The volume, 1933

Town Clerk, Winthrop · from the Internet Archive · 518 pages · 52.5 MB
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FORM R-301

Every itenk Gt

PHYSICIANS should state

Y, WITH UNFADING BLACK INK—THIS IS A PERMANENT RECORD.

hould be caref

CAUSE OF DEATH in pla

Exact statement of OCCUPATION

ified.

MARGIN RESERVED FOR BINDING

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

ully supplied. AGE should be stated EXACTLY.

in terms,

See ins

Pe j

EE
FEEL
‘

——. -

The Commonwealth of Massachusetts
OFFICE OF THE SECRETARY

DIVISION OF VITAL STATISTICS (City or town making return)

STANDARD
1 CERTIFICATE OF DEATH Registered Now..cccdeemscnenn
(If death occurred in a hospital or institution,
SeonrcanstM suhnestnccytoukstonaseigheounasaanGic steal sc=¥s< give its NAME instead of street and number)
oY ps J (If U. S.
2 FULL NAME .(....64tQcs War Veteran,
(If feceased i is” specily, WAR): «:2:.::iscsasseoneeseossotnnenal .
Ren Ng oN LN EN iene eecc csc SDE eg nd dosvsnenscos, WAM). scccssocsscovecconecessncvecenssvaducocsesenisebssnvsessscesse cormete
(Usual place of abode) (If nonresident, give city or town and state)
Length of residence in city or town where death occurred yrs. mos. days. How long in U. S., if of foreign birth? yrs. mos, days.

PERSONAL AND STATISTICAL PARTICULARS

5 SINGLE (write the word)
or 4 COLOR OR RACE MARRIED 2
4 WIDOWED oa
gontate Vk or DIVORCED, ;
5a If married, widowed, or divorced
NM UININN TNMs a a rescence i reno ac wautectizesigce aan checccndvedeeeeassgesctabisassbosn catinenchsneecs
( o ¥ (Give Panidentaae fwiféin full) | frterenstPRT ease see eceeseeneenecneeneensp LQ GAD ce ooscc dle Tincesteaneerceedasnnassatensensey pk] 3.2

af. 2.<;death is said

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

uf wee
AGE... B At fies Nh] eubeecert Arg Months...2~2 Days

| 8 Trade, profession, or particular
kind of work done, as spinner,
sawyer, bookkeeper, etc..................
9 Industry or business in which |
work was eons as silk mill, {
saw mill, bank,
10 Date deceased ee worked at
this occupation (ech and
year)...

12 BIRTHPLACE Oe (AO.
(State or sist

13 NAME OF /
FATHER

to have occurred on the date stated above’ af: 430 fe im

The principal cause of death and related causes of import
‘! ance
onset were as follows: r

in_order of

If less than 1 day Date of Onset

11 Total time (years)

spent in this”
occupation... F ee a

OCCUPATION.

14 BIRTHPLACE OF

rs FATHER (City) ............ iis OE Ae Se ony ee opsy?..AAs
Z| (State or country) Z ___ |] 20 Was disease or igpiry fy_any way related to occupation of deceased?...A--5......
= J =
= If so, specify... fy : : es
< (Signed) .. A-ha oe
a P
16 BIRTH oe ; = iA (Address)...
gs Se ae 21 PLACE OF BURIAL,
(State or country) CREMATION OR REMOVAL . Kid as
7, — Ws “ (Cemetery) (City or town)
WO | ; DATE OF BURIAL... 2422 nee A coc Bi Becsrvsssnsnvn 19....
vies oma EF ADIG ae! oS ees a. io, Ce Oe OR eS aS
22 NAME OF
UNDERTAKER =<... 7s; pcanad dh Ui frie.
REBY CERTIFY that a satisfactory standard certificate of death was
fl d a me eB ry burial or/transit permit was issued: appress../..6.. . 42. Rae acd. et) Aare ee
aeeee ol ped eA EL Ba es ccecceceverareaaccvesscacecceccsscce . . er , . ~~
ignature: of Agent of A ° aith or other Received and FADO. ...eeesereeeesseeeecerenesnneretscerreesb fale DB ceacatter i as oe 1: eae
Mat dd. pS oS a eA Loo WO MEPENRE oy NC tr oo
hg Designation if) i (Date of Issue of Permit. A TRUE COPY, ATTEST: (Registrar)

Revised United States Standard Certificate of Death

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

To be complete, an occupation return must state:

8.—The trade, profession, or particular kind of work done.

9.—The industry or business in which the work was done.
10.—The month and year the deceased last worked at the occupation.
11.—The number of years the deceased followed the occupation.

In stating the occupation, avoid the use of such indefinite 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
en 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 whelesale 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, é. 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

July 5, 1927

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 eause 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 LA
COMMONWEALTH OF MASSACHUSETTS
GOVERNING THE

RETURN OF CERTIFICATES OF DEATH

a
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.

erson died; and no undertaker or other person shall exhume a human

ody and remove it from a town, from one cerietery 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 ‘ror 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 reaiured 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 py law. or in lieu thereof a certificate
as hereinafter provided. Ir there is no attending physician, or if, for
sufficient reasons, his certificate cannot be obtained early enough
for the pErpote: or is insufficient, a physician who is a member of the
board of health, or employed Ld it or by the selectmen for the purpose,
shall upon application maive the certificate required of the attending
physician. If death is caused by violence, the medical examiner shall
make such certificate. If sucha permit for the removal of a human body,
not previously interred, trom one town to another within the common-
wealth cannot be obtained early enough for the purpose, the certificate
of death made as above provided and in the possession of the undertaker
desiring to make such removal shall constitute a permit for such re-
moval; provided, that such body shall be returned to the town from’,
which it was removed within thirty-six hours after such removal, unless
a permit in the usual form for the removal of such body has been sooner |
obtained hereunder. If the death certificate contains a recital, as re-
quired by section ten of chapter forty-six, that the deceased served in |
the army, navy or marine cone of the United States in any war in
which it has been engaged, such recital shall appear upon the permit.
The board of health, or its agent, upon receipt of such statement and
certificate, shall forthwith 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 ba
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 by Chap. 48, Acts of 1927 and Chap. 414, Acts of 1931.

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 shallin all cases certify to the town clerk or registrar in the
place where the deceased died his name and residence, if known;
otherwise a description as full as may be, with the cause and manner
of death.—Gen. Laws, Chap. 38, Sec. 7.

No undertaker or other person shall bury a human body or the
ashes thereof which have been brought into ‘the commonwealth until
he has received a permit so to do from the board of health or its agent
appointed to issue such permits, or if there is no such board, from
the clerk of the town where the body is to be buried or the funeral
is to be held, or from a person appointed to have the care of the ceme-
tery or burial ground in which the interment is made....Chap. 114,
Sec. 46, G. L. as amended.

RULES OF PRACTICE

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

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

(2) Board of Health physicians will certify to such deaths only
as those of persons who, though disabled by recognized disease un-
related to any form of injury, have died without recent medical attend-
ance or whose physician is absent from home when the certificate of
death is needed. ; ;

(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 resultin 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.

pus

The Commonwealth of Massachusetts

ORM R-301 = ib OFGIGE OF THE SECRETARY —— —ossscisseesecsssaletaviivcssaeee
we on < (County) Peszanresstasersers tpn i ze; DIVISION OF VITAL STATISTICS (City or town making return)
° 30 a fe STANDARD
oe 14 5 Mele ie Se CERTIFICATE OF DEATH Registered No........ 8. cdecartuel .
~o< ta tei or Town)
aa < Ys ats (If death occurred in a hospital or institution,
B20 a No. 2.2: give its NAME instead of street and number)
2 E
“ (If U.S.
ind
2 FULL NAM War Veteran,
gee specily WHAM) iin. 5sscGhevns ccsoncsteceteeneaene
»

OE (a) Residence. < Weare. o.so5 ei oecsaates cee conaszettaaconsis oeveadttvensaces ae eee
On £ (Usual place of sbode) (If nonresident, give city or town and state)
Be ° s Length of residence in city or town where death ey, yrs. mos. days. How long in U. S., if of foreign birth? yrs. mos, days.

a ee
io]
z s & PERSONAL AND STATISTICAL PARTICULARS
ee) 5 SINGLE write the word)
F.. $y 3 SEX 4 COLOR OR RACE ye ae —7
At Mi | Aw oe |
ry - 2 y 7 (f or f 7 ZL “4
a3 Me 2 If married, be pies or 2 diverted fame ce
B) HUSBAND of <A ALAM E MR habe cb LA ta Ao -
Ps 3 3 (Give piniten name of wife in n full)
4 Be (or) WIFE of ....-..2-essessse Peer ery ge igen | VRORE $M Redan HIVE. OR rnnnnnnnnnnnni
usDand s name in fu PY ad
ra) <35 . f to‘have occurred on the date stated above, alah Low
Zz ng $ 6 IF STILLBORN, enter that fact here. aie wee cael) Geics) ck Mane: Grated ek F
< e and related causes of importance in order of
re Os 7 : ; If less than 1 day onset were as follows: Raia
o = a 4 5 Ms : Bate of Onset
ae 3 s AGE...... Le rfaee Aone cee Years.....£....... Months -<.4-—Days | ............ Hours........-.-. Minutes
° Feng ge | 8 Trade, profession, or particular ede Saeed
a 13 £ oa kind of work done, “4 spinner, {yp y ge a | aE i tree eee A, otf EM bey rer, Beer
° o sawyer, bookkeeper, CIC.............0-.....2050...0000d avs LanatenTiphunnnacsressnaghd Ratu eams rin teannnvae nes
W Mess | 9 Industry or business in_which tew...198 2
- » a a work was done, as silk mill, “ap Z ot

hl] £ ¥ 2 saw mill, bank, €tC......0-....0000.004-. OE 2 ce Sk oR SE Maen IRS ma MS a i ea al air ce ae eg
sy 4 8 S| 10 Date deceased last worked at UPL AORARRTIR MCI Sia oc SWE ater ravperane cen:ze fPrcdcs astganecstarnnc-tgchester suahcsdiveertocstae ovo Sacuoct cass ee LI ee

ma this occupation (month ba spent in this_.

; < 4 “ 4 year) .......... FE a A fo NS ee occupation..«;-.= Nich :

ZS Sz || 12 pirtupiace (city) A terra See pr nt ie tan lata ee ge pesos
ant 9 Cc) (State or country) Z ene Maar TIME RN We MEER Gy PL cxtoeca stu spSaacnctps bh feud -cntias ed avant scstectea ti sevsitcacfidee.cscevop ah vee ee Ge ee PRL

ee. ; Bie

Atdsé& at Sc CAP LMA Ng MN Bs UN cape civeate ns ccee es oct chy bape atosacvbc boas dcdbscdinbshinnsdenenbstteoms Mo bers oes eisciardened| nota

S eas FATHER “) ,

2s 5 . = [iy (Natte otoperation®..,.sosetc. Qe tt. net. ee >Date Ofer onan fam

3+ 2 alae PATER (Cites : Ah hed on What test confirmed diagnosis? Koa ..Was there an autopsy?“ ©...

ee | FATHER (City) .......... lo. MG aay a a
= i] Z| (State or country) Ue R

' — Ww ——

‘Baed c/o omen | nat toy

- - a . i ‘s 4

, Pao] i 4

. 16 BIRTHPLACE OF 2s Ln AT je
er MOTHER (City) ab ticpepeids, 22 ee 7,
piss ey ff 21 PLACE OF BURIAL, : |

Z: ecu (State or country) 4 ae CREMATION OR REMOVAL tla me Cosi Zs Bing heen ore

f par - eme ery ity or town
= o if

. aE e % (ee DLL: DATE OF BURIAL LE NN MEME Me OD oe ET bere

= a eee “4. pase > 7 — Co

E eas 4 ey aA) 2? UNDERTAKER Ms Z

n eee) CSC CUUNDERTAKER 44a SOONG invnefvch doce Mcatkarsvevafota Cae iad sencansarnstnghsstigehcecy
= om © | HEREBY ela sgt a satisfactory standard certificate of death was ie y oe
Bag? - bay a heparial or transit permit was issued: ADDRESS. 7). 6. a Need CML Covina even ve eh MRE ove LEON, 7,

£62 < Af, OA d-
| ae i ible, BY ee yeas KALE je ee ee eae , JAN.6..80
es B (Signature f Agent of Boar alth or oP, BC RRVEM) ANIC HCCI 55, Nae asccadecavsndtaactercsssssessénvcaccustee wJ/+ Yo Gen F29Q.-19 frostee
S ii : ft, ba 7] 2 ——— oe
e 2) | | BEA ae foc etenseccetstan seaghefecbodgecces Siete ne oo. wah suena Sonanaaucancs waked picamanutcne : Seduntt tetsedus vines aesbe<con sedans abardesunsdnseesda Guach besGeehedesepensuueessedeencannsaasansentsdaShaessGueneesee
z J | (Date of tasie ot Beratit) A TRUE COPY, ATTEST: Gepiatrat)

= bon Za wd
Revised United States Standard Certificate of Death

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

To be complete, an occupation return must state:

8.— The trade, profession, or particular kind of work done.

9.—The industry or business in which the work was done.
10.—The month and year the deceased last worked at the occupation.
11.—The number of years the deceased followed the occupation.

In stating the occupation, avoid the use of such indefinite 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
oy of store, factory, mill, etc., as grocery store, soap factory, cotion
mill, etc.

Distinguish carefully the different kinds of engineers by stating
the full descriptive titles, as civil engineer, mechanica! 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:

Raat

Date of onset

Chronic interstitial nephritis

Cerebral hemorrhage

Thea Re hae

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 T = LAWS —
COMMONWEALTH OF MASSACHUSETTS
GOVERNING THE

RETURN OF CERTIFICATES OF DEATH

oe ag
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 cerietery 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 irova the board of health

is buried. No such permit shall be issued until there shall have been
delivered to such board, agent or clerk, as the case my 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 jaw, or in lieu thereof a certificate
as hereinafter provided. 1x there is no attending physician, or if, for
sufficient reasons, his certificate cannot be obtained early enough
for the purpose, or is ins.fficient, a physician who is a member of the
board of health, or employed py it or by the selectmen for the purpose,
shall upon application make the certificate required of the attendin
physician. If death is caused by violence, the medical examiner shall
make such certificate. If such a permit for the removal of a human body,
not previous, interred, trom one town to another within the common-
wealth cannot be obtained early enough for the purpose, the certificate
of death made as above provided and in the possession of the undertaker
desiring to make such removal shall constitute a permit for such re-
moval; provided, that such body shall be returned to the town from
which it was removed within thirty-six hours after such removal, unless
a permit in the usual form for the removal of such body has been sooner
obtained hereunder. If the death certificate contains a recital, as re-
quired by section ten of chapter forty-six, that the deceased served in
the army, navy or marine corps of the United States in any war in
which it has been engaged, such recital shall appear upon the permit.
The board of health, or its agent, upon receipt of such statement and
certificate, shall forthwith 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 by Chap. 48, Acts of 1927 and Chap, 414, Acts of 1931.

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, Chad. 38, Sec. 7.

No undertaker or other person shall bury a human body or the
ashes thereof which have been brought into the commonwealth until
he has received a permit so to do from the board of health or its agent
appointed to issue such permits, or if there is no such board, from
the clerk of the town where the body is to be buried or the funeral
is to be held, or from a person appointed to have the care of the ceme-
tery or burial ground in which the interment is made....Chap. 114,
Sec. 46, G. L. as amended.

RULES OF PRACTICE

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

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

(3) Medical Examiners will investigate and certify to all deaths
supposably due to injury. These include not only deaths caused
directly or indirectly by traumatism (including resulting septicemia)
and by the action of chemical (drugs or poisons), thermal, or electrical
agents, and deaths following abortion, but also deaths from disease
resulting from injury or infection related to occupation, the
sudden deaths of persons not disabled by recognized disease,
and those of persons found dead.

met feu /— 3/— 33 ‘
The Commonwealth of Massachusetta To be filed for burial permit

‘ORM R-301A OFFICE OF THE SECRETARY with Board of Health
a DIVISION OF VITAL STATISTICS or its Agent.
525 STANDARD
g ta CERTIFICATE OF DEATH Registered No... Swi.
< .
=3o (If death occurred in a hospital or institution,
p30 give its NAME instead of street and number)
bn8 (It U. S.
War Veteran
ng *
; ga 9 , SOC GWM) eo cvnch onteat hesvenasiassicae cae
wOs (a) Residence. No........... LALk PLA
)) Sa £ é (Usual place of abode) (If nonresident, give ‘city or town and state)
; Es 8 s 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.
as 8 PERS@! AL AND STATISTICAL PARTICULARS MEDICAL CERTIFICATE OF DEATH
.: 8= ti yak As OR/OR 5 ee Pi the word) 18 DATE OF
o
8 ra) WIDOWED © CePPeer erie, 6 ieee, eerie itt os oat TELL ee
Ant Be VA TRA 3 or DIVORCED~ y
454 ——— widowed, or divorced — ‘ I HEREBY CERTIFY} That! attended deceased from
| ORME fan wars sane date Recs cuss conc se aaaaas on wan cies suscapnca cabateunahe > Mauneas Gevaneasesneesduvac’
g i} es (Give maiden name of wife in full) Y , ’ 19.0...
a INET ec oc scan nn Baca ams eo URN cei oaawaareinn snag nae nde Tecweas ods aedessenensnenlte) 2 i 77 is sai
: ral <3 E § (Husband’s name in full) ¢ V/ ¢ pet
( tml - = .
ns 3 2 6 IF STILLBORN, enter that fact here lath éa FL to a occurred on the date stated above, at.........2.......... m.
ngs ae € principal cause of death and related causes of importance in order of
| i = 7 If less than 1 day onset were as follows; minal qual
ig = 3 Bg BRE So citsdescsvsdtasorosvs WBA ES) s.csc200c0-7 Months............ DayS)}))-:e0:c20:en: Hours........... Minutes y : Smear
) ° escccveseses
Fz Be l 8 bia person, or particular ee ee ee ee ao eG FE ee
= 2 SUPRATRSS MUM ENT FROORERNT ES tor SESE R ce Ny eer IR RRN cern ae HEDS SRMBNOEUE hn oxny ecb crceeeccv¥asctesWiensSuranrWcaseccettupensqvenssivnesesnn sll se .cc¥enssnacssaretelschensvansssaahs
I 2 3 9 5 sawyer, bookkeeper, etc. Tela er cottor toner crt ote te aonecortacesttei! Aor eee (| i nn, ae |e in meee
i s oy =| 9 Industry or business in which P=
! at o2 = ea hg aye as silk mill, Ee,
lo 3] 3 saw E BRE ere teehee cere Mec entree Pceg ast Seeteecc cree Pe PE MRD, ph eager ope unerbtracngnpseneegsvavaacenteincnsesaeeecnsdaavarncasceonwaasl cage sdeyseeusentes oa
49 & S &| 10 Date deceased last worked at 11 Total time (years)
om 4 this occupation (month and — / SEITLETENIS See NS eter meee eae Beak Ra a ee ee t,t aie
I. | 226 See ee Be SRS im occupation... ......
= Sse 12 BIRTHPLACE (City)..... PA <tB ja = VY Ss Sy
oO M4 a 9 oS (State or conahy) Of BE Rr ct Nt he a ieee eats ee a ae 4
Z “4 x See
> E 3 = A Vig sPt€, Name of operalion.......... Cie Or Date of... oer Cf, Tae
i 3 3 be 14 BIRTHPLAC OF What test ae ree ee alien 12) Of... Bede ae
7 me) ~ FATHER (Citys ....... @LANDEUS* LL. i st confirmed diagnosis - .-Was there an autopsy? =
ick: = (State or courtry) 20 Was i or injury in any way related to occupation of Secdissat ess pn
Ben | 15 MAIDFN NAME — /
B85 <| OF MOTHER ( 4
. = \ j
Sse a 16 BIRTHPLACE OF y ei (Address)... oT 6 <<
iets MOTHER (City) ...........< htt : =
q 2a an ; t 21 PLACE OF BURIAL, tus) 4 A)
wg ate or country) CREMATION OR tons f Vp Ab acs Nn AP COED L1G
4c S - f ome (City or town)
7 sk A en) Ao hy, Lag & id CY, (Ad A DATE OF BURIAL... SAB onc KD fovressisstiesessssssssssscitsonsaneine Se
L a 2 (Address) Sy Le , a 4a 22 NAME OF tmx d 4
BEaP ae ee ee UNDERTAKER . |. :
o~ ¢ s 1 EREBY CERTIFY Eth * Sotist or tr standard certificate of death was
/ 26 @ S filed. with me per burial or transit permit was issued: ADDRESS... f.4..
Jom
| Pec. 5 LIE SNOT EES, oat a Si a
iM — 9 i], ignature ie of Boatd of Health or Cte 7 wee Received and filed ...
4 ;
. ed ON A he Tee wee Ler) napa anfecrarens ers cs reseed Le nwwewer cera ranean reme ee ee eee tee se eeeee eae seeneeeees Pi
z bebech Designation, i i/ (Date of Issue of 4 it), (Registrar)

Revised United States Standard Certificate of Death

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

To be complete, an occupation return must state:

8.—The trade, profession, or particular kind of work done.

9,—The industry or business in which the work was done.
10.—The month and year the deceased last worked at the occupation.
11.—The number of years the deceased followed the occupation.

In stating the occupation, avoid the use of such indefinite 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
ay of store, factory, mill, etc., as grocery store, soap factory, cotton
mill, etc.

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

Statement of cause of death.—Cause of death means the disease,
or complication which causes death, not the mode of dying, ¢. &-, 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

——_———

Date of onset

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

Arteriosclerosis

Chronic interstitial nephriti

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 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 anotherin the
same cemetery, until he has received a permit irom 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 purports 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 a plication make the certificate required of the attending
physician. If death is caused by violence, the medical examiner shall
make such certificate. If stitha permit for the removal of a human body,
not previously interred, trom one town to another within the common-
wealth cannot be obtained early enough for the purpose, the certificate
of death made as above provided and in the possession of the undertaker
desiring to make such removal shall constitute a permit for such re-
moval; provided, that such body shall be returned to the town from
which it was removed within thirty-six hours after such removal, unless
a permit in the usual form for the removal of such body has been sooner
obtained hereunder. If the death certificate contains a recital, as re- |
quired 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 wpon the permit.
The board of health, or its agent, upon receipt of such statement and
certificate, shall forthwith countersign jt 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 by Chap. 48, Acts of 1927 and Chap. 414, Acts of 1931.

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 shallin 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.

oS ae

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.

FORM R-301

MARGIN RESERVED FOR BINDING

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

‘Every item of

PHYSICIANS should state
Exact statement of OCCUPATION

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

terms, so that it may be properly classified.

in
See ins

tant.

information should be carefully supplied.

CAUSE OF DEATH in pla

is very impor

No. 7180-a

200'M-11-'29.

S&S The Commonmeslth of Massachusetts
= OFFICE OF THE SECRETARY

DIVISION OF VITAL STATISTICS errr tert eee pent tet eee tt
(City or town making return)
STANDARD j
CERTIFICATE OCF DEATH Registered No...... 74

Septet eeeeeeeeeeseee

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

(If U.S.
Peas es dasha cee aneasactarnge Fae War Veteran,

opecety WAR) «5. 0.o:ioccsciass.0cscses-caaneseee

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

PERSONAL AND STATISTICAL PARTICULARS
3 SEX | 4-COLOR OR RACE | 5 SINGLE Kester word)

Say ere

; MARRIED , 18 DATE OF

lf cte WIDOWED W. YO en ee
or DIVORCED

5a If married, widowed, or divorced

19
HUSBAND of 2.0.0.0. 0 sie peep eres Bea V9 19 Vrc
(or) WIFE of .......L. ;

| Past saw het p...alive on........ oar... fg. 19.9.9. death is said
to Ree CS on the date stated above, aiff FOL.m.

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

/ CHasbon oe eaters seeder ea cnneeeeeste nie eae neat 2st

, enter that fact here.

8 IF STILLBO

nce. OG
AGE......@.@........ Years O ene Months...@..... Days

8 Trade, profession, or particular
kind of work done, as spinner,
BRWSEL, DOOKREEDETS OlGcc..0.-scccsccltse erates: cose cevovercovnnnaneeasst Petco PIR sccasnasuonssnasanenseus

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

| saw mill, bank, etc................:0000- 200% ee AM ease ans me ok wae sizzanesevavevaieed

10 Date deceased last worked at 11 Total time (years)
this occupati (month and 30 spent e this
wf JD O.,.... occupation....................

If less than 1 day

OCCUPATION)

Contributory causes of importance not related to principal cause:

ore eee eee er eee ee eee eer r reir eer eee rere rr Stee rere rere ere e eee ee eer eres Pier rrr tr irre

Name of operation? ees ee Oe So et ee Date of... 3 lf.
2 | 14 ACE OF a ; What test confirmed diagnosis w@-Was there an autopsy? fy J
z= (State or country) 20 Was disease or injury in any way related to occupation of deceased?.49.@......
lu a 5
c«|15 MAIDEN NAME If so, Specify....gp.....--..00 f be Sarees
< OF MOTHER (Signed) ¢-p.: RE < ae
5 i
- (Address). : . ae
21 PLACE OF BURIAL, ;
CREMATION OR REMOVAL pa, toc co
sa . - : : (Cemetery)
Ls ( (Fy ae obj DATE OF BURIAL. JG Jeo ccccccecnspaceve es eee
Informant ....\*~-¥... ne SL, “CN. See ee W, ee ae
(Address) ‘D4 Z yd cthhAegg 22 NAME OF
/ —— SSS SS UNDERTAKER

| HEREBY CERTIFY, that a saiisfactory standard certificate of death was
filed with me BEF he burial or tran cotter . eee

i r WA 3 rere auvensanws poeaqsenyr ;

(Registrar)

Revised United States Standard Certificate of Death

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

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
Eee ee 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 relail merchants
and wholesale merchants. A person who sells goods should be called a
salesman and not a clerk.

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

Example

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

Arteri:

Date of onset

Cerebral hemorrhage ‘ SS

Contributory causes of importance not related to
principal cause:
Fracture of arm

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

EXTRACTS
FROM THE LAWS OF THE
COMMONWEALTH OF MASSACHUSETTS
GOVERNING THE

RETURN OF CERTIFICATES OF DEATH

A physician or registered hospital medical officer shall forth-
with, after the death of a person whom he has attended during
his last illness, at the request of an undertaker or otber
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 aim remove it from a town, fronr oe cerietery tO anotiier, 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 attend
physician. If death is caused by violence, the medical examiner sha
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
chal thereaiber 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.

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

State cause for which surgical operation was undertaken.

Bronchopneumonia: If primary cause, write the word
“‘primary”’; if secondary, give primary cause.

Certificates will be returned for additional information which
give any of the following diseases, without explanation, as the
sole cause of death: Abortion, cellulitis, childbirth, convulsions,
hemorrhage, gangrene, gastritis, erysipelas, meningitis, mis-

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

— |"
The Commonwealth of Massachusetts To be filed for burial permit

SRM R-301A S uffolk pass= OFFICE OF THE SECRETARY with Board of Health
Se e E weeeeeeee .' ~ (County) Pret eee . DIVISION OF VITAL. STATISTICS or its Agent.
3 26 ‘ STANDARD
* a moe. Winthrop... CERTIFICATE OF DEATH Registered Noi... 20s) ae
Suo< = (City or Town)
22 (If death occurred in a hospital or institution,
> a5 a No.............99., Hormon Rddde hecaSctdazccsdocvausancrvagpecnicnscuded ee = Ward give its NAME instead of street and number)
ot
> 20 (If U. S.
ak I es | SD 2 ee {We Veteran,
gz ° (If deceased is a married, widowed or divorced woman, give also maiden name.) pacity WAM) 2h sscsseonnccdenusscensseysccousnee tet
OE (a) Residence. No.......... 9 2... Hermon oP Ee Occ EEE SURGE a eee Wards, 55ers has Be iets: eee
OF E . (Usual place of abode) (If nonresident, give city or town and state)
ra 3 2 Length of residence in city or town where death eccarsd-O yrs. mos. days. How long in U. S., if of foreign birth? yrs. mos, days.
mass PERSONAL AND STATISTICAL PARTICULARS MEDICAL CERTIFICATE OF DEATH
B.. BF 3 SEX 4 COLOR OR RACE | © MARRIED (write the word) || 18 DATE OF
Zeue Male white or Divorcep MAaTYied
a. 5a If married, widgyed, or di a j 19
S332 ||nsaws. ey Josephine Sawyer oo.
tj s (Give maiden name of wifeinfull) ft
8 TS Ea cone ie CR UES eh eae arenes I ast
<3 a 6 (Husband's name in full) 3 P
on 3° fs 6 IF STILLBORN, enter that fact here. to have occurred on the date stated above, at=....".. SelM :
me z hg principal Grom of death and related causes of importance in order of
tie £5 mt T If less than 1 day onset were as follows: Date of Onset
: =e: £ 2 AGE........ 6 9 eee WGarS!.......2..... Months............ Days | .......-.-.- HOUWES.c5-:-:- Minutes IMPORTANT
BD 5 8 LS ee peer, or particular
: = ind of work done, as spi ;
PwES6 |S] mers tatines, de Ont, Of fteer
=| 9 Industry or business in which : "Ts
zZ ‘a > e Pa work was done, as silk mill, ( Retired ) Winthr op
ya £% = MMR METRLD ARRAN TIES Ls canes iets as ee ccs <p alse cnturcs cock fib veecs actu vhansrscppazdenscaed sactcasaseees
) bg ‘ § 6/10 ae eoeencd y eee = 11 Total time (pars)
= is occupation (month an spent in this
< Pr) 3 year) ...... AE eae occupation. Pe 20 anise
AG Ey Wob
es 2 12 BIRTHPLACE (City)... 8 OUT ec cccsescsntnenee 2 me
Sag (State orcountry) Massachusetts
7) 2 ag 13 NAME OF Gl i ena 2
= > Es ican bum hre Hrench Name of operation hw Date of :
sencosovaussee events gitus cwoaevauush éoncsavdends nuh nevesen OT. ....cccccccccscsccccsccssesses-==
23 . 5 w| 14 Tat cite Bedford What test confirmed diagnosis? Mdaamm.[iaaa<adeWas there an sutopsy?.6
| FATHER (City) .... a a aR a cock ctuonace
x83 & z (State or country) NV ow Hampshire
Bro ||ce|15 MAIDEN NAME ; nie snectty'e-
S85 <| OF MOTHER Susan Laton (Signed)...
) "3 “ MOTHER (City) ......... WOOUE. “let LIES See ae EP eg aaa
pes < (State or country) Massachusetts CREMATION OR REMOVAL
Pia) r) (Cemetery) (City or town)
S58 g DATE OF BURIAL JaNnUary..7.........
6 e 22, NAME OF B ;
BEG Ps UNDERTAKER ......... Charles R. Bennison
s2s . appress.....inthrop, Mass
4 F , 4 ale
i E Received and filad...........ecccssssesscsesssesesseene ay \\ aes AG Od ie eel he 1D tea.
z eI a EESTI 6 SCT 7 OA CE Il it bahebalatalaler ay Sed “Cy etedcalch itehdaiidalatahatalaadl |) (ath eet (i, Sh gS aes: icaemennaraamra emmy ocesmeoe so

Statement of occupation.—Precise statement of occupation is
very important, so that the relative healthfulness of various pursuits
can be known. Make some entry in this section for every person
aged 10 years or over. 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—privale
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
ne 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.

Example

——_————-_

The principal cause of death and related causes|” Pate of onset

of importance in order of onset were as follows:

seevensecsonees aavvcccdhscbapatbececescisbccconcescomanccsshoansshesso| e

Chronic interstitial nephritis

ro2t

uly 5, 1927

Cerebral hemorrhage

Contributory causes of importance not related to
principal cause:

adeeneeecescencnseasenenseness

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 1n 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 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 such a permit for the removal of a human body,
not previously interred from one town to another within the common-
wealth cannot be obtained early enough for the purpose, the certificate
of death made as above provided and in the possession of the undertaker
desiring to make such removal shall constitute a permit for such re-
moval; provided, that such body shall be returned to the town from
which it was removed within thirty-six hours after such removal, unless
a permit in the usual form for the removal of such body has been sooner
obtained hereunder. If the death certificate contains a recital, as re-
quired by section ten of chapter forty-six, that the deceased served in
the army, navy or marine corps of the United States in any war in
which it has been engaged, such recital shall appear upon the permit.
The board of health, or its agent, upon receipt of such statement and
certificate, shall forthwith 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, Fae OPE
as amended by Chap. 48, Acls of 1927 and Chap. 414, Acts of 1931.

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.

the clerk of the town where the body is to be buried or the funeral
is to be held, or from a person appointed to have the care of the-ceme-
tery or burial ground in which the interment is made....Chap. 114,

Sec. 46, G. L. as amended.

RULES OF PRACTICE

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

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

(3) Medical Examiners will investigate and certify to all deaths
supposably due to injury. These include not only deaths caused
directly or indirectly by traumatism (including resulting septicemia),
and by the action of chemical (drugs or poisons), thermal, or electrical
agents, and deaths following abortion, but also deaths from disease
resulting from injury or infection related to occupation, the
sudden deaths of persons not disabled by recognized disease,
and those of persons found dead.

GO entO aol /— 9/9 G

The Commonwealth of Massachusetts To be filed for burial permit

IRM R-301A x Be
=... ouffolk | ras vorurries qh Boe ae
a = ei DIVISION OF VITAL STATISTICS :
“ 8Z is or its Agent.
gis a Wint hrop X= STANDARD
ny A SR ce eat — AS i yp
Sic 8 ees eee CERTIFICATE OCF DEATH Registered No....... A te
sy = : : PrN) ote
pee 5 noWiinthrop..vommunity. Hospiteke, oo. Weed | leh cs WHITE tated of taeet ack coated
o er
>e
Bnd
ne 2 FULL NAME... Jessie..Catherine..(Garmen). Ennis... War Vera
a< ie (If deceased is a married, widowed or divorced woman, give also maiden name.) | enero specify WAR) Bs nana tre
ROE (a) Residence. No.........: 55). Hast State St St Ward, Lrenton, NJ
om : eee ea te Saute as cevveys ard, mag eT Be te hi f corey # Wipesan ane ‘ eacs hanya
ae : ‘ Length of residence in city or town where death occurred yrs. mos. 16 days. How long in U. S., if of foreign birth? Pi % ee iz sm
on PERSONAL AND STATISTICAL PARTICULARS - MEDICAL CERTIFICATE OF DEATH
.. St 3 SEX 4 COLOR OR RACE | © SINGLE | (write the word) || 18 DATE OF %
Aste emale W hite wor W idowed Selves her. (Month) Juisauaneedddcanene pizav asp £. Pangduwuste ri , 33 veapueenpreden
sv oa) 5a If married, widowed, or divorced 19
ae 3 aie demlpaaaa ll I HEREBY =i ag ee That | attended deceased from
wpe 8 (Give majden ngme of wife in full) i ir. om 40 Ln Jase een ln, ad paPensavers aes 19 t 7 97.3
u's (or) WIFE » Will dam “Bdw : . 193 to... puamerny fo. 1973.
<32 g r of .....3 ae win. ann ! w...alive on... aaaeetrthy ’ 1922.3, death is said
a 5 Ss 6 IF STILLBORN, enter that fact here. pes occurred on the dafé stated above, at pme ¢...mM.
> incipal i i
ns >i = ca aie a as aoe ae + death and related causes of importance in order of
z 8 2 Cl Ce Months............ Days | ........... Hours..........-- Minutes gathers
: e tp af: 8 a, or particular
work done, i
¥ £3 ° 5 sawyer, Sikleaa te Musi ¢.. teacher Ah eee
Zaye | 9 Industry or business in which
ee Sa (Retired)
¥OER 3 : < TLE SRS pr aR ES ae aS
Ozu 5 6| 10 Pee ceenased last worked at 11 Total time (years)
7 t t i i
a. 2% ee POC e 1990 Seuston. 22...
ois :
ss 12 BIRTHPLACE (City)... OAV EOS og cc cescsecssssesereee
oe 9 : (State or country) z eons y. Vtania i...
Qe2s || | Bike" Jonas Garman
Q 8 ieee
> O
Zsy 7A RINTEPLACE OF Name of operation os f.. AAA... f.
23 = 5 a FATHER (City)... Snyder County ie' as What test confirmed diagnosis FE. Was th an autopsf?...7
Ee £ = (State or country) Pp enns lvan ia
[7
115 MAIDEN MAME cw re —i—i(C*C@diYC:*CE Se, SOC sn nnnncnennnenncneeennnegpnnnnsnncgpenge
+ BW cern vit | Be eee ee
a" =e 4 co IO I, Or Sore in <a a
) efor MOTHER (City) Millersburg: ——$ thee tat
21 PLACE OF B
sue (State or country) Pennsylvania - CREMATION OR REMovaL DOWLing Gi
20 5 Ale (Capote Se re tne
abe § ..-Bhanche. 2, 0sGrabem,, J) eee cred Lor ee: et: Oe oe eee 19.50.
Sot || Address) ast state renton NV. ' i
a 22. NAME OF a
REM P 2 UNDERTAKER... CHATLES RK. Bennison
s2 a 1 HEREBY CERTIFY that a satisfactory standard certificate of death was launthron. if flacg A ee oan eee
g rt} 2s filed with = BEFORE the burial or transit permit was issued: __appress. WANE RTOD, MASS cum
3 NESS SB. : *
E (Signature - Agent of Bo;
os Wea2th TS OSL Ar. Of, OVALE QAn..... [2 ed /,
Zz (Official Designatio Date of ane poe
(Registrar)

a e OO

Revised United States Standard Certificate of Death

Statement of occupation.—Precise statement of occupation is
very important, so that the relative healthfulness of various pursuits
can be known. Make some entry in this section for every person
aged 10 years or over. If the occupation had been given up or changed
on account of the disease geusing death, report the occupation prior
to illness. If the deceased ha 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
‘a answer to Question 8 and own home in answer to Question 9.
For a person engaged in domestic service for wages, however, designate
the occupation by the appropriate terms, as housekeeper—private
family, cook—hotel, etc. For a person who had no occupation what-
ever write none.

To be complete, an occupation return must state:

8.—The trade, profession, or particular kind of work done.

9,—The industry or business in which the work was done.
10,—The month and year the deceased last worked at the occupation.
11.—The number of years the deceased followed the occupation.

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

In stating the industry or business, avoid the use of such general
terms as “store,” “‘factory,”’ “mill,” etc. State the particular
ad 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, ¢. 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:

Arlteriosclerosis

Chronic interstitial nephritis

Cerebral hemorrhage

rors

r92r

July 5, 1927

ga creeceenseccenserccssenenasnsasseneees pocdecndecuccaneecctascacuscunssésee|sacscudvesccgsonccsuccasns

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

hanvens 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.

ody and remove it from a town, from one cemetery to another, or
from one grave or tomb other than the receiving tomb to another in the
same cemetery, until he has received a permit from the board of health
or its agent aforesaid or from the clerk of the town where the body
is buried. No such permit shall be issued until there shall have been
delivered to such board, agent or clerk, as the case may be, a Satis-
factory written statement containing the facts required by law to
be returned and recorded, which shall be accompanied, in case of an
original interment, by a Satisfactory certificate of the attending
physician, if any, as required by law, or in lieu thereof a certificate
as hereinafter provided. If there is no attending physician, or if, for
sufficient reasons, his certificate cannot be obtained early enough
for the Purpose, or is insufficient, a physician who is a member of the
board of health, or employed by it or by the selectmen for the purpose,
shall upon application make the certificate required of the attending
physician. If death is caused by violence, the medical examiner shall
make such certificate. If such a permit for the removal of a human body,
not previously interred from one town to another within the common-
wealth cannot be obtained early enough for the purpose, the certificate
of death made as above provided and in the possession of the undertaker
desiring to make such removal shall constitute a permit for such re-
moval; provided, that such body shall be returned to the town from
which it was removed within thirty-six hours after such removal, unless
a permit in the usual form for the removal of such body has been sooner
obtained hereunder. If the death certificate contains a recital, as re-
quired by section ten of chapter forty-six, that the deceased served in
the army, navy or marine corps of the United States in any war in
which it has been engaged, such recital shall appear upon the permit.
The board of health, or its agent, upon receipt of such statement and
certificate, shall forthwith 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 sha!l 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. Les
as amended by Chap. 48, Acts of 1927 and Chap. 414, Acts of 1931.

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.

Se ees

the clerk of the town where the body is to be buried or the funeral
is to be held, or from a person appointed to have the care of the ceme-
tery or burial ground in which the interment is made....Chap. 114,

Sec. 46, G. L. as amended.

RULES OF PRACTICE ~

The fulfillment of the purpose of these laws calls for the observance -
of the following rules of practice: ,

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

(3) Medical Examiners will investigate and certify to all deaths
supposably due to injury. These include not only deaths caused
directly or indirectly by traumatism (including resulting septicemia),
and by the action of chemical (drugs or peat 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.

Pa Cor eatpunre —s— 3S/-93 :
The ninealth of Massachusetts To be filed for burial permit

PRM R-301A OFFICE OF THE SECRETARY with Board of Health
mys E DIVISION OF VITAL STATISTICS or its Agent.
Ow a STANDARD +7
3 1) 8 CERTIFICATE OF DEATH Registered Now....cfeseennnun
o
27 a (If death occurred in a hospital or ‘astitution,
a = give its NAME instead of street and number)
=
is ( ic (IU. S.
n 2 FULL NAME...” /1A4. eae eR cece Me cree cee i a8 eS Mca aR eee scans Sopevvosuaseaneeah ditcannveenteoNtee War Veteran,
Z : : - specify WAR)
3)
—
n
=
&

Exact statement of OCCUPATION

a :
(<4 RRM RRG@BRELGNTCO INOS. 6250. t etapa Feces coco sec Ds wes enh one css apts cota 62d: Gny x Sore ASSCONV MOG) ccccalestctonsessacnrconscsarasassadesesuciosstesersorssuerveseveare
° (Usual place of abode (If nonresident, give city or town and state)
3 3 Length of residence in city or town where death occurred yrs. mos. 4/ days. How long in U. S., if of foreign birth?. J OQ yt. mos, days.
m é PERSONAL AND STATISTICAL PARTICULARS MEDICAL CERTIFICATE OF DEATH
ee 2 va (prs 4 COLOR edie ae Gerite'tie word) |) 18 DATE OF a q 19 33
o TEL Ln aN ORR pen” Cot te rarer, ances ABER ry Oa MORE er i CL Das
i) WIDOWED y
Ze % or DIVORCED —~ ' (Year)
S454 5a If married, widowed, or divorced 19 I HEREBY CERTIFY, That | attended deceased from
) MN Mam ets. 8 Y.29, Ceca csctessnpasvsncsece sete hoses tas snscic wpdasestoavcdondbodventeoauubapivecesebescest
yes r) « (Give maidepfame of gyife in full) | freee oe. SNe 2 Lele ae ,19 33, 10.13 a te Pee 193.3.
a 3 f (or) WIFE of ...... f (LMA AZ,.... AO. = re Se A <2 oo ree ! last saw h..-r alive on........ Jowm& Fir ee 19 2.3, death is said
<3 30 déband’s name if f full) 7 a r asad ae Ws,
om o have occurred on the date stated above, at... m.
“as 3 GIF STILLBORN, enter thatfact here. The principal cause of death and related causes of importance in order of
n = 8 If less than 1 day onset were as follows: Date of Onset
=32 2 bec * lal Patt Years... ~~... Months ...2.....Day$ } ves... Hours..........- Minutes IMPORTANT
Es he 8 Trade, profession, or particular ?
|3 a = kind of work done, as spinner, Grcccensiee
o3 re) So sawyer, bookkeeper, etC...............000 Bodom A A AA “Se Mies. eee
Se > | 9 Industry or business in which
EE eee Sn en | (er eae en ene ne
3) rz) saw TS re cer er aren abod ec Sor Ge PERO cp. ECE EEL NCEE Ree eB
Fah E 6 &| 10 Date deceased last worked at 11 Total time (years)
<x 3 this occupation (month and in this
s “ 5 Pe eieere aba censase curt ata canter pein Aosareass sans Pia OM iisesececeeac-oc05-c01
AV cy : x
ese 12 BIRTHPLACE (City).............. KEN 2B sp BOF UIA... eae
OSoa (State or country. eG: é A —<s
z a8 ® ya ——
— SY
336 13 NAME OF S ;
Hl es 2 cae |
2 $3 PieaiMAreoF | a i, Name of operation.............. DAR R eon eeesenrnnee Date tem ata
e3 " 5 i FATHER OF Os Oe oa Opel wo gS. eae What test confirmed diagnosis? .......2c.ceccccccceceeceeceseeeee Was there an autopsy?../7.0
= as £ Z| (State or country) TE SA 20 Was disease or injury in any way related to occupation of deceased? ...................-
— om ww .
Ro c|15 MAIDEN NAME Y 7 AUG SD,;,| SINCCUY os cans sae aocttes beat ccs as casq austen geo eead toe scons oop a ieee ge her seu
SSen ||<| oF MOTHER 4 OT AL; A/a (Signed) AS A: (ess eee ee .D.
Or aa “a 7 Address)... 30% (2rahuore
SSE “ 16 BIRTHPLACE OF Inf ( TESS) spat) ckvenees = auciinauwisaivscwanres ees y Tip 2 Si. Bap ie . Date fe AGES...»
33 + MOTHER (City) ................ 6. i geeaeee LZ} tS Hl ai PLAGE OF BURIAL.
Zeus (State or country) za 4 CREMATION OR REMOVAL Yi lente. abd
4 go § 77 7 : - y (Cemetery) _ Mle or town)
was : DATE OF BURIAL. we Lite Es 1S
3S 1] (Address) oi 22 NAME OF ie
6 E a7 eS > eit .
Bm UNDERTAKER ..<.....2 Loe Lif, Da: CME crise
E Eu F | HEREBY CERTIFY that a satisfactory standard certificate of death was - Se {Z pa
cigs = filed with me BEFORE Ane | burial or fraps permit was issued: ADDRESS .......-..@ ee en a A LE Nig oon ensnennencies seneeeennnsenseey
bel
| || | S/he Ae 4 © am Cchitkd ES ELS LE eee ee eee ‘ :
J i Gites of Reeayeh Board ot "a ee or ates) Received and filed...........:csscsssssssseeesees JAN pr Leon tn ares 1S
@ — a a ; = ‘i i 1$32 f
Z ov cnpeic ge deececcccceveccsesviscccsabccccvecscccuawescessessaces evvcees| |e AP YS ReTSO SSE ADE SOS SUES EOF HF OTTERS OEE SEE eO SEES SEES Heeeeseeewessosee soreness senebd des acensannencesense aes any

cia re ps wiaae f vous (Registrar)
si r=.

Revised United States Standard Certificate of Death —

' 5

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

To be complete, an occupation return must state:

8.—The trade, profession, or particular kind of work done.

9,—The industry or business in which the work was done.
10.—The month and year the deceased last worked at the occupation.
11.—The number of years the deceased followed the occupation.

In stating the occupation, avoid the use of such indefinite 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
Poe of store, factory, mill, etc., as grocery store, soap factory, cotton
mill, etc.

ish 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.

Distin

Example

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

Date of onset

. Arteriosclerosis

Chronic interstitial nephritis

r9o2r

July 5, 1927

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.

2 eae
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.

ody and remove it from a town, from one cemetery to another, or
from one grave or tomb other than the receiving tomb to another in the
same cemetery, until he has received a permit from the board of health
or its agent aforesaid or from the clerk of the town where the body
is buried. No such permit shall be issued until there shall have been
delivered to such board, agent or clerk, as the case may be, a Satis-
factory written statement containing the facts required by law to
be returned and recorded, which shall be accompanied, in case of an
original interment, by a satisfactory certificate of the attending
physician, if any, as required by law, or in lieu thereof a certificate
as hereinafter provided. If there is no attending physician, or if, for
sufficient reasons, his certificate cannot be obtained early enough
for the parol: 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 sucha permit for the removal of a human body,
not previously interred from one town to another within the common-
wealth cannot be obtained early enough for the purpose, the certificate
of death made as above provided and in the possession of the undertaker
desiring to make such removal shall constitute a permit for such re-
moval; provided, that such body shall be returned to the town from
which it was removed within thirty-six hours after suchaemoval, unless
a permit in the usual form for the removal of such body has been sooner
obtained hereunder. If the death certificate contains a recital, as re-
quired by section ten of chapter forty-six, that the deceased served in
the army, navy or marine corps of the United States in any war in
which it has been engaged, such recital shall appear upon the permit.
The board of health, or its agent, upon receipt of such statement and
certificate, shall forthwith 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, GCG. Las
as amended by Chap. 48, Acts of 1927 and Chap. 414, Acts of 1931.

Medical examiners shall make examination upon the view of
the dead bodies of only such persons as are supposed to have died
by violence... .Gen. Laws, Chap. 38, Sec. 6.

He shall in all cases certify to the town clerk or registrar in the
place where the deceased died his name and residence, if known;
otherwise a description as full as may be, with the cause and manner
of death.—Gen. Laws, Chap. 38, Sec. 7.

No undertaker or other person shall bury a human body or the
ashes thereof which have been brought into the commonwealth until
he has received a permit so to do from the board of health or its agent
appointed to issue such permits, or if there is no such board, from
the clerk of the town where the body is to be buried or oe funeral
is to be held, or from a person appointed to have the care of the ceme-
tery or burial ground in which the interment 1s made....Chap. 114,

Sec. 46, G. L. as amended.

RULES OF PRACTICE

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

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

(3) Medical Examiners will investigate and certify to all deaths
supposably due to injury. These include not only deaths caused
directly or indirectly by traumatism (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

tructions and extracts from the laws on back of certificate.

—THIS IS A PERMANENT RECORD.

AGE should be stated EXACTLY.

pplied.
terms, so that it may be properly classified.

tant. See ins

is very impor

information should be carefully su
100m-9-'30. No. 9954.

CAUSE OF DEATH in plain

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

SOLA

»
PLACE OF DEATH

2 FULL We Pee

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

AA, Ce8POCR=... (77 7 a Ward,

(a) Residence. No... d, f.
(Usual place of abode)

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

PERSONAL AND STATISTICAL PARTICULARS

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

STANDARD
CERTIFICATE OF DEATH

To be filed for burial permit
with Board of Health

or its Agent.
Registered No.......... x Seven pees

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

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

days.

5 SINGLE (write the word)
3 SEX 4 COLOR OR_RACE MARRIED .
WIDOWED S22trecd
Z '~ or DIVORCED

5a If married, widowed,
HUSBAND of .............. é

ase

Mem EMR ocr acess srcer a concnecactksteevacduavesaauincesicnconsssenesestdalebotedspovecssedth .sdaedovepedeni<anet
(Husband's name in full)

6 IF STILLBORN, enter that fact here

If less than 1 day

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

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

10 Date deceased last worked at
this eae (month and
year

"4 1 Total time (years)
spent in this >
occupation... S...°7..#...

OCCUPATION|

12 BIRTHPLACE (City)...............0000.:9t%c-senee oe
(State or country)

13 NAME OF
FATHER

14 BIRTHPLACE OF
FATHER (City)

(State or country)

15 MAIDEN NAME
OF MOTHER

—————— — :
16 BIRTHPLACE OF G1 . y, PPP
MOTHER (City) ..... im

PARENTS

(State or country)

ale
(Address)

standard certificate of death was

| HEREBY CERTIFY that a satisfacto
i EFORE th permit was issued:

Peres rete rtl / >, ae pre Bere ee eee

eee 8 Me Uf. Bb.

(Date of Issue of P

| last saw h

to have occurred on the date stated above, at &.., A- peas ?

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

a ..Date of...

i hice: Was there a an 1 autopsy? We

ation of deceased?

If so, specif
(Signew)_.\

CREMATION OR REMOVAL ..4.+4<44
(Cemetery)

22 NAME OF
UNDERTAKER .

ADDRESS......

Pe Rete ee oes aca knoe shfl fib.--tes Jou AQVD .orenen0s- eaigusetunusduneteeses f

Received! and) ‘fil@d!s.<.c0:..0ccc0csccccovsecssctecsocssss-esenane Baar reba causeivavenuatemmrs pert oeaaa ted

A A j
(Registrar)

Revised United States Standard Certificate of Death

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

In stating the occupation, avoid the use of such indefinite terms
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
nits 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 “Jaborer’”’ when a
more precise statement.of the occupation can be secured. Deenot
use the word “mechanic,” but give the exact occupation, as carpenter,
painter, machinist, etc. Distinguish carefully between retail merchants
and wholesale merchants. A person who sells goods should be called a
salesman and not a clerk.

Example

The principal cause of death and related causes

3 4 t
of importance in order of onset were as follows: Date of onset

Arteriosclerosis

July 5, 1027

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

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 Famers 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 pePiceHon 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 tequired by section ten cf chapte® 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 ceed is so given and the physician certifying the cause ot death
shall thereafter furnish for registration any other necessary information
which can be obtained as to the deceased, or as to the manner or cause
of the death, which the clerk or registrar may require.—Chap. 114,
Sec. 45, G. L., as amended.

Medical examiners shall make examination upon the view of
the dead bodies of only such persons as are supposed to have died
by violence... .Gen. Laws, Chap. 38, Sec. 6.

No undertaker or other person shall bury a human body or the
ashes thereof which have been brought into the commonwealth until
he has received a permit so to do from the board of hgalth 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: | f

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

(3) Medical Examiners will investigate and certify to all deaths
supposably due to injury. These include not only deaths caused
directly or indirectly by traumatism (including resulting septicemia),
and by the action of chemical (drugs or oisons), thermal, or electrical
agents, and deaths following abortion, but also deaths from disease
resulting from injury or infection related to occupation, the
sudden deaths of persons not disabled by recognized disease,
and those of persons found dead.

Every item of

PHYSICIANS should state
Exact statement of OCCUPATION

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

pplied.
terms, so that it may be properly classified.

tructions an

See ins’

formation should be carefully su
tant.

CAUSE OF DEATH in plain

is very impor

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

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

The Commonwealth of Massachusetts

OFFICE OF THE SECRETARY To be filed for burial permit

E DIVISION OF VITAL STATISTICS with Board of Health
= STANDARD or its Agent. ~
os oS CERTIFICATE OF DEATH Registered No........ 4 Seti ares
tw
< (If death occurred in a hospital or institution,
Ps Ser ee eee tosavesrese: Ward give its NAME instead of street and number)
, (If U. S
aN MIN a I eae ae ars ee A eae ER eer Me Soe eae Biase METRE Cov hss sewsciovSuchostavcucsousosapuesesvoceveaevsatsvdsesncosssvsese War Veteran,
x i i woman, give also maiden name.) speek WAR). 0i:..:eissscrsovissdeen dete
(a) Residence. 6.0% Bosctie SM 0 OL Stree Ae thoe Kood al | Jee SE sso once WW 5 owns oss api cuss on scan oenesevie bevesieestonssacs eee

(If nonresident, give city or town and state)

(Usual place of abode)
days. How long in U. S., if of foreign birth? yrs. mos. days.

Length of residence in city or town where death occurred

MEDICAL CERTIFICATE OF DEATH

PERSONAL AND STATISTICAL PARTICULARS

3 SEX 4 COLOR ORjRACE | © SINGLE (write the word) |! 18 DATE OF P
y {/ es : DEATH... (1 I ae | Meee Uk: Se LF...
y {/

4 a pWoRce fA LLLP DY — (Month) (Day) (Year)

5a If married, widowed, or diverced 19 I HEREBY CERTIFY, That | attended deceased from

4
HUSBAND of (2 ee eee SN eS Nate 199-7. toc eG Wale ed , 19.3%.
(or) WIFE of . JY ast saw hPtn....alive on.......\een...... TO ee ee as , 19.2.%., death is said
(Husband's name
to have occurred on the date ‘stated above, at.de dete Ad sevenai 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
samira Hours............Minutes

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

S sawyer, bookkeeper, etc.............. sau RT LE OU er

| 9 Industry or business in which

a work was done, as silk mill,

= saw mill, bank, etC..............00.0000c0e sec EREC Re CEEEC ee eee

| 10 Date deceased last worked at 11 Total time (years
this occupation (month and spent in this A:
year)...... el ie ee eee cee occupation Z

EMMI NEUSTAR NESE CCG TEU) a, re tee cre cn hc 2: Biss ce casei dpc orsise esa cdaveatwivcbasevecessfe@fivchateess eH ama

(State or country)
13 NAME OF
FATHER

Name of operation............... i arena be eo
2 14 ACE OF cot WES a oY a I ea an EO ee al What test confirmed diagnosis? . Coke eee vee Was there an aulopsy/.*Sa..
z= (State or country) f LAA a 20 Was disease or injury in any way related to occupation of deceased? so bacsret
Lee) ‘ .
«| 15 MAIDEN N 3 (J If so, specify..... inde be Ae iannaad cnt al cenaes sae anne Parnsscovnncucersenceesenesrsrendoupesersnnnee
me . OF MOTHER a (Signed) 2 ee ea 1 das Pre barca LAr... , M.D.
16 BIRTHPLACE OF (AddressA70. © Ae Pehpecerse i. ~ IPA... Date ee 19.22...
MOTHERS (CuEY)oestisssese--coedeceecteriecrees oe steffi SOT oy aCe OF BURIAL
(State or country) j MV: OBEMATION OP REM
alr é
teen 4 ¢ 2... F ied GR Nee” (ee Y MO | Bere Or Suna
(Address) Zz 22 NAME OF
UNDERTAKER/.7&

| HEREBY CERTIFY that a satjsfactojy standar@ certificate of death was
fi me BEFORE leaks oF ZAransit permit was issued: ADDRESS........... Le

Nt Jai Gish ck AER oe seh ohne ate ket ane. einai eutatta’ ioe
Shek MA. ptt CLE cit OD 1/23 (LEG po Re eee)! [a a rr
C

ial Designation) / (Date of Issue of Permit) (Registrar)

Revised United States Standard Certificate of Death

Statement of occupation.—Precise statement of occupation is
very important, so that the relative healthfulness of various pursuits
can be known. Make some entry in this section for every person
aged 10 years or over. 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 relail 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
selated to principal cause, name other important diseases.

Example

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

Date of onset

Arteriosclerosis

Chronic interstitial neph

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 or 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

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 apeotiies 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
tnake 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 Tegistrar 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.

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: . c

(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
divectly or indirectly by traumatism (including resulting septicemia),
and by the action of chemical (drugs or oisons), thermal, or electrical
agents, and deaths following abortion, but also deaths from disease
resulting from injury or infection related to occupation, the
sudden deaths of persons not disabled by recognized disease,
and those of persons found dead.

Every item of

PHYSICIANS should state
Exact statement of OCCUPATION

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

ified.

AGE should be stated EXACTLY.
be properly class

pplied.
terms, so that it may

information should be carefully su
CAUSE OF DEATH in plain

—WRITE PLAINLY, WITH UNFADING BLACK INK—THIS IS A PERMANENT RECORD.
is very important.

ies

a
'

wo
2
>

No. 5469

75m-5-'32.

The Commonwealth of Massachusetts To be filed for burial permit

OFFICE OF THE SECRETARY with Board of Health
E Ce aaeneceuecerecerscseroans DIVISION OF VITAL STATISTICS or its Agent.
a . STANDARD w
_ ee Winthrop CERTIFICATE OF DEATH Registered Now. ssdsniusco-
3 ee Gf death occurred in a hospital
* eath occurred in a hospital or institution,
a Nis Sods: 9 Grovers Ave Bar tessuiuouapswevosaesitnedassesex St., Se vieteedaiiberouaaasa Ward give its NAME instead of street and seas
; : . (If U.S.
2 FULL NAME. Euma..Dorothy. (Gillespie) Gillespie oo. {We Veteran,
(If deceased is a married, widowed or divorced woman, give also maiden name.) BOACHT WAR occs si sccsene ose oe
(a) Residence. No.......... Pats Chi 3 eS A er aie Sh eats, Wrardntscs Metta es ce tk 2s, cade ee
(Usual place of abode) 5 (If nonresident, give city or town and state)
mos. days.

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

"PERSONAL AND STATISTICAL PARTICULARS
3 SEX 4 COLOR OR RACE | © SINGLE prrte see ord)

WIDOWED ,
Female | white wy bivorcen Married
5a _ If married, widowed, or divorced

18 DATE OF

(Month)

I HEREBY CERTIFY, That! attended deceased from

MEDICAL CERTIFICATE OF DEATH

HUSBAND of «.........00.0:--0000005 (Gi EE Se Sen anne, fis ie koe ae 2 a 2 = ee a.» Osleeby signet aaaaaneeee a 19. 32-to.. fe ce 72 Vaeealiaacasaas . 19.3.3.
(or) WIFE of Herbert Bie it Qi:;,.: Gy ‘ Tespie NG A Se Re | last saw h.@+_.alive on... pen... tel. see ,19.34.., death is said
(Husband's name in full)
to have occurred on the date stated above, at. =...

6 IF STILLBORN, enter that fact here.
onset were as follows:

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

i If less than 1 day Date of Onset
AGE........ Sa N@aYSs..5...0:-:.:. Months............. Days)|)-u-....... HGUIS 2 2.-<-5-4 Minutes IMPORTANT
8 ct oleate or particular
x ind of work done, as spinner,
3 sawyer, bookkeeper, etc....... Bttveneast House w eh ee
| 9 Industry or business in which 1
<x
a work was done, as silk mill, ( wn
3 Bee, Renal, Btieascccrcsecsncteesscee ee osc mci
6| 10 a aeeeesee one - 11 Total oe oe) cops tk Sotaceasces soon ebertaeebete cetet Papi cece tteocere Roscoe ER rePr eer Fever recomyncthriotharee eA cpr
is occupation (month an ent in this
MEBRU Nice seas Ser spaaiecenctuceo cu Janell 9 Bccupation 16
12 BIRTHPLACE (City. FarnumsVville. Bec ee dee ceecec ehecesc eth MIMP crternatttenttseencttreseaeee caress ccararsysadansv canteen dees svonuseecouasscrerneszzsassnscnsnse nstasacnavernntocen | wetnnsenstrasnecnasnaps
(State or country) Ma a sachuset po AMM ie hy MR UMTS MME EI iG geen Sey crc Zcyostss cis a ceptsgveirs tat saetgu ovks sal eesotavdentes ouaheke te enabadeucabecrsoubenea oyneetneceds
13 NAME OF « a
FATHER JOS@ph Gillespie
Name of operation............ tema. a ea ies ei Date of

inlet Se OF What test confirmed dlagnosis¥2 Beery St? A.Was there an autopsy?. ly.
Gof) EATER (City) ns nce sss csecsecsssenteeeenseeesestenesoneensnnanesannsnenvnnnsenenesceinseed
z (State or country) England 20 Was disease or injury in any way related to occupation of deceased? . Veo ane
ra 15 MAIDEN NAME If so, spect Rea Ge, aA reir Mee (3 ee (2 sovsesonennnnuecececnnessonsessconsnsnanacceensscsecegeenss
<| oF MoTHR vane Bullock (Signed) Soya J. Ce (OP eee tee _ M.D.
ee cae are OF (Address) 4 Mae AA... ess oe ess Dated Mtg... 319.83

INVESTEC Be Pe ec ee ce ee escacte hs vaseeal

(State or country) England

\ Lie ton ¢ .
21 PLACE OF BURIAL, A
CREMATION OR REMOVAL 22 TMUMS Ville GEES S non

ae a Herbert..Ms..Gillespie De tede ney (iin One tr Bune eee Dee cl 16) 2
| (Adsres) _9 Grovers Ave, Winthrop Mass 22 MMEOr.. Charles. Re. Bennison.............

{ HEREBY CERTIFY that a satisfactory standard certificate of death was

filed with me_BEFOR apie bua rf transit permit was issued:
4,

ES dala Saote ae ae j A eas Ab ,
nw 1 Foes 2 5 RN
esignation) / (Date of Issue of P it)

25-9

(Registrar)

Statement of occupation.—Precise statement of occupation is
very ao, co 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.

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
fate of store, factory, mill, etc., as grocery store, soap factory, cotlon
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 ek. Serie
Chronic interstitial nephritis |e roar! od
Cerebral hemorrhage i _July 5, 1927

aeeeserccsnnssseensesesnstsseeessanereees seesenenereaeeensspasees

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

ody and remove it from a town, from one cemetery to another, or
from one grave or tomb other than the receiving tomb to another in the
same cemetery, until he has received a permit from the board of health
or its agent aforesaid or from the clerk of the town where the body
is buried. No such permit shall be issued until there shall have been
delivered to such board, agent or clerk, as the case may be, a Satis-
factory written statement containing the facts required by law to
be returned and recorded, which shall be accompanied, in case of an
original interment, by a satisfactory certificate of the attending
physician, if any, as required by law, or in lieu thereof a certificate
as hereinafter provided. If there is no attending physician, or if, for
sufficient reasons, his certificate cannot be obtained eafly 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 sucha permit for the removal ofa human body,
not previously interred from one town to another within the common-
wealth cannot be obtained early enough for the purpose, the certificate
of death made as above provided and in the possession of the undertaker
desiring to make such removal shall constitute a ermit for such re-
moval; provided, that such body shall be tunnel to the town from
which it was removed within thirty-six hours after such removal, unless
a permit in the usual form for the removal of such body has been sooner
obtained hereunder. If the death certificate contains a recital, as re-
quired by section ten of chapter forty-six, that the deceased served in
the army, navy or marine corps of the United States in any war in
which it has been engaged, such recital shall appear upon the permit.
The board of health, or its agent, upon receipt of such statement and
certificate, shall forthwith 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 by Chap. 48, Acts of 1927 and Chap. 414, Acts of 1931.

Medical examiners shall make examination upon the view of
the dead bodies of only such persons as are supposed to have died’
by violence... .Gen. Laws, Chap. 38, Sec. 6.

....He shall in all cases certify to the town clerk or registrar in the
place where the deceased died his name and residence, if known;
otherwise a description as full as may be, with the cause and manner
of death.—Gen. Laws, Chap. 38, Sec. 7.

No undertaker or other person shall bury a human body or the
ashes thereof which have been brought into the commonwealth until
he has received a permit so to do from the board of héalth or its agent
appointed to issue such permits, or if there is no such board, from
the clerk of the town where the body is to be buried or the funeral
is to be held, or from a person appointed to have the care of the ceme-
tery or burial ground in which the interment is made....Chap. 114,
Sec. 46, G. L. as amended.

RULES OF PRACTICE

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

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

(3) Medical Examiners will investigate and certify to all deaths
supposably due to injury. These include not only deaths caused
directly or indirectly by traumatism (including resulting septicemia),
and by the action of chemical (drugs or poisons) thermal, or electrical
agents, and deaths following abortion, but also deaths from disease
resulting from injury or infection related to occupation, the
sudden deaths of persons not disabled by recognized disease,
and those of persons found dead.

The Commonwealth of Massachusetta To be filed for burial permit

75m-5-"32.

RM R-301A g ff ; OFFICE OF THE SECRETARY with Board of Health
< a E Prrrr i suttolk Tretrirrr iii) DIVISION OF VITAL STATISTICS or its Agent.
Se 3 a STANDARD
ESE SE ee Winthrop. CERTIFICATE OF DEATH Registered No.......... L/ RS 3
8 oe rs (City or Town)
2D (If death occurred in a hospital or institution,
pap A 1, te ie eee 516. Pleasant...St.. faesaieevear® LAS 7 oh Ward give its NAME instead of street and number)
oc
ake (If U. S.
iyo ES EN sl) 0 ee =) =) a War Veteran,
aa ° (If deceased is a married, widowed or divorced woman, give also maiden name.) POSEY IW AMG) =: 5-05 -<<css0s0:¢¢hnanlibogsnen
E :
ZOE (a) Residence. No............ 516..Pleasamt...St.. Fe iets earns St. gk. WV civil y) 5s ids ee Ts tenes
OF £ : (Usual place of abode) (If nonresident, give city or town and state)
oO ~ov 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.
) O i >} aw ae RSS RR SS SSS SS SS {
as &é PERSONAL AND STATISTICAL PARTICULARS MEDICAL CERTIFICATE OF DEATH
ge 3 SEX 4 COLOR OR RACE | © SINGLE (write the word) |] 18 DATE OF
Bk MARRIED DE zn WALK gi | 33
| 5 S 9 5 WIDOWED * ATH ............... AQ AL YOAL..! PI eg Ace he Re ate
Zras Male Vi S er DIVORCED Widowed (Month) (Day) (Year)
= aa) 5a If =, idowed, Bh fixe ed 9 I HEREBY CERTIFY, That | attended deceased from
| Zo || nuspanD of MAreare. . J... Queenan. Butler... cu ;
| ae mars qnaiden mame of wife in full) iF, bwaahdatiiae cao Roe ert ass sctcavenesaghscs 19 2, to....... (AAA. ee [Ae 19.3.3
_ 3 f 0 TLE CoD cells ene ee a oe SE Ce ee MRE coe, eee / } last saw h..44.,...alive on.. cruel |..b2. sae , 19..37>..., death is said
<3 30 (Husband’s name in full) \ 3 & i; y;
| vn oO have occurred on the date stated/ above, at...S2....Z.... m
Ce)

“ns >, = ape ney Seter ‘that fect hore The principal cause of death and related causes of importance in order of
ln Om 7 If less than 1 day onset were as follows: Date of Onset
= 3 a 2 AGE...... 79 re a NBAYSe.c0os< 200552 Months............ Days: [hic Hours............ Minutes IMPORTANT
Es ee 8 ier DS shi or particular

= ind of work done, as spinner, ce oessennenncnns
J 8 2 ° é sawyer, bookkeeper, eee conemnaaerest pact Retired “eee coro: cane nq 6)
oié | 9 Industry or business in sich 5 a oe ae
Z > 0 a work was done, as silk mill YW ny
pylles iis sew mill, bank, etc.... EET STIs af a) Be | Rae Sc a al pee
rape ee 8/10 _ deceased last worked at 11 Total oe Bag et Barc ae Ses
b= is — mo spent in this
a on year). mh ba ae puciie) ieee Duaventiys' occupation... 55 Beane
} °3S% || 12 wiRtHpiace (city)........... EC fit Oe ars A i eG cae Mamma Came aac BET ns
OF @ OTE 8 Genta) OI a hs RS i aes | | orto teemrwemnmene sey A 1S Of Art Od (1 O deme PS an OS ae 1" | 0! OS Ia Y ah. au...
z Qo. o D2 °
Baas a a RR cae Met) UD Fe SH OE a ao a, sat aesccaces ls ssauSosovuculh eistduqasccdbweucondssudevaddesbobessiiocte Real iosedtuccoreReeeett
)a°es FATHER ae eS
25 a} Narnia Ghfoneratlans.... 62.0 tecsciee coatce Peace ob-cercuestosaeed Date Off shies cestosscrsvssencoencsoeees
ga : 5 2 14 Ae OF ass PY AS CS ee pas 7 What test confirmed diagnosis? .......ccss.ccssecsssssessssseessseee Was there an autopsy?..........
Ee £ z]| (State or country) I re lan dq 20 Was disease p* injury in any way related to occupation of deceased?..................-.
= a =r MAIDEN NAME If son specify) fh tfl etek Nc pin eps A Men, Ppp dene
S8e0 < OF MOTHER (Signed) ....f. da. LAMA... Wy. 71 Oe D . Sen Oe M.D.
. 0 5 (Address)... 30.%.. weet SAL... Date... F./....193..2..
° 16 BIRTHPLACE OF
i mah MOTHER (City) ...Cannot Be. Learned...............
4 21 PLACE OF BURIAL,
1 { 5 (State or country) CREMATION OR REMOVALEL Lv
Sn, el] 17
' BOE 5 epafarmant ch? ae _Thonas a Butler vets Be: ae aS
e:
. a a 2 a UNDERTAKER .
g F Viper CERTIT art a satisfactory standard certificate of death was
iledwvith me BLF, i i i i :
a :
@

Revised United States Standard Certificate of Death

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

To be complete, an occupation return must state:

8.—The trade, profession, or particular kind of work done.

9.—The industry or business in which the work was done.
10.—The month and year the deceased last worked at the occupation.
11.—The number of years the deceased followed the occupation.

In stating the 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
Las of store, factory, mill, etc., as grocery store, soap factory, cotton
mill, etc.

ish 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.

Distin:

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: ale

rors

ilis 192r

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

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 i 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 sucha permit for the removal of a human body,
not previously interred from one town to another within the common-
wealth cannot be obtained early enough for the purpose, the certificate
of death made as above provided and in the possession of the undertaker
desiring to make such removal shall constitute a permit for such re-
moval; provided, that such body shall be returned to the town from
which it was removed within thirty-six hours after such removal, unless
a permit in the usual form for the removal of such body has been sooner
obtained hereunder. If the death certificate contains a recital, as re-
quired by section ten of chapter forty-six, that the deceased served in
the army, navy or marine corps of the United States in any war in
which it has been engaged, such recital shall appear upon the permit.
The board of health, or its agent, upon receipt of such statement and
certificate, shall forthwith 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, (ste
as amended by Chap. 48, Acts of 1927 and Chap. 414, Acts of 1931.

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: y

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

(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 polene 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.

301A

Every item of

PHYSICIANS should state
Exact statement of OCCUPATION

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

AGE should be stated EXACTLY.

it may be properly class

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

-%
2s
#8
a@
:
55
-s
z

ac} .

see

£as

foe

BOERS
3) 6

Fab 2
ow?
= .
5.2 =|),

ww
E
£

FSI

= ‘
3 wn tn

ra (City Uh

A Noe ooo ceeceeecete cee eee te Au. AMY, VAAN in
2eBOLL NAME. NAZ YAO Lke

(If deceased i is a married,

(a) Residence. No.. eVe ENG

(Usual place of abode)

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

PERSONAL AND STATISTICAL PARTICULARS

5 SINGLE (write the word)
SEX 4 COLOR OR RACE SINGLE q
WIDOWED
wi or DIVORCE

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

lie eee § * | aes Yea Oo cores Months V5 bas

8 Trade, profession, or particylar
kind of work done, as spinner;
sawyer, bookkeeper, etc............07 y

9 Industry or business in which
work was done, as silk mill,
saw mill, DT) CRS eee eee, ee :

10 Date deceased last we

If less than 1 day

OCCUPATION;

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

12 BIRTHPLACE (Cit
(State or country) h

13 NAME OF
FA

15 MAIDEN NAW
OF MOTHER

16 BIRTHPLACE OF”
MOTHER (City

(State or country)

we Zi
ee ee ee a aan a rr a. wr. Wan ee

isi ndard ce

it permit

Wate e seer eeeenscneseeuseeeeensaesneen dens

aaitis or vee,

Designation) / Y (Date of Issue of kbd

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

STANDARD
CERTIFICATE OF DEATH

ae qe reves sorasesesseoensrssseves LAS ORES OER Ee HORE eRe nesereeses ane eseeeassenenesaeesessenneseseaneeneme

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

Registered No........, / pe Soe

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

(If U. S.
War Veteran,

aieden name.)

Prnacnrattee Ward, :
“(If nonresident, give cit:
How long in U. S., if of foreign birth? yrs.

or town and state)
days.

days, mos.

MEDICAL CERTIFICATE OF DEATH

18 DATE OF

to have occurred on the

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

IMPORTANT

“Ohi Motevie os
= LG A?.

“Contributory causes of importance not related to principal cause: Ss Bers. 9

(3 SEO (a Saree Pe bee 1? 2%,

Name of operation..........7.....

Datta? Of... sccsstevassataimtecceee
What test confirmed diagnosis’... ... Was there an autopsy?... Ae

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

ie (Cify or town)

21 PLACE OF BURIAL,
CREMATION OR REM

DATE OF BURI

22 NAME OF
UNDERTAKER

ADDRESS..........Y.. Menudo a as ition. ot oe
1

RECHIUEIS AIT Hila errata scter tee eresc tes eeceiediwncccscoee cree eae Rees er csdasecttocnenes 1S: A=.

(Registrar) 7

e nited States Standard Certificate of Death —

Statement of occupation.—Precise statement of occupation is
very important, so that the relative healthfulness of various pursuits
can be known. Make some entry in this section for every person
aged 10 yearsorover. Ifthe occupation had been given up or changed
on account of the disease causing death, report the occupation prior
to illness. If the deceased had retired from business, report the
occupation prior to retirement. Children not gainfully employed
may be returned as at school or at home. For a woman whose
only occupation was that of home housework, write housework
in answer to Question 8 and own home in answer to Question 9,
For a person engaged in domestic service for wages, however, designate
the occupation by the appropridte 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
Jend 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 t
of importance in order of onset were as follows: Bie Ch OFRE

rors

ro2r

Jul

Cerebral hemorrhage

Contributory causes of importance not related to
principal cause:

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

EXTRACTS FROM THE LAWS OF TH
COMMONWEALTH OF MASSACHUSETTS
GOVERNING THE

RETURN OF CERTIFICATES OF DEATH

No undertaker or other person shall bury or otherwise dispose
of a human body in a town, or remove therefrom a human body
which has not been buried, until he has received a permit from
the board of health, or its agent appointed to issue such permits,
or if there is no such board, from the clerk of the town where the
person died; and no undertaker or other person shall exhume a human
body and remove it from a town, from one cemetery to another, or
from one grave or tomb other than the receiving tomb to another in the
same cemetery, until he has received a permit from the board of health
or its agent aforesaid or from the clerk of the town where the body
is buried. No such permit shall be issued until there shall have been
delivered to such board, agent or clerk, as the case may be, a Satis-
factory written statement containing the facts required by law to
be returned and recorded, which shall be accompanied, in case of an
original interment, by a satisfactory certificate of the attending
physician, if any, as required by law, or in lieu thereof a certificate
as hereinafter provided. If there is no attending physician, or if, for
sufficient reasons, his certificate cannot be obtained early enough
for the parm e, 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 such a permit for the removal of a human body,
not previously interred from one town to another within the common-
wealth cannot be obtained early enough for the purpose, the certificate
of death made as above provided and in the possession of the undertaker
desiring to make such removal shall constitute a permit for such re-
moval; provided, that such body shall be returned to the town from
which it was removed within thirty-six hours after such removal, unless
a permit in the usual form for the removal of such body has been sooner
obtained hereunder. If the death certificate contains a recital, as re-
quired by section ten of chapter forty-six, that the deceased served in
the army, navy or marine corps of the United States in any war in
which it has been engaged, such recital shall appear upon the permit.
The board of health, or its agent, upon receipt of such statement and
certificate, shall forthwith 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 by Chap. 48, Acts of 1927 and Chap. 414, Acts of 1931.

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.

Sec. 46, G. L. as amended.

RULES OF PRACTICE

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

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

(3) Medical Examiners will investigate and certify to all deaths
supposably due to injury. These include not only deaths caused
directly or indirectly by traumatism (including resulting septicemia),
and by the action of chemical (drugs or porns 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.

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

mrs BO BAW BH. WOM! Si. cove KS

Every item of

PHYSICIANS should state
Exact statement of OCCUPATION

AGE should be stated EXACTLY.

so that it may be properly classified.
See instructions and extracts from the laws on back of certificate.

in te

information should be carefully supplied.

CAUSE OF DEATH in pla
is very important.

100m-9-'31,

No. 3385-f

The Commonwealth of Massarhusetts
OFFICE OF THE SECRETARY

eo - Town) J P
(If death occurred in a hospital or institution,

No. Sinden MOBS ALIN... J En eee erst, Bee Pee cccccttoaxe Ward give its NAME instead of street and number?

EF °) EFL a seams DIVISION OF VITAL STATISTICS "ity se scfm sinker pataleay aa
a STANDARD

14S “awa rer. CERTIFICATE OF DEATH Registered No.......... KS pas | .
SI
5
Bu

2 Fut NAMEL LL LL Aly...<_ PARR... BLAZO Oe re Be {Wer

aif pr eal is a married, widowed or divorced woman, give also maiden name.) SECM WAM) n5:0.;0::0nczaccosaceneeeae
(a) Residence. No.. 0 Baw (AE eS Se ema Sti, een. Ei: eee See he Se ee
(Usual place of abode) (If nonresident, give city or town and state)
Length of residence in city or town where death occurred 26: yrs. mos. dzys. How !ong in U. S., if of foreign birth? yrs. mos. days.

PERSONAL AND STATISTICAL PARTICULARS MEDICAL CERTIFICATE OF DEATH

5a If married, widowed, or divorced

18 DATE OF

hat | a f dggeased
ivi ide: st} 334 1 J3
(or) WIFE of Ch & KE ta. a tL a= Ae OQ =D eer te meet, Oe - Si fe said

Husband's name in full)

6 IF STILLBORN, enter ra fact here.

ae ieee vie feonin GANS ae ocases! Months... Days
| 8 bic a or particular .
ind of work done, as spinner, yf : = = 1
sawyer, bookkeeper, etc... . Bis oy f= : WALA file... “4
9 Industry or business in which
work was done, as silk mill lee \ es
saw mill, bank, etc... Gd. if WAS T=)

10 Date 2 amt last worked ‘ot 11 Total time «vears)

5 nth, aad spent in this
Scns a : occupation... AF.

ee Pari
Name of operation..........4.%..

14 BIRTHPLACE OF aad
oS I i eae, eae ee What test confirmed diagnosis?

(State or country)

n
= , Y i

= «
{15 oe If so, specify...
- (Signed)

a VO g

(Address)
TT ETS Ges ee OR, Ba eee a Pey AGE ey ee TOs Sapa

If less than 1 day
= ioe Eanes Hours............ Minutes

OCCUPATION,

21 PLACE OF BURIAL,
(State or country) C-LF# {\ CREMATION or REMovAL A.V. T-A. ne CP. WV [Ths Ree
(Cemetery, (City or town)
BATE GFIBURIAD. kB ccf Once lst 19

17 ; be YL yc
diet CP ara au Wagan oe 79 eBerthner Ase drrepeed Aho Mb Pet

| HEREBY CERTIFY thet a 7 engl standard certificate of ae was ADDRESS........ LEAL: ]

Received and filed

“A TRUE COPY, ATTEST: Cegistrar)

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
ae 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, ¢. g., heart
failure, asphyxia, asthenia, etc. As principal cuse 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|” Pate of onset
of importance in order of onset were as follows:

Cerebral hemorrhage

peererrrrrrrr tt eeeeeeeeeeeeees connadbpneedéuh sdapuucdvancnusctovacsyucssdusssedpousdo=cah| Siswaqusngasenenes¥elhannh

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 HE LAWS OF T *
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 re uired by section one,
where same was contracted, the duration of his last illness, when last
seen alive by the physician or officer and the date of his death....
Gen. Laws, Chap. 46, Sec. 9.

ody and remove it from a town, from one ceraetery 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 .rom 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 tnere 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. lr there is no attending physician, or if, for
sufficient reasons, his certificate cannot be obtained early enough
for the puters: or is insufficient, a physician who is a member of the
board of health, or employed Dy it or by the selectmen for the purpose,
shall upon application maize the certificate required of the attendin:

physician. If death is caused by violence, the medical examiner shail
make such certificate. If sith a permit for the removal of a human body,
not previously interred, trom one town to another within the common-
wealth cannot be obtained early enough for the purpose, the certificate
of death made as above provided and in the possession of the undertaker
desiring to make such removal shall constitute a permit for such re-
moval; provided, that such body shall be returned to the town from

which it was removed within thirty-six hours after such remoyal, unless

a permitin the usual form for the Temoval of such body has been sooner

obtained hereunder. If the death certificate contains a recital, as re-
quired by section ten of chapter forty-six, that the deceased served in
the army, navy or marine corps of the United States in any war in
which it has been engaged, such recital shall appear upon the permit.
The board of health, or its agent, upon receipt of such statement and
certificate, shall forthwith countersign it and transmit it to the clerle
of the town for registration. The eget to whom the eae is 50
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 by Chap. 48, Acts of 1927 and Chap. 414, Acts of 1931.

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 shallin 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 pen 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 seoticemia),
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.

R-301A

Every item of

PHYSICIANS should state
Exact statement of OCCUPATION

IS IS A PERMANENT RECORD.

AGE should be stated EXACTLY.

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

y supplied.
terms, so that

See ins

i tant.

is very impor

-9-"30.

formation should be carefull:

CAUSE OF DEATH in pla

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

No. 9954.

The 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.
ERTIFICATE OF DEATH Registered No..wttt
I“ (If death occurred in a hospital or institution,
wf x ie, ce 7 give its NAME instead of street and Paz, Sp
s (If U. S.
isc Se OE oho AEE ee War Veteran,
(If eceased i isa, married, widowed or ght specify WAR)...............0.4 Ce ee
(a) Residence. Not G... 7 sate ( LG eae FEE MOA sere 4 le oy GSP one Ward, SE ae Poin A hide CC
(Usual place of abo ce (If nonresident, give city of town and state)
Length of residence in city or town where death occurred ~ yrs. mos. days. How jong in U. S., if of foreign birth? yrs. r mos, ' days.
PERSONAL AND STATISTICAL PARTICULARS MEDICAL CERTIFICATE OF DEATH
y oR RA 5 SINGLE (write the word)
8 va fp cata yay pees = Y}| 18 eo | Ee
}} VY WIDOWED eg I DEAT cscrccshescccsssesressss BinsctsgotseneannssseenrscnnnenrefennsefcereesezechauneceyssMpecraretgaicessnn
w72xtt{\ “77 or DIVORCED (Month) (Day (Year)
5a If married, widowed, or divorced I HEREBY CERTIFY, That! attended deceased from
IPI SENDD 8 ces cacscccaseocscessscossasoadpsasnessis Borcher tec erect cies Ce Ra AP NECN eee ~.J 1 3
(Give maiden name of wife in full) . rae bee ’ 19,3. ke
ETE, of 3 -erketetth dal ene dies ROR ee i set fat ee ter , 19.4..3., death is said
(Husband's name in full) Ae —
6 IF STILLBORN, Setar that factors. _to have occurred on the date stated above, at........... 99
The principal cause of death and related causes of importance in order of
If less than 1 day onset were as follows: " Uathiet Ganat
oe eres ick YOaMS...ccececeee Months............ Days | --c-:--<a. Hours.,.«<.......Minutes oe

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

9 Industry or business in which
work oy ate, as silk mill,
Sa nanmme aD FP NE SNEAD eT Lee Ree asco cass pn ante oa wv cceess Meant Fee Sone NWN Ew samen «ant da doeedoneececets-ceese
10 Date deceased last worked at 11 Total time (years)

this occupation (month and spent in this

MM oso ade cece ncc age oe tascn cadences vosatvevese occupation.............

OCCUPATION,

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

13 NAME OF j
FATHER ys

= Name of operation ;
14 BIRTHPLACE 0 A / What test confirmed diagnosis?.....c>t................. .........Was there an autopsy?....

20 Was disease or injury in any way related to occupation of deseaSe?...e..-...--s..-..-

PARENTS

HERSOySPIGCL EMS cas cares cc scessctes ts. -cassousrtrsuevce dt sevctenctitevsaasscpccecces A eet eee ee eee
(Signed) .......Acz|... MAYS ved, _, oo a Ve Ra peed
16 BIRTHPLACE OF rae (Address)..... :
Fa) BA cate ae ie) Pat Una 4 ae = eR ee ‘Spe ee eee J
(State or Sets Y / 2” CREMATION OR REMOVA Ly
4 & - aa
= ~ = +e Rk ae = (Cemetery) (Citysor town)

3 Fe Cay j Z x 2" _ 8 vs re, >
ee Ws Ai Lie * ce Ae af PP 14, DATE OF BURIAL...é<: Me <2 Ph Fn EE es 19.
ess)“ f 2 PY, - : 2 NAME OF :

0 eS eS Se Se UNDERTAKER wc:
EREBY eee thatas yd standard certificate of death was 5
Jed with m a t transit permit was issued: ADDRESS.“
‘ae yo" Bionature of é Ree Ives Archit: corsets nce cccnes tees soxteceah ofa ces acoccesccdnstentesdbcees«pucavcusecusrousteemavnesvore
Ld... f- , Z Ee See nr tl UN Q eed OES
Official Designation) } +t te rd 4933 (Registrar)

Revised United States Standard Certificate of Death

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

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
“orth 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.

Example

The principal cause of death and related causes

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

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

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 ermits,
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 Pyepor, 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. i114,
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.

(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.

=
rd
&
>

Every item of

PHYSICIANS should state
Exact statement of OCCUPATION

ified.
tructions and extracts from the laws on back of certificate.

AGE should be stated EXACTLY.
properly class

in terms, so that it may be

See

ion should be carefully supplied.

CAUSE OF DEATH in pla
important.
No. 5469

is very

75m-5-'32.

N. sigh ve a a WITH UNFADING BLACK INK—THIS IS A PERMANENT RECORD.
‘orma

\ The Commonwealth of Massarhusetta To be filed for burial permit
x OFFICE OF THE SECRETARY with Board of Health
2 ae hehabenndenensvases ( aban Neceneasorsessenssencaes DIVISION OF VITAL STATISTICS or its Agent.
a STANDARD 4+
116 CERTIFICATE OF DEATH Registered No........./ } PR po 5
ta
S (If death occurred in a hospital or institution,
BING 6... LP. BR... ALIA. coscsssncnvsnsenssagflersevveserecsscensesenseevagian ses See Soaiuaeeviveasexeabe +6 Ward give its NAME instead of street and number)
y (If U. S.
2 FULL NAME........’ Sheil i ee noe of thesia ene War Veteran,
(If deceased isa a marsjed, widowed or divorced re, give also maiden name.) SRCEUG WAM) iavcieicccceccsossacnctey
(a) Residence. No........ ZO Bye aot er owe ee ALS Sn. 21 2 yeas Were oie oases eens toe
(Usual place of abode) ba y a (If nonresident, give city or town and state)
Length of residence in city or town where death occurred <4 Ov. 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
MARRIED
WIDOWED FP Hs Sies Br fer Se ee 33 becpren
Ze, or DIVORCED
5a If married, wi i ! / CERTIFY, That I attended deceased from
HUSBAND of I. Qeamcey. LE... 190308 to, SAO... LE... 19.8.3
SY Ee Sy A aR oe ee 0 ee wher. j ge 23. , death is said

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

to have occurred on the d

The principal cause of Geath and eiaied causes of importance in order of
If less than 1 day onset were as follows: “Date of Onset
Dick Hours............ Minutes IMPORTANT

ii ">?
AGE........ 1. 7 ae Ae Rae Months 42x Days

| 8 Trade, profession, or particular

kind of work done, as spinner,
sawyer, bookkeeper, etc,..............

9 Industry or business in which

work was done, as sik mill,

cwse

OCCUPATION,

saw mill, bank, etc... Pain ,
10 ar pees om worked at 11 Tctal ane a)
is occupation (month an spent in this
year) cae OE eee et fon ee occupation... pea
12 BIRTHPLACE (City)... em ccccccccsnssseneseesnnece |
(State or country) Fra auiz7z e

13 NAME OF "
PAMMER 2. ¢ foe &

SUeareRLiTe oF Name of operation.............4..< s
FATHER (City) What test confirmed diagnosis?. <<

(State or country) vy 4Ft4éa2zsv 20 Was disease or injury in any way related to Bat
16 BIRTHPLACE OF

15 MAIDFN NAME ——~ If so, ro RUS ae) CP ee ee
OF MOTHER (Signed 1 Oe ng So are
MOTHER (City) ...08

ial ta eS ie A

pb ea ae ata

= flawloru
i. J DATE OF BURIAL sth AE Po forgo 19. AF

PARENTS

(Address) 6 s 22 NAME OF
UNDERTAKER ......
! HEREBY CERTIFY ae a satisfactory ihdard certificate of death was FoR:
fil with me BEFORE t | transit permit was issued: ADDRESS.......... a

<E. + eed <tr 1k 3 Sed seebep eee Pee Sere Received and filed................. J AN.20.4 sede 1933 ee ren Repo tee cee te 1 ees
oo page Seg ora LITLE hovachvafansersvarscessch [ncevoeee essences icaeccbe pers eee Eeneans Sa a

~ Revised United States Standard Certificate of Death

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

To be complete, an occupation return must state:

8.—The trade, profession, or particular kind of work done.

9.—The industry or business in which the work was done.
10,—The month and year the deceased last worked at the occupation.
11.—The number of years the deceased followed the occupation.

In stating the occupation, avoid the use of such indefinite 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
wad 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, é. &., 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
ofimportance in order of onset were as follows:

Arteriosclerosis 1gls

Chronic interstitial nephritis 1o2r

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 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
hapvvers to be the second cause given.

EXTRACTS FROM THE LAWS OF THE :
COMMONWEALTH OF MASSACHUSETTS
GOVERNING THE

RETURN OF CERTIFICATES OF DEATH.

ody and remove it from a town, from one cemetery to another, or
from one grave or tomb other than the receiving tomb to another in the
same cemetery until he has received a permit ‘rota 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 tnere shall have been
delivered to such board, agent or clerk, as the case m~y be, a Satis-
factory written statement containing the facts reauired 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 pee or is insufficient, a phvsician 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. Tf such a, permit for the removal of a human body,
not previously interred, trom one town to another within the common-
wealth cannot be obtained early enough for the purpose, the certificate
of death made as above provided and in the possession of the undertaker
desiring to make such Temoval shall constitute a permit for such re-
moval; provided, that such body shall be returned to the town from
which it was removed within thirty-six hours after such removal, unless
a permit in the usual form for the temoval of such body has been sooner
obtained hereunder. If the death certificate contains a recital, as re-
quired by section ten of chapter forty-six, that the deceased served in
the army, navy or marine corps of the United States in any war in
which it has been engaged, such recital shall appear upon the permit.
The board of health, or its agent, upon receipt of such statement and
certificate, shall forthwith 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 sha!l 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. OE
as amended by Chap. 48, Acts of 1927 and Chap. 414, Acts of 1931.

Medical examiners shall make examination upon the view of
the dead bodies of only such persons as are supposed to have died
by violence... .Gen. Laws, Chab. 38, Sec. 6.

..He shallin 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.

Che Commonwealth of Massachusetts ,
2 OFFICE OF THE SECRETARY Che lsea
PEAT Rauavuckansdlapuncaiapracvudaxas> Oiscuend@snsynideusvvetavubensicece A DIVISION OF VITAL STATISTICS sutacasnsungedisarUeanas scudcus¥ebucaiatt codttadan aCe
a (County)
a Pat soa STANDARD
14 & CERTIFICATE OF DEATH .- Registered No 53
ra}
a
[7

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

U.S. | Mt
2 FULL NAME............ Le age ogee oN Ts {We Veen, ‘Yorld War
specify WAR)...........ccc0c000

(a) Residence. No. 145 Somerset av. St. sates Ward, _“inthrop, Mass. :.

Meat lacs ck Stoies edcvnveccccecerscasssccceusoceconecscsosecsevosbeasueeseceeesasvessscvacesonees Ceci ce culo wea

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.

Every item of informa-

PERSONAL AND STATISTICAL PARTICULARS MEDICAL CERTIFICATE OF DEATH
5 SINGLE (write the word)
3 SEX 4 COLOR OR RACE MARRIED 18 DATE OF Jan.18.19%33

DEAT -ccictescsstassccevsseccrcres kh Reeth coal haere Mahi By nes oe 2 Vm a is Wo, «fd
male white a bivoRcen Single oe) (Day) Grav
a IN eg NA a Nee ah | (ee SE en eee ee
5a If married, widowed, or divorced 19 I HEREBY CERTIFY, That | attended deceased from

Hesesass dant... poo. Oan Hrs vcr es tiuctr cr

(or) WIFE of | last saw fi alive Pen RBs ml N= le

PHYSICIANS should state CAUSE
Exact statement of OCCUPATION is very

to have occurred on the date stated above, at

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

6 IF STILLBORN, enter that fact here.

7
GEo. 46 Tw. Days Minutes

8 Trade, profession, or particular
kind of work done, as spinner, Traffic man
MRWREYT OGKIEEDER, | GLC iirc oh a is cicssaasscsoscintcscaazbasaounburvansvarsavodgauvorsdeisuasdcsesussansanveed

9 Industry or business in which Ba chelder & § nyd e
work was done, as silk mi M rs
saw mill, bank, etc. QO.7.5 AE 8.2.e speeches CM aE

10 Date deceased last worked at 11 Total time (years)
this occupation (month and U/ie /19% a eeent in this] 4

occupation

OCCUPATION

Contributory causes of importance not related to principal cause:

AGE should be stated EXACTLY.

TES Ts cacstivonsccctese

(Registrar of cit

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

i
F
a
o
a)
I
B
i]
o
2
b ..ggeneral...perit.onitig.......... 1/4/19 43....(:2.)
I fete or couneee) _Sangrenous appendicitis 1/4/1935 |
Cd
= -
3 13 NAME OF ee Meteora ora ne» cnt mmem amen oe asian mente ce pasan es aaeaseendersadnencee= cea densgneaareeti= al peaee eee
35 FATHER Walter McLeod ao Dendectomy
2s Lee ee EERE eee Name of operation.............0ee0e ope ret bene: Date of...25
2 i} «| 14 BIRTHPLACE OF --- What test confirmed diagnosis?.......... a eae Sr eee Was there an autopsy?......0
Q t es RATHER) (CILY)) oi. Reoseseceess Canad Beas te conse ctet noses coe tv wae elacieneseGancpsvaveal
aa z (State or country) vanada 20 Was disease or injury in any way related to occupation of deceased?
De = 15 MAIDEN NAME : 4 é LfiSO) SPECITY Rs 2 cusctccccae i temnoe apc es boa noe ev ens cabew~ cals bele ac wcrPa tee etee Se eager
34 <| OF MOTHER Ada Helen Baxter (Signed) .... Vnh.ten Jamin, fn? Nemes! a M. D.
5 * ss > == ey Saal (Address)... U.eS.2.Naval. Hosp pate L/18..19.33
ar 16 BIRTHPLACE OF sesedres @2.B..%8 bee SA cb NAID beh Meee DAle. (Pee Of ae BERS IS ke |
$a MOTHER (City) Re OOS Ge ee a |
a. 21 PLACE oF Burial; C2. MASS. aa
gs (State or country) CREMATION OR REMOVAL _flintiaren Pech. dant hrap
sa au emetery ity or town
Bra y|| 17 Dorald McLeod DATE OF BURIAL.....‘) an.20, 1053 Peat eee 19. nog)
S Ones age er
ERE 2} | Gdaress) 145 Somerset ave. ,Winthr Ep. ees «Rk. Bennison
c. B 2 ||A TRUE copr. Hi rofl . spnarss: Mab TO Dp Mes 5 occu cscnlie
368s { Cche7
q
FS
S

(Registrar of City or Town where deceased resided)

AS gars

if vse | "
“The Gundnonwedish of Masnnthundtie To be filed for burial

R-303B
— OFFICE OF THE SECRETARY permit with Board of
e mnenens DIVISION OF VITAL STATISTICS
om 4 /§, & ji ealth or its Agent
° a MEDICAL EXAMINER’S J
Ex § hs Gree \A A CERTIFICATE OF DEATH Registered Now... J. .cccccsecseee
2 % g (If death occurred in a hospital or institution,
E q a No. bIwawk Me ...Ward { give its NAME instead of street and number)
> ° .
woss , , (If U. S.
a8Ss 2 FULL NAME...--}<. $ d \ os Ge APR eek leiceudabacwsencntvtenens War Veteran,
52 3 ceased isa married, widowed or divorced also maiden name.) SOraty WAR): 05. <ccaves>,ccsstiesdiceiaecinee
ow % (a) Residence. No...\e WRAL. i . 2D AO nS Wierd Shige sesctee a enh RRs penaatnes 2
ONO 3 (Usual place of abode) (If nonresident give city or town and state)
g 25 = Length of residence in city or town where death occurred days. How long in U. S., if of foreign birth? yrs. mos. days.
3)
ea PERSONAL AND STATISTICAL PARTICULARS MEDICAL CERTIFICATE OF DEATH
222% 3 SEX 4 COLOR OR RACE | © SINGLI Kesxite Boywayd)
| co
7)
o's i abe utd. Oe OIVORCED Fy z
f755 0 or
-_ . « a
0 24 5 ee a widowed, or divorced 19 I HEREBY TIFY that I have investigated the death
es £3 ay (Give maiden name of wifein full) SS of the person above-named and that the CAUSE AND MANNER thereof are
y MUMMIES 2955 cu8 sons cast hs vce oniosccbeesrtane ty Bericht Cecenetiasssctode as wed. apteeopahtcosseartaned as follows: (df an injury was involved, state fully.)
<0 Se (Husband’s name in full)
nes 5 2 6 IF STILLBORN, enter that fact here.
as 2 7 If less than 1 day
ate
Ee He 8 Trade, profession, or particular
J i = kind of work done, as spinner,
rs) ° sawyer, RM NL Tap at % neta costo eaei cop va esate vbiesdccbspans vses sends obiagesmonsnemtcs
Zo > PS =| 9 Industry or business in’ which
mT a work was done, as silk mill,
“9 Ro = RUE RRRINE SUEG vase egl os <1 ss adanvwceaca sanndanisdaeesOersaatePeurias sé sirabte daha dgubeedgabeoneecsonass
Ue oc S 10 Date deceased last worked at 11 Total time (years)
= Be this "Shaheed inane i spent in this
4 8 £ year) .. ‘, OCCUPATION... ....-..-00-000000+
3 °
28 12 BIRTHPLACE (City)........0...4.!
(State or country) - s ‘
13 NAME OF ; y)
a
2 FATHER ogy , hina, Aang

14 BIRTHPLACE OF
MR MNMRS CRONE) ick sgh « Meee Salva sc ee saat vin vsennsnsescecdpoatascdeivienevs

(State or country) 7a Ade we)

15 MAIDEN NAME
OF MOTHER ;
16 he OF

MOTHER (City) ......... SMart eae ATSS scons kee Geos casa ege Wena yo ones Spoeaiaesaterencanete
(State or country)

PARENTS

See reverse side for extracts

information should be carefully suppl

DEATH in plain terms, so that

N. B.—WRITE PLAINLY, WITH UNFADING B

Informant 5
2 22 NAME OF
s =) ot a UNDERTAKER
o& HEREBY CERTIFY t At a sper grea? standard certificate of death was
As ith me EFORE I e burié eld. permit was issued:
a U,
6 WM WP Me? hig t. SS a See
S 1a 86 Ie ‘of Bo ealth or other)
‘ 3
- Ell x cial Designation) es tits efmit) mit) /

EXTRACTS

FROM THE LAWS OF THE
COMMONWEALTH OF MASSAGHUSETFTS
GOVERNING THE

RETURN OF CERTIFICATES OF DEATH

A physician registered hospital medical officer shall forth-
with, after the death of a person whom he has attended during his
last illness, at the request of an undertaker or other authorized
person or of any member of the family of the deceased, furnish for regis-
tration a standard certificate of death, stating to the best of his knowledge
and belief the name of the deceased, his supposed age, the disease of
which he died, defined as required by section one, where same was con-
tracted, the duration of his last illness, when last seen alive by the
— or officer and the date of his death....Gen. Laws, Chap. 46,
ec. 9.

No undertaker or other person shall bury or otherwise dispose
of a human body in a town, or remove therefrom a human body which
has not been buried, until he has received a permit from the board of
health or its agent appointed to issue such permits, or if there is no such
board, from the clerk of the town where the person died; and no under-
taker or other person shall exhume a human body and remove it from
a town, from one cemetery to another, or from one grave or tomb other
than the receiving tomb to another in the same cemetery, until he has
received a permit from the board of health or its agent aforesaid or from
the clerk of the town where the body is buried. No such permit shall
be issued until there shall have been delivered to such board, agent or
clerk, as the case may be, a satisfactory written statement containing
the facts required by law to be returned and recorded, which shall be
accompanied, in case of an 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 porpos. 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 apueaion 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 pee i of such statement and
certificate, shall forthwith countersign it and transmit it to the clerk
of the town for registration. The person to whom the permit is so given
and the physician certifying the cause of death shall thereafter furnish
for registration any other necessary information which can be obtained
as to the deceased, or as to the manner or cause of the death, which t

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