The volume, 1931

Town Clerk, Winthrop · from the Internet Archive · 538 pages · 53.5 MB
open the file ↗ · original at the source ↗

i
at

$f)

#535
Batees
chee

Coes
ee wpe ae
aeetiretsienes

os
re

Skat
eat

ay
i

eeetertapis Boi

%
pissed:

Hi f

eiets i

UTE ; t :

i Ay reat
re]
ue

pe tch F 5 i 4525)
‘2 iT
3542
tare

shia

Eppa bea: .
Bt)

aes

iets :
ag tx : ; : 4 if

Bo,

satseets pee
eth ir sise- tibbe ete!

J. L. FAIRBANKS & CO.
Stationers

43 FRANKLIN STREET
—BOSTON—

Exact statement of OCCUPA

PHYSICIANS should

¥;

‘ .3, ty dein
NENT RECORD.

sified.

; IS A PERMAI
tated EXACT

rly classified. —
xtracts from the laws on back of certificate.

ie ay

HIS
be
per.

‘°)

it may be pr

7s
c= |
Ef
cf
o)
7
435
2%
* 3s
>)

1ons an

rms, so that

See instruct

‘important.

is very
75m-2-’30. No. 7997-4

Aneneaeeteeeeeeeaneeereauenesccnsseesnsssseeeeeneeeareananeasensanen

(County)

IEATH

The Commonmealth of Massachusetts
: OFFICE OF THE SECRETARY
DIVISION OF VITAL STATISTICS

STANDARD

To be filed for burial permit
with Board of Health
or its Agent,

= fete Winthroo............. CERTIFICATE OF DEATH Registered No...:..:02 ane
wl (City or Town)
2 (If death occurred in a hospital or institution,
A Die Pee eM EEE Dk Aner stb vanes tarceccscannscnsseosscenssehcigeties St5 25 sssannnnnnnnannn Ward j give its NAME instead of street and number)

2 FULL NAME... 52r2h MacDonald Holland

(If deceased is a married, widowed or divorced woman, give also maiden name.)

100 Marshall

(a) Residence.

(Usual place of abode)
Length of residence in city er town where death occurred

PERSONAL AND STATISTICAL PARTICULARS

5 SINGLE (write the word)
3 SEX | 4 COLOR OR RACE MARRIED
Femald White or DIVORCED «/ LGOwed

5a If married, widowed, or divorced

HUSBAND of : é
(Give maiden name of wife in full)
(or) WIFE of ........ aoeae ol land: ©...

(Husband’s name in full)
6 IF STILLBORN, enter that fact here.

7 If less than 1 day
1c] Reins Scere GATS! -ccncvces-s Months............ Baysiicvcriu Hoars:.....2-4 Minutes
8 Trade, profession, or particular
=> kind of wore apne, a spinner,
=) Sawyer, bookkeeper, €IC................42 3 . ew ee aan cis od cadesbtiteetyc--cccatdycoare ;
{&| 9 industry or business in which Hous ite
a work was done, as silk mill,
2 saw mill, bank, tC... Sho re a
©6| 10 Date deceased last worked at 11 Total time (years)
this occupation (month and 26 spent in this
year) ....... ecember...29...1930 occupation. fF)...
TU RIMAHP LAGE » (City)... :c0vc-occtesssseecstvonvcwes-cceecineeessesese voffinniroy sreanyfthatesthredbcopcheeeens:
(State or country) Nova 3 co 5 1a
13 NAME OF
FatHER Angus MacDonald

14 BIRTHPLACE OF
FATHER (City)

(State or country)

15 MAIDFN NAME
OF MOTHER

ova Scotia

Vary MacDonald

PARENTS

16 BIRTHPLACE OF “
MOTHER (City)

(State or country)

Wova jcotia

5 Ur ¢

1 HEREBY CERTIFY that a satisfactory standard certificate of death was

(If U.S.
War Veteran,
specify WAR)

cee eeeeacecaeccessenseeeseesaseseseeas

(If nonresident, give city or town and state)

How long in U: S., if of foreign birth? yrs. mos. days.

days,

(Year)

» That | attended deceased from

ie eed ees

, death is said

to have occurred on the date stated above, at. Ge7..7.&/
The principal cause of death and related causes of importance in order of
Dateofonset

onset were as follows:

EERE PEST ELT eRe ie, Se
What test confirmed diagnosis? ... Was there an autopsy?...........

20 Was disease or injury in any way related to occupation of deceased? .................
If so, specify...
(Signed)
(Address)

21 PLACE OF BURIAL,
CREMATION OR REMOVAL

22 NAME OF
UNDERTAKER

ADDRESS........

(Registrar)

Se ae
(Dannie +

Statement of occupation.—Precise statement of occupation is
very important, so that the relative healthfulness of various pursuits.
can be known. Make some entry in this section for every person
aged 10 yearsorover. Ifthe occupation had been given up or changed
on account of the disease causing death, report the occupation prior
to illness. If the deceased had retired from business, report the.
occupation prior to retirement. Children not gainfully employed)
may be returned as at school or at home. For a woman whose
only occupation was that of home housework, write housework
in answer to Question 8 and own home in answer to Question 9.
For a person engaged in domestic service for wages, however, designate
the occupation by the appropriate terms, as housekeeper—private
family, cook—hotel, etc. For a person who had no occupation what-.
ever write none.

To be complete, an occupation return must state:
8.—The trade, profession, or particular kind of work done.
9.—The industry or business in which the work was done.
10.—The month and year the deceased last worked at the occupation.
11.—The number of years the deceased followed the occupation. }

In stating the occupation, avoid the use of such indefinite anil
as ‘‘employee,’’ ‘‘worker,”’ ‘‘operative,’’ etc. Find out the parti-'
cular kind of work done and return that, as spinner, weaver, etc. }

In stating the industry or business, avoid the use of such general |
terms as ‘‘store,” “‘factory,"’ ‘‘mill,"’ etc. State the particular |
ae of store, factory, mill, etc., as grocery store, soap factory, cotton
mill, etc.

Distinguish carefully the different kinds of engineers by Be oe
the full descriptive titles, as civil engineer, mechanical engineer, mining |
engineer, Stationary engineer, etc. Avoid the term “‘laborer’’ when a
more precise statement of the occupation can be secured. Do not
use the word ‘“‘mechanic,”’ but give the exact occupation, as carpenter,
painter, machinist, etc. Distinguish carefully between retail merchants
and wholesale merchants. A person who sells goods should be called a
salesman and not a clerk. :

Statement of cause of death.—Cause of death means the disease, |
or complication which causes death, not the mode of dying, e. g., heart |
failure, asphyxia, asthenia, etc. As principal cause name the disease |
causing death. As related causes, name earlier morbid conditions,
if any, related to the principal cause and any important complication
of the principal cause. Under contributory causes of importance not |
related to principal cause, name other important diseases. i

Example ;

The principal cause of death and related causcs|~ pate of onset
of importance in order of onset were as follows: }

Arteriosclerosis

Chronic interstitial nephritis

Contributory causes of importance not related to
principal cause:

In a group of causes containing the principal cause and related
causes, the causes should be given in the order of onset, so that in a
group of three causes the principal cause may appear in either first,
second, or third position. )
happens to be the second cause given.

The principal cause in the above example

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, aiter 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 stz ndard certificate of death, stating to the
best of his knowledge and be ief 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.

ody and remove it from a town, from one cemetery to another, or
from one grave or tomb other than the receiving tomb to another in the
same cemetery, 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 satis-
factory 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 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 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 certificate contains a recital,
as required by section ten of chapter forty-six, that the deceased
pea fh 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 state-
ment and certificate, shall forthwith countersign 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 ceme-
tery or burial ground in which the interment is made....Chap. 114,
Sec. 46, G. L. as amended.

RULES OF PRACTICE

The fulfillment 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 un-
related to any form of injury, have died without recent medical attend-
ance or whose physician is absent from home when the certificate of
death is needed, eer : :

_resulting from injury or infection related to occupation, the
/ sudden deaths of persons not disabled by recognized disease,
and those of persons found dead.

MARGIN RESERVED FOR BINDING

N. B.—WRITE PLAINLY, WITH UNFADING INK—THIS IS A PERMANENT RECORD

. Every item of informa- 2

PHYSICIANS should state CAUSE
Exact statement of OCCUPATION is very

AGE should be stated EXACTLY.

tant.

OF DEATH in plain terms, so that it may be properly classified.
No. 7180-b

tion should be carefully supplied.

impor

S50M-11-’29,

WIDOWED

The Commonwealth of Massachusetts

OFFICE OF THE SECRETARY Boston
E ,... Sarrelx Perreeer Tie terrrrr rir irs DIVISION OF VITAL STATISTICS Prrtrt tiie trees OAR RR Otenaneveuneeseenerns Litt eeeeweeeeernseceeeseeenene
sg _ (County) (City or town making return)
a STANDARD ae
ane Boston... CERTIFICATE OF DEATH Registered No... >>... >w........
~ (City or Town) (If death di Penta
? eath occurred in a hospital or institution,
a No....the Infent's Hospital SGe ae tbinicdeies oxpiew ais 0's St., Sawaritaedactsesnceeve Ward { give its NAME instead of street and number)
(If U. S.
2 FULL NAME................. pte Sh age EE ee War Veteran,
(If deceased is a married, widowed or divorced woman, give also maiden name.) SAME LH WAR) Stirs ee ssthns tesuseipopcnsvosoissiven’
(a) Residence. No.............. 14 Bates Ave LAS ipl ORS oat the PE pe ce SST eile Bae Ward, Winthrop cb A! SO ee See a ees
(Usual place of abode) (If nonresident, give city or town and state)
Length of residence in city or town where death occurred yrs. mos. days. How long in U. S., if of foreign birth? yrs. mos. days.
PERSONAL AND STATISTICAL PARTICULARS MEDICAL CERTIFICATE OF DEATH
3 SEX 4 COLOR OR RACE | © SINGLE (write the word) || 18 DATE OF re
MARRIED e
White Single BEATS esctemie cc NR a OPM REL he Pe aaa

Male

5a If married, widowed, er divorced
HUSBAND of

or DIVORCED

(or) WIFE of

(Husband’s name in full)

6 IF STILLBORN, enter that fact here.

If less than 1 day

Years.....: 5... Months .@O. Days Minutes

8 Trade, profession, or particular
kind of work done, as spinner,
Mm Wrw er ROK ee reN EL Cee sasceacany os <a cs srs cat evnevossv0es oie nsccyai'vvavghesGepersersusveadvessased
9 Industry or business in which
work was done, as silk mill,

saw mill, baak, etc
10 Date deceased last worked at
this occupation (month and

11 Total time (years)
spent in this
occupation......

eA MIRTHPLACE, (City)... PVP WING. ccasccc cece cscs sscssecssenssesssensbnssatssssnnssntn

(State or country)

13 NAME OF
FATHER

OCCUPATION|

Lucius Peterson
14 BIRTHPLACE OF

LT Ee |. nh er
(State or country)

15 MAIDEN NAME
OF MOTHER

Doris Brown

PARENTS

16 BIRTHPLACE OF
MOTHER (City)

(State or country)

Ly.
Se Samuel A Brown cue
(Address) 14 Bates Ave

| HEREBY CERTIFY that a satisfactory standard certificate of death was
filed with me BEFORE the burial or transit permit was issued:

(Signature of jen of Roard, yout or other)

ee (Ome af Desigaationy : anenahses sSensek at dale Ges poe es

Ya“ -=12/8/s

(Month)

CERTIFY, Jhat,! attended deceased from

/z Oa 5 YOO abe oe eS
sant 21/30 1/3/31 Piyarhatncere ae eer F pons said

to have occurred on the date stated above, at L42 15am

The principal cause of death and related causes of importance in order of
onset were as follows: =a

Date of onset

Nain: OfOPOra ki OMe cconcesct ss tceesoss ev sssanxtaceacnectas saeerosssanromncrecae Date oft. s-tcssnuccee
What test confirmed diagnosis? ......0........0c::0ccceeceeeee Was there an autopsy?... yes
20 Was disease or injury in any way related to occupation of deceased? ...............0006
If so, specify.
(Signed) ............00 Se LG ARE BADE SO on eee a eRe
(Address).........300. Longwood..Ave tee. Date 1/3/1931...
21 PLACE OF BURIAL,
CREMATION OR ReMovaL.. Winthrop Winthrop
(Cemetery) (City or town)
DATE (OR BURIAL. 3-<hccccteenacesee-t

22 NAME OF
UNDERTAKER

ADDRESS

Received and filed......... ho

|
:
i
|

a ee

Metin.

R-301A
= OFFICE OF THE SECRETARY with Board of Healtli
< DIVISION OF VITAL STATISTICS feook t
es a STANDARD eee
"4 5 egistered No......nQecicccsocscssavese
1) 8 CERTIFICATE OF DEATH Registered No.......3
oO wl
2s < E (If death occurred in a hospital or institution,
D8 = ie cee Ea War { give its NAME instead of street and number)
Oo
w a — (If U. S.
n 2 FULL NAME..... War Veteran,
= specaty, WAR) ccsiccevovsvcvvevaceuappavcemaonsmeen
3) (a) Residence. NoAge).. COMA EPCODUR.. MBs. SES iat. oe Wir ee 8 soca honccs ade ea nese ee ee
n (Usual place of abode) (If nonresident, give city or town and state)
Length of residence in city or town where death occurred -—— yrs. -—— mos days. How long in U. S., if of foreign birth? yrs. mos. days.
PS y
x
oQ PERSONAL AND STATISTICAL PARTICULARS MEDICAL CERTIFICATE OF DEATH

AGE should be stated EXACTLY.
terms, so that it may be properly classified. Exact statement of OCCUPATION

d extracts from the laws on back of certificate.

y supplied.
in
tructions an

See ins’

ion should be carefull
tant.

CAUSE OF DEATH in pla

format
is very impor
75m-2-'30. No. 7997-a

N. B.—WRITE PLAINLY, WITH UNFADING BLACK INK—THIS IS A PERMANENT RECORD.

5 SINGLE (write the word)
35 4 COLOR OR’ RACE SINGLE ed
Jl WIDOWED
Mate, or DIVORCED

The Commonwealth of Massachusretta

To be filed for burial permit

18 DATE OF
DRAM s soon eer: } [gle hee We, Bc SE OF mien
y

5a If married, widowed, or divorced
HUSBAND of

(or) WIFE of

(Husband’s name in full)
6 IF STILLBORN, enter that fact here. Oo Ls

7 — ope If less than 1 day _
IRGES. .ccissrnnssacpemessse GATS: -crs----t-y- Months............ Daysilinvccrces: Hours.......-.-.- Minutes

8 Trade, profession, or particular
kind of work done, as spinner,

S RONOUE VI MHI COTIEN NCEE aco oo een ec xs veo San nx cans ceaweb eWeek ca caves vice eaen eae
| 9 Industry or business in which

a work was done, as silk mill,

= MW, MULLET EMM OE e 52.25, Senne ee onvca sv zae Sachsewase sran conn teknadaenneeh wees antenn stl vaceesaedeson
S| 10 Date deceased last worked at 11 Total time (years)

spent in this
occupation.

this occupation (month and
year)

12 BIRTHPLACE (City)..........é4 Ca CatedfA. pigie Soe 27
(State or country) y, Wz Z
a ee 3
—_-), -
1 A £01 os =

14 BIRTHPLACE OF

(City) ...... Qeaseccaclly)

a”
FATHER URS. renee eo alten eee
= f
=z (State or country) — (42 :
Ww 7
m|15 MAIDFN NAME ws 4 j
<x OF MOTHER Af “ps Cay
a
16 BIRTHPLACE OF
MOTHER (City) .......... CCA ABAD... St. Sn LP ore...
(State or country)
17
—st
Informant pi CAMA ERELY: ED, Ce oot matte no eee
(Address) Este “ee VLE 2 FZ. ee
=e = = ee

| HEREBY CERTIFY that a satisfactory standard certificate of death was
filed with se the burial or transit permit was issued:

ie CA

(Signature of gd of ealth or other)
f Se to iy) 7) bie! eed.
it

(Official Designation) i/ J x (Date of Issue of Pe )

(Month) ( ) (Year)
19 I HEREBY CERTIFY, That | attended deceased from
Be. esters eA eo ONS (: oes mn (1 ee see ORME Ne pe Nf) ee
I last saw h............ LIV BT OME snssevseuescetencnosszetccveeecevsasneceseennes at LO etieeess , death is said
to have occurred on the date stated above, at.............00. m,

The principal cause of death and related causes of

importance in order of
onset were as follows:

Date of onset

Name of operation

What test confirmed diagnosis? . Was there an autopsy?..........

O Was disease or injury in any way related to occupation of deceased? .............-....+
If so, specify
(Signed)

(Address)... Te

21 PLACE OF BURIAL, ce a
CREMATION OR REMOVAL 74207

DATE OF BURIAL...

2 NAME OF J ft
UNDERTAKER .....<....- AEE :

/ eS
appress. fa. Mie cs
mics Asti Poe A ey eG onl tee Re mERE ANS ASR 19
be Toke. 30 ) ine a ee

(Registrar)

Onn. + |

ited States Standard Certificate of Death

Shi
Revised

Statement of occupation.—Precise statement of occupation is
very important, so that the relative healthfulness of various pursuits
can be known. Make some entry in this section for every person
aged 10 yearsorover. Ifthe occupation had been given up or changed
on account of the disease causing death, report the occupation prior
to illness. If the deceased had retired from business, report the
occupation prior to retirement. Children not gainfully employed
may be returned as at school or at home. For a woman whose
only occupation was that of home housework, write housework
in answer to Question 8 and own home in answer to Question 9.
For a person engaged in domestic service for wages, however, designate
the occupation by the appropriate terms, as housekeeper—private
family, cook—hotel, etc. For a person who had no occupation whate
ever write none.

In stating the occupation, avoid the use of such indefinite terms
as ‘‘employee,’’ ‘‘worker,’’ ‘‘operative,’’ etc. Find out the parti-
cular kind of work done and return that, as spinner, weaver, etc.

In stating the industry or business, avoid the use of such general
terms as ‘‘store,’”’ ‘“‘factory,’’ ‘“‘mill,’’ etc. State the particular
ite of store, factory, mill, etc., as grocery store, soap factory, cotton
mill, etc.

Distinguish carefully the different kinds of engineers by stating
the full descriptive titles, as civil engineer, mechanical engineer, mining
engineer, stationary engineer, etc. Avoid the term ‘‘laborer’’ when a
more precise statement of the occupation can be secured. Do not
use the word ‘“‘mechanic,’’ but give the exact occupation, as carpenter,
painter, machinist, etc. Distinguish carefully between retail merchants
and wholesale merchants. A person who sells goods should be called a
salesman and not a clerk.

Statement of cause of death.—Cause of death means the disease,
or complication which causes death, not the mode of dying, e. g., heart
failure, asphyxia, asthenia, etc. As principal cause name the disease
causing death. As related causes, name earlier morbid conditions,
if any, related to the principal cause and any important complication
of the principal cause. Under contributory causes of importance not
related to principal cause, name other important diseases.

Example

The principal cause of death and related causes

F , Date of onset
of importance in order of onset were as follows: cane

Arteriosclerosis Tors

Contributory causes of importance not related to
principal cause:

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 registration a ste ndard certificate of death, stating to the
best of his knowledge and be ief 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 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, from one cemetery to another, or
from one grave or tomb other than the receiving tomb to another in the
Same cemetery, 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 Satis-
factory 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 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 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. tf death is caused by violence, the medical examiner shall
make such certificate. If the death certificate 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 state-
ment and certificate, shall forthwith countersign 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.

RULES OF PRACTICE

The fulfillment 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.

(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.

MARGIN RESERVED FOR BINDING

N. B.—WRITE PLAINLY, WITH UNFADING BLACK INK—THIS IS A PERMANENT RECORD.

Every item of

PHYSICIANS should state
Exact statement of OCCUPATION

AGE should be stated EXACTLY.
tructions and extracts from the laws on back of certificate.

terms, so that it may be properly classified.

y supplied.

See ins’

formation should be carefull
CAUSE OF DEATH in pla
tant.

is very impor

OO - —

No. 7180-a

200M-11-'29.

The Commonmesith of Massachusetts
OFFICE OF THE SECRETARY
DIVISION OF VITAL STATISTICS —___ereteeetettzeess ss essansateerseessessssereees cesepeceeesrsersseseepesseeses

(City or town making return)
STANDARD
CERTIFICATE OF DEATH Registered No........ 6 . 3 aero .

Cat, ( ) (If death occurred in a hospital or institution,
AS! 3 gl a Oe pi kS RA ee Sek ee Ward { give its NAME instead of street and number)

(If U.S.
War Veteran,

specify WAR) e250) ss55co tes, nt

(a) Residence. No....... ee stisagitre Wades Beer sacessagh ecspatest ts eras, clare

(Usual place of abode) (If nonresident, give city or town and state)
Length of residence in city or town where death occurred ye mos. days. How long in U. S., if of foreign birth? yrs. mos, days.

PERSONAL AND STATISTICAL PARTICULARS
5 SINGLE (write the word) 5
3 SEX 4 COLOR OR RACE MARRIED 1 / Go 3

an IK. i ( ixu-nduuuiesu Ax espeanstnescanDavagienewenss cans tf sata ce <4 “eas) syeveasvastaus

5a If married, widowed, or divorced That | attended deceased from
HUSBAND of .....2 72 AD BANAT. fT ercnrescngre fecsvnnersnnnessnincvsnnecctsnnceed | NE ng Pf } eit ae 19.. 3 “fe

cee TELL © 0) ec reed ana RO ec | dast saw h Si! alive on... Og teeta | Laie ins eee Siglo death is said

to have occurred on the date stated above, at. a Li. m.

The principal cause of death and related causes of importance in order of
onset were as follows: i
Date of onset

6 IF STILLBORN, enter that fact here.

GE....... Me hos Vea tGiecss..-rese Months...........- Days

8 ‘Trade, profession, or particular

= kind of work done, as spinner,
° sawyer, bookkeeper, etc............0...0.0 4&6
| 9 Industry or business in which
a work was done, as silk mill, made
a faw: mill shank, etc. oso5so nL eee
S| 10 Date deceased last worked at LAWL DLELOU LI. 0CE tes Sn Il TR Ea, AA, Se Re RE A ee ee ee ca Oe ee lee
this occupation (month and spent in this
t) do cgeneente ast ahaa Vent see ipa ners cao obs anos anand occupation......\...200.5.5.4

12 BIRTHPLACE (City) ............ eA ehh IN onic cceeeeeenatereteenees
(State or country)

13 NAME OF =
FATHER
Name of operaticn............... sedge any actvoess Maw: . ccacvastueatat Ronee ony | ELARO! Ofccsass.ccecsc tener
14 BIRTHPLACE OF aH ?
i FATHER (City) ........ : What test confirmed Afeisacmis?! Pee ae oka . Was there an autopsy?..........
z (State or country) 20 Was disease or injury in any way related to occupation of deceased? ....................
Lut A
ATS SPR CHY Tepnataarss festa ca tvy faespc wees fine scat ts Cah eeasone tens | Ae ee
|} 15 MAIDEN NAME t Naf x :
<| OF MOTHER Signed) ....... (Ub td renter...
a
16 BIRTHPLACE OF (Address). 2.4 Y. LD apy acy pps ARPES Miedo cc esis cme ceenad
Solano: CARS 21 PLACE OF BURIAL, , Leh
(State or country) CREMATION OR REMOVA t, me a Mey AYE.
Cotte steny) (City or town)
17 DATE OF BURIAL.....+>¢4e2-... Ye ei tee eee. 19.3...
Informant 4.44% PONS NY Bd Sa eer acne ells! aoe: SE ee SEE Enero

(Address) 22 NAME OF

UNDERTAKER «4.
©)
ADDRESS... es PANY

| HEREBY CERTIFY tak a satisfactory standard certificate of death was

iu me BEFORE th Ler transit permit was issued:
ee (YMA: Se hts Aisne
L es

geignature of

t= Oincial Dekcnatony” adhe CORI eee ne

DAK. a 143A ,-

Revised United State. Standard Certificate of Death

Statement of occupation.—Precise statement of occupation is
very important, so that the relative healthfulness of various pursuits
can be known. Make some entry in this section for every person
aged 10 yearsorover. If the occupation had been given up or changed
on account of the disease causing death, report the occupation prior
to illness. If the deceased had retired from business, report the
occupation prior to retirement. Children not gainfully employed
may be returned as at school or at home. For a woman whose
only occupation was that of home housework, write housework
in answer to Question 8 and own home in answer to Question 9.
For a person engaged in domestic service for wages, however, designate
the occupation by the appropriate terms, as housekeeper—private
family, cook—hotel, etc. For a person who had no occupation what-
ever write none.

In stating the occupation, avoid the use of such indefinite terms
as “‘employee,’’ ‘‘worker,"’ ‘‘operative,’’ etc. Find out the parti-
cular kind of work done and return that, as spinner, weaver, etc.

In stating the industry or business, avoid the use of such general
terms as “‘store,’’ “‘factory,’’ “‘mill,’’ etc. State the particular
ane rs store, factory, mill, etc., as grocery store, soap factory, cotton
mill, etc.

Distinguish carefully the different kinds of engineers by stating
the full descriptive titles, as civil engineer, mechanical engineer, mining
engineer, stalionary engineer, etc. Avoid the term ‘‘laborer’’ when a
more precise statement of the occupation can be secured. Do not
use the word ‘‘ mechanic,"’ but give the exact occupation, as carpenter,
painter, machinist, etc. Distinguish carefully between retail merchants
and wholesale merchants. A person who sells goods should be called a
salesman and not a clerk.

_ Statement of cause of death.—Cause of death means the disease,
injury, or complication which causes death, not the mode of dying,
e.g., heart failure, asphyxia, asthenia, etc. As principal cause
name the disease or injury causing death. As related causes, name
earlier morbid conditions, if any, related to the principal cause and
any important complication of the principal cause. nder contri-
butory causes of importance not related to principal cause, name
other important diseases or injuries.

Example

The principal cause of death and related causes
of importance in order of onset were as follows:

Arteriosclerosis

Date of onset

Chronic i

Peeeeeeeeeeeerrerery

Contributory causes of importance not related to
principal cause:

Fracture of arm

In a group of causes containing the principal cause and related
causes, the causes should be given in the order of onset, so that ina
group of three causes the principal cause may appear in either first,
second, or third position. The principal cause in the above example

happens to be the second cause given.

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 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 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. 40, 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, from one cemetery to another, or
from one grave or tomb other than the receiving tomb to another in the
same cemetery, 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 satis-
factory 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 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 insufficient, a physician who is a member of the
board ot 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 certificate 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 state-
ment and certificate, shall forthwith countersign 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.

State cause for which surgical operation was undertaken.

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 expianation, as the
sole cause of death: Abortion, cellulitis, childbirth, convulsions,
hemorrhage, gangrene, gastritis, erysipelas, meningitis, mis-
carriage, necrosis, peritonitis, phlebitis, pyemia, septicemia,
tetanus.

R-301A

& The Commonwealth of Massachusetts To be filed for burial permit
: OFFICE OF THE SECRETARY with Board of Health

DIVISION OF VITAL STATISTICS e
«OF or its Agent.
° re) STANDARD
gem 1 CERTIFICATE OF DEATH Risistered Nabi sae
oO
ot OY (If death occurred in a hospital or institution,
> rs} (V4... Sacacseearenenma WET) fia bocce EOE Ward give its NAME instead of street and number)
229 ; (If U.S.
wn 2 FULL NAME..../.\ CAL, OVC ff) OA eee AANAAAAOTMAD ns War Veteran,
aa S (If a9 is a Ti idowed or divopfed Woman, e also maiden name.) spccihy, WAR) |< cdsciccccivsceasesnssdacernesoasspeaas
od
ROS (a) Residence. No...... 2... eS ere NS ARAL. S| ERS eee Ward scree acetic Retna tes Ee ee
Sa eg ° (Usual place of abode) : ; (If nonresident, give city or town and state)
Pas] m~ oO 2 Length of residence in city or town where death occurred yrs. mos. days. How long in U. S., if of foreign birth? yrs. mos, days.
mes —— ee ee =
al -W £2 PERSONAL AND STATISTICAL PARTICULARS
ae 3% 3 SEX 4 COLGR OR RACE | 5 SINGLE (write the word) |/ 18 DATE OF 1G wef
1a g 3 WIDOWED EAU ieee -s-cssceseepeet rote Wize cosine sea scscnosorercsceamnaset §- peeiaap sy tas aae Rp Mates ett Gate caste ea at eae
intts ox DowED | VAQUULL I (Day) (Year)
btn
So _.4 || 5a it married, widowed, or divorce” | ; 19 1 HRBEBY CERTIFY, That | attended deceased from
ravi g HUSBAND of -.-2020000--000-000000022- L{NOAAARL..... De RES. ..| “
wey e a (Give maiden name of wife in full) (M0 C=*d rrcecneeeeneeeeveeceveenveecnsecnnscnncovscensecnscssnenp LQeeesscep tOsccrsesssscssnesssessnecsnresssecesenssasesnecesas ae eae
en Be (CALI: Cee ee ctomuae vice RCE er rears eS eee I last saw h............ AliVOUON See cree Oe i [Pe es , death is said
4000 (Husband’s name in full) re < e
a + ae 6 IF STILLBORN, enter that fact here. O have occurred on the date stated above, at™......°........ m.
mae The principal cause of death and related causes of importance-in order of
Nos rf (0 / V, x If less than 1 day onset were as follows: eee
m0 6,0 1 \c] Seen, Se ee Wears inscit4> Months EDAYS: isesa-cck->- Heirs Minutes
os
BUS ~ 8 Trade, profession, or particular : =
| 2 ma: = kind of work done, as spinner,
° iS) sawyer, CONTE oC Peer eee nee CERO Eee DEEPECEE RTT ie ether EPO ort ee ore ct, <A CEES EERE CEE REER
Bets E| 9 Industry or business in. in which ron 1.0
= o a work was done, as silk
AQ Eo = saw mill, bank, etC..........-0:00++ mill, () -S. W TRAQLAZ.. oe
rae we E |B) 10 Date decegrnd last worked at 11 Total time (years)
< = ¥ year =een bee ( Sera oe ae Contributory causes of importance not related to principal cause:
6 z
ino] 1 IT ie oe ish Aor SE EERE ee et recta ATE, ee RSS SEE PERE PPE PEPER CRY i steer
4 ones 12 BIRTHPLACE (City)...... p.CEAQRL CAR ora... } ae Dy) :
© ZzeSs (State or country) ING PA As AAA Pe LAM CYP =€ 5 B ok
<q ra) 3 6 13 NAME OF f) Fa cats te ts ae mes S aes nie tu Se acm ns se CRE Pn eS ENRON OY maa oe eerse so nana eee
= a"Es FATHER et Hg
> 5 3 7 i4¢dme of operation
wees 14 BIRTHPLACE OF iagnosi
1 Sas |" FATHER (City) ......... | agi eee 0 / FD Mecieceessereesssinssed Lent test confirmed diagnosis 9M
| t 7 it f z (State or country)
x ile! Ww
“eo c| 15 MAIDEN NAME
SOs ||<| OF MOTHER %
r Go) EE
Ser A 16 BIRTHPLACE OF / 3
chink MOTHER (City) ............. <n ae ean 4. OATS herds ‘ene
Fas a 21 PLACE OF BURIAL,
fs (State oxcountry) CREMATION OR R
< a) 5 ES
Boh e g ae f TUARL DATE OF BURIA
eT) Gy J oy A OA v4 Somat aklad
a gals, 3} |_ (Address) 5 22 NAME OF
Yn : UNDERTAKER ....
Se) o Ss | HEREBY ee that a satisfactory standard certificate of tal was
S as “ae FOR b ADDRESS vu
+ oa em OS /
S (3
| ee kt oe eR Recahod and: fitedictn REINA... Act
# & A ee Me ee aa te
a | (Official Designation) , (Registrar)

; Mme Is Z )
nited States Standard Certificate of Death

Statement of occupation.—Precise statement of occupation is
very a nag so that the relative healthfulness of various pursuits
can be known. Make some entry in this section for every person
aged 10 years or over. If the occupation had been given up or changed
on account of the disease ceeee death, report the occupation prior
to illness. If the deceased had retired from business, report the
occupation prior to retirement. Children not gainfully employed
may be returned as at school or at home. For a woman whose
only occupation was that of home housework, write_ housework
in answer to Question 8 and own home in answer to Question 9.
For a person engaged in domestic service for wages, however, designate
the occupation by the appropriate terms, as housekeeper—private
family, cook—hotel, etc. For a person who had no occupation what+
ever write none.

In stating the occupation, avoid the use of such indefinite term§
as ‘‘employee,” “worker,” ‘‘operative,” etc. Find out the partir
cular kind of work done and return that, as spinner, weaver, etc. H

terms as ‘‘Store,"’ ‘“‘factory,’’ ‘‘mill,” etc. State the particular
kind of store, factory, mill, etc., as grocery store, soap factory, cotton,
mill, etc. ‘

ish carefully the different kinds of engineers by statin)
the full descriptive titles, as civil engineer, mechanical engineer, minin,
engineer, stationary engineer, etc. Avoid the term ‘‘laborer’’ when a
more precise statement of the occupation can be secured. Do not
use the word ‘‘mechanic,”’ but give the exact occupation, as carpenter.
painter, machinist, etc. Distinguish carefully between retail merchants
and wholesale merchants. A person who sells goods should be called a
salesman and not a clerk.

Distin

Statement of cause of death.—Cause of death means the disease,
or complication which causes death, not the mode of dying, e. g., heart
failure, asphyxia, asthenia, etc. As principal cause name the disease
causing death. As related causes, name earlier morbid conditions»
if any, related to the principal cause and any important complicaiion
of the principal cause. Under contributory causes of importance not
related to principal cause, name other important diseases.

Example

———$—_—"

Date of onset :

The principal cause of death and related causes
of importance in order of onset were as follows:

Arteriosclerosis

Contributory causes of importance not related to
principal cause:

In a group of causes containing the principal cause and related

causes, the causes should be given in the order of onset, so that in a
group of three causes the principal cause may appear in either first,
The principal cause in the above amps

second, or third position.
happens to be the second cause given,

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 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 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 ofjhis death....
Gen. Laws, Chap. 46, Sec. 9.

from one grave or tomb other than the receiving tomb to another in the
same cemetery, 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 Satis-
factory 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 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 Papen 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
make such certificate. If the death certificate 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 state-
ment and certificate, shall forthwith countersign 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 ot 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, Chab. 38, Sec. 6.

(ieee See Eee

Sec. 46, G. L. as amended.

RULES OF PRACTICE

The fulfillment 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.

(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 oisons), 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.

Every item of informa-

PHYSICIANS should state CAUSE
Exact statement of OCCUPATION is very

AGE should be stated EXACTLY.

in plain terms, so that it may be properly classified.

tion should be carefully supplied.

OF DEATH

important.

50m-2-'30. No. 7997- |

_N. B.—WRITE PLAINLY, WITH UNFADING INK—THIS IS A PERMANENT RECORD.

E tenn eeneeeeee Suffolk UPPe TTP errr) DIVISION OF VITAL STATISTICS Prrrrrri iris Chelse 8¢e Dedeccoresccovocceconsceeseoecece
ig (County) ity or town A return)
a STANDARD
i aie oh Gneh e::)- CERTIFICATE OF DEATH Registered No... 22.00...
g seme iy (If death d in a hospital
eath occurred in a hospital or institution,
a No.... Soaldiers'...Home.. Hosp. Eee tee SEs Ward give its NAME instead of street and number)
“ (If U. S.
SSN PYAAR. MM Mreme MINIM, occas dascssssacsonenassssdestoepecespsssssccanentecsonennntcensoonn War Veteran,
(If deceased is a married, widowed or divorced woman, give also maiden name.) specify WAR)...... Civil
an RC BICLOMIC Bee ING chs ranges se op eckassdeen havens cbvscetsndooass¥ohoast Stee one Ward, . Winthrop, Sie Mass
(Usual place of abode) (If nonresident, give*city or town an
Length of residence in city or town where death occurred §yss. 8 mos. days. How long in U. S., if of foreign birth? yrs. mos. days.
PERSONAL AND STATISTICAL PARTICULARS MEDICAL CERTIFICATE OF DEATH
3 SEX 4 COLOR OR RACE | © SINGLE (write the word) || 18 DATE OF
al ie J january..B,1951 ta eee =
i t
Mole White or DIVORCED Wi dowe (Month ay) (Year)
5a If married, widowed, or divorced 7 19 I HEREBY CERTIFY, That! attended deceased from
ROR, |, he a _ Dec. 19
(Give maiden name of wife in full) 2. fn cevesveresseeeees 19. oO to... Figs tes Pe , 19. Si.
(OL Cc sp saelzolitn cet ae Se a cs te te | last saw h......L live on......... Pb: ne . ec Re a. death is said

(Husband's name in full)
6 IF STILLBORN, enter that fact here.

us
AGE........ 82. ayaa Years... asians Months .2.&..Days

8 Trade, profession, or particular

If less than 1 day

> kind of work done, as spinner,
5 sawyer, bookkeeper, tte... SULDWrights Wpecdaststeasavereveveves
| 9 Industry or business in which
a work was done, as silk mill,
= RMON, (MMR OL re co recente Saaeo sack a ceiiacata toot andatecevidetustoaveserdchivessucvescscpsssecssnnes
S| 10 Date deceased last worked at 11 Total time (years)
2 this occupation (month adnetired spent in this
BAD icis de seas vonatevctocel cov sete nc tsuh Meera neasercalciessis occupation...........-.......
12 BIRTHPLACE (City)... Ciariestoun,......................
(State or country) ¥ asa
13 NAME OF
FATHER John
14 BIRTHPLACE OF .
@| FATHER (City) ............ ss er
a (State or country) En ou l 2 nd
Ww
| 15 MAIDEN NAME
S OF MOTHER Mor :
16 BIRTHPLACE OF
MOTHER (City) cccccssceccseccerse A TOMO Bc cece
(State or country) N = Ss
17
Informant... POSPLtAL, PeCOPaSs
(Address) )
aT.
A TRUE COPY. UL detancl/ GeRY
Raa e Ue CEI ss. areata aso hae oi deb exaust abictedatsosdnaal asta seuadaroncgeshecuseusscascidoenessspuesene’
(Registrar of city or town where death occurred)
BRE FILED ooscatncas a Che Pag & Pens 2° 5) eh. eee

The Commonwealth of Massachusetts
OFFICE OF THE SECRETARY

to have occurred on the date stated above, at..6..<-5m.P. RM,

The principal cause of death and related causes of importance in order of
onset were as follows: |
Dateofonset

Arteriosclerosis 2 yeare |
Chronic Myocarditis... fn

Contributory causes of importance not related to principal cause:

Bronchopnevmonia oo... Dece1950
Name of operation............ i a Riera ame BE ato Date oben ee
What test confirmed diagnosis? .................cccccceseeeeeees Was there an autopsy?..........

20 Was disease or injury in any way related to occupation of deceased? ae. ae
PEE SOS HE CIO ote ro otis cass onntauasensazuvcarsevucssssssevacvacaessstevésapactanieccandens descr dareovevseinrvansess@bEonseeres

Gime ewe E

(Address). SOLALers *..

21 PLACE OF BURIAL, Ww

CREMATION OR REMOVAL ge ~ oe oe

etery ity or town

DATE OF BURIAL......... Jane a» cn, ee oO.
22 NAME OF

UNDERTAKER .......... David Fudge roa & Son A Tne. Bieae

anpress.. cOmMerville,sMasse .ssssai( (a
Received and filed....................2 Ooo rere ime ber URE, Ste: Maye ;

Registrar of City or Town where deceased resided)

ce a ca ne al

’ ib) fae 4 : 3 }
-R-303B The Commonwealth of Massachusetts To be filed for burial
y : OFFICE OF THE SECRETARY permit with Board of
A E oposite ‘4 Health or its Agent.
‘ igal a o/
& 148 AMA. CERTIFICATE OF DEATH l Registered No..." fan cea
a 3 (City or Town) pee
hg ‘5 s ‘ (If death occurred in a hospital or institution,
ine = No... f.4g.! Can. Cucd ESS at a ths" Eee ae Ward give its NAME instead of street and number)
Bese (It U. S
Qa Ss 2 FULL NAME....\....W0 NM NALAAMA...... eh GATES... RA CUTAN... cececececceceeeeneee War Veteran,
<3: “(f ‘deceased is a guetlty WAND ii:.siiscieccvsstsdtivcendeee
is 0 (a) Residence. No...... | Ae D,.' BE fel Ts 9 RR eR DE EIT 7 Nee Ae
a 2D 3 (Usual place of abode) (If nonresident give city or town and state)
: ‘ F 3 Length of residence in city or town where death occurred /) ) yrs. mos. days. How long in U. S., if of foreign birth? ~~) yrs. mos. days.
: Eg PERSONAL AND STATISTICAL PARTICULARS | MEDICAL CERTIFICATE OF DEATH
a 3 SE 4 COLOR £ aes (write the word) {/ 18 DATE OF LQ. /
2 Wi ‘ WIDOWED u DEATH acsineocestvessisessans ig sess RAO RO rieced Am. ee, eee Mopar iceninred G3.)
ag SS or DIVORCED “Ze ~ 2 ¢Z ||. GE faa Day) (Year
-_
= “ae aoe eM 19 | HEREB ERTIFY that I have investigated the death
ie eee “lice M. Kelly... faa a nth ESE ND MAREN
5 at SEE as de lp ade Ryn ae RE 15 ES a pee aE 2 OP Ee a as f $: |
= <2 52 si (Husband's name in full) “Woy
,
fz 2@z5 8 6 IF STILLBORN, enter that fact here. |
1 wn}
Es & |[ace...... IY veers nn MOMS. DEVE
' l 4 8 Tra od eboaetil or particular
a ofwork done, as spinner, B — f° 4. YY _ ff ji....... {
“=U 3 sawyer, bookkeeper, etc. ........0@..nbe Pom Sno OL. LE : ae fhead |
ZU > ; | 9 Industry or business in which L Se) | Cas :
, “= TS ~ work was =, as silk mill, mh
7 “a § = Ainsley saaalll Doorn s! {055 sss. eerte cts iad ldo eo hase ecnecn eee onavdhcepnncacss
Boe) 2 S| 10 Date deceased last worked at _11 Total time (years)
t= 5s this oe (month ~~ AI oY ti 5 spent in this ‘0
- fs 3 £ year) .......... occupation.. $24. <77
en oo?
5 ok BON AS BIRTMPLACE (Citg) nc Yorn Server nena flssamndh...\fr
Y ze £ £ CU OSU! URN 2 ee I an || 2 a Ed ne ee eR ny ene on eran
soO2.8 13 NAME OF
< ans rT LTB RY Ly Sy IS SSR Vera ren eee dakpamesy bin bee sesasenssebasseebsasgasaenenstesnecsectsceneeesesnenee
Ke mw S (See reverse side for description for unknown person)
Z=s 14 BIRTHPLACE OF
Ya) ” . 20 IN WHAT CITY OR TOWN
att 7 he iia SS Bele iets A
: e = tate or country ’
Da! a} ee | Se ne ee a ek fo Tee he. (Signédy ore e Prem...
E ’ ee | 15 MAIDEN NAME f ;
Ege g ||<| OF MOTHER
i a) CHM CL MCCeenmta || (sdf Ast Ng 56...
0 8 16 BIRTHPLACE OF :
: 21 PLACE OF BURIAL, ‘
co. : MOTHER (City) 2. Li SES, Ce CREMATION OR REMOVAL »

(State or country)

n shoul
he:

Z
17 / i DATE OF BURIAL. 4g
Jefernast 22 NAME OF (Dy
i Rabi essy/ Ye i ase e UNDERTAKERE x

Tne HEREBY CERTIFY that a satisfactory standard certificate of death was
r transit permit was issued:

Mite Ze. the byrial ¢

ature of

pba life TORS Gh) ee C
(Official Designation) (Date of Issué of Peemit) (Registrar)

No. 7997-c
\

DEATH in
of Death.

5m-2-'30,

)
y

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 regis-
tration 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 as required by section one, where same was con-
tracted, the duration of his last illness, when last seen alive by the
oe gaa or officer and the date of his death.,..Gen. Laws, Chap. 46,

ec. 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 under-
taker or other person shall exhume a human body and remove it from
a town, from one cemetery to another, or from one grave or tomb other
than the receiving tomb to another in the same cemetery, 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 originalinterment, 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 purpose, or is insufficient, a physician who is a member of the
board of heaith, or empioyed by it or by the selectmen for the purpose,
shall upon Aenean make the certificate required of the attending
physician. If death is caused by violence, the medical examiner shall
make such certificate. If the death certificate 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 ese of such statement and
certificate, shall forthwith countersign 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.

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

Medical examiners shall make examination upon the view of the
dead bodies of only such persons as are supposed to have died by violence.
If a medical examiner has notice that there is within his county the
body of such a person, he shall forthwith go to the place where the body
lies and take charge of the same;...—Gencral 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.
—General Laws, Chap. 38, Sec. 7.

...The medical examiner certifies the cause and manner
of death to the best of his knowledge and belief.

RULES OF PRACTICE

The fulfilment of the purpose of these laws calls for the observance
of the following rules of practice:

(1) Attending physicians will certify to such deaths only as those
of persons to whom they have given bedside care during a last illness
from disease unrelated to any form of injury.

(2) Board of Health physicians will certify to such deaths only
as those of persons who, though,disabled by recognized disease unrelated
to any form of injury, have died without recent medical attendance or
wires Di is absent from home when the certificate of death is
needed.

STATEMENT OF CAUSE OF DEATH

Medical Examiners in certifying to a death will state the cause and
manner thereof, and will specify:
injury and of its consequences; and (2) under manner, the mode of
its production together with the circumstances when these are known.
Forexample: ‘‘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 anzesthetic.’’ ‘‘Fracture of the skull with
associated internal injury sustained under circumstances unknown.”

If disease or injury was related to occupation, specify. Ifinvestigation
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: ‘‘ Hemorr-
hage spontaneous, of the brain (basal ganglia) (found dead in bed).’”’
“Heart disease, presumably coronary sclerosis. (Sudden death.)"

1) Under cause, the nature of an.

Anne nen e ease een ennnnnasnns see sees esas eee eS es SEABED En nneeueEEEsessereneeeEneseee On eee ee eee eereeeeeeeneeeeseeseOeeeeeranseseeeenanstsereseteseesssSSESRGE SEES ESSEE DOE OEER OLED EES SsESSEESEESSSOSSOESEEEE SHEE HOEEESSOeEESEuseeeseneres

NOTICE TO UNDERTAKERS: No embalming fluid, or any substitute therefor, shall be injected into th
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

| R-B01A

Every item of

PHYSICIANS should state

RMANENT RECORD.
it may be properly classified. Exact statement of OCCUPATION

AGE should be stated EXACTLY.

lain terms, so that
See instructions and extracts from the laws on back of certificate.

information should be carefully supplied.
in p
tant.

CAUSE OF DEATH

is very impor

75m-2-'30. No. 7997-a

N. B.—WRITE PLAINLY, WITH UNFADING BLACK INK—THIS IS A PE

g ae SuSGfolk.......
pee Winthrop - ee
ae ae, aH... Winthro

2 FULL Reisen TV. Ar. 1 &. tral AST 1:
(a) Residence. No.. a. ef-s.

(Usual place of abode)

Length of residence in city or town where death occurred re yrs. mos.

PERSONAL AND STATISTICAL PARTICULARS

The Commonwealth of Massachusetts
OFFICE OF THE SECRETARY
DIVISION OF VITAL STATISTICS

STANDARD
CERTIFICATE OF DEATH

s\Lad.d

(If deceased is a married, widowed or dive vo wo

Winthrop =

ee RT) Singin Waray

To be filed for burial permit
with Board of Health
or its Agent.

(if death occurred in a hospital or institution,
give its NAME instead of street and number)

d.). Knomiles| War Veter,
den name.)

ive also Sppeeaty WAM) occ cBeisvs0eze¥sscesescacmenneaen

(If nonresident, give city or town and state)

days. How long in U. S., if of foreign birth? yrs. mos, days.

MEDICAL CERTIFICATE OF DEATH!

3 SEX 4 COLOR OR RACE | 5 SINGLE Speer)
ae WIDOWED
emale | White wpivoxcen Widowed

5a If married, widowed, or divorced
HUSBAND of

(or) WIFE of He en ‘ 4 vg wi\eS.. ho ee ee

usband's ke in Dye
6 IF STILLBORN, enter that fact here.

8 Trade, profession, or particular
kind of work done, as spinner,
sawyer, bookkeeper, etc... aeeenae

9 Industry or business in which,
work was done, as silk mill,
saw mill, bank

10 Date deceased last worked at
this occupation (month and
year)

OCCUPATION|

11 Total time (years)
spent in this
occupation................06.

12 BIRTHPLACE (City)....... \ Laste.v).. Le Ree ae ee eee

(State or country) f\ /\ A < S ach SCTE 4

13 NAME OF
FATHER

Hast

14 BIRTHPLACE OF
FATHER (City) ....%7.. f

(State or country)
15 MAIDEN NAME e
OF MOTHER ebecca Haven.
16 BIRTHPLACE OF
MOTHER (City)
(State or country)

“hte Ue eat Has: in sladd. Be.

1 HEREBY CERTIFY that a satisfactory standard certificate of death was
filed with BEFORE thevbyrial or transit permit was issued:

| Lz bee. be. aks

PARENTS

(Ad

REE Chan cme casa ide tetas ss next mat name -ct cpr eeacnnnAbesuaaceecbsenseevsecovoerns eeu

to have occurred on the dt stated above, at(Z...... ei

The principal cause of death and related causes of importance in order of
onset were as follows:

Name of operation..........0 tt...
What test confirmed diagnosis? .. Ck

20 Was disease or injury in any way related to occupation of deceased?........

If so, specify,
(Signed) C

21 PLACE OF BURIAL

CREMATION OR REMOVAL ¥. N.O.OC
ao “(City or town) —
DATE OF BURIAL. ce AN Vary _| ate ice Eo, ue eee 1933.1.
22 NAME OF
UNDERTAKER PLA ASON).......
ADDRESS MOSS cy ee ee
Received and fiJed...................... ai AAA ea 7 a 19.2...

(Registrar)

a5 &'B | = yey
nited States Standard Certificate of Death

}

Statement of occupation.—Precise statement of occupation 1s_

very og ty so that the relative healthfulness of various pursui
can be known. Make some entry in this section for every person
aged 10 yearsorover. Ifthe occupation had been given up or changed
on account of the disease causing death, report the occupation prioz
to illness. If the deceased had retired from business, report th»
occupation prior to retirement. Children not gainfully employed
may be returned as at school or at home. For a woman whose
only occupation was that of home housework, write housework
in answer to Question 8 and own home in answer to Question 9.
For a person engaged in domestic service for wages, however, designate
the occupation by the appropriate terms, as housekeeper—private
family, cook—hotel, etc. For a person who had no occupation what-
ever write none.

To be complete, an occupation return must state:
8.—The trade, profession, or particular kind of work done.
9.—The industry or business in which the work was done.

10.—The month and year the deceased last worked at the occupation.
11.—The number of years the deceased followed the occupation.

In stating the occupation, avoid the use of such indefinite terms
as ‘‘employee,”’ ‘‘ worker,” “‘operative,’’ etc. Find out the parti-
cular kind of work done and return that, as spinner, weaver, etc.

In stating the industry or business, avoid the use of such general
terms as “store,"’ ‘‘factory,’’ ‘‘mill,'’ etc. State the particular
ind of store, factory, mill, etc., as grocery store, soap factory, cotton
mill, etc.

Distinguish carefully the different kinds of engineers by stating
the full descriptive titles, as civil engineer, mechanical engineer, mining
engineer, stationary engineer, etc. Avoid the term ‘‘laborer’’ when a
more precise statement of the occupation can be secured. Do not
use the word ‘‘mechanic,”’ but give the exact occupation, as carpenter,
painter, machinist, etc. Distinguish carefully between retail merchants
and wholesale merchants. A person who sells goods should be called a
salesman and not a clerk.

Example

The principal cause of death and related causes
of importance in order of onset were as follows:

Date of onset

July 5, 1027

Contributory causes of importance not related to
principal cause:

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 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 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 ofjhis 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 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, from one cemetery to another, or
from one grave or tomb other than the receiving tomb to another in the
same cemetery, 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 Satis-
factory 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 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 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 certificate 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 state-
ment and certificate, shall forthwith countersign 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 ot 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.

No undertaker or other person shall bury a human body or the
ashes thereof which have been brought into the commonwealth until
he has reccived 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 ceme-
tery or burial ground in which the interment 1s made....Chap. 114,
Sec. 46, G. L. as amended.

RULES OF PRACTICE

The fulfillment 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.

(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 (includin 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.

state

item

should

Exact statement of OCCUPATION

very

PHYSICIANS

ified.

K—THIS IS A PERMANENT RECORD.

WITH UNFADING BLACK IN
AGE should be stated EXACTLY.

t may. be properly class
tructions and extracts from the laws on back of certificate.

y supplied.
terms, so that

See ins’

NLY,

P pyrs —T ; ane
N. B.—WRITE PLAI

Sad

is very important.

75m-2-'30. No. 7997-a

information should be carefull
CAUSE OF DEATH in pla

E eee eeeeeee suffolk Pere DIVISION OF VITAL STATISTICS with Board of Heal

PY (County) STANDARD or its Agent,
1)3 Winthrop CERTIFICATE OF DEATH Registered No...........5

wl cite Tow E : : ;

o er nt St (If death occurred in a hospital or institutio

A N es: Bete es aeteldceicekts se sadewut duu sakinass -voavsaunaevbahawecnecuanadet =~ <b Np Bagh y cet cksen oer: Ward give its NAME instead of street and

i (If U.S.
2 FULL NAME... GLAZEDOETN DONE. ROBO no cccccccccssesscssscessseseesseesten War Veteran,
(If deceased is a married, widowed or divorced woman, give also maiden name.) speeity WAR) <.i:....5-c0scssctyes
(a) Residence. No... 0+. eremont ch AR ss Be a Rs ie ne re SEs arene Wards .23 2.5 ne Sees dae

(Usual place of abode)
Length of residence in city or town where death occurred

PERSONAL AND STATISTICAL PARTICULARS

- Che Commonwealth of Massachusetts
; OFFICE OF THE SECRETARY

(If nonresident, give city or town an

How long in U. S., if of foreign birth? yrs. mos.

days.

number

To be filed for burial permit

d state)
days.

5 SINGLE (write the word)
3 SEX 4 COLOR OR RACE MARRIED
omak wh = or Divorcep Married

5a If married, widowed, or divorced
HUSBAND of

(Husband's name in full)
6 IF STILLBORN, enter that fact here.

If less than 1 day

8 Trade, profession, or particular

kind of work done, as spinner, :

sawyer, bookkeeper, CtC,.........--.:::0000+5 BH 011-5-e%- 5 32 vf enone nee pCO
9 Industry or business in which

work was done, as silk mill, ,
saw mill, bank, @tC.........-.......-.00-0-0e---+- ee ee ss

10 Date deceased last worked at 11 Total time (years)

ie ee pecusdien a

occupation..
OT ee a
(State or country) Tréland

13 NAME OF
FATHER

OCCUPATION|

Thomas Doherty

14 BIRTHPLACE OF
FATHER (City)

(State or country)

15 MAIDEN NAME
OF MOTHER

PARENTS

Mary Lawless

16 BIRTHPLACE OF
MOTHER (City)

(State or country)

17 VW

Informant ..*:
(Address)

iS hhh

18 DATE OF
DEATH .............4f-.

to have occurred on the date tated above, at” saaeee m.

The principal cause of death and related causes of importance in

onset ges

order of

Welt OF GPE TALON Secceitce aos dass acta kcac es suas eohcsseuccovtes vos pseecagenastucee Date ‘Of: 25:4 :.tecsnteeuee

What test confirmed dtapwosig7el?

Was there an autopsy?..........

20 Was disease or injury in any way related to occupation of deceased? ...
BESO SPCC TE ica ten ee ee os ee reo es ee ae
COT TT(E Wie Bee, te a EY of [a a eh
(Address)...

21 PLACE OF BURIAL, .
CREMATION OR REMOVAL Holy

January 14”

_6ross. valde

DATE OF BURIA]-

22 NAME OF
UNDERTAKER ....

aay Te S

j ‘

GA~. \\.\A3\- ; .
States Standard Certificate of Death —

Revised U

To be complete, an occupation return must state:
8.—The trade, profession, or particular kind of work done.
9,—The industry or business in which the work was done.
10.—The month and year the deceased last worked at the occupation.
11.—The number of years the deceased followed the occupation.

In stating the occupation, avoid the use of such indefinite terms
us ‘‘employee,”’ ““worker,”’ ‘‘operative,’’ etc. Find out the parti-
cular kind of work done and return that, as spinner, weaver, etc.

In stating the industry or business, avoid the use of such general
terms as ‘‘store,” “factory,’’ ‘‘mill,’’ etc. State the particular
ind of store, factory, mill, etc., as grocery store, soap factory, cotton
mill, etc.

Distinguish carefully the different kinds of engineers by stating
the full descriptive titles, as civil engineer, mechanical engineer, mining
engineer, Stationery engineer, etc. Avoid the term ‘‘laborer’’ when a
more precise statement of the occupation can be secured. Do not
use the word “‘mechanic,”’ but give the exact occupation, as carpenter,
painter, machinist, etc. Distinguish carefully between retail merchants
and wholesale merchants. A person who sells goods should be called a
salesman and not a clerk.

Example

The principal cause of death and related causes
of importance in order of onset were as follows:

Date of onset

Arteriosclerosis

Cerebral hemorrhage

Contributory causes of importance not related to
principal cause:

second, or third position. The principal cause in the above example
happens to be the second cause given.

EXTRACTS
FROM THE LAWS OF THE
COMMONWEALTH OF MASSACHUSETTS
GOVERNING THE

RETURN OF CERTIFICATES OF DEATH

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, from one cemetery to another, or
from one grave or tomb other than the receiving tomb to another in the
same cemetery, 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 Satis-
factory 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 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 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 certificate 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 state-
ment and certificate, shall forthwith countersign 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.

RULES OF PRACTICE

The fulfillment 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.

To be filed for burial permit \

_ The Commonwealth of Massachusetts
e with Board of Health

OFFICE OF THE SECRETARY

WITH UNFADING BLACK INK—THIS IS A PERMANENT RECORD.
AGE should be stated EXACTLY.

it may be properly classified.
xtracts from the laws on back of certificate.

y supplied.
terms, so that

See instructions and e

| ” 14 HACE On What test confirmed diagnosis? Was there an autopsy?..........
“- —
ba z= (State or country) 20 Was diseaseoninjury in any way ‘Cx SY gob Of deceased? ........-....2::000
> — lw 5 fj
92 c|15 MAIDEN NAME If so, specify... pigs lisissaschl, ly. Nhe: MANE Bie =r
} 3 g < OF MOTHER (Signed) AV fYUAAZ.Y Ld GF * V/ ,M.D
f 3 a
Sex 16 BIRTHPLACE OF (Add Date Hf J 2 334
Suse ees 21 PLACE OF BURIA 7
—2fu5 (State or country) CREMATION OR REMOVAL . i. oly.¢ OSS... ren den
¥ < a) 5 emeteiy). or tow a
Ok, & fF Mrs_W Mars DATE OF BURIA sanuary. 14) 931. ea
) BSOES ae! Bote eis OR Gece
) a7 S| (Address) Oritan vé 22 NAME OF
EB ENP « UNDERTAKER ..,
— 3)
ges 3 = os E ial ADDRESS... eX £ aB.
" om O om ie C ¥ : Z
5 I > tM fon bt of Agent of f Health or otter) Received and filed...........--et Pee AE....0.. ta eee etek 19... r
= = abla bs TL “ip | a ee er geese Sn
; Official Designation, (Date of Issue of it)

~..

HUSBAND of

Pa: "7.0 00) ,19

“=
: = E neewenee BUSSOLE seneeeesereeescesceseesee i. DIVISION OF VITAL STATISTICS . it r t
7 um © or its Agent,
rts Seite STANDARD
ats ee) CERTIFICATE OF DEATH Registered Now.....¥- Quien
Cit el
. fus g 13 Caley (If death occurred in a hospital or institution,
: acts) a No. AQ... Or lando..AVe.. Goadedpovevaesunmmeusenastavescaparraa PE gis Setresuahas sacks Ward give its NAME instead of street and number)
20
S30 (s ) (U.S.
EN 2 Fut name..V@ry 4.(Sullivan)Mckenna {We
2% (If deceased i “tT amas widowed or divorced woman, give also maiden name.) npecily WAR).....:.1.5-cavsisotoraitninde
» a o Ave
Of (a) Residence. No.,..0.2,, Ortan Ne snare Device Assen SEs; .. ete Wards! -tceic ss eeruaek sides ese cus) tence ee Reema
n g (Usual place of abode) (If nonresident, give city or town and state)
~o Length of residence in city or town where death occurred yrs. mos. days. How long in U. S., if of foreign birth? yrs. mos. days.
oe)
= 3 PERSONAL AND STATISTICAL PARTICULARS
2 3 SEX 4 COLOR OR RACE | 5 iene (write the word) 18 DATE OF 2 oe ee
; 12/4 ifs ligteen bonereeess eres arp RRC PE cv 2 I aie Ree ee ee ot...
& female; white wipowed widowed hears ane ieee
5a If married, widowed, or divorced 19 \E HEREBY CERT X Ey, That! attended deceased from

ate ee

, 19%)...

Ferry “ >,
(or) WIFE of j I last saw hu... alive on...........dF@,---1ag.-- ard, Bi death i is said
(Husband's name in full) :
to have occurred on the date stated above, at....... oe ere | }-m.

6 IF STILLBORN, enter that fact here.

If less than 1 day
Minutes

The principal cause of death and related causes of
onset were as follows:

8 Trade, profession, or particular

kind of work done, as spinner, =
sawyer, bookkeeper, et................00-5 Hous. ewit | eee eet

9 Industry or business in which
work was cone as silk mi
saw mill, bank, etc

10 Date deceased last worked at
es oS month 4a

11 Total time (years)
spent in this
occupation

OCCUPATION|

12 BIRTHPLACE (City)
(State or country)

13 NAME

Massachusetts

FATHER» Patrick Sullivan

Name of operation

importance in order of

|Dateofonset

Date Often tata

(Registrar)

Revised United States Standard Certificate of Death —

Statement of occupation.—Precise statement of occupation is
very important, so that the relative healthfulness of various pursuits
can be known. Make some entry in this section for every person
aged 10 yearsorover. Ifthe occupation had been given up or changed
on account of the disease causing death, report the occupation prior
to illness. If the deceased had retired from business, report the
occupation prior to retirement. Children not gainfully employed
may be returned as at school or at home. For a woman whose
only occupation was that of home housework, write housework
in answer to Question 8 and own home in answer to Question 9
For a person engaged in domestic service for wages, however, designate
the occupation by the appropriate terms, as housekeeper—private
family, cook—hotel, etc. For a person who had no occupation what
ever write none.

In stating the occupation, avoid the use of such indefinite terms
us ‘‘employee,’’ “‘worker,’’ ‘‘operative,”’ etc. Find out the parti-

cular kind of work done and return that, as spinner, weaver, etc.

In stating the industry or business, avoid the use of such general
terms as ‘‘store,” “factory,” ‘‘mill,’’ etc. State the particular
ind of store, factory, mill, etc., as grocery store, soap factory, cotton
mill, etc.

Distinguish carefully the different kinds of engineers by stating
the full descriptive titles, as civil engineer, mechanical engineer, mining
engineer, stationary engineer, etc. Avoid the term ‘‘laborer’’ when a
more precise statement of the occupation can be secured. Do not
use the word ‘‘mechanic,’’ but give the exact occupation, as carpenter,
painter, machinist, etc. Distinguish carefully between retail merchants
and wholesale merchants. A person who sells goods should be called a
salesman and not a clerk.

Statement of cause of death.—Cause of death means the disease,
or complication which causes death, not the mode of dying, e. g., heart
failure, asphyxia, asthenia, etc. As principal cause name the disease
causing death. As related causes, name earlier morbid conditions,
if any, related to the principal cause and any important complication
of the principal cause. i
related to principal cause, name other important diseases.

Example

The principal cause of death and related causes

- r Date of onset
of importance in order of onset were as follows:

Arteriosclerosis

IOrs

Contributory causes of importance not related to
principal cause:

Under contributory causes of importance not |

EXTRACTS
FROM THE LAWS OF THE
COMMONWEALTH OF MASSACHUSETTS
GOVERNING THE

RETURN OF CERTIFICATES OF DEATH

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, from one cemetery to another, or
from one grave or tomb other than the receiving tomb to another in the
same cemetery, 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 Satis-
factory 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 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 purpases 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 certificate 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 state-
ment and certificate, shall forthwith countersign 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.

RULES OF PRACTICE

The fulfillment of the purpose of these laws calls for the observance
of the following rules of practice: . f

(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.

MARGIN RESERVED FOR BINDING

N. B.—WRITE PLAINLY, WITH UNFADING BLACK INK—THIS IS A PERMANENT RECORD.

R-301A

Every item of

PHYSICIANS should state
Exact statement of OCCUPATION

AGE should be stated EXACTLY.
tructions and extracts from the laws on back of certificate.

terms, so that it may be properly classified.

3
=
is
a,
3
a
2
ee
Oo. 9
oo 8
0Be
o
DEN
ak
tes
EE
ogee
526
Ou e ¢
SOEs
kJ] a
EnP ©.
622 5
sa?
£08 S
a
5
x

Che Commonwealth of Massachusetts To be filed for burial permit

= rate Gol tee. OFFICE OF THE SECRETARY qitliodurd of Halt
Sa Denon «Be DIVISION OF VITAL STATISTICS e
4g ‘ounty) or its Agent,
A STANDARD
eae Wi inc hx.9 ave CERTIFICATE OF DEATH Registered No........\.\oecccscsssene
tal (City or Tov
oO (If death occurred in a hospital or institution,
A No}. 5.2. ne} 5. 8... a 4 roe hh. co. P seesesee sepnecences St; See ea eer re Ward { give its NAME instead of street and number)
atu.s. Spanish War.
2 FULL NAME...... Ste Ve ine. ee E vex Cals. = Minny ohn & {We Veter Agel WY
AS de ns is a married, widowed or divorced woman, give also maiden name.) specify WAR) or ia NN ac...
(a) Residence. No... QSo bas Whoa a ts Sea oe ere oe EES Ca [A kee: 5 Sa ts ee RO MMR SEES
(Usual place of abode) (If nonresident, give city or town and state)
Length of residence in city or town where death occurred l © yrs. days. How long in U. S., if of forcign birth? yrs. mos. days.
PERSONAL AND STATISTICAL PARTICULARS
5 SINGLE (write the word) Ty
3 SEX 4 COLOR OR RACE MARRIED / aes 4g # ¥
V\a le WN hite or DIVORCED Warri ed : (Year)
5a If married, see) cae givaresd he Fe <, That | attended deceased from
HUSBAND of ............. >S VA... ovise. Le. Fare... (7% oF /
jae maiden name of wife in full) ‘ Ps Besar ch gig aesaew a inaghactnasescDysrnnnak » 1$-..f..
or ET AE Spec lie, aR IS eo eo OS, eet eae oe Ge Ae PY a Or eta 1 ene Sat Nol, death is said

(Husband’s name in full)

to have occurred on the date) stated above, af™. VAY, A m.

The principal cause of death and related causes of importance in crder of
onset were as follows: Aare

6 IF STILLBORN, enter that fact here.

7 <=
ace 4. Vinge ae eet pease monte OY bays

8 Trade, profession, or particula
kind of work done, as spinner, Ree

If less than 1 day

SI sawyer, bookkeeper, Ctc...........-..-.)
=| 9 Industry or business in_ which
a work was done, as silk mill,
= saw mill, bank, etC.............-....°7
6 | 10 Date deceased last worked at 11 Total time (years)
this en (month and f eg Contributory causes of importance not related to principal cause:

12 BIRTHPLACE (City)........: Metal ANS Sah Gab” Bh OP ER Oo, Ae eee
(State or country)

BATHE Tet Gtebh en Dieter Sm eh

14 BIRTHPLACE OF
FATHER (City) ......

(State or country)
15 MAIDEN NAME

OF MOTHER Faunce Av osta Curtis

16 BIRTHPLACE OF :
MOTHER (City) ....... Bay cae ee ees, oe aes)

(State or country)

“dermal ys 2... Lew al. Ps Sach Za tee eS

Namojoftroperationnct choo teres he ee ees Datevof..2 ec ees
What test confirmed diagnosis?...................................... Was there an autopsy?..........

20 Was disease, or injury in any way related to occupation of deceased? ...............00

If so, specify. 9 — Se aft Oe Ee) Wee eR EO SE bol

(Signed) .A-
(Address)...-f,..&<@-a2-te

PARENTS

BSS.
21 PLACE OF BURIAL, :
CREMATION OR REMOVALY. MU <s nck. Teac

eae City or town)

____ DATE OF BURIAL Sancarde pale WO) 5 eae 1953.f..

dress) A 22 NAME OF ( 7 =
| HEREBY CERTIFY that a satisfactory standard certificate of death was

Hed with me BEFORE the uri or,transit permit was issued:

aopress WNi vy no ee bY

Received and filed.............. bo OMY oe... > ee A583 Vn it eee 1 eee

(Registrar)

S iacig alia ss EE Ln 2h .
United States Standard Certificate of Death

Statement of occupation.—Precise statement of occupation is
very important, so that the relative healthfulness of various pursuits
can be known. Make some entry in this section for every person
aged 10 yearsorover. Ifthe occupation had been given up or changed
on account of the disease causing death, report the occupation prior
to illness. If the deceased had retired from business, report the
occupation prior to retirement. Children not gainfully employea
may be returned as at school or at home. For a woman whose
only occupation was that of home housework, write housework
in answer to Question 8 and own home in answer to Question 9.
For a person engaged in domestic service for wages, however, designate
the occupation by the appropriate terms, as housekeeper—private
family, cook—hotel, etc. For a person who had no occupation what-
ever write none.

To be complete, an occupation return must state:
8.—The trade, profession, or particular kind of work done. P
9.—The industry or business in which the work was done.
10.—The month and year the deceased last worked at the occupation.
11.—The number of years the deceased followed the occupation.

In stating the occupation, avoid the use of such indefinite terms
as ‘‘employee,”’ ‘‘worker,’’ ‘‘operative,’’ etc. Find out the parti-
cular kind of work done and return that, as spinner, weaver, etc.

In stating the industry or business, avoid the use of such general
terms as ‘“‘store,’”’ “‘factory,”’ ‘‘mill,’’ etc. State the particular
a of store, factory, mill, etc., as grocery store, soap factory, colton
mill, etc.

Distinguish carefully the different kinds of engineers by stating
the full descriptive titles, as civil engineer, mechanical engineer, mining
engineer, stationary engineer, etc. Avoid the term ‘‘laborer” when a
more precise statement of the occupation can be secured. Do not
use the word ‘‘mechanic,’’ but give the exact occupation, as carpenter,
painter, machinist, etc. Distinguish carefully between retail merchants
and wholesale merchants. A person who sells goods should be called a
salesman and not a clerk.

Statement of cause of death.—Cause of death means the disease,
or complication which causes death, not the mode of dying, e. g., heart
failure, asphyxia, asthenia, etc. As principal cause name the disease
causing death. As related causes, name earlier morbid conditions,
if any, related to the principal cause and any important complicaiion
of the principal cause. Under contributory causes of importance not
related to principal cause, name other important diseases.

Example

The principal cause of death and related causes
of importance in order of onset were as follows:

Date of onset

Arteriosclerosis

Chronic interstitial nephritis

Cerebral hemorrhage

Contributory causes of importance not related to
principal cause:

In a group of causes containing the principal cause and related
causes, the causes should be given in the order of onset, so that ina
group of three causes the principal cause may appear in either first,
second, or third position. The principal cause in the above example
happens to be the second cause given,

~ 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 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 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 ofjhis 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 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, from one cemetery to another, or
from one grave or tomb other than the receiving tomb to another in the
same cemetery, 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 Satis-
factory 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 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 purpaaes 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 certificate 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 state-
ment and certificate, shall forthwith countersign 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 ot 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.

RULES OF PRACTICE

The fulfillment 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.

(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 oisons), 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 Massachusetta To be filed for burial permit

R-301A x uv OFFICE OF THE SECRETARY witht Hoard of Health
scetifetness, DIVISION OF VITAL STATISTICS .
he 5 aM. aa el or its Agent.
° a
g 1) ate ies ee CERTIFICATE OF DEATH Registered Now...) Quiros
8 rs ty or i ; . ae e,
2 (If death occurred in a hospital or institution,
> a ING icscscess:: a ps q Jong eal. de. Ave ae Slee eee Ward } aive its NAME instead of Giceat and nuntbes)
$ ge te, Ei . c hy (If U. S.
a 2 FULL NAME{Yanices.. li: a eth {| Ty icleane’ ioe AAG, clk Wee. 1 {We Veteran,

specify’ WAR) | «.ccc05\c0.ccvespiedecsssetet
(a) Residence. No.....02.4 eee vq. esid e..Ave:st., Ee ee Wards tis). cere eee Bt SS. ee

(Usual place of abode) (If nonresident, give city or town and state)
Length of residence in city or town where death occurred if of foreign birth?

(If deceased is ried, widowedor divorced woman,

days. How long in U. S., yrs.

PHYSICIANS should state
Exact statement of OCCUPATION

xtracts from the laws on back of certificate.

PERSONAL AND STATISTICAL PARTICULARS

3 SEX 4 COLOR OR RACE | © SINGLE (write the word) ~ | 18 DATE OF
- Seay W. DEATH.......::,... a; AN aa ed Fe 16 erect PeOe 193 |
temale.| White or DIVORCED Ao weed. | (Month) (Day) (Year)
5a If married, widowed, or divorced 19 I HEREBY CE = TILEY, That | attended deceased from
RIRRR PIM DEMME cs Ra a oc Seo a ec Te sence yc pee Rene o aes cate wnacindseccussasdeceouadandh cmetmetacente vii Saes
o \ ie ides int ene Net Bn 192 De er AB on v19dl..
(or) WIFE of f- (red S.A. M.. MW &. «) I 8 ee eA, last saw hSAC....alive on. ae tame 3 Bey 19.31... death is said
(Husband's n oe ih mit

to have occurred on the date stated above, at 2A ences m.

The principal cause of death and related causes of importance in order of
onset were as follows: igi. gaan
Dateofonset

6 IF STILLBORN, enter that fact here.

ke sheers Years...... g hates M onthe... ...Days
8 Trade, profession, or particular

kind of work done, as spinner,
sawyer, bookkeeper, CtC,..........0:0c0000 Art eee home... ak a ee

9 Industry or business in which
work was done, as silk mill,
MUON NATAL Me MTURS CLG seed ec tec dso snv sus donaee¥dnc cues svosaeeusdacetecossnbsscduadstedacnechsedevaunessssosesees
10 Date deceased last worked at 11 Total time (years)

this occupation (month and spent in this
Di avcrooc -spedetoas i vossuactoanpencsctvnns coetazares days Occupationss...:-..:-..-..:..

HIS IS A PERMANENT RECORD.

AGE should be stated EXACTLY.
OCCUPATION]

it may be properly classified.

12 BIRTHPLACE (City)...
(State or country)

13 NAME 0)
PATHER Cav \ es pA ae |
14 BIRTHPLACE OF
(State or country)

15 MAIDEN NAME

OF MOTHER Lucy “ereiqo

16 BIRTHPLACE OF

MARGIN RESERVED FOR BINDING

y supplied.

Name of operation ..... 7 @G We 9c cccecceceeee cee 6 Of ss dccaatsapsso-8s ave

What test confirmed dearest aatnnad YT a there an autopsy?. Le.
Wo

20 Was disease or injury in any way related to occupation of deceased? .../%.@.........

$a tee EN sec ate nee Sy | Pon) a ee
ake (Tegner d C3. (See

(Address) sandler. A Aten... au. Date... wer

in plain terms, so that
See instructions and e

PARENTS

formation should be carefull

N. B.—WRITE PLAINLY, WITH UNFADING BLACK INK—T

Renee
Be PGE RRE NRTA CLL) hes cox ov suc tees ee RT a eR I vcs haven cisacesen
g 21 PLACE OF BURIAL, Ne Wi
a S (State orcountry) ig F CREMATION OR rémovWNinthro hows inthro
Q 5 + ay (Cemeter®) Tg. (City or town)
by & g]}| 17 E OF B anuar. Bee 19.3
GE el! tatormaalNYS.:.4-0 re... atte ie ae. Jee BENE OF BU hs be see
Bie a (Address) A Ad id 22 NAME O ri -
np : SS Le eer €s... C a:
o | HEREBY CERTIFY that a satisfactory standard certificate of death was
S : % filed with me BEFORE the burial or transit permit was issued: ADDRESS... Ni linthre ee
ot O om =
: we NOW S ‘ : : ee)
a AS anes. (Signature of Agent of Board of ae or other) Received and filed............... Sethe enn Ae Foci oe 19..2..£.
&
ra me 5.0.......[b.. eer Nee at eee We ee «.
: ate of ils of Permit) (Registrar)
4

_
’
’

N Oe nN ey " , \Q3 \ .
Revised United States Standard Certificate of Death

Statement of occupation.—Precise statement of occupation is
very important, so that the relative healthfulness of Various pursuits
can be known. Make some entry in this section for every person
aged 10 yearsorover. Ifthe occupation had been given up or changed
on account of the disease causing death, report the occupation prior
to illness. If the deceased had retired from business, report the
occupation prior to retirement. Children not gainfully employed
may be returned as at school or at home. For a woman whose
only occupation was that of home housework, write housework
in answer to Question 8 and own home in answer to Question 9.
For a person engaged in domestic service for wages, however, designate
the occupation by the appropriate terms, as housekeeper—private
family, cook—hotel, etc. For a person who had no occupation what-
ever write none.

To be complete, an occupation return must state:
8.—The trade, profession, or particular kind of work done.
9.—The industry or business in which the work was done.

10.—The month and year the deceased last worked at the occupation.
11.—The number of years the deceased followed the occupation.

In stating the industry or business, avoid the use of such general
terms as ‘‘store,’’ “factory,”’ ‘‘mill,’’ etc. State the particular
pa of store, factory, mill, etc., as grocery store, soap factory, cotton
mill, etc.

more precise statement of the occupation can. be secured. Do not:

use the word ‘‘mechanic,” but give the exact occupation, as carpenter,
Painter, machinist, etc. Distinguish carefully between retail merchants
and wholesale merchants. A person who sells goods should be called a
salesman and not a clerk.

Statement of cause of death.—Cause of death means the disease,
or complication which causes death, not the mode of dying, e. g., heart
failure, asphyxia, asthenia, etc. As principal cause name the disease
causing death. As related causes, name earlier morbid conditions,
if any, related to the principal cause and any important complication
of the principal cause. Under contributory causes of importance not
telated to principal cause, name other important diseases.

Example

The principal cause of death and related causes| Date of onset

of importance in order of onset were as follows:
Arterviosclerosis

Chronic interstitial nephritis

Cerebral hemorrhage

Contributory causes of importance not related to
principal cause:

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, atter the death of a person whom he has attended during
his last illness, at the request of an undertaker or other
authorized person or of any member of the family of the deceased,
furnish for registration a standard certificate of death, stating to the
best of his knowledge and belief the name of the deceased, his supposed
age, the disease of which he died, defined 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 ofjhis 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 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, from one cemetery to another, or
from one grave or tomb other than the receiving tomb to another in the
Same cemetery, 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 Satis-
factory written statement containing the facts réquired 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 PUEDORE, 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 certificate contains a recital,
as required by section ten of chapter forty-six, that the deceased
Served.in the army, navy er marine corps.of the United States in any
war in which it has been engaged, such recital shall appearupon the
permit. The board of health, or its agent, upon receipt of such state-
ment and certificate, shall forthwith countersign it and transmit
it to the clerk of the town for tegistration. The person to whom
the permit is so given and the physician certifying the cause ot 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.

RULES OF PRACTICE :

The fulfillment of the purpose of these laws calls for the observance
of the following rules of practice: y ;

(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 un-
telated to any form of injury, have died without recent medical attend-
ance or whose physician is absent from home when the certificate of
death is needed. Yad . ;

MARGIN RESERVED FOR BINDING

N. B.—WRITE PLAINLY, WITH UNFADING BLACK INK—THIS IS A PERMANENT RECORD.

ig
Ww
4
>

Every item of

PHYSICIANS should state

AGE should be stated EXACTLY.
terms, so that it may be properly classified. Exact statement of OCCUPATION

tructions and extracts from the laws on back of certificate.

pplied.

See ins

formation should be carefully su
tant.

CAUSE OF DEATH in plain
is very impor
75m-2-'30. No. 7997-4

Che fc cipal a, Al iene adil To be filed for burial permit
DIVISION OF VITAL STATISTICS with Board of Health

oritsAgent. \%

STANDARD
1 CERTIFICATE OF DEATH Registered No. ar =/-@~.....
(If death occurred in a hospital or institution,
{ give its NAME instead of street and number)
(If U.S.
24 TELIA D SP 9 a a Sk 7 hd FE el OT A Se Cn War Veteran,
i specify WAR) |. i5.scisidesessccchovegnstt cacoeceeen
(a) Residence. No..4 Nene eet teem NT SMR Est VAN Ly. savsus save cdesecess isccdeasisbaononchstyiedseatstvonsasathoanaaere
(Usual place of abode) (If nonresident, give city or town and state)
Length of residence in city or town where death occurred 7 O xs. mos. days. How long in U. S., if of foreign birth? yrs. mos. days.

PERSONAL AND STATISTICAL PARTICULARS MEDICAL CERTIFICATE OF DEATH

5 SINGLE (write the word)
le 4 COLOR OR RACE MARRIED LE J y:
wz yy SY . WIDOWE! wanaesns, X LE nen EAA severe vavenesssseceess, D Basen 7) vibandaieawase AA adanapcuasees
MPAA 2 or DIVOR (Day) (Year)

That | Stig deceased from
ee { dacctifitd £0... 19.
| last saw ee alive on... AAA hsf.... ld 19. a death is said

to have occurred on the déte stated above, (LOS: . GY -

The principal cause of death and related causes of portance in order of
onset were as follows:

5a If married, widowed, or divorced
LUE) STP gaat th hot tee geet keer chen oe

ive maiden na af
lop wire ot . PAL aopee. ae

(Husband’s name in full)
6 IF STILLBORN, enter that fact here.

Minutes

8 Trade, profession, or particular
kind of work done, as spinner,
sawyer, bookkeeper, CtC,...........:0c00 eh hore eRe East ONS CoE nen Mere aR

98 Industry or business in which
work was done, as silk mill,
MNPNTUNN Le RIMM Che cece ect 5-2. teem emcee as nave c nduaurcencecuanuenovesokacsseWsoseccresovsaaeeeet

10 Date deceased last worked at 11-Total time (years) -

this occupation (month and spent in this
DUGAN) ieiteasccas aa cp cnet sang Ores = 4s spineraer eect caaeteeee occupation

OCCUPATION|

12 BIRTHPLACE (City).......0¢&0 Nee eae RC eee ogee maRe eh cerucec da nos vee gsusspsceis
(State or country)

13 NAME OF

FATHER é y A.

Name of operation... SZ. PIN... cccsscssagecnecsneeneenees Date of.............. re

What test confirmed diagnosis? Was there an autopsy.

FATHER ~ EOF ate, A a RE ee soo dap stae Seapine

(State or SEE

”
=

o|15 MAIDEN NAME }

< OF MOTHER 7

16 BIRTHPLACE OF
MOTHER (City) ............ BEE 6a chreatope Co REECE Re COA RS ba >: ee

(State or country)

(Signed) .
(Addres

21 PLACE OF BURIAL,
CREMATION OR REMOVA

DATE OF BURIAL...

22 NAME OF
UNDERTAKER ........-.-..->- Ce, a ue ae Fn Rees
a oe) bere Lara)... ded Boot...

Received and filed..............:.scssoss@feWeeetlws Wicssssescoes (Mpdevars oh RES ct 19.4 /..

naan nnnecneeancncssansasnsnanenthsncadabsrfusssscsecenssesen| [unanrersnsesneneseraunereensesrnestsneeneeeeeess ease iRSSESSSEESSEOE SSO ee ee en nneennnnnesasenntnensneweenwes —

(Date of Issue of Pefmit) (Registrar)

ma \ e is

; eT
Revised United States Standard Certificate of Death

In stating the occupation, avoid the use of such indefinite terms
as “‘employee,”’ ‘‘worker,”’ ‘‘operative,”’ etc. Find out the parti-

cular kind of work done and return that, as Spinner, weaver, etc.

In stating the industry or business, avoid the use of such general
terms as “store,” “factory,’’ ‘‘mill,’’ etc. State the particular
ate of store, factory, mill, etc., as grocery store, soap factory, cotton
mill, etc.

Distinguish carefully the different kinds of engineers by stating
the full descriptive titles, as civil engineer, mechanical engineer, mining
engineer, stationary engineer, etc. Avoid the term ‘‘laborer” when a
more precise statement of the occupation can be secured. Do not
use the word ‘‘mechanic,"’ but give the exact occupation, as carpenter,
painter, machinist, etc. Distinguish carefully between retail merchants
and wholesale merchants. A person who sells goods should be called a
salesman and not a clerk.

Statement of cause of death.—Cause of death means the disease,
or complication which causes death, not the mode of dying, e. g., heart
failure, asphyxia, asthenia, etc. As principal cause name the disease
causing death.
if any, related to the principal cause and any important complication
of the principal cause. Under contributory causes of importance not,
related to principal cause, name other important diseases,

_Example : ‘ 43

The principal cause of death and related causes
of importance in order of onset were as follows:

Date of onset

Contributory causes of importance not related to
principal cause:

Tn a group of causes containing the principal cause and related
causes, the causes should be given in the order of onset, so that ina
group of three causes the principal cause may appear in either first,

second, or third position. The principal cause in the above example
happens to be the second cause given.

As related causes, name earlier morbid conditions, N

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 Tequest of an undertaker or other
authorized person or of any member of the family of the deceased,
furnish for registration a stz ndard certificate of death, stating to the
best of his knowledge and be ief the name of the deceased, his supposed
age, the disease of which he died, defined as Tequired 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 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, from one cemetery to another, or
from one grave or tomb other than the Teceiving tomb to another in the
Same cemetery, 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 satis-
factory 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 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 enouch
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 certificate 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 state-
ment and certificate, shall forthwith countersign 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 tegistrar 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 shail 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 ceme-
tery or burial ground in which the interment is made....Chap. 114,
Sec. 46, G. L. as amended.

RULES OF PRACTICE

The fulfillment 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.

(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 fram 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.

301A The Commonwealth of Massachusetts To be filed for burial permit
OFFICE OF THE SECRETARY uithitoard of Health
DIVISION OF VITAL STATISTICS

or its Agent,

i Oo
02% TANDARD
gee 1 CERTIFICATE OF DEATH Registered No... Mfr
.
28 \ (If death occurred in a hospital or institution,
> 8° give its NAME instead of street and number)
B29 Rn\ (KU. S.
be 2 FULL NAME. 74/427 £ CZ St lal be ean ee War Veteran,
2) is a i specify WAR).........:.1:::.c0 sedation
Su |
Os Bes ER CESK @ENCE se N Ge eteccecte Nec cM cece es acer cae AMES acre Ena secees chav eaas WARD, saccciccvesicccnsescssvadsscussssssdesersebsusdoocteseacesartoheventie
n e (Usual place of abode) (If nonresident, give city or town and state)
~ oO Length of residence in city or town where death 4D O ys. mos. days. How long in U. S., if of foreign birth? yrs. mos, days.
+ SSS SS
as PERSONAL AND STATISTICAL PARTICULARS
2 3 SEX 4 COLOR OR RACE | © SINGLE (write the word) || 18 DATE OF
3) MARRIED / Uais.)
8 4 ; DEATH ooo JXAAAAA AAA | Ac... eee
3 eel) LWnits | wwown Lerarrce { eS pas

5a If married, widowed, or divorced That | attended deceased 3]

HUSBAND OF 0.0.0: eoessceeseoseeseeons ie tate ata ; i eae

(Give maidegngme of WAfeyn full) «i —C—C—~*sids«Ci nn RR LOE, £0... Re fee 19.97.49.
(or) WIFE of .......f... Cot od BY... Goce ee eres crane nna Jreaareaiccoss onus aL: death is said

-Z (Husband s name in full) : BI.
6 IF STIL GORN, enter that fact here. ~————_ = ere?
The principal cause of death and related causes of importance in order of

7 io Ee If less than 1 day onset were as follows: Dateofonset
AGE.....£22.07/......... WEAFS..c.esa2.5.2 Months.....4.... Days) | crrnes-snx-s Hours.......-.... Minutes

8 Trade, profession, or particular
kind of work done, as spinner,
GRMN REN HIOOMMERDERS CLO ns. ce ssaseicncsacce esas MrcsscoM esta Wane mraccraarer cacoebcectnttesasvecvecosesnesst
9 Industry or business in which
work was done, as silk mill,

AGE should be stated EXACTLY.

terms, so that it may be properly classified.
tructions and extracts from the laws on back of certificate.

OCCUPATION|

MO MMA Navan LCs os Lanes nnagncoataexsekt oxuctvnvsoasccsneesiesCoanssvsscalsensdeiveearearbecensreodeane pearel
10 Date deceased last worked at AMANO ADS EEMTCN CY CALS) CEM inh eer ee age cas Cau cea REPO, as sos na oo nwizere te eRe me ooo com cn lar cove oo ase | eee
this eoerpaton (month and aA. spent in this Contributory causes of clase not related to principal cause:

12 BIRTHPLACE (City)........<© fel he Se Fe Sa er

(State or country) oe 7 { age

MARGIN RESERVED FOR BINDING
» WITH UNFADING BLACK INK—THIS IS A PERMANENT RECORD.

y supplied.

Name of operation nowt

= a” What test confirmed diagnosis? ...

Sais! - ;

ae 2 = et ox: Consitry) ia 20 Was disease or injury in an

pt ont lw .

9g «|15 MAIDEN NAME : If so, specify weg)” Jeccantecnessreehs wear Apt SA Spot

o,9 4 Z :

L.Ed ||<| OF MOTHER ye et (Signed) ..... Sicha Te... A Ape
wef 3 16 BIRTHPLACE OF =, ty : (Address
<r Tat Ona) eee, Ok a et oe Se ere
258 (State or country) ve Ce ee CREMATION OR REMOVA SB renee aire:
= f Q = : Te (City or town)
a25 e ki a, =f gan te ™. BS © Pte DATE OF BURIAL.....4.. aes Die eer {cco

SOE 5 ormant ...,f.. A246. 28. 7” GE 2 eee Fe ee Oh, tee
a 7 UNDERTAKER ow A ft. Fz | Gan, ae aoe:
m EDO Oo 1 HEREBY CERTIFY that a satisfactory standard certificate of death was gy ; =) ,
ZS > 24 filed with me BEFORE the/burial or transit permit was issued: ADDRESS......4°47.... “kb -bea Ka its fire Y PACE L Bs s steab nace sade
SEU S iy .
| ay ae "Signatu nt of BoaurGayf Health or other) 7 Received amd filed css... CGA Nt ccccnne Loses Lovvns phessassescsssvesesssssssetesnnanneese 19:2.f...
a & Cece recnatauiacusaanystuennaces ps oa one We fa <Sesceaeeony | BRBses once bdnoratn dn dena chiang cians dleveconc ne teh aasowisdslapupan an wakuasdas’cduncecnunuceudeaasenene cama doses o<
z (Date of Issue of Permit) (Registrar)

United States Standard Certificate of Death

Statement of occupation.—Precise statement of occupation is
very important, so that the relative healthfulness of various pursuits
can be known. Make some entry in this section for every person
aged 10 yearsorover. Ifthe occupation had been given up or changed
on account of the disease causing death, report the occupation prior
to illness. If the deceased had retired from business, report the
occupation prior to retirement. Children not gainfully employed
may be returned as at school or at home. For a woman whose
only occupation was that of home housework, write housework
in answer to Question 8 and own home in answer to Question 9.
For a person engaged in domestic service for wages, however, designate
the occupation by the appropriate terms, as housckeeper—private
family, cook—hotel, etc. For a person who had no occupation what-
ever write none.

To be complete, an occupation return must state:
8.—The trade, profession, or Particular kind of work done. af
9.—The industry or business in which the work was done.
10.—The month and year the deceased last worked at the occupation.
11.—The number of years the deceased followed the occupation.

In stating the occupation, avoid the use of such indefinite terms
as ‘‘employee,’’ ‘worker,’’ “‘operative,”’ etc. Find out the Parti-
cular kind of work done and return that, as spinner, weaver, etc.

In stating the industry or business, avoid the use of such general

terms as ‘“‘store,’’ “factory,”’ ‘‘mill,”” etc. State the particular
nae of store, factory, mill, etc., as grocery store, soap factory, colton
mill, etc.

Distinguish carefully the different kinds of engineers by stating
the full descriptive titles, as civil engineer, mechanical engineer, mining
engineer, stationary engineer, etc. Avoid the term “‘laborer” when a
More precise statement of the occupation can be secured. Do nat
use the word “‘ mechanic,” but give the exact occupation, as carpenter,
Painter, machinist, etc. Distinguish carefully between retail merchants
and wholesale merchants. A person who sells goods should be called a
Salesman and not a clerk.

Statement of cause of death.—Cause of death means the disease,
or complication which causes death, not the mode of dying, e. g., heart
failure, asphyxia, asthenia, etc. As Principal cause name the disease
causing death. As related causes, name earlier morbid conditions,
if any, related to the principal cause and any important complication
of the principal cause. Under contributory causes of importance not
related to principal cause, name other important diseases,

Example

The principal cause of death and related causes Date of onset

of importance in order of onset were as follows:
Arteriosclerosis

Chronic interstitial nephritis

Tors

1921

TA TREN ON eeweeneeeenesennes

July 5, 1927

Contributory causes of importance not related to
principal cause:

roup of causes containing the principal cause and related
in the order of onset, so that ina
the principal cause may appear in either first,
The principal cause in the above example

Ina L
causes, the causes should be given
group of three causes
second, or third position. 1
happens to be the second cause given,

EXTRACTS
FROM THE LAWS OF THE
COMMONWEALTH OF MASSACHUSETTS
GOVERNING THE

RETURN OF CERTIFICATES OF DEATH

seen alive by the
Gen. Laws, Chap. 46, Sec. 9.

No undertaker or other person shall bury or otherwise dispose
of a human body in a town,

person died; and no undertaker or other person shall exhume a human
body and remove it from a town, from one cemetery to another, or
from one grave or tomb other than the receiving tomb to another inthe
same cemetery, until he has received a permit from the board of health
town where the body
No such permit shall be issued until there shall have been

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
for the BETES; or is insufficient, a Physician who is a member of the
board o i

certificate contains a recital,

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
The board of health, or its agent, upon receipt of such state-
ment and certificate, shall forthwith countersign it and transmit
The person to whom

the permit is so given and the physician certifying the cause of death

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.

in which the interment is made... -Chap. 114,
Sec. 46, G. L. as amended.

RULES OF PRACTICE

The fulfillment 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.

& The Commonwealth of Massachusetts Ta Gehled for burial peers

*R-301A

OFFICE OF THE SECRETARY C
DIVISION OF VITAL STATISTICS with Board of Health
| = 2 STANDARD or its Agent, /
3
of 1 CERTIFICATE OF DEATH Registered No. APH.
| . o
27 (If death occurred in a hospital or institution,
bd coor gte de agoe CoOL e Ward { give its NAME instead of street and number)
oO
Bay Se Lae Solis
n POOLED DIS PY 1 ee ree OL Al OF oe ad OO 2” Cet ak OR et A Cae ce War Veteran,
- (If deceased married, widowed or divorced woman, give also maiden name.) specify, WAR) .si<s06icsscccessosc0tsvearqaereaeen
3) (a) Residence. No...... 19 wD) LLAMA OG MK .. Ula STA eee NURI 5 os cvncevsseesd pecs SeoVavedecetcedepdvcse dues: 1- eae ee
n (Usual place of abode) (If nonresident, give city or town and state)
~ Length of residence in city or town where death ce 5 yrs. os. days. How long in U. S., if of foreign birth? yrs. mos, days.
mn PERSONAL AND STATISTICAL PARTICULARS

‘ 5 SINGLE (write the word)
W 4 COLOR OR RACE MARRIED Aye 3 i
y, -, NEE ey A EAN rns ses cace arsedePeamssns-cveceatesstsnuscconcnensaarnsa+7 theta: WPtnoatesturniccansaracsteNestseasnacanant Ve
i +A (zy or DIVORCE (Year)
5a If married, widowed, or divorced
HUSBAND of

(or) WIFE of

to have occurred on the date stated above, at......}.5...

The principal cause of death and related causes of
onset were as follows:

6 IF STILLBORN, enter that fact here.

Me ae Ge oO maa Years........ 7 Se Months ..~......

importance in order of
Dateof onset

MAINGIN RESERVED FOR BINDING

N. B.—WRITE PLAINLY, WITH UNFADING BLACK INK—THIS IS A PERMANENT RECORD.

a ?
7

AGE should be stated EXACTLY.

y supplied.
terms, so that it may be properly classified. Exact statement of OCCUPATION

tructions and extracts from the laws on back of certificate.

formation should be carefull
CAUSE OF DEATH in plain
is very important. See ins
75m-2-'30. No. 7997-4

8 Trade, profession, or particular
kind of work done, as spinner,
sawyer, bookkeeper, etc... ie

9 Industry or business in which
work was done, as silk mill,
saw mill, bank

10 Date deceased last worked at
this occupation (month and

OCCUPATION!

11 Total time (years)
spent in this
occupation.

RSM ee 6 SUE Me Bate rte nEeipeidu circ oon acesn itrese edeb its olekiieneedse cece use ae

EAE ee rs Rc a eran. eesti ase eo alnaetacse as iz
12 BIRTHPLACE (City).. Es ae Fs oo & ree L A i<fe aera eerie Le Honea ct I LOO RDO i Pee

(State or country)

13 NAME OF
FATHER

a a on NAM
MOTHER AP

16 BIRTHPLACE OF

IRB REDE RES GOLGI on a0 fe ccste-<+cveausgath eauteee epee sep eEeSeNt oe Uo dpedngacsasdaaincanesuedehesecsseses ‘
(State or country) Gg S

a Pe oro:

1! HEREBY CERTIFY Ly a Reis clad standard certificate of death was
ilgd with me EFORE, the burial or transit permit was issued:

VE BK f Health or other)
ig a ey (1B "an
(Date of Isshe of Pet

Name of operation........ I © “on nen Date of............
What test confirmed diagnosis? len, Was there an autopsy? Maa
20 Was disease or injury in any way related to ceeupation of deceased? ... ba (axe

(Signed) ..........9774.. Ad
(Address)...%.

21 PLACE OF BURIAL,
CREMATION OR REMOVA

sar ies ts nec

DATE OF BURIAL...css Bm Pn. el.
7? UNDERTAKER of

sens n enna gOOty scence tecegdees nates sofas cancevocncvases pe, ce eeectensseccecectccsescesccee

ADDRESS ..2..00.0001.. Cxcad | on Ce ae CTI AR 5 nic cic

Received and MCU er -crrcses- norte fe Wen MDM rensnegscs Mecsecennae hues ncovcumastersuedenearecevennds th ae Ae

(Registrar)

"may be returned as at school or at home.

) United States Standard Certificate of Death

Statement of occupation.—Precise statement of occupation is
very important, so that the relative healthfulness of various pursuits
can be known. Make some entry in this section for every person
aged 10 years or over. Ifthe occupation had been given up or changed
on account of the disease causing death, teport the occupation prior
to illness. If the deceased had retired from business, report the
occupation prior to retirement. Children not gainfully employed
For a woman whose
only occupation was that of home housework, write housework
in answer to Question 8 and own home in answer to Question 9,
For a person engaged in domestic service for wages, however, designate
the occupation by the appropriate terms, as housckeeper—private
family, cook—hotel, etc. Fora person who had no occupation whate
ever write none.

To be complete, an occupation return must state:
8.—The trade, profession, or particular kind of work done.
~ 9.—The irtdustry or business in which the work was done.
10.—The month and year the deceased last worked at the occupation.
11.—The number of years the deceased followed the occupation.

In stating the occupation, avoid the use of such indefinite terms
as ‘“‘employee,’’ ‘‘worker,”’ “operative,” etc. Find out the Pparti-
cular kind of work done and return that, as spinner, weaver, etc.

In stating the industry or business, avoid the use of such general
terms as “‘store,” “factory,” ‘‘mill,”? etc. State the particular
ats of store, factory, mill, etc., as grocery store, soap factory, cotton
mill, etc.

Distinguish carefully the different kinds of engineers by stating
the full descriptive titles, as civil engineer, mechanical engineer, mining
engineer, stationary engineer, etc. Avoid the term “laborer’’ when a
more precise statement of the occupation can be secured, Do not
use the word ‘‘mechanic,’’ but give the exact occupation, as carpenter,
painter, machinist, etc. Distinguish carefully between retail merchanis
and wholesale merchants. A person who sells goods should be called a
salesman and not a clerk.

if any, telated to the principal cause and any important complication’ °
Under contributory causes of importance note) ) the

of the principal cause. l r
telated to Principal cause, name other important diseases.

Example

The principal cause of death and related causes

2 Date of on
of importance in order of onset were as follows: aor Or onnee

Arteriosclerosis Tors

Contributory causes of importance not related to
principal cause:

In a group of causes containing the principal cause and related
Causes, the causes should be given in the order of onset, so that in a
group of three causes the principal cause may appear in either first,

second, or third position. The principal cause in the above example
happens to be the second cause given.

EXTRACTS “©.

FROM THE LAWS OF E

COMMONWEALTH OF MAssg.
GOVERNING THE +

RETURN OF CERTIFICATES: OF DEATH

A physician or registered hospital medical officer shall forth-
with, atter 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 fy ily of the deceased,
furnish for registration a stz ndard certificate ofdeath, stating to the
best of his knowledge and be ief the name of the eceased, his supposed
age, the disease of which he died, defined as 1, uired by section one,
where same was contracted, the duration of hi@jast illness, when last
seen alive by the physician or officer and the date .of, his death... .
Gen. Laws, Chap. 46, Sec. 9. oy ng

No undertaker or other person shall byry orotherwise 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 ermits,
or if there is no such board, from the clerk of the town w ere the
person died; and no undertaker or other person shall exhume a human
body and remove it from a town, from one cemetery-to another, or
from one grave or tomb other than the receiving tomb to another in the
Same cemetery, until he has received a permit from the board of health
or its agent aforesaid or from the clerlc 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 satis-
factory 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 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 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 tequired of the attending
physician. If death is caused by violence, the medical examiner shall
make such certificate. If the death certificate 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 state-
ment and certificate, shall forthwith countersign it and transmit
it to the clerk of the town for registration. The person to whom
he 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 Tequire.—Chap. 114,
Sec. 45, G. L., as amended.
Medical examiners shall make examination upon the view of
dead bodies of only such persons as are supposed to have died
. by violence....Gen. Laws, Chap. 38, Sec. 6.

HUSETTS

‘

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 ceme-
tery or burial ground in which the interment is made... -Chap. 114,
Sec. 46, G. L. as amended.

RULES OF PRACTICE

The fulfillment 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.

(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 frornm injury or infection related to occupation, the
sudden deaths of persons not disabled by recognized disease,
and those of persons found dead.

Every item of

PHYSICIANS should state

terms, so that it may be properly classified. Exact statement of OCCUPATION

tructions and extracts from the laws on back of certificate.

AGE should be stated EXACTLY.

MARGIN RESERVED FOR BINDING ”

N. B.—WRITE PLAINLY, WITH UNFADING BLACK INK—THIS IS A PERMANENT RECORD.

ae]

2
et
fas
oem
SEA
"oO
SEe
oa S
2a
cA5
Si
SOE
he
En
528
S<
£08

2h al

200M-11-'29. No. 7180-a

The Commonwealth of Massachusetts
OFFICE OF THE SECRETARY

E DIVISION OF VITAL STATISTICS —_—__sreeersteeeeeese Nreenneetassanaasasencsnsenncceesnneenernenrosssseseseaenee
4 (City or town making return)
a STANDARD
11 CERTIFICATE OF DEATH Registered No......\.. 0...
tw
< : 4) (If death occurred in a hospital or institution,
me NOs. eat... Deneele sina yen stots isuatensenstneseascntsscsncsssersscasensceateneeersenes Stzee-...:. 4 Oe Ward give its NAME instead of street and number)
C= —f, (If U.S.
2 FULL NAME cbt Bee CE ET ras ANON oh stab adunsaths War Veteran,
r 53 aly se Be woman, give also maiden name.) spocity: WAR))<<00:::0<1s0scssasessetesasddvoouneeean
(a) Residence. No..2I00. 1 4&Ase Se Te. See Weed, akon gee a
= sual place of ee (If nonresident, give city or town and state)
Length of residence in city or town where death occurred xb ys.) = mos. — days. ~How long in U. S., if of foreign birth? yrs. mos, days.

Ki: A
5a If married, widow | om
HUSBAND of .. mee

(or) WIFE of .......... eg TE ert as os Sago Maer ny! reece ce ae I fast Saw’ Wi.fgace cAliVO Oftesec:sesscsetecodorsessseessss eee aes Pa: Spee , death is said

to have occurred on the date stated above, at.............0... m.

The principal cause of death and related causes of importance in order of
onset were as follows: Rae oe
Date of onset

19 I HEREBY CERTIFY, That | attended deceased from

Iflessthan 1 day —
eee Hours...<.......Minutes

8 eee ol. or particular +f f,
ind OT WOrK Gone, aS spinner,
sawyer, bookkeeper, €tC............:..-.S04... ae a a) Ba
9 Industry or business in which ee

work was done, as silk mill,
Sep ann A Do) Pogtnd ce CS Roeder crate asa sooo des 22a note - cat cpeacadeincateve\iveshcecsrsnsousy

f Y 11 Total time (years)
a) spent in this
occupation.. Al —

10 Date deceased last worked at
this occupation (month and

OCCUPATION|

12 BIRTHPLACE (City)......<
(State or country)

13 NAME OF

14 BIRTHPLACE OF = SL
FATHER (City) Av. be Fi wes tinlces

Wwe

Name of operation ..7.ae........... Fy Seer eRe reer ridtekes = Date Of:-:..ccsecoeee
What test confirmed d

(State or country)

15 MAIDEN NAME ~ L
OF MOTHER Yl OPA
16 BIRTHPLACE OF ~/ 3
MOTHER (City) ..... Zu vasae

(State or country)

If so, specify.»
(Signed) ....... A ey a
(Address)........%.%

21 PLACE OF BURIAL, eS r J
CREMATION OR REMOVAL 4... 0<( IATA fa:
| Nowra

PARENTS

Ui ate if
ity or town

___DATE OF BURIAL... Pe PA LEI EE, ee ee ee

22 NAME OF
ae: A. ye =

UNDERTAKER ..
Received and filed...............sscesssssseess9e SC Ae Be RES 19. sewron /

| HEREBY CERTIFY that a satisfactory standard certificate of death was

filed wi BEFORE the burial or trapsit permit d:
oa oy ee
i nmt‘of Board of Health or other)

| (Official Designation)

ADDRESS..... Ae AML...

i er Aue GES De ee

er oe \ LA ee =
Revi nited States Standard Certificate of Death

To be complete, an occupation return must state:
8.—The trade, profession, or Particular kind of work done.
9.—The industry or business in which the work was done.
10.—The month and year the deceased last worked at the occupation
11.—The number of years the deceased followed the occupation.

In stating the occupation, avoid the use of such indefinite terms
as “‘employee,’’ ‘‘worker,”’ “‘operative,’’ etc. Find out the parti-
cular kind of work done and return that, as spinner, weaver, etc.

In stating the industry or business, avoid the use of such general
terms as ‘‘store,”’ “‘factory,"’ “‘mill,"’ etc. State the particular
<r a store, factory, mill, etc., as grocery store, soap factory, colton
mill, etc.

Distin ish carefully the different kinds of engineers by stating
the full escriptive titles, as civil engineer, mechanical engineer, mining
engineer, stationary engineer, etc. Avoid the term “laborer’’ when a
more precise statement of the occupation can be secured. Do not
use the word ‘‘mechanic,”’ but give the exact occupation, as carpenter,
Dainter, machinist, etc. Distinguish carefully between retail merchants
and wholesale merchants. A person who sells goods should be called a
salesman and not a clerk.

_ Statement of cause of death.—Cause of death means the disease,
injury, or complication which causes death, not the mode of dying,
é.g., heart failure, asphyxia, asthenia, etc. As principal cause
name the disease or injury causing death. As related causes, name
earlier morbid conditions, if any, related to the Principal cause and
any important complication of the principal cause. nder contri-
butory causes of importance not related to principal cause, name
other important diseases or injuries,

Example

The principal cause of death and related causes |" Date of onset

of importance in order of onset were as follows:
Arteriosclerosis

Contributory causes of importance not related to
Principal cause:

Fracture of ar

May 3,

A lomobile accident

In a group of causes containing the principal cause and related
causes, the causes should be given in the order of onset, so that ina
group of three causes the principal cause may appear in either first,
second, or third position. The principal cause in the above example
happens to be the second cause given.

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 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 as Tequired 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. 0.

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, from one cemetery to another, or
from one grave or tomb other than the receiving tomb to another in the
same cemetery, 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 Satis-
factory 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 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 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 certificate 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 state-
ment and certificate, shall forthwith countersign 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.

State cause for which surgical operation was undertaken.

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, mis-
carriage, necrosis, peritonitis, phlebitis, pyemia, septicemia,
tetanus.

—— |

Every item of informa-

PHYSICIANS should state CAUSE
Exact statement of OCCUPATION is very

AGE should be stated EXACTLY.

OF DEATH in plain terms, so that it may be properly classified.

MARGIN RESERVED FOR BINDING

N. B.—WRITE PLAINLY, WITH UNFADING INK—THIS IS A PERMANENT RECORD.

tant.

tion should be carefully supplied.
No. 7180-b

impor

50M-11-'29.

The Commonmealth of Massachusetts
OFFICE OF THE SECRETARY / |

E eeeeeeee NORFOLK. Pereeeet ii irrtrr rr rtrd DIVISION OF VITAL STATISTICS nue BROOKLINE teteeeeweneeees sreeeses
q (County) (City or town making return)
a STANDARD
116 ....,BROOKLINE ou. CERTIFICATE OF DEATH Registered No.... bp o.oo
ra (City or Town) dE death 4i pee
eath occurred in a hospital or institution,
a No. .. BROOKS Rherzese HOSPITAL. SSuneneanaessaebananenrtconcs® sottke leet eee i Ward give its NAME instead of street and number)
(If U.S.
SMM TRAIL eke Fog ME access sssennsitsscnannsscosessnconcdansuesecebgnvssapsseovscnsnsssece War Veteran,
(If deceased is a married, widowed or divorced woman, give also maiden name.) ODBC y WIAD) is cacy autres yeinvsnelicveadoseheneties
(a) Residence. No.6. QUINCY. AVE. ose CRE OA Ward, .WINTHROP MASS =.
(Usual place of abode) (If nonresident, give city or town and state)
Length of residence in city or town where death occurred yrs. mos. days. How long in U. S., if of foreign birth? yrs. mos, days.
PERSONAL AND STATISTICAL PARTICULARS MEDICAL CERTIFICATE OF DEATH
"BSEX | 4 COLOR OR RACE | © SINGLE ‘(write the word) || 19 pate oF i
|) | DEATH eevee ANUARY 5 Ae «a
Male White or DIVORCED Married Se (Day) ae
5a If married, widowed or divorced Boll 19 I HEREBY CERTIFY, That | attended deceased from
HUSBAND of .............! eneve.......5O. es.
: gine Geeta hin ee eve SORVALY..... VY.......,19 FF, to Jamwary...23., 19.52
(or) WIFE of I last saw h.. AML. alive on....... January..23 ree , 193.1... death is said

(Husband's name in full)

to have occurred on the date stated above, atlheO5D..m.

The principal cause of death and related causes of importance in order of
If less than 1 day onset were as follows: Ee a ae

.. Years i Double Broncho ®neumonia ivan!

Cees To Bans as aotiens caecinis oe eciet cements eet tas soa et Sete GT eT eee ee ron kawigunsuetareads <a
ee ee ier ST ERO, ee ee Novo a UN
sawyer, bookkeeper, etc
9 Industry or business in which

work was done, as silk mi
cou mili bank Bt cece BOSTON, GODS |] cere ceceeet cece teeta ee eeetee cscs eneneneneteceenenesaneneneneneneeeeeesenenanene: fseeneneneeny
10 Date deceased last worked at PALER RCCA RENEE (VEAES I Bieta sora eco ae avon tc austen teeeuuaind dees anasensovuvesacpeNacudgvanacceasaevcssesoae(|rassanaeacmeet

this occupation (month and 31 Se Contributory causes of importance not related to principal cause:

6 IF STILLBORN, enter that fact here.

OCCUPATION

12 BIRTHPLACE (City) ..cccccscssscsccsscssssecesosee Boston

(State or country) Mas sachusetts Se aaeie ae Coneaee taka sas Auakne sys acnateak cans esacss «tdeanchwnsakantentanssaass aaebeciacas'ause
TIS) TOOT Ges EE EO en) | cee reese ec oreee es core

FATHER

Name of operation

14 BIRTHPLACE OF i ? ? °
FATHER’ (City) | What test confirmed diagnosis?......‘ Clinical... was there an autopsy? nm

(State or country) i 20 Was disease or injury in any way related to occupation of deceased? .............. no
15 MAIDEN NAME PERSO SHO CH scares cia. po asvessauromcioncustetaeeavathvehctsrnartasaaue®

PARENTS

OF MOTHER Unimown Cotting (Signed) ... George....... e..... Mors
16 BIRTHPLACE OF (Address 4475. econ! wealth. fee Date oe aa
Boston
cannes 2% PLACE OF BURI
(State or country) CREMATION OR REMOVAL See! Cc alvar PY sah oo Boston............
Cemetéfy) (City or town)
DATE OF ey eee Oo eee 19... 3.4
“fora sake sHtge Sade Sista po iaivas Wint RE sa rauovcketa ca sacioeav nai oucheats Lak eee
= UNDERTAKER ..... Gas botany Peete f=. ee EWR co!
filed wih me: BEFORE § E'the a ae Aa ADDRESS 179 Atlantic Sts ae Wimthrep. ou.
2th i UY

; J
cosh 1S ot a AO peaaceens Received and ed. op Ape et BMF ona Cont vp

M9 VOCE Cyd ae
‘ae te
(Official Designation) (Date of Issue of Permit) A TRUE COPY, ATTEST: ° ners (Registrar)

ad ; >

we Y ei a

ame ae
ey toss wok

ANE PAINS EEN ERE OREN VELL? PES ESPEN EJ INGS

N. B.—WRITE PLAINLY, WITH UNFADING BLACK INK—THIS IS A PER

R-301A

Every item of

PHYSICIANS should state
Exact statement of OCCUPATION

tructions and extracts from the laws on back of certificate.

MANENT RECORD.

AGE should be stated EXACTLY.
ified.

it may be properly class

y supplied.
terms, so that

in
See ins’

nformation should be carefull
tant.

CAUSE OF DEATH in pla
is very impor
75m-2-'30. No. 7997-a

The Commonwealth of Massachusetts ; :
: OFFICE OF THE SECRETARY WO Se Bled tor berial penis

E ‘ § DIVISION OF VITAL STATISTICS with Boar vies Health
wi , STANDARD or its Agent, o
148 CERTIFICATE OF DEATH Registered-No.”.. +0 3". Se.
\\y0\>% , ~ : 4 et
g ; (if death occurred in a hospjifaF or institution;*
= “ rr. a Prrsupp cea enst sussess Ward }.. give ‘its NAME instead -of age andé number)
jo, (It U.S.
2 FULL NAME/J.@..‘ ; War Veteran,
"SpOCUy WAM) h<+csicicscssectvsieactendsetemal
(a) Residemte. No.....7......50.... db. LEME... Sth STE OPED L TO ooo cccccecetcceescesegesesescscetecescneevanens

(If nonresident, give city or town and state)
days. How long in U. S., if of foreign birth? yrs. mos, days.

(Usual place of abode)
Length of residence in city or town where death occurred

PERSONAL AND STATISTICAL PARTICULARS
4 COLOR OR RACE 5 SINGLE (write the word)

WIDOWED
or DIVORCED hua chs

18 DATE OF
DEATH |..c.2.:....sege

3 SEX

wht

5a If married, widowed, or divorced

I last saw h.&.¥“alive on.......4

to have occurred on the date stated above, at...............0. m.

The principal cause of death and related causes of importance in order of
Dateofonset

onset were as follows:

rade, profession, or particular Fr
kind of work done, as spinner,
sawyer, bookkeeper, CtC,.....:--::A-.huce easrnees ont etree neers enttaoecoacsoescesees P
9 Industry or business in which
work was done, as silk mill,
OW RAIDEN AO RNERC GLC 22 tase Re Seon ra 8e MR. ocioadaotoesaahikeseidddsesaeceodsyadecesec%e
10 Date deceased last worked at 11 Total time (years)
this occupation (month and spent in me | =”
MEAD) oo ocr Peeve cst ceosh Ra oer ee oe ee occupation § A :

OCCUPATION|

Be MUR TP GACE . (City) | coicicccoccscccsssccsasbeancensacss enero Baraca ta cic enase escapees cantes ities
(State or country)

13 NAME OF
FATHER

Name of operation ...=<..... DE SO nn Perego fh et DALCROT ne ee

14 BIRTHPLACE OF i i is? here an autopsy? —#
= FATHER (City) .............. Mine Oe et ae Son, Be What test confirmed diagnosis? 4 =m. ad ig there an autopsy? A—#
= (State or country) 20 Was disease or injury in any way related to occupation of deceased? ~ 22...
lu 4
c|15 MAIDEN NAME If so, specify.............
< OF MOTHER (Signed) ..........4.. Vee LN].
a

(Address)...

16 BIRTHPLACE OF
UCT ag IRR BR Bs co a ence’ (ip a A a 4
4 f @i PLACE OF BURIAL,

(State or country) (ALL GREMATION OR RE

" = a
17 a: Lata au) Pi. OF BURIAL

| HEREBY CERTIFY that a satisfactory standa Af ertificate of death was - aa
filed with me BEFORE the burial or transit pésmit was issued: ADDRES6..........-. che <

Dan 2 Gian. ho l Ane. Ae Gilani Received and filed...............::c:cs0000 rs Wana am BS re peta shanties (0 pds
he ne Se | ee

ation) (Date of Issy¥ of Permit)”

]

(Registrar)

Revised United States Standard Certificate of Death

be returned as at school or at home. For a woman whose
ae occupation was that of home housework, write housework
in answer to Question 8 and own home in answer to Question 9.
For a person engaged in domestic service for wages, however, designate
the occupation by the appropriate terms, as housckeeper—private
family, cook—hotel, etc. For a person who had no occupation whate
ever write none.

In stating the occupation, avoid the use of such indefinite terms
as ‘‘employee,” ‘‘worker,”’ “‘operative,"’ etc. Find out the Pparti-
cular kind of work done and return that, as spinner, weaver, etc.

In stating the industry or business, avoid the use of such general
terms as “‘store,” “factory,”” “mill,” etc. State the particular
ey of store, factory, mill, etc., as grocery store, soap factory, cotton
mill, etc.

Distinguish carefully the different kinds of engineers by stating
the full descriptive titles, as civil engineer, mechanical engineer, mining
engineer, stationary engineer, etc. Avoid the term ‘‘laborer’’ when a
more precise statement of the occupation can be secured. Do not
use the word “‘ mechanic,"’ but give the exact occupation, as carpenter,
painter, machinist, etc. Distinguish carefully between retail merchants
and wholesale merchants. A person who sells goods should be called a
Salesman and not a clerk.

Statement of cause of death.—Cause of death means the disease,
or complication which causes death, not the mode of dying, e. g., heart
failure, asphyxia, asthenia, etc. As principal cause name the disease
causing death. As related causes, name earlier morbid conditions,
if any, related to the Principal cause and any important complication
of the Principal cause. Under contributory causes of importance not
related to principal cause, name other important diseases,

Example

The principal cause of death and related causes Date of onset

of importance in order of onset were as follows:
Arteriosclerosis rors

Chronic interstitial nephritis

Contributory causes of importance not related to
principal cause:

SOAs ee ee ee eeeeenenesseresecsenssee seencecees HAA n eee te eeeneneeesenseee

Ina

‘oup of causes containing the principal cause and related
causes, the causes should be given in the order of onset, so that in a
group of three causes the principal cause may appear in either first,

second, or third position. The principal cause in the above example

happens to be the second cause given.

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, afte:

the board of health, or its agent appointed to issue such Poms,

; ere the
person died; and no undertaker or other person shall exhume a human
body and remove it from a town, from one cemetery to another, or
from one grave or tomb other than the receiving tomb to another in the

for the PETHORS| or is insufficient, a physician who is a member of the

If the death certificate 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 state-
ment and certificate, shall forthwith countersign it and transmit
it to the clerk of the town for registration, The person to whom
the perme is so given and the physician certifying the cause of death

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 Tegistrar may Tequire.—Chap, 114,

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 fulfillment 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 pres bedside care during a last
illness from disease unrelated to any form of injury.

(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 Peon) 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.

AVES ENS E EN EINER WE? PUN ESPINELVI INNS

R-301A

ry item of

PHYSICIANS should state
it may be properly classified. Exact statement of OCCUPATION

tracts from the laws on back of certificate.

Eve

NT RECORD.

AGE should be stated EXACTLY.

y supplied.
terms, so that
tructions and ex

See ins

formation should be carefull
tant.

CAUSE OF DEATH in plain

is very impor

N. B.—WRITE PLAINLY, WITH UNFADING BLACK INK—THIS IS A PERMANE

The Se eerie To be filed for burial permit

DIVISION OF VITAL STATISTICS with Board of Health
STANDARD

CERTIFICATE OF DEATH Registered No.....\ ~~ —

(if death occurred in a hospital or institution,
give its NAME instead of street and number)

(If U.S.
War Veteran,

epecity WAR): - <2 citevtsccssassecucsulehe eto

or its Agent,

nat ennenacescensesaVenseresseseseesegaseerMdaseNeccnstasucnstWensusnseatecnsen

(a) Residence. No... 1.40.8 die Nas atds sea nage An ecvahe eae eae sea ee
(Usual place of abode) (If nonresident, give city or town and state)
Length of residence in city or town where death occurred 2 yrs. mes, davs. How long in U. S.., if of foreign birth? yrs. mos. days.

PERSONAL AND STATISTICAL PARTICULARS

5 ie Ps the word)
3 SEX 4 COLOR OR RACE MARR 18 sags 2. 5 a3 /
mg a a | at So eae comme Ne et | oo
Woke White er DIVORCED (ifouth) (Day) (Year)
5a If married, widowed, or divorced : } p 19 I HEREBY CERTIFY, That! attended deceased from

1D tcc mM, 19.8.4
I last saw h.Néwme,.alive on.......... (a Lay Bip eas P 19..8..f, death is said

to have occurred on the date stated above, at.../...¢J.....t™.

The principal cause of death and related causes of importance in order of
onset were as follows: Fees
Date of onset

HUSBAND Of ......0....--c0.-csss00esse0ses-s0 AAR LO oe 2 ie Skt, eee

(Give iden name of wife i in fu

Te each die ne hh s-dgeaepe Pn er he a un

(Husband's name in full)
6 IF STILLBORN, enter that fact here.

>a
m
x
o
»
a
=
°o
at
=
a
—

8 Trade, profession, or particular
kind of work done, as spinner,

S sawyer, bookkeeper, etc............ A
| 9 Industry or business in_ which
oa work was aoe as silk mill,
= many MUNI MANTA UG 2 oe oe asd cca eam erareeee area Os en caeoe raes vaisc nner enseboSvednacte<cesns
S| 10 oe poenieed rag eabig . 11 Total Be een)
is occupation (month an spent in this
BAL) acer tNee aecensas ease evies sees 19/6. occupation fo. :

12 BIRTHPLACE (City).......<<"OMAWIe.

(State or country) Yn 2 | net settteterettteerseeeeceresterrceeesesetersirenserertetnescesecerteettenacesesenrescceners

183 NAME OF SV FR AGE pee eS on ree tee Sa eo CEE Ee Eee ce oe eee eer er SEE

FATHER y ; —- i

ee) a Je Leatntd— EEL GPTadA ale (12 (0 (3 | NeRpercee eee RE 8 ey poe a ET, Date of.. sed
14 BIRTHPLACE OF 7 i is? sy?..

FATHER (City) ao Pe it ee eke, ey | Sea ae What test confirmed diagnosis? Sa an ie _ there an autops SY Esse

(State or country)

15 MAIDEN NAME
OF MOTHER

16 BIRTHPLACE OF
MOTHER (City) ....... Craze fbb on KA PCLA.
(State or country)

PARENTS

21 PLACE OF BURIAL
CREMATION OR an hou bi bba. bn Neer Mente

2 (City or | Teclar

DATE OF BURIAL. MB Be Bee 19. G.I.

22
DABERTAKER 9.77. e. es ee OR se

ADDRESS..A-J. mete De uM -
Received and) filed)... pcghe teers hoon ML If cccsencssscseccssecrnagenmsensseneertanese 19.0)...

Ina nw awnccncecsecsassassesse| beneeavessnrsensnnswnutsrtenaseessrsenseseeeseass sees iaee sees eeeeeeeensenesnassewenateessatsnnasessseseeseesenes

(Registrar)

Revised U: States Standard Certificate of Death —

Statement of occupation.—Precise statement of occupation is
very important, so that the relative healthfulness of various pursuits
can be known. Make some entry in this section for every person
aged 10 years orover. Ifthe occupation had been given up or changed
on account of the disease causing death, report the occupation prior
to illness. If the deceased had retired from business, report the
occupation prior to retirement. Children not gainfully employed
may be returned as at school or at home. For a woman whose
only occupation was that of home housework, write housework
in answer to Question 8 and own home in answer to Question 9.
For a person engaged in domestic service for wages, however, designate
the occupation by the appropriate terms, as housekeeper—private
family, cook—hotel, etc. For a person who had no occupation whate
ever write none.

In stating the occupation, avoid the use of such indefinite terms
as ‘“‘employee,’’ ‘‘worker,”’ ‘“‘operative,’’ etc. Find out the Parti-

cular kind of work done and return that, as spinner, weaver, etc.

In stating the industry or business, avoid the use of such general
terms as ‘‘store,’’ “‘factory,’’ ‘‘mill,’’ etc. State the particular
od of store, factory, mill, etc., as grocery store, soap factory, cotton
mill, etc.

Distinguish carefully the different kinds of engineers by stating
the full descriptive titles, as civil engineer, mechanical engineer, mining
engineer, Stationary engineer, etc. Avoid the term ‘‘laborer’” when a
more precise statement of the occupation can be secured. Do not
use the word ‘‘ mechanic," but give the exact occupation, as carpenter,
painter, machinist, etc. Distinguish carefully between retail merchants
and wholesale merchants. A person who sells goods should be called a
Salesman and not a clerk.

Example

The principal cause of death and related causes

3 7 Date of onset
of importance in order of onset were as follows: 5 e

Arteriosclerosis

Contributory causes of importance not related to
principal cause:

second, or third position. The principal cause in the above example
happens to be the second cause given.

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 registration a stg ndard certificate of death, stating to the
best of his knowledge and be ief the name of the deceased, his supposed
age, the disease of which he died, defined as Tequired 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 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, from one cemetery to another, or
from one grave or tomb other than the receiving tomb to another in the *
Same cemetery, 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 satis-
factory 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 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 parease, 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 certificate 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 state-
ment and certificate, shall forthwith countersign 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.

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