, peritoneum, ete., Carcinoma, Sarcoma,
etc., Of..-.--6--s (name origin; “Cancer” is less definite; avoid use
of ‘‘Tumor’”’ for malignant neoplasms); Measles; Whooping cough;
Chronic valvular heart disease; Chronic interstitial nephritis, etc. The
contributory (secondary or intercurrent) affection need not be stated
unless important. Example: Measles (disease causing death),
29 ds.; Bronchopneumonia (secondary), 10 ds. Never report mere
symptoms or terminal conditions, such as “Asthenia,” ‘‘Anemia’’
(merely symptomatic), “Atrophy,” “Collapse,” ‘‘Coma,”’ “Convul-
sions,” ‘‘Debility” (‘‘Congenital,”’ “Senile,” etc.), ‘‘Dropsy,”’ “Ex-
haustion,” ‘‘Heart failure,” ““Flemorrhage,” ‘‘Inanition,”’ ““Maras-
mus,” ‘‘Old age,”’ ‘‘Shock,” “Uremia,”, ‘‘Weakness,” etc., when a
definite disease can be ascertained as the cause. Always qualify all
diseases resulting from childbirth or miscarriage, as ““PuPRPERAL
septicemia,” ‘‘PUEBRPBRAL peritonitis,” etc.
State cause for which surgical operation was undertaken.
(Recommendations on statement of cause of death approved by Com-
mittee on Nomenclature of the American Medical Association.)
Bronchopneumonia: If primary cause, write the word
“‘primary”’; if secondary, give primary cause.
Certificates will be returned for additional information
which give any of the following diseases, without explanation,
as the sole cause of death: Abortion, cellulitis, childbirth,
convulsions, hemorrhage, gangrene, gastritis, erysipelas,
meningitis, miscarriage, necrosis, peritonitis, phlebitis,
pyemia, septicemia, tetanus.
o-
- ~
EXTRACTS
FROM THE LAWS OF THE
COMMONWEALTH OF MASSACHUSETTS
GOVERNING THE
RETURN OF CERTIFICATES OF DEATH
A physician or registered hospital medical officer shall forth-
with, 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 registra-
tion a standard certificate of death, stating to the best of his knowl-
edge and belief the name of the deceased, his supposed age, the disease
of which he died, defined as required by section one, 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. ...—Gen. Laws, Chap.
46, Sec. 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. ..& satisfactory written statement con-
taining the facts required by law to be returned and recorded,
which shall be accompanied, in case of an original interment, by a
satisfactory certificate of the attending physician, if any, as required
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 pur-
pose, or is insufficient, a physician who is a member of the
board of health, or employed 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 registration 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 re-
quire.—Gen. 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.—Gen. Laws, Chap. 88, Sec. 6.
_..He shall in all cases certify to the town clerk or registrar in the
place where the deceased died his name and residence, if known;
otherwise a description as full as may be, with the cause and manner
of death.—Gen. 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 unre-
lated to any form of injury, have died without recent medical at-
tendance or whose physician 1s 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 injury or infection related to occupation, the
sudden deaths of persons not disabled by recognized disease,
and those of persons found dead.
Bs]
t
®
°
See instructions and extracts from the laws on beck of certificate.
plied. 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.
971-2031
~_
200,000. 9-26. NO. 6373
2 OF THE SECRETARY Che Commonumealth of Massachusetts
DIVISION OF VITAL STATISTICS STANDARD CERTIFICATE OF DEATH BOSTON
1PLACE OF DEATH (City or ) q
County. FOO KK CCCCState 3S CCUM a ssachusetts Registered No. Stee ‘7-
City or Town Wi thro No. 949 Shirle Street, Winthrops, ward
: (If death occurred in a hospital or institution, give its NAME instead of street and number)
QFULL NAME. Thomas F,. Meagher
(if U. 5. War Veteran, specify WAR)
(a) Residence. N._ 949 Shir@ey StreeG st, Ward,
(Usu2! place of abode) (if non-resident give city or town and state)
Length of residence in city or town where death occurred months How long in U. S., if of foreign birth? months
PERSONAL AND STATISTICAL PARTICULARS MEDICAL CERTIFICATE OF DEATH
|
3 SEX 4 Se OR RACE SO (7 26-
5 SINGLE, MARRIED, WIDOWED, OR (
| DIVORCED (write the word) 15 DATE OF DEATH Z f
(Day) (Year)
Y , That i attended deceased from
| White “Single ire
192
(Month)
5a If married, widowed or divorced
HUSBAND of
(or) WIFE of
6 AGE Years | Months =| Days iF LESS than
| 1 day,........ hrs and that death occurred, on the
|
| -iN'S* “The CAUSE OF DEATH was as follow: (State fully) ;
66 | | MBE ave: min.
eS: ae ate b és
IF STILLBORN, enter that fact here >= — > eee b- e
iG raion ie DECEASED .
a) Trade, profession, or — ae
particular kind of work Blacksmith,
uration). yrs. mos. 2 3 de:
(b) Name of employer A tele oh a
PS a (Secondary)
@ pirTHpiace city) Halifax, (duration) ___yrs.__mos._____ds.
(State or country) 17 Where was disease contracted
Nova Se te) tia rs ae if not at place of deat
9 NAME OF ‘ g f
Did an operation preceded For what___
FATHER John Meagher ame
10 BIRTHPLACE OF ‘ Date of operation ___.# s =
FATHER (City) ee
(State or country) Ir eland > Was there an autépsy
ft der_one, ye was i reg SOU? us.
11 MAIDEN NAME what fast ¢onnitmed gnosis 5 -~L-
sata Ellen Condon 7 (Signed)
1 2 BIRTHPLACE OF
MOTHER CCity)
PARENTS
(State or country) J
T tf 4G 2 £2 i
13 R REMOVAL DATE OF BURIAL
Informant John Meagher
(Address) S
_St. Josephs, Boston Jam 12,1928
(Cemetery) (City or town) |
Ss
14 ERTAKER ADDRESS
Filed LP x YE" od awe a
m—emanthy Cay} (Year) REGISTRAR tetanr nO Jer, Bast Boston
20 I HEREBY CERTIFY that a satisfactory stan-
dard certificate of death was filed with me
BEFORE the burial or transit permit was issue
Date of
2
L > issue / rmit —
Ys f pom Yt 2a bi ee
ay). 10 ’ / FR
REVISED UNITED STATESSTANDARD CERTIFICATE OF DEATH
(Approved by U. S. Census and American Public Health Association)
Statement of occupation.—Precise statement of occupation is
very important, so that the relative healthfulness of various pursuits
can be known. The question applies to each and every person, irre-
spective of age. For many occupations a single word or term on the
first line will be sufficient, e. g., Farmer or Planter, Physician, Com-
positor, Architect, Locomotive engineer, Civil engineer, Stationary fire-
man, etc. But in many cases, especially in industrial employments,
it is necessary to know (a) the kind of work and also (b) the nature of
the business or industry, and therefore an additional line is provided
for the latter statement; it should be used only when needed. As
examples: (a) Spinner, () Cotton mill; (a) Salesman, (b) Grocery;
(a) Foreman, (b) Automobile factory. The material worked on may
form partjof the second statement. Never return “Laborer,” ‘‘Fore-
man,” “Manager,’’ “Dealer,” etc., without more precise specification,
as Day laborer, Farm laborer, Laborer—Coal mine, ete. Women at
home, who are engaged in the duties of the household onty (not paid
Housekeepers who receive a definite salary), may be entered as House-
wife, Housework, or At home, and children, not gainfully employed, as
At school or At home. Care should be taken. to report specifically the
occupations of persons engaged in domestic service for wages, as
Servant, Cook, Housemaid, ete. If the occupation has been changed
or given up on account of the DISEASE CAUSING DEATH, state occupa
tion at beginning of illness. If retired from business, that fact may
be indicated thus: Farmer (retired, 6 yrs.). For persons who have
no occupation whatever, write None.
Statement of cause of death.—Name, first, the Disease Causing
Death (the primary affection with respect to time and causation),
using always the same accepted term for the same disease. Exam-
ples: Cerebrospinal fever (the only definite synonym is “Epidemic
cerebrospinal meningitis’); Diphtheria (avoid use of ‘“Croup’’);
Typhoid fever (never report “Typhoid pneumonia’); Lobar pneu-
monia; Bronchopneumonia (‘‘Pneumonia,”’ unqualified, is indefinite);
Tuberculosis of lungs, meninges, peritoneum, etc., Carcinoma, Sarcoma,
eto:, Ol.wes (name origin; ‘‘Cancer”’ is less definite; avoid use
of ‘Tumor’ for malignant neoplasms); Measles; Whooping cough;
Chronic valvular heart disease; Chronic interstitial nephritis, etc. The
contributory (secondary or intercurrent) affection need not be stated
unless important. Example: Measles (disease causing death), 29 ds.;
Bronchopneumonia (secondary), 10 ds. Never report mere symptoms
or terminal conditions, such as ““Asthenia,’”’ ‘“Anemia’’ (merely symp-
tomatic), “Atrophy,” “Collapse,” “Coma,” “Convulsions,” “Debility’”’
(“‘Congenital,”’ ‘‘Senile,’’ etc.), ‘‘Dropsy,”’ “fxhaustion,” ‘Heart
failure,’ ‘‘Hemorrhage,”’ “Jnanition,’ ‘“Marasmus,” ‘Old age,”
“Shock,” ‘Uremia,” “Weakness,’’ etc., when a definite disease
can be ascertained as the cause. Always qualify all diseases resulting
from childbirth or miscarriage, as “PUERPERAL septicemia,”’ ‘PUERPERAL
peritonitis," ete.
State cause for which surgical operation was undertaken.
(Recommendations on statement of cause of death approved by Com-
mittee on Nomenclature of the American Medical Association.)
Bronchopneumonia: If primary cause, write the word
‘‘primary’’; if secondary, give primary cause.
Certificates will be returned for additional information
which give any of the following diseases, without explanation,
as the sole cause of death: Abortion, cellulitis, childbirth,
convulsions, hemorrhage, gangrene, gastritis, erysipelas, menin-
gitis, miscarriage, necrosis, peritonitis, phlebitis, pyemia,
septicemia, tetanus,
EXTRACTS
FROM THE LAWS OF THE
COMMONWEALTH OF MASSACHUSETTS
GOVERNING THE
RETURN OF CERTIFICATES OF DEATH
A physician or registered hospital medical officer shall forth-
with, 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 registra-
tion a standard certificate of death, stating to the best of his knowl-
edge and belief the name of the deceased, his supposed age, the disease
of which he died, defined as required by section one, 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.....den. Laws, Chap. 46,
Sec, 9.
No undertaker or other person shall bury or otherwise dispose of a
2puman body ina town, or remove therefrom a human body which has
Onot been buried, until he has received a permit from the board of
health or its agent appointed to issue such permits, or if there is no
such ‘board, from the clerk of the town where the person died; and no
+ undertaker or other person shall exhume a human body and remove
qi
opt from a town, or from one cemetery to another, until he has received
2 permit from the board of health or its agent aforesaid or from the
clerk of the town where the body is buried. No such permit shall be
éssued until there shall have been delivered to such board, agent or
#5clerk, as the case may be, a satisfactory written statement containing
@the facts required by law to be returned and recorded, which shall be
@accompanied, in case of an original interment, by a satisfactory certi-
fificate of the attending physician, if any, as required by law, or in lieu
+ thereof a certificate as hereinafter provided. If there is no attending
C2 physician, or if, for sufficient reasons, his certificate cannot be ob-
tained early enough for the purpose, or is insufficient, a physician
Pavho is a member of the board of health, or employed by it or by the
® sclectmen for the purpose, shall upon application make the certificate
ttrequired of the attending physician. If death is caused by violence,
fithe medical examiner shall make such certificate. If the death certi-
*r4 fcate contains a recital, as required by section ten of chapter forty-six,
that the deceased served in the army, navy or marine corps of the
W2 United States in any war in which it has been engaged, such recital
shall appear upon the permit. The board of health or its agent,
upon receipt of such statement and. certificate, shall forthwith counter-
Wsign it and transmit it to the clerk of the town for registration. The
© person to whom the permit is so given and the physician certifying
@ the cause of death shall thereafter furnish for registration any other
fynecessary information which can be obtained as to the deceased, or as
;Qto the manner or cause of the death, which the clerk or registrar
«cq may require.—Chap. 114, Sec. 45, G. L., as amended.
Medical examiners shall make examination upon the view of the
dead bodies of only such persons as are supposed to have died by
violence —Gen. Laws, Chap. 38, Sec. 6.
He shall in all cases certify to the town clerk or registrar in the
place where the deceased died his name and residence, if known;
otherwise a description as full as may be, with the cause and manner
of death—G@en. Laws, Chap. 38, Sec. 7.
No undertaker or other person shall bury a human body or the
ashes thereof which have been brought into the commonwealth until
he has received a permit so to do from the board of health or its agent
appointed to issue such permits, or if there is no such board, from the
clerk of the: town where the body is to be buried or the funeral is to
be held, or from a person appointed to have the care of the cemetery
or burial ground in which the interment is made.—Chap. 114, Sec. 46,
G. L., as amended,
305
OFFICE OF THE SECRETARY e Commontwealth of Massachusetts
DIVISION OF VITAL STATISTICS 8) € mmontwealth of Masse chi 5 Reatod
Medical Examiner’s Certificate of Death == Gierte e
1 PLACE OF DEATH (ISSUED UNDER THE PROVISIONS OF GENERAL LAWS, CHAPTER 38) LE
County ............. Suffolk ee SL Ce POE ks. 82 A a Registered No. : je oo Pate eee Registered aie 899. JO:
ace of residence,
City or Town................/ B oston BESSY eee SR ci eee oe No. PA: 0 Ss TON “CIT YHOSPITAL [oe Sts pense Ward
(If death occurred in a hospital or institution, give its NAME instead of street and number) f
2 FULL NAME ..... REBECCA...BARON.........0000000000.... eee sessnininn ee ere
in the Army or Navy o: e " e rang, ization, i
i dedeise No. 294 OOIOLEY = St. Ward. WERT AROP MASS rn
(Usual place of abode) (If non-resident, give city or town and State)
Length of residence In clty or town where death occurred years months days How long in U.S., If of toreign birth? years months days
PERSONAL AND STATISTICAL PARTICULARS
3 SEX 4 COLOR OR RACE 5 SINGLE, MARRIED, WIDOWED, OR 15 DATE OF DEATBH.............. VAR U8, t980) ne .
DIVORCED (write the word) (Month) (Day) (Year)
Ps We Me 16
i HEREBY CERTIFY that I have investigated the death
5a If married, widowed, or divorced
HUSBAND of of the person above-named and that the CAUSE AND MANNER thereof
(or) WIFE of HARRI S are as follows: D i
6 AGE Years Months “Days ittesstn || CHRONIC ASTHMA>~-ODABETESe--— |
1 day,..... hrs ‘
75 or.....min PSR R EP CSSELGROR IS. ge i |
IF STILLBORN, enter that fact here FRACTURED. FEMUR---ACCIDENTAL....FALL |
ee ee (i
7 OCCUPATION OF DECEASED
(a) Trade, profession, OF nn nee eee e eect centre ee teen eee eenrancneretetctetetesesccccccecrcecceteneeseseeneeteasaeesarenaeerenans
particular kind of work oo... o.oo ccc. HOUSEWORK...
(b) Name of employer veees""""""(Gee reverse side for additional space) sst—<“i‘“‘;:*~S
17 Where was injury sustained :
MIpIRTHPEACK. (ety or'town) |.0. (Me Reem LIE ACe UE, MEIN 2 ook h rt a hank uk heey ine ites omee as ase hewacaeadies uadate sake
(State or country) RUSSIA (Signed) ......... ‘a4 14) oe CORR ee MD.
9 NAME OF FATHER J AC 0B P j KE (Address) ............ BOST ON UF a Riek cea eee Fe RE SR, A: ah ee
te SUFFOLK
” i MRTHPELACE OF FATHER (city or town)... ‘Medical Exam eA enc ne I ots cao Saran ge dnokacKa
z (State or country) Date JAN. it 9 1ge see
= ier ee ee eS eeeess
. 11 MAIDEN NAME OF MOTHER CARRS SRP ADRS REESE RTE OT A EE ARE OE TS
= |—_——_—__________TRIWA exw---ee 18 PLACE OF BURIAL, CREMATION, OR REMOVAL DATE OF BURIAL |
12 BIRTHPLACE OF MOTHER TUS OFAGOWT) 04> oon cet os teaches < I = 28
peereace OF (ety OF HOW) vo cesene eee (OHEL JACOB) WOBURN on ed OE Rca
19 UNDERTAKER ADDRESS
pe H.B
SHI
b
14 4
ea¥AN AZ. ECCH LLeorrecr- | ss,
Filed Za 4.14, SR es ee... SE Dalke of
Teo dan to eat ae sea Re Re RO RPS Ne ee Re ee
jan. Porta c
oe, ee ee eee
Exact statement of OCCUPATION is very important. See instructions on back of certificate.
The Commonwealth of Massachusetts
BOSTON
STANDARD CERTIFICATE OF DEATH (City or viva L-
1 PLACE OF DEATH Registered No.
: i 5 f death)
County Suffolk __——————s State. Massachusetts Registered No._F ae
(Pl f residence)
City or town Boston _ PETER BENT BRIGHAM HOSPITALS... Ward
ao death occurred in a hospital or institution, give its NAME instead of street and number)
2 FULL NAME__ CHARLES CARRQ
(If in the Army or Navy of the United States, give rank, organization, etc.)
(a) Residence. Rintac WA@Oe =f 22 Sei, or Town WINTHROP No._93 CREST AVE pe 2 2 i8e:
(Usual place of abode) 3
Length of residence im city or town where death occurred years months days. How long in U. S., if of foreign birth? years months days
PERSONAL AND STATISTICAL PARTICULARS
4 COLOR OR RACE
_We
5a = emcee =e, or divorced
(Oy) WiFt WIFE ae
MEDICAL CERTIFICATE OF DEATH
15 DATE OF DEATH JAN, 16, 19 Max
(Month) (Day) (Year)
5 SINGLE, MARRIED, WIDOWED, OR
DIVORCED (write the word)
16
I HEREBY CERTIFY, That I attended deceased from
See te to! Bhan Ae, 1G BE
that I last saw h__1 Mative on _ JAN » 16 719 28
6 AGE Years Months Days If LESS than
1 day,____hrs. and that death occurred, on the dated stated above, at__._————s mm.
0 or... The CAUSE OF DEATH was as follows:
If STILLBORN, enter that fact here CHRONIC NEPHRITIS
VALVULAR HYPERTENSION
7 OCCUPATION OF DECEASED
(Tis mies or SC OLAMOND SETTER
(b) Name of employer fie eto Meat tomy Bo mos. ds.
CONTRIBUTORY SS wena e see
8 BIRTHPLACE (city or town) (SECONDARY)
(State or country) > (duration) yrs. mos. ds.
i ; 17 Wh was di contracted
9 Sree of | ea if Bot at Place of death? :
awh
| 10 BIRTHPLACE OF Did an operation precede death? Date of
. Boe ore Weirrer town) Was there an autopsy? N 0
(State or country)
e li MAIDEN NAME What test confirmed diagnosis? Cc LI NIC A L.
< MINNIE LIFSKITZ Guat ESLIGC W, WRIST M.D.
2.| 12 BIRTHPLACE OF
MOTHER (city or town) (Address) a
(State or country) RUSSIA Date JAN, $6, 1928 ;
18 PLACE OF BURIAL, CREMATION, OR REMOVAL DATE OF BURIAL
14 : SESS 19 UNDERTAKER ADDRESS
Filed JAN,18 1988 ©<CU ,
Registrar of city or town where death occurred MANUEL STANETSKY
Registrar of city or town where deceased resided
: 8
RADE OF JACOB) BOSTON I-12 ox
Statement of occupation.—Precise statement of occupation is
very important, so that the relative healthfulness of various pursuits
can be known. The question applies to each and every person, irre-
spective of age. For many occupations a single word or term on the
first line will be sufficient, e. g., Farmer or Planter, Physician, Composi-
tor, Architect, Locomotive engineer, Civil engineer, Stationary fireman, etc.
But in many cases, especially in industrial employments, it is necessary
_ to know (a) the kind of work and also (b) the nature of the business or
industry, and therefore an additional line is provided for the latter state-
ment; it should be used only when needed. As examples: (a) Spinner,
(b) Cotton mill; (a) Salesman, (b) Grocery; (a) Foreman, (b) Automobile
factory. The material worked on may form part of the second state-
ment. Never return ‘‘Laborer,”’ “Foreman,” ‘‘Manager,”’ “Dealer,”
etc., without more precise specification, as Day Laborer, Farm Laborer,
Laborer—Coal mine, etc. Women at home, who are engaged in the
duties of the household only (not paid Housekeepers who receive a defi-
nite salary), may be entered as Housewvfe, Housework, or Athome, and
children, not gainfully employed, as At school or Athome. Care should
be taken to report specifically the occupations of persons engaged in
domestic service for wages, as Servant, Cook, Housemaid, etc. If the
occupation has been changed of given up on account of the DISEASE
CAUSING DEATH, state occupation at beginning of illness. If retired
from business, that fact may be indicated thus: Farmer (retired, 6 yrs.).
For persons who have no occupation whatever, write None.
Statement of cause of death.— Name, first, the DISEASE CAUSING
pEATH (the primary affection with respect to time and causation), using
always the same accepted term for the same disease. Examples: Cere-
brospinal fever (the only definite synonym is ‘‘Epidemic cerebrospinal
meningitis”); Diphtheria (avoid use of “Croup”); Typhoid Fever (never
report ‘Typhoid pneumonia”); Lobar pneumonia; Bronchopneumonia
(“‘Pneumonia,”’ unqualified, is indefinite) ; Tuberculosis of lungs, men-
inges, peritoneum, etc., Carcinoma, Sarcoma, etc., Obes tate es (name
origin; ‘“‘Cancer” is less definite; avoid use of “Tymor” for malignant
neoplasms); Measles; Whooping cough; Chronic valvular heart disease;
Chronic interstitial nephritis, ete. The contributory (secondary or inter-
current) affection need not be stated unless important. Example:
Measles (disease causing death), 29 ds.; Bronchopneumonia (secondary),
10 ds. Never report mere symptoms or terminal conditions, such as
“Asthenia,” ‘‘Anemia’”’ (merely symptomatic), “Atrophy,” ‘“Col-
lapse,” ‘‘Coma,”’ “Convulsions,” ‘Debility”’ (“‘Congenital,”’ “Senile,”
etc.), “Dropsy,” “Exhaustion,” “Heart failure,”’ ‘Hlemorrhage,”’ ““Ina-
nition,” ‘‘Marasmus,” “Old age,” “Shock,” “Uremia,” ‘'Weakness,””
etc., when a definite disease can be ascertained as the cause. Always
qualify all diseases resulting from childbirth or miscarriage, a8 ‘PUER-
PERAL septicemia,” ‘‘PUBRPERAL peritonitis,”’ etc.
State cause for which surgical operation was undertaken.
(Recommendations on statement of cause of death approved by Com-
mittee on Nomenclature of the American Medical Association.)
Bronchopneumonia: If primary cause, write the word ‘‘pri-
mary;’’ if secondary, give primary cause.
——_—_—————————————
Certificates will be returned for additional information which
give any of the following diseases, without explanation, as the
sole cause of death: Abortion, cellulitis, childbirth, convulsions,
hemorrhage, gangrene, gastritis, erysipelas, meningitis, miscar-
riage, necrosis, peritonitis; phlebitis, pyemia, septicemia,
tetanus.
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 stand-
ard 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 as required by section one, where same was contracted, the du-
ration of his last illness, when last seen alive by the physician or officer
and the date of his death. . . —Gen. Laws, Chap. 46, Sec. 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 con-
taining the facts required by law to be returned and recorded,
which shall be accompanied, in case of an original interment, by a satis-
factory certificate of the attending physician, if any, as required 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 insuffi-
cient, a physician who is a member of the board of health, or em-
ployed by itor by the selectmen for the purpose, shall upon ap-
plication make the certificate required of the attending physi-
cian. 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 registration 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.—Gen. 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 vio-
lence.—Gen. Laws, Chap. 38, Sec. 6.
_..He shall in all cases certify to the town clerk or registrar in the
place where the deceased died his name and residence, if known; other-
wise a description as full as may be, with the cause and manner of death.
—Gen. 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 4 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 poison), thermal, or electrical
agents, and deaths following abortion, but also deaths from disease
resulting from injury or infection related to occupation, the
sudden deaths of persons not disabled by recognized disease,
and those of persons found dead.
R-301
Sane itiea ey 200,000. 9-26. NO. 6373
plied. 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.
7-20M,
OFFICE OF THE SECRETARY
DIVISION OF VITAL STATISTICS
1PLACE OF DEATH
a) Residence. No.
Length of residence in city or town where death occurred
PERSONAL AND STATISTICAL PARTICULARS ‘ MEDICAL CERTIFICATE OF DEATH
3 SEX 4 COLOR OR RACE 5 SINGLE, MARRIED, WIDOWED, OR ? Cc
. DIVORCED (write the word) 15 DATE OF DEATH Ke is MA : / 7 = _
A ( { Ik on ay ear
County.
City or Town
FULL NAME ‘= CG uw BE
26
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
ae eee eel
(City or town) )
State_______- Massachusetts __ Registered ae] |
TEITH ROP
[e)
ATA H
Reacs-\
(Usual place of abode)
2
ears
months
Win THRO RP
CO one Heep. Wine ROP wag
If death occurred in a hospital or institution, give its NAME instead of street and n number)
. War Veteran, specify WAR)
Ward,__ 7a
(lf non-resident give city or town and state)
days. How long in U. S., if of foreign birth? ears months days.
St,
5a lf married, widowed or divorced
(or)
6 AGE
WIFE of
Years | Months | _ Days
f
IF STILLBORN, enter of i here
7 OCCUPATION OF DECEASED
(a) Trade,
particular kind of work
rofession, or
va Italo
(b) Name of employer
& BIRTHPLACE (City) Neale
(State or country)
14
PARENTS
Yer
9 NAME OF WwW eh
iene
eee
16 | HEREBY CERTIFY , That | attended deceased from
us IJ 19.27 to
that | last saw h-2“S alive on
and that death occurred, on the date Stated above, a ze FO ! m.
The CAUSE OF DEATH was as follows: (State fully)
(durafion). mos. ds. |
CONTRIBUTORY peod C, |
(Secondary) '
(duration). yrs. mos2 2 = = tis. |
17 Where was disease contracted as ae
if not at place of deat
‘
Did an operation i For -
10 BIRTHPLACE OF Date of operation ony J
FATHER (City) a :
(State or country) ne Was there an autopsy lo Rees
= f under on ear was inf BASE EU Pe IY,. ., 0 Se tee vcah apie Niveniecetde ‘
1 1 MAIDEN NAME / at test conhrm iagnosis
OF MOTHER Haw.ec. pve
* (Signed) i; _M.
‘12 BIRTHPLACE OF
MOTHER (City) Meowark, (Addre
(State or country) — AY — Date
jj 18 PLACE OF BURIAL se ibdon 0 sul PL obat- DATE OF BURIAL
et 3 i RD PAS L Arg 2 Auk Comifiry € st chats 1/7 FF
Gidsress) 44to+e-,- a (Cemetery goog ng > A Ag 4 2
16 foe 19 UNDERTAKER ADDRESS |
aA (ay) (Year) REGISTRAR fi VYaflol C heloe. nee i
O | 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 issue Permit
W0.Chibdaera ih Kom § zen ak Mya
Ary. #7. eG,
(Approved by U. S. Census and American Public Health Association)
Statement of occupation.—Precise statement of occupation is
very important, so that the relative healthfulness of various pursuits
ean be known. The question applies to each and every person, irre-
spective of age. For many occupations 2 single word or term on the
first line will be sufficient, ¢. £., Farmer or Planter, Physician, Com-
positor, Architect, Locomotive engineer, Civil engineer, Stationary fire-
man, etc. But in many cases especially in industrial employments,
it is necessary to know (a) the kind of work and also (0) the nature of
the business or industry, and therefore an additional line is provided
for the latter statement; it should be used only when needed, As
examples: (a) Spinner, (b) Cotton mill; (a) Salesman, (b) Grocery;
(a) Foreman, (>) Automobile factory. ‘The material worked on may
form part of the second statement. Never return “Laborer,” “‘lore-
man,” “Manager,” “Dealer,” etc., without more precise specification,
as Day laborer, Farm laborer, Laborer—Coal mine, etc. Women at
home, who are engaged in the duties of the household onty (not paid
Housekeepers who receive a definite salary), misty be entered as House-
wife, Housework, or At home, and children, not gainfully employed, as
At school or At home. Care should be taken to report specificaily the
occupations of persons engaged in domestic service for wages, 38
Servant, Cook, Housemaid, etc. If the occupation has been changed
or given up on account of the DISEASE CAUSING DEATH, state oceupa-
tion at beginning of illness. If retired from business, that fact may
be indicated thus: Farmer (retired, 6 yrs.). For persons who have
no occupation whatever, write None.
Statement of cause of death.—Name, first, the Discase Causing
Death (the primary affection with respect to time and causation),
using always the same accepted term for the same disease, [Exam-
ples: Cerebrospinal fever (the only definite synonym is “Epidemic
cerebrospinal meningitis”); Diphtheria (avoid use of “Croup”’);
Typhoid fever (never report “Typhoid pneumonia’); Lobar pneu-
monia; Bronchopneumonia (““Pneumonia,” unqualified, is indefinite) ;
Tuberculosis of lungs, meninges, peritoneum, etc., Carcinoma, Sarcoma,
OtGey Ofte. daca uenne-vsene (mame origin; “Cancer” is less definite; avoid use
of “Tumor” for malignant neoplasms); Measles; Whooping cough;
Chronic valvular heart disease; Chronic interstitial nephritis, ete. The
contributory (secondary or intercurrent) affection need not be stated
unless important. Example: Measles (disease causing death), 29 ds.;
Bronchopneumonia (secondary), 10 ds. Never report mere symptoms
or terminal conditions, such as ‘“Asthenia,” ‘Anemia’ (merely symp-
tomatic), “Atrophy,” “Collapse,” “Coma,” “Convulsions,” ‘‘Debility”
(‘‘Congenital,”” “Senile,” etc.), “Dropsy,” “Pxhaustion,” ‘Heart
failure,” “Hemorrhage,” “Jnanition,” ‘Marasmus,” “Old_age,”
“Shock,” ‘“Uremia,” “Weakness, ete., When a definite disease
can be ascertained as the cause. Always qualify all diseases resulting
from childbirth or miscarriage, as ““pUBRPERAL septicemia,’ ‘PUERPERAL
peritonitis,” ete.
State cause for which surgical operation wes undertaken.
(Recommendations on statement of cause of death approved by Com-
mittee on Nomenclature of the American Medieal Association.)
Bronchopneumonia: If primary cause, write the word
‘primary’; if secondary, give primary cause.
Certificates will be returned for additional information
which give any of the following diseases, without explanation,
as the sole cause of death: Abortion, cellulitis, childbirth,
convulsions, hemorrhage, gangrene, gastritis, erysipelas, menin-
gitis, miscarriage, necrosis, peritonitis, phlebitis, pyemia,
septicemia, tetanus,
EXTRACTS
FROM THE LAWS OF THE
COMMONWEALTH OF MASSACHUSETTS
GOVERNING THE
RETURN OF CERTIFICATES OF DEATH
A physician or registered hospital medical officer shall forth-
with, after the death of a person whom he has attended during his
Jast illness, at the request of an undertaker or other authorized person
or of any member of the family of the deceased, furnish for registra-
tion a standard certificate of death, stating to the best of his knowl-
edge and belief the name of the deceased, his supposed age, the disease
of which he died, defined as required by section one, 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.....@en. Laws, Chap. 46,
Sec. 9.
No undertaker or other person shall bury or otherwise dispose of a
human body in a town, or remove therefrom a human body which has
not been buried, until he has received a permit from the board of
health or its agent appointed to issue such permits, or if there is no
such board, from the clerk of the town where the person died; and no
undertaker or other person shall exhume a human body and remove
it from a town, or from one cemetery to another, until he has received
a permit from the board of health or its agent aforesaid or from the
clerk of the town where the body is buried. No such permit shall be
issued until there shall have been delivered to such board, agent or
clerk, a8 the case may be, a satisfactory written statement containing
the facts required by law to be returned and recorded, which shall be
accompanied, in case of an original interment, by a satisfactory certi-
ficate of the attending physician, if any, as required 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 ob-
tained early enough for the purpose, or is insufficient, a physician
who is 2 member of the board of health, or employed 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. If the death certi-
fieate contains a recital, as required by section ten of chapter forty-six,
that the deceased served in the army, navy or marine corps of the
United States in any war in which it has been engaged, such recital
shall appear upon the permit. The board of health or its agent,
upon receipt of such statement and certificate, shall forthwith counter-
sign it and transmit it to the clerk of the town for registration. The
person to whom the permit is so given and the physician certifying
the cause of death shall thereafter furnish for registration 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.—Chap. 114, Sec. 45, G. L., as amended,
Medical examiners shall make examination upon the view of the
dead bodies of onty such persons as are supposed to have died by
violence.—Gen. Laws, Chap. 38, Sec. 6.
....He shall in all cases certify to the town clerk or registrar in the
place where the deceased died his name and residence, if known;
otherwise a description as full as may be, with the cause and manner
of death.—Gen. Laws, Chap. 38, Sec. 7.
——————<————— ne
No undertaker or other person shall bury a human body or the
ashes thereof which have been brought into the commonwealth until
he has received a permit so to do from the board of health or its agent
appointed to issue such permits, or if there is no such board, from the
clerk of the town where the body is to be buried or the funeral is to
be held, or from a person appointed to have the care of the cemetery
or burial ground in which the interment is made.—Chap. 114, Sec. 46,
G, L., as amended,
BY
®
E
plied. 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.
200,000. 9-26. NO. 6373
See instructions and extracts from the laws on back of certificate.
OFFICE OF THE SECRETARY
DIVISION OF VITAL STATISTICS
1PLACE OF DEATH
STANDARD CERT
(City or town)
County fiolk State Massachusetts Abn Nee dey
City or Town No. Gun—_1, herp 4 St,____Ward
(If death occurred in a hospital or instituti ve its NAME instead of street and number)
FULL ne erwra le
(Usual place of abode)
Length of residence in city or town where death occurred months
PERSONAL AND STATISTICAL PARTICULARS
The Commonwealth of Massachusetts
(if U. S. War Veteran, specify WAR)
a) Residence. No. Va 26 fgZeomeenv
nila
IFICATE OF DEATH _§»,eosFOos
SE ET A ee ee: ae i}
(if non-resident give city or town and state) |
How long in U. S., if of foreign birth? ears months :
MEDICAL CERTIFICATE OF DEATH
days.
3 SE 4 COLOR OR RACE 5 SINGLE, MARRIED, WIDOWED, OR
| . DIVORCED (write the word)
A ——
5a if married, widowed or divorced
HUSBAND of
(or) WIFE of
—— anal
6 AGE Years IF LESS than
Months | Days
1 day.........hrs.
7 OCCUPATION OF DECEASED Te
(b) Name of employer
IF STILLBORN, enter that 72 Pe
(a) Trade, profession, or
particular kind of work
& BIRTHPLACE (City) Winshap
(State or country) a yr s
e
9 NAME OF
FATHER
10 BIRTHPLACE OF
FATHER (City)
(State or country)
-—
11 MAIDEN NAME
OF MOTHER
PARENTS
12 BIRTHPLACE OF
MOTHER (City)
(State or country)
13
Informant LY
sila
LLL LAE
(Month) (D (Year)
16 | HEREBY CERTIFY, That! attended deceased from
Sas trays
that Mast saw h alive on.
and that death occurred, on the date s
15 DATE OF DEATH
d above, a
The CAUSE OF DEATH was as follows: (State fully)
aie /
(duration). yrs. ;
CONTRIBUTORY
(Secondary) |
(duration). yrs. mos. ds.
17 Where was disease contracted |
i opvatnisce, ofesthn 2 os a ee a et |
Did an operation precede death For what
Date of operation
Was there an autopsy
ler one year, was infant Breast BE a DP sseedahautpyiasteae ts vecpiteabertoted alteothenaatrs
What test confirme
(Signed) Se M E
(Addres
Date
Pow 8 PLAC DATE QF BURIAL
Few hu - r
Af! 1 52 Vs |
Whe :
14 12 UNDERTAKER
Filed o Ind-
fen! 2 og (Year) REGISTRAR
20 | HEREBY CERTIFY that a satisfactory stan-
dard certificate of death was filed with me
BEFORE the burial or transit permit was issued
WA We, halons
Ran.
Official issue Permit pie ws
th Cogent 5 pei LPL No. ng 2 of.
antianetiel
: L ba 7X
(Approved by U, S. Census and American Public Health Association)
Statement of occupation.—Precise staterhent of occupation is
very important, so that the relative healthfulness of various pursuits
can be known. The question applies to each and every person, irre-
spective of age. For many occupations a single word or term on the
first line will be sufficient, e. g., Farmer or Planter, Physician, Com-
positor, Architect, Locomotive engineer, Civil engineer, Stationary jire-
mam etc. But in many cases, especially in industrial employments,
it is necessary to know (a) the kind of work and also (b) the nature of
the business or industry, and therefore an additional line is provided
for the latter statement; it should be used only when needed. As
examples: (a) Spinner, (v) Cotton mill; (a) Salesman, (b) Grocery;
(a) Foreman, (b) Automobile factory. The material worked on may
form part of the second statement. Never return ‘‘Laborer,” “Fore-
man,” Manager,” 'Dealer,’’ etc., without more precise specification,
as Day laborer, Farm laborer, Laborer—Coal mine, etc. Women at
home, who are engaged in the duties of the household omy (not paid
Housekeepers who receive a definite salary), mify be entered as House-
wife, Housework, or At home, and children, not gainfully employed, as
At school or At home, Care should be taken to report specificaily the
occupations of persons engaged in domestic service for wages, as
Servant, Cook, Housemaid, etc. If the occupation has been changed
or given up on account of the DISHASH CAUSING DEATH, state oceupa-
tion at beginning of illness. If retired from business, that fact may
be indicated thus: Farmer (retired, @ yrs.). Yor persons who have
no occupation whatever, write None.
Statement of cause of death.—Name, first, the Disease Causing
Death (the primary affection with respect to time and causation),
using always the same oecepted term for the same disease, Pxam-
ples: Cerebrospinal fever (the only definite synonym is “Epidemic
cerebrospinal meningitis’); Diphtheria (avoid use of “Croup’’);
Typhoid fever (never report “Typhoid pneumonia’); Lobar pneu-
monia; Bronchopneumonia (“Pneumonia,”’ unqualified, is indefinite) ;
Tuberculosis of lungs, meninges, peritoneum, etc., Carcinoma, Sarcoma,
BUGM, Obici teenscxsonsred (name origin; ‘‘Cancer’’ is less definite; avoid use
of “Tumor” for malignant neoplasms); Measles; Whooping cough;
Chronic valuular heart disease; Chronic interstitial nephritis, etc. The
contributory (secondary or intercurrent) affection need not be stated
unless important. Example: Measles (disease causing death), 29 ds.;
Bronchopneumonia (secondary), 10 ds. Never report mere symptoms
or terminal conditions, such as ‘‘Asthenia,”’ Anemia’ (merely symp-
tomatic), “Atrophy,” ‘“‘Collapse,”’ “Coma,” “Convulsions,”’ ‘“Debility”
(‘‘Congenital,” ‘‘Senile,”’ ete.), ‘Dropsy,” “Exhaustion,” “Heart
failure," ‘‘Hemorrhage,” “Tnanition,’’ ‘‘Marasmus,’”’ ‘Old age,”
“Shock,” ‘Uremia,”’ ‘Weakness,’ etc., when a definite disease
can be ascertained as the cause, Always qualify all diseases resulting
from childbirth or miscarriage, as ‘‘PUBRPERAL septicemia," ‘PUERPERAL
peritonitis,” ete.
State cause for which surgical operation was undertaken.
(Recommendations on statement of cause of death approved by Com-
mittee on Nomcnelature of the American Medical Association.)
Bronchopneumonia: If primary cause, write the word
‘‘primary’’; if secondary, give primery cause.
Certificates will be returned for additional information
which give any of the following diseases, without explanation,
as the sole cause of death: Abortion, cellulitis, childbirth,
convulsions, hemorrhage, gangrene, gastritis, erysipelas, menin-
gitis, miscarriage, necrosis, peritonitis, phlebitis, pyemia,
. septicemia, tetanus.
EXTRACTS
i FROM THE LAWS oF THE
COMM NWEAt TH OF MASSACHUSETTS
GOVERNING THE
RETURN OF CERTIFICATES OF DEATH
A physician or registered hospital medical officer shall forth-
with, 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 registra-
tion a standard certificate of death, stating to the best of his knowl-
edge and belief the name of the deceased, his supposed age, the disease
of which he died, defined as required by section one, 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.....den. Laws, Chap. 46,
Sec. 9.
No undertaker or other person shall bury or otherwise dispose of a
human body in a town, or removo therefrom a human body which has
not been buricd, until he has received a permit from the board of
health or its agent appointed to issue such permits, or if there is no
such board, from the clerk of the town where the person died; and no
undertaker or other person shall exhume a human body and remove
it from a town, or from one cemetery to another, until he has received
a permit from the board of health or its agent aforesaid or from the
clerk of the town where the body is buried. No such permit shall be
issued until there shall have been delivered to such board, agent or
clerk, as the case may be, a satisfactory written statement containing
the facts required by law to be returned and recorded, which shall be
accompanied, in case of an original interment, by a satisfactory certi-
ficate of the attending physician, if any, 2s required 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 ob-
tained early enough for the purpose, or is insufficient, a physician
who is a member of the board of health, or empioyed 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. If the death certi-
ficate coritains a recital, as required by section ten of chapter forty-six,
that the deceased served in the army, navy or marine corps of the
United States in any war in which it has been engaged, such recital
shall appear upon the permit. The board of health or its agent,
upon receipt of such statement and certificate, shall forthwith counter-
sign it and transmit it to the clerk of the town for registration. The
person to whom’ the permit is so given and the physician certifying
the cause of death shall thereafter furnish for registration 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.—Chap. 114, Sec. 45, G. L., as amended.
Medical examiners shall make examination upon the view of the
dead bodies of onty such persons as are supposed to have died by
violence.—Gen. Laws, Chap. 38, Sec. 6.
...He shall in all eases certify to the town elerk or registrar in the
place where the deceased died his name and residence, if known;
otherwise a description as full as may be, with the cause and manner
of death.—Gen. Laws, Chap. 38, Sec. 7.
No undertaker or other person shall bury a human body or the
ashes thereof which have been brought into the commonwealth until
he has received a permit so to do from the board of health or its agent
appointed to issue such permits, or if there is no such board, from the
clerk of the town where the body is to be buried or the funeral is to
be held, or from a person appointed to have the care of the cemetery
or burial ground in which the interment is made.—Chap. 114, See, 45,
G, L., as amended,
may be properly classified. Exact statement of OCCUPATION is very important.
4312
The Commonwealth of Massachusetts
Boston
STANDARD CERTIFICATE OF DEATH City re : a
1 PLACE OF DEATH Registered No.
(Place of death)
nee ERED ees ss Rentge Registered No. # E
(Place of residence)
City or town__BOStOn so, ~HAYMARKET RELIEF STATION cst, Wara
(If death occurred in a hospital or institution, give its NAME instead of street and number)
IIE ———E——————————————————e
If in the Army or Navy of the United States, give rank, organization, e
(a) Residence. State_MASS, -——S—SCity or Town__WINTHROP No THORNTON PK, st.
(Usual place of abode)
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
PERSONAL AND STATISTICAL PARTICULARS MEDICAL CERTIFICATE OF DEATH
3 SEX 4 COLOR OR RACE 5 SINGLE, MARRIED, WIDOWED, OR J AN |
DIVORCED (write the word) 15 DATE OF DEATH 1928
(Month) (Day) (Year)
Fe, | W, =! . ..W, ..__|ié THEREBY CERTIFY, That I attended deceased from
5a If married, widowed, cr divorced
saneot RE FREDERICK =| gear reer :
that Ilast saw h_** _alive on Ld , 19.28 ,
If LESS ee
1 Satis |and that death occurred, on the date stated above, POEL, 28 dsc eers e
6 8 | The CAUSE OF DEATH was as follows: (State fully)
If STILLBORN, enter that fact here |
6 AGE Years Months Days
BGEREGRAL HEMORRHAGE
7 OCCUPATION OF DECEASED (DR, MAGRATH CONSULTED) cS
[aiid WOUSEREEPER |
() N t : (duration) yrs. mos, ds.
2 hale CONTRIBUTORS. | eS eee
(SECONDARY)
ee ee SBOE Keity ox town) —____—________ (duration) yrs. mos. ds.
(State or country) j RE LA N ‘OS. ae 17 Where was disease contracted
eke OF if not at place of death
FATHER T eaters CU AMOTHY SCULEV M 0 T H Y S C U L L i Did an operation precede death________ For what.
@
10 BIRTHPLACE OF i
NNR tect 88 || Date of operation —_-_—___—
z (State or country) IRELAND Was there an autopsy
| A AAA
@| i1 ae What test confirmed diagnosis.
< (Signed) ___ __ GEORGE R, MURPHY M.D.
| 12 BIRTHPLACE OF
CUES CGR San 1) a aR i (Address)
(State or country) }RELAND Date JAN, 20, 1928
DA’
- FRED CURTIS F RED C U RT } Ss 18 PLACE OF BURIAL, CREMATION, OR REMOVAL TE OF BURIAL
(Address) eh aaa OP eee otoeceeer | eidtmcfeA VARY (City or town) -23 19 28
14 19 UNDERTAKER ADDRESS
Filed_J AN, 24 JAN, 24, 19 » LCOTH Zlerrev
rua Bann LLL era Je S. WATERMAN
Registrar of city or town where deceased resided
arr14. 1q72&
plied. AGE should be stated EXACTLY. PHYSICIANS should state CAUSE OF DEATH in plain terms, so that it may. be properly classified"
-301
See instructions and extracts from the laws on back of certificate.
Exact statement of OCCUPATION is very important.
OFFICE OF THE SECRETARY
DIVISION OF VITAL STATISTICS
1PLACE OF DEATH
CityorTown_ Winthrop
Bayt OeeORE Seater tas SYED te
N 09 5
Che Commonmealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
Winthrop
(City or town)
{ Pe eGgs es SSS Registered wos? PS,
Court Rd. St.,___Ward
200,000. 9-26. NO. 6373
2FULL NAME__Mary Louise Harwood
(lf death occurred in a hospital or institution, give its NAME instead of street and number)
a) Residence. No. 95 Court Rd
(Usual place of abode)
Length of residence in city or town where death occurred
years months
PERSONAL AND STATISTICAL PARTICULARS
days.
(17 U. 5. War Veteran, specify WAR)
Si =.S= * Ward.
(If non-resident give city or town and state)
if of foreign birth? years months
MEDICAL CERTIFICATE OF DEATH
How long in U. S.,
3 SEX 4 COLOR OR RACE 5 SINGLE, MARRIED, WIDOWED, OR
te
DIVORCED (write the word)
5a If married, ered or divorced
Single
D of
(or) WIFE of
Months
-F Sid be ee
IF STILLBORN, enter that fact here
IF LESS than
Inday;...4.8 hrs.
Years Days |
26
7 OCCUPATION OF DECEASED
(a) Trade, profession, or :
particular kind of work ;
(b) Name of employer
15 DATE OF DEATH os L i 7 1F
(Month) (Day) (Year)
Warren
8 BIRTHPLACE (City)
(State or country)
Vass
9 NAME OF
FATHER
10 BIRTHPLACE OF
FATHER (City)
Warren Vass
(Siate or country)
11 MAIDEN NAME fa
OF MOTHER 3
Vinnie Delores — i
ee 3 WO, Breckfield
PARENTS
(State or country)
13
Informant_ Git) Be Harwoo d
(Address) 95
Pine Grove Li seem
(Cemetery) Pes or town
EBY CERTIFY that a satisfactory stan-
dard certificate of death was filed with me
BEFORE the burial or transit permit was issue
Date of
Official ; issue
post of permi
CERTIF
ae
16 | HERE That | ny deceased from
<< )
that | last saw h__4“alive ee a
and that death occurred, on the date stated above, at__ ie a
The CAUSE OF DEATH was as follows: (State fully)
é } i — =
Le —s - x Vo 7
(duration). yrs. nis = _- de:
CONTRIBUTORY i
(Secondary)
(duration). yrs. mos. ds.
17 Where was disease contracted
if not at place of death
Did an operation precede Bae Pa r,, Whatton ae
Date of operation
Was there an autopsy
What test HG je
(Signed)
18 PLACE OFBURIAL, CREMATION, OR REMOVAL
DATE OF BURIAL
Eee
o£
Cis fal .
m
OX, o
ITEDSTATESSTANDARD CERTIFICATE OF DEATH
(Approved by U. S. Census and American Public Health Association)
Statement of occupation.—Precise statement of occupation is
very important, so that the relative healthfulness of various pursuits
can be known. The question applies to each and every person, irre-
spective of age. For many occupations a single word or term on the
first line will be sufficient, e. g., Farmer or Planter, Physician, Com-
positor, Architect, Locomotive engineer, Civil engineer, Stationary jire-
man, ete. But in many cases, especially in industrial employments,
it ig necessary to know (a) the kind of work and also ()) the nature of
the business or industry, and therefore an additional line is provided
for the latter: statement; it should be used only when needed. As
examples: (a) Spinner, (b) Cotton mill; (a) Salesman, (b) Grocery;
(a) Foreman, (b) Automobile factory. The material worked on may
form part of the second statement. Never return ‘‘Laborer,” ‘‘Fore-
man,” Manager,” ‘Dealer,’ etc., without more precise specification,
as Day laborer, Farm laborer, Laborer—Coal mine, etc. Women at
home, who are engaged in the duties of the household ony (not paid
Housekeepers who receive a definite salary), may be entered as House-
wife, Housework, or At home, and children, not gainfully employed, as
‘At school or At home. Care should be taken to report specificaily the
occupations of persons engaged in domestic service for wages, as
Servant, Cook, Housemaid, ete. If the occupation has been changed
or given up on account of the DISPASE CAUSING DPATH, State occupa-
tion at beginning of illness. If retired from business, that facet may
be indicated thus: Farmer (retired, 6 yrs.). For persons who have
no oceupation whatever, write None.
Statement of cause of death.—Name, first, the Discase Causing
Death (the primary affection with respect to time and causation),
using always the same accepted term for the same disease. .xam-
ples: Cerebrospinal fever (the only definite synonym is “Epidemic
cerebrospinal meningitis’); Diphtheria (avoid use of ‘Croup’’);
Typhoid fever (never report “Typhoid pneumonia’); Lobar pneu-
monia; Bronchopneumonia (“Pneumonia,”’ unqualified, is indefinite) ;
Tuberculosis of lungs, meninges, peritoneum, etc., Carcinoma, Sarcoma,
WSLO MOL 7 -cccdhe ss caitans (name origin; ‘‘Cancer’’ is less definite; avoid use
of “Tumor” for malignant neoplasms); Measles; Whooping cough;
Chronic valuular heart disease; Chronic interstitial nephritis, ete. The
contributory (secondary or intercurrent) affection need not be stated
unless important. Example: Measles (disease causing death), 29 ds.;
Bronchopnewmonia (secondary), 10 ds. Never report mere symptoms
or terminal conditions, such as ‘‘Asthenia,” ‘Anemia’ (merely symp-
tomatic), “Atrophy,” ‘‘Collapse,”’ “Coma,” Convulsions,” “Debility”
(““‘Congenital,” ‘Senile,’ ete.), “Drops " “Txhaustion,” ‘Heart
failure,” ‘‘Hemorrhage,’’ ‘“‘Inanition,”’ “Marasmus,” “Old age,”
“Shock,’”’ ‘Uremia,”’ ‘Weakness,’ ctc., when a definite diseare
can be ascertained as the cause. Always qualify all diseases resulting
from childbirth or miscarriage, a8 ‘‘PUDRPERAL septicemia,” ‘PUERPERAL
peritonitis,” ete.
State cause for which surgical operation was undertaken.
(Recommendations on statement of cause of death approved by Com-
mittee on Nomenclature of the American Medical Association.)
Bronchopneumonia: If primary cause, write the word
‘‘primary’’; if secondary, givo primary cause.
Certificates will be returned for additional information
which give any of the following diseases, without explanation,
as the sole causo of death: Abortion, cellulitis, childbirth,
convulsions, hemorrhago, gangrene, gastritis, erysipelas, menin-
gitis, miscarriage, necrosis, peritonitis, phlebitis, pyemia,
septicemia, tetanus,
EXTRACTS
FROM THE LAWS CF THE
COMMONWEALTH OF MASSACHUSETTS
GOVERNING THE
RETURN OF CERTIFICATES OF DEATH
A physician or registered hospital medical officer shall forth-
with, 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 .registra-
tion a standard certificate of death, stating to the best of his knowl-
edge and belief the name of the deceased, his supposed age, the disease
of which he died, defined as required by section one, 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.....den. Laws, Chap. 46,
Sec. 9.
No undertaker or other person shall bury or otherwise dispose of a
human body in a town, or remove therefrom a human body which has
not been buried, until he has received a permit from the board of
health or its agent appointed to issue such permits, or if thére is no
such board, from the clerk of the town where the person died; and no
undertaker or other person shall exhume a human body and remove
it from a town, or from one cemetery to another, until he has received
a permit from the board of health or its agent aforesaid or from the
clerk of the town where the body is buried. No such permit shall be
issued until there shall have been delivered to such board, agent or
clerk, as the case may be, a satisfactory written statement containing
the facts required by law to be returned and recorded, which shall be
accompanied, in case of an original interment, by a satisfactory certi-
ficate of the attending physician, if any, as required 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 ob-
tained early enough for the purpose, or is insufficient, a physician
who is a member of the board of health, or employed by it or by the
selectmen for the purpose, shall upon application make the certificate
required of the attending physician. lf death is caused by violence,
the medical examiner shall meke such certificate. If the death certi-
ficate contains a recital, as required by section ten of chapter forty-six,
that the deceased served in the army, navy or marine corps of the
United States in any war in which it has been engaged, such recital
shall appear upon the permit. The board of health or its agent,
upon receipt of such statement and certificate, shall forthwith counter-
sign it and transmit it to the clerk of the town for registration. The
person to whom the permit is so given and the physician certifying
the cause of death shall thereafter furnish for registration 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.—Chap. 114, Sec. 45, G, L., as amended,
Medical examiners shall make examination upon the view of the
dead bodies of oniy such persons as are supposed to have died by
violence.—Gen. Laws, Chap. 38, Sec. 6.
He shall in all cases certify to the town clerk or registrar in the
place where the deceased died his name and residence, if known;
otherwise a description as full as may be, with the cause and manner
of death —Gen. Laws, Chap. 38, Sec. 7.
No undertaker or other person shall bury a human body or the
ashes thereof which have been brought into the commonwealth until
he has received a permit so to do from the board of health or its agent
appointed to issue such permits, or if there is no such board, from the
clerk of the town where the body is to be buried or the funeral is to
be held, or from a person appointed to have the care of the cemetery
or burial ground in which the interment is made.—Chap. 114, Sec. 46,
G. L., as amended,
Exact statement of OCCUPATION is very important. See instructions on back of certificate.
The Commonmealth of Massachusetts
tks. 2 eee Cambrids
STANDARD CERTIFICATE OF DEATH ie ea — st
1 PLACE OF DEATH Registered No. 106 _
bir 8 \ ace O:
Gounty Middlesex State Mass. Registered tS A ay de wes
(Place of residence)
eer Sona Gabaea ARS Heh we perro
ed in a hospital or institution,
(If death its NAME instead of street and number)
2 FULL NAME Elizabeth M |
(If in the Army or Navy of the United States, give rank, organization, etc.)
(a) Residence. State Mass, City or Town_\jinth rop No._ 68 Creg+——__—__St. |
(Usual place of abode) (|
Length of residence im city or town where death occurred years months days. How long in U. S., if of foreign birth? years months days
— |
PERSONAL AND STATISTICAL PARTICULARS MEDICAL CERTIFICATE OF DEATH
€ 2
15 DATE OF DEATH :
(Month) (Day) (Year)
4 COLOR OR RACE 5 SINGLE, MARRIED, WIDOWED, OR
DIVORCED (write the word)
iy ' I HEREBY CERTIFY, That I attended deceased from
5a If ‘ied, widowed, or divorced | 5 Jan 24255
Lam = Pie eth ee
re that I last saw h_€@T alive on Jan 719. 28 i
and that death occurred, on the dated stated above, it BPS {
The CAUSE OF DEATH was as follows: |
Cancer of 3reast
7 OCCUPATION OF DECEASED
(a) Trade, profession, or
particalar kind of work
Candy Maker
he Oe ee ee re yrs. mos. ds. 4
CONTRIBUTORY. == |
8 BIRTHPLACE (city or town) 30s ton (SECONDARY) |
(duration) ™ yrs. mos. ds.
(State or country)
9 NAME OF
FATHER
17 Where was disease contracted
if not at place of death?_____ h ome
3sermard
Did an operation precede death? no Date of.
| 10 BIRTHPLACE OF eo
. FATHER (city or town) Feland Sia tidate ari wuitepes? =
State ee .
w ( See) What test confirmed diagnosis? C Bi nica 1 {
tz| 11 MAIDEN NAME ; ‘ a Bi
<| OF MOTHER ann Sheridan Simead) Selix Me Girr 2 » MD.
| 12 BIRTHPLACE OF aoa 1436 Cambridge 3
MOTHER (city or town) — pe ere ahs
pte Jan 24 1928 ;
18 PLACE OF BURIAL, CREMATION, OR REMOVAL
| 7 se oe : -EM 30316 ¢ Jan 2648. 8
M4 wa Jan 25 1928. ae og / -j}a9 UNDERTAKER ADDRESS
Registrar of Gy or town where death cared |) TO) WO Maley Winthrop |
(State or country)
Ireland
DATE OF BURIAL
ieien eS Ce. Gres
68
Registrar of city or town where deceased resided
Statement of occupation.—Precise statement of occupation is
very important, so that the relative healthfulness of various pursuits
can be known. The question applies to each and every person, irre-
spective of age. For many occupations a single word or term on the
first line will be sufficient, e. g., Farmer or Planter, Physician, Composi-
tor, Architect, Locomotive engineer, Civil engineer, Stationary fireman, etc.
But in many cases, especially in industrial employments, it is necessary
to know (a) the kind of work and also (b) the nature ot the business or
industry, and therefore an additional line is provided for the latter state-
ment; it should be used only when needed. As examples: (a) Spinner,
(b) Cotton mill; (a) Salesman, (b) Grocery; (a) Foreman, (b) Automobile
factory. The material worked on may form part of the second state-
ment. Never return ‘‘Laborer,” ‘‘Foreman,”’ ‘‘Manager,” “Dealer,”
etc., without more precise specification, as Day Laborer, Farm Laborer,
Laborer—Coal mine, ete. Women at home, who are engaged in the
duties of the household only (not paid Housekeepers who receive a defi-
nite salary), may be entered as Housewife, H ousework, or Athome, and
children, not gainfully employed, as At school or At home. Care should
be taken to report specifically the occupations of persons éngaged in
domestic service for wages. as Servant, Cook, Housemaid, etc. If the
occupation has been changed or given up on account of the DISEASE
CAUSING DPATH, state occupation at beginning of illness. If retired
from business, that fact may be indicated thus: Farmer (retired, 6 yrs.).
For persons who have no occupation whatever, write None.
Statement of cause of death.—Name, first, the DIsrase CAUSING
DEATH (the primary affection with respect to time and causation), using
always the same accepted term for the same disease. Examples: Cere-
brospinal fever (the only definite synonym is “Epidemic cerebrospinal
meningitis”); Diphtheria (avoid use of “‘Croup’’); Typhoid Fever (never
report “Typhoid pneumonia’’); Lobar pnewmonia; Bronchopneumonia
(“Pneumonia,” unqualified, is indefinite) ; Tuberculosis of lungs, men-
inges, peritoneum, etc., Carcinoma, Sarcoma, etc., Ob ionic (name
origin; “Cancer” is less definite; avoid use of “Tumor” for malignant
neoplasms); Measles; Whooping cough; Chronic valvular heart disease;
Chronic interstitial nephritis, etc. The contributory (secondary or inter-
current) affection need not be stated unless important. Example:
Measles (disease causing death), 29 ds.; Bronchopneumonia (secondary),
10 ds. Never report mere symptoms or terminal conditions, such as
“Asthenia,” ‘‘Anemia’”’ (merely symptomatic), “Atrophy,” ‘“Col-
lapse,”’ “‘Coma,” “Convulsions,” ‘‘Debility” (“‘Congenital,’’ ‘‘Senile,”
etc.), ‘‘Dropsy,” “Exhaustion,” “Heart failure,” ‘Hemorrhage,”’ ‘‘Ina-
nition,” ‘‘Marasmus,” “Old age,’’ “Shock,” “Uremia,’”’ ‘“‘Weakness,”
ete., when a definite disease can be ascertained as the cause. Always
qualify all diseases resulting from childbirth or miscarriage, as ‘‘PUDR-
PPRAL septicemia,” ““PUERPPRAL peritonitis,” etc.
State cause for which surgical operation was undertaken.
(Recommendations on statemeat of cause of death approved by Com-
mittee on Nomenclature of the American Medical Association.)
Bronchopneumonia: If primary cause, write the word ‘‘pri-
mary;’’ if secondary, give primary cause.
Certificates will be returned for additional information which
give any of the following diseases, without explanation, as the
sole cause of’death: Abortion, cellulitis, childbirth, convulsions,
hemorrhage, gangrene, gastritis, erysipelas, meningitis, miscar-
riage, necrosis, peritonitis, phlebitis, pyemia, septicemia,
tetanus.
FROM THE LAWS OF THE "OST
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 stand-
ard 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 as required by section one, where same was contracted, the du-
ration of his last illness, when last seen alive by the physician or officer
and the date of his death. ...—Gen. Laws, Chap. 46, Sec. 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 con-
taining the facts required by law to be returned and recorded,
which shall be accompanied, in case of an original interment, by a satis-
factory certificate of the attending physician, if any, as required 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 insuffi-
cient, a physician who is a member of the board of health, or em-
ployed byitorby the selectmen for the purpose, shall upon ap-
plication make the certificate required of the attending physi-
cian. 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 registration 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.—Gen. 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 vio-
lence.—Gen. Laws, Chap. 38, Sec. 6.
_..He shall in all cases certify to the town clerk or registrar in the
place where the deceased died his name and residence, if known; other-
wise a description as full as may be, with the cause and manner of death.
—Gen. 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 wil! 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 poison), thermal, or electrical
agents, and deaths following abortion, but also deaths from disease
resulting from injury or infection related to occupation, the
sudden deaths of persons not disabled by recognized disease,
and those of persons found dead.
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4312
The Commonwealth of Massachusetts SE
STANDARD CERTIFICATE OF DEATH City or By
1 PLACE OF DEATH Registered No. ee
(Place pt )
Suffolk
Ee ee ea i OS 3 Repinteréd No Jee
Boston (Place of residence)
City or town No. E, HOSPITAL FOR WOMEN St., Ward
(If death oceurred in a hospital or institution, give its NAME instead of street and number)
ULL NAME :
2F (If in the Army or Navy of the United States, give rank, organization, etc.)
(a) Residence. State_MASS, _—s———sGity or Town__W. THROP No. 292 WINTHROP St.
(Usual place of abode)
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
PERSONAL AND STATISTICAL PARTICULARS By MEDICAL CERTIFICATE OF DEATH
3 SEX | 4 COLOR OR RACE 5 SINGLE, MARRIED, WIDOWED, OR
DIVORCED (write the word) 15 DATE OF opera REG gs)
W M 3 (Month) (Day) (Year)
ee ® is §| HEREBY CERTIFY, That I attended deceased from
5a If married, widowed, or divorced 6
HUSBAND et SL eee 19 27 © te. WAR 26 1928 ,
Name of } (or) WIFE J OSEP H 6
| If LESS than that I last saw i SM alive Pa Se 1 Cee Sr 19.28
6 AGE Years Months Days
*| Iday,....hrs. | and that death occurred, on the date stated above, —e #55 P=
73 or... .min. The CAUSE OF DEATH was as follows: (State fully)
es
If STILLBORN, enter that fact here
“LOBAR PNEUMONIA
7 OCCUPATION OF DECEASED
ae Trade, Ren Se Mme yor ear =n
Po ‘kind ° A Eee sta. TPS
(b) Name of lo | Se Se ee eo ee. eS duration), yrs.
e of employer
| cowrmmutoryC HRONIC MYOCARDITIS
EE LR itn town) ee Semconpary) TERRE ein spe a
EE al |17 Where was disease contracted
9 NAME OF if not at place of dea’
PAtHER _ FaTHER JAMES SHIPPERLVY A ME s S H ! P P E R L Y Did an operation precede death____ For what__
®) 10 BIRTHPLACE OF “
a FATHER (city or town) a CER eee eee eee
2 (State or country) Was there an autopsy __ NQ
=| Gutecreonty) == ENGLAND ae
o:| 11 MAIDEN NAME % What test confirmed diagnosis USUAL Cit
q|__ormotaer | SUSAN wemwemmmm-= | | MARJORIE WOODMAN nel
0.| 12 BIRTHPLACE OF
MOTHER (city or town) RONG ECS a eS
(State or country) EN 6L AN Set Er ia 7 2 2
13 18 PLACE OF BURIAL, CREMATION, OR REMOVAL DATE OF BURIAL
Informant SU NSSPARR eo ce 8. H ' ae 8
a Leo, ass, CC REARE ’ (City or town) » 19,
14 19 UNDERTAKER ADDRESS
>
Filea-4//- 3, 1928
Biel hits 3 0- 1928
= ® Registrar of city or town where death occurred J . S » W ATER MA Wi & Ss ON $s
Registrar of city or town where deceased resided
au
'
®
°
—
plied. 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.
200,000. 9-26. NO. 6373
RTT
7-20M ,
OFFICE OF THE SECRETARY Che Commonwealth of Massachusetts |
DIVISION OF VITAL STATISTICS STANDARD CERTIFICATE OF DEATH BOSTON H
1PLACE OF DEATH i (Ci dntowa = ae ik
| LS Pat Cee eee Wie Le Registered gan 5 2-8 \
City or Town__ ay No. St, Ward H
(lf death occurred in a hospital or instituti ive its NAME instead of street and number)
a) Residence. met HD
_ (Usual place of abode)
Length of residence in city or town where death occurred
St,,___ Ward, Min thse, Peoes
(lf non-resident give or ta and sate a -
How long in U. S., if of foreign birth? ears months
MEDICAL CERTIFICATE OF DEATH
kA SAG |
onth) (Day) (Year) .
16 LHERE = CE B Ta That | attended, deceased fro
_ ekki Pn pt eb nd 19-2
ve de ’ 2.
months
' PERSONAL AND STATISTICAL PARTICULARS
3 SEX 4 COLOR OR RACE | 5 SINGLEMARRIED, WIDOWED;-OR
BWORCED (write the word)
15 DATE OF DEATH
5a if married, widowed or divorced
,
(or) WIFE of J
~ that | last saw h4g ____alive on 19.
6 AGE Years Months Days IF LESS than 4
1 day,.......hrs. |] and that death occurred, on the date stated above, a FA. Li m. 1)
Uf. wee ; & pa The CAUSE OFDEATH was as follows: pate fully) ; (
al
—
IF STILLBORN, enter that fact here
Ae “a ws 14%
)
7 OCCUPATION OF DECEASED
(a) Trade, profession, or
particular kind of work
eit) craplover (duration). yrs mos ‘ds: :
CONTRIBUTORY
(Secondary)
& BIRTHPLACE (City) 4 Vrirab Le, lat Se (duration). yrs. mos. =. = ds!
(State or country) 17 Where was disease contracted
= if not at place of death
? hag LI (Purr: La oO Cntisieo Did an operation precede deat PA Sco Whatse At BB Re
Date of operation
on 10 BIRTHPLACE OF
. FATHER (City) :
= . Gtate or country) Wap there fa,autaps ear, was infant Breast 3 FS ie RR) REE ee
c | 11 MAIDEN 3 IAS as Be What test confirmed diagnosis _ {
OF MOTHER Ae eg PS —=
a : Gece (Signed) fO24 422-3 _.M.D.
12 BIRTHPLACE OF ae ha
MOTHER (City) % (Address) SY QV Z LODLY AD
, (State or country) Z 32 ry ‘3 > ee . Y Unc? pas
13 ? f - OF BURIAL, CREMATION, OR REMOVAL DATE OF BURIAL
Informant - cy Fe
(Address) er (City or town) OK >
ADDRESS
Cine ae (|
Date of
sacar fe see EDS cd
“a aed
onth) (Day) (Wear)
20 1 HEREBY CERTIFY that a satisfactory stan-
dard certificate of death was filed with me
BEFORE the burial or transit permit was issue
er
Statement of occupation.—Precise statement of occupation is
very important, so that the relative healthfulness of various pursuits —
can be known. The question applies to each and every person, irre-
spective of age. For many occupations a single word or term on the
first line will be sufficient, e. g., Farmer or Planter, Physician, Com-
positor, Architect, Locomotive engineer, Civil engineer, Stationary fire-
man, etc. But in many cases, especially in industrial employmants,
a
it is necessary to know (a) the kind of work and also (b) the nature of ©
the business or industry, and therefore an additional line is provided
for the latter statement; it should be used only when needed. As
examples: (a) Spinner, (b) Cotton mill; (a) Salesman, (b) Grocery;
(a) Foreman, (b) Automobile factory. The material worked on may
form part of the second statement. Never return “Laborer,” ‘‘Fore-
man,” Manager,” “Dealer,” ete., without more precise specification,
as Day laborer, Farm laborer, Laborer—Coal mine, etc. Women at
home, who are engaged in the duties of the household onty (not paid
Housekeepers who receive a definite salary), may be entered as House-~
wife, Housework, or At home, and children, not gainfully employed, as
At school or At home. Care should be taken to report specifienily the
occupations of persons engaged in domestic service for wages, 23
Servant, Cook, Housemaid, ete. If the occupation has been changed
or given up on account of the DISEASE CAUSING DEATH, state occupa-
tion at beginning of illness. If retired from business, that fact may
be indicated thus: Farmer (retired, 6 yrs.). Yor persons who have
no occupation whatever, write None.
Statement of cause of death.—Name, first, the Discase Causing
Death (the primary affection with respect to time and causation),
using always-the.same_accepted term forthe same_discase._Exam->.»——geeompanied,-in-ease-of-an-eriginalinterment, Jpy.n-satisfactory-certie
ples: Cerebrospinal fever (the only definite synonym is ‘‘Epidemic
cerebrospinal meningitis’); Diphtheria (avoid use of ‘“Croup’’);
Typhoid fever (never report “Typhoid pneumonia’); Lobar pneu-
monia; Bronchopneumonia (“Pneumonia,” unqualified, is indefinite);
Tuberculosis of lungs, meninges, peritoneum, etc., Carcinoma, Sarcoma,
(name origin; ‘‘Cancer’’ is less definite; avoid use
of “Tumor” for malignant neoplasms); Measles; Whooping cough;
Chronic valvular heart disease; Chronic interstitial nephritis, ete. The
contributory (secondary or intercurrent) affection need not be stated
unless important. Example: Measles (disease causing death), 29 ds.;
Bronchopneumonia (secondary), 10 ds. Never report mere symptoms
or terminal conditions, such as ‘‘Asthenia,’’ “Anemia” (merely symp-
tomatic), ‘“Atrophy,’’ ‘‘Collapse,’ “Coma,” “Convulsions,” ‘‘Debility”
(‘‘Congenital,”’ ‘‘Senile,’’ ete.), “Dropsy,” ‘Exhaustion,” ‘Heart
failure,” ‘Hemorrhage,’ “TInanition,”’ ‘‘Marasmus,” “Old age,’’
“Shock,” ‘Uremia,”’ ‘Weakness,’ etc., when a definite disease
can be ascertained as the cause. Always qualify all diseases resulting
from childbirth or miscarriage, as “PUERPERAL septicemia,” ‘‘PUPRPERAL
peritonitis,” ete.
State cause for which surgical operation was undertaken.
(Recommendations on statement of cause of death approved by Com-
mittee on Nomenclature of the American Medical Association.)
Bronchopneumonia: If primary cause, write the word
‘‘primary’’; if secondary, give primary cause.
Certificates will be returned for additional information
which give any of the following diseases, without explanation,
as the sole cause of death: Abortion, cellulitis, childbirth,
convulsions, hemorrhage, gangrene, gastritis, erysipelas, menin-
gitis, miscarriage, necrosis, peritonitis, phlebitis, pyemia,
septicemia, tetanus,
6
CA IMNAV tS
FROM THe LAWS OF THE
COMMONWEALTH OF MASSACHUSETTS
GOVERNING THE
RETURN OF CERTIFICATES OF DEATH
A physician or registered hospital medical officer shall forth-
with, 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 registra-
tion a standard certificate of death, stating to the best of his knowl-
edge and belief the name of the deceased, his supposed age, the disease
of which he died, defined as required by section one, 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.....Gen. Laws, Chap. 46,
Sec. 9.
No undertaker or other person shall bury or otherwise dispose of a
human body in a town, or remoye therefrom a human body which has
not been buried, until he has received a permit from the board of
health or its agent appointed to issue such permits, or if there is no
such board, from the clerk of the town where the person died; and no
undertaker or other person shall exhume a human body and remove
it from a town, or from one cemetery to another, until he has received
a permit from the board of health or its agent aforesaid or from the
clerk of the town where the body is buried. No such permit shall be
issued until there shall have been deiivered to such board, agent or
clerk, as the case may be, a satisfactory written statement containing
the facts required by law to be returned and recorded, which shall be
ficate of the attending physician, if any, as required by law, or in licu
thereof a certificate as hereinafter provided. If there is no attending
physician, or if, for sufficient reasons, his certificate cannot be ob-
tained carly enough for the purpose, or is insufficient, a physician
who is a member of the board of health, or employed 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. If the death certi-
ficate contains a recital, as required by section ten of chapter forty-six,
that the deceased served in the army, navy or marine corps of the
United States in any war in which it has been engaged, such recital
shall appear upon the permit. The board of health or its agent,
upon receipt of such statement and certificate, shall forthwith counter-
sign it and transmit it to the clerk of the town for registration. The
person to whom the permit is so given and the physician certifying
the cause of death shall thereafter furnish for registration 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.—Chap. 114, Sec. 45, G. L., as amended.
Medical examiners shall make examination upon the view of the
dead bodies of oniy such persons as are supposed to have died by
violence.—Gen. Laws, Chap. 38, Sec. 6.
_..He shall in all cases certify to the town clerk or registrar in the
place where the deceased died his name and residence, if known;
otherwise a description as full as may be, with the cause and manner
of death.—Gen. Laws, Chap. 38, Sec. 7.
No undertaker or other person shall bury a human body or the
ashes thereof which have been brought into the commonwealth until
he has received a permit so to do from the board of health or its agent
appointed to issue such permits, or if there is no such board, from the
clerk of the town where the body is to be buried or the funeral is to
be held, or from a person appointed to have the care of the cemetery
or burial ground in which the interment is made.—Chap. 114, Sec. 46,
G. L., as amended,
4
16, 227- |
es OFFICE OF THE SECRETARY The Commontwealth of Massachusetts
S&S DIVISION OF VITAL STATISTICS d ie ee tG
=o 3 Medical Examiner’s Certificate of Death == ‘City or towny 000" |
|= 3 1 PLACE OF DEATH (IssUED UNDER THE PROVISIONS OF GENERAL Laws, CHAPTER 38) |
Oo i
pa County..........-.. Me Wee eS CUT Pee Si oe ne eee ae Registered No. .......-........:0:000 i
5 g ; City or Town.....’ _ Pai. Cee Meee ae een ee eee No. ... fs Stas Ward (
a=. (If death ogcurred in a hospital or institution, give its NAME instead of street and number) |
233 [Rear douls
$453) 2 FULL NaME ..A/4K2a.__.. rt OVD Hi eran eM
ont nN in the Army or Navy of the United States, give rank, organization, etc.
An 3% (a) Residence. nol AJ senbleop., 63 ae AMA =...St., ee Wir i aral ee e ee o e eeeS
dD (Usual place of abode) (If non-resident, give city or town and state) \|
oe iA S Length of residence In city or town where death occurred years months days How long In U.S., If of toreign birth? years months days
. a a ;
gos MEDICAL CERTIFICATE OF DEATH )
: — =
a5 SINGLE, MARRIED, WIDOWED, OR .
gé 5 SINGLE, MARRIED, even 15 DATE OF DEATH........~\.. GAA W Dnb poonanaaed 2. =
(State or country)
9 NAME OF
FATHER
(See reverse side for description for unknown person)
_10 BIRTHPLACE OF
;
G o
°
. @ » 5 || 5a If married, widowed, or divorced |! HEREBY CERTIFY that I have investigated the
“458 Hel etal of death of the person above-named and that the CAUSE AND MANNER |
nie S 2 ||6 ace Years Months Days if less than || thereof are as follows: +4,
SECS) ee (<0 (ee OL) (oo : “fa
che 2 QS | smi _e < | |
2 Sf... LYS. co ae A... PAZ, oP AV eee ee 1
ie & |] IF STILLBORN, enter that fact here f sit A qe Sion a, |
44 = OME rh aj 5 Spel had area RTs eee neg RAND Ss TM ok eS
ZS 11 7 OCCUPATION OF DECEASED |
= mn (a) Trade, profession, or ee ee eee) Sn oe oteetomct toe acrcsacces scbexaeacber cusse>naeceeelas ss ecqenee eens. cowebe hen epacesa cee «deste rvenscens sme |
4A = particular kind of work ............. LL PO er Ae, EON IG ON EE ‘
Sa5s |
<= 2 (b) Name of employer
~~ 7 y
g 8 BIRTHPLACE (City) rds SY Sth Be =
&
n
=
s
H
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cl
cy
a
=
)
aa)
in terms, so that it may be properly class
—
Sy
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Ze
= &
35
<i
=
Z=
=F 7) Pe Pa RANG RG COLE) pee neree n= @ nanrcnen pean annty menana?rare¥-saunstenacerd-vere+-vaxeurer||\ 10 Where Was injury sustained
z = if not at
x F z (State or country)
Ww
mt
c
SSea <| OF MOTHER
rs Qo
ot rs 12 BIRTHPLACE OF
=i - 8 MOTHER (City) ............-00..- :
=
oS x (State or country)
a | Oale.....................,
Sad 13 Y
Es 3 Informant QQ 7 a >. OSs A Aan a 9 e TE OF Page
— ’ : a 4
he (Address) GPA .,.-mh $5.4 -§ 2Y
ey : onthy (Day) Baw!
aa 4 , : i. } pa
| File debe 7 tale oe S| Seaiaeen ete highs rep aan na sac Sias esnavasecewensenduaseninacenssnans an,
os (Month) (Day) /(Y¥ :) REGISTRAR .
20 Burial permj Official Jj o44 2 Date of
issued by... Cg Se Q L; ELBA... aa Mk badd LA EK 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 at-
tended during his last illness, at the request of an under-
taker 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 clas-
sified under the international classification of causes of
death), where same was contracted, the duration of his
last illness, when last seen alive by the physician or officer
Si the Cate of his death. . . .—General Laws, Chapter 46;
ection 9.
. . » No undertaker or other person shall bury or other-
wise dispose of a human body in a town, or remove there-
from a human body which has not been buried, until he
has received a permit from the board of health... , orif
there is no such board, from the clerk of the town where
the person died; and no undertaker or other person shall
exhume a human body and remove it from a town, or
from one cemetery to another, until he has received a
permit from the board of health... or from the clerk of
the town where the body is buried. No such permit shall
be Issued until there shall have been delivered to such
board, ... or clerk,. . . a satisfactory written statement
containing the facts required by law to be returned and
recorded, which shall be accompanied... by a satisfac-
tory certificate of the attending physician, if ary, as
required by law, or in lieu thereof a certificate as herein-
after 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 physi-
cian who is a member of the board of health, or employed
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 board of
health or its agent, upon receipt of such statement and
certificate, shall forthwith countersign it and transmit
it to the clerk of the town for registration. The per-
son to whom the permit is so given and the physician
certifying the cause of death shall thereafter furnish
for registration any other necessary information which
can be obtained as to the deceased, or as to the man-
ner or cause of the death, which the clerk or regls-
trar may require.— General Laws, Ohap 115, Sec. 45 as
amended.
DESCRIPTION (for unknown person)...............
Medical examiners shall make examination upon the
view of the dead bodies of only such persons as are sup-
posed 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. .. . General Laws,
Ohap, 38, Sec. 6.
.. - He shall in all cases certify to the town clerk or
registrar in the place where the deceased died his name
and residence, 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 physiclans will certify to such deaths
only as those of persons to whom they have given bedside
eare 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 physi-
cian is absent from home when the certificate of death is
needed.
(3) Medical Examiners will investigate and certify to all
deaths supposably due to violence. These include not only
deaths caused directly or indirectly by traumatism (in-
cluding resulting septicemia), and by the action of chemi-
eal (drugs or poisons), thermal, or electrical agents, and
deaths following abortion, but also deaths from disease re-
sulting from Injury 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 ex-
ample: ‘‘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, homicidal.’’ ‘‘Asphyxiation by suspension,
suicidal.”” ‘‘Syncope while under the influence of ether
administered as a surgical anesthetic.” ‘‘Fracture of the
skull with associated internal injury sustained under cir-
cumstances unknown.”
If investigation shows the death to have been due to
disease, specify: (1) Under cause, its known or presumable
nature; and (2) under manner, indicate the circumstances
leading to medico-legal inquiry. For example: ‘‘Hemor-
rhage spontaneous, of the brain (basal ganglia) (found
dead in bed).’” ‘‘Heart disease, presumably coronary
sclerosis. (Sudden death.)’’
~ 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, Sec. 14.
THIS CERTIFICATE CONSTITUTES SUCH PERMIT
eS eee eS Oe eS ee) eee eee
SEVEUS Cur FN FS Se EUV ee eet SE UP ewe eee
oe ee Veet aa || aoe wann yy VC kes Wes Ctr es Seow. See
should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state CAUSE OF DEATH a
f
©
S
it 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.
200,000 9-25 NO. 2662-3.
OFFICE OF THE SECRETARY
DIVISION OF VITAL STATISTICS
Che Commonmealth of Massachusetts |
STANDARD CERTIFICATE OF DEATH
I PLACE OF DEATH (City or town) .
County__¢45 £6} j-—__________________State}ie sg ,_____—— Registered Nea ae i
City or Town Winthro No.vv_ - 53 Reed St. 3 St., Ward
(lf death occurred i in a hospital or institution, give its NAME instead of street and number) i
2 FULL NAME_Anders Prederick Lindbohm __
(If in the Army or Navy of the United States, give rank, organization, etc.)
Si Ward.
(a) Residence. No.6 Reed Sts
(Usual place of abode) ~
Length of residence in city or town where death occurred years months
=
PERSONAL AND STATISTICAL PARTICULARS
4 COLOR OR RACE 5 SINGLE, MARRIED, WIDOWED, OR
DIVORCED (write the word)
White
Married
5a If married, widowed or divorced
HU of
(or) WIFE of
If LESS than
1 day,___hrs.
of____min.
7 ag OF DECEASED
4) 1rade, BSsiOn, OF
2) Mate onteeson, «We tohmen
(b) Name of employer Retired
8 BIRTHPLACE (City)
(State or country)
9 NAME OF
FATHER
10 BIRTHP
FATHER (City)
(State or country)
11 MAIDEN NAME
OF MOTHER
Gweden
PARENTS
12 BIRTHPLACE OF
MOTHER (City)
(State or country)
Sweden
(Month) (Day); (Year)
ZO | HEREBY CERTIFY that a satisfactory stan-
dard certificate of death was filed with me
BEFORE the burial or transit permit was issued
REGISTRAR
days,
(If non-resident give city or town and state)
if of forsign birth? years months days
MEDICAL CERTIFICATE OF DEATH
‘Py 29 (G2 F&
({ (Month) (Year)
| HEREBY CERTIFY, That! attended deceased from
How long in U. S.,
15 DATE OF DEATH
(Day)
16
f , 192), to 19°F,
that | last saw h 4#—~ __alive on , 192,
and that death occurred, on the date stated above, ats- ASS e m. jj
The CAUSE OF DEATH was as follows:
|
( Se ay mae
(duration) yrs. 2 mos. ds.
CONTRIBUTORY
(SECONDARY)
(duration) yrs. mos. ds
17 Where was disease contracted
if not at place of death?.
Did an operation precede death? 4e Date of
Was there an autopsy? We
irmed CQ ae ae
R eee. M. 0.
mi) 2 oe
(Year)
DATE OF BURIAL
Month)
BURIAL, CREMATION OR REMOVAL
Winthrop
Date.
(Day)
18 PLACE OF
Jinthrop
Official ¢
positio
| {28
ADDRESS
(Cemetery) (City or town)
19 UNDERTAKER
Long & Margeson
Date of
issue
seat 4/1
Gila us
ITA
STATES STANDARD CERTIFICATE OF DEATH
(Approved by U. S. Census and American Public Health Association)
Statement of occupation.—Precise statement of occupation is
very important, so that the relative healthfulness of various pursuits
can be known. The question applies to each and every person, irre-
spective of age. For many occupations a single word or term on the
first line will be sufficient, e. g., Farmer or Planter, Physician, Com-
positor, Architect, Locomotive engineer, Civil engineer, Stationary fire-
man, etc. But in many cases, especially in industrial employments,
it is necessary to know (a) the kind of work and also (b) the nature of
‘the business or industry, and therefore an additional line is provided
‘for the latter statement; it should be used only when needed. As
examples: (a) Spinner, (b) Cotton mill; (a) Salesman, (b) Grocery;
(a) Foreman, (b) Automobile factory. The material worked on may
form part of the second statement. Never return ‘‘Laborer,”’ ‘‘Fore-
man,” “Manager,” “Dealer,” etc., without more precise specification,
as Day laborer, Farm laborer, Laborer—Coal mine, etc. Women at
home, who are engaged in the duties of the household only (not paid
Housekeepers who receive a definite salary), may be entered as House-
wife, Housework, or At home, and children, not gainfully employed, as
At school or At home. Care should be taken to report specifically the
occupations of persons engaged in domestic service for wages, as
Servant, Cook, Housemaid, ete. If the occupation has been changed
or given up on account of the DISHBASE CAUSING DHATH, state occupa-
tion at beginning of illness. If retired from business, that fact may
be indicated thus: Farmer (retired, 6 yrs.). For persons who have
no occupation whatever, write None,
Statement of cause of death.—Name, first, the DISHASH CAUSING
prarH (the primary affection with respect to time and causation),
using always the same accepted term for the same disease. HExam-
ples: Cerebrospinal fever (the only definite synonym is “Bpidemic
cerebrospinal meningitis’’) ; Diphtheria (avoid use of “Croup’’);
Typhoid fever (never report ‘‘Typhoid pneumonia”); Lobar pneu-
monia; Bronchopneumonia (“Pneumonia,” unqualified, is indefinite) ;
Tuberculosis of lungs, meninges, peritoneum, etc., Carcinoma, Sarcoma,
EG. , \Olcl.\< Aah! s aus (name origin; ‘Cancer’ is less definite; avoid use
of ‘‘Tumor” for malignant neoplasms); Measles; Whooping cough;
Chronic valvular heart disease; Chronic interstitial nephritis, etc. The
contributory (secondary or intercurrent) affection need not be stated
unless important. Example: Measles (disease causing death),
29 ds.; Bronchopneumonia (secondary), 10 ds. Never report mere
symptoms or terminal conditions, such as ‘‘Asthenia,”’ “Anemia”
(merely symptomatic), “Atrophy,” “Collapse,”’ ‘‘Coma,” “Convul-
sions,” ‘!Debility”’ (““Congenital,”’ ‘‘Senile,’’ etc.), “Dropsy,” ‘‘Ex-
haustion,” ‘‘Heart failure,’’ “Hemorrhage,” “‘Inanition,’”’ ‘‘Maras-
mus,” “Old age,” “Shock,” ‘‘Uremia,’’, ‘‘Weakness,” etc., when a
definite disease can be ascertained as the cause. Always qualify all
diseases resulting from childbirth or miscarriage, as ““PUPRPERAL
septicemia,” ‘‘PUBRPERAL peritonitis,” ete.
State cause for which surgical operation was undertaken.
(Recommendations on statement of cause of death approved by Com-
mittee on Nomenclature of the American Medical Association.)
Bronchopneumonia: If primary cause, write the word
“‘primary”’; if secondary, give primary cause.
Certificates will be returned for additional information
which give any of the following diseases, without explanation,
as the sole cause of death: Abortion, cellulitis, childbirth,
convulsions, hemorrhage, gangrene, gastritis, erysipelas,
meningitis, miscarriage, necrosis, peritonitis, phlebitis,
pyemia, septicemia, tetanus.
EXTRACTS
FROM THE LAWS OF THE °
COMMONWEALTH OF MASSACHUSETTS
GOVERNING THE
RETURN OF CERTIFICATES OF DEATH
A physician or registered hospital medical officer shall forth-
with, 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 registra-
tion a standard certificate of death, stating to the best of his knowl-
edge and belief the name of the deceased, his supposed age, the disease
of which he died, defined as required by section one, 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. ...—Gen. Laws, Chap.
46, Sec. 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 con-
taining the facts required by law to be returned and recorded,
which shall be accompanied, in case of an original interment, by a
satisfactory certificate of the attending physician, if any, as required
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 pur-
pose, or is insufficient, a physician who is a member of the
board of health, or employed 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 registration 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 re-
quire —Gen. 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.—Gen. Laws, Chap. 38, Sec. 6.
_..He shall in all cases certify to the town clerk or registrar in the
place where the deceased died his name and residence, if known;
otherwise a description as full as may be, with the cause and manner
of death —Gen. 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 unre-
lated to any form of injury, have died without recent medical at-
tendance 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 injury or infection related to occupation, the
sudden deaths of persons not disabled by recognized disease,
and those of persons found dead.
The Commonwealth of Massachusetts
Boston
STANDARD CERTIFICATE OF DEATH Scena -e
1 PLACE OF DEATH Registered No. Lip ee
- OL i Registered N get ae A
(Place of residence)
eg ers ss ye SPROGO” NOSE ITAL Pi aeevuaaee
0 Y D (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, Hie rank, organization, etc.)
(a) Residence. State_MASS,. ———————City or Town WINTHROP 4, 19 WHEELOCK St.
(Usual place of abode)
Length of residence in city or town where death occurred
PERSONAL AND STATISTICAL PARTICULARS
years mouths days. How long in U. S., if of foreign birth? months days
MEDICAL CERTIFICATE OF DEATH
years
3 SEX 4COLOR OR RACE | 5 SINGLE, MARRIED, WIDOWED, OR ine
DIVORCED (write the word) pare or pean SA, Sp
wW S. (Month) (Day) (Year)
s
5a If ate “Lo a divorced
Name of } (00) WiFE
Cae Oe. a OR io. . BAM, 48> 1928,
PRPEPQOIVTAING SHOUD Stale UAUVOL VF VOCAIEE Tl Plalll LOriiio, oO Lilal it
may be properly classified. Exact statement of OCCUPATION is very important.
ee eo 16 f HEREBY CERTIFY, That I attended deceased from
| Tf LESS Fra that Ilast saw h__] [M_aliveo JAN » 0 , 1928 _ ,
6 AGE Years Months Days ' € A
| 1day,....hrs. and that death occurred, on the date stated above, a m.
9 or...min. The CAUSE OF DEATH was as follows: (State fully)
If STILLBORN, enter that fact here
| CONGENITAL HEART
7 OCCUPATION OF DECEASED
(a) Trade, flee puans or “=
a N f sss ee ab ree SI 2 2 2. (duration) yrs. os_9 as.
lame of employer
conrrpurory_ ENLARGED THYROID
(duration) yrs.
(State or country) 17 Where was disease contracted
if not at place of death
9 NAME OF
a 1
Did an operation precede death__ For what.
(SECONDARY)
8 BIRTHPLACE (city or town) __BOSTON == : mos._9 ds.
:
a
J
4
5
4 2]
»
| Pe eon CAMBRIDGE Detect operation ___
5 ™ (State or country) MASS ~ Was there an autopsy. NO
= we! 1 M AIDEN NAME What test confirmed diagnosis XR A Y
BS |q|_ OFMoTHEE ETHEL MC LAUGHLIN ____ 8, LYNDE saTEL
5 (Signed) y: , M.D.
&| 12 BIRTHPLACE 0)
E oumeeiccre ten) SOGTOR Gadirees)
D
= (State or country) MASS, Date WAN, 28
25
- et F AT H ER 18 PLACE OF BURIAL, CREMATION, OR REMOVAL DATE OF BURIAL
>
- (Address) WINTHROP HER OP HATH RAR tony tach ai 4 } H (idvor town) 2a. 1925
q 19 UNDERTAKER ADDRESS
“ried FEB, —3— 1928
A Registrar of city or town where death cecurred R, » K IRBY
ihe SO” 3S 3 ee ee eee eee
Registrar of city or town where deceased resided
ae | a0)
HEARS
_ ee area
SA Hagia A
£0R Fe
etek aie
rt a Nee cr at
S's
a
fe ‘
: }
a py
eer ek TAT EG
‘
©
¢ * ¥
a
S
* ~~. ;
| ¥ ‘ v¢ ; : .
t : ' ccs.
2 & scanty mst te 4879 1
* 5 eT
, * . a taiia Ment
_— . lll, 4 vic
| R-301
OFFICE OF THE SECRETARY Che Commanmealth of Massachusetts
DIVISION OF VITAL STATISTICS
STANDARD CERTIFICATE OF DEATH ©
1PLACE OF DEATH
Gnugty. = =~ Spay fee
CityorTown_Winthrop
= (City or town)
Stae___ Mass .. —_suRegistered No 2b
No Winthrop ‘iommunity Hospital wad
(If death occurred in a hospital or institution, give its NAME instead of street and number)
200,000. 9-26. NO. 6373
QFULL NAME__ Lawrence P, Shannon
a) Residence. No__20 Neptnne Ave
(Usual place of abode)
Length of residence in city or town where death occurred
years months
PERSONAL AND STATISTICAL PARTICULARS
3 SEX 4 COLOR OR RACE 5 SINGLE, MARRIED, WIDOWED, OR
DIVORCED (write the word)
Male White
Single
5a If married, widowed or divorced
P HUSBAND of
(or) WIFE of
Years | Months Days | IF LESS than
IF STILLBORN, enter that fact here
7 OCCUPATION OF DECEASED
(a) Trade, profession, or
particular kind of work
(b) Name of employer
See instructions and extracts from the,laws on back of certificate.
§ BIRTHPLACE (City) Winthrop
(State or country)
(if U. S. War Veteran, specify WAR)
days.
Mass
9 NAME OF
FATHER Lawrence P, Shannon
1O BIRTHPLACE OF “
FATHER (City) Boston Vass
(State or country)
11 MAIDEN NAME
OF MOTHER
PARENTS
Ee yw anera MeCarthy
12 BIRTHPLACE OF yw) . 3
MOTHER City, WOrcester Vi
(State or country)
13
Informant Lawrence P, Shannon
(Address) 2£O Neptune Ave
Re, “Bay i
Filed Zoe by Ah i
(Month) (Day) (Year)
20 | HEREBY CERTIFY that a satisfactory stan- _)
dard certificate of death was filed with me G
BEFORE the burial or transit permit was issue
plied. 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.
REGISTRAR
St,
Ward, 3 ee oe CES
(lf non-resident give city or town and state)
How long in U. S., if of foreign birth? years months
MEDICAL CERTIFICATE OF DEATH
j:
15 DATE OF DEATH Aa aD
(Month) (Day) (Year)
16 | HEREBY CERTIFY, That! attended deceased from
iS. teeta 6 ho” wed,! eT 1925
that I last saw h_tcxe_alive on 27 3 spiel
and that death occurred, on the date stated above, at_
5 SS A m.
The CAUSE OF DEATH was as follows: (State fully)
ty tons LS ae ay Ve | Sees ‘
(duration). yrs. mos. —___ ds.
CONTRIBUTORY i OF,
(Secondary)
(duration). yrs. moss = > - — ds
17 Where was disease contracted ___,
if not at place of death.
; : 2
Did an operation precede death__sZeae. Forwhat__ SS
= a
Date of operation
Fg]
Was there an autopsy =
What test confirmed diagnosi:
(Signed) __xfers
, M.D.
18 PLACE OF BURIAL, CREMATION, OR REMOVAL DATE OF BURIAL
Holy Cross Malden 2/3/28
(Cemetery) (City or town)
—— Lee
REVISED UNITED STATESSTANDARD CERTIFICATE OF DEATH
(Approved by U. $, Census ond American Public Health Association)
ee
Statement of occupation.—Precise statement of occupation is
very important, so that the relative healthfulness of various pursuits
ean be known. The question applies to each and every person, irre-
spective of age. For many occupations a single word or term on the
first line will be sufficient, e. g., Farmer or Planter, Physician, Com-
positor, Architect, Locomotive engineer, Civil engineer, Stationary fire-
man, etc, But in many cases, especially in industrial employments,
it is necessary to know (a) the kind of work and also (b) the nature of
the business or industry, and therefore an additional line is provided
for the latter statement; it should be used only when needed. As
examples: (a) Spinner, (b) Cotton mill; (a) Salesman, (b) Grocery;
(a) Foreman, (0) Automobile factory. The material worked on may
form part of the second statement. Never return “Laborer,” “Fore-
man,” “Manager,” “Dealer,” ete., without more precise specification,
as Day laborer, Farm laborer, Laborer—Coal mine, etc. Women at
home, who are engaged in the duties of the household onty (not paid
Housekeepers who reccive 4 definite salary), may be entered as House-
wife, Housework, or At home, and children, not gainfully employed, a3
At school or At home. Care should be taken to report specificaily the
occupations of persons engaged in domestic service for wages, aS
Servant, Cook, Housemaid, etc. If the occupation has been changed
or given up on account of the DISPASH CAUSING DDATH, state occupa-
tion at beginning of illness. If retired from business, that fact may
be indicated thus: Farmer (retired, 6 yrs.). For persons who have
no occupation whatever, write None.
Statement of cause of death.—Name, first, the Discase Causing
Death (the primary affection with respect to time and causation),
using always the same accepted term for the same disease. Exam-
ples: Cerebrospinal fever (the only definite synonym is “Epidemic
cerebrospinal meningitis”); Diphtheria (avoid use of “Croup’’);
Typhoid fever (never report “Typhoid pneumonia’); Lobar pneu-
monia; Bronchopneumonia (‘‘Pneumonia,”’ unqualified, is indefinite);
Tuberculosis of lungs, meninges, peritoneum, ete., Carcinoma, Sarcoma,
CtC., Of. .seeseeereere ee (AME origin; ‘‘Cancer’’ is less definite; avoid use
of “Tumor for malignant neoplasms); Measles; Whooping cough;
Chronic valvular heart disease; Chronic interstitial nephritis, ete. The
contributory (secondary or intercurrent) affection need not be stated
unless important. Example: Measles (disease causing death), 29 ds.;
Bronchopneumonia (secondary), 10 ds. Never report mere symptoms
or terminal conditions, such as “Asthenia,” ‘Anemia’ (merely symp-
tomatic), “Atrophy,” “Collapse,” ““Coma,”’ “Convulsions,” 'Debility”
(‘‘Congenital,”’ “Senile,” ete.), ‘Dropsy,” “Pxhaustion,” “Heart
failure,” ‘Hemorrhage,’ “Tnanition,’”’ ‘Marasmus,” “Old age,’
“Shock,” ‘Uremia,” Weakness,’ etc., when a definite disease
ean be ascertained as the cause. Always qualify all diseases resulting
from childbirth or miscarriage, 45 “pUPRPERAL septicemia,'' ‘PUERPERAL
peritonitis,” ete.
State cause for which surgical operation was undertaken.
(Recommendations on statement of cause of death approved by Com-
mittee on Nomenclature of the American Medical Association.)
Bronchopneumonia: Ii primary cause, write the word
“primary’’; if secondary, givo primary cause.
Certificates will be returned for additional information
which give any of tho following diseases, without explanation,
as the sole cause of death: Abortion, cellulitis, childbirth,
convulsions, hemorzhago, gangrene, gastritis, erysipelas, menin-
gitis, miscarriago, necrosis, peritonitis, phlebitis, pyemia,
septicemia, tetanus.
EXTRACTS
FROM THE LAWS OF THE
COMMONWEALTH OF MASSACHUSETTS
GOVERNING THE
RETURN OF CERTIFICATES OF DEATH
A physician or registered hospital medical officer shall forth-
with, 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 registra-
tion a standard certificate of death, stating to the best of his knowl-
edge and belief the name of the deceased, his supposed age, the disease
of which he died, defined as required by section one, 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.....@en. Laws, Chap. 46,
Sec. 9.
Wo undertaker or other person shall bury ot otherwise dispose of a
human body in a town, or remove therefrom a human body which has
not been buried, until he has received a permit from the board of
health or its agent appointed to issue such permits, or if there is no
such board, from the clerk of the town where the person died; and no
undertaker or other person shall exhume a human body and remove
it from a town, or from one cemetery to another, until he has received
a permit from the board of health or its agent aforesaid or from the
clerk of the town where the body is buried. No such permit shall be
issued until there shall have been deiivered to such board, agent or
clerk, as the case may be, 2 satisfactory written statement containing
the facts required by law to be returned and recorded, which shall be
accompanied, in case of an original interment, by a satisfactory certi-
fieate of the attending physician, if any, as required 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 ob-
tained early enough for the purpose, or is insufficient, a physician
who is a member of the board of health, or employed 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. If the death certi-
ficate contains a recital, as required by section ten of chapter forty-six,
that the deceased served in the army, navy or marine corps of the
United States in any war in which it has been engaged, such recital
shall appear upon the permit. The board of health or its agent,
upon receipt of such statement and certificate, shall forthwith counter-
sign it and transmit it to the clerk of the town for registration. The
person to whom the permit is so given and the physician certifying
the cause of death shall thereafter furnish for registration 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.—Chap. 114, Sec. 45, G. L., as amended.
Medical examiners shall make examination upon the view of the
dead bodies of only such persons as are supposed to have died by
violence.—Gen. Laws, Chap. 38, Sec. 6.
He shall in all cases certify to the town clerk or registrar in the
place where the deceased died his name and residence, if known;
otherwise a description as full as may be, with the cause and manner
of death —Gen. Laws, Chap. 38, Sec. 7.
No undertaker or other person shall bury a human body or the
ashes thereof which have been brought into the commonwealth until
he has received a permit so to do from the board of health or its agent
appointed to issue such permits, or if there is no such board, from the
clerk of the town where the body is to be buried or the funeral is to
be held, or from a person appointed to have the care of the cemetery
or burial ground in which the interment is made.—Chap. 114, Sec. 46,
G. L., as amended,
OFFICE OF THE SECRETARY
DIVISION OF VITAL STATI
)
'
i)
&
(a) Residence. No.
és
STANDARD CERTIFICATE OF DEATH
Che Commonmealth of Massachusetts
St.
give its NAME infftead of street and nu
0. SiGgh
a
(Usual place of abode)
Length of residence in city or town where death occurred
4 COLOR OR RACE
5a If married, widowed_or divorced
ay orm
6 AGE Years
(6
7 OCCUPATION OF D
(a) Trade, profession, or
particular kind of work
bs
Divo
a itty
HUSBAN
(or) WIFE of Tcceqarke
Months Days.
(3
Kbnig
States, give rank, organization, etc.)
LE, MARRIED, WIDOWED, OR
RCED (write the word)
15 DATE OF DEATH
How long in U. S., if of foreign birth?
(If non-resident give city or town and state)
years
months days
EDICAL CERTI 7, CATE OF DEATH
D/N 1/7
16
¢
that | last saw h_ [ae —aliv
If LESS than
1 day, hrs.
of___min. The
: (Month)
eon
te)
and that death occurred, on the date stated above, at 6 OG p
SUSE OF DEATH was as foll
(Day) (Year)
me |
mber)
{
1 HEREBY CERTIFY, That! attended deceased from ,
“ 19D to 3
Bty 5 “oe
192,
(b) Name of employer
8 BIRTHPLACE (City)
(State or country)
9 NAME OF
FATHER
10 BIRTHPLACE OF
FATHER (City) __
(State or country)
11 MAIDEN NAME
OF MOTHER
PARENTS
12 BIRTHPLACE OF -
MOTHER (City) enn
Sol.
U.
(State or country)
13
~
CONTRIBUTORY
(SECONDARY)
(duration)
&
(duration)
Did an operation precede de.
Was there an autopsy? _
(Signed)
(Address)
(
ie + | er AA i ne Mei LAW
Date
17 Where was disease contracted
if not at place of death?
yrs
noslie
LOS gm.
Ss
Be
[2 2.
Es
Ye e
Month)
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.
(adéress) / SD SKML : fm
should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state CAUSE OF DEATH
LE laur
Mtr
18 PLACE OF BURIAL, CREMATION OR lnc aes
“eat
DATE OF BURIAL
(Cemetery)
19 UNDERTAKER
14 i
/
rues Zens) Vo
(Month) (Day) (Year)
2O | HEREBY CERTIFY that a satisfactory stan-
dard certificate of death was filed with me
), 000 BEFORE the burial or transit permit was issu
. . uaa siete
Se:
REGISTRAR
Date of
Officia ae
positi
(City or ae ee 2
at / OLB. a oo
ADDRESS
Wut fi
An,
Zz)
SE Oo A =
REVISED UNITED STATES STANDARD TIFICATE OF DEATH
(Approved by U. S. Census and American Public Health Association)
Statement of occupation.—Precise statement of occupation is
very important, so that the relative healthfulness of various pursuits
can be known. The question applies to each and every person, irre-
spective of age. For many occupations a single word or term on the
first line will be sufficient, e. g., Farmer or Planter, Physician, Com-
positor, Architect, Locomotive engineer, Civil engineer, Stationary fire-
man, etc. But in many cases, especially in industrial employments,
it is necessary to know (a) the kind of work and also (b) the nature of
the business or industry, and therefore an additional line is provided
for the latter statement; it should be used only when needed. As
examples: (a) Spinner, (b) Cotton mill; (a) Salesman, (b) Grocery;
(a) Foreman, (b) Automobile factory. The material worked on may
form part of the second statement. Never return “Laborer,” ‘‘Fore-
man,” ‘‘Manager,”” “Dealer,” etc., without more precise specification,
as Day laborer, Farm laborer, Laborer—Coal mine, etc. Women at
home, who are engaged in the duties of the household only (not paid
Housekeepers who receive & definite salary), may be entered as House-
wife, Housework, or At home, and children, not gainfully employed, as
Al school or At home. Care should be taken to report specifically the
occupations of persons engaged in domestic service for wages, a8
Servant, Cook, Housemaid, etc. If the occupation has been changed
or given up on account of the DISHASH CAUSING DHATH, state occupa-
tion at beginning of illness. If retired from business, that fact may
be indicated thus: Farmer (retired, 6 yrs.). For persons who have
no occupation whatever, write None.
Statement of cause of death.—Name, first, the D1sHAsH CAUSING
pwatH (the primary affection with respect to time and causation),
using always the same accepted term for the same disease. Exam-
ples: Cerebrospinal fever (the only definite synonym is ‘Epidemic
cerebrospinal meningitis’); Diphtheria (avoid use of “Croup”’);
Typhoid fever (never report ‘‘Typhoid pneumonia’); Lobar pneu-
monia; Bronchopneumonia (‘‘Pneumonia,”’ unqualified, is indefinite) ;
Tuberculosis of lungs, meninges, peritoneum, etc., Carcinoma, Sarcoma,
Bie TOS wn, sre Say = (name origin; ‘“‘Cancer”’ is less definite; avoid use
of ‘'Tumor” for malignant neoplasms); Measles; Whooping cough;
Chronic valvular heart disease; Chronic interstitial nephritis, etc. The
contributory (secondary or intercurrent) affection need not be stated
unless important. Example: Measles (disease causing death),
29 ds.; Bronchopneumonia (secondary), 10 ds. Never report mere
symptoms or terminal conditions, such as “Asthenia,” ‘Anemia’
(merely symptomatic), “Atrophy,” ‘‘Collapse,”’ “Coma,” “Convul-
sions,” ‘‘Debility”’ (““Congenital,’”’ “‘Senile,’’ etc.), “Dropsy,” ‘‘Ex-
haustion,” ‘Heart failure,’’ “Hemorrhage,” ‘‘Inanition,” ‘‘Maras-
mus,” ‘‘Old age,” “Shock,” ‘‘Uremia,’’, “‘ Weakness,” etc., when a
definite disease can be ascertained as the cause. Always qualify all
diseases resulting from childbirth or miscarriage, as ‘‘PUPRPERAL
septicemia,” ‘‘PUBRPERAL peritonitis,’’ etc.
State cause for which surgical operation was undertaken.
(Recommendations on statement of cause of death approved by Com-
mittee on Nomenclature of the American Medical Association.)
Bronchopneumonia: If primary cause, write the word
‘‘primary”’; if secondary, give primary cause.
Certificates will be returned for additional information
which give any of the following diseases, without explanation,
as the sole cause of death: Abortion, cellulitis, childbirth,
convulsions, hemorrhage, gangrene, gastritis, erysipelas,
meningitis, miscarriage, necrosis, peritonitis, phlebitis,
pyemia, septicemia, tetanus.
EXTRACTS
FROM THE LAWS OF THE
COMMONWEALTH OF MASSACHUSETTS
GOVERNING THE
RETURN OF CERTIFICATES OF DEATH
A physician or registered hospital medical officer shall forth-
with, 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 registra-
tion a standard certificate of death, stating to the best of his knowl-
edge and belief the name of the deceased, his supposed age, the disease
of which he died, defined as required by section one, 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... .—Gen. Laws, Chap.
46, Sec. 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. ..OFr. .-
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 con-
taining the facts required by law to be returned and recorded,
which shall be accompanied, in case of an original interment, by a
satisfactory certificate of the attending physician, if any, as required
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 pur-
pose, or is insufficient, a physician who is a member of the
board of health, or employed 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 oxaminer 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 registration 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 re-
quire.—Gen. 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.—Gen. Laws, Chap. 38, Sec. 6.
_..He shall in all cases certify to the town clerk or registrar in the
place where the deceased died his name and residence, if known;
otherwise a description as full as may be, with the cause and manner
of death.—Gen. 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 unre-
lated to any form of injury, have died without recent medical at-
tendance 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 follo wing abortion, but also deaths from disease
resulting from injury or infection related to occupation, the
sudden deaths of persons not disabled by recognized disease,
and those of persons found dead.
Che Commonmealth of Massarhnsrtts
ANDARD CERTIFICATE OF DEATH
Ye j ee (City or town)
Stat Registered No. ‘eee
R-301 OFFICE OF THE SECRETARY
DIVISION OF VITAL STATISTICS
1 PLACE OF DEAT
County.
2 FULL NAM
(lf in the Army or Naya of the United States, give rank, anization, etc.)
(a) Residence. No. 3S AG as aa St., Ward. ‘RQ NR en Q. ~ ji
(Usual place of abode) (If non-resident give ai or town and state)
Length of residence in city or town where death occurred 6 years months s. days. How long in U. S., if of foreign birth? years months days |
PERSONAL AND STATISTICAL PARTICULARS MEDICAL CERTIFICATE OF DEATH
A COLOR OR RACE 5 SINGLE, MARRIED, WIDOWED, OR Fu 4 ; 7 g }
% DIVORCED (write the word) 15 DATE OF DEATH /7-
. . (Month) (Day) (Year)
16
=a a ia 5 < I HEREBY CERTIFY, That! attended deceased from
a If married, widowed or divorce , 2
HUSBAND of Et. @ R28 on ae pa 25a |
(or) WIFE of
that | last saw h A~ __ alive on Ft: 7 ,19 ZF | |
Months
oO > , 5 and that death occurred, on the date stated above, at 7 Am. |
S 0 mi
The CAUSE OF DEATH was as follows:
If STILLBORN, enter that fact here GK ; Apa os ao 3 Sar ae |
7 OCCUPATION OF DE
FE D . \
particular kind of work i.
(a) Trade, profession, or
(b) Name of employer ea Cees
(duration) [ yrs. mos._ ds.
CONTRIBUTORY ae
Hi
(SECONDARY) =
(duration) os. ds
17 Where was disease contracted (2.
if not at place of death? PEERS “fe. a
Did an operation precede death? 72? Date of
9 NAME OF
FATHER
10 BIRTHPLACE OF
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 FATHER (City) eter: ‘pate ben, Oe) |
z (State or country) as there an autopsy: = ==
«| 41 MAIDEN NAME What test Ey tes glace” }
< OF MOTHER (Signed) es
{ v7,
12 BIRTHPLACE OF (Address) sh Watt
MOTHER (City) _—_—N i= Wi ie 19 2,
t t Date —t-
(State or country) i AMonth) (Day) (Year)
18 PLACE OF BURIAL, CREMATION OR REMOVAL DATE OF BURIAL
at HERA Caron Wernaedigs evo lig.
é = (Cemetery) (City or town) ec eee eee
“ried ae > 2 Labaa Seana Dare (ghdDRESs
Month) nme af REGISTRAR weer. ;
2O | HEREBY CERTIFY that a satisfactory stan-—
dard certificate of death was filed with me
BEFORE the burial or transit permit was issued
7
Date of 1]
Officia issue debs |
aan of Sp ted. Aa ee L3by i
(Approved by U. S. Census and American Public Health Association)
Statement of occupation.—Precise statement of occupation is
very important, so that the relative healthfulness of various pursuits
can be known. The question applies to each and every person, irre-
spective of age. For many occupations a single word or term on the
first line will be sufficient, e. g., Farmer or Pianter, Physician, Com-
positor, Architect, Locomotive engineer, Civil engineer, Stationary fire-
man, etc. But in many cases, especially in industrial employments,
it is necessary to know (a) the kind of work and also (b) the nature of
the business or industry, and therefore an additional line is provided
for the latter statement; it should be used only when needed. As
examples: (a) Spinner, (b) Cotton mill; (a) Salesman, (b) Grocery;
(a) Foreman, (6) Automobile factory. The material worked on may
form part of the second statement. Never return ‘‘Laborer,” ‘‘Fore-
man,” ‘‘Manager,”’ “Dealer,’’ etc., without more precise specification,
as Day lavorer, Farm laborer, Laborer—Coal mine, etc. Women at
home, who are engaged in the duties of the household only (not paid
Housekeepers who receive a definite salary), may be entered as House-
wife, Housework, or At home, and children, not gainfully employed, as
At school or At home. Care should be taken to report specifically the
occupations of persons engaged in domestic service for wages, as
Servant, Cook, Housemaid, etc. If the occupation has been changed
or given up on account of the DISBASE CAUSING DEATH, state occupa-
tion at beginning of illness. If retired from business, that fact may
be indicated thus: Farmer (retired, 6 yrs.). For persons who have
no occupation whatever, write None.
Statement of cause of death.—Name, first, the DISHASE CAUSING
peats (the primary affection with respect to time and causation),
using always the same accepted term for the same disease. Exam-
ples: Cerebrospinal fever (the only definite synonym is ‘‘Hpidemic
cerebrospinal meningitis’); Diphtheria (avoid use of ‘‘Croup’’);
Typhoid fever (never report “Typhoid pneumonia”); Lobar pneu-
monia; Bronchopneumonia (“Pneumonia,” unqualified, is indefinite) ;
Tuberculosis of lungs, meninges, peritoneum, etc., Carcinoma, Sarcoma,
PIED © ota pity ats aks (name origin; ‘‘Cancer’’ is less definite; avoid use
of “Tumor” for malignant neoplasms); Measles; Whooping cough;
Chronic valvular heart disease; Chronic interstitial nephritis, etc. The
contributory (secondary or intercurrent) affection need not be stated
unless: important. Example: Measles (disease causing death),
29 ds.; Bronchopneumonia (secondary), 10 ds. Never report mere
symptoms or terminal conditions, such as ‘‘Asthenia,” ‘‘Anemia’’
(merely symptomatic), “Atrophy,” ‘Collapse,’ ‘‘Coma,”’ ‘‘Convul-
sions,” ‘‘Debility” (‘‘Congenital,” “Senile,’’ etc.), ‘“Dropsy,” ‘Ex-
haustion,” ‘Heart failure,” “Hemorrhage,” “Inanition,’’ ‘“‘Maras-
mus,” “Old age,” ‘‘Shock,” “Uremia,’’, ‘‘Weakness,’”’ etc., when a
definite disease can be ascertained as the cause. Always qualify all
diseases resulting from childbirth or miscarriage, as ‘“PUERPPRAL
septicemia,” ‘‘PUBRPHRAL peritonitis,”’ ete.
State cause for which surgical operation was undertaken.
(Recommendations on statement of cause of death approved by Com-
mittee on Nomenclature of the American Medical Association.)
Bronchopneumonia: If primary cause, write the word
“‘primary’’; if secondary, give primary cause.
Certificates will be returned for additional information
which give any of the following diseases, without explanation,
as the sole cause of death: Abortion, cellulitis, childbirth,
convulsions, hemorrhage, gangrene, gastritis, erysipelas,
meningitis, miscarriage, necrosis, peritonitis, phlebitis,
pyemia, septicemia, tetanus.
EXTRACTS
FROM THE LAWS OF THE
COMMONWEALTH OF MASSACHUSETTS
GOVERNING THE
RETURN OF CERTIFICATES OF DEATH
A physician or registered hospital medical officer shall forth-
with, 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 registra-
tion a standard certificate of death, stating to the best of his knowl-
edge and belief the name of the deceased, his supposed age, the disease
of which he died, defined as required by section one, 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. ...—Gen. Laws, Chap.
46, Sec. 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 con-
taining the facts required by law to be returned and recorded,
which shall be accompanied, in case of an original interment, by a
satisfactory certificate of the attending physician, if any, as required
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 pur-
pose, or is insufficient, a physician who is a member of the
board of health, or employed 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 registration 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 re-
quire.—Gen. 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.—Gen. Laws, Chap. 38, Sec. 6.
_..He shall in all cases certify to the town clerk or registrar in the
place where the deceased died his name and residence, if known;
otherwise a description as full as may be, with the cause and manner
of death.—Gen. 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 unre-
lated to any form of injury, have died without recent medical at-
tendance 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 injury or infection related to occupation, the
sudden deaths of persons not disabled by recognized disease,
and those of persons found dead.
The Commonwealth of Massachusetts
Boston
STANDARD CERTIFICATE OF DEATH (City or town) >
1 PLACE OF DEATH Registered No. —1315
Suffolk (Place o' Be:
nee ee ee te Registered No. : !
Boston TON c ; Ty HOSP ITAL Wines of anaes
City or oe eee es ee eee CITY BVSretAG se. Ward
(If death occurred in a hospital or institution, give its NAME instead of street and number)
EDWARD MELANSON
2 FULL NAME (If in the Army or Navy of the oe Be or give rank, organization, etc.)
(a) Residence. State__MASS, itty or Town WINTHROP wo 10o LINCOLN ogg
(Usual place of abode)
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
PERSONAL AND STATISTICAL PARTICULARS MEDICAL CERTIFICATE OF DEATH
3 SEX 4 COLOR OR RACE 5 SINGLE, MARRIED, WIDOWED, OR FEB i] 1928
DIVORCED (write ‘the word). i5 DATE OF DEATH ®
M W Ss (Month) (Day) (Year)
Wek. ° ® ie ee ee AE NG ' HEREBY CERTIFY, That I attended deceased from
5a If married, widowed, oe divorced 28
Name of | HUSBAN Me i 2 yee SPER PE ee |
(or) Wire, M FEB 1] }
| If LESS - that I last saw EES. Pi) «im Se TL A aR ial are as
6 AGE Years Months Days 10 A |
x 1 eee and that death occurred, on the date stated above, ee eee 2m, i
8 10 The CAUSE OF DEATH was as follows: (State fully) ;
If STILLBORN. enter that fact here A
SCARLET FEVER i{
7 OCCUPATION OF DECEASED it
(a) Trade, ion oF SS SS SS SS |
ie artiemlar kind of work (duration) yrs. mos. ds. i
conrriputory___BRAIN ABSCESS =MASTOIDITIS .
8 BIRTHPLACE (city or town)_ BOSTON (seconpary) ee . /
oo eR Aer see. Se SC oration) 22 yra; mos. ds.
(State or country) MASS ° 17 Where was disease contracted |
9 NAME OF Tf mG at, pin Geld chem thi ese ee ee
25 ee i 2 eee BRA iN ABSCESS |
Did an operation precede death
OE P| SE a ee
(b) Name of employer
|
|
|
as i Ht
eee. sreny pusotemenin HOV 1541927 AND DEC. 1741928
2 (State or country) N ‘ S. Was there an autopsy.
i
f| 11 MAIDEN NAME What test confirmed diagnosis }|
q|___OF MOTHER ROSE THIBEAU ‘Gan » H, PLACE M.D. |
| 12 BIRTHPLACE OF DIGBY | ‘ t
MOTHER (city or town). ! (Address)
(State or country) N. Sig | Date FEB, j BY 1928 q
PLACE OF BURIAL, CREMATION, OR REMOVAL DATE OF BURIAL
Witmer» -F ATHER 4
(86 LINCOLN ST. WINTHROP — { } 2 2
eeenCnmairese) oe er iy eae De Oe os : tery) : ath or town) wt » 1928
FEB. 14 ,,28 ina FEB, 142 GCOPH Sacre C5, gue | 19 UNDERTAKER ADDRESS
Registrar of city or town where death occurred R ® Cc ° K j R B Y
Filed ES Se ea
Registrar of city or town where deceased resided
May DC propery ClassilleG, EAGLE StalLeHieiit Ul UUUUPATIUOIN Is Very HMpOrlalit.
i312
dled Lsidets 25
u
o
=
OFFICE OF THE SECRETARY Che Commonwealth of Massachusetts VUsrtIrye
zy DIVISION OF VITAL STATISTICS STANDARD CERTIFICATE OF DEATH Bes Fon
. 1 PLACE OF DEATH (City or town) / ¥
nN
re County. Suff I a State Massachusetts Registered No. ae i
5 maar or ee : eee
a City or Tins t2 eae ee Alt Dele 2a " St, ‘Ward ~
a (If death occurred in a hospital or institution, give its NAME instead of street and number) “a
o
3 || 2 FULL NAM @
S (If in the Army or Navy of the United States, give rank, organization, etc.)
as (a) Residence. Nos St., Ward. E hj
(Usual place of abode) 4 (If non-resident give city or town and state) |
Length of residence in city or town where death occurred / 3 years months days. How long in U. S., if of foreign birth? years months days j
MEDICAL CERTIFICATE OF DEATH | |
15 DATE OF DEAR a : {|
7 30 (Month) (Day) 25 (Year) vf
16 1
Ps - , I HE REBY CERTIFY, That! attended deceased from
a If married, widowed or divorced : pH. % aoe "4 )
HUSBAND of Ah nti tg he)_fi al dS
(or) WIFE of Nie
ee ae ee SS eee |
i Ace ance Months ae id that | last saw h_W alive on U5 Yy-S 7 Jf 3 Se Fe oa
1 day,___hrs. and that death occurred, on the date stated above, LED Ss
12 BIRTHPLACE OF Ki frapuol, ,
MOTHER (City) UP pS ghre ‘JE Lae
et 2?’
(State or country) Whiter 2 a Month) (Day) (Year)
13 LRA SO 18 Pie OF BURIAL, CREMATION OR REMOVAL
LA E/ AL_£. ; Wy
Informan Hall upbfit
‘DATEOF BURIAL
should be carefully supplied. AGE should be stated EXACILY. PHYSICIANS should state CAUSE UF DEATH oy
in plain terms, so that it may be properly classified. Exact statement of OCCUPATION is very important. See
we
8 of____min.
— The CAUSE_OF DEATH was as follows: a |
a a ( |
= piety AvAliyniag, |
Oo ig i
-_
© |] 7 OCCUPATION OF DECEASED :
=< (a) Trade, profession, or — <
i particular kind of |
a
c ot ae (duration) yrs. mos. ds.
° "|
” || 8 BIRTHPLACE (City) PGs CONTRIBUTORY. |
z (State or country) (SECONDARY) 1 |
5 4 (duration) yrs. mos. ds
17 Where was disease contracted |
E 9 oe ; j if not at place of death?__gag wip) ———$____ |
° 10 BIRTHPLACE. OF Oo “if Did an operation precede death====== Date of
2 r ov wae LO pla d is “ as there an autopsy?
oz (State ‘or-country) yf a ” it'under one year, was Infant Breast Fed?. Zee nay
oa | el —— |) What firmed di 2
£ | 41 MAIDEN NAME 5 at test confirme iagnosis
oO x OF MOTHER ADA. ly DAA (Signed)
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cabana AYLIViALZ | ~ f((Cemetery) (City or town) 2
14 IS'UNDERTAKER = ADDRESS,
File ails > 4/9 & WY y FIR Fh
(Month) (Day) (Year) REGISTRAR os “6 U Re .
2O | HEREBY CERTIFY that a satisfactory stan-
dard certificate of death was filed with me a \ Official
BEFORE the burial or transit permit was issued a WS LO CPM Raw position
tw AfID28 i t3G2, Me
—
Se
ae
REVISED UNITED STATES STANDARD CERTIFICATE OF DEATH
(Approved by U. S. Census and American Public Health Association)
Statement of occupation.—Precise statement of occupation is
very important, 80 that the relative healthfulness of various pursuits
can be known. The question applies to each and every person, irre-
spective of age. For many occupations a single word or term on the
first line will be sufficient, e. g., Farmer or Planter, Physician, Com-
positor, Architect, Locomotive engineer, Civil engineer, Stationary fire-
man, etc. But in many cases, especially in industrial employments,
it is necessary to know (a) the kind of work and also (b) the nature of
the business or industry, and therefore an additional line is provided
for the latter statement; it should be used only when needed. As
examples: (a) Spinner, (b) Cotton mill; (a) Salesman, (b) Grocery;
(a) Foreman, (b) Automobile factory. The material worked on may
form part of the second statement. Never return “Laborer,” “‘Fore-
man,” ‘‘Manager,”” “Dealer,’’ etc., without more precise specification,
as Day laborer, Farm laborer, Laborer—Coal mine, etc. Women at
home, who are engaged in the duties of the household only (not paid
Housekeepers who receive a definite salary), may be entered as House-
wife, Housework, or At home, and children, not gainfully employed, as
At school or At home. Care should be taken to report specifically the
occupations of persons engaged in domestic service for wages, as
Servant, Cook, Housemaid, etc. If the occupation has been changed
or given up on account of the DISHASH CAUSING DHATH, state occupa-
tion at beginning of illness. If retired from business, that fact may
be indicated thus: Farmer (retired, 6 yrs.). For persons who have
no occupation whatever, write None.
Statement of cause of death.—Name, first, the DISHASE CAUSING
pears (the primary affection with respect to time and causation),
using always the same accepted term for the same disease. Exam-
ples: Cerebrospinal fever (the only definite synonym is “Epidemic
cerebrospinal meningitis’’); Diphtheria (avoid use of “Croup”’);
Typhoid fever (never report “Typhoid pneumonia”); Lobar pneu-
monia; Bronchopneumonia (‘‘Pneumonia,”” unqualified, is indefinite) ;
Tuberculosis of lungs, meninges, peritoneum, etc., Carcinoma, Sarcoma,
ET OL ay wists tern ® (name origin; ‘‘Cancer”’ is less definite; avoid use
of ‘“‘Tumor’”’ for malignant neoplasms); Measles; Whooping cough;
Chronic valvular heart disease; Chronic interstitial nephritis, etc. The
contributory (secondary or intercurrent) affection need not be stated
unless important. Example: Measles (disease causing death),
29 ds.; Bronchopneumonia (secondary), 10 ds. Never report mere
symptoms or terminal conditions, such as ‘‘Asthenia,’”’ “ nemia”’
(merely symptomatic), “Atrophy,” “Collapse,” ‘‘Coma,’’ * Convul-
sions,” ‘‘Debility” (‘‘Congenital,”’ “Senile,” etc.), ‘‘Dropsy,” ‘“Ex-
haustion,” ‘‘Heart failure,” “Hemorrhage,” ‘‘Inanition,” ‘“Maras- The text goes on. The rest is in the file.