The volume, 1934

Town Clerk, Winthrop · from the Internet Archive · 498 pages · 53.0 MB
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J. L FAIRBANKS & CO.

Stationers
43 FRANKLIN STREET
—BOSTON—

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CCUP

PHYSICI
Exact statement of O

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

“IS A PERMANENT R

‘AGE should be stated EXACTLY.

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

tant.

information should be carefully “supplied.
is very impor

. B.—WRITE PLAINLY, WITH UNFA

No. 7070-h

100m-12-'32.

(a) Residence.
(Usual place of abode)

Length of residence in city or town where death ee, 2 yrs.

The Commonuealth of Massachusetts
OFFICE OF THE SECRETARY

E uti ORK near DIVISION OF VITAL STATISTICS (City or town making return)
a STANDARD 41
(Ss CERTIFICATE OF DEATH Registered Now....c.ctnesesue-
ww (City or Town) (If death di hospital or institution:
eath occurred in a hospital or institution,
a No.....69...7 9hnson. Ave Peet de ncnnhak aanee valde sity tapes denen St., ewan naianseoan iene Ward { give its NAME instead of street and number)

2 FULL NAME...AmMbrose Albert Martin

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

No.........0.9...9.0HMS 0. AVS...

(If U. S.
War Veteran,

specihy WAR) sisisovecssssasecdhavienscosaesale

(If nonresident, give city or town and state)

3 SEX

Male

HUSBAND of
(or) WIFE of

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

82. (Shae ae Shays... @... Months ..cke-e Daya

8 Trade, profession, or particular
Yacht —— &

kind of work done, as spinner,
REWER E HOOK REED ET. CLGs.ccesvaipucsacseavsevreMMe ge rnns7eeorgcree rat narasteocesnonsceereranvecovorsusk

9 Industry or business in which

ee awk a, Bul lding “plant

11 Total time (year.
spent in this

If less than 1 day
peeeccees Hours............Minutes

OCCUPATION

10 Date deceased last worked at
this occupation (month and

CEE) ce an SO nee ee OCCUPATION... cceeeeeeree
12 BIRTHPLACE (City)....... VAS... BOSTON cc cscnseemee
(State or country) Mas sa echus 8 + ¢ Ss

‘13 NAME OF

FATHER’ Albridge Gerry Martin

14 BIRTHPLACE OF

@| "FATHER (City) ....... Mere lenena: =. eo...

= (State or country) Ma s sa chus 8 4 7 s

=|°° Or MOIHER” ##$Rebecea Dixie

a INI EEE —EEE—————E————E——E—EE———E SS
Tan ce Unable to obtain... .

(State or country)

ile §

Informart ..........0.57
(Address)

| HEREBY CERTIFY ead a satisfactory standard certificate of death was
i me BEFORE the fal or, yy permit was issued:

mos. days. How long in U. S., if of foreign birth? yrs. mos. days.
PERSONAL AND STATISTICAL PARTICULARS MEDICAL CERTIFICATE OF DEATH
5S SINGLE (write the word)
4 ss OR RACE MARRIED 18 hl ¥ 1z 2 a 2
Whit 8 or DIVORCED Merri 1ée a (Day) ee ear)

5a If married, weowae ou A: ie Beadle EBY CERTIFY, That | attended deceased from
Se laa Sag Pe Mame of Wien full) eet SPIN EN nt) Denese roche. WP scons sca wcvanencsan vedaivodsinestinaen 193, to Rs Me... es 193%.
ROR eee eee eee ee ees SOO CCE Oe Het a sees ee eeE EE ESSE BECO e Ee One SEE EEE EEE® HERE ree EEE EEE Hee eH Eee nsenEE Dense eEHEtnneennensee j 17-SZ., death is said

Macca A occnces ceaeteaveesaeappetteess
to have occurred on the nay above; at 3.22 fie
The principal cause of death and related causes Of importance in order of
onset were as follows: Date of Onset _

Names off Ope Ration staiccnecss-casauisuaysaectieeeesscseaggliooeszsss.cscess
What test confirmed diagnosis$44“4e<

20 Was disease or injury in any way related to occdpation of deceased? .....4.<@/....
If so, specif
(Signed)

Winthrop... {

7) CREMATION OR REMOVAL i inthrop
(Cemetery) (City or 054 i
DATE OF BURIAL...) PILE LY... cccccssnstnenssnnrnern
22, NAME OF .
| OO UNDERTAKER ........ CARER LEOS..ReBEMMAS OM. ccc

ADDRESS: <u. We COP, MASS ee

_ i

Revised Unitéd 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 houscke 'per—private
family, cook—holel, etc. For a person who had no occtujation 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
a 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, a3 rar penter,
painter, machinisi, 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:

Tors

Chronic interstitial nephritis 1o92r

Arteriosclerosis

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 LA
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 tne
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 attendigg physician, or if, for
sufficient reasons, his certificate cannot be obtained early enouh
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 errnit 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 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. f ‘

(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.

N. B.—WRITE PLAINLY, WITH UNF:

SOUR RE re = Reneete.. ane

Un Binet

PHYSICIANS should etate
Exact statement of OCCUPATION

AGE should be stated EXACTLY.

Cae

formation should be carefully supplied.
terms, so that it may be properly classified.

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

mportant.
No. 7070-h

is very i

100m-12-'3

CAUSE OF DEATH in

EZ
|| AGE...%%.... CAG... Years..............Months ....... ....Days

The Commonwealth of Massachusetts
OFFICE OF THE SECRETARY
DIVISION OF VITAL STATISTICS (City ox tomdinikina <aGn yo nee

STANDARD a
CERTIFICATE OF DEATH Registered No.................

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

(lf U. S.
War Veteran,

SPEC YG WAL) tees scckrencatteecessctencctastoitt

ra
PLACE OF DEATH

2 FULL NAME.

(a) Residence. No................ ‘ Z.. VME ark. OEE Ae ne A Se Ae a ye Mae ns
(Usual place of abode) (If nonresident, give city or town and state)
Length of residence in city or town where death cccurred yrs. mos. days. How long in U. S., if of foreign birth? yrs. mos, days.

a AND STATISTICAL PARTICULARS
3 SE a & COLOR R RACE 5 SINGLE (write the word)

yh MARRIED
0). WIDOWED
2 er DIVORCED _</

5a If married, widowed, or divorced
PTS) 0) as be Sa Oe Ee eee eee

18 DATE OF
PEAT vec cteccteessds cesta scceascurceateceeceest arn ucn roves -caih ansevauaeresnstr sate mano arep See een em

MRRP IN, sco chan pos ace Rc ech vine oa send oak dupa cdsnsines usdabe tees ASLRNE wddceia vane
(Husband's name in full)

6 IF STILLBORN, enter that fact here.

The principal cause of death and
onset were as follqws: ~

If less than 1 day

-8 Trade, profession, or particular
kind of work done, as spinzer,
sawyer, bookkeeper, CLC......0.0

9 Industry or business in which
work was done, as silk mill &
saw mill, bank, etc.........-..-eA.--.0 AK be

10 Date deceased last worked at
this =e rab leds and vi
yeer).. : : oe

OCCUPATION

Total time (y:
spent in this
occupation........./. =...

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

-183 NAME OF
. FATHER

14 BIRTHPLACE OF
FATHER (City) .

(State or country)

Es _L/
15 MAIDEN NAME or, YW. \f so, specify...

GF MOTHER
: Lh PAM ALG GAG (Signed) .......

16 BIRTHPLACE GF
MOTHER (City)

(State or country)

PARENTS

17%

|| 22 NAME OF
Es UNDERTAKER .... erie ae |
ADDRESS So. Ladd

PRPC HU ene TAMIL GaEN ta eco cee ossctevies ch nan scan nctet Siu gmop ego scegucsvseavtstsvedvenchicecasneb oroueennsonenveasy

(Official Designation)

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—privule
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
et of store, factory, mill, etc., as grocery store, soap factory, cotton
mill, etc.

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

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

Example

The principal cause of death and related causes

F e Date of onset
of importance in order of onset were as follows:

CN 22, SO Sr ae | ee et
Chronic interstitial nephritis Sec RR Ml ran eects
Cerebral hemorrhage July 5, 1927

Contributory causes of importance not related to
principal cause:

lhanoens to be the second cause viven.

EXTRACTS FROM THE LAWS OF THE
COMMONWEALTH OF MASSACHUSETTS
GOVERNING THE

RETURN OF CERTIFICATES OF DEATH
A Phgsician 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 purport 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 i pees 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
whichit 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. 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 given bedside care during a last
illness from disease unrelated to any form of injury.

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

MARGIN RESERVED FOR BINDING

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

Every item of informa-

PHYSICIANS should state CAUSE
Exact statement of OCCUPATION is very

AGE should be stated EXACTLY.

DEATH in plain terms, so that it may be properly classified.
tant.
97-d

a
eek

tion should be carefully supplied.
50m-2-'30,.'No,.

Che Commonwealth of Massarhusetts

SUFFOLK OFFICE OF THE SECRETARY
= Prrrrreritiririiririitit tT itrit terre eet ee eer DIVISION OF VITAL STATISTICS
< (County)
a BOSTON STANDARD
(ORES erste deli CERTIFICATE OF DEATH Registered No....... 14.0.0... |
ww (City or Town) |
< (If death occurred in a hospital or institution, |
mw Now... Mass..Memorial..Hospital................ | eee Ward } give its NAME instead of street and number)
(If U. S. |
0 TS hn et a avai” San a ade War Veteran,
(If deceased is a married, widowed or divorced woman, give also maiden name.) BRETT AVIA DR as 6ilasa iden neascerpnessousecvecisheee
(a) Residence. No........... 9.. Tewksburry. ye Oc ee ee Steen eae Ward, ........... W: hrop Pee ences vee ae
) (Usual place of abode) . ; (If ~ Want! , givé city or town and state) |
Length of residence in city or town where death occurred yrs. mos. days. How long in U. S., if of foreign birth? yrs. mos, days. |
PERSONAL AND STATISTICAL PARTICULARS MEDICAL CERTIFICATE OF DEATH
5 SINGLE (write the word)
— |» | ee aa Lae dee ey ; SAR 1934...
er DIVORCED married (Month) (Day) (Year)

5a If married, widowed, or divorced

MUNNAR MNNN DRE aaa ons Pare eek eal rene cskabuee te pntn tok Posh ans vsnches oueat Cesc ancesoinenstsitarbvaeincesvecoveees |
° ie oe geet Gees ae caer | Deg... rs” Seeds 19.999 tO. SIMD occ bee _ 19.34. |

(or) WIFE of .................... j i Lam. Laws Mase oe seenee ren tanaceasnrkces seep areas ates I last saw h...@J*..alive on........ |. eee eres: reer , 19.34, death is said
ms , Lie s -B.. in full oF Jan 1
to have occurred on the date stated above, at4e1.5P.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: ae er

If less than 1 day
Paes tess Opeeeesiss» ¥ CANS. :s-.00:2-.- MOMNEHS'-.2-2.-:.-.. DAYS! |. .0s20050:- HOUSSi:.<s55:..:

8 Trade, profession, or particular

kind of work done, as spinner, housewife and..ducts..with.generalized.abdomina Ret=

sawyer, bookkeeper, CLC............:0:::eccoccseee See etree ee een sonccnsseceaseeseesssessensses
B Indistry or business in. which astases,21s0..liver., lung,pleura,thoradgis..duc

work was done, as silk mill,

OCCUPATION|

Pree ear EMMI NG Eos nese csocau-catmncaae eve cnc arse ceb ence vos cotapse ban o'eseteSat smazarindrosers one
10 Date deceased last worked at ERT aeRO Rell BRANES VANS Mery es leek raze i einac oc ss sea danaet te cedte sues smuup cess acavass anonacasueuscdemevessseeb:caseuoete iitescaameerated
this occupation (month and spent in this
Deere aaack ecb tensa: cases Tusa na cameos ish aisustiexscksaradd we occupation............ ae

USA PTEMIN EA ORT ES EAA COEE Yo) csec ace ou ne tee wake cetera eden er Pacers thoy Nvainea ovadbugudsunissyoaseoeepsacivardess
(State or country)

13 NAME OF
FATHER

14 BIRTHPLACE OF
FATHER (City)

(State or country)

PARENTS

a oR IR PE e HE BE SAREE ash erence sepestereriendengendimmnrnivoreceniersetiniepnetnne onclagrbanobevperrestd
OF MOTHER ES | aC eae et be ee , M.D.
ee ae eS Date... (2/1934.
EEN arte cere nee a een ects eyes evar acvavnnstdinacnsacvSavacepbestudeGnesasens
21 PLACE OF BURIAL,
(State or country) Maine CREMATION OR REMOVAL..........- Winthrop es Winthrop .. np
emetery ity or*town

ee waves teccnsess gm petecsons ike 8 Harr, y Lewis : ental

(Address) A 22 NAME OF
~ f ; a] : UNDERTAKER ........ Ae Pie URTRRNINE ep icingsan le

ADDRESS

{Registrar of City or Town where deceased resided)

|
.
|

)

MARGIN RESERVED FOR BINDING

—

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

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

pplied.
terms, so that

nformation should be carefully su
tant.

CAUSE OF DEATH in plain

is very impor

CET

No. 7180-a

200M-11-'29.

The Commonwealth of Massachusetts
OFFICE OF THE SECRETARY

3 (County DIVISION OF VITAL STATISTICS (City or town ‘making Sateen)
a STANDARD 4
11 6 CERTIFICATE OF DEATH Registered Now............2 5 .cccccccseee
iy
< ; (If death occurred in a hospital or institution,
Ps OER ep Ward give its NAME instead of street and number)

2 dere NAME

sa (IE deceased i is: a married, widowed or divorced woman, give also maiden name.)
id esidence. No. 1-7

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

(If U.S.
War Veteran,
Gpecthy: WAR) scs-scrccvsccossssschessavvdasensewea 2

days.

PERSONAL AND STATISTICAL PARTICULARS MEDICAL CERTIFICATE OF DEATH
5 SINGLE (write the word)
3 SEX 4 COLOR OR RACE MARRIED 18 ate OF : /93 of
, WIDOWED q Sy a eee ite et ae Ae eee ee Zz ee i asnanloewin usar CE aa
ad | Me |__ or DIVORCED Aor (Month) (Day) (Year)
5a _ If married, sajidqwed, or divorce: So 19 IT HEREBY CERTIFY, That | attended deceased from
HUSBAND of .478.. 404A AAT... -
(Give maiden eae a wite 4 ES 1 full) scascceoefe Pe cf. Seccunecsaccrcoce 198.3
“ENTE cE baie Geis Ree te Oe ee ieee Oe a I last saw h..4e=s...alive on.........$ Sar
(Husband’s name in full) - 6:30
6 IF STILLBORN, enter that fact here. to have occurred on the date statéd above, at..8...°°4.
= ieee d - UG principal a of death and related causes of ania in order of
ess than ay onset were as follows: Seba eae
ee. / ZZ ee Years. 4.@.....Months............ Dayeilieeen HOUTS......----+- Minutes Datasfeuset
Mi tetstetsees lasses poreensensnsceneceseessesenssssssesnacsesceesaesoss[enggaesaavans
8 Trade, profession, or particular ae a Ee
=> kind of work done, as spinner, a oct Bg Ps TN Se REET CLEP Uc cnccacpecgencaccescccccsse ls F3Z
° sawyer, bookkeeper, etc.............%0@.R
Slee hiisyorbusinessin which § () J—O7 J 7) gg yc Gfrrecccercrecertmerrrrrteenreecenerceceneennennnanenneeacnrsccrcnernentece nonnnnntnons
o. work was done, as silk mill, Aiea
FI scant ig or re || ics asan= (Aho ncncafewaslenesss-=doc-scesaeqch cee ae sne deen ecesdee heads ov cnsnsWar<Mensnsesce| fees nerewanead
eemparontecsaseanaskworked sate ode fa) GP dTdtalitinie (years)! U7. ck season te Leqeen vance cosas evades cargucueds coontecedes Sucve estncesnsateueduadedaeuseceede Pas edecemawens
this paral onth and
year) .. a GY er ES Le a eee pal
é 07> Sv berom harbor Peeves sbochascdapeueeetl Z Pawel
12 BIRTHPLACE (City)...
Pena te rect mn ee ee Wl (eatnceanantenevuccusunccsdnnrsdonsaccdncveaMnanenacuceeesucaenehntscensnneathasnnzer aan-aeeee? | «sr aanseneas
13 NAME OF a) a gf restesestesessesesessecessscsenssseesscesessesnensensnsssessesansnsensesssssnesecsscsenessens | reseseesnees
FATHER : Nu ee teense
Name of operation........ “4 ONE Ra ns Date” Of:sssce cc eee
” i” ar Are OF C What test confirmed diagnosis? lseerel. TFaceedas there an autopsy?. uo
ni ae
z (State or country) 4
ee bes ie
| 15 MAIDFN NAME C7—
<x OF MOTHER
o
10 ROME
(City) .....! a. a“ a et ne 21 PLACE OF BURIAL,
(State or country) ME A CREMATION OR REMOVAL ..
17

DATE OF BURIAL.

, Wy = f
Me Sad ILD ee Ee hauled

UNDERTAKE

ry standard certificate of death was
sit Permit was issued: ADDRESS.....;

1 HE, ey ea that a satisfa

yp phen earesutaveter nts Received and filed...........-...... Bf ppseespycceeecessesssseencernnesnneenneesareenteunseenes 195505
ies (Gh. JAHN G 4534
(Official Designation) / 77" (Date of Issue of Pexmit)/ i) MIRUELCORY AYIEST: a) Regen)

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 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.

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

nd - 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 wholesuie merciianis” A “person who seils goods should be called a
Salesman and not a clerk.

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

Example

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

Arteriosclerosis

Chronic interstitial n

Date of onset

Cerebral hemorrhage

POO ence e news enaeeeseeeessssseeeseeessscsesces see

Contributory causes of importance not related to | - “i
principal cause: ie

Fracture

Automobile accident

happens to be the second cause given.

EXTRACTS
FROM THE LAWS OF THE
COMMONWEALTH OF MASSACHUSETTS
GOVERNING THE

RETURN OF CERTIFICATES OF DEATH

No undertaker or other person shall bury or otherwise dispose
of a human body in a town, or remove therefrom a human body
which has not been buried, until he has received a permit from
the board of health or its agent appointed to issue such permits,
or if there is no such board, from the clerk of the town where the
person died; and no undertaker or other person shall exhume a human
body and remove it from a town, from one cemetery to another, or
from one grave or tomb other than the receiving tomb to another in the
Same cemetery, until he has received a permit from the board of health
or its agent aforesaid or from the clerk of the town where the body
is buried. No such permit shall be issued until there shall have been
delivered to such board, agent or clerk, as the case may be, a satis-
factory written statement containing the facts required by law to
be returned and recorded, which shall be accompanied, in case of an
original interment, by a satisfactory certificate of the attending
physician, if any, as required by law, or in lieu thereof a certificate
as hereinafter provided. If there is no attending physician, or if, for
sufficient reasons, his certificate cannot be obtained early enough
for the purpose, or is insufficient, a physician who is a member of the
board of health, or employed by it or by the selectmen for the purpose,
shall upon application make the certificate required of the attending
Puysician. If death is caused by violence, the medical examiner shall
make such certificate. If the death certificate contains a recital,
as required by section ten of chapter forty-six, that the deceased
served in the army, navy or marine corps of the United States in any
war in-which it has been engaged, such recital shall appear upon the
permit. The board of health or its agent, upon receipt of such state-
ment and certificate, shall forthwith countersign it and transmit
it to the clerk of the town for registration. The person to whom
the permit is so given and the physician certifying the cause of death
shall thereafter furnish for registration any other necessary information
which can be obtained as to the deceased, or as to the manner or cause
of the death, which the clerk or registrar may require.—Chap. 114,
Sec. 45, G. L., as amended.

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

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.

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.

R
M R-301A
x) £Z
Se
. S.5<
: bas The Common
5; ° iP
B20 OFFICE OF alth of Massa
Y Ae ST TATIS o
a<e CERTIFI! ANDARD i be filed fo
“£55 CATE with r buri
Be ses mn Ath ban OF Board ial pe
oa pose sane PEA en. DEAT 5 of H rmit
o> E ( po: ee St H or its pele a
a P9reeeeee .
a 5 3 p ) Residence. é 6 SP akensancdes Ward { (If death Registered N r-
no ength of al place o. 3. give i occurred i Os...
2: s & residence in aed ag Zz (= eits NAME HP aE sian he > a2...
= Seed. e . Mier
, ae si = PERSON hun where daaik A Xk Ad ad of street eerans
t < Eu § SEX qi AL AND STAT ; tt WES (lt U.S number)
% IS Tia Aaa fe
“as? ac eee TICAL PAR aad eae a War Veteran
iste ee iS TICU ek speci ;
esa, ics mae | a rans a : wat.
ft 3 H married, wi RIED Gori ong in U Wau LANOZA n.
= = USBAN , widowed : WIDOW: ATP Ss . S., if of : f non Fea | eae
* Bee (or) D Off -sse-seesseess » or divorced 2 DIVORCED mn =~ 18 —— aa i give Gl or tow ay
Ar c or t cd,
a 3 * ° WIFE of ......... POR eect ge DATE OF AL CERTIF yrs. Drei duidiatate ane
n Se 5 ee maiden name of + DEATH ICATE OF — pi
a tee eats wget a ACS 4 D ays.
a a 7 soles uel ead er cepeneee wife in full) 7" 19 (V7 Mortis) t A ses
o act censure 8 ah a i
Fzas AGE. = Stiles, ee rg wer age [Poy
weg pie Years. puss. eee com TTF (sa x
2 T eS eas
Pact re E = ied professi ‘Months ..%& If le ae a HS (Year) fe
— B a ° of work jon, or parti at pls SEEN Days ss than 1 to h ali
i) e = sawyer. done ee Gat day ave
ih 2 , bookk , aS spi r H occu
¥o £ M| a Industry or b eeper, ns OUIS.......- : Theltprin rred on the d
Wi u H ean cip: a
<2 3 g uae was 3 elgg EC A. pe nore a og canue-ch te stated abo
a oh | SRagiaadaey a ilk Tee. ye ee Serge Ms ae » death i
uo * thi eceased iB OEVaresesersese ig. he Oe €q Ca a es i i
vs © is o jlast worked at abe ie uses '
wnt year) ecupation eoried at eee atkvemtvecsss 2 Sa Saas “of iinperianes in
z a8 g et, Me 4h oe gk 11T aa Cees | See Hee
ra) 3 22 tate E city Mea ———=—=— ve! time Ge OT ram ame IMP of Onset
a Z £ Senate tf e seth in thi ae a! MPORTANT
be Eg 13 NAME OF di f ccupation |
=o FA coe
5é - : ae - r Tt tha SA. |e
H es | 14 BIRTHPLA = 1 pit Jn
a) a El FAT! aia a a a i fore
z= _ a5 = (S aed ey ae Ea. etree ee Ts
o wi tate o fe ctejaline | pe viee ts od }
B25 3 | 15 MA = coat) ejecta | chal omet 1? oe
Bm <| OF IDEN NAME 5 eam
rs Sew nae S qo Ca fe t/LACG ier rita gb
ong 16 BIRTH 4 Ss aa eee eeeierceras a
Fag c non PLACE wy, Z oa ee
ewas HER (City) Dhol Pager
s Q i (Stat (City) g y 2 PRUNE elie T ST | Widens &
er iG. ate or cou —_ AW) O Was di eT SRL
$k a ¢ ntry) isease aca! Wee Sane ER D | Se shes
. oar} (eo) £ . Zz If so, s f ee ate of... 95-25%, 7.
SO om q Info ’ » Specify...» kGORCE EAS dis thareiaiy Gite
- Ea ay (Address)}o- ‘Nag (Senos) LLY ts. related to occ ere an autopsy?
= 52 | ice = ) ( b J pany Ad Pere O17 YSU i ard upation afi sy? 3 ame
Fes $4 RES faces (/ A dress). AY. Se fc eceased? ....
| OR os r “CERTE ees: PLACE OF CSM SSS eee
a afhata s isf 2. p SeaASEN On AL, =
‘. g a y) 4 A 4 26
i WN AL Le Sy Gi { 2 sey. Ae. S., > : F
S MY AA MALE ” NAME OF ” L- AA. (Cemetery) oe ~ Baltpu
of c= A. (City or town
, =

Statement of occupation.—Precise statement of occupation is
very important, so that the relative healthfulness of various pursuits
can be known. Make some entry in this section for every person
aged 10 years or over. Ifthe occupation had been given up or changed
on account of the disease causing death, 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 eccupation 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
femily, cook—hotel, etc. Fora 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 Pparti-
cular kind of work done and return that, as spinner. weaver, etc.

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

mill, etc,
Distin: 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.

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,
ifany, related to the Principal cause and any important complication
of the s eancigal cause. Under contributory causes of importanoe 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:

July 5, 1927

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,

F 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 anotherin 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 tients 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 attendin

physician. If death is caused by violence, the medical examiner shal
make such certificate. If such a permit for the removal of a human body,
not previously interred, from one town to another within the commons
weal 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 1t 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. Ts
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, Chad. 38, Sec. 6. :

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

RULES OF PRACTICE

The fulfillment of the purpose of these laws calls for the observance
of the following rules of practice: Z 4

(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 parershs 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.

dnd

PHYSICIANS should state

— “

very item

RECORD. Er

Exact statement of OCCUPATION

AGE should be stated EXACTLY.

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

INLY, WITH UNFADING BLACK INK—T

tant.

information should be carefully supplied.

CAUSE OF DEATH in pla

is very impor

N. B.—WR

a
w
o
_
>

No. 9321-a

100m-9-'33.

i ee ee

polrw iL yf 3 ¢ ,
& HR Tr * canal phic a To be filed for burial permit

eS OFFICE OF THE SECRETARY with Board of Health

= y DIVISION OF VITAL STATISTICS iz
4 or its Agent.
STANDARD 7
CERTIFICATE OF DEATH Registered Now...ccccccccssseesse dee

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

~
PLACE OF DEATH

(If U. S.
ME EL WAM, (£0..\..0cct Pscccetesscesfcana® BNE EN ses ee cde ce cnsua Ori cane tavslacedttensabecuctovecs davesesieosectiees War Veteran,
i ied, widoweA or divorced woman, give also maiden name.) specify WAR) 2.0. ffrorssccossscvorcsensertuttoase

Pee mmecleriCes | NO... foci psnibCodsestcreres seteeti sci acsst sas sestdtpqeassescsnsisccstevansvas Co Se een ere War aad ¥ Lib tn..:

(Usual place of abod (If nonresident, give city or town
Length of residence in city or town where death occurre: How long in U. S., if of foreign birth?

days. yrs.

PERSONAL ra ND STATISTICAL PARTICULARS

B P0LOR) 5 SINGLE « write the word)
fp sex Vv ‘OR RACE ieniey/ } op
' 1) fee ee A “eSB E Mii 6 fitreetrrrriretrrrrir irre «se ee
VY qY or DIVORCED (Month) (Day) (Wear)

3 If married, wi foygifor divorced Y, BY CERTIFY, That! oF deceased from
HUSBAND of .<7..-<7Z. HC , a. et, CA Dearernercsrcecse Ds coxescuthnvasvoessroretinn CL
[] (Give maiden name of wife in full) J frrtrenggften Mectenctees esses Mee Trcaneseenenneneens ¥ 5

ChEMR DAES eran e eet ee a ek ee aa ie
6 IF STILLBORN, enter that fact here. 0 have occurred on the date stated above, at..... ne p>...
The principal cause of dédih and related causes of importance in order of

7 Zz Iflessthan lday onset were as follows: Date of Onset
[Saale 22 col Years......¥..... Months.......4... Days: |ic:2s-sas HOUFS.........4.- Minutes 4 fe Vea (MPORTANT

8 Trade, profession, or particular y / 2
= kind of work done, as spinner, gta ea 7 Cie Ae lio Paes A BES peg 5 Sop re cian eee Ages 9 Lc IY
) sawyer, bookkeeper, etc.........
| 9 Industry or business in wig
o work was done, as silk mils
= saw mill, bank, CtC,...........0:cesseeesceeseeese WOO
| 10 Date deceased last worked 11 Total time (years)

this occupation (month

oie in 64 imgertance not related to principal cause:
11 3/3xK

Deiocdisccsteaamietbssuestertrvacs it; ees
14 BIRTHPLACE OF NAMG Of OPS FA OM ai cscsavsceacssnndasasnsectauvnscsposvecusernaaspreves cane Dat OF: ce op astesnaderattnalasrencamee
ce REO CIES YN Mie cO env es aesbecdis s JAM gM oie earvacesd tapthatatienice>cvederoneee eae What test confirmed diagnosis?.............scssseeseeceecsecssenene Was there an autopsy?.........
a Eeate & country) 20 Was disease or jury in any way related to occupation of deceased? ...........00..-+-
m|15 MAIDEN NAME i
< OF MOTHER If so, specify.....
a. (Signed) ...4..5 7 Os
16 BIRTHPLACE OF
MOTHER (City) occ. cccscscscssscsesenes eA eh ee a ANA (Address)... fa
tat . yy, 21 PLACE OF BURIAL,
Slabs ag Libtval/ CREMATION OR REMOVA
17 ff

Informant DATE OF BURIAL
(Address) 2 22 NAME OF
: UNDERTAKER...£! ph
that a satisfactory standard certificate of death was
FORE ul or Aransit permit was issued: ADDRESS | A.U....0..4.4..28
u“

oa ignatu Ohi yet Received and filed..........sssessessssereseererenens ag ssppeagestocascaconsasoorsssesserasarsapessossneseanons 19. .s:coase
OR OP Oe alee

cal

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

Example

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

Arteriosclerosis

Chron

Cercbral hemorrhage July 5, 1027

interstitial nephritis ro2r

HAAO ER ERAA SENS EEE AOR HHRAH OREO ee ebeeeEeeseenees

Contributory causes of importance not related to
principal cause:

Aeenenennesensceesesessaesesaceseaseenesseessaessenensssnnesssecsseseeneeereteeneeenensesenanen| seacsseseneseeseuereeeser

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 belicf 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.. vs
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 pecans 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 punecees or is insufficient, a physician who is a member of Se
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 1¢ 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. Li}
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.

No undertaker or other person sha!l 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: 5

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

. R-302 SUFFOLK The Commonwealth of Massachusetts

2 OFFICE OF THE SECRETARY BOSTON
ARR E EERE REE E EERE ERED ORO R EERE E REE E HEHE EEEEREHESOOOEEEESEEEES ESSER OS DIVISION OF VITAL STATISTICS snouccousavacerassseesetsensnsunscuseasnessescensesencessesscsssesesenees
1) > = (County) (City or town making return)

gS $ : BOSTON She ta aioe

a4 sai te = eh eee CERTIFICATE OF DEATH Registered No......80..............
1) 2 = (City or Town)

(If death occurred in a hospital or institution,
= 33 = No........ Beth Israel] Hospital _sisi(i(‘iéa Sh tie ee Ward 4 give its NAME instead of street and namber)
° w=

oe GS: i wy
Hobs 2 FULL NAME............. ree ere | ee OM gp hcnsswtncnc War Veteran, ‘

- a0 (If deceased is a married, widowed or divorced woman, give also maiden name.) SHELLY WAI) 2s drisncecostiscitsseccssvatnczoreieeen

PES (a) Residence. No.............. ar NR ee ocn screens Seer cadsotsecs Wears. WPM mS eos - cacao tase cadkesosaeseawigee
=

gn? (Usual place of abode) (If nonresident, give city or town and state)

z . 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.
B0« PERSONAL AND STATISTICAL PARTICULARS MEDICAL CERTIFICATE OF DEATH
Ong 3 SEX 4 COLOR OR RACE | © SINGLE (write the word) |[ 1g DATE OF
a s M W WIDOWED ied DEATH ses. 3itcond Jan eee peeesinatntavo coh St... oe BS etaten teoio nace
iw 8 er DIVORCED mrr (Month) (Day) (Year)

- 5a If married, widowed, or divorce 19 I HEREBY CERTIFY, Th
ae . > - at | attended deceased from
=v ae Rachel. Greenber i... See.
2 > § (Give maiden name of wife in full) & be DOG eee agpanestussescssnppssectee 19..39 10...0.04 Jan: sneces 3 pnusns sopsteaasasavnas ae i: lPae 34
Aste ab Ss Sai i Baia ie eee, | last saw h...LUM alive on........ SOM............ SEES , 19.04., death is said
= aC to have occurred on the date stated above, at Le OSP m.
— - o The principal cause of death and related causes of importance in order of
oO Co's onset were as follows: atanfensal
fia 3 INE PEES Eau duseuntecrtecscnasece 5 CGE SS. 0 nnnecesens--EVBODTLINS << cvcncsnee MAYS | cccdicveccacKOURS: -0scccesnns mi:
o<28 - ! Sse I a Sock Sec ch eet tate, cbnen Secdenet cane tenee aatucese [oer
a) 8 Trade, profession, or particular
F n 2 re = kind of work done, as spinner, undertaker .. Obstructing. prostate | ER ene RENE San Se EN eee 7...mos
"c ° sawyer, bookkeeper, etc....................... MBBS MA eee cccteee cere ene ees
ul ns < | 9 Industry or business in_ which
> ro
z zy 9 = Brome Cone, as silk mill,
Wes = saw mill, Ae ORE Pee AOS Bee Sue sua asbbsslacastvs
4 | . % &| 10 Date deceased last worked at UPSTOPMI ITER US ERES) jee 94 '|l| 0 caveats adits occa) an Secce’ nas untete cata andunk cpudsnscuctamt scntsisevsens@endaeavasecsdascr at |taodedetantaze
- wes : etn (month and Deg LL penal al
PI | (uns nn 1» Reeser 2) eee
1
Zz oO F 12 BIRTHPLACE (City)
g z< » (State or country)
ca 13 NAME OF
= a5 s FATHER
Pe rr] Nainiaid Woneration irene cs reg ct ectecrccite eevee ee eerste Daterofoe
5 a 8 = 14 PLACE OF What test confirmed diagnosis? ...... Xwke: 5: eee Was there an autopsy?.:
= @ £ a (State or country)

>F =
ayy ce} 15 MAIDEN NAME
Bae <| OF MOTHER |
Eg 16 BIRTHPLACE OF |

) Bon meee ty) 21 PLACE OF BURIAL |
Zes (State or country) CREMATION OR REMOVAL ... Sharo..Tfilho.W. Rox...
< oT = (Cemetery) (City or town)
ashe x SA eee aay eee: DATE OF BURIAL........... EN 19... 9%
s aS 2||_ Gddes) “s } i) ¥. 22 NAME OF
Es as : x aa += =e UNDERTAKER ........ URC... LWA sc ccccssccscscscssssnssscnsesenssenneesenece

Zllamuartce (2 iWe PCN YP,
5S gO Vp Ky, ry © ADDRESS....rrnnneeeeee es
-™ ” =
~, || ATTEST:..... 4 SE ia TE CER STR | et es ;
L $ ‘64 (Reebicm cfeted Pes oe SE pera ES Sa pn ye EMR ec ain! al nck ae een eee
. S * :
z RN VONTE FILED ccc itcrecencee aM... Wiis init Ca | aaa = Seger Grete tats Bic aes epmamea 2 5 et eect

(Registrar of City or Town where deceased resided)

a
1

wo
=
>

cag Rd
Every item of

PHYSICIANS should state

oe wre vie ad

did

Oe ee

K INK—THIS IS A PERMANENT RECORD.

AGE should be stated EXACTLY.

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

d extracts from the laws on back of certificate.

tructions an

WITH UNFADING B
See

tant.

No. 5469

information should be carefu
CAUSE OF DEATH in plai
is very impor

75m-5-'32.

N. B.—WRITE PLAINLY,

f wichltalll ot Massachusetts To be filed for burial permit

OFFICE OF THE SECRETARY with Board of Health

fasvvssensssanses 12: DIVISION OF VITAL STATISTICS or its Agent.
STANDARD

ee ee eth... CERTIFICATE OF DEATH Recisterad Nesey ee

2 v )
gi (If death: oceurred in ga hospital or institution,
Aner BOr eeucuanun set cooeercatia atta. Bs ERE eae | give its NAME instead of street and number)
JAC CA, (If U. S$.

Ee See sok thee, Be AS Ra eS OE one SOR ied EPR Be A War Veteran,
BIORLE SEW ANE) oo coke o cccnen sions sciguany ie etiameceed

(a) Residence. No... AMV. EARP BOL ASV... CW Me sie Foch ecatea PW RMA cre ctpeas cécdpsconades ome nabceops dash ac enee tes gaekinit es alms
(Usual place of abode) (If nonresident, give city or town and state)

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

~
PLACE OF DEATH

days.

PERSONAL AND STATISTICAL PARTICULARS

5 SINGLE (write the word)
3 oN 4 COLOR OR RACE MARRIED
WIDOWED i
si or DIVORCED

5a If married, widowed, or divorced
INUNY Ah oe ee ca tu aeciit ccagenchyaase

(Give maiden na

ee as a ae

That | attgnled deceased from fr
Que. 4 ra : 3 B
3 ;

ast saw h,4#A.....alive on... Cot /L......

to have occurred on the

The principal! cause of
onset were as follows:

(or) WIFE of

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

eath and related causes shi importance in order of

Date of Onset
IMPORTANT

if less than 1 day

ig
AGE..... p= oe! eee hs Months.......... Days

| 8 Trade, profession, or particular
kind of work done, 2s spinner,
sawyer, bookkeeper, @iC...............-./

9 industry or business in. which
work was done, as silk = 1 a
saw mill, bank, etc... ee I Ee eA ee. ca caaed duceneauvarerhce ia treseqaneneaaeencanensaneenarnavenanigesesenanscensessssrsnnessupatecanansecasnasege| snenessansctssunee Sct

10 Date deceased last worked at 11 Total time ‘veats)
spent in this
fs ; occupation. oh °

OCCUPATION,

14 BIRTHPLAC
FATHER

(State or

What test conf urmad diagnosis?...

20 Was disease or injury in any way related to fusteatind Of deceased?........s.ee
SEG OF SADA FEE 25s, Ar aks Stoo ts ks he she Oh cdl osnng inv ous «Mab ap acccaeacgpsexsakesettatiaeeci ste

(Signed) ..... A > paar W ge
(Address). LA.

21 PLACE-OF BURIAL,
CREMATION OR REMOVAL ., “3
DATE: OF: BURIAL...........-...

22 NAME OF
UNDERTAKER . J.) <L2-770.1....4 ;

Se nADDREBS...1c25-d5.00: Apmrae A CG athe Ss Ree be Ee

PARENTS

16. BIRTHPLACE ©@
MOTHER (City) ........8....S5

(State or country)

Tnfermant ..a—_gGh FORA anno noocovveccetecceteneseeteses
(Address) :

if HEREBY CERTIFY that 2 satisfacto ov standard ceriificate of death was certificate of death was
ith_me BEF ORE (Ze al orAra it Lape, was issued:

a... Catia doa

Ay
MOOSIVER AG HIG. <.--...... i ceecsseessssesovareceeseeree J, A V8 eeteaeh a ac eee PO snrace

~~ (Registrar)

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
ead 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: eg wy

| ey 52 2927

Cerebral hemorrhage

seneeecneessseesseneresenusneneesnateenesnneesreees a eeceeeeenes we eeeeeesneesenceeensesseuceee

Contributory causes of importance not related to
principal cause:

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 anotherin 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 ofa 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 hasbeen sooner
obtained hereunder. If the death certificate contains a recital, as re-
quired by section ten of chapter forty-six, that the deceasedserved 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, Acis 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 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.

OSD MANNER OF —

d CAUSE
be properly classified under the International Classification of Causes

EXAMINERS should state

he laws relative to the return of certificates of death.

MEDICAL

from t

so that it may

be corcfully ways

‘8

information shou
DEATH in

of Death.

in terms,
reverse side for extracts

N. B.—WRITE PLAINL

The Commonwealth of Massachusetts To be filed for burial

= OFFICE OF THE SECRETARY a it with Board of
< DIVISION OF VITAL STATISTICS ealth or its Agent.
a MEDICAL EXAMINER’S c
145 Yaad Ley? OF DEATH Registered No.............. 9 Nine
uy
< (If death occurred in a hospital or institution,
= IVA... Ward a{ give its NAME instead of street and number)
: (If U.S.
2 FULL NAME...) £/0C#4.................. ib, f BAA! Sf sg oy RUN Ses caer a as ee War Veteran,
i i i ya. Ole © maiden name.) pulecthy WAR) osu cosvccoactivccvenpesotesespsdeanded
(a) Residence. No...W..W... Sor M ESAS. SD oscesen em tesnmerncnsnsaceeseneetiees a Ba gerrrecesees oe WM ERNIE goa Rents cee Lda cieda tats oe geen eica sce dade savas Daal
(Usual place of abode) (If nonresident give city or town and state)
Length of residence in city or town where death occurred yrs. mos. days. How long in U. S., if of foreign birth? yrs. mos. days.

PERSONAL AND STATISTICAL PARTICULARS / MEDICAL CERTIFICATE OF DEATH

4 COLOR OR RACE 5 SINGLE 18 DATE OF . ue & one (5 i)

(write the word)

DEATH a tecccceas fy IR Tee ao iotcncy otter tans

19 I HEREBY CERTIFY that I have investigated the death

of the person above-named and that the CAUSE AND MANNER thereof are
as follows: df an injury was involved, state fully,

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

ah, Mannct...€

Ni If less than 1 day
AGE... 45 its facene BANS: che iessest Months............ Days: sett .ck Hours..........-. Minutes
8 jieck lan al or particular 4

ind of work done, as spinner,
SI sawyer, bookkeeper, etc. ........ RS ee A 22k -2- pia ia aye
= 9 Industry or business in bye
a work was done, as silk mill
= MERA in aT OICN ee eee tae Chere ie, UOT A. os, area eatiastenste
6| 10 Date deceased last worked at 11 Total time (years)

this occupation (month and spent in this

Pie ee Pas v-nBparaaa dees Sécenasanenocs suanea oss occupation.............-..-.-.-

12 BIRTHPLACE (City)<..0Z4-05& Se Oo cle Oe
(State or country)

13 NAME OF
FATHER

(See reverse side for descfiption for unknown person)

20 IN WHAT CITY OR TOWN) 7,
WAS aa PAWS mi! 4

(Signed) 4...

(Address) .......--he-.2 ¥ Li

14 BIRTHPLACE OF.
ae “iach Uae, Ns Ca 8 oe

FATHER (City) ...... AO

(State or country)

15 MAIDEN NA
OF MOTHER 27-0 Z

PARENTS

OA LAAA.....
16 BIRTHPLACE OF Lt J a
i 21 PLACE OF BURIAL, bp.
MMAR ARE COAL). cade ego MA von cess stheispuancyesscesocnavapucepessesd%-sagorbsvancrodecvons4 CREMATION OR “es J = .
(State or country) (Ceshetery) “Gity or fais
DATE OF BURIAL .-.0.0e¢<Zoe 2st one 2. rat
le ee ee Ce Fe ahiensd elas Rei 3 22 NAME OF 4 : ¢s d ¢ .
LS PPFILZL a LA “ SL eh). sat giles

| HEREBY CERTIFY that a aah ber standard certificate of death was ~
fiJed/with me BEF RE the sit permit was issued:

No. 7997-c

EXTRACTS

FROM THE LAWS OF THE

COMMONWEALTH OF MASSACHUSETTS
GOVERNING THE

RETURN OF CERTIFICATES OF DEATH

A physician or registered hospital medical officer shall forth-
with, after the death of a person whom he has attended during his
last illness, at the request of an undertaker or other authorized
person or of any member of the family of the deceased, furnish for regis-
tration a standard certificate of death, stating to the best of his knowledge
and belief the name of the deceased, his supposed age, the disease of
which he died, defined as required by section one, where same was con-
tracted, the duration of his last illness, when last seen alive by the
— 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 purpose, or is insufficient, a physician who is a member of the
board of health, or employed by it or by the selectmen for the purpose,
shall upon application make the certificate required of the attending
physician. If death is caused by violence, the medical examiner shall
make such certificate. If the death certificate contains a recital, as
required by section ten of chapter forty-six, that the deceased served
in the army, navy or marine corps of the United States in any war in
which it has been engaged, such recital shall appear upon the permit.
The board of health or its agent, upon receipt of such statement and
certificate, shall forthwith countersign it and transmit it to the clerk
of the town for registration. The person to whom the permit is so given
and the physician certifying the cause of death shall thereafter furnish
for registration any other necessary information which can be obtained
as to the deceased, or as to the manner or cause of the death, which the
clerk or registrar may require.—Chap. 114, Sec. 45, G. L., as amended.

town where the body is to be buried or the funeral is to be held, or from
a person appointed to have the care of the cemetery or burial ground
in which the interment is made... .—Chap. 114, Sec. 46, G. L. as amended

Medical examiners shall make examination upon the view of the
dead bodies of only such persons as are supposed to have died by violence.
If a medical examiner has notice that there is within his county the
body of such a person, he shall forthwith go to the place where the body
lies and take charge of the same;...—General Laws, Chap. 38, Sec. 6.

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

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

RULES OF PRACTICE

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

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

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

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

STATEMENT OF CAUSE OF DEATH

Medical Examiners in certifying to a death will state the cause and
manner thereof, and will specify: (1) Under cause, the nature of an
injury and of its consequences; and (2) under manner, the mode of
its production together with the circumstances when these are known.
Forexample: ‘ Cicer fracture of the femur with ensuing septicemia
(gas bacillus) caused by a steam railway accident.’’ ‘‘ Pistol shot wound
of the chest with associated hemorrhage, homicidal.” ‘‘Asphyxiation
by suspension, suicidal.’’ ‘Syncope while under the influence of ether
administered as a surgical anzesthetic.'’ ‘Fracture of the skull with
associated internal injury sustained under circumstances unknown.”

If disease or injury was related to occupation, specify. Ifinvestigation
shows the death to have been due to disease, specify: (1) Under cause,
its known or presumable nature; and (2) under manner, indicate the
circumstances leading to medico-legal inquiry. For example: ‘‘ Hemorr-
hage spontaneous, of the brain (basal ganglia) (found dead in bed).”’
“Heart disease, presumably coronary sclerosis. (Sudden death.)”

Ae nee e eee e eee neeeeneeeenneeeeees een ee eeeeseen sess SeSSeuns ese asestEsssensseeeEsEsnseeesenereeeneeeenenessees eeeesceccetacecesccccccnccccescuenweeeseesseseseeeaeneessstuneseseessesesseenOOeEeeeeweseesseseEnseeeneeeneseesanesseseseesass

NOTICE TO UNDERTAKERS: No embalming fluid, or any substitute therefor, shall be injected into the
body of any person supposed to have met his death by violence, until a permit, signed by the Medical
Examiner, has first been obtained.—General Laws, Chap. 38, Sec. 14.

THIS CERTIFICATE CONSTITUTES SUCH PERMIT i

MANNER

* Se
Every item fs

oan et

AND
ational Classification of Ca
tificates of death.

d. MEDICAL EXAMINERS should state CAUSE AN
be properly classified under the Intern

carefully suppli

DEATH in plain terms, so that it may

information should be
See reverse si

of Death.

N. B.—WRITE PLAINLY, WITH UNFADID

de for extracts from the laws relative to the return of cer

No. 7997-c

(or) WIFE of %.

5m-2-'30.

The Commonwealth of Massachusetts To be

filed for burial
OFFICE OF THE SECRETARY

ermit with Board of

E DIVISION OF VITAL STATISTICS lealth or its Agent.
a MEDICAL EXAMINER’S 40
145 CERTIFICATE OF DEATH Registered No.........%-5 © emad iY
g (If death occurred in a hospital or institution,
= give its NAME instead of street and number)
(If U.S.
OM OLUT ES SONY, | pl pet (th ca ad Beer arent A thee Bee RO hii SO ae War Veteran,
i i wppecety WAR) f:csesesscscsecsscvecsofeacssiscasepehe

(a) Residence. No... We
(Usual place of abode)

Length of residence in city or town where death occurred

Perrreerirrrrrr tir t trite ttre terre iti tr rr eee

(If nonresident give city or town and state)

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

PERSCNAL AND STATISTICAL PARTICULARS
een

MEDICAL CERTIFICATE OF DEATH

3 SEX 4 Jae We (write the word) 1/18 DATE OF 3

4. WIDOWED 2d DEATH ccscsssconsselfs QUAM cs csscsssessseee OD vnnees = mh hay MP Ty og Mewenee
LAL A, or DIVORCED 2-4 LY (Day)
Speman widawed, or (eae 19 | HEREBY CERTIFY that I have investigated the death

of the person above-named and that the CAUSE AND MANNER thereof are

i mae njury 4 involved, state p” .)
[minal “fle
y

AHusband’s name in full) —

6 IF STILLBORN, enter that fact here.

i uUunrvnz

If less than 1 day
Paleeap ate Hours............Minutes

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

5 sawyer, bookkeeper, etc. ........ Daeg A eee pee oe AD aA aa
| 9 Industry or business in which Vi
a work was done, as silk mill, 4
= faerie pment ental Tah ye See a a cata w she caa tata botNcadhs aaibaevaven doh fecstbabinbensosvcnisieees
S| 10 Date deceased last worked at 11 Total time (years)

this palmate Al Aron ate) spent in this
j year)... eae ets aoeredc OCCUPATION...........-eeee-

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

| FATHER ( AED .. Les g
=z (State or aay i gor ~ y ly a fs
&|15 MAIDEN NAME // (Signed) .. fl WEL)... (haere 5 a eae or ree , M.D
ny vi MOTHER t (Address) .......e--0b-- > oa 5 errs 19.5¢
16 BIRTHPLACE OF “7. , 7 / pA LAED
Ag (Sty, 21 PLACE OF BURIAL, Lert t
ne oe) hel tlie CREMATION OR REMOVAL«e.<22 tihsde Uk... FA. VED Es
eg y j ~ pCemetery) (City or town) ie
fet a - J ‘ - / ;
1 f - / DATE OF BURIAL. suf thom. ' OB. 1934
Utd AAS KE J d ee me ie
Akeesy, OMEOES S - Et A EE (ea ose liga 22 NAME OF Y ; oT g) ee A
TR UNDERTAK Tea a bets. pe

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

i (4,
(Signature of Agent of Board OFE

Y (Official Designation) Rypoesecseneacennnensenengenenennseentonss

(Registrar)

EXTRACTS

FROM THE LAWS OF THE

COMMONWEALTH OF MASSACHUSETTS

GOVERNING THE

RETURN OF CERTIFICATES OF DEATH

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

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

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

RULES OF PRACTICE

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

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

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

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

STATEMENT OF CAUSE OF DEATH

Medical Examiners in certifying to a death will state the cause and
manner thereof, and will specify: (1) Under cause, the nature of an
injury and of its consequences; and (2) under manner, the mode of
its production together with the circumstances when these are known.
Forexample: ‘Compound fracture of the femur with ensuing septicemia
(gas bacillus) caused by a steam railway accident.’’ ‘Pistol shot wound
of the chest with associated hemorrhage, homicidal.’’ ‘Asphyxiation
by suspension, suicidal.’’ ‘Syncope while under the influence of ether
administered as a surgical anzsthetic."’ ‘‘Fracture of the skull with
associated internal injury sustained under circumstances unknown."

If disease or injury was related to occupation, specify. Ifinvestigation
shows the death to have been due to disease, specify: (1) Under cause,
its known or presumable nature; and (2) under manner, indicate the
circumstances leading to medico-legal inquiry, For example: ‘‘ Hemorr-
hage spontaneous, of the brain (basal ganglia) (found dead in bed).”
“Heart disease, presumably coronary sclerosis. (Sudden death.)”

nn eeedenareeseenssurcscensnsereesevessessssseessess rrr

THIS CERTIFICATE CONSTITUTES SUCH PERMIT

25m-2-'30. No. 7997-e

AAn ne ene ee ae eee enneeencenaseeeeeeaueneateneenessesenenaneneeneenea®

(City or Town)

~
PLACE OF DEATH

No..........Mass.. Generel. Hospital... a ae Ward {

Che Commomuralth of Massachusetts
OFFICE OF THE SECRETARY
DIVISION OF VITAL STATISTICS
MEDICAL EXAMINER’S

CERTIFICATE OF DEATH

Registered No.......... pT ee -

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

(If U. S. 1 j
Ae eS. Sd a. War Veteran,
(If deceased 1S a married, widowed or divorced woman, give also maiden name.) BIIELAN YA WHAT) si avinsegssscescseascosstessvvyentvedl

(a) Residence. No................. 81...Shore...Drive.....0 oo... Siete Ward; cs ee Winthrop et:
(Usual place of abode) (If nonresident, give city or town and state)
Length of residence in city or town where death occurred yrs. mos, days. How long in U. S., if of foreign birth? yrs. mos. days, |
PERSONAL AND STATISTICAL PARTICULARS MEDICAL CERTIFICATE OF DEATH )
3 SEX 4 COLOR OR RACE | © nae (write the word) || 18 DATE OF 6 1934
WIDOWED DEATH irises score [0 Repeat, Eee SI See Sd ee
M W or DIVORCED married (Month) (Day) (Year)
5a If married, widowed, or divorced lee 19 | HEREBY CERTIFY that I have investigated the death
ony oe of the person above-named and that the CAUSE AND MANNER thereof are
RMD TMM cage tesa ssc ses cnsox toss onaceeahteceevar steve ssnacsscvdctactaresoukinsdcneticacseccscedndnpeteussecsscens as follows: (If an injury was involved, state fully)

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

If less than 1 day
a eragjotend Hours............Minutes

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

sawyer, bookkeeper, CtC..............2:c0:ecceseeeee) meat.. eutter beasapanvaseysedes

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

saw mill,

10 Date deceased last worked at

this occupation (month and
IAT ote sees oiitcr ics bdecteietetas Jan 5.1934
Saar ENERDEMNS BNC CLEND ecu ehie codes cic ova gmap exeas hee asetac unaaes oxdeeiaduineavereencvctatepspatvuoavassssnsans
(State or country)
13 NAME OF

ice eae Abraham D Thompson

~| 14 BIRTHPLACE OF
FATHER (City)

(State or country)

15 MAIDEN NAME
OF MOTHER

OCCUPATION

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

PARENT

Freeda Lazarus
16 BIRTHPLACE OF

MRCUT HIER (CIGD io csees Secsteaszeeonsscanceasens
(State or country)

— Beco erie rte Be da. i Thompson PREP ps teartar yas sunan spurtancecamacregeee,
(Address) ‘

Yd
ATES
( E-FILED5.0....3.....

ans Pee ne lbegs yo as cscacvecsdeg Mi onveccascucnscerscssssccceucs

acute cardiac failure

20 If death was due to external causes (VIOLENCE) fill in the following :
Accident,
Suicide or Dealt GF NGG sissseck Sesecesecactaca-cun-cranteovee 19.
Homicide ?
Where did
BSUT WAG OCU 2. 2 Scsveresreraatcccirsacessrs snecacnsos {edeonaandeaypattecesescstoadzest yaerasovscsau pttes eveycaxitaven otaneeee
(City or town and State)
Manner of
MRAJUEEY 220s saircixens Sececsssnuscacarsmbreteta cee acastuceos tds desngaetaraes aplonsskceesbbnp natives cuvdtieh codose nese as onehuse suastebaeneeact
Nature of
JOVI PERSE sy ances evened «eye toneote seme ronnie anon sceceinscencunbeah deste asilcaunkavaneatliesuieantonhacescvees soe dvatvacassmuabves ancy
21 Was disease or injury in any way related to occupation of deceased? .................-. |
FERSIPASIIOBTEM ss-5 pe stoter yo aiisasdaceexacpacrelnsinnasestosstinsi- centuuy onesie aetdncen ave bs poco os nesuaupouscamisonentkveudatnaiandions
(Simmel). ct-ccseseciocse eS) 5. a a M.D.
(Address) iaritrcrcesns Beston.......-.------ ee patel /6,/. sus 19...3@
22 PLACE OF BURIAL,
CREMATION OR REMOVAL...... Pride..of..Boston.. Woburn...
aoe (City or town) 34
DATE OF BURIAL...---ccccecscssscsee co <3
23 NAME OF
D) UNDERTAKER ..osososeee eck ERE a ee aR A
PSE Oe ne vik rentrttink

aes :

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

Every item of

PHYSICIANS should state
Exact statement of OCCUPATION

tructions and extracts from the laws on back of certificate.

AGE should be stated EXACTLY.

y supplied.
terms, so that it may be properly classified.

See ins

information should be carefull
tant.

CAUSE OF DEATH in plain

No. 9954.

is very impor

100m-9-’30.

The Commonwealth of Massachusetts To be filed for burial permit

OFFICE OF THE SECRETARY ith B d Healt
= ensued Suttol k.............. ceannsenspe DIVISION OF VITAL STATISTICS ae sy of — h
= (County or its Agent.
8 STANDARD 12
1,5 .AMAntbrop...... Pees CERTIFICATE OF DEATH Registered Now.......ccccccccssssssesseee
8 ie teen) (If death d in a hospital or instituti
eath occurred in a hospital or institution,
a No....9.0..P@LLevue..Av. Baptach.ccageckwaay ohaerssnneranastos eae oe ee. wire Ward { give its NAME instead of street and number)
(If U. S.
2 FULL NAME..LGA@RCLLO. LOWEN. .TODL OT oo ccccccscsssecssssessssssesseenuseessenee War Veteran,
(If deceased is a married, widowed or divorced woman, give also maiden name.) Bpeicaty)) WAM) ees c en cs¢e5ack- scpvsucctcssneaeeeee
(a) Residence. No...90..peLLlevue.AV. 5 Seco SR EE SE ies kteescs 1 UE Ce MAR SRE iy Sone Any AN Reis SREP
(Usual place of abode) (If nonresident, give city or town and state)
Length of residence in city or town where death occurred 8 yrs. 9 mos. days. How long in U. S., if of foreign birth? yrs. mos. days.

PERSONAL AND STATISTICAL PARTICULARS

5 SINGLE (write the word)
3 SEX 4 COLOR OR RACE MARRIED
WIDOWED :
female Wh 2 or DIVORCED Widowed

5a If married, widowed, or divorced
Sa NUNAN ERTS SP te Mes Mes Wis cave vaste ssuah <Sadanotsiacbwdsberes taibubalestnscnei) ae

(Give maiden f wife in full)
(or) WIFE of... HEOTES. TOGTOTO nu

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

Ey. TO. montns BG. boys

8 — porn. or particular
ind of work done, as spinner, -
sawyer, bookkeeper, etc..........-.... N one _ an sei aha ae aiid tet nc ee

9 Industry or business in which
work was done, as silk mill,
saw mill, bank, etC..........00-00000 sinshandhopiesev te? eee enee Ae ee aT eats Bac szenl

10 Date deceased last worked at 11 Total time (years)
this occupation (month and spent in this
BEA UGOe oerenemtbe ct cvs dre CoavecwnessaviDeyorexaienerevese occupation....................

12 BIRTHPLACE (City) ROUGE WAGD oc ccccencnentntnerntnsee
(State or country) Nova Se ot 1a

13 NAME OF

FATHER J } D l i

to have occurred on the date stated above, at /0°204.m.

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

If less than 1 day
sbdaasiuyrs Hours............Minutes

OCCUPATION:

=e Name of operaiion..... “oO ) Pisses bE veto Date of
0 FATHER (City) Pictou. 3 3:1) hee) What test confirmed diagnosis? {#rananad...O ane, WAS there an autopsy’. /2..
z (State or country) Nova Se ot j 2 20 Was disease or injury in any way related to occupation of deceased? . Ms
Lee) .
ce| 15 MAIDEN NAME If so, specify...
< GF MOTHER Ma ry A nn D ewar (Signed) Siete week tanita re N taccan eantectiensaccuae SMtrenwtccccun ee eesti
a
16 BIRTHPLACE OF
MOTHER (City) PUQWASD es cea
(State or country) Wo we sat a CREMATION OR REMOVAL Woodlawn
z emetery
17 January 14
Informat..AnnLe A.Websater..... Te rt | Se Rh a aaa YA. pee _
(Address) Re aviie Sf Ninthroan Maaal| 22 NAME OF
= a UNDERTAKER ..... La
1! HEREBY CERTIFY that a satisfac standard certificate of death was
al t tr ' ADDRESS..... OOQ....M
Ly ; ,
intl A Received and aces (0 \\ et Ee eo cob.)
oY hagecres| [oneqewerenparanenesenereeressanarstesssseeessessnaen ae eeeeseeseeesenseee sens aawnrnnaasncsensnenstaserenonens

(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 heme 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
ari 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, Slationary engineer, etc. Avoid the term “‘laborer’’ when a
more precise statement of the occupation can be secured. Do not
use the word ‘“‘mechanic,’’ but give the exact occupation, as carpenter,
painter, machinist, etc. Distinguish carefully between retail merchants
and wholesale merchants. A person who sells goods should be called a
salesman and not a clerk.

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

Example

The principal cause of death and related causes

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

Arteriosclerosis

Contributory causes of importance not related to
principal cause:

EXTRACTS
FROM THE LAWS OF THE
COMMONWEALTH OF MASSACHUSETTS
GOVERNING THE

RETURN OF CERTIFICATES OF DEATH

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

. 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 Pumpor: or is insufficient, a physician who is a member of the
board of health, or employed by it or by the selectmen for the purpose,
shall upon application make the certificate required of the attending
physician. If death is caused by violence, the medical examiner shall
make such certificate. If the death certificate contains a recital,
as required by section ten of chapter forty-six, that the deceased
served in the army, navy or marine corps of the United States in any
war in which it has been engaged, such recital shall appear upon the
permit. The board of health, or its agent, upon receipt of such state-
ment and certificate, shall forthwith countersign it and transmit
it to the clerk of the town for registration. The person to whom
the permit is so given and the physician certifying the cause of death
shall thereafter furnish for registration any other necessary information
which can be obtained as to the deceased, or as to the manner or cause
of the death, which the clerk or registrar may require.—Chap. 114,
Sec. 45, G. L., as amended.

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

RULES OF PRACTICE

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

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

(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

onal Classification of

state CAUSE AND MANN

NENT RECORD.

MEDICAL EXAMINERS sh

WITH UNFADING BLACK INK—THIS IS A PE
tive to the return of certificates of death.

rly classified under the Internat

from the

—_

it may be prope:

lly supplied.
See reverse side for extracts

DEATH in plain terms, so that

of Death.

5m-2-'30. No. 7997-c

information should be carefu

N. B.—WRITE PLAINLY,

laws rela

The Commonwealth of Massachusetis To be filed for burial
; OFFICE OF THE SECRETARY permit with Board of

E ha DIVISION OF VITAL. STATISTICS Health or its Agent.
5 ~ MEDICAL EXAMINER’S a
145. wri CERTIFICATE OF DEATH) 4 A} Registered Now... At de oo
g (If death o€curred in a hospital or institution,
a No. give its NAME instead of street and number)
(If U. S.
2 FULL NAME War Veteran,
Wee y WAR) yin siicsscestevsnsossctvpsooanssnnaccle
(a) Residence. No..JaJ\« | og Ne 4 REE Sk SIRE a apo PP AE Mat SUP eet ok

(Usual place of abode) ( } (If nonresident give city or town and state)
Length of residence in city or town where death occurred 3 yrs. mos, ~=days. How long in U. S., if of foreign birth? 4 yrs. mos, days.

PERSONAL AND STATISTICAL PARTICULARS

MEDICAL CERTIFICATE OF DEATH

5 SINGLE (write the word) |
3 SEX 4 COLOR OR RACE MARRIED 18 DATE OF \ t \ q 4
WIDOWED DEATH iataacahsetan ea UY, Y. My in Leh ok SRR IAI ADL Alan |e }
Male White or DivorceD Married

5a If married, widowed, vy ones

of the person above-named and that the CAUSE AND MANNER thereof are
Co TPE Ea a OF SN ks PL A a AI Ae en Rr se Ber as follows: (If an injury was involved, state fully.)

If less than 1 day
Pesctes Weght os Rs----. VOBES.-..00---..-: Months..©..... Days sereseeesees HOUTS..-.--0+0-+-Minutes
8 al rai pioession, or particular
ind of work done, as spinner, AF,
5 sawyer, bookkeeper, etc. 5 ae _Rruggiat btuhoedyr ect area oe
E 9 poutustey or et ae ‘tik mill, :
a work was done, as si i
BY tow mil, bank, Chea acpherson' 9. Store
8/10 Sed persed last month of 11 Total inthis
is peeuya! ion ahion an spent in this
year)... : 93S... occupation.. 29...
12 BIRTHPLACE cay Naper OO Lo? ee

(State or country) On an ar i fe)
13 NAME OF
FATHER

W (See reverse side for description for unknown person)
14 BIRTHPLACE OF
a” . 20 IN’WHAT CITY OR TOWN
2 long paeee ay a EST cates eam a ee WAS INIURY SUSTAINED? cnsoal Ce ei Sg iedats of
=z count -
uu y = : _— Evy: prt PPT ITI ona cs Bente gpee ANB.
| 15’ MAIDEN NAME f
cool Ummenewn 6 Ue M e Scr
16 BIRTHPLACE OF

21 PLACE OF wigs
CREMATION OR REMOVAL . Pe on ota Tae ot 4
(Cemetery) ity or own) —

Benen (Cir ORTPOW Ee
(State or country) Unknown
alg

faformant AZTECS. B .Macphe OD,

(Address) RZ Y aghington A

EXTRACTS

FROM THE LAWS OF THE
COMMONWEALTH OF MASSACHUSETTS
GOVERNING THE

RETURN OF CERTIFICATES OF DEATH

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

ed, the duration of his last illness, when last seen alive by the
erage 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 peer 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 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.

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

RULES OF PRACTICE

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

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

(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.

STATEMENT OF CAUSE OF DEATH

Medical Examiners in certifying to a death will state the cause and
manner thereof, and will specify: (1) Under cause, the nature of an
injury and of its consequences; and (2) under manner, the mode of
its production together with the circumstances when these are known.
Forexample: “ Copousd fracture of the femur with ensuing septicemia
(gas bacillus) caused by a steam railway accident.’’ ‘‘ Pistol shot wound
of the chest with associated hemorrhage, homicidal.” ‘‘Asphyxiation
by suspension, suicidal.’’ ‘‘Syncope while under the influence of ether
administered as a surgical anzesthetic.”’ ‘‘Fracture of the skull with
associated internal injury sustained under circumstances unknown.”

If disease or injury was related to occupation, specify. Ifinvestigation
shows the death to have been due to disease, specify: (1) Under cause,
its known or presumable nature; and (2) under manner, indicate the
circumstances leading to medico-legal inquiry. For example: ‘‘ Hemorr-
hage spontaneous, of the brain (basal ganglia) (found dead in bed).”
‘‘Heart disease, presumably coronary sclerosis. (Sudden death.)”

AeA n ne ween en ennennesss een seeen sees eeee seen Geese eR Bene ees eteesEEESeLEESEDESSEEEEE ESSE SEES ED EEEO EEE EhEEeeeS aeecescencee

THIS CERTIFICATE CONSTITUTES SUCH PERMIT

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

Every item of

PHYSICIANS should state

it may be properly classified, Exact statement of OCCUPATION

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

supplied.
terms, so that

ortant.

formation should be carefully

CAUSE OF DEATH in plain

is very imp

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

i
e
>

OCCUPATION|

PARENTS

: The Commonwealth of Massachusetts To be filed for burial permit~~

OFFICE OF THE SECRETARY with Hoardof Healt
= DIVISION OF VITAL STATISTICS A
P| STANDARD or its Agent,
1. 6 CERTIFICATE OF DEATH Registered No.......... 44 eee
3 (If death occurred in a hospital or institution,
A eee eats unset cre eon cee seeeea Raunanwavercnceveescasceuss «vances <@ieee<oges give its NAME instead of street and number)
(If U. S.
Se PNET PADUA ee OTe ee ae eI os RUSE RE Rene cae oes Soc OTE Kaveh nnn vsshianadervotsnetsoveeczecededecdveaceers War Veteran,
(If oo) a i , give also maiden name.) GUPGENEG WIAIR) onsos oi snazevcacy onveauansaeeneeeeee
(a) Residence. No......9....... y irs oe ees csatiieniccsevdem eee Wien con: Resiatie asses Rises hedge EE as ee
(Usual place of abode) (If nonresident, give city or town and state)
Length of residence in city or town where death occurred hs yrs. F mos. days. How long in U. S., if of foreign birth? yrs. mos, days.

5a If married, widowed, or divorced

HUSBAND of

MUR RRED cg sec coe, oa a ccskecevesadsnivaasscaetaeitessscs Bere Petnts co eater neces ep ec veapeMrepepoeeeacroct
(Husband's name in full)

6 IF STILLBORN, enter that fact here to have occurred on the date gfated above, at..V...7.%.... m.¢

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

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

this occupation (month and spent in this
occupation

12 BIRTHPLACE (City)
(State or country)

13 NAME OF

Name of operation...... : DatS COR S issccocst cemseonee ee
What test confirmed diagnosis? Was there an autopsy? ee

(State or country) 20 Was disease or injury in any way related to occupation of deceased?4=>..............
If so, specify..

15 MAIDEN NAME A
OF MOTHER Cy ee ee Rey (Signed) ...
isiumriAkEOF iGo vf sf, ). .
MOTHER (City) ......... Ae, ih ak, ob: aay Le ie a

(State or country)

21 PLACE OF BURIAL,
CREMATION OR REMOVAL d
(Cemetery)

DATE OF BURIAL

NAME OF
* UNDERTAKER
ADDRESS...

wanbenasspeqaauesapansunsseee oo}

ial Designation) “oo ag it) / (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
pene of store, factory, mill, etc., as grocery store, soap factory, cotton
mill, etc.

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

Example

The principal cause of death and related causes

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

Arteriosclerosis

rors

eer)

nanenesetesseeusenncenraeseepesereeaeasenees aeeeeeveeaeeceteees| coeeseeseennenenaeenesenee

Cerebral hemorrhage July 5, 1027

Contributory causes of importance not related to
principal cause:

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

EXTRACTS

FROM THE LAWS OF THE
_COMMONWEALTH OF MASSACHUSETTS
GOVERNING THE

. RETURN OF CERTIFICATES OF DEATH

No undertaker or other person shall bury or otherwise dispose
of a human body in a town, or remove therefrom a human body
which has not been buried, until he has received a permit from
the board of health, or its agent appointed to issue such permits,
or if there is no such board, from the clerk of the town where the
person died; and no undertaker or other person shall exhume a human
body and remove it from a town, from one cemetery to another, or
from one grave or tomb other than the receiving tomb to another in the
same cemetery, until he has received a permit from the board of health
or its agent aforesaid or from the clerk of the town where the body
is buried. No such permit shall be issued until there shall have been
delivered to such board, agent or clerk, as the case may be a Satis-
factory written statement containing the facts required by law to
be returned and recorded, which shall be accompanied, in case of an
original interment, by a satisfactory certificate of the attending
physician, if any, as required by law, or in lieu thereof a certificate
as hereinafter provided. If there is no attending physician, or if, for
sufficient reasons, his certificate cannot be obtained early enough
for the Bese or is insufficient, a physician who is a member of the
board of health, or employed by it or by the selectmen for the purpose,
shall upon application make the certificate required of the attending
physician. If death is caused by violence, the medical examiner shall
make such certificate. If the death certificate contains a recital,
as required by section ten of chapter forty-six, that the deceased
served in the army, navy or marine corps of the United States in any
war in which it has been engaged, such recital shall appear upon the
permit. The board of health, or its agent, upon receipt of such state-
ment and certificate, shall forthwith countersign it and transmit
it to the clerk of the town for registration, The person to whom
the permit is so given and the physician certifying the cause ot death
shall thereafter furnish for registration any other necessary information
which can be obtained as to the deceased, or as to the manner or cause
of the death, which the clerk or registrar may require.—Chap. 114,
Sec. 45, G. L., as amended. U

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.

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: | 4

(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.

aie.

The Commonwealth of Massachusetts ; ;
, OFFICE OF THE SECRETARY To be filed for burial permit

5 DIVISION OF VITAL STATISTICS with Board of Health
Se A Ps or its Agent
° 40 a STANDARD eon
£3E 1) & CERTIFICATE OF DEATH Registered Now....... ecu
wi / ue
Fach s Y E. (If death occurred in a hospital or institution,
ban = ae Oo a aE 1 La | ce a a Ward give its NAME instead of street and number)
<x
> a r (If U.S.
Hind 2 FULL NAME....0<024406K. he PEE G6 (eg {We Veteran,
a ° (If deceased is a married, widg'w give also maiden name.) SHIGE G WARD cass eussaxsustonsocopucecocsnatveneenia
»
ROE (a) Residence. eR A 3) ep nes a Warr coe, eh eo cscde rca oetasoiiiiae soi Oe
OF g 3 (Usual place of abode) : : (If nonresident, give city or town and state)
mi 3 2 Length of residence in city or town where death occurred WA 0 yrs. mos. days. How long in U. S., if of foreign birth? yrs. mos. days.
6
Mase PERSONAL AND STATISTICAL PARTICULARS MEDICAL CERTIFICATE OF DEATH
z 32 3 SEX 4 COLOR OR RACE | © SINGLE (write the word) || 18 DATE este
ele ¢ 8 White WIDOWED LA. - DEATH ...... SIM : N. aceteiatatais anes \ AWM cae Macastcawapnuitaae \So ieesapeeenan
Aa pe VGrnate’ or DIVORCED “7724227 CL - Gfonth) Day) Year)
34% 4 || 5a I married, widowed, or divorced 19 I HEREB ER TIF X. That | attended esa from
TLE AO ae) ke a a a Pn 3s Ae
ayes HUSBAND ef ..........; PSBNV ABS AY 824. to... BESNVARK MM ), 1924.
ae MUL? cc AZ. 4 of i ca eS ee I last saw h@.2..l.alive on. SAN MRY...G.., 19%44..., death is said
foao
<T to have occurred on the date stated above, at......©.... Im
On ’ :
ns > ; ee principal ores of death and related causes of importance in order of
oe} Tf If less than 1 day nset were as follows: . Bate of Onset
2s a2 AGE...../! oe Pre BANS: :.-.--21-. MONthS,-..0--.-.2 DAYS) |) cos..-c0-0s- Hors%......-1 Minutes F p= uve, Ww , “W< =e 2-NY |
By ls 8 Trade, profession, or particular
| 3 z £ = kind eaves a spinner,
° jo) GRWYET, DOOKKEEDEM, CLC i: cis <sesre-cnnsvaancrvevenkaeMasdnensvcdvesvesacceuss eranpn0s-
Fans | 9 Industry or business in_which
— oo oa work was done, as silk milli, :
via § = = cers poy TA An AT rig lis aaa Reo ie a0 ie oe ds See, SO 5 |
og 2 § 6| 10 ad Seale last worked s ISS ROA RELI EROV GANS pg me ta tceacs etc anasceraeeecasnancvat cSeoscoconecorss dasapccaracauantoayccaay’ otertoutdonoe nedin Resttasovsee oe Lect ae
< : : ee ge te Koonth and yf! y as apa ta ‘ YS. ete causes Of importance not related Zihee > cause: “ 4 rs
io] : VASA Yu d- >
mts? 12 BIRTHPLACE (City)... arte... het Mabe, Nees ee oes Petes Speers Y wetetennerenernenteeaoetenernrsnreteemsesneneaeetet Bn Perches
So 2 9 cr Cerne SESE) i DT DG ER pe I ie ate aiid | evecare eres Ot a mr Oe Oe), A ee Re MMSE [Frets 2 Ln :
a Og
~~ 5 13 NAME OF Za / Sede ren
a 2 Be tO ECORI ssesentnnnnnnnnnannnsusnananssccscoonecnesecccnccnnsnnnensrsee svasddle soszeate unre Muccectusedscdey di cefondteetl ca: aaa Ree eee
< ES FATHER y, :
> eo Name of operation.........0™..... Pat tora t COC Ree Date (Off sscccn eres ee
e3 . 5 2 14 BELACE oF a0 Wiha SLY, Fae __| |_ What test confirmed diagnosis? :...-..:% ALK OA Was there an autopsy?.lAda.
7 ae & * (State or country) 20 Was disease or injury in any way related to occupation of deceased? ....A.Ap....-...-
Ee on 0 | 15 MAIDEN NAME a If so, specify......
Baan heigl aca Ciclilew es! 2 Wee (Signed) ...
-Dr (Address)........
> 3 a AS 16 BIRTHPLACE OF le :
MOTHER (City) .....4/. LUKE... EA MARK... ee en or | te
re 5 Se ; 21 PLACE OF BURIAL,
4 a = (State or country) CREMATION OR REMOVAL ...
¢ °
Om & x DA
MEO E S|) Informant hb. tt ha.. Md Mc J IALL Biter ee ah ice WAS ae ae ie allege
Bem > oc Aas = 72 INDERTAKER. <A Z402 %
EDO A | HEREBY CERTIFY that a satisfactory standard certificate of death was Se rater ne
ets} = 3 filed with me BEFORE the burial or transit permit was issued: ADDRESS=>..2.7.. GA MAL. ae
ot Dom , a) i) unt pes | i y rn %
5 ees ee mane Qa... Pe LA \ AeA Ae a Ca o's 6 6 Fe uloo eh caine = "| s GDA AC) =) 4
| ° RD (Signature of Agent of Board of Health or other) Received and filed..............:.:cceseseees BURR RE Se preR NOR Ne oa ond cusnadecsooceanseusiesiee
eee OL 1Y/ 34 aid
Se Doe ee Cras...L. diet S Gad eee | Sa
Z 4 1 (Official Desi afon) PAGulennGh be iy Seed aenet ee necaescenascvesnccoscoscoucsmaseusscsesccesccoecesccas

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—holel, etc. For a person who had no occupation what-
ever write none.

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

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

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

use the word ‘‘mechanic,’’ but give the exact occupation, as carpenier,
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

: Daie of 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.

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 purppee: 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 attendin
physician. If death is caused by violence, the medical examiner shail
make such certificate. If the death certificate contains a recital,
as required by section ten of chapter forty-six, that the deceased
served in the army, navy or marine corps of the United States in any
war in which it has been engaged, such recital shall appear upon the
permit. The board of health, or its agent, upon receipt of such state-
ment and certificate, shall forthwith countersign it and transmit
it to the clerk of the town for registration, The person to whom
the permit is so given and the physician certifying the cause of death
shall thereafter furnish for registration any other necessary information
which can be obtained as to the deceased, or as to the manner or cause
of the death, which the clerk or registrar may require.—Chap. 114,
Sec. 45, G. L., as amended.

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

...He shall in all cases certify to the town clerk or registrar in the
place where the deceased died his name and residence, if known;

otherwise a description as full as may be, with the cause and manner
of death.—Gen. Laws, Chap. 38, Sec. 7.

RULES OF PRACTICE

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

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

(2) 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. a . ,

(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 electrica
agents, and deaths following abortion, but also deaths from disease
resulting from injury or infection related to occupation, the
sudden deaths of persons not disabled by recognized disease,
and those of persons found dead.

The Commonwealth of Massachusetts To be filed for burial permit

R-301A OFFICE OF THE SECRETARY with Board of Health
mm | lhUhh fp CO ES DIVISION OF VITAL STATISTICS or its Agent.
62% STANDARD
hye ae pper<Llt2 Ot CERTIFICATE OF DEATH Registered No... 233 7A.
7) ww (City or Tow
#ze = ZS (If death occurred in a hospital or institution,
2p = OS TN il 5 ogo ae “cP bb, Bees Ward give its NAME instead of street and number)
£0
ea (If U. S.
Hind 2 FULL NAME... ‘pee Sot a ie | We Veteran, 416
az ° (If deceased is a mparried, widowed or divorced woman, give also maiden name.) epecsty WAR) ..0iis.cccencs<ccterneeereoiaes
A ue
ZOt Se ate De ee = Rp ae ee Wards 2 30 or ee
Om 2 (Usual place of abode) (If nonresident, give city or town and state)
n ° :
= » E 2 Length of residence in city or town where death occurred / yrs. mos, days. How long in U. S., if of foreign birth? yrs. mos. days.
33 ae
ene PERSONAL AND STATISTICAL PARTICULARS MEDICAL CERTIFICATE OF DEATH
B .et 35 4 COLOR OR RACE | 5 SINGLE (write the word) || 18 DATE OF
Phe 8 8 oa ~ WIDOW: D Wass cnanbaie denen RA: pancetta MeV Gunde dundenohne ans ein / pa duns coigablapeansvxutserdeens ce aens peeeeene SF
Zriy . or DIVO
3454 5a If married, widowed, or divor .) 19 1 HEREBY CERTIFY, That | attended deceased from
e HUSBAND of |...0.0...00-.----00---0.- AIDS fs
ages (Give maiden na e of wife in Ail. Se F-Ghb-=-: “4 ae Ye $6.4 < Seseeee Beeerer eee pees! to... 2). Li eect | a 193 br
a8 3 ER ily Cee | SE cit 5 a a ee Sees I last saw h..Mer..alive OM... ed 16... oe death is said
ate E to have occurred on the date stated above, at........: 4g.
8 The principal £ death and relat Ss of
a ape oe pe a eath and related causes of importance in order_of
eee B. 2 BGS. CAs... UR ees Monihs............ DAYS i. occ: Hours............ Minutes | IMPORTANT
°
BURY | 8 Trade, profession, or particular
| 35 OE = kind of pec. aS spinner, : eh Y LYSY
° ° ) sawyer, eeper, etc....... Aad AA SoM ire ists asendtin sascuvins«davasnteats ;
Meas Peeentiy Ornisiness inc Which, «PS Udi we ie ee NS en
—_ » an a work was sg as silk mill, }
vid £ = saw mill, bank, €tC...2...02-.0.-0-02--p IEEOOLR.eccsteecce i
5g s S| 10 Date deceased last worked at 11 Total time (years)
<x 4 this ~r ewes “sare and, spent in Bee
_ a o year) .. occupation.
pas 12 BIRTHPLACE (City)... Yr en oe oe | > 0 Sanna Se GEE ae
g a ° cf (State cr country) 3 |
aS Sa
Oies 13 NAME OF ay Wane mers tee
aes FATHER oe REY
mess 14 BIRTHPLACE OF aoeepaleg ole tare 5 See | a se
Z3 . 5 2 FATHER (City) seecoccc- Ps What test confirmed di agnosis? —.. * Was there an autepsy?, len)
2 bag = (State or country) aa 20 Was disease or injury in any way related to occupation of deceased?..... eee.
FOoRy «|15 MAIDEN NAME If so, specify... wieeeie tf ,
BB 5u = OF MOTHER e (Signed)
me) oaeres S$ Se
op eee oe ;
ros pees 21 PLACE OF BURIAL,
Z2fui5 (State or country) CREMATION OR REMOY
< i) 5 ° 17 LS (City or tow n)
on aS > ; y DATE OF BURIAL mUer 4
meO E ” “ey a a C4 c Z, Shee cee ee eee te 93 4
opahe =: €SS. = ee: FEE, 22 NAME OF
gu Zz = thf Ah A Eng ho OE EP BE UNDERTAKER .... /——— i ee Ne ah
e a2 E 2 | HEREBY CERTIFY ye = pec tandard certificate of = was
Ses ee filgdwith me BEFORE r ADDRESS ae:
om - a ,
I E é 4 franeived! apttdfiled:stsc!. oo-ta0s.capgeaceles ce. WOE ists!
a ~H7 : ( Vi Uf
z Official Desi Sei -Base ‘ ay wn * oa aang as ATE. Wettedaesats taal hates oaee sens \ ass Suneand Ousepsaeeeae ee “Gute

Statement of occupation.—Precise statement of occupation is
very aig mona 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
wad 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.

if any, related to the principal cause and any important complicatio
of the principal cause. Under contributory causes of importance no
related to principal cause, name other important diseases.

Example

The principal cause of death and related causes

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

Arteriosclerosis

Chronic interstitial nephritis

Cerebral hemorrhage

seeeeees ee ncceneeereseresssescussenssnnesscessstecannsasenescnsecsessesessnesensasssseeesnsesens

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.

\certificate, shall forthwith countersign it an

1 4 x As -of the town for registration.
causing death. As related causes, name earlier morbid conditions, \ e

‘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.

btained 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
transmit it to the clerk
f 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, Chad. 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.

Every item of

PHYSICIANS should state
Exact statement of OCCUPATION

certificate.

AGE should be stated EXACTLY.

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

formation should be carefully supplied.
tant.

CAUSE OF DEATH in pla

in
is very impor
100m-11-’30. No. 605-b

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

<The Commonwealth of Massachusetts
OFFICE OF THE SECRETARY

DIVISION OF VITAL STATISTICS (City or town making return)
STANDARD I
CERTIFICATE OF DEATH Registered No........... 1 P¢ Site

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

(If U. S.
War Veteran,

Specie: WAR) qcsnscescvseccsoceupees-stasdenenccnee

~
PLACE OF DEATH

2 FULL NAME.. Wh s he AeA agin =

(If deceased
(a) Residence. No.. OaG:

(Usual place of abode) (If nonresident give city or town and state)
Length of residence in city or town where death occurred 2 § yrs. How long in U. S.., if of foreign birth? g yrs.

PERSONAL AND STATISTICAL PARTICULARS
4 COLOR RACE 5 SINGLE ig (write the word) 18 DATE OF

MARRIED
WIDOWED
or DIVORCED

5a If married, 19

HUSBAND of ..<4-<-4 ett

MUNA PEE WHE ibs .cdhavaastveavcassacesccassssaciaagossaAtrocneds Paces cats nas ass esata ona rcases nary ceocbutee reat snorecse I las :
(Husband’s name in full) =.
to have occurred on the daf¢ stated above, at.. =. Sm.

6 IF STILLBORN, enter that fact here. The principal cause of death and related causes’ of importance in order of

7 vi If less than 1 day onset were as follows: Date of Onset

AGE..... wae Years..L/.....Months......... Daysi|| 0. Holrsie..2 Minutes ee Set od eee wen
8 Trade, profession, or particular “f JOD oa

= kind of work done, as spinner,

° sawyer, bookkeeper, LG! esc. centres RS Re eee ate Ma ed ac ARO aN r Roce aaonnetevtes HUI ce Deh sec g a -oadsUne se cee owen, Ors cece Cue eae eettcc ec ose ewertecodceesececttatcseocses:dyllta. de /ae eee eaee

| 9 Industry or business in which /

a work was done, as silk mill J7f7-, pj §_ f/ —_ Jj sd J. ceweceec eee ececcecercencrcesccccccsceccesestesessusasnescaseenscsacsssuceesseseseeseceenes [sescectsceraeeeens

= COE Saat AS TA) Co ete SI la oe re

Ss 10 Date deceased last worked ae 11 Total time (years) SOS AREER Oo SECO enn Ee COCR ESCORTED Ee EDP P RECEDES unr ROCEE COL SECO CE Og 0) dae Sasepe cer gan sic

this oc tion (month and spent in this @O Contributory causes of importance not related to principal cause:

be eis baa tesdeneniaicn occupation.....

SNES BMRB ERE CGICN) ccc cncnenceh doen a chaz oxuciseccetenscnasnccvesadsoet-wanvseraredsnssaenspancoctusousebcoversieswed
(State or country)

13 NAME OF
FATHER

Namierof op@rationsssiceserecotsccsenescecvvescsoososastvscrcnerucbesaensaxt Dale) Of: -:-nussssscsetaxesasrenotesanerse
een 7 i What test confirmed diggin Was there an autopsy. ay
z\| (State or country) 20 Was disease or injury in any way related to occupation of deceased? ....5=tm........
eS ,
~|15 MAIDEN NAME If =e) SpeCify......... 9-0-8 Pie aescr cose cy dccowscukapcnd age case soinaatveasvosdcacsbevon tates teats ssseetceustateeeeio nated
<x OF MOTHER (Signed) ........:(. convene fpfe
o

16 BIRTHPLACE OF UES
i paeaacaal 21 PLACE OF BURIAL, Y
(State or country) CREMATION OR REMOVAL .&. 424.24. LAP eth
(Cemetery (City or town)
/)
DATE OF BURIAL... Yeager. see? iy SAE one BE 19.4f

22 NAME OF A 7

=| name oF ZT, La tecth Sc. EZ EBA he os
/

appress...27%..2... A Ye et OE or NM ictcenies Rt

Received and FDC seenssnsceuenrcnserneerneevsenennesnneenetnnetseesen eae nee ett EO anart

ped oa ea eee INNA OSA. 2

A TRUE COPY, ATTEST: (Registrar)

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

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

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

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

Example

The principal cause of death and related causes

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

eee 0a ee a ae We eS ee
Chromic interstitial mepnrigs oc ssssssssssseesnseses| orseeest ez sccesse
Cerebral hemorrhage July 5, 1927 |

HOO eeRAROO ORR e een neenennenneneneenesneseeneresnaeenseasseeanrenessneeseeseaseeseneseneeee

Contributory causes of importance not related to
principal cause:

Revised United States Standard Certificate of Death

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 poe ee mas obi the Cumtien ry ay last illness, when last
Seen alive by the physician or officer and the date of his rah
Gen. Laws, Chap. 46, Sec. 9. ee

No undertaker or other person shall bury or otherwise dispose
of a human body in a town, or remove therefrom a human body
which has not_ been buried, until he has received a permit from
the board of health, or its agent a pointed to issue such permits,
or if there is no such board, from the clerk of the town where the
person died; and no undertaker or other person shall exhume a human
body and remove it from a town, from one cemetery to another, or
from one grave or tomb other than the receiving tomb to another in the
same cemetery, until he has received a permit from the board of health
or its agent aforesaid or from the clerk of the town where the body
is buried. No such permit shall be issued until there shall have been
delivered to such board, agent or clerk, as the case may be, a satis-
factory written statement containing the facts required by law to
be returned and recorded, which shall be accompanied, in case of an
original interment, by a Satisfactory certificate of the attending
physician, if any, as required by law, or in lieu thereof a certificate
as hereinafter provided. If there is no attending physician, or if, for
sufficient reasons, his certificate cannot be obtained early enough
for the purpose, or is insufficient, a physician who is a member of the
board of health, or employed by it or by the selectmen for the purpose,
shall upon application make the certificate required of the attending
physician. If death is caused by violence, the medical examiner shall
make such certificate. If the death certificate contains a recital,
as pegiired by section ten of chapter forty-six, that the deceased
Served-in the army, navy or marine corps of the United States in any
war in which it has been engaged, such recital shall appear upon the
permit. The board of health, or its agent, upon receipt of such state-
ment and certificate, shall forthwith countersign it and transmit
it to the clerk of the town for registration. The person to whom
the permit is so given and the physician certifying the cause of death
shall thereafter furnish for registration any other necessary information
which can be obtained as to the deceased, or as to the manner or cause
of the death, which the clerk or registrar may require.—Chap. 114,
Sec. 45, G. L., as amended.

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

RULES OF PRACTICE

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

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

The Comutanmeslth of Massachusetts

-301
eS OFFICE OF THE SECRETARY
E DIVISION OF VITAL STATISTICS
2% a STANDARD
g= 1,6 CERTIFICATE OF DEATH Registered No............ Rie eee
wy
us % (If death occurred in a hospital or institution,
2) oe Cconemeey (~ Xi Sena V+ Dy 7 / po CRE CREE ee eee RN Ree a nkcipasaace Ward give its NAME instead of street and number)
0
28 (If U. S.
n= 2 FULL NAME... P 4 War Veteran,
z 3 i SPUCUPAWAD) 9 0isociceookit ee
»
OF (a) Residence. No.....@¢2.../.. Hash a Od RR eB res Steck Wee Pee At ees tS ee
n g (Usual place of 0-3 (If nonresident, give city or town and state)
~ oO 8 Length of residence in city or town where death occarred o yrs. mos, days. How long in U. S., if of foreign birth? yrs. mos. days.
P=) eee nnn nnn nnn nnn nnn nnn nnn nnn
a eee
ne3 PERSONAL AND STATISTICAL PARTICULARS
i ite the gord) jj
ee 3 SEX 4 COLOR OR RACE | © SINGLE (write t 18 DATE OF
= g 8 ” WIDOWED An anud DEATH 4. ncoqeec Pe ae Ah. ae 9 3! A
Baw. or DIVORCED onth) (Day) Year)
Css 5a If married, widowed, or divorced LOR ek EL Re CERTIFY, That! attended deceased from
PEE HUSBAND of ........ Se eRe Rae err a | Jeter. 23, 5 Pa 0 Witter. Dp voy WOH.
oe ¢ (or) WIFE of . f&O VOW... WI... AD OWA oes cess cccccnneeecennneenee : ! last saw hé@-¢~...alive on ard ’ z Z) a aes S| death is said
oad ‘b,)
= to have occurred on the date stated above, at./ VOL m.
s ae ee net, enter that fact here The principal cause of death and jeiated causes of importance in order of
* = s 7 0 sd If less than 1 day onset were as follows: we "Date of Onset
28 2 AGE.....a@®....Years.....9. Months &¢S.-Days |...» Hours..........- Minutes f LPI PON gs Y Lg, 933
v g* 8 Trade, profession, or particular : .
3 Q £ = kind of work done, as spinner, ianks scnnpm coords couhmnepustvnss Qataeset ns Cane ssahveaivrash -AcE- Fd baanannuhauseucus vedauuanseanesinensbaycetae
° 3 (7) ro) sawyer, bookkeeper, etc... AEE: 2 TE AD eaten Meret errs
< & = 9 Industry or business in which Sniucnanenwe ¢scphqubhps dducsvcccesh) -dcxapesaudunnuqeuutaaugaubhhsphscaucanckuwowsguee |
Po a EDS SINT, SISTA aN ee a Fig ge Fig, Rai | nares reso SOV ee NEE ee |
ba) £ os} = MMPTTS INS MCSICN Seas, oot Paka cats Reh on ehek oapes ean Soo fonda cd ov avnscecg de - sateen sons or
1S) S &| 10 Date deceased last worked at 11 Total time (years) I cee RPC cRe MS eRe eee Pee hs Wee cee Rees eee ae
<25 this occupation (month and spent in this
4 * 53a 7 ee a eee 2 Ia f. occupation. ...................
io] A
oss 12 BIRTHPLACE (City)......../>
a 9 o (State or country)
r)
cae 13 NAME OF
<2 FATHER
St:
| S32 | 14 BIRTHPLACE, OF Y,)
ae te] is FATHER (City) ......... ) her
2 “S £ z (State or country)
BOT 115 MAIDEN NAME
oO fond . A | aX
. in < OF MOTHER (Signed) . 4
| -_ a ;
‘SE 16 BIRTHPLACE OF d (address)... LIZZ. |
o< g DUUERNNNPRLON CO os ccencesccccee ye once cnc neca catasstn ae vaupasenctrsicenanneecceytns<00:0N » : 21 PLACE OF BURIAL, /
ons (State or country) CREMATION OR REMOVAL oi VAG...
emetery a ab or town
aa 5 c MG )
Su FI a DATE OF BURIAL......-f...4 =
es] 31] ‘Informant .........-.--.,4.----.-- hn’.
aed g 22 NAME OF
«&Y) Cj UNDERTAKER ........: AJ...
EOE s
fea ADDRESS........ eee
FEU. Ss a\,
2 ‘ 4
' ae Received and aS oS aN ee A Ra Nee ee 19).3.....
) eC vi
4 8 So edeccccnsaasccccccccesescccecs he a] [enone ecw ccnssaccnes emma OM tet Fo ecccowcscece oj
, 3 A TRUE COPY, ATTEST; YP cs

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
gts 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 enginecr, mining
engineer, stationary engineer, etc. Avoid the term “laborer” when a
more precise statement of the occupation can be secured. Do not
use the word ‘‘mechanic,”’ but give the exact occupation, as carpenter,

- painter, machinist, etc. Distinguish carefully between retail merchants

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

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

Example

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

Arteriosclerosis rors

AUSESASe Ree easanease Sanu neanassauaseueenaeaseeeensseusrstvsrstssesessnsassanessensesssassrenss| ietseeeeeeeeeneneeessseeee

Chronic interstitial nephritis 5 ro2r
Cerebral hemorrhage

Contributory causes of importance not related to
principal cause:

APRA ESOS Oe RO nee eneeenneeneeseseG See Dee snneseseesseseseeenseectsarteensecrncassnessssnsesnnees| -seeeees ee eseseecnseeees

In a group of causes containing the principal cavse 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,

i OF :
COMMONWEALTH OF MASSACHUSETTS
GOVERNING THE

RETURN OF CERTIFICATES OF DEATH

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

No undertaker or other person shall bury or otherwise dispose
of a human body in a town, or remove therefrom a human body
which has not been buried, until he has received a permit from
the board of health, or its agent appointed to issue such 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 purpose, or is insufficient, a physician who is a member of the
board of health, or employed by it or by the selectmen for the purpose,
Shall upon application make the certificate required of the attending
physician. lf death is caused by violence, the medical examiner shall
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-wpon the
permit. ‘The board of health, or its agent, upon receipt of such state-
ment and certificate, shall forthwith countersign it and transmit
it to the clerk of the town for registration. The person to whom
the permit is so given and the physician certifying the cause ot death
ahail thereattar furnish for registration any other necessary information
which can be obtained as to the deceased, or as to the manner or cause
of the death, which the clerk or registrar may require.—Chap. 114,
Sec. 45, G. L., as amended.

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

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

RULES OF PRACTICE

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

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

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

Every item of informa-

PHYSICIANS should state CAUSE
Exact statement of OCCUPATION is very

AGE should be stated EXACTLY.

tant.

50m-2-’30. No. 7997-d

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

impor

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

Che Commonwealth of Massachusetts

: OFFICE OF THE SECRETARY .
E eeeeee Middlesex Seerrrrrrrretiriiti itt tits * DIVISION OF VITAL STATISTICS Prereet tit teers asaenes Melrose Prrri titer treet treed
Ps (County) (City or town making return)
a STANDARD <
me eeirese. CERTIFICATE OF DEATH Registered No... eet...
| ee Tom) df death diy a hospital oc -idistitactl
* eath occurred in a hospital or institution,
a No SAC Melrose Hospital S duauuaekidarubstaderueadivasmtustenans St, eanestaceasbasar scene Ward give its NAME instead of street and number)
(If U.S. i
2 FULL NAME.......... Mary H. Carstensen (MacNaughton) oe War Veteran,
(If deceased is a married, widowed or divorced woman, give also maiden name.) SUPECIE WANNA We) ssc ssackasssazesuvaatmsacosvsereionstinw
r.
(a) Residence. ee 28 OT a Stren Weird) | eee i es
(Usual place of abode) (If nonresident, give city or town and state)
Length of residence in city or town where death occurred yrs. mos. A. 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
wigan DEATH Moscoso! Ct ae ee: Rc
Female White or DIVORCED Widowed (Month) (Day) (Year)
5a If married, widowed, or divorced 19 £ Too4 EBY CERTIFY, That | attended deceased from
HUSBAND of {
0! x aide name Of wife in full) |||SCS* fesnssecevnessesucneconnsnevesevonscnssonconssssnononnes SU See Am (Ses JON» Ere 22/34 wesc BLO scunaenss
(or) WIFE of enr I last saw h.@%....alive on...... SAM... OL BB eecccccne aS Lye , death is said
to have occurred on the date stated above, at.2290 fe Me

If less than 1 day
Hours

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, etc

10 Date deceased last worked at
this occupation (month and

At home

11 Total time (years)
spent in this
occupation

12 BIRTHPLACE (City) ..ccccccccccsen N@WDUTYVPONE oc cccccccccesesceee
(State or country) Mea ss
13 NAME OF
FATHER

OCCUPATION

James MacNaughton
NOW DUT YPOR EG oc cccccsceccccereee

14 BIRTHPLACE OF
FATHER (City)

(State or country)

15 MAIDEN NAME
OF MOTHER

PARENTS

Unable to Obtain

16 BIRTHPLACE OF
MOTHER (City)

(State or country)

Unable to Obtain

Ae el pannel ti NCE Se
(Registrar of city or town where death occurred)
DATE FILED ..cccscse CORe eg See EN '

The principal cause of death and related causes of importance in order of
onset were as follows: Rie aT,
Dateofonse?

eerie. Corebral Embolism = -t).06* ee

Contributory causes of importance not related to principal cause:

Blockers Arterio Sclerosis & Hypertentibn........
Name of operation Cholecystot omy
What test confirmed diagnosis?
: =srne’ %
20 Was disease or injury in any way related to occupation of deceased?...... a Auieaven
WSO SPERM pwn sssicy otc ee suacarachan cnves'stoasareiavoas cnesazeacy cantemmeeetecaureracsuete voartaacbeeeceniecauerGaleaseuesuaiee
(Signed) .ssccs R,...V fa -heyrhon LA. | Slants cee? ae _M. D.
(Address)....... BO Ston, Ma: A) RS sap Date...... 1/22484..
21 PLACE OF BURIAL, Rr
CREMATION OR REMOVAL......... Food iam ieee Everett... Bt
€ (City or town
DATE_OF BURIAL... 022*...2 8, 1884 CRO. AR ce iit
22 NAME OF Rr
UNDERTAKER .... prank &, Brown
ADDRESS...........7.%...29 8S ¥US4
Received and filed........... 2

(Registrar of City or Town where deceased resided)

}-
a a
Weiers? 2 y
ay a ie
7
é2\¢
F
“i
: ae
- ¥

The Commonwealth of Massachusetts
OFFICE OF THE SECRETARY

a CISC ESTROUS UE te Vee per scr a ssacnvecsunsenesuesangnnesussavenuisszcsnesrossoessotanetnention
S 2% 5 DIVISION OF VITAL STATISTICS (City or town making return)
Se E STANDARD
So eA ees CERTIFICATE OF DEATH Registered No.... 20 he
- [3 tw
+) < ( (If death occurred in a hospital or institution,
529 Gg Ne. sect Pera Pac ence e Peumescnsene see stes cere eM Poa ses Din cenevecccoeses seecnsnouce St., Sideinaueseddsanadavews Ward 1 give its NAME instead of street and number)
>
<e)
wn (If U.S.
2S SEE Rear <8 ls Fe So 2 | Wer Veteran,
os o (If deceased is a married, widowed or divorced woman, give also maiden name.) Sycetiy WAR) 5.00.5: onsgaceterssacchapnattesoe
Os
stp g (a) Residence. No....... -oL.. Hieshland. Ave We stash fastticins Sekt Wardiise oes oi nee teat ieee ee
é oO (Usual place of abode) (If nonresident, give city or town and state)
mm ry 5 8 Length of residence in city or town where death occurred yrs. mos. days. How long in U. S., if of foreign birth? yrs. mos. days.
-
= oe PERSONAL AND STATISTICAL PARTICULARS MEDICAL CERTIFICATE OF DEATH
Pla go || 3 sex 4 COLOR OR RACE | 5 SINGLE ee ee) || ta DATE O
DEATH....
ae 3 1 WIDOWED
So 2 |\Female! White or bivorceoS ingle ee Se
ees 5a If married, widowed, or divorced a BY
MRRP coy sc ec eth cous sc cenicancespe re aodeb vcveav oan snus uatws y soupttvcdeandvsyocbvedaausvaesetiers
amt (Give maiden name of wife in full) SSCS pessvstencoStesesesenncectnnnnncnntnsccscncnnnsnsscnngne ;
| (eb nog cite See tl SARI A ce ele oe ,
< 24 Fi or o Gece eae : | last saw h...Z&.... alive oe ~
n Sb ° 6 IF STILLBORN, enter that fact here. to have occurred on the as stated above, at... 9 OTs. m.
+ —— --—--. Th al f death and related f importance in order of
ng Ae 7 77 ifiees ancl dey ee eam oO ea! and related causes Of importanc sae or baa
Es - ° ae cinctris te cre ce NO@AISicsn<-oco050:- Months........ DAYS | eecress- -0-e Houls............ Minutes Gate SE Gieial?
= Uf: whe
Bat) 8 Trade, profession, or particular z Wis
38 £ z= kind of work done, as spinner, (
mM ans ° sawyer, bookkeeper, etc...........2:.0... Retired Sopeve cokenen Cabiov oy Visucce tA cons one
Za > | 9 Industry or —— "i
a work was done, as
GES |ls| swaill bak ct... SCHOOL Teacher
BS + S| 10 Date deceased last worked ‘at 11 Total time (years)
Sse || ercren “Tort E50
Pe | 1 2 8 ee ee occupation 4 ..............--
mo. o
oF te 12 BIRTHPLACE (City)....00.0..0.. a a ae
z Ook ceevecmnry) ~~ . -*. -3. Mass | . 5 a i eS Rd |
o2a¢g 13 NAME OF |
a E5 A ese Rs et ea a eee ai | (erect OP te he Ee, Pe oe
we RS Josenoh ee
Z5e 8 ~ 14 BIRTHPLACE OF =~ Name of operation...............- asp QD Dale foficke arene
Sec § | FATHER (City) .. £0 se Seats scape What test confirmed diagnosis? Lscocegtin 5. | Agaakwas there an autopsy?..7
- ® :
= fae Ee _Gtateorcountry) a ee 20 Was disease or injury in any way reiated to occupation of deceased? an
© | 15 MAIDEN NAME If so, Specify hy Pea or Se ae ie a Se ets eee |
£ < OF MOTHER * 5
S53 |\< ie Catherine Healy 8 | ll

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