The volume, 1932

Town Clerk, Winthrop · from the Internet Archive · 484 pages · 49.9 MB
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. J. L. FAIRBANKS & CO.

| ree Stationers
43 FRANKLIN STREET
—BOSTON—

‘(ail a The Commonwealth of Massachusetts To be filed for burial permit _
: OFFICE OF THE SECRETARY with Board of Health

Be ceeecceeseessnennacecnssobeet SeeeeGorrectescnccereshePersessess DIVISION OF VITAL STATISTICS were
P| Dy STANDARD or its Agent.

BS oh Ae fo CERTIFICATE OF DEATH Registered Now... Ae Kal
al (City or To : mS
< (If death occurred in a hospital or institution,

Be INO e Meee cceeeneeceeteCeveenssnecennnnntsstsonsnaenssvensesseses@osesastensesertrye give its NAME instead of street and number} ‘

Sgeua 2... Vor Sot be eae Wer Vera, | we

(If deceased is a married, J bs wed or divorced ea give also maiden name.) specify WAR)

(a) Residence. No..../.. Lb PBoccdl ptoth Aba GA Oe pa ee a Wards eal ik eet ok ee ee
(Usual place of aoe (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

Exact statement of OC

trructions and wktrante te laws on back of certificate.

7 cA 5 SINGLE (write the word)
3 SEX 4 Py OR MARRIED 18 DATE OF é
/ WIDOWED DEATH..........
or DIVORCED
AEN 5a If married, widowed, or divorced 19 I HEREBY CERTIFY, That | attended deceased from
4 OR eee
= - — : SER Oa. Ree MMi, ta Blache” PINTS cies akorgs frievisvosacoscracncessosesanccopissksnsece
ec maiden name ob fife in fulff Css rr testcneeete rev ceceneeceerseteeceecersersnnnepeserseee
ee) (or) WIFE of -.2.2.- ASIP TIG oostcs) tennesstesnnig ood I fast saw h............ i
; 4 (Husband's name in fu i it A
Bei 6 IF STILLBORN, enter that fact here to have occurred on the date stated above, at.@....£2..s....m.
2 : : : The principal cause of death and related causes of importance in order of
a If less than 1 day onset were as follows: ng a seereeg

‘ope

8 Trade, profession, or particular
kind of work done, as spinner,
emmrmeeer Rinses MPN SES See a lon ccs Vann cote Seer ad vo coeStavab ate caenscdaconsfaes+qiS-csndsacctvornsbat

9 Industry or business in which
work was done, as silk mill,
(UL: CO Se a ee 2 ae

10 Date deceased last worked at 11 Total time (years)
this occupation (month and spent in this
en nee Ee ee are occupation....................-

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

OCCUPATION|

Contributory causes of importance not related to principal cause:

Name of operation .../84°.......g.....

14 BIRTHPLACE OF
SCS RE So a Teco eee A Pe begiesac eostapaiae) so a seer nee

(State or country)

15 MAIDEN NAME
OF MOTHER

What test confirmed diagnosig?*#t-2#-2-

PARENTS

(Signed) Fi op Oe
(Addreg@) 7 ‘va.
ste aes Nae PA oa nates cat cen BUM conrea pode PF ekagp baer nplsnisacnenadsscéacdes

/ y 21 PLACE OF BURIAL,
(State or country) { CREMATION OR REMOVAL

If so, spec fy.
16 oot OF

____ DATE OF BURIAL.........

22 NAME OF ae F
UNDERTAKER “/...... LN Aeod

| HEREBY CERTIFY that a satisfactory standard certificate of death was ‘er a
} with me ORE urial oy transit permit was issued: ___ ADDRESS....4.. ae
——

(Sfenatur ofBdard-of Geaith orother) / 7 Received and filed.............c.ccee0e Bae L apeacreneietoatits sSavhovirenaerel (eRe

—e ae

d States Standard Certificate of Death

def PF

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 sone.

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,’’ .
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
ao 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, Siaiionary 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 merchanis. 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, mot the mode of dying, ¢. 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: BME :

Arteriosclerosis

Chronic interstitial nephriti

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.

etc. Find out the parti- |

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 sté 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. 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;

othetwise 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. 8 r .

(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.

RM 301

ae a

PHYSICIANS should state
Exact statement of OCCUPATION

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

FOR BI

VED FO!

GIN RESERV
AGE should be stated EXACTLY.

See instructions and extracts from the laws on back of certificate.

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

information should be carefully supplied.

is very impor

100m-11-"30. No. 605-b

g The Commonwealth of Massachusetts
OFFICE OF THE SECRETARY

BUG GOLK enn

& County) DIVISION OF VITAL STATISTICS (City or town making return)
a STANDARD
LIA 4 yaa, as \ Qthce | C= De aan ae CERTIFICATE OF DEATH Registered No......... Be ante
ey ‘ow
Ss (If death occurred in a hospital or institution,
A Noe ee caces a Bs SecA aqamor.e.... Aver, aSece S+., Seeateshedssneeseauere Ward { give its NAME instead of street and Sees
Ps Fa . i¢ i yi) Z \ (if U.S.
2 FULL NAME... OF SNC... ae! t. 4. uel S Wt an alee ~ War Veteran,
(If deceased is a married, a or divdreéd woman, give also mkiden fC ) specuty, WAR): sscoscstessesaccoswesavacsrcthtaren ras

Vieun LD A \ UCT oe Rae aie, op Nae fancier ROR MEME SP ERRNe f oon EL

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

(a) Residence. No......... 14... RAG oO. en Aiea

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

PERSONAL AND STATISTICAL PARTICULARS
3 SEX 4 COLOR OR RACE 5 eon (write the word)
emale | White = BORED Married.

5a If married, widowed, or divorced

AES GREMNINROTIRIN NS Ieee ae onc soch co sch a nscccetvchevedeisuihawnvadecsancSeelcvwssensasscevaedspechaiaceutauscbanserssesese

(Give maidew name of wife jerfull)
(or) WIFE of ctredec: cM oem AMLC. S oso En. q.han, dl. Sees

Husband’s name in full)

| last saw h

to have occurred on the dat
The principal cause of death and related causes of importance in order of
onset were as follows: Date of Onset

6 IF STILLBORN, enter that fact here.

Deesoae Hours............Minutes

8 Trade, profession, or particular

kind of work done, as spi “ce
S sawyer, bookkeeper, etc. = A. ON. Se. wWorKk. is tacelanenstaeesee
| 9 Industry or business in which
= pe ae rie Oyo. 0.1.2.
oO saw . AT tre is SA eee Peeepaeren caress
= 10 a ames ae month 3 = e 1 Total aE eee rs)

is occupation (month an spent in this

year) ...... z ee epee 'N Ov. ot 430 EecueaMon: HOU

12 BIRTHPLACE (City)... “O.ek. and... At te. ae

(State or country)

3 NAME OF
FATHER ce. i

MS FATHER’ (city)... NAG ONY IN

Name of operation’
What test confirmed diagnosis?...........2..-..ccesceeeoceecerseeeee Was there an autopsy?

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

(State or country)

Ee Sarah la
RTT aa es

(State or country)

PARENTS

21 PLACE OF BURIAL, intheop.... ae

emetery) VAL; r town)

DATE OF BURIAL o.-iecense0. Januar i me rs! 193.2.
22 ME Piven, SOR | cane

| Rae tr atred' : ee

(Address)

| HEREBY CERTIFY that a satisfactory standard certificate of death was \l
BEFORE érAransit permit was issued: __ADDRESS...... W.N.. eb io See 4 aoe. Met ts, ee
AM MMe. fr... ODI EES, EL “yy, Aj) .
ignature of Age Logs ith or W/ PEPER AT TT TD AUN oa pics vcd. Wea anaxtucsnvaudeccvbcassoaswedechaceasensceMmpicnye Fcbcnsadisantentouctes sexta : |: ee
4 j/ *)
MY, >» YL i, 3 »
Yeh aes es ‘(Date of Issue of Perfnit LEY a “A TRUE COPY, ATTEST: SNe Se ES ALON, (Registrar)

Statement of occupation.—Precise statement of occupation is
ervy 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
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
kind 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 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:

IOIs

interstitial nephritis 1921

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 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, 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 hi
Gen. Laws, Chap. 46, Sec. 9. 7 Same 4a

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 Bee ceron 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.

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.

Every item of

PHYSICIANS should state
Exact statement of OCCUPATION

aws on back of certificate.

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FOR BID

MARGIN RESERVED

AGE should be stated EXACTLY.

tructions and extracts from theQ

See

information should be carefully supplied.
CAUSE OF DEATH in plain terms, so that it may be properly classified.

is very important.

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She Commonvralth of Massachusetta To be filed for burial permit
= OFFICE OF THE SECRETARY with Board of Health
< rte fo) ee DIVISION CF VITAL STATISTICS or its Agent.
a STANDARD
1,8 Nfperctye ir CERTIFICATE OF DEATH Registered No Ate
=] (City or Town),
< V4 o , ye (If death occurred in a hospital or institution,
= EL acpcneece CAO NC NOR ete i aE EP give its NAME instead of street and number)
(If U. S.
FASS) OUT SN | OY a9 OSL area ar oy 7 2 a ee ag AE, En, War Veteran,
(If deceased i: atried, widowed or divorced woman, give also maiden name.) specify WAR) «2... <..2.00c.Xgaeessccoeeeease
(a) Residence. No... 22 ARN LC Sancti, ERI <1 = 358 eek a aS A Sees tae ae NEV Ce Say Oe hs Re eR eee STE ol
(Usual place of abode) (If nonresident, give city or town and state)
Length of residence in city or town where death occurred Pa J yrs. mos. days. How long in U. S., if of foreign birtkaS J yrs. mos. days.
PERSONAL AND STATISTICAL PARTICULARS | MEDICAL CERTIFICATE OF DEATH

5 SINGLE (write the word) ||
3 SE¥—> | 4 COLOR OR RACE SINGLE 18 DATE OF ee: ime)
a. WIDOWED DESAI fescscae «tool ss ate es soca cas ep avuseeaassasvandevebsb-guabuussasaushécvansieantns «obs cotoainecaatearnevesse
‘ oz DIVORCE
5a If married, widowed, or divorced HEREBY CERTIF
HUSBAND of ;

(or) WIFE of .........0.--.-... - <<_—P#OR PR ee........ 2h Low nh£Aq..alive on....... Zee

(Husband’s name in full)
to have occurred on the date \s¥ated above, ath Oz Dee eee m.

6 IF STILLBORN, enter that fact here.
The principal cause of death and related causes of importance in order of
onset were as follows:
Dateofonset
>)

If less than 1 day

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8 Trade, profession, or particular
kindofwork done, as spinner, $$ J9 pi pg I rete ee seeeeeetttteteetetteseetenteeeseseseeseneeceeeeseeeeeseesecceeseeeseneseceeeesereneceeees [eseeerenenens
sawyer, bookkeeper, etc

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

enna e new n enn e nce e eee annnseeneneaanensasaeansensnnssnsasaasansnasssrasarnersersnaseeesas nesses ese eeeee

OCCUPATION|

eae roesd CMU Naot Eee Peano cern sn nteca eh aneeten cacti steccersrunnrnovesddasucenecsbsebeducepesosts
10 Date deceased last worked at Bis PUSAN EAN ETI ROY OAANS) mites We (fee weeeee erent ars 8 2c cee on eee ae moan sneha we rue sessouscvsscecesares teaneanreeae
this occupation (month and spent in this

Vieicasteconrae ase nennveeM Dae teek sancdesicssesneoa occupation...............0.0-.

12 BIRTHPLACE (City)
(State or country)

Name of operation is Sid Parnes ee
What test confirmed diagnosis?

15 MAIDEN NAME () | Ogg FE S80, SP OCIFY- nesses AD Porreereerrnernnsccnseserrensgmyscerffecey
OF MOTHER Y Uf eX:

16 ay “os ,
NO nr gah -rnssaioonaccsSotetieiyeesndatsigesnensensvnectych-inct Wnnedtttnsocssnaviiscscbans 21 PLACE OF BURIAL, »
(State or country) Zi CREMATION OR REMOVAL <>?

DATE OF BURIAL...... So er Att ee ee OPER eo boty

22 NAME OF
UNDERTAKER

ADDRESS....

FUe OA MITEL LILO A ssotevsscncdsdevnsvetsaicibovessicpossusencee vt isda,

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

(Registrar)

ee eT ee

KF Cas
Revised United States Standard Certificate of Death

rl PG Fo)

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
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
kind 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
moré’ 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

: : Date of onset
of importance in order of onset were as follows: ate of/cuse

Arteriosclerosis Iorg

Chronic interstitial nephritis r92r

July 5, 1927

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 forthe
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. 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 ep icaron make the certificate required of the attending
physician. 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 oi 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.

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.

‘

MARGIN RESERVED FOR BINDING

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

5
wo
°o
-—

Every item of

PHYSICIANS should state
Exact statement of OCCUPATION

AGE should be stated EXACTLY.

See instructions and extracts from the laws on back of certificate.

important.

CAUSE OF DEATH in plain terms, so that it may be properly classified.
100m-11-'30. No. 605-b

information should be carefully supplied.

is very

OFFICE OF THE SECRETARY
DIVISION OF VITAL. STATISTICS

STANDARD ;
1 CERTIFICATE OF DEATH Registered Nowe. 2adeseen
(If death occurred in a hospital or institution,
Ward { give its NAME instead of street and number)
, (If U. S.
poem ENE Nea POW NO Reset ee rte Bah a re oat RecA RE aS car na ssai ves eccvaccsavencedseesineosevdcesacescefvoses War Veteran,
i HATHE i i i i specity: WAR) sicsic.cdscccscscetcastenchescestaesatt

(a) Residence. No................5%0. Ga nr ea A Saar Fo pace ones Se TID Giby sa sesivnsuvann sais WW AN GLip asks ott an cd ecdncsabs soapasucaseossicbsestoasksoseadisesscusdaetors
(Usual place of abode) (If nonresident give city or town and state)

Length of residence in city or town where death occurred days. How long in U. S., if of foreign birth? yrs. mos. days.

yrs.

PERSONAL AND STATISTICAL PARTICULARS

5 SINGLE (write the word)
3 SEX \ 4 COLOR QR RACE HARKIED
——————— Pp
female or DIVORCED

5a If married, widowed, or divorced

MU SS RROPRMNN eas reactor ac tees sooo «ses < cMCTNT aaah cul duscus sath cvasatt pbbsedseoncsosadecdencvoubdathactassieesescests
(Give nen name of wife in full)

(or) WIFE of ..... REESE Tar nn OOM cP RWERED TET CT PST IPRS SRT ES cneiplne unos sein cutesh nensancvenses: sates: | last saw h-

(Husband's name in full)

to have occurred on the date stated above, 4t................-..- m.
6 IF STILLBORN, enter that fact here. The principal cause of death and related causes of importance in order of
onset were as follows: ; “Date of Onset

If less than 1 day

8 Trade, profession, or particular
kind of work done, as spinner, —————————e=_______>

S aan earn MMR PRIOR ELEN aetaban ca snidascecnscnneecavessastesdecerasrssstevesanssvedssceocsdocsawecse ects ecback

| Q Industry or business in which

oa work was done, as silk mill Se a

= Op DEES Se ee re ee

S$] 10 Date deceased last worked at 2ST | PME) 1 ea 1 MASS Se S92 207 ae aE | ee CR rc | gp ca
this ‘gh on creat ane ——$——_"* spent in this —«——

Se RE eee occypation...............2+

RUM RTP ACE. (GIG) sonicecescsdcoccsnsnccceeontnec<areoeoriaastincy Beers pissais iasanec opteaaecthnenetes
(State or country)

13 apt TE Ce cage Soe
fez

Name of MOTSAFALLO NR) eas .ayesarsorsesceice Wie sc sackencdnaveatiesasccattreres

14 BIRTHPLACE OF t fi dd Pesrenantysinstuskitadsncsstaassundetres
» FATHER © (City) cccase-s-ssceceseecneeseezeee AEE |_What test confirmed diagnosis? ricci t-reenreeWas there an autopsy?. 2.00
= (State or country) 20 Was disease or injury in any way related to occupation of deceased? ................0.+
33/5 IERSO ASDC cormseeccasacscetvetve cs vce cate putoscstusucuene.cssopSplveenege tocaatastchthassveneckoaiete aenereeteoine
m/15 MAIDEN N 5 >
<| OF MOTHER (signed) <G22¢24 bn...
a LOL bl tctethghe

16 BIRTHPLACE OF oe hee es 1

sce 7g ie eae aaa 21 PLACE OF BURIAL,

(State or country) CREMATION OR REMOVAL

(Cemé¢tery) (City or town)
DATE. OF (BURIAL .isccccsssnicssnencsis}coresoe Ee ne a ee ee 19.02

(Address) * fe 22 NAME OF

UNDERTAKER

REBY CERTIFY that a satisfactory standard certificate of death was
ith me BEFORE Y burial 9 transit permit was issued:

ADDRESS........

th or o The oe") 1 Received and SOR Bead fae Se Cir

) A TRUE COPY, ATTEST: (Registrar)

Se oF = sili

Revised United States Standard Certificate of Death

oa phe tS G2)

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
kind 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 ceeupation can be-seeured. _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, ete. 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 IOIs

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,
wees sane wae penizected, the guration his last illness, when last
seen alive by the physician or officer and the date of hi Datay
Gen. Laws, Chap. 46, Sec. 9. ats ol-bis 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.

:
}

MARGIN RESERVED FOR BINDING

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

ry item of

Eve

PHYSICIANS should state
Exact statement of OCCUPATION

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

important.

CAUSE OF DEATH in plain terms, so that it may be properly classified.
100m-9-'30. No. 9954.

information should be carefully supplied.

is very

R-301A

OCCUPATION:

Che Commonwealth of Massachusetts
OFFICE OF THE SECRETARY

To be filed for burial permit

DIVISION OF VITAL STATISTICS with Board of Health
STANDARD or its Agent.
CERTIFICATE OF DEATH Revistered No:.|., eaoae

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

(If U. S.
Sep i oh A ee ee eee Bee War Veteran,

eased is a married, widowed“%r divorced woman, give also maiden name.)

(a) Residence. No....@...Z. Soe ¢ AU. ‘ded WA

Sante nee eee nena see eeseeeeeessseseeee een assesses eseeseresnsee SEeeee®

(Usual place of abode) eae i (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

5 SINGLE (write the word)
3 SEX 4 COLOR OR RACE MARRIED ar
Va Act? \ Wibowen
or DIVORCED
5a If married, widowed, or divorced x ; 19 I HEREBY CERTIFY, That I attended deceased from
HUSBAND of ..... IPs PMY xe rca RR AA Siz RD + lg Ed. 4
(Give maiden name ofWife in full) [poses Leatee LATE cca 1944, to... 640 TE... yA ed earns 7 192...2-
Ramey IMMA eR ce ea acca accom sene ect epsaeee cn eso count uesseabanesasecsddennsossarabasctocencuatbcsdsearesessaeesed | last saw W4Zaq.alive On LAL adh LY in cck de , 19..49..2, death is said

(Husband's name in full)

6 IF STILLBORN, enter that fact here. to have occurred on the date stated above, at...... i Ree Mm,

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

If less than 1 day

ff Fe
AGE’. .....3f3 Se Was nee feet Months...<2....Days

8 Trade, profession, or particular
kind of work done, as spinner,
Fo SES A aR BOOP i leon i a ee

9 Industry or business in which
work was done, as silk mill, YU tre

SORTS 82s Se. a i 2 ee !

10 Date deceased last worked at 11 Total time (years)
this occupation (month and spent in this
te Ae ha or, ee One Se eS eee 2 occupation..

12 BIRTHPLACE (City).......... Lt ALAA ,.. Lee AZ.

(State or country)

13 NAME OF Bi
FATHER Salauc2en VEY) Vithy
i/ 4 j

Name of operation

14 BIRTHPLACE OF What test confirmed diagnosis?

FATHER (City) ...........
(State or country)

15 MAIDEN NAME

OF MOTHER CLLZ~qgtf
16 BIRTHPLACE OF
MOTHER (City) .......//

(State or country)

PARENTS

(Signed) A abellahMe

(Add ress). zene, Egan

21 PLACE OF BURIAL,
CREMATION OR REMOVAL YA RL. ar

= (City or town)
re ] F
eel ch te i en Soe: DATE OF BURIAL......... vied 2) Pee ey
(Address) 4 Z Z, 22 NAME OF
bo pal iiss Lae ES UNDERTAKER .... J Ai set Pe Serta Fon So
| HEREBY CERTIFY that a satisfactory standard certificale of death was bs
ped with me B ve r transit permit was issued: ADDRESS....... wy Ir an Oy. WU F245
Accent of Boardot Eecitt RRR AeN a —" | W RRecehveKd Mtl IOC vnicecseoscveses<seocnevesszocerade. Sesconserct Masso oWcrccecdenccrncses ceaey |: Rar

Ith or other)
ae ED Le on
(Date of Issue of Permit

(Registrar)

“wg

J a

Revised United States Standard sew he Death

VAL AK TF
aS.

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
kind 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 merchanis. A person who sells goods should be called a
salesman and not a clerk.

Example

The principal cause of death and related causes

? D f t
of importance in order of onset were as follows: ae cake

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 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. 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 countersi| 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.

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.

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

ORM R-301A

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.

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

information should be carefully supplied.
See ins

CAUSE OF DEATH in plain

is very important.

100m-9-'30. No. 9954,

GQ The Commonwealth of Massarhusetts
OFFICE OF THE SECRETARY
DIVISION OF VITAL STATISTICS

STANDARD

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

CERTIFICATE OF DEATH Registered No......... i} eae
(If death occurred in a hospital or institution,
=p EA COROLEORE Os Ward give its NAME instead of street and number)
(If U.S.
LUT MIR A NGA 8 Wh Ea nods Secret sie babs ost REET War Veteran,
ed woman, give also maiden name.) specify WAR).........:......ccsscseosssescessessoees

(a) Residence. No...\3..
(Usual place of abode)

Length of residence in city or town where death

PERSONAL AND STATISTICAL PARTICULARS

5 SINGLE ) (write the word)
3 SEX 4 et ie RACE MARRIED Bh hee
UYy y [7 WIDOWED ty A yt
LUKAL) UAL or DIVORCED LAW
5a If marriedy® ioaed: or divorced 4 LY i /
HUSBAND of (UMAR. SIN MELALY, J A Nn Sel gh en eG ALR
(Give maiden name of wife in full)
pg) LETS, Oo SOE ales 2 Re eee a ee a ne ey en

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

8 Trade, profession, or particular
kind of work done, as spinner, f
sawyer, bookkeeper, etc...............-- £4 LIAS LLL once

9 rare or pisitters Na ee y
work was done, as P 4 <
coe ie aimee aie te MaAdbwww.

last worked at 11 Total time (years)
i spent in this
occupation... /

12 BIRTHPLACE (City)................5 ed Yeo, A
(State or country)

13 NAME OF y 4
FATHER LEAL by,
14 BIRTHPLACE OF , ff
= FATHER (City) ..........., LALLA UAAMA «.. “Seats
=z (State or country) /
Ww
74
«|15 MAIDFN NAME / |
<| OF MOTHER i é aha d fe hi
16 BIRTHPLACE OF /
Tih y (Cera ie ae ae J Rae nea i
(State or country)
17
Informant OI AOI LMG SAKL....... PMOL A Yn
(Address) 4-4 J &, /

| HEREBY CERTIFY that a sdfisfactory standard certificate of death was
ed with m eT bifria} or transit permit was issued:
~ . fs y .

Meakele:

(Official Designation) y y

eUcecestese 7 Du nevvncsencccersccescscsccccvssescscesscces

Health or othep) .
a »- fis

ot, 2 Re nee pee ae f , AZ, ae p
(Date of Issue of Permit)

oy),
Mf. mos.
MEDICAL CERTIFICATE OF DEATH
18 DATE OF Zs
Wes. DENTE sso terion. aN Ua i LG sA
(

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

Soren err eery

days,

AN eee =f Pee ats

(erator Ld ca] vemberJo ah, wm panvaiy TL, 19.0.
1 last saw h.4M....alive on... WA NY ARH... 1&......., 19p.23.., death is said

to have occurred on the date stated above, dt}. em;

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

Name O1 OPBraulOn yc ete cone esc eee Date (Of:..ctimes sate mtyenes
Was there an autopsy?.W.Q

What test confirmed diagnosis? ......-~

(Signed) .<.
(Address)....

21 PLACE OF BURIAL

CREMATION OR REMOVAL) AAS 6 AEE OM, We YWERMAAL,
(Cemetery) _ (City or town) /
DATE OF BURIAL.......)....0:4 UE... SE MR AN a D2.
22 NAME OF 4 P\4
UNDERTAKER .......0.- > ted. LAY MLE neg
ADDRESS........ ZL Aaddé
Received and files. PS pgtee Nae. § Baik Aly Fee eee tne
/ Af Af
eeseteccnsersewes cunsan ASE tp hawk n rants chen ahabaneecnnnenne lena cenneseeneesseccrenentane meme
av (Registrar)

ee
nited States Standard Certificate of Death

LAN NEE jot

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
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
par 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

3 : Date ot onset
of importance in order of onset were as follows:

Arteriosclerosis

Chronic interstitial nephritis

July 5, 1927

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.

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. 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 ouried, 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.

- R-301A

fae

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

properly classified.
See instructions and extracts from the laws on back of certificate.

AGE should be stated EXACTLY.

CAUSE OF DEATH in plain terms, so that it may be

is very important.

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

information should be carefully supplied.

AGE.......Q... 1 yes Years... (a rer! Months. oe, oem

_ Che Commonwealth of Massachusetts To be filed for burial permit
2 OFFICE OF THE SECRETARY with Board of Health

DIVISION OF VITAL STATISTICS
or its Agent.

STANDARD
CERTIFICATE OF DEATH Registered No........../ b,. sean
rs {If death-accurred in a hospital or institution,
SLs ease eee. Ward { give its NAME instead of street and number)

(If U. S.
War Veteran,

specify WAR) <<c0s:cccescececisast-asessveveoessiven

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

PERSONAL AND STATISTICAL PARTICULARS MEDICAL CERTIFICATE OF DEATH

4 COLOR OR RACE | © ee 18 DATE OF

WIDOWED
or DIVORCED

(write the word)

tees...

5a If married, widowed,

MRUISBANDD OR ecto ene A AL ten oc Ger icncn cadet senses SS Bae eee cr Stn Boe
KGMWIRERDE eee cc sasa 3 lees, Pee Se eee ee eee || ldulast saw (haere. alive OMNs.-..s5l erie Prboccncscy 199.22, death is said
(Husband's name in full) ge 2. YS
6 IF STILLBORN, enter that fact here. to have occurred on the stated above, atw@n...0000. zm,
The principal cause of death and related causes of importance in order of
If less than 1 day onset were as follows: ’ eee east

ssece Record EL Scat peers i On che

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

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

=
=
=
=<
a
>
oO
o
o

ney nN TARR WRC HOU uc s0t otra ces ieee: ax ecsas chaos yeveassacoxcvchivasdscstscvsisseecus -seetenaninduedarivecasésery
10 ae pee at last mde at / 9 2 11 Total ane
is occupation (month an spent in this
year) ...... ? Renneatree Wear Waaaeeceee eoenbecdaben<chdsappne 0 aT occupation 17
(State or country) Le al pL
13 NAME OF // | ‘ : et.
FATHER fo oe ae
z. Z : ReITIAL OT OREEALIONM icc. .ccctes rrastoneresiaoscssecesosertvoteS ot theoptececen aves Date" of.........a.ckeoe
0 ds PATHERS (Cites ate og What test confirmed diagnosis? Oe . Was there an autopsy?.: 220
z (State or country) 20 Was disease or injury in any way related to occupation of deceased? .... Ae,
lu é ——_1
| 15 MAIDEN NAME sil ae |p
< OF MOTHER (Signed ee
a fans
16 BIRTHPLACE OF A (Address¥. 2-5. J Cusominasseeburvonece BOER costgn avian a es cee eree
MOTHER (City) ......0.....-54 PDA AA LAB cc pecscccccccsnescsnnsnssnnsnesen

Vatarg. 2Lf | LE: 75/_ a

21 PLACE OF BURIAL,
(State or country) Whi CREMATION OR REMOVAL ..
by etesy) feet da De |
DATE OF BURIAL yh hol EPP Pon iA... ie |
D 7 a=
22, NAME OF pe

UNDERTAKER .... Che. a mA iALe- |
ADDRESS........ My. aa eee 0d ber Vea |

Received and filed... nn ll. 8.0 Ras cotadvonaviussctenstdvash pepmentucotbenen eee i te ee

ty | URES ai eerie
(Date of exe's Crd (Registrar) ie:

Revised United States Standard Cert; of Dea
7 v4 Fe

eae

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—holel, 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
aaa 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

Arteriosclero

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 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 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 conttacted, 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. 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.

(Q) 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. Dee i i

svescme eee 8 wees 1 SS FOS S23 eS eee ee ee

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

tem of 2 .

Every i

PHYSICIANS should state

AGE should be stated EXACTLY.
CAUSE OF DEATH in plain terms, so that it may be properly classified. Exact statement of OCCUPATION

See instructions and extracts from the laws on back of certificate.

information should be carefully supplied.
tant.

is very impor

100m-9-'30. No. 9954,

R-301A

The Commonwealth of Massachusetts

OFFICE OF THE SECRETARY To be filed for burial permit
DIVISION OF VITAL STATISTICS with Board of Health
STANDARD oritsAgent. _
; CERTIFICATE OF DEATH Registered No............ 4 tere.

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

(If U.S.
War Veteran,

specify WAR) ic:..ciccscassencsocscndontssenocevzece

2 FULL De

(a) Residence. No.....°%°Z... A Ic eT IG o gc att scald WW ELE 9 Soc scesc ett vs sae oa och vena vento ste saaeaeetado neonate
(Usual place of on i

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

if of foreign birth?

How long in U. S.,

days.

PERSONAL AND STATISTICAL PARTICULARS

5 SINGLE (write the word)
3 SEX 4 te OR RACE MARRIED

p Z, :
Cie. (a Se We SE ge aes ee | ee ee Se se
5 a

5a If married,
HUSBAND of

ie % cee 19
dF seatn is said

(or) WIFE of

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

7
ey A, Aa pe eSesessoset Months............ Days

8 Trade, profession, or particular

to have occurred on the date stated above, at. RL Vie.

The principal cause of death and related causes of rine ance in order of in ee =
ollows

3 follows: @

if less than 1 day

= kind of work done, as spinner,

So sawyer, bookkeeper, etc....... .

| 9 Industry or business in which

a work was done, as silk will, <

= Sew, MARL Moma CLC... «onc c= dese cccsovcccecsStrovasvsessncee Eo eet chases tt-crs «nsccncetsoomeowenteceme ie
S| 10 Date deceased last worked at 11 Total time (vears)

this occupation
V@aN) lest eo-

. . !
iw gs we spent in this pr ae

Occupation..

12 BIRTHPLACE (City) Oe a Eee
(State or country)

13 NAME OF
ATHER

Name of operation...

14 BIRTHPLACE 0 2
FATHER ‘Git. ind What test confirmed dineneeeer!
=z (State or ieee ===
a = V4 ~
« 15 MAIDEN NAME Aire eee eee ee eee)
<| OF MOTHER r igned) ... C9. LAE nae
a

18 BIRTHPLACE. OF - (Address @4F 424A =

bia 21 PLACE OF BURIAL,
(State or country) CREMATION OR REMOVAL . LAE.
ae
aid DATE OF BURIAL.»
22 NAME OF
UNDERTAKER ...S.- oe &.<....

ADDRESS...

Received and filed.................. ee oe rei cxencassiitniere ses hataos inks codistouairectoes ly.

| | Official Designation) ermit (Registrar)

(Date of Issue of

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
and 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
of importance in order of onset were as follows:

Date of onset

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 of, his death....
Gen. Laws, Chap. 46, Sec. 9.

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.

EVE PLENNS EEN ENE OREN VW ER PN EN BPP IN EV EINGS

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.
See instructions and extracts from the laws on back of certificate.

portant.

100m-11-'30. No. 605-b

CAUSE OF DEATH in plain terms, so that it may be properly classified.
is very im

information should be carefully supplied.

5 SINGLE (write the word)
ag |= OmtoR OR REE SINGLE
WIDOWED Set
or DIVORCE

Che Commonwealth of Massachusetts
OFFICE OF THE SECRETARY

DIVISION OF VITAL STATISTICS (Gily Gr town eralins aera
STANDARD
CERTIFICATE OF DEATH Registered No......... pie ee

(City or Town) : ] j f
(If death occurred in a hospital or institution,

No..-f,.7. Orta aocsncctscedppaccese Cé2-E_, “onsencer g ive its, NAME instead of street and number)
a ; (If U. S.

fz <C | Skbin, Ue ee RN MEA Wh. War Veteran,

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

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

<P yrs. a oo days.

PERSONAL AND STATISTICAL PARTICULARS

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

5a If married, widowed, or divorced
ERUISHANNDD Glee (56 -oacta hi csn0seso0cse: pear PREP roocnneerecceenceesoeee ffcerceneprppettinrcr efcogepeendencennen eceeee EEE

(or) WIFE of .....

(Husband's name in full)

6 IF STILLBORN, enter that fact here.

OCCUPATION

PARENTS

a hao
Uma Bs. pelissip 7
4

8 Trade, profession, or particular
kind of work done, as spinner,
RMUE FET OOMURMRCE DET. ELCs) rook cedars ccossnctdcthacceucteecaceisuctcevocvassesacbocessasessetssaveceaivecrst
9 Industry or business in which
work was done, as silk mill, \_~
saw mill, bank, etc. .................9 er Ka, A ee eee SE Gee eae

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

this Ss teen eens aad spent in this
ep ee ee On erenrrte Occupation.............ce

12 BIRTHPLACE (City)............ He . Lo ee ba cin. fsceeencenttee tte

(State or country) : Fincse nf
13 NAME OF ee
FATHER =

14 BIRTHPLACE OF
FATHER (City) ......... 0 Er 4 aes SA

(State or country)

15 MAIDEN NAME
OF MOTHER

Name of operation’... LA
What test confirmed diagnosis? —s

eeseenaJenscsscnnsenss

16 BIRTHPLACE OF

MOTHER (City) .........4.4 él (kts , ; 21 PLACE OF BURIAL, Zz
(State or country)

CREMATION OR REMOVAL

by 4 TEE Lt, ie 4%
Informant AR Vin Gad 2 Vee OS Se DATE OF BURIAL nA Sr on a Gann
(Address) 2 NAME OF i;
UNDERTAKER
| HEREBY CERTIFY that a satisfactory standard certificate of death was ,
ADDRESS..

filgd with me BE ORE ' Lue burial or fransit permit was issued:

RNS CANS SAARasSckvadouredsnsonsecace dp nase ecvssnpusadacuvecy>ndaesp +a:
A TRUE COPY, ATTEST: 2 ecaisvass

Revised Unite tes Standard Certificate of x

tt PPL BGS

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
kind 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

Arteriosclerosis

1927

Contributory causes of importance not related to
principal cause:

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 ee ae. Se ERSCe the Can ie his last illness, when last
seen alive by the physician or officer and the date of hi
Gen. Laws, Chap. 46, Sec. 9. lee

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 pipers: 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 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.

— 2

— is
Sn 2-301 Che Conumonwealth of Massachusetts
OFRICE/OF THE, SECRETARY = 8 # # ...
“ Os DIVISION OF VITAL STATISTICS (Giby x town tialiae tame
°sO STANDARD
E om 1 CERTIFICATE OF DEATH Registered No.......... /| Ee a
< wo)
c=) 3 oa A Scie (If death occurred in a hospital or institution,
> 05 { give its NAME instead of street and number)
oc
BS : (If U.S.
a ca aE Meese NAMIE Risse soc casi c enc tane feeraginsties Loc daccsoNconc@cdecsoosagpactbocrenzeasoetes War Veteran,
z ° i i i specify WAR)... tu sscaedstysavascenewadecteasisnetetice
—_—
O§ (a) Residence. ae he 2
wn £ (Usual place of abode) (If rowroadent give city or town and state)
me 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.
6
o. 4 PERSONAL AND STATISTICAL PARTICULARS ICAL CERTIFICATE OF DEATH |
3 3 SBX eine on Wage | Ff ee werd) |] 18 DATE OF A a 3 WA |
g ak ZA WIDOWED DEATH.........! SATE 2 AT i od cence a ee
ik) or DIVORCED (Month) (Day) (Year) |
5a If married, widowed, ; 19 HEREBY CERTIFY, That | attended deceased from |
HUSBAND of ...... 1 Se ESE a RT OE ae eer ag DE aa aa 1 (ER nese } 19a 198 ff tee Garr. AA ee , 19.35.47 4

(or) WIFE of
(Husband's name in full)

6 IF STILLBORN, enter that fact here.

he eed ¥Y See Years

Months 3 ra Days
8 Trade, profession, or particular

kind of work done, as ——

sawyer, bookkeeper, Wit cette
9 Industry or business in which

work was done, as silk mill,

saw mill, bank, etc..........-.. Bp iecrpdar nei ceee sce wokecsourentepehcnascot voxsoui susevrovvcsvesasacdinercouet

10 — is month 2 1 Total inthe iis
is ecetiga ion (month an spent in this
year).. 3 075 ( occupation fo

If less than 1 day
Hours

should be stated EXACTLY.

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

12 BIRTHPLACE (City)......°

(State or country)

14 BIRTHPLACE OF
FATHER (City)

2! (State or country)
z| 15 MAIDEN NAME
«| OF MOTHER

See instructions and extracts from the laws on back of certificate.

16 BIRTHPLACE OF
MOTHER (City) ..4.-#

(State or country)

information should be carefully supplied.
tant.

is very impor

100m-11-"30. No. 605-b

(Date of Issue of Z mit)

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

CS Ul eel INN Ome weeks CPs ESLINGel iar

I last saw h.uXgy alive OM... My 19.3. /aeath is said

to have occurred on the date (tated above, ‘2b!
The principal cause of death and related causes of importance in order of

ae as follows: Date of Onset

( rebe ed to occupation of deceased? ....

Gio Ck

If so, specify.....
(Signed)

(Address)... 4? itis

21 PLACE OF BURIAL,
CREMATION OR REMOVAL
(Cemetery)

DATE OF BURIAL....:.... 66 en A
22 NAME OF Dike
UNDERTAKER

____ ADDRESS.......

(Registrar)

A TRUE COPY, ATTEST:

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
kind of store, factory, mill, etc., as grocery store, soap factory, colion
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

: 4 Date of onset
of importance in order of onset were as follows:

Arleriosclerosis | ieee RECO See
1921
Cerebral hemorrhage July 5, 1927

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 of hi
Gen. Laws, Chap. 46, Sec. 9. peg HE aPRee aes

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.

....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.

ORM R-301A

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.
ified.

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

terms, so that

information should be carefully supplied.
See ins

CAUSE OF DEATH in pla

is very important.

100m-9-’30. No. 9954

nov
Che Commoarnnestth of * Massachusetts To be filed for burial permit
OFFICE OF THE SECRETARY with Board of Leal
DIVISION OF VITAL STATISTICS
STANDARD
CERTIFICATE OF DEATH Registered No............. ieee
\

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

(If U. S.
War Veteran,

Bpecity, WAR) -<c0-cc-ctonsucaneatevsuecncttncreset

or its Agent.

»
PLACE OF DEATH

2 FULL NAME
(If deceased is a marri dd, widowed or divorced woman, give also maiden name.)

(a) Residence. No............. ri as A" La A 2 ASLaug.....| he fica ehperoes Ward, .. ie

(Usual place of abode)

resident, give city or town and state)

Length of residence in city or town where death occurred yrs. mois days. How long in U. S., if of foreign an yrs. mos, days.
PERSONAL AND STATISTICAL PARTICULARS MEDICAL CERTIFICATE OF DEATH
4 COLOR OR [RACE 5 tone (write the word) 18 DATE OF 4
50
DEATHE:. ners Bicep dat ataascietaastaapevanishe,sormeuemeeeteeeee es toe ee
wipe __ (Month) (Day)) (Year)

5a _ If married, widowed, or divorced I HEREBY CERTIFY, That! attended deceased from

RST) Cl eee ee Bee tence Be ee chee et cccaee | g O 1932_/ sy) Ae ae a ee.
ey UMM Es OE eee ce aco secs sca scscenocparvoaeyeotyantesncsosazssnctvccopasseesvhvasvinestgior sescccbidicderssseneseiced BE «SaW) Mis-cnntec GliVEUONe fect tates heres ., death is said

(Husband’s name in full) pee e Lb Sd -.
O have occurred on the date stated above, at./@: m.
6 IF STILLBORN, enter that fact here The principal cause of death and related causes of importance in order of
if less than 1 day onset were as follows: Date of Onset

8 Trade, profession, or particular

= Kindofwork done, as spinner, YY tts sesetn ee ffa rnc feseserrg fl frre forrrvrcrrersrerensrencrercearssenssvsnenenenensarsnessessensies [eanercisasneeaneneacens
(>) BUWNER; WOURIEOHET 5 Ol G oes ccccosessscerscxcscsestnstasecssetenassoscycatesvissbedatesoesy svvacsiesuasatecevaes,

SE YTGTES TI STRSTR ety 0 GPR Tr IIS SIN "Pl og TBP {Fae i Ge cE a a ae a aT ecg
a work was done, as silk mill,

a SETA TTR SUES Tones catcaa staf crete eee bocca oan Serr cer! eh Dae a aes ie oa ea eae a aaa cena acca facades Ct
S| 10 Date deceased last worked at PULAU EAITIO: (VOCALS Mpamcte. aU cece Maan 20 ee cnn v daha caccty cv ccd ts seie ous vacances asacnitetvoveptustesssdocostiorndnucacll aeeaee Sete ete ee

12 BIRTHPLACE (City)........... CSO: ae? A DOME See eo,
(State or country) Poa irene pies Ree we ye ee OE Se

13 NAME OF |

this copacahane: (month and an this oe causes Of paecay to principal cause:
Catt pre. c=

FATHER SS
Name IOMUBO LATION AL .02-0rs<csctssettee Seroancoesecs ni heen ea Date) Oftiiis.ccvcsssessscsvececrrsateree:
What test confirmed diagnOSis?.......sesseeceeeeee---- Was there an autopsy

14 BIRTHPLACE OF
FA

ra THER (City) ........ yD Oe orties Paes Oe
z| (State or country) -E> a cs 20 Was disease or injury in any way relat yd to occupation of deceased? ....................
WwW

«!15 MAIDEN NAME If so, poe Oy ecscncescdiol tls S$ cs igen siaaseeert dita ena
< OF MOTHER (Signed) ., : A , .D.
~ (Address)... cB (Ge? eee Se j

21 PLACE OF BURIAL,
CREMATION OR REMOVAL ....

16 BIRTHPLACE OF Ae bea ae:
ity,
(State or country) W627,

‘<
cae. ‘ vod hy 0 rags es F ee Fae

| HEREBY CERTIFY thata tilaatistectory standard te of death was

gi me BEFORE the busial or transit permi i S issued: ADDRESS..........72... A ve 2
Th ble ZA aa Recaied and fnnonnn OQ

: (Signature of Agent of Béard ealth or other) is : ff P-o
Mali piped, Ee Lie MME lh, Miia Mn Gli Skee i Ig AEE 4
(Official Designation) / (Date of Issue of Vermit) (Registrar)

DATE OF BURIAL.................... fet

22 NAME OF
» UNDERTAKER

Revised United States Standard Certificate of Death
Lar IG, 7 ie ee

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
kind 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

5 * Date of
of importance in order of onset were as follows: ate jorlonsee

Arteriosclerosis

Chronic interstitial nephritis

July 5, 1927

r192r

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 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: | 3

(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.

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

=
4
'
wo
o
~

Every item of

PHYSICIANS should state
Exact statement of OCCUPATION

AGE should be stated EXACTLY.

See instructions and extracts from the laws on back of certificate.

tant.

formation should be carefully supplied.
CAUSE OF DEATH in plain terms, so that it may be properly classified.

is very impor

g The Commonwealth of Massachusetts

OFFICE OF THE SECRETARY
DIVISION OF VITAL STATISTICS f (City or town anakineetucn)
STANDARD
1 CERTIFICATE OF DEATH Registered Nott fae Pe ee
(If death occurred in a hospital or institution,
ak. AL AYL St., aaa decevste petsecns sss Ward { give its NAME instead of street and number)
Kate 5 ee r (IE U.S.
a see eam aN Nort ot mE eA aw cc ne eons lati Woe akcsaacsceactkewccsnccncssstastevnisoucalecsvoscoost seadonceseiosscssceec¥ads War Veteran,
married, widowed or divorced woman, give also maiden name.) specify, WAR) vtaccccctessvssvecclvcssscvectuchisaste

(a) Residence. No........ We eee Le Oe. ee SE Ward’ 8 5 Sonat ceca oe

(If nonresident give city or town and state)

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

PERSONAL AND STATISTICAL PARTICULARS MEDICAL CERTIFICATE OF DEATH

days.

5 SINGLE (write the word)
ee aa a 34.L23
he DIVORCED (Day)

5a If married, widowed, or divorce

- —~ 19 I EREBY CERTIFY, \fhat | attended deceased from
(A G42 > - , 10D a Al
JUS UN IIPS 2 ce Ree ES Sp a RECESS EEL 1 certo coerce eco | ag G7 ee aA. 9F2..., Weer a ee eh SENG eee , 19.3..2—
(op VTE a) col see co roeteereaeeereeermcepreornos aos Ber te cwcrn eres canetunactcsseseas efi oedeschestasesene I last saw h..f.x4e1.alive eS «Ae 19.A.2_death is said
(Husband’s name in full) C-
to have occurred on the date stated above, at.... Ace. 2d0O—A ori:
6 IF STILLBORN, enter that fact here. The principal cause of death and related causes of importance in order of
7 72. If less than 1 day onset were as follows: Date of Onset
AGE acvesctocceraattesecs Weare... .montis®, race DAYS ||. osesscest HOUSi=...:.0.\¢ Minutes
8 hoe peesson, or particular. \
ind of work done, as spinner, * :
é sawyer, bookkeeper, etc: ..... rane a M1... Ua. La bisspudeasest
=| Q Industry or business in which NSTr Uw en
a work was done, as silk mill,
= ST TE Ae eee bi ee, (nee ee
S 10 as “occupation last month 2 i 11 Total eee (yeara
is es ion onan an spent in this
Weal see eh Sa occupation... S.OUNS
Lig CPTI CAGES fea ere a a a
(State or country) Galas
13 NAME OF QA 77 - :
FATHER Sema Peo © 0 A fete
SE ie Name of operation...........€...55
14 BIRTHPLACE OF 7 eae What test confirmed diagnosi
‘ FATHER (City) oss... KS 2A, Yc oa RI
z}| (State or country) PH.azaso 20 Was disease or injury in-any way related to revel Of deceased? ..........s0.0..000-
a 15 MAIDEN NAME If SO, SPOCIfY......0..-, 74 oooh AP organ maateene 3
< OF MOTHER LE ac fir (Signed) eee lnn etn ara breeder
- a ean ice Oe (Add teSS) ne 0 AGIA i. Capate. fae 29. Zac
MOTHER (City) .. TP) Oo*.. NOMMrae ochsewietern ss sa0-isavd, cesdevetocadaedt J
21 PLACE OF BURIAL, LEAL AV La 4. LOLSe< r
(State or Pasi Pes 5) CREMATION OR REMQYAL fa arent SAtiaeat oad Ce Cpe mt ER
: (Cemetery) (City or ‘ani
2 DATE OF BURIAL......-. ew OS a ea WB
w a
i} 22 NAME OF ; 4 Sigs ee
3 UNDERTAKER ....... Ge<&.. ase. co Ea Sie ee 5 ORES
a 2
ADDRESS.......-...
cd
“~ i Mites savenusecbarctibicetceccassoadll iaieaanies tons! Beinn siecetpectah hvaentipadihe Gueitiencdunzesh 1S Sew
3 Received and filed Pri
& } i
. MMO. Sodogee : 7 : x ° MRCS FE COND EKeWes 0 o 80dcreccasbapStapectncasavarvcevetccerucoadiuey yuo ctled duecvee Deere agsrccccccccovnccnsevavevscesees
8 (Official Designationy A TRUE COPY, ATTEST: 193 Registrar)

Revised United States Standard Peter
| Cr ee

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
kind 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

5 ? Date of onset
of importance in order of onset were as follows:

Arteriosclerosis

LE CLT

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.

EXTRACT!
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 dat i r
Gen. Laws, Chap. 46, Sec. 9. 3 ck Memes eee

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
pr 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.

...Ee 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.

= The Commonwealth of Massachusetts
Geom Fe-S02 : OFFICE OF THE SECRETARY
_ > < sco ceeeneren oS ROX LAPP SOS e eesrceepeEtT a DIVISION OF VITAL STATISTICS oo wrtsssse: ‘ae BV OF 2, See PCA EETY
gu i a STANDARD
a” 5 = hanes Danvers... CERTIFICATE OF DEATH Registered Now.....ccccccsccne
£ 1S) m ty (City or Town)
r= a < (If death occurred in a hospital or institution,
* 26 = - NaTVEES SESES” Sept tal Beles eek es SUS fe ree Ward { give its NAME instead of street and number)
ow 4.
i>) (If U.S
Ei < — f
om ZEEE SIN AIVIR coc RWIS crcl PES Reema 6 5n.nss soso odecensaseoessssscencessecseocecoasuetecioveacbéscscorenetesapedts War Veteran, J LL
fa 35 Ligys-« fsa Jgtd-tsem: divorced woman, give also maiden name.) specify WAR).......... ran dasinisiccrsapattebespce
> 20
te) Rpbperekeesrclersce., NO ses cre aie cee ks ooo conc oes soca Sade vtendcoseccvessedbennesd Shoat esses NEEL BARS 8 Cac a Re a
ne ) (Usual place of abode C 6ri tY 6 ‘ ta inthrep:. give city or town and state)
Zz * 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.
< =e
Oo z PERSONAL AND STATISTICAL PARTICULARS MEDICAL CERTIFICATE OF DEATH
B g 3 SEX 4 COLOR OR RACE | 5 SINGLE (write the word) |118 DATE OF *
o WIDOWED DEATH 22.255... Fi. OS 2: See rechaedncniadeanncadeccprasvancsdadsnwauasaseaaeaen
Zs vs a ee or DIVORCED. | ici Day) (Year)
S 5a If married, widowed, or divorced ~ 19 I HEREBY CERTIFY, That | attended deceased from
3) HUN ODO Heres, ee eee
s : (Give Bille he a rant Weecrc ae aha 119 gg gytO orn ei BO es
Wl (CDS TLC cb ites ce cepa ee Own deeper I last saw hg-von..... # atve? Olio ecnie oe Mo 35 d@ath is'oafd
(Husband's name in full) Jans 30,

MARGIN RESERVED FOR BINDING

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

AGE should be stated EXACTLY.

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

tion should be carefully supplied.

impor

50m-2-'30. No.

997-

~
‘

6 IF STILLBORN, enter that fact here.

7 If less than 1 day
AGE.....77.Q.......... WealS:s;tr. Months............ Days: |igsncest HoUurs:....02:-... Minutes
8 be paisa, or particular

= ind of work done, as spinn
5 sawyer, bookkeeper, etc... One cutee Nie ee i Be Ad oie 2
| 9 Industry or business in which
a work was done, as silk mill,
= etme ele MRR SCRE LE em acc ac ucauannienrasrouderoncass
4 10 Date deceased last worked at 11 Total time (years)

this occupation (month and spent in this

PRED) rere eT erator vas ces sctncedenenesen OCCUPATION: recietneas sta
CS Cr 9 RS 5

(State or country) ; f

13 NAME OF

FATHER Ivory Jellison

14 ap ee OF

= aR ROU ENO Tir Pechaa ec ope taco nate Pens wv se ccs ese: vavones’asvovanetersnctnrat naseseaied
=z (State or country)
Ww or _____ Wlajne@—— __
| 15 MAIDEN NAME
< OF MOTHER Eunice oe
a

16 BIRTHPLACE OF

RM NL Tere gn fone cash 22 aS oddeaot sons og PADRE Nene ahha non canesscaeauazantathieyventodavsoage
(State or country) Ma i ne
aT 4 G
2 OS Dyan Se erty ane. ae; oe
dsferman ertrude Fl, Smith,
eeet witty it
A TRUE COPY.
a ae A aa ih ae Al eater mee cc te ay catnecatien s<<Lenovucnsvescccnanrs soc TWPeveve¥encecroscovesess
(Registrar of city or town where death occurred)

DATE FILED ............. 2/6/32 . alee Oc

21 PLACE OF BURIAL,
CREMATION OR REMOVALLA DLewood...Pars

(Cemetery)

to have occurred on the date stated above, at g3. 5. FS fm.

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

Generalized.Arterioseleresis -?t927

Contributory causes of importance not related to principal cause:

Uhronie Nephritis ih ah ee cs 2 “4gR4~
INRIA Y OE ODO YALIN sarc sussecansracescessaseastovassdus Gait teeth sivansdScnlehtvaddsucved Date: Ofverseccs career
What test confirmed diagnosis? GlLinicsal eee Was there an autopsy?..yeey
20 Was disease or injury in any way related to occupation of deceased? .............000+
WE Shay S POC Weetos snes nssdecavbiecastusunstsvunsaspoxantiougieatncetauce sak adlsvatiootaenshcityen speragSbnhpeaateere o iGiiaie
(Signed) ...........5......... eo fee «Padgelt a Ye eae ee a , M.D.

7 CEC.) anne oun OF SRE EES Ski ees YN see 1Shiaece

24 petagie >

22 NAME OF
UNDERTAKER ...... 82.9... Ah. RODD DTS genni
ADDRESS .ccsccsccsccscsoneevnee %e Boston, | "i dasse
rr Try
Received and filed.................008 ge A RR AGREES Cops Coa" Ss. anne pe

Registrar of City or Town where deceased resided)

3
4
S
-
>

Every item of

PHYSICIANS should state
Exact statement of OCCUPATION

AGE should be stated EXACTLY.
be properly classified.
d extracts from the laws on back of certificate.

so that it may

terms,

WITH UNFADING BLACK INK—THIS IS A PERMANENT RECORD.

See instructions an

is very important.

information should be carefully supplied.

CAUSE OF DEATH in pla

N. B.—WRITE PLAINLY,

9-"30, No. 0054.

100m-

The Commonwealth of Massachusetts To be filed for burial permit
OFFICE OF THE SECRETARY with Board of Healt aa
DIVISION OF VITAL STATISTICS ‘1

or its Agent.

STANDARD =
1 CERTIFICATE OF DEATH Registered No.......... Ate
: F (If death occurred in a hospital or institution,
Beata Te Mea) eaceencd faawdnuuehuiolunashicddispesasaacdecvooncutenneaasisdasuuskbvassanead bee. .Ward give its NAME instead of street and number)
ats F (If U.S.
2 FULL NAME.......—..: Ch Gens... COs& SE, A a, CE rte Ao War Veteran,
(If deceased is a married, widowed or divorce i 5 Syceity WAR) s+. -cosscsss cessctotatncsctessesterss
(a) Residence. No....... Al ner oh St Eee, Shi ar ee 2 he ee
(Usual place of abode) ie) (If nonresident, give city or town and state)
Length of residence in city or town where death occurred << Ae) mos. days, How long in U. S., if of foreign birth? yrs. mos, days.

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

bodcte, | Maem

WIDOWED
or DIVORCED are

a If married, widowed, or divorced

MUUUNCPRUN Negi sree cn cere ee cece Co oa de aoa c satan amen ssbe noes tosiatacetetsansnendssvennebsssenpnestl

last saw

(Hypband’s name in full)

6 IF STILLBORN, enter that fact here

7 ¢
AGE...... YL Eee Years...... re Montis..%.,.Days

8 Trade, profession, or particular
kind of work done, as spinner,
sawyer, bookkeeper, @tC......-....:--2:c00:001 Ohi ee ree

9 Industry or business in which
work was done, as silk mill,
eeeies puta Ramen EEE nt etc Servs cht ces Zs cs cnnscsec ys kéas cp taecoanesevacephnsectnigghtuscane=shoscrH

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

this occupation (month and spentinthis .£% [7
eee passe eel iieorserseg occupation

to have occurred on the m.

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

If less than 1 day

OCCUPATION |

12 BIRTHPLACE (City) ee
(State or country) tre Z MebstRRs aaa AONE CEN Cis cee oie ann dedstumndbascasatnsenciuuscssccevedencacessasey coasbivegebsasdesarmtnshen | st neehele eee enema are
13 NAME OF = . ~ IE ae OD ee, ee SOE DMS a wn cacnasnasiagneel a ee
eae ne & VC Ler

14 BIRTHPLACE OF

Name of opersttes BW ee et | Rares Sat lee
What test confirmed diagnos

a” *
“i WARE A CLE iy ose0s0csse05-s00qscerexcear ff oe * sf aoe
z (State or country) an 20 Was disease or injury in any way related to occupation of deceased? . PD...
os IGiS0) SHOCHY:.- 25-205 -.00c-nttbnapgcenser tages :
<| OF MOTHER Ce ZZ EI * (Signed)
(Add r6sS)A.. 9.2. <7 Ee IEF. gt. fo vococccss

16 BIRTHPLACE OF
0 orn TL ES RANG el se! etn Se

(State or country)

21 PLACE OF BURIAL, J :
CREMATION GR REMOVAL (5. occ ss. catestscatatsgscvartgygeteenscvevessntenyn

~
pile oaN A COCO Fee ae

22 NAME OF
UNDERTAKER Cc GS

abneeGnenscccerceDiccccsvaccesccseccssenscesceececesssecesncusessensseenescectssccessaseessescocscccase

OO — oe

‘Revised United States Standard Certificate of Death

Heh fp py 32)

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 pérson

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 owm 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
an 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.

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

ee eeeeeeee pecencsececcascascnsccccsecsesceaescsnssasscsussctsnseaseassssnsnsscsscssesnenssscersr | ss

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, 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 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. Jf 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.

and those of persons found dead.

a
=
a
'
ie)
°o
=

Every item of

PHYSICIANS should state
Exact statement of OCCUPATION

AGE should be stated EXACTLY.

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

N. B.—WRITE PLAINLY, WITH UNFADING BLACK INK—THIS IS A PERMANENT RECORD.
information should be carefully supplied.

See instructions and extracts from the laws on back of certificate.

is very important.

100m-11-"30. No. 605-b

gy Che Commonwealth of Massachusetts
= OFFICE OF THE SECRETARY

Suffolk
EP URS. sa cara ee Seok UITAL STATISTICS iP aang eae
8 STANDARD ‘. a
Se Cl ae CERTIFICATE OF DEATH RegisteredNo....... ~.. Se ERs
4 (City or Town) (iedeath 7 ‘ :
: eath occurred in a hospital or institution,
a INot.222: 314 Kevere Strect. eoreeah eecepecsassevc St. Buses andseoyasswcda se Ward { give its NAME instead of street and number)
(If U. S.
rere remette OI Nice apeeeeeerevcseecsserscgeuregesvcigesentnns War Veteran,
(If deceased is a married, widowed or divorced woman, give also maiden name.) epecnty WAR) s. 2 cdsicversoccesensseoratvanscens
(a) Residence. No.......... $14 Revere Strect. Fees oe CO Ee ee NUE ea ECs AR Sue RSE A a ee ee Ped Bae send oa OS
(Usual place of abode) (If nonresident give city or town and state)
Length of residence in city or town where death occurred a! yrs. Qg 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 2
MARRIED pre oS
M. W 4 WIDOWED DEAD cach-cuss0ccdes EEO cca sisctisuccasdonbicissasspasercatenppasse=s v ei A Sanat 3
or DIVORCED (Day) (Year)
5a If married, widowed, or divorced 19,1 HEREBY CERTIEY, That attended deceased from
BAUESTEAWNDD O86 ecg sscee ocpecivson ees Pevesbssanes eoperenpa cWetrpgg;icnsetaaretaspontenseusccisBpeMOD aise sosebeapenstenstorns
(Give maiden name of wife in full)
ee MITT Re eer caren oR Se cS, sccc oprah cope nc uc seaneceawansstoceep Seeappayy aresap upesiutaviipe

(Husband’s name in full)

6 IF STILLBORN, enter that fact here.

to have occurred on the date stated above, sang he

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

7 If less than 1 day
IBGE Scenes ts) fo cay Years.....- i Months [i eae sponnascehes Hours............ Minutes
8 Trade, profession, or particular
= kind of work done, as spinner,
° aeaieae ere A RMaR UE COMRADES. el/c ined p¥ nar nas oa doses 'yavtusbfeey acsvexaBsdpssvousanestnespnsisse
| 9 Industry or business in which
oa work was done, as silk mill,
=z ne aN er EAN Seles ese ica snes Anus satan <aossrnvysen eat ss suv0csedraveseseceaguatuaprveraarrs
S| 10 Date deceased last worked at 11 Total time (years) Z A are
this occupation (month and spent in this Contributory causes of importance not related to principal cause:
WEBI) op voce atc nncenarardennncancsto nn) Med verradsosorensosnasonns OccupatioN.......-.-..-.000--
12 BIRTHPLACE (City)... CAMORAGTSs ree
(State or country) Mas ar
13 NAME OF
FATHER Archie Fulmore f2srra
ee Name of operation...............c000+. “9
14 BIRTHPLACE OF 7 ; i i is?lZ
| "" FATHER (City) ....... Can not be leaened. net Reet coriiemiedl Somsrs
=z} (State or country) CG “ 20 Was disease or injury i
w ; = $F; SO PSPS IMIG osha ens on cnsicsaceghoosongapngf- cpa asansaceimpo Mh sanonofroptraspiosi fphatent lope ax ppvsitnaxanekeemeepesaTiCs
|! 15 MAIDEN NAME
2 6 ee Esther tierney. (Signed) ........ a ie 4b e722) 3 ,M. D.
a ; AN. ; »... Date... <f/. rs ‘s
16 BIRTHPLACE OF CG brid (Address) ....Ai2.@....4.. LUE ~ Date fe 19.32,
MOTHER (City) .............¥! Slo 21d oD ee eS eee Be os pie GE SIRI: Win.throp Winthrop
(State or country) Mass. CREMATION OR REMOVAL ..5-2So0. ic NO ct AN
(Cemetery) (City or town)
DATE OF BURIAL...% CO EUOLY, 4,1998 wee...
22 NAME OF
UNDERTAKER ..... DVLA... CORCORAN occccccsseremeneen
ADDRESS ROAM... CAMO.» Hb.».9 CAMP PIA TOs cnn
Tealth or oth aes) ee PN ENER MEETIN @ MOUND os cvs sor vrindnvbniisnroninarigiaciouunaubinusudretedeakeapavehifiteetventersnsvandcabuxael > inesbante |:
eal
Mealee LT | FEB ode: eee
(Official Designation (Date of Issue of Permyt) A TRUE COPY, ATTEST: (Registrar)

Revised United States Standard Certificate of Death

eee A LP 32)

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
kind 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:

Arterii i

Date of onset

hte) ELC

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, 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 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 hi
Gen. Laws, Chap. 46, Sec. 9. . laa hae

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 tequired 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.

sae

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.

a
item of &
7
‘
w
°
-=

Eve

PHYSICIANS should state
Exact statement of OCCUPATION

AGE should be stated EXACTLY.

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

N. B.—WRITE PLAINLY, WITH UNFADING BLACK INK—THIS IS A PERMANENT RECORD.
information should be carefully supplied.

See instructions and extracts from the laws on back of certificate.

tant.

is very impor

(a) Residence. No...... a <A,
(Usual place of abode)

Length of residence in city or town where death occurred

PERSONAL AND STATISTICAL PARTICULARS
(write the word)

5 SINGLE
4 COLOR OR RACE MARRIED
pleat

5a If married, wi

HUSBAND of

ive sad name ff wife in full)

(or) WIFE of

(Husband’s name in full)

6 IF STILLBORN, enter that fact here.

ia sco a 4 asa Years months. B

ays
—-~.

If less than 1 day
ce ee Minutes

8 Trade, profession, or particular -
kind of work done, as spinner, LW “A LLL,
sawyer, bookkeeper, etc.

9 Industry or business in which
work was cme as silk mill,
saw mill, bank, etc.

10 Date deceased last worked at
this occupatio
VGar))--%-<c0s--

OCCUPATION

11 Total time (years)
spent in this
occupation

12 BIRTHPLACE (City) .ccccccseecsooe da

(State or country) Cee?) 2 = eee
3 NAME OF x
FATHER L blir: ra, Yur

(State or country)

15 pg —
r OF ae ms Pe hoa a

16 BIRTHPLACE OF

PARENTS

MPTTIEM (CSC YY. ccs sicccncesscctsansscisucs We cchattrs Pee eet cee a ase
(State or country) Se pf SE A
=
3 (Address)
g | HEREBY CERTIFY that a satisfactory standard certificate of death was
filed with me BEFORE ss transit permit was issued:
> | Von.» KL, tA. v {ne
a (Signature of Agent of Board of Health or other)»
es f var Poe i
| Tes 1 Of ee YEE GTS: a Ae
3 (Official Designation) (Date of Issue of Pershit)

Che Commonwealth of Massachusetts |
OFFICE OF THE SECRETARY
DIVISION OF VITAL STATISTICS

STANDARD
CERTIFICATE OF DEATH

Sd (City or Ca making return)
Registered Now............cceeeeeeeeee

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

(If U.S.
War Veteran,

SPeciiy, WAR) csicsverscncsacsectvaseesssteeapesassn

(If nonresident.give city or town and state) *

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

Aeanicus Wee cadi ven setcurapiaeesnrs a fone FE hcaecath i is said

to have occurred on the date stated aboye, tf
The principal cause of death and related causes of importance in order of
onset were as follows: Date of Onset

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

20 Was disease or injury in any way related to occupation of deceased? ...........0....00
If so, specify
(Signed)
(Address)

21 PLACE OF BURIAL, Wy
CREMATION OR REMOVAL ..
DATE OF BURIAL

22 NAME OF
UNDERTAKER

(Registrar)

A TRUE COPY, ATTEST:

Revised United States Standard Certiticate ot Death

AL O- JG3/

Statement of occupation.—Precise statement of occupation is
ervy 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
kind 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| Pate of onset
of importance in order of onset were as follows:

Arteriosclerosis J9OTs

July 5, 1927

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.

BAN TINA TO
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 dat i .
Gen. Laws, Chap. 46, Sec. 9. ci Se Pe tet

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 ak 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.

LL? PBIAE??PLCL?PE EN ee eases Ceemesanse SG 8 WED GEES aw EE

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.
See instructions and extracts from the laws on back of certificate.

tant.

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

is very impor

information should be carefully supplied.
00m-11-'30. No. 605-b

Che Conmmonmeslth of Massachusetts
OFFICE OF THE SECRETARY

DIVISION OF VITAL STATISTICS (City or town making return)
STANDARD 12
1 e: CERTIFICATE OF DEATH Registered Now... 2 csccsssessees
or Town)

= . . . . :
Pe liae Latina la ad ras. Ninth cogs { churns,
2 FULL NAME........ PGA vcs See! ee YN Se if) aie M OR Seo hens {We Velen,

(If Ves is a married, widowed or rced Woman, give also maiden name.) SPOCUY WAR) -cssascasscsceusesetvcesp-tvcenPeancreee
(a) Residence. No........%..... occa To carn Tht Da cited, Ceaser Peta St see re Ward). 2. os ch eh Be et oad Be ES ees
(Usual place of abode) (If nonresident give city or town and state)

be mos, “ days.

PERSONAL AND STATISTICAL PARTICULARS

Length of residence in city or town where death occurred How long in U. S.., if of foreign birth? yrs. mos. days.

(or) WIFE of

6 IF STILLBORN, enter that fact here.

5 SINGLE (write the word) Te = D
3 SEX 4 COLOR = RACE MARRIED 18 peor es Q ro SEF <7
Tevwral Wuer e or DIVORCED { NiAowed- (Mbnth) (Day) (Year)
5a If married, widowed, or divorced 19 I HEREBY CERTIF ¥> That | attended deceased from
EMS HUD cio ccak ct aca ascSevstdvaccndccs Guasdconsvooaesaiice retcorthc cos pss ore neeetea too ceo. =

‘(HuSband’s name i

to have occurred on the date stated above, at%..an. GM.
The principal cause of death and related causes of importance in order of

7 If less than 1 day onset were as follows: Date of Onset _
AGES ab...-cbee ree Years:.-.1-......- Months...l....... Days licecccresvers FIOUESscc0202:23: LITO ON eo: a il a ae RE eat BAR) ae a ener A RE PO RPE BREEN Fo aciciciny- iste tii
8 mae ged or particular Lead aN 8 Bites Ay
ind of work done, as a
iS sawyer, bookkeeper, Clee a ZIONS ON ME . ee ee
E| 9 basses or poe in which
a work was done, as MN ( Vane nn Wa he CO __i(CéOCd*CYS:SC cre een cence nee nce nee e ee ecernsnsnensavssncescecssecssecsceseneesesenensecscasaeas |sececestsasenceeees
2 saw mill, bank, ofe................- Wy) Y.WA....... howe... Boe...
8 10 Date deceased last worked at PEE ROLAL TMG: (VESTS) oo. NIE Soa eee en eee ee ee eee eee Caren iar ete ¢ ana ee
this occupation caer nv andy i spent in ne
"CED eee OV. G3 occupation..../.2.0). MAY.
FO POR 2 OS
(State or country) NA
13 NAME OF
FATHER ev amen Wai . Pin
\ = Name of operation............20. ie teeeeeees
14 BIRTHPLACE OF i i 1Stiscnees < 2. AO
” FATHER (City) . A ¥\! What test confirmed diagnosis S there an cma
z| (State or country) 20 Was disease or injury in any way related to occupation of deceased? ......©.. mates
= PE gta cnn eu nagurusuzuee tse vuetonagaiopiseden's Spe sa chen gu nna cone ut tasmaemtne sv ved iaey-teucyaanaeeeeneaaetae
| 15 MAIDEN NAME oh gah ¢ ;
<| OF MOTHER a (Signed nd d
e 16 BIRTHPLACE OF (Address) Fee oe yim irwhchc&
MOTHER (City)... ae Mier. 2 En ae oe a oa
21 PLACE OF BURIAL, r |
(State or country) NE CREMATION OR REMOVAL Likbes...OV T LAM,
S u i a) tery) 4 (City or town) Me
<7. ) me tienes
“Etemat ks chy. Mose: ep Pelchen. bass DATE OF BURIAL... oA st SE senen Wome
Tress
f\ wae 22 NAME OF cs : =
= : UNDERTAKER . Ser: SA Aa CODES Oo Ow Oe, Ss 0. Cae
| HEREBY CERTIFY that a satisfactory standard certificate of death was ie UV : > ;
filed with me BEFORE the burial or transit permit was issued: ___ ADDRESS ce Oe ASO 7 ee RL O90, Oe
r Taiecsonre of pen of Board of Health or other) PASSSETOEREL CAFICA TAL Gthagsasisnevesv oh evse¥ecesavaserancvasniseessesssiahivednsynechn sesh 432 fists eer th: ees
(Official D&Mfignation) = (Date of Issue of Permit) “A TRUE COPY, ATTEST: ~~ yb umeematnaietsy (: 2" sty, cay eee ee

Revised United States Standard Certificate of Death
BEF FPL ie gr

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
kind 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] Date of onset
of importance in order of onset were as follows:

i IOIs

Arterioscl

Chronic interstitial nephritis

Contributory causes of importance not related to
principal cause:

happens to be the second cause given.

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 hi ‘
Gen. Laws, Chap. 46, Sec. 9. Re a ee

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.

_..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.

resulting from injury or infection related to occupation, the

sudden deaths of persons not disabled by recognized disease,
and those of persons found dead.

2
=
a
'
3
N

3rr: INMI-AITSSTIN MEO MVE PV EIN IING

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

—————

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.

important.

tion should be carefully supplied.

No. 3385-0

50m-9-'31.

The Commonwealth of Massachusetts

= ...dorcester AE A agente ns hls Rutland oo.
=) (County) (City or town making return)
a STANDARD
os ee at CERTIFICATE OF DEATH Registered No... 2 csscccsccueee
) (City or Town)
< F z (If death occurred in a hospital or institution,
= No. Rutland..State..Sanatorium.......St., 0.0.00. Ward } give its NAME instead of street and number)
(fU.S. Sz
Se eee et: ai ROS oe Es War Veter =.
(If deceased is a married, widowed or divorced woman, give also maiden name.) specify WAR ec eaeninacsidetasi cee
(a) Residence. No..........0../ auline Sey phate aaa een aston Sie nee. Ward, ..... ' /inthrop,““ass Seen Setee
(Usual place of abode) (If nonresident, give city or town and state)
Length of residence in city or town where death occurred 2 yrs. *. mos. 6 days. How long in U. S., if of foreign birth? yrs. mos. days.

PERSONAL AND STATISTICAL PARTICULARS

Male White or Divorced Single

5a If married, widowed, or divorced

CESS Tc oS. paces OP ee OI a ce Aug.30 29
° eee ee Le: sf eo 19.2. 3tokebsDs1932....., 19
ERNE Ciiinck tires 1 GS a IIIc ce = I fast saw fh. 22O alive om.cceecsesessssse Feb. neem
(Husband's name in full) 4

6 IF STILLBORN, enter that fact here.

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

ef If less than 1 day onset were as follows:
AGE... 24 doe Aes Years ie ® ae Months... Days iis: HOUrS.....2::2.+. Minutes Date cfonset
8 Trade, profession, or particul re - 5
oF or ae Se aan Pulmonary tuberculosis | 1924
=) aE MEM RMU MERE D PTIO Soe rete a, ca, cxghasesavaaetns ovasediceatnsindvadadeuunr gbenostt>
| © Industry or business in which SSS | senvnseensnszsnnsvssvsvssssssssccecncsensennmmesesssssccecececcennenssnnansnanevsnescesteestens [ossnesnnnases
a work was done, as silk mill,
= CS OTE 2 Rs veo cca cnvectneneeettte cote or ne Spe sR SIE SSC Bg a a cam ee sani 7
&| 10 Date deceased last worked at eeu Oe HAITI: AVES) nee ll tear ena ene RS one <> ash eles ons o5a.n 8c odcaatnnnsteshasccancecaswe)casccaundasodvsees|+a2aeeee eens
this occupation (month and spent in this Contributory causes of importance not related to principal cause:
WAN) Meera Ree tonacs caesar oo doa in co ader Dede anda rae occupation.....................
ia MerueLace (Cis)... Palmyray f eetetserstessetesteeeecccesceesennnnnnnenneseecstececeeessssenssnneeanmnimtssesateeceesseneaey [oneasenannan
(State or country) New Jersey duduehWaenenanavevonne scar sopnsnsnvencesecsoadsesadeasdanaenscctdndauneecnsensdscnonuescvqcovend ssenenmscsass
13 NAME OF BE oe ES or ee re care ore see ocean ecoming Mir te =
ee Alexander XY. Davidson Name of operation a Date of
«| 14 tea ol ee i). ee eS What test confirmed diagnose ~Vay..& Lala there an autopsyN.....
- (State or country) Pennsylvania 20 Was disease or injury in any way related to occupation of deceased? NO oe
bo BECSEN pS UISCA US sy aces ac oes Voaglagn Ogre eared cos Cesta grew eeb oe vais ck sue Lacanen Sobnausteceaeroveee

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