The volume, 1935

Town Clerk, Winthrop · from the Internet Archive · 522 pages · 56.9 MB
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‘J. L. FAIRBANKS & CO.

Stationers |
43 FRANKLIN STREET
—BOSTON—

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PHYSICIANS
Exact statement of OCCUPATION

certificate.

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CAUSE OF DEATH in plain terms, so that

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

woe Commonuralth of Massachusetts
OFFICE OF THE SECRETARY

DIVISION OF VITAL STATISTICS (City or town making return)
STANDARD ; i
CERTIFICATE OF DEATH Registered Now.............00cereseeee

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

»
PLACE OF DEATH

ay } Sf po aa. (If U. S.
2 FULL NAME, 6.007.220 Ree Mee War Veteran,
i i i RIN WOM rc corast] sss onegpndascaavuvicneatenden

(a) Residence. No.. p40, wae “2 erties ot, OC EY Ae ee Oa Er See PUAN 20s cal Ola cass sv cohn icdei nn pee <i thnctnntwseesh acgeepecienearetons

(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?

PERSONAL AND STATISTICAL PARTICULARS MEDICAL CERTIFICATE OF DEATH

i 4 COLOR OR, RACE | © SINGLE (write the word) |! 18 DATE OF / S934
; ae ne : 3 ZLY9O
: Vale

days. yrs. mos. days.

MARRIED L
WIDOWED yj (Month) (Day) (Year)
19 I HEREBY CERTIFY, That | attended deceased from

or DIVORCED,
aN ee Ma? ,1934,,, to........ : wee oe , 1944.9.
1 lasbSaw i. Qetey.-.-AliVE OM.cesssecsssssssnsetp Ad oo \........5 198@..., death is said
to have occurred on the date state ae

bove, at dfn.
The principal cause of death and related causes of ‘importance in order of

If less than 1 day Date of Onset
eas Hours..........--Mi A ‘ : aL st /sy

5a If married, widowed, or divorced ,
HUSBAND Ol .........0.0c00c0ecccesenes eae D.. 24K nc bce®: . “A.
(Give maiden name of i

Miele MPU REA E tease ccisetracessase0ceccnsectcnacousaassscucoesteincsct foreel Seb geeeecen caabenaecnn aig Ve -onr Pipe
(Husband’s name in full)

6 IF STILLBORN, enter that fact here.

ree Ti Se Meo’... Monts...» i

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

5 sawyer, bookkeeper, etc. .

SN: industry or og in which fi, 7

a work was done, as si 5 : f =, i, en MN tee obs cual iclanaindac ences es encebas cn «cee ap enaas atec arn qeeeeeras sums te eeemenmeeas nates ISGdr\~ aa Semana

= saw mill, bank, etc. seeaeuScanscnua hc... Lh Se tent een a. eesasussaersseciee

8 10 Date deceased last worked at 11 Total time (years) eevecnen Sone ee ec gee SSE ely -Scecee CS Sc CACORE SECT I oe TIER rt
this pecapation pant spent inthis — Contributory causes of importance not related to principal cause:

Dieettnay ACen of Fone Occupation....-m.-1-4.>-.--

IMAM Of DPOF ALON =< pace scceewacvcesenas scsevi-stasecerectsuuccsticesesetue DANO Ol ccescrabelcs iseas-oncasts, ot..

ot non is NE Sh Giles pie ae san What test confirmed diagnosis?...a..1----.eTommenWas there an autopsy?
= (Seateocepuntry) 7s 20 Was disease or injury in any way related t to occupation of deceased? .........baa)..
lu
«|!15 MAIDEN NAME PESOS DECHY screed asurtValseertavanceseacresnscotestewce ssn Se Sere scrap eoaadsss= cetera Seonvsss0susoceVineye®
< OF MOTHER (Signed) .....
a
16 BIRTHPLACE OF addres);
NNO MENA: (ROSE aera cates cit cece sae afexinacde th csamccuacdo cosaéziceuraast ssaysb acest vubauclecdscesebactene 21 PLACE OF BURIAL,
(State or country) ra ccs CREMATION OR Le nova of
- 2 (Gomidlers)) (City or town) 2
i hg SS _»y fof / //) soe 7 ‘ >
_isermant Sop eee began tf. (Zh LAT, Te A Mod heme: ERS BURIAL eee = > aie ees ———
aay oa Mt d Zodawnf - TIE o #4 22 NAME OF Ah. r
———— _ UNDERTAKER 0. Juche MO Me te) =
| HEREBY CERTIFY thata ee standard certificate of death was ris a= z-
filed with ransit” Dep Saeed PO ee a on
BREST WEEN ANTENA NE ceecce tb eri acc dake aens doce vactaecOsesnaesbvesadsuwacuavsanseasho-veeveongacenstscnagenepecd AG i. ccnicnk
40) .
3) ae JAN. 8.1935...
A TRUE COPY, ATTEST: (Registrar)

Revised United States Standard Certificate of Death

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

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

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

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

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

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

Example

The principal cause of death and related causes

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

Arteriosclerosis BEA Nie ie ali 0 ea ON are Freel at Meee
Chromic interstitial mepnr ites... ssssessssssssssesesenssss|csssseust oe cssscene
Cerebral hemorrhage _July 5, 1927

SdOeAeenaeeneeenenneeeneseetsnuennserasscssnrenarennseensensensannenanennes seecesences eves

Contributory causes of importance not related to
principal cause:

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

EXTRACTS
FROM THE LAWS OF THE
COMMONWEALTH OF MASSACHUSETTS
GOVERNING THE

RETURN OF CERTIFICATES OF DEATH

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

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

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

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

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 4

(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.

ro Bee scs w The pl ettneean of Massachusetts To be filed for burial
iat HE SECRETARY i "
ae ‘si 3 DIVISION OF VITAL STATISTICS PO ih with Board of
i 2°: MEDICAL EXAMINER'S / 9) 7 /12ei! % its Agent.
>
A £85 CERTIFICATE OF DEATH Registered No............... a rare Be
A A 6 (If death occurred in a hospital or institution,
A 4 g t give its NAME instead of street and number)
. ™
rt a $3 GU, s.
J £ 233 aay is a married, widowed or divorced woman, give also maiden name.) sas pa Y ike hens ad) Rea
ees (a) Residence. No..}.S.ii.... With $e... CLO — St w
O20 2 ce ee a ee ee apes <teerbecaens sree Ladue gee ey ei oe a
2 ‘ ie nonresident give cit: t d
fz 33 g Length of residence in city or town where death occurred Posts yrs. mos, days. How long in U. S., if of foreign birth? yrs. a peer r ath
Es $3 = PERSONAL AND pee PARTICULARS MEDICAL CERTIFICATE OF DEATH
ai § é 8 4 COLOR OR RACE MARRIED ‘ae the word) 18 DATE OF Q r os
oes une wy a DIVORCED (3 U1 L i
oe rh or <j
of S55 £ || 5a If married, widowed, or divorced ,
BES || HUSBAND of nn ise ei ee ee eee as 19 I HEREBY CERTIFY that I have investigated the death
o * 252 yon maiden name of wife in full) of the person above-named and that the CAUSE AND MANNER thereof are
< <2 5 2 Rsseenbsieecs cbecseh ae Le a ee as follows: (If an injury was involved, state fully.)
z az 5 2 6 IF STILLBORN, enter that fact here.
aQgQn © 7
n 2 If less than 1 day
- ™ as AGE Be eo Years..............Months............Days |... Hours.........-.- Minutes
L 7 25 8 ae peas, or particular
h ind of work done, as spinner,
a was o S sawyer, bookkeeper, were Raves. Neh E Evrae ven hers i 4
> ZU >F =| 9 Industry or business in which’ —Jo f/f Oo
| z ae i a Mark gas. done, as silk mill, /-@7U*™ «
i} S saw mill, hGH ER Ma a sea sstcaicttnceantasone
| w Oe og | 10 Date deceased last worked a i
rd <= Be who (month at Doo, mes Clr ge
—. cP a tecat eee .
i os a 12 BIRTHPLACE (City)...... DUS PATO Ahsan
; : 9 a : 2 ee oo nee ee
—
= a5, §8 13 NAME OF \\
< : a5 FATHER y Sf
* 5 e Fave
Zee ° 2 14 BIRTHPLACE 9, : x (See reverse side for description for unknown person)
~ae 2 ae FATHER (City L/| 20; IN WHAT CITY OR TOWN
x : 8.9 z 7 EDS ce mar ' WAS INJURY Patac Satins det .) ays reheat Boch vintlahcmahapetiv’ sAalss vadaas ed scabs Ande See
‘ § KB ° a) <A Se x ry
= 9 0 m/|15 MAIDEN NAME ra
i <| OF MOTHER Me
| SES || aM Kasi
a roe) » 2 16 BIRTHPLACE OF
4 2 ¢ o MOTHER (City) ............., :
| ae Poteet cuunteo) CREMATION OR REMOVAL ....s=. SA. SMA... UM. , UY
4 25's 0 ry Ps q J
fe c *a3 -- (Cemetery) (City or town)
Ea ony : DATE OF BURIAL. :csccsesoeeo J OZ*UAL LEE Mt SR eet 19.3.8
e eta g Dentin OREM ERC E™ GUE Cane Ta YO a PR er i) ——>
ip fs 23 SSS i UNDERTAKER tAken Cre Se 7 bse
= : ! E at a satisfactory standard certificate of d % :
> S888 g ay le the bygalor nsit permit ufieate ok death yas apres... 46.0... AB AMON AS. Pi scosceostrealee “
‘e ad ° z. Yl ME ae /
Ld 5 $ ignature of Agent of Board of Hi Niner other) 7 or an Revelved tardy filgdce caters eet eet succes Lene Rihaalocecacotkateunenetebeciptatatbasss 19:20.
¢ a oA ny ; 4
se LAK AL T=... LL eI AIG AAR at AER ck RA OL. Wee ellioks ;
, Zz & (Official Bled ff i co ep ge Ven y i IOP AVENA Ne son IA SU uA scab utones We JAN.8 Ledanaa 1935 sissies ON enacts

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
gee 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 Purpore, or is insufficient, a physician who is a member of the
board of health, or employed by it or by the selectmen for the purpose,
shall upon application make the certificate required of the attending
physician. If death is caused by violence, the medical examiner shall
make such certificate. If the death certificate contains a recital, as
tequired by section ten of chapter forty-six, that the deceased served
in the army, navy or marine corps of the United States in any war in
which it has been engaged, such recital shall appear upon the permit.
The board of health or its agent, upon receipt of such 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 1ave 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
whee, physician is absent from home when the certificate of death is
needed.

STATEMENT OF CAUSE OF DEATH

Medical Examiners in certifying to a death will state the cause and
manner thereof, and will specify: (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 anzesthetic."’ ‘‘Fracture of the skull with
associated internal injury sustained under circumstances unknown.”’

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

seeeee SAEeRRnanenenensasnsssssessseeesEESESSSSEUSSGEESSaEsEEEEESEEESETEEHSEEEESESSEEEEESSSEEREEEESEEE SEES ET EEESONOREGEEEESHEEE SEE OESSESESEEEESEEESEESROEEEEEESSEESEESEEESESOESEEOESSSEESEEOSEESESSESESESSEEES ESSE SENSO SEES OSHS EEE S EEE ES

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

FORM R-301A

MARGIN RESERVED FOR BINDING

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

Every item of

PHYSICIANS should state

AGE should be stated EXACTLY.

t may be properly classified.

tructions and extracts from the laws on back of certificate.

information should be carefully supplied.

CAUSE OF DEATH in pla

Exact statement of OCCUPATION

terms, so that

tant. See ins

1s very impor

100m-9-"33.

No. 9321-a’

STANDARD 3

1 CERTIFICATE OF DEATH Registered No. 4237 F ow

e224 (If death occurred in a hospital or institution,

ED aR 9 A rte, Seeueataxeiieasd Sta SER eeeinaiesteieeManaey Ward { give its NAME instead of street and number)

(If U. S.
2 FULL NAM War Veteran,
(If deceased is a married, widowed or divorced woman, give also maiden name.) Spectly: WA) csiscidocustvcosscsossdecdecstvecpotvees
(a) Residence. No.7 L...2 ne 2, La 5 Se eee WV AEC gio tciscosth tw syatorusescabest cecsesa ts steavabivesssctte cnet
(Usual place of abode) (If nonresident, give city or town and state)
Lengih of residence in city or town where death occurred ‘. mos. days. How long in U. S., if of foreign birth? yrs. mo3. days.

35 4 COLOR OR RACE | © SINGLE (write the word) || 18 DATE OF | 37S
ee WIDOWED BOAT IH sssecctesssecscosarasonsesccM snd nnosaxcesssens pssceteveoqeoxas 7 siicenSnnee¥ 1 chapas'sdties he ete ae eee ca
: or DIVOR At Beane (Month) (Day) (Year)
5a If married, widowed, or divorced 19 I HEREBY CERTIFY, That! attended deceased from
PONS OU N on ce cy gomscehir iu inmavibess Sataycieswinve cake anuisigeavase Wasssavacug ck descvencapaenpudgpuacbeaeucenudsose: —- - aS abs 34 °
(Give maiden name of & F cgundipenp aM cradensarseeee Pisin: Mme ecioo inate PL DM cRay UDeacccccencsaelpusnctercans &f Bets eee sssasery 19 G.60....
far) WIFE of EMT riGeintatame ings)... 0h. Chee I last saw h..Q4....alive OM...sceseeseden Beecaseaet 1 feerttrectrer cere : 19.2.9, death is said

6 IF STILLBORN, enter that fact here.

OCCUPATION

PARENTS

The Commonwealth of Massachusetts To be filed for burial permit
OFFICE OF THE SECRETARY Sith: Boned of Health
DIVISION OF VITAL STATISTICS a

or its Agent.

PERSONAL AND STATISTICAL PARTICULARS MEDICAL CERTIFICATE OF DEATH

to have occurred on the date stated above, at. Af... fete ry ft
The principal cause of death and related causes of importance in order of
onset were as follows: Date of Onset

IMPORTANT

If less than 1 day

8 Trade, profession, or particular
kind of work done, as spinner, QS
sawyer, bookkeeper, €tC.............srccreGheersenosenstnee Roun Mer tet <

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

MAP TNT RCM EIIC HELE eo tes fee uss acttinnateats dencezosueatnecdinencsne ceressaubcssctvdsecapddscksnsasussnoarscpdavas

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

this occupation (month and spent in this
Dee casscete iene tind seins nage ee rans ate oss gisesitva OLCUPATON coxceeaeecseceoass.

BIRTHPLACE, (City) <..0::stey street ete Oe Mw onc ens scccssonsacsossessnsnensencctsessacnsaneatoneses
(State or country)
a2. Se mthenet chin saan ac ale vile ain a's dev cibiMiar ila sae abte uate Shu ctaidiued totam daha came aes Seem Otee cates Pee ha stones aa tes
13 NAME OF c
IGT A ee A a a Aza | ire Ee
14 BIRTHPLACE OF i 5 Spiga ns Oictss eeeee
FATHER (City)
(State or country) don aw
15 MAIDEN NAME Serna ema gh er OS ES A T(E Sa SECU... cP RicscadeacesuscetevcesseSedelacecogcesna Mes
OF MOTHER : J) || If SO, SPECIFY ....sssdesescssseesssnsisscssnnesscssnecsesaneesese Mesendbeeeeeet:

16 BIRTHPLACE OF

(Signed) ert: Tune. Se gies
veo ere Piven CES Sh aa me i ee aa (Address)......: ae re

tat 21 PLACE OF BURIAL, 4 Pee
‘nie paar CREMATION OR REMOVAL (<2 bitin A. AR.
fComeers) (City or town)
whet DATE OF BURIAL... 2 BBL. Dp AG BBircnvsissiie MQunn se

(Address) Hike, li” Prpae Ch || 22 NAME OF “ }
UNDERTAKER .. é Be AC acalgy Pe Se Ae Ae aed
! HEREBY CERTIFY ete satisfactory standard certificate of death was —-

filedAvith me B or transitypermit was issued: ADDRESS 3.08.0 2 Caer. —s Da el tee ee

ii Designation)

/
neta As a) ta aay Paha ae Mea hee Cae AM...
ES 2B AY Se Bie
(Date of Issue of Pefmit) (Registrar)

Revised United @... 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, teport 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
ay of store, factory, mill, etc., as grocery store, soap factory, cotton
mull, etc.

Distin

ish carefully the different kinds of engineers by stating
the full

escriptive titles, as civil engineer, mechanical engineer, mining
engineer, stationary engineer, etc. Avoid the term “laborer'’ when a
more precise statement of the occupation can be secured. Do not
use the word ‘‘ mechanic,” but give the exact occupation, as carpenter,
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
pelted to principal cause, name other important diseases.

Example

The principal cause of death and related causes

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

Arleriosclerosis wee ARR R EERE RRR EERE EERE EEE EEE HEHEHE RROD
Chapile titarsual mephrttgs eo ssssasterssonesevered| anfstgot O2E scree
Cerebral hemorrhage July 5, 1927

AH ARAEENeA AREA OANA OA AH OEAA SEBO SRUEAAAEUS HDRES RABIN aEOesEED es Eeueeeateeseoesbenesernssnensusarene|cunee Beerterreerrrrerrrres

Contributory causes of importance not related to
principal cause:

In a group of causes containing the principal cause and related
causes, the causes should be given in the order of onset, so that ina
group of three causes tie 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 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 athens 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
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 Temoval, 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 res
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 Teceipt of such statement and
certificate, shall forthwith countersign it and transmit it to the clerk
of the town for registration. The person to whom the permit is so

‘ given and the physician certifying the cause of death shall thereafter

furnish for registration any other necessary information which can be
obtained as to the deceased, or as to the manner or cause of the death,
which the clerk or registrar may require. — Chap. 114, Sec. 45, G. L.,
as amended by Chap. 48, Acts of 1927 and Chap. 414, Acts of 1931.

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

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

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

(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 posers, 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.

PHYSICIANS should s

t
Exact statement of OCCUPATION

Every

ificate.

AGE should be stated EXACTLY.
it may be properly classified.

See instructions and extracts from the laws on back of cert

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

[> og

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aan,
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35

N. B.—WRITE P
In

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

< Che Commonuealth of Massachusetts
Sufflok Sega peed ei TRE es ccscesabstontrsadberssovseasorscnssiatas
E Besahancusiimaabeneds ale davasaatuessisareyees DIVISION OF VITAL STATISTICS escts) car Ceraraaktg vetieeet
a STANDARD
196 .W in throp. aN hee aed, ence CERTIFICATE OF DEATH Registered No....0.......0000.... 4...
| (City or Town) (it death . : : =
eath occurred in a hospital or institution,
a Noz::<...... 69 aaemesenn Sargent Gfacshsaeubasrebacsunsaeaesessescspedtecteschs. Ener eevtsesiecese Ward { give its NAME instead of street and number)
(If U. S.
2 FULL NAME........... a ae cacasnazaahcSbansesbncqeevccdon War Veteran,
(If deceased is a married, widowed or divorced woman, give also maiden name.) SPecaty) WA) os ccvsssc-socvsivadisryronantospeyaste
(a) Residence. No..........: BO PT IU occa ccccal Soicsces.0nss ee eros [oF ea a NER Ye ENR EM n Pipp Ne, ae 1 ei ce ay Peer RP ee Se

(Usual place of abode)

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

days.

PERSONAL AND STATISTICAL PARTICULARS

yrs.

mos.

MEDICAL CERTIFICATE OF DEATH

(If nonresident give city or town and state)

days.

(write the word)

Married

4 COLOR OR RACE | © SINGLE 18 DATE OF

3 SEX MARRIED
Whi te

WIDOWED

or DIVORCED (Month)

BEATHE. tal MUR ie cdiscsdecinchontamns ee Rs t. a ee
(Year)

5a If married, wid 19
HUSBAND of .......6U.U4.9............ ea DL. 2 ee Oe) ee
Oe TEC a SSS SE SP ie Sao a oe Ri oP | last saw h..lesn...alive on

(Husband's name in full)

6 IF STILLBORN, enter that fact here.

If less than 1 day onset were as follows:

reer Minutes

"G
AGEs Seen i: i NOSIS: ...ccc20s-- Months..... 2.....Days

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

sawyer, bookkeeper, etc. nna seesssasesessess AK BTV, Mage debasucastepenssancrecicer

9 Industry or business in which
work was done, as silk mill,
saw mill, bank, etc, ..........-...-.se:sessccesseeeee he {

10 Date deceased last worked at

eee oo ”

12 BIRTHPLACE (City) .....cccccccccc00 i a a eee
(State or country) Pa.

13 NAME OF

FATHER J hn R a

14 BIRTHPLACE OF
FATHER (City)

(State or country)

15 MAIDEN NAME

OF MOTHER Cc t} : in F 36n

16 BIRTHPLACE OF

OCCUPATION

11 Total ee
spent in this
occupation...... 20...

What test confirmed diagnosis

Ingland

PARENTS

Name of operation.......0. ccs pepegeccnscescecesegpes

4 Pets Cot f ens Was there an autopsy?
WD °

to have occurred on the date~stated above, at 252d. fm.
The principal cause of death and related causes of importance in order of

"Date of Onset

MOTHER (City)

21 PLACE OF BURIAL,
CREMATION OR REMOVAL .

(State or country)

(Cemetery) (City or town)
a9 DATE OF BURIAL c1c--.80 BAO. .000 coco Boe 5 ee 19.3.
aman OY a EI Da BOBS nnn
22 NNDERTAKER Bienard EH, White... oe.
ADDRESS) mace tc. ma OUNDEOD:. “ete 5 fe
Recaivedirand tiled sccsceccssstceserrccssserescsrreccesvectsssertrons ae 4035 ne 19 nie

=
58
=
a
oo

(Registrar)

Revised United States Standard Certificate of Death

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 years orover. 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 housckeeper—private
family, cook—hotel, etc. For a person who had no occupation what-
ever write none.

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

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

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

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

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

Example

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

Date of onset

Arlteriosclerosis

Chronic interstitial nephritis

July 5, 1027

Cerebral hemorrhag

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 sh ll forth-
with, after the death of a person whom he has atbeonaaal Buriae

furnish for registration a standard certificate of death, stating to the
best of his knowledge and belief the name of the deceased, his edpaored
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 office. d the dat i ‘
Gen. Laws, Chap. 46, Sec. 9. i ee iis dea

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 nena 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 tequired of the attending
physician. If death is caused by violence, the medical examiner shall
make such certificate. If the death certificate contains a_ recital,
as required by section ten of chapter forty-six, that the deceased
served in the army, navy or marine corps of the United States in any
war in which it has been engaged, such recital shall appear upon the
permit. The board of health, or its agent, upon receipt of such state-
ment and certificate, shall forthwith countersign it and transmit
it to the clerk of the town for registration. The person to whom
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.

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No. 3385-f

100m-9-'31.

The Commonmealth of Massachusetts

OFFICE OF THE SECRETARY

g ey camer ty, Res SRE TA cesscconenasvuassenccecasanessscgcssbissedoreesicoreobeasdiiaahel
E savonsasnvoesshoneaswenste 2 ETOLK ereeeseusnsncnens DIVISION OF VITAL STATISTICS (City or town making return)
a Want] STANDARD ps
aes. oh: OOD cna CERTIFICATE OF DEATH Registered Now... 2 Eee
Fs] (City or Town) A deek i y, ‘
T iia * eath occurred in a hospital or institution,
S No. Jinthrop Community Hospitake oo. Ward give its NAME instead of street and number?
P a . (If U. S.
BOPULE NAME....c-ODTL WGNCGGLAUE. CAM DSL oii ces ccssesssesssssssssseesesessssesseenes War Veteran,
(If deceased is a maprted, widowed or divorced woman, give also maiden name.) opacity WAM). « :cccsinyncsnscencicscersvesaheoavese
(a) Residence. Nos POG INOV. AMG... cchclccheccsus ROSEN nok. c cence 1 Tce Ae A gare ne es 9 PRE EEA Deen Me Se
(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
5 SINGLE (write the word) =
3 SEX 4 COLOR OR RACE MARRIED 18 DATE OF | 4
WIDOWED i . DEATH ............... ea 2 | n° re) Py Ll of
Male 1 er DIVORCED ia rried (Month) (Day) (Year)

5a If married, widowed, or divorced 19 1 HEREBY CERT Y, That | attended deceased V4

HUSBAND of... ABLE. LAUT LE MON Caddell PLAN bDe..133 Be... BrAr..C0.9..193
RNR SURE OSes fee Pee Se ce tac, BR ee ccs aep aco cand Boataaiossbasisosaaits I last saw hsndaghe ive ON aie ccc cc ee ae 2 Yager is said

(Husband's name in full) ‘ak c : 5a &
o have occurred on the date stated above, ath@.2.%%..G0)..m.
f s . Sas
6 IF STILLBORN, enter that fact here The principal cause of death and related causes of importance in order of
OTS ALL teh

7 ° If less than 1 day onset s follows: a
AC WEATS a cccctunnns Months............ Daysiliicecnss Hoursi<.....35 Minutes |]
| 8s le AL sgt or particular
= ind of work done, as spinner, Feat ae ee a
FI sawyer, bookkeeper, €tC....-.......-00000+ oh. inpwright, et Ae one Bene ie
=| 9 Industry or business in_which
ee ap. Yard. ............
6| 10 _ —- last worked at 11 Total plat oe
is occupation (mp oth a spent inthis ¢
SO ee eee, FA. pp amt O19 Pentre occupation....... 60. :
12 BIRTHPLACE (City) .....cccccscssssoo OE fos. i7 Sige aides aaa
tate orcountry) Prince Edwards Island
13 NAME OF
FATHER Allan
Ee Name of operation...............0.0.. Ld
| Eo What test conmed gnosis?
=| (State or country) Seotland 20 Was disease or injury in any way related to occupation of deceased?.....
= 15 MAIDEN NAME If so, specify. Seren m..... Sap is ni A oa “a Sees EEE US OS a
< OF MOTHER t e en fl ‘ (Signed) f o ccerrern LO. GP conn AW. A...
a 4 5 v -
16 BIRTHPLACE, OF Pl mou th (Address) atl. G ye Dat¢
MOTHER (City) ..........2.5 ee re es ail. Pek Bia 2 Wy
21 PLACE OF BURIAL, Y
(State or country) ne land CREMATION OR REMOVALY...F¢t7.140..0-24-@2.... LLL KALLA
= (Zemng¢tery. “ ity or town) ——-
17 : . : y- Zz:
ees bal. 4an,.Cappbe i ‘ee BS ee ie ee | DATE OF BURIAL.../............ ff pf fou oh, er oe, ae frig 19 GAO
(Address) JUING ive Winthrop 22 NAME OF Y Ay (/ 7 Y hh NA)
UNDERTAKER ...06 ...M MJ aS... AA
ADDRESS. cece J coceceeoroee Winthrop Mass nae
Received and fi Bde cease secu coven caresatascoibhcate nzcvsoianetessvdsttannesascnpesccetadervaaipetattvectintes 1h |S

si Lo Se ey eee ee

NTU copy, artes. ii

Revised United Wes 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 aed 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
Jamily, 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
ean of store, factory, mill, etc., as grocery store, soap faciory, 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 showd be called a
salesman and not a clerk.

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

Example

The principal cause of death and related causes

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

Arteriosclerosis

Chronic interstitial nephritis

I9o2r

July 5, 1927

Cerebral hemorrhage

Contributory causes of importance not related to
principal cause:

Pee OPT aK YS
Pree

EXTRACTS FROM THE LAW
COMMONWEALTH OF MASSACHUSETTS
GOVERNING THE

RETURN OF CERTIFICATES OF DEATH

No undertaker or other person shall bury or otherwise dispose
of a human body in a town, or remove therefrom a human body
which has not been buried, until he has received a permit from
the board of health, or its agent appointed to issue such ermits,
or if there is no such board, from the clerk of the town what the
berson died; and no undertaker or other person shall exhume a human
body and remove it from a town, from one cemetery to another, or
from one grave or tomb other than the receiving tomb to another in the
same cemetery, until he has received a permit from the board of health
or its agent aforesaid or from the clerk of the town where the body
is buried. No such permit shall be issued until there shall have been
delivered to such board, agent or clerk, as the case may be, a satis-
factory written statement containing the facts required by law to
be returned and recorded, which shall be accompanied, in case of an
original interment, by a satisfactory certificate of the attending
physician, if any, as required by law, or in lieu thereof a certificate
as hereinafter provided. If there is no attending physician, or if, for
sufficient reasons, his certificate cannot be obtained early enough
for the purpose, or is insufficient, a physician who is a member of the
board of health, or employed by it or by the selectmen for the purpose,
shall upon application make the certificate required of the attending
physician. If death is caused by violence, the medical examiner shall
make such certificate. If such a permit for the removal of a human body,
not previously interred from one town to another within the common
wealth cannot be obtained early enough for the purpose, the certificate
of death made as above provided and in the possession of the undertaker
desiring to make such removal shall constitute ot 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 Tecital, 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. Dar
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 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, fom
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 cerne-
tery or burial ground in which the interment is made....Chap. 114,
Sec. 46, G. L. as amended.

RULES OF PRACTICE

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

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

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

. i t

a P <Q The Commonwealth of Massachusetts Ve be Bled for bat
ve lial Suffolk = OFFICE OF THE SECRETARY saya vcacia re permit
SS Oo” = em eneencrecc vacccanesevaccccvccccccccouscesevescssesece DIVISION OF VITAL STATISTICS oard o ealth
<0 < (County) or its Agent
at = Se STANDARD * Sirnies
1 Sod ee ee CERTIFICATE OF DEATH Registered Noe.csesccssssssssen 2...
oe Oy by (City or Town)
35 cs) Whe (If death occurred in a hospital or institution,
B20 A No........ 3 69. Winthrop Lcscueidl a dlaiae hnlaie anata «asa aie iti si St., Rihsvdinpulakanaenaas Ward { give its NAME instead of street and number)
>a
WO
n a FE 4 (If U.S.
2S 2 FULL NAME.......... ee I es caciscnnteencnnsubjnnivedetnesqnsnevenstzouies War Veteran,
Q < w (If deceased is a married, widowed or divorced woman, give also maiden name.) SEL WAR io visvcscevesevscexsacctuisy tertoes
Os Cee
2s (a) Residence. Mises eee 2 69. Winthrop LRT eh Nas ah Soe Lo) Ap ee Rr Ward,...... cpa cabinsdh iodo ints habia at danieapeee evo
Lx o (Usual place of abode) (If nonresident, give city or town and state)
mm = > 6 Length of residence in city or town where death occurred 44 yrs. mos. days. How long in U. S., if of foreign birth? yrs. mos. days.
Pee) aa ee
= oe PERSONAL AND STATISTICAL PARTICULARS MEDICAL CERTIFICATE OF DEATH
~ O55 5 SINGLE eters tees SS Pe
it a 3 SEX 4 Tum OF RACE MARRIED Z 18 ad ¢ b 19 25S
35 is Femal White WIDOWED S ingle secrete fs artes Fam Badeataes eoesesaskicantseg Fo GaN Cee bart
= x3 hs 5a If married, widowed, or divorced 19 I HEREBY CERTIFY, That attended deceased from
‘ OEETN TIN CQR te eee en eho cea tutes nannitie Larevisscgsasacdusavnts des ceo sapauvohasuandepnnsaauphuseetivovsvarese#
| Y eas (Give maiden name of wife in full) Gea ieroas Y pausuisduidaves faseospeseactics i BS. to...
z a coor SITE af essai cnc at YD Se a ;
= < 26 g or ° ete aD 1 last saw h-@4s...alive on......
Last n a be 6 IF STILLBORN, enter that fact here. to Side ed on ie ue ened ae atl Oem ' :
levers = —— @ princi s and related causes of importance in order o
| iu) n 3 Fy 8 ¥4 57 9 If less than 1 day onset OES faites i Late of Onset
a x 2 @ eae 2 Years.ectoceene: Mantis Days eras HOUTS...-0es--00: Minutes wetane
ORZES ; AMEOTAAT,...
| mm A 8 Trade, profession, or particular
| | 3 kind of work done, as spinner, A inte Mea:
i wes g 3 sawyer, bookkeeper, as vimerBOOk keeper Rena tstdinsecusuadadendarstaneas 4 2
} ! gal > | © Industry or business in which Oe ee ReRMe Tn 7, LN AMP IUN I ai Dianne gaan eee a ARS ty snes eis ee ae.ny © Mans Shs Ab sina Cen Ele sie 8 Sarrn es nee Se eiaeh [oa a Waa nae ee
fia mie ea a work was done, as silk mill, O ffice
ul MU £ my = SDUWe Wan) ama: CLG aoa cass casevensenssasvevacns oscpesuchvesvssasesesessavde¥aapeeensxacadeesdeysienioassoveceas| |) Beets tecensasdententcesecesaseoavecucnasasaisecesccesensceasscesereBeseednot@enmsnes sestomstazane tual nsentdeaua
HH Ofte x S| 10 oe deceased last worked at Zz 11 Total time Hee TOE ee ih A et Se Se i AONE OR Oe PARE Rae MARES Be 2 EROS, A, gee ee | omer Gh tenel |
ws us years ccumation mone LISS spent in nis 5 || “Contributory causes of importance not telaied to principal cause:
|Z M9.ce
0 oe wry 12 BIRTHPLACE (City).......... Fre. d.om mela) prvssessvenssnsnnssssenncecenncncncensenenneed| | Suter tteesscssesssnceeecsanerscesectsesssusssestesenseevanscessesrsenseanaacessensaneas |eeeseutgccetecases
& eRe UU st ae et | Anca eee See ee Re Pen 1
I ee tee) ee ee eee
z ES ta John C. Churchill wf —
A 14 BIRTHPLACE OF é A Name of operation.........%! 1 Seca peree cE riccuzeteaat Dale Of .22.scacct teaacrartateecwer te:
ae] 5 e FATHER (City) i Orth..Parsontield rec RE cep What test confirmed diagnosis? Yfeey-mrs—-- «se-Was there an autopsy?... \9
Ao £ ss (State or country) Ma ine
Saeg |2|°° Mah annie Burk
Base IIs

16 BIRTHPLACE OF
MOTHER (City) .:

's
nformation should be carefully su

to aE OPI EEN sie eI ey

£ :

E é —

21 PLACE OF BURIAL, rst a3

z aS Beebe dale) «if td. CREMATION OR REMOVAL LIb.ATON.....Winthron........
4 5 17 (Cemetery (City or town)
ESO al] Informa £reSton..Ba.. DATE OF BURIALS) OY. w.... Gg le DOD ces csvssnsnsnsntnincne Wee
a wt S| |__ Address) B69 wi nthrop it Li nt hrop 22 NAME OF 1 .
EERE | UNDERTAKER 70M hn PS. PR BATALI G. O10. ecrnrsnesnrn
eases 4) ti BEFORE th appress... VEMEHPOD MASS o.oo nih
Shae oe
| i i ’ AT Racemed! arid diledss ap jicatousicarpacccancoseccsoseteces
Re at
2 E CEG, ft (2 AA ENTS), RAM Sc MSA 5 Beare

Revised UnitecMtes 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
may be returned as
only occupation was
In answer to Question : } in answer to Question 9.
Fora person engaged in domestic service for wages, however, designate
the occupation by the appropriate terms, as housckeeper—privaie
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
~y of store, mill, etc., as grocery store, soap factory, colton
mill, etc.

Distin

factory,

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,
if any, related to the Principal cause and any important complication
of the tincipal 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

senscercccossrcecssesvacongscrecscaccsoess| ovcechecccecsosteccsccccee

ro2r

Arteriosclerosis

Chronic interstitial nephritis

Cerebral hemorrhage

TTA ARN ERO Eee een ean eaneeeaeenneeseneeneusseassesnsecneteartssnnes 0] see snresseceesecnerensces

SU nem eeneeneerecearesassarneeesesecseeess| sesenceeniscesenecessssene

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
gtoup 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.

} of the town
" given

OF THE

EXTRACTS FROM THE LA
COMMONWEALTH OF MASSACHUSETTS
GOVERNING THE

RETURN OF CERTIFICATES OF DEATH

A physician or registered hospital medical officer shall forth-

whom he has attended during

seen alive by the physician or officer and the date of his
Gen. Laws, Chap. 46, Sec. 9.

of a human body in a town, or remove therefrom a human body
which has
ermits,

is no such board, from the clerk of the town nee the

petnon died; and no undertaker or other person shall exhume a human
»ody 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

or its agent aforesaid or from the clerk of the town where the body
No such permit shall be issued until there shall have been

a Satis-
factory written statement containing the facts Tequired by
be returned and recorded, which shall be accompanied, in case of an
i by a satisfactory certificate of the attending
or in lieu thereof a certificate
attending physician, or if, for
reasons, his certificate cannot be obtained early enough
for the Ppisnane, or is insufficient, a physician who is a member of the

make such certificate. If sucha permit for the removal of a human body,
not previously interred, from one town to another within the common-
weaite 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 Se ge 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 Temoval, unless
a permit in the usual form for the removal of such body has been sooner
If the death certificate contains a recital, as re-
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
for registration. The person to whom the permit is so
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. i Bs
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 Tegistrar in the
place where the deceased died his name and residence, if known;
otherwise a description as full.as may be, with the cause and manner
of death.—Gen. Laws, Chap. 38, Sec. 7.

No undertaker or other person 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 froma person appointed to have the care of the ceme-
tery or burial ground in which the: interment is made... -Chap. 114,
Sec. 46, G. L. as amended.

RULES OF PRACTICE

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

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

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

law to.

tte

MARGIN RESERVED FOR BINDING

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

: SY

Every item of

PHYSICIANS should state
Exact statement of OCCUPATION

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

AGE should be stated EXACTLY.

it may be properly class

pplied.
terms, so that

See ins

formation should be carefully su
tant.

CAUSE OF DEATH in plain

is very impor

iz R-3S0O1A

No. 9321-a

100m-9-'33.

@ The Commonwealth of Massachusetts To be filed for burial permit
OFFICE OF THE SECRETARY with Board of Health
DIVISION OF VITAL STATISTICS 4

or its Agent. pay
STANDARD ¢
CERTIFICATE OF DEATH Registered No.

(If death occurred in a hospital or institution,

tal
o
a LAL... Loring..-Rde Seni aa dan sian piiem ada sian che cap havee bene nen St., peiwadsnenee davae samen Ward { give its NAME instead of street and number)

(If U.S.
2 FULL NAME............ Mande... (Lindaoy)..Philoreck Fe oo ee RIE fF {Wr Veteran,

(If deceased is a married, widowe vorced woman, give also maiden name.) SBROCIUG: WADA ss sccdespavadaverssvxnvbadensoeevoree

(a) Residence. No...... 44)... UARINE..Rd.».. Winthrop... eaves SSsgatscbrsstevavers Wea 5 oi eee iccasenihlonss static tu caseses euch caeads eco eete he ae

(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
S SEX 4 COLOR OR RACE | © SINGLE (write the word) || 18 DATE OF
Ct" eet. en cas 1%... Ome ee

MARRIED
: WIDOWED [ aXe
Female White er DIVORCED Married (Month) (Day) Year)
5a If married, widowed, or divorced 19 I HEREBY CERTIFY, That | attended deceased from

CE TAR caer eee eee ae abs Shou clactsdaedabtiadens apnenbagivesdsuasseesss . { th .
(habs oe eae Tlast saw h.#......alive on...... FS pee a Pie ee , death is said

6 IF STILLBORN, enter that fact here. to have occurred on the date stated above, gee ay

(2 0 Seuss SS Se Se The principal cause of death and related causes of importance in order of
If less than 1 day onset were as follows: Date of Dasstl:
Paessesarte Hours............Minutes IMPORTANT

8 Trade, profession, or particular

kind of work done, as spinner, Housewife

RMN HOMME COTET, | BIC sa civs occaicsvcsoccxsussuhassooevcevesudsonberisserisistarssusevascsovvesssevecheacuesi2
9 Industry or business in which

work was done, as silk mill,

OCCUPATION

Beers ym Ble LC. s nc os concdichesuvenerocacecaaestsicdawesausunseccsoosucausisabayo¥iNhdigamevesaeysnrenie evs
10 Date deceased last worked at PS NOFANT MON VERESI AM, ww Mberat) ttt Os bth ue Wa Nl ce. Culbert Ie, ae Mae a
ee ea dls colar jot a Contributory causes of importance not related to principal cause:
TD BURTHPLACE (City) .ecccsssscccsc EOI C LATA -cecscisssscsssnssssssessssnonsssnsscnsnnnesccsn| | so0eeeteeesteeeeencsanssesescassesescsesseunsnsssssanssssssssesseusoeeananansnsasenecsvene] egeareesetreneney
(State or country) EO RT | EEN een ia Tee raphy Mint ee ORME De So RRRL A rt
ESSE ELE ET a, Aan | ie alee nee enn ee ed ee ea aha Ree
14 BIRTHPLACE OF Naina OF OPGratiONys -psas:acncaeseasnenemetusteansrsAscnasaarsenpachrspnsectE) QAO! O fest vates rosacnsncseverspvaenents
a FATHER (City) ............. South-West. Ba rope ccc What test confirmed diagnosisKOfacerwm flip gssa-------Was there an autopsy? Ze
= es Sey) ak 20 Was disease or injury in any way related to occupation of deceased? Vie ee
2/16 m= Clara E. Randall 5, SE DQ
cl See Es Se Ee ee ee Se ee ee ee ee (Signed) ...!..3... paoatnasnatdt es sesssasssacpanisieent <n vie eda coc twe talus cele pneu iapetsecnueduceas. epee ea
PO MOTHER CCA) cece AEE EGO cneennennnnentonn (Address) Laden. A
: 21 PLACE OF BURIAL, s ¥
ee) Maine CREMATION OR REMOVAL... WA22 0ATOD....
17 Ral h W Philb | aimee!
Informant ....; Yat T; beets ee AO AOE EONS, Reno DATE OF BURIAL... QMLo..05. 9. LABS can lseencecitlnv oe
4 r .
|? iE Oren Be Ee. Whi te
menu eee sad Gece ideath wae || CMDERTAKER Sd eam Fe Cae) Cy ape gre fa
pee BEFORE the byrigl or trans) appreSs...... -4¢.. Wanthrop.St.,..Winthroap.........
CaN ae
soeeeee be. Wt NAMA fn tort tin . ee Received and filed
Mal bevbit fick EEG 7 om

Revised Unitca’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——privale
Jemily, 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
=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, as carpenter,
painter, machinist, etc. Distinguish carefully between relail merchants
and wholesale merchants. A person who sells goods should be called a
salesman and not a clerk.

Example

The principal cause of death and related causes

p 2 Dat
of importance in order of onset were as follows: ie ee

Arlteriosclerosis rors

Chronic interstitial nephritis ro2zr

Cerebral hemorrhage J uly 5, 1027

Contributory causes of importance not related to
principal cause:

happens to be the second cause given.

EXTRACTS FROM THE u.8WS OF THE
COMMONWEALTH OF MASSACHUSETTS
GOVERNING THE

RETURN OF CERTIFICATES OF DEATH

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
sdme cemetery, until he has received a permit from the board of health
or its agent aforesaid or from the clerk of the town where the body
is buried. No such permit shall be issued until there shall have been
delivered to such board, agent or clerk, as the case may be, a satis-
factory written statement containing the facts required by law to
be returned and recorded, which shall be accompanied, in case of an
original interment, by a satisfactory certificate of the attending
physician, if any, as required by law, or in lieu thereof a certificate
as hereinafter provided. If there is no attending physician, or-if, for
sufficient reasons, his certificate cannot be obtained early enough
for the purpose, or is insufficient, a physician who is a member of the
board of health, or employed by it or by the selectmen for the purpose,
shall upon application make the certificate required of the attending
physician. If death is caused by violence, the medical examiner shall
make such certificate. If such a permit for the removal of a human body,
not ae aney 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
whicbit 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 res
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 recistrar 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 violerice....Gen. Laws, Chap. 38, Sec. 6.

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

RULES OF PRACTICE

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

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

Every item of informa-

MARGIN RESERVED FOR BINDING

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

PHYSICIANS should state CAUSE
Exact statement of OCCUPATION is very

AGE should be stated EXACTLY.

lain terms, so that it may be properly classified.

tion should be carefully supplied.

in p

OF DEATH

tant.

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

impor

Che Commonwealth of Massachusetts

OFFICE OF THE SECRETARY Rp »
E wanes MORAG SLOT 2 <2... DIVISION OF VITAL STATISTICS seeeeeeeenee Rutland | Prrrirritiiirititii tt
Fe (County) (City or town making return)
a STANDARD € 3
09S RUC LONG nn CERTIFICATE OF DEATH Registered No... ....ccccse og
g asioy Tem) (If death d in a hospital or instituti
7 ' e ° ea occurre ina ospital or insti ution,
A No. Veterans ‘Administration. Fasdé lity. Sepanaipes Ward give its NAME instead of street and number)
WT : -2 (If U.S.
ee ee Cee ae War Veter, PT LE,
(If deceased is a married, widowed or divorced woman, give also maiden name.) SPECIE Y WAM) ves secsvedsersesssnserdscoscscaivocnaté
(a) Residence. No.............: S) 5 Beale Pe eet att Coates ons 8s Stee rer Ward, ....... Winthrop, Mass.. ene Past
(Usual place of abode) (If nonresident, give city or town and state)
Length of residence in city or town where death occurred a yrs. qi mos. 2 a) days. How long in U. S., if of foreign birth? yrs. mos. days.
PERSONAL AND STATISTICAL PARTICULARS MEDICAL CERTIFICATE OF DEATH
3 5 SINGLE (write the word) 138
SEX 4 COLOR OR RACE MARRIED = oieal J anuar 1Z 1s 35
‘ ° WIDOWED a Pe es | Len cot oto Oe Po cocervcnsvcnsseremtnBedes! Prsveeeesensensaees ae Serer
Male White or Divorced i arried (Month) (Day) (Year)
5a If married, widowed, or divorced R 2 19 I HEREBY CERTIFY, That I attended deceased from
, iuth Hardin os
MER INNPN NED NA reer nape eoaecancouysceaeeancosscseatpeadduvsavecunseske«ss Sis ainda ackencerssia - age i ey rs
o eT ETT Al OVember.22..... 198, £9. OOY ELS LS ‘ae 1935.
(or) WIFE of I last saw h.c.--alive on.....0. oar, ¥.AY......, 1922... death is said
(Husband's name in full) 10: 29 A.M
6 IF STILLBORN, enter that fact here. to have occurred on the date stated above, at....%.4.%.&. Pp elie
The principal cause of death and related causes of importance in order of
2 If less than 1 day onset were as follows: Datsatonsat
ays
8 Trade, profession, or particul T ae is 9 - >: Inte ay
kindof work dori, as spinner, Jy: ameses on ee Tuberculosis of oN The: same s...!....% Unknown
Been wemeseener, cic Tuberculosis...of...the...larynx.....Unknoewn

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

10 Date deceased last worked at 11 Total time (years)
this occupation (month and spent in this
occupation

OCCUPATION|

Contributory causes of importance not related to principal cause:

12 BIRTHPLACE (City) i
(State or country) LOST ace! or TE lier ee ae aie eae | Naar ieee ! NON € SSL onan ond HESS ete eee obec ce nero none sane Eee) Serre en

13 NAME oF a ee ene Ne ce a Se co eee ee epee ote et On Os ee ree
William Mil: Name of operation PIE: Se s,. eomern ae: Date. OF .scserencnrsrsernae
” 14 ACE OF What test confirmed diagnosts? YS eX-ray, le tere an autopsy?¥©...
| od Ni
Z| (State or country) Texas 20 Was disease or injury in any way related to occupation of deceased? ...... EO ir
a 15 MAIDEN NAME TR SOs SPOCHY i scccc:ctesscetsonrce sosesennneennenenceeeeeeestussausnuustonnantnnennentennasannenananvennaneneeeeneneceenensane
< OF MOTHER Olivia Lucas Signed fe Cal elitler, Officer..of£ ..the MDe y
16 BIRTHPLACE OF VARAddress) SULLEand Hts -Mass.«. patelLZ13...19.05
MOTHER (City) i sacl ecratcemrmeibt hae
4 Ss 1 | 5
(State or country) T . CREAMER on LEMOVAL Bese Hid +9 Gr ematory
> egy 19 si 5 (City or town)
17 ~ Januar 6 re)
I norman Se ee een Hospital..Recordgevcvcwu- & cee = BURIAL........2. UBL hfe ne) Cad BS sto ee 2 eee ca
Sy AME 0 In T Wl
4 : UNDERTAKER ...ssec00 rank H Miles Co...
A TRUE COPY. ADDRESS..0-.c0escceseooe Pe ET BOE pM OSC ee a
as / ee IE nce eG RR naman Bann SH cB “RAB Ne Ans em ROR ce een Bee N= a RU BRASS CaaE tine send senna iran scenARCER
ATTEST: OV Aa /,- Kang ,
Fal wa erteN (Registrar of city or town where death occsryed) i oe Received and filed..............0-..0000 =EB =. froeeeenaags es eames Geta is
tb + 1935

(Registrar of City or Town where deceased resided)

8S Trade, professicn, or particular

kind of work done, as spinner, House work

MUMEMEM TIBOR RGOBEY: CLC oases sc sahsdascscneenatestveredvsetasseiscnctesteventeteruoscsatereacedesevsecrotassnes
9 Industry or business in which

work was done, asaik mill, QOyn home

: sot A <q The GCommonmeaslth of Massachusetts To be filed for burial permit
% Ta Iz OFFICE OF THE SECRETARY ith B x
b Suffol wi oard of Health
tae oz = Suansnneusas suescqautdaucavacsecobascupa cecascesspacosge DIVISION OF VITAL STATISTICS Y
| o40 < (County) STANDARD or its Agent. ba
Se a
7) Ts a e °
m8 = th ly CERTIFICATE OF DEATH Registered Now...cccccsssue 3 Me
=a a ro] (City or Town) ES : J oe Ae
fs 35 < eee See (If death occurred in a hospital or institution,
a £9 re No.....2.0...uLnbhrop Nee deth anti nnceuindeabvedanadvateelthtdaass Loy ats pe ae ees Ward give its NAME instead of street and number)
> a
Hl ,° (IE U.S.
w) . a\. —. s \
2S 2 FULL NAME........1 QS SDDANG....C BAILS). DOG en cccecsssssecssssessssssessssesssssssssseuee War Veteran,
SE5 we (If deceased is a married, widowed or divorced woman, give also maiden name.) Speite WANE) ossnccuscscseccbetectemiete Aer
= x oO fe 5 +s
wore (a) Residence. Noe.ccsscise 2 locos AAR IAT. QD eccsssssscssnsssssnesesees PE at Ward nnnnrnensninnnannnny nnn
“oO (Usual place of abode) : nonresident, give city or town and state
= z Length of residence in city or town where death occurred S 5 yrs. mos. days. How long in U. S., if of foreign birth? yrs. mos. days.
ny
be PERSONAL AND STATISTICAL PARTICULARS MEDICAL CERTIFICATE OF DEATH
-¢ & SINGLE (write the word)
= s 3 SEX 4 COLOR OR RACE | =e cn ( |
5 ) Fema le tt hi o e | eh Marr i e a aduspaumsguomt MavenpeenMaincsvedeenscevssunenca®
3 5a If married, widowed, or divorced I HEREBY C
de BRPPITERNNAD OF 'cnsacevconchsecd natesncenine sheeted Babcescse poise Satan bLcoanetonpr ee ia area cis er =
-_ i graye en name of wife in full) + ese EM: BR eneeresecnsseseptenseeressenstenessuseeeer
2 (or) WIFE of eecessevene: Hara... ) OQ: BE... sib obGnDAnDuscscdeEnsoccnedsovesdovebuvccnrdepacuscueusscosce 1 last saw h&4.....alive i
mo (Husband's name in full)
4 6 IF STILLBORN, enter that fact here. to have occurred on th : ¢
The principal cause of death and related causes of importance in order of
| 3 ea 57 + Lis 105 li less a 1 day te onset were as follows: “Date of Onset _
hot el Cae eass......S¢.....Months....4-s2Days | ............Hours............ Minutes
ow
3
°
3
i]
16)
<

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

CCCUPATION

MARGIN RESERVED FOR BINDING
ITH UNFADING BLACK INK—THIS IS A PERMANENT REC

mamma ares MOMaNNONE SECS eae aeons 2 ce cetisend nen cca oceania hilov usd olssuacsdeinrecisecmdsaessvesives
10 Date deceased last worked at 11 Total es eee) Sl talc Nie Ae ee eR RR ORM WOR, eM Ae eeces, | Ae ol
33 Yea ee TAN eID —__ eeupation.2........|| Contributory causes of importance not related to principal cause:
po} a
=e 12 BIRTHPLACE (City)... POCHATURGO ene
a Prd (State or country) Vea. Ss $2. echus e C 7S Ss
o | 183 NAME OF . 3 ‘ a : az
a E FATHER Den jamin Franklin Bailey
qs . Name of operation.......A bet
os 14 BIRTHPLACE OF
& # |” FATHER (City) ....... Cochitua te Ve aint ee a ae What test confirmed diagnosis
5's F Z| (State or country) liassachusetts
Deco ut
o«/15 MAIDEN NAME :
£53 < OF MOTHER YerImMie A. Howe
a
-Um 16 BIRTHPLACE OF P
~SRS aI Gotz) OTN ee (Aaidess)-C44
pes § 21 PLACE OF BURIAL,
< zo % (Cemetery) (City or town)
BSS S|] tater Se Olive Be PET eUs OM mm DATE OF BURIAL... J @MLe Lg. LIS 5. 19 snn
co nN E
i E'S 22 MAbraaker Charles Re Bennison ou.
Ne | HEREBY CERTIFY that a satisfactory standard certificate of death was TE = :
wes 24 filed wth me BEFOR the byt pra nsit permit was issued: appress... M1 n¢hrOn.. pl | Pee OS ee See
mes
2) . - ont — ~
a es SL DR or coe git cae fea SD SSE Ray a ace fei antyaee br 147] Ee aes age aR Ss a ca ROR RS Aco coe lel Pare ae Bea i ke RO
. } ie ra) a
a a Ee SS YS Ae As Se | 1 Ag 2 <a
. (Registrar
Zz S (R trar)

Revised Unis tates Standard Certificate of Death

Statement of occupation.—Precise statement of occupation is
very Sy ag 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 causin 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.
Fora person engaged in domestic service for wages, however, designate
the occupation by the appropriate terms, as housekeeper—private
Samily, cook—hotel, etc. For a Person who had no occupation what-

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
2 ag 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, stalionary engineer, etc. Avoid the term “‘laborer’’ when a
more precise statement of the occupation can be secured. Do not
use the word “‘ mechanic,” but give the exact occupation, as carpenter,
painter, machinist, etc. Distinguish carefully between retail merchants
and wholesale merchants. A Person who sells goods should be called a
Salesman and not a clerk.

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

Example

The principal cause of death and related causes Date of onset

of importance in order of onset were as follows:
Arleriosclerosis

ic interstitial nephyitis 1921

Cerebral

hemorrh

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 | S OF THE
COMMONWEALTH OF MASSACHUSETTS
GOVERNING THE

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

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

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

delivered to such board, agent or clerk, as the case may be, a satis-
factory written statement containing the facts Tequired by law to

physician, if any, as Tequired 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 Puree: or is insufficient, a physician who is a member of the

board of health, or employed by it or by the sclectmen for the Purpose, ©

not previously interred, from one town to another within the commons
wealth cannot be obtained early enough for the Purpose, the rertificate~
of death made as above provided and in the possession of the undertaker

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 rezistrar 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 froma person appointed to have the care of the ceme-
tery or burial ground in which the interment is made... - Chap. 114,
Sec. 46, G. L. as amended. __ :

RULES OF PRACTICE

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

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

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

a
'
w
°o
o
ts

Every item of

NENT RECORD.
uld state CAUSE AND MANNER OF

MARGIN RESERVED

WITH UNFADING BLACK INK—THIS IS A PE
properly classified under the International Classification of Causes

from the laws relative to the return of certificates of death.

MEDICAL EXAMINERS

so that it may be

See reverse side for extracts

ar Sa coats ee

information should be carefully supplied.

DEATH in plain terms,

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

a oan

) N. B.—WRITE PLAINLY,

vee

The Commonwealth of Massachusetts To be filed for burial

le OFFICE OF THE SECRETARY permit with Board of
= an " ean DIVISION OF VITAL STATISTICS Henhh ob ite Adont

MEDICAL EXAMINER'S /9) €O6 gihnes’
CERTIFICATE OF DEATH Registered No............... 2.0).

hi (If death occurred in a hospital or institution,

Ld aera uy ee bate Ward { give its NAME instead of street and number)

(If U.S.
eA ee veeeet Renee EER foe eee os cu ses ensibavecsvacedoesdesalscecutsecoublsivesecwvevcecesces War Veteran,

vorced woman, give also maiden name.) SHOE GWAR). ai0isdovesducsnabec feppondy osacech ance
(a) Residence. No.V. Sheer itr: Wares 26st cic casasshensererrete sks eee eter

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

Length of residence in city or town whass 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

5 SINGLE write the word)
MARRIED an r 18 DATE OF rr 193.
_. or DIVORCED ante ( Js
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: (If an injury was involved, state fully.)

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

If less than 1 day

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

9 Industry or business in which,
work was done, as | 2k

BT Total ei
2 yo j spent in this
he Deiat / _ occupation of a

OCCUPATION

12 BIRTHPLA NCE (City) Wee FLT Cia U/ ba citeeee bie ad ha GA)
(State ér country) Vt ei Cr
FOetan fT!" (See reverse side for description for unknown person)
14 BIRTHPLACE OF iy Dy,
” x: = 20 IN WHAT CITY OR TOWN
ry ia HOY) iecisccccsetere digg gp ee BPietr neat cffesiarasscasandavyens WAGAINJURY. SUSTAINED Z)..occc.vic comme cccdiccatcabida tesssceccsecaduced ae a eae
= (State or gountry) a>
wd ) ont i .
=| 15 (MAIDEN NAME ] fi M7) Ce nck (S$ fs Ans... | La ath, fees raeas , M.D
a MOTHERS AN ee g Cite t <p nw enue Dato Wamn......19840-
ES SRS REL a EO ae i CR a GY DR (Bea i eT — -S = = —-
16 BIRTHPLACE OF =. ae ae, T/,
‘ A \ - i 21 PLACE OF BURIAL, { “4 =
veh ama ee gua : ° CREMATION OR REMOVAL. Ae van Ad Panto pe
ASiaie or country) Zi G1 a 2“ (e< , Se (Cemetery (City or oe.
ke ) ff ap i nT DATE OF BURIAL... LYRA oqo or ceecentcenye ADENY.......
Atta... pI ISAL TE. eoeGQhACE il... ars ;
iat sgt ; 22 NAME OF
aye ne foe UNDERTAKER .... Jeo.
REBY_GER FY that’a satisf factory standard cértificate of death was :
Be ‘OREAhe Wurial or transit permit was pe ADDRESS.» cf eae aa agiuA
a8 sad | ; a / J /
Board of oa ata Pe pe pre |] Received! and/Filed.........ssvssssssccccsscsssssseseseeeeessees Priscvaersting facfayfBcveerrsnnrene 19/.hcs%.
a "A > ( 6) L Ww ere
Sushi 9 SL EAE a | Coal ake sd LSC TOO AC ta Rf Ay AY. 8 rai SSE RE aap
lS S.. of Permit) - ase (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
Eten or officer and the date of his death....Gen. Laws, Chap. 46,

eC.

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 ee 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.

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

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

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

RULES OF PRACTICE

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

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

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

STATEMENT OF CAUSE OF DEATH

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

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

DESCRIPTION (for unknown person)... cones tlgartilttbec Re ccs ducne taanialay acclaim es ae See

| 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

MARGIN RESERVED FOR BINDING

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

Every item of =

PHYSICIANS should state

AGE should be stated EXACTLY.

y supplied.
terms, so that

nformation should be carefull
CAUSE OF DEATH in plain

is very impor

Exact statement of OCCUPATION

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

t ma

tant.

No. 9321-a

100m-9-"33.

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

To be filed for burial permit
with Board of Health

= Pen a Reena roe Se Vea Racine
5 STANDARD
Ce niches “fh Be ake A? ko en CERTIFICATE OF DEATH Registered No.w...........ccte. G..
Pe (City or Town) (If death pie eo Per Rit
y eath occurred in a hospital or institution,
a INOeisctss 205 Main Divacuntaasethassssuasus ekestasauand goxbe canes St., Sy shuld upebankwnenarn'y War { give its NAME instead of street and number)
eS p (If U.S.
2 FULL NAME........ Higbdert..llazd,..Qdaax Pie Ue PEM oes Ni sey cteeicden nba War Veteran,
(If deceased is a married, widowed or divorced woman, give also maiden name.) eyseciiy: WAR) siscciscsisetdepsseoseconstenstteamone
(a) Residence. No... ro I SS he, a Bee er EG SE ah aed oi eg eg 2
(Usual place of abode) (If nonresident, give city or town and state)
Length of residence in city or town where death occurred 5 yrs. mos. days. How long in U. S., if of foreign birth? yrs. mos. days.

PERSONAL AND STATISTICAL PARTICULARS

MEDICAL CERTIFICATE OF DEATH

3 SEX 4 COLOR OR RACE | © SINGLE | (write the word) || 18 DATE OF
TT 4 WIDOWED . DEATH seeeenseees
Male Vhite wc Married
5a If married, widowed, or divorced E 19 I HEREBY CERTIFY, That | attended deceased from
HUSBAND of ........ Wax y...42neS...MeGuny jale tte Rae
(Give thaiden name of wife in tu Psmuent asergyiresnrsectmcenarsenneasnnscgsie
(or) NS TREE x, sta ak ies caaccat wake pa schcevanap sabnavecat carvers cchansardecgnsainect uetertnaaasivasenveyes ] Past AW if Ven SUB OMicterecos cote atte ee : 19s. death is said

(Husband's name in full)

G IF STILLBORN, enter that fact here.

to have occurred on the date stated above, at. 2.504 m.
The principal couse of death and related causes of importance in order of

sfa
av,

tory standard certificate of death was

(Date of Issue Sf Permit

b
ZA =
th ther) pad
hes allo l 22 ce

Js If less than 1 day hate at ineata
IAG Esp ccseve 68 poe. Years...... 2....Months....22.QDays ae Hours..........+ Minutes pete
8 ory ie aan tla or spa xiehihicanggeig Aled | dlc ap GROG aaa OP DR aR Na, We £45
ind of work done, as spi | 5 ¥ Si ee a ne eg) i Meeeeee Saree, ME Remer ree Ae Si knee SS REN Enero ee aon ner) | ae ee Bee...
3 sawyer, bookkeeper, as vimerarine cain iy ngineer aeevnesivauatis re
=| 9 Industry or business in which 142
<
a. work was done, as sil ill, > cy q 3K
3 er em Bish, ote. in cn Ge! 8 ay aad ee | RES me Eee Senet Davee neaey semester ae 3
&| 10 Date deceased last worked at UemORALIMOMVOORS) Ry ONIN cet tePenin ck ney UPS a) oe Nes Te ee eae ee ee
ee eek occupation .....4:(....{| Contributory causes of importance not related to principal cause:
IN IN Ter ois ins ARM MRE MM OWN ga ccietacectictesanss | ones epndensonch eevee rbeencueogenculpurennnnecoarselodscooneps nvanehnenntcnendenevadea Heahapeane tugs
(State or country) Ma ine
13 NAME OF a aE, a eR tO. Fh yh AY Tok TY es ds, tack Gacy coc secs te tna aba ca Leb owsioh cs os ast elnh an tubal sae Aad lor ccosshwcwee Sellen weeeteame tae
FATHER Calvin Oliver Wine CES
14 BIRTHPLACE OF Name of operation......S.seestserssteteriessssees seteeenceetastmecte anes DAU BYOF: ressseycssntveameot cette ftna
“i FATHER (City) vn AB OL OF OWM irs Ne ae ee Raa What test confirmed diagnosis?9ma+teé lo
. eeet conntry Ma 1 20 Was disease or injury in any way related to upation of deceased? .£Y.. QS caus
«{!15 MAIDEN NAM WES FS DECI aca decp rectum vchcscotyndekedsssAivensetd caabanesti (ao. Pees ef
<| OF MOTHER ‘frances Garth toe Jr wat a3
16 BIRTHPLACE OF 4 s ‘ -
MOTHER (City) ......... Chester ELS SDT ie ae eae nae (Addresstt/ natant Sa Acet. gl a Da ‘
(State er country) Hngland 2. CREMATION OR REMOVAL LLM DTOD. Winthrop.......
17 (Cemetery) (City or town)
hres phhed I...Olive Len Ee ee pate oF BURIAL. YAMUATY 24. 1 IBB 1p
(Address) ‘] Commonwealth Ave O}| 22 NAME OF

UNDERTAKER
ADDRESS........ W201, 077.OP........ MLSS Sn ieenseersersnnereorerernes

(Registrar)

ae
Revised Unitvotates Standard Certificate of Death DA TRASTS FROM THE EWS OF THE

COMMONWEALTH OF MASSACHUSETTS
GOVERNING THE

: 5 i 4 with, after the death of a person whom he has attended during
Statement of occupation.—Precise statement of occupation is his last illness, at the request of an undertaker or other
very important, so that the relative healthfulness of various pursuits authorized person or of any member of the family of the deceased,
can be known. Make some entry in this section for every person furnish for registration a standard certificate of death, stating to the
aged 10 yearsorover. If the occupation had been given uporchanged _ best of his knowledge and belief the name of the deceased, his supposed
on account of the disease causing death, report the occupation prior | age, the disease of which he died, defined as required by section one,
to illness. If the deceased had retired from business, report the where same was contracted, the duration of his last illness, when last
occupation prior to retirement. Children not gainfully employed seen alive by the physician or officer and the date of his death... ,
may be returned as at school or at home. For a woman whose Gen. Laws, Chap. 46, Sec. 9.
only occupation was that of home housework, write housework No undertaker or other person shall bury or otherwise dispose
in answer to Question 8 and own home in answer to Question 9, of a human body in a town, or remove therefrom a human body
For a person engaged in domestic service for wages, however, designate which has not been buried, until he has received a permit from
the occupation by the appropriate terms, as housekeeper—private the board of health, or its agent appointed to issue such erinits, ;

family, cook—hotel, etc. For a person who had no occupation what- or if there is no such board, from the clerk of the town where the
ever write none. erson died; and no undertaker or other person shall exhume a human !
4 ody and remove it from a town, from one cemetery to another, or |
To be complete, an occupation return must state: from one grave or tomb other than the receiving tomb to another in the |

s F 5 Same cemetery, until he has received a permit from the board of health

8.—The trade, profession, or particular kind of work done. or its agent aforesaid or from the clerk of the town where the body

9.—The industry or business in which the work was done. is buried. No such permit shall be issued until there shall have been

2 delivered to such board, agent or clerk, as the case may be, a satis«
10.—The month and year the deceased last worked at the occupation. factory written statement containing the facts required by law to
11.—The number of years the deceased followed the occupation. be returned and recorded, which shall be accompanied, in case of an
onan saier many by a Subintartory phair t= ee attending
tati ion, . . . Physician, if any, as require y law, or in lieu t ereot a certificate
ig Pore Boy Rerunation Ath wc pe ot Sen a aiaite poms as Seroinar er moyicens hae is no gaged physibian: or if, a

A Hi , i sullicient reasons, his certificate cannot be obtained early enoug
cular kind of work done and return that, as spinner. svegver, Otc. for the pusness, or is insufficient, a physician who is a member of the
board o health, or employed by it or by the selectmen for the purpose,

shall upon ap lication make the certificate required of the attendin
physician. I 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
wealth cannot be obtained early enough for the purpose, the certificate
the full descriptive titles, as civil engineer, mechanical engineer, mining of death made as above provided and in the possession of the undertaker
engineer, stationary engineer, etc. Avoid the term “laborer” when a desiring to make such removal shall constitute a permit for Such re«
more precise statement of the occupation can be secured. Do not ™oVval; provided, that such Body shall be returned to the town from
F use the word “mechanic,” but give the exact occupation, as carpenter, which 1f was temoved within thirty-six hours after such removal, unless
painter, machinist, etc. Distinguish carefully between relail merchants a permitin the usual form for the removal of such body has been sooner

4 . obtained hereunder. If the death certificate contains a recital, as Tes
=e pd A person who sells goods should be called a 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

ee - which it has been engaged, such recital shall appear upon the permit,
Statement of cause of death.—Cause of death means the disease, The board of health, or its agent, upon receipt of such statement and

fathures aaphiynia, sithan aire the mode of oy Ps bo certificate, shall forthwith countersign it and transmit it to the clerk
causing death. ‘As related causes name earlier morbid conditions, } of the town for reistration. The person to whom the permit is so
if any, related to the principal caian and any important complication given and the physician certifying the cause of death shall thereafter
of the rincipal cause. Under contributory causes of importance not furnish for registration any other necessary information which can be
related to rincipal c nuue name other important diseases obtained as to the deceased, or as to the manner or cause of the death,

Pp P users pox ye ie which the clerk or registrar May require. — Chap. 114, Sec. 45, G, a oe
as amended by Chap. 48, Acts of 1927 and Chap. 414, Acts of 1931,

Medical examiners shall make ¢xamination 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
Example of death.—Gen. Laws, Chap. 38, Sec. 7.

: No undertaker or other person shall bury a human body or the

ipal f death and related causes| p,.c7--- «SOC aShees thereof which have been brought into the commonwealth until
{bs principal cause of de Date of onset mit so to do from the board of health or its

of importance in order of onset were as follows: he has received a per c 1 I
appointed to issue such permits, or if there is no such board, from

Arteriosclerosis IOIS the clerk of the town where the body is to be buried or the funeral
< ames © is to be held, or from a person appointed to have the care of the ceme-
45 asiehesbhssesavassassel|astineenie oo ceteeat's fey. or bumal ground.in, which the interment is made....Chap. 114,
eEt fatshchsndptivencasstsgnactelestheiesastseccsal lie Sea. 0, Got as cade
Cerebral hemorrhage sei Becuscctens| ue eee. RULES OF PRACTICE
The fulfillment of the purpose of these laws calls for the observance
RE erecta te i artian« Se EE Flieememcine ot iattirks

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

Chronic interstitial

samaions Mepeacsnasonsancenesevesssessunsssorvaconsssecasevascncsassassesssssesansesens| suscesssgrocseseerseceence (1) Attending physicians will certify to such deaths only as
F ; those of persons to whom they have given bedside care during a last

Contributory causes of importance not related to illness from disease unrelated to any form of injury.
principal cause: (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 tecent medical attend-
sss ance or whose physician is absent from home when the certificate of
death is needed. 5 : 4

seaneeeesansnrnessesessessaeeesens|ssensseeeesessesssesstesee (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 ncoulting septicemia),

In a group of causes containing the principal cause and related and by the action of chemical (drugs or poisons), thermal, or electrical
Causes, the causes should be given in the order of onset, so thatina agents, and deaths following abortion, but also deaths from disease
group of three causes the principal cause may appear in either first, resulting from injury or infection related to occupation, the

sete

second, or third position. The principal cause in the above example sudden deaths of persons not disabled by recognized disease,
happens to be the second cause given. and those of persons found dead. ;

state Pi

ATION

Every item of

PHYSICIANS should

t may be properly classified? Exact statement of OCCUP

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

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

See instructions an

information should be carefully supplied.

CAUSE OF DEATH in plain terms, so that

s
2 cay
Su. 8
B20
BENE
wows
S504
I
re]
oe

100m-11-’30. No. 605-b

g The Commomuralth of Massachusetts
OFFICE OF THE SECRETARY

Suffol SPadiey resins thaan dy ei aba causdtaun se seasnilos Cowal erent ieee
FE cecssesseees DOE goak.. Ht eS Se a res ih tw maine rags)”
STANDARD 42 me
oc SE - i CERTIFICATE OF DEATH Registered Now.........c:.seen esses
g aes. (If death di hospital ti
ny eath occurred in a hospital or institution,
= NGintexesesscs3 ° 7 Belcher eenanceasccnteegneccscccnsecacnsscosesccoones veces SEs ia cuectaacceins Ward { give its NAME instead of street and number)
(If U.S.
2 FULL NAME................ eT ee OATS CPS D3 War Veteran,
(If deceased is a married, widowed or divorced woman, give also maiden name.) SDECIG: WANE) wasccccssscasosccspinioe<ccesescactane
(a) Residence. Noe essen. BELE eee MCE aceite cess Satie ncvsnntPachosssanatese Ao chy BAe ee rire (ante Ak ie pete SP ase A ERA ol ye
(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? yrs. mos. days.

PERSONAL AND STATISTICAL PARTICULARS

3 SEX 4 COLOR OR RACE | © ey (write the word) || 18 DATE OF
aE WIDOWED ‘ DOAMEN ccorasssss ts treontetetatt ctaesouasodensaconeosesvoscuty cosbaneeattoledqneteaiandate
Male White La Married
ch married, aie or ari
HUSBAND of ..........4.4.99 gfe. RN YS Pod:
¢ (Give maiden Gx SHda £95.
| Ree ee oe eee B28 en oe aa olny ee
(Husband's name in full)
6 IF STILLBORN, enter that fact here. The principal cause of death and related causes of importance in order of
7 68 18 If less than 1 day onset were as follows: Date of Onset
BAGG Ree senccsbienscere VO@ANSic.065.5-0020 Months...©.-.... DayS)||eesse0-o5:- HOUPS:.....-0-<-: i
8 ae. plea atoll or particular
ind of wor one, aS spinner,
z sawyer, bookkeeper, CLC. ..........ccsesecsenees C haut fer Beeesentaie <suansdcersenenevee
Eat 69 pened or pate ines
a work was done, as si ill,
= Saw rill: Bank, Ct, .-:<ccssscccse-cosseoncecosssosenees Me ae he.
8/10 ee erased last waried at 11 Total ane ee
is ee io nth a spent in this
YEAT) nnr--.-eese0e peee 38934... OccupatiOn...........-.-..000-
12 BIRTHPLACE (City)............ pets hi a a
(State or country) Ma $3
13 NAME OF ,
FATHER Noah Fred Bosworth
a ae ES PUNTA raat SADDEST REA OND fw cris ncos ans we hectare do vay dau nssnacepuvieesanssecpus ones iD ENELIO Nusaucavel «anweagsteosuanssogyeenten
a | Wheto enined ding Masur on weer
z| (State or country) 20 Was disease or injury in any way related to occupation of deceased? ..................+
If so, specify..........
m/ 15 MAIDEN NAME
<| OF MOTHER Arzilla Averill (Signed) ......--
a SS
16 BIRTHPLACE, OF | aes
MOTHER (City) .....ccccccccsssese ONTOS 5 27 A “a 21 PLACE OF BURIAL,
(State or country) CREMATION OR REMOVAL Ce fees
emete
. } e
a7 Wife e Frederics Soderen Bosworth —= || __ pare oF BURIAL........VAMBG 20g VDD crrsrsserssrrrset ee AQ
“les 39 Belcher Sts.” Wnt AvOp SP aKe Bieta See z
es

UPDATE Ri csecteers eteaaeestteaccasnteneoetecterreselunsesndcsacsucppesesticeusBayssoiouanthp ates evn Uaeatennnint core
| HEREBY CERTIFY ge a oad reid standard certificate of death was
filed with me eae NBER oI MIMI aiNasg ISU bane coe aE M5, (ADDRESS easicas ose dasatonss costs fea hecvssssctcussse tte oo sun ccsnsovaebocbskaecnmettsosectuersestgpant Mretoassaahsfepeve

Va.

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

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

Example

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

Arteriosclerosis ors

Chronic interstitial nephritis 1921

Cerebral hemorrhage July 5, 1027

Contributory causes of importance not related to
principal cause:

EXTRACTS

FROM THE LAWS OF THE
COMMONWEALTH OF MASSACHUSETTS
GOVERNING THE

RETURN OF CERTIFICATES OF DEATH

seen alive by the physician or officer and the date of hi \
Gen. Laws, Chap. 46, Sec. 9. gE gle coe

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

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

RULES OF PRACTICE

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

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

MARGIN RESERVED FOR BINDING

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

R-302

Every item of informa-

PHYSICIANS should state CAUSE
Exact statement of OCCUPATION is very

AGE should be stated EXACTLY.

so that it may be properly classified.

tion should be carefully supplied.
OF DEATH in plain terms,

important.

50m-9-'31,

No. 3385-0

The Commonwealth of Massachusetts

NORFOLK OFFICE OF THE SECRETARY BROOKLINE
E Sa aa a ere sesensovonsnersccssessens DIVISION OF VITAL STATISTICS Don) tia Gan cuking aca cenveveneos
a STANDARD P
1/5 BROOKLINE oo. CERTIFICATE OF DEATH Radidated Mac 432
S rete Be nate (If death occurred in a hospital or instituti
or institution,
a No. ... FRUMBULL..... HOSPITAL pyaddanenikstnesapiuansesieees ROR Oy HOR... Ward { give its NAME instead of street and number)
(If U. S.
OSB at SE) OE oe a cc cc War Veteran,
(If deceased is a married, widowed or divorced woman, give also maiden name.) Oe a |) eS ae eee re
(a) Residence. No....28... PLEASANT. ee: PARK... RQAD..... waege............ Ward, WINTHROP MASS 0.0.0...

(Usual place of abode)

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

PERSONAL AND STATISTICAL PARTICULARS

5S SINGLE (write the word)
3 SEX 4 COLOR OR RACE MARRIED
Male White or DivorceD Married

mussaDer Wdttred =F, Henry

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

(or) WIFE of

ve If less than 1 day
(_( 2) SERS BATS: - Arccicc kes Months............ DVS: fi <.casesce HOUYSi:..<..< Minutes
8 pee protein, or particular
= ind of work done, as spinner,
5 sawyer, bookkeeper, = oie seinen aie Ass 't Manager eae eee
| 9 jenn id or Essiness gl
a work was done, as silk mill,
are eee beck. Clea: Insurance Office
6| 10 ie pang ey a 11 Total alae ght
is occupation (month an spent in this
year) ecupation (month and = 1/35 occupation....... 1 5 eee }
12D BIRTHPLACE (City) ....ccsccccccssccccsessscsesseeesee Combridse.
(State or country) Massechusetts
13 NAME OF
coahlemies Williem Je Grady
a 14 BIRTHPLACE OF
= Ca ECS 5-2 Be epee oe oe
z| (State or country) Trelend
la
= Unknown Unknown
16 BIRTHPLACE OF
AARNE Lr omen en RR Fey Ee ot lessee iee, bank vascereevsudaseCosdandpnivtecan as covevaretoee
(State or country) Trelend
17
Patrick

COU Sys eke ee ee J: anuary/25 hgh eee So ae :

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

MEDICAL CERTIFICATE OF DEATH

Pees Cee ee 1935

ae Jemuery,.22 1935, January. 25 19.39
I last saw h 25 Sencne . 19.35, death is said
to have occurred on the date stated above, at 200 30¢m

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

Contributory causes of importance not related to principal cause:

ioe Intestinal Obstruction | 1/21/
2 EE CEE RAE Ae CR eee SES 1935
Name of operation... CA@COSTOMY occa pate of (29/35.
What test confirmed diagnosis? ™...=....%%....%....™....... Was there an autopsy?..™....%
20 Was disease or injury in any way related to occupation of deceased?............ no.
DE ers GTLCCA NA oescc ees cat cas ce casas hoe ce nao naoernniv eb uth tcauey ose ei daoein milees capascas seadajovckauuaordtesaeeeeens
(Signed) ..... ;

M. D.
(Address) 77-+19..Com'*weealth av. pate. 1/25... 19.25.

7. CREMATION OF RémovaL.. New. Calvary = Boston...
22 UNDERTAKER... Widdiem Ae Treanor

appress..77999..Seratoge Street,East Boston .
Received and tet BT 1935 bt i, tae ae epee

(Registrar of City or Town where deceased resided)

v= &

7 a) i al, = a fo
: d — Che Comrtonmealth ot Massachusetts To be filed for burial permit

RM R-301A
= Suffolk : OFFICE OF THE SECRETARY with Board of Health
< ae ee ites seeeeee m4 DIVISION OFr VITAL STATISTICS ae its Agérit;
2% a STANDARD
gem (la CERTIFICATE OF DEATH Registered Now... 4.4.
oO Cit Town) S
sus g ca Cte oe (If death occurred in a hospital or institution,
> +) A give its NAME instead of street and number)
620
> 00 . i (If U.S.
Fin mR RR ATE sy TO a cceesgntcvecetcessnivesecinsotensnsrers
Zz S (If deceased is a married, widowed or divorced woman, give also maiden name.)
<° | : 2
| 6 (a) Residence. No..4.2... He ¥AGN..dt., Oe 1.5 Sanaa Seer ees voncs Ward,) ......@.. Yk Pires AG 7 Bx RE ces
n g (Usual place of abode) : (If nonresident, give city or town and state)
z oO Length of residence in city or town where death occurred OO yrs. mos, days. How long in U. S., if of foreign birth? 5 8) yrs. mos. days.
oe) ee ——
a, $ PERSONAL AND STATISTICAL PARTICULARS AL CERTIFICATE OF DEATH
5 SINGLE (write the word)
g 3 SEX 4 COLOR OR RACE MARRIED ustf. 7°” 7 IR
rs] Malw White or DivorceD Widower

5a If ied, widowed, i That | attended, deceased from
HUSKANDs -F4YOmena Fortunata | TW. Oke Pe ee

MU RRS coo, ceca ccna useage Et so shiasds cen bassasonncacedercaas Coe Cacsantactawiusesascditytansescteneceey // I last saw ha. alive On... peta foo. ie 19 FF seath is said

to have occurred on the/ da Mate oC pe
The principal cause of Weath 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.

work was done, as silk
saw mill, bank, etc

10 ae ee sage abi at 11 Total pve oor)
is occupation (mon spent in this
) 2 Jen 19359 occupation... 7a

AGE should be stated EXACTLY.

terms, so that it may be properly classified.

OCCUPATION|

d extracts from the laws on back of certificate.

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

Hi z © ETD EPETLUICETSY ACERS eR a ee PnP
Zoe ae ERR IP aS LS) | rma TN eee ceccavnnatroes scence crcerec sacs ccar are ups oa cousddnsdecestocsaccesacacaschvonanckbcsovecenteecbeavipsvupttes|oantesscvevesceaneeeeee
a%~o
3 e 13 ag 5 . : Wendl assists Setoasaseeidcenss im? gsbietaeatenee
> 3 ilvestro Ricci Name of operation 2 seis! Mmmm) 4 AL 3Y Pk eae ie ea
5322 salele =p Seared What test confirmed dlagn0sis?..........sssssecegfeeeeeone--- Was there an autopsy?..........
wee SC MAMMMERE © (C1) assoc en cig geceemagesaceeneenecneessesunenseanttcneenrbstcsntentnenevtensenn -
ei f = (State or country) I taly 20 Was disease or injury in any way related to occupation of deceased? .............
=m Ww
oe jfe/15 MAIDEN NAME !
2 fn = F MO Unknown (Signed) ....f.. 14 elec! (Brett ced: Aci, Naeperter oe
Zz cs 16 eerie OF (Address).....8.°}..! ;
5 c RUG Va foceadsgie steep acuasacavaes opecekie acide Srey ecarot ee Seer EPSP eee: Leap eo eee 21 PLACE OF BURIAL,
aa $ (State or country) CREMATION OR REMOVAL VA LVALy.......... BOs ten... cscs
geo .
Ok, & x)| 17 DATE OF BURIAL..Jdanuar
F=f) £ 3 Inform giera. Re...G A See eee Fact bon eee
Gt 2 || (Address eyden 22 NAME OF
Eap UNDERTAKER 4444 LC
So o | HEREBY CERTIFY that a satisfactory standard certificate of death was :
eat? filgdAvith me BEFORE t lo it permit was issued: §= || ADDRESS.7eM...20 Mon wae... ee
S082 5 iy ;
_ 54 || Feerseae : i OO Ree NER AK LAL Manado le tesuswanasen-sesnonseass ase Raceigedvand Milled 935 * 19
4 ture of Agent of Board Tr other) i! FAN SOF RROD ee duachcnasisnecesietcestnbelg. crest
8 hehe. UKKkf. ed 2
= a hetadew ret Annee ns sssernsnnsensansnssafenas\tanadanscnnasseensenesenl [naw Reese, FA ER MRED EERE OEP AER sRsRnasaaESEesESESR SSeS ROSS ESEDSOEESeeeeenaanmennnnans Perr) ol
(Date of Issue of Permit) 4 (Registrar)

24, UV

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

_more_ precise statement. of the occupation can be secured.—Do~not.pemg

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, mot 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

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

Arteriosclerosis rors

eeeeeee Annee eens eeeeeeeneeseeeseneseeneeeeeasencesenseecrsesaensnssaseseesusseeanemnasanssesns | ensseeeSeSeHe anes senaeeee

A OOe nen enen ne neeeneueeeene seen eeeneeeeens renee se eeernsereeserses nee e neue eeeeeeeneewaneeener | sreeeseeeeeeeesneneeeeneee

Contributory causes of importance not related to
principal cause:

In a group of causes containing the principal cause and related
causes, the causes should be given in the order of onset, so that in a

group of three causes the principal cause may appear in either first,

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

EXTRACTS
FROM THE LAWS OF THE
COMMONWEALTH OF MASSACHUSETTS
GOVERNING THE

RETURN OF CERTIFICATES OF DEATH

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

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

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

RULES OF PRACTICE

The fulfillment of the purpose of these laws calls for the observance
of the following rules of practice: | .
(1) Attending physicians will certify to such deaths only as

those of persons to whom they have given bedside care during a last
illness from disease unrelated to any form of injury.

(2) Board of Health physicians will certify to such deaths only

as those of persons who, though disabled by recognized disease un-
related to any form of injury, have died without recent medical attend-
ance or whose physician is absent from home when the certificate of
death is needed. - * " ;

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

directly or indirectly by traumatism (including 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.

a
=
2
wo
So
—
>

item of

Eve
should state

PHYSICIANS

NT RECORD

IS A PERMANE
stated pagal

operly classi

AGE should be

y supplied.
ms, so that it ma

uld be carefull
plain ter

information sho

ct statement of OCCUPATION

t stat f
k of certificate.

ed. Exa

pr
the laws on bac

y be

and extracts from

ions

See instruct

is very important.

00m-9-'33.

CAUSE OF DEA

The Commonwealth of Massachusetts To be filed for burial permit

OFFICE OF THE SECRETARY with Board of Health

DIVISION OF VITAL STATISTICS or its Agent.
STANDARD a

CERTIFICATE OF DEATH |. Registered NocASOG .

oft A <fA Kove Ste presriigeesscesseees Ward { give its NAME instead of street and number)

red (If U. S. AE
reer eA Fie TO LE. War Veteran, io

a married, widowed spectty WAM) 5 scstce-sctsstassscsco ee

(a) Residence. No.@u.0 ACCH.
(Usual place of abode)

Length of residence in city or town where death occurred

PERSONAL AND STATISTICAL PARTICULARS

5 SINGLE (write the word)
35 4 COLOR PR RACE MARRIED € r
WIDOWED
or DIVOR

5a If married, widowed, or divéte 19 I HEREBY C ER TIE Y, That | attended deceased from

HUSBAND OF «......0roceveetnevne ORLBG. Xn... — CCP p Bye yg. / E =
ame of wifeinfull) 0 [ssesses MOYES Param, ee py 4 avtaeee ,19.8.2, to
(or) WIFE Bee MRee Bede rnin clase trcerelagety ns lerevess iach prs ansiechigdid,.ceeat Lo, | last w hhewen..alive on
to have occurred on the date state above, ate. /AE.m.
The principal cause of death and related causes of importance in order of
If less than 1 day onset were as follows: “Dale of Onset
setivtbeiyes Hours............Minutes {IMPORTANT
8 Trade, profession, or particular Ns OR | NE Mae le Ly.
z= kind of work done, as spinner <3 eons
° sawyer, bookkeeper, etc.........“°/4E bs S
TI Te ab OY aia iis | Vesieene ee nn ae a Jt =
a work was done, as silk mil
= on PS. Sei hie ee ee ene eed | (scam kes: Ae aa ne ee ee OP
S| 10 Date deceased last worked a e Kins daar ueaeseeedoums chu pe/ Pity cv see hee ae
this eanon (month anae

a a an Mi. é Contributory causes of importance not, related to principal cause: a
: oe DA ~ ~Olerrars \Q3i
12 BIRTHPLACE (City). Z

(State or country)

| 13 NAME OF
FATHER

14 BIRTHPLACE OF
FATHER (City)

(State or country)

15 MAIDEN NAME , 5
OF MOTHER 7
16 BIRTHPLACE OF
MOTHER) (City) J.) occlu
(State or country)

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

IF/SO; SPECIFY Siesessin fiaseices ch.cosael ‘Ge
(Signed) ..... PUnctg Zt
(Address)... 2. OY. 9s

21 PLACE OF BURIAL,
CREMATION OR REMOVAISSS=AE-P2E 06 Sr

PARENTS

ny Informant ...... 7 ; Z DATE OF BURIAL...........

3 ||_Address) Kg 22 NAME OF

3 1 ge = UNDERTAKER oe. .sssecessseeeooes

6 p) Ory Standard certificate of death was

a e burial ¥ ans ae it was issued: ADRESS) ois = ‘
tt, V big = ee

Revised United States standard Certificate of Death

Statement of occupation.—Precise statement of occupation is
very important, so that the relative healthfulness of various pursuits
can be known. Make some entry in this section for every person
aged 10 years or over. If the occupation had been given up or changed
on account of the disease causing death, report the occupation prior
to illness. If the deceased had retired from business, report the
occupation prior to retirement. Children not gainfully employed
may be returned as at school ot 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—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 ‘‘empioyce,”’ “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
=n of store, factory, mill, etc., as grocery store, soap factory, colton
mill, etc.

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

Statement of cause of death.—Cause of death means the disease,
or complication which causes death, not the mode of dying, é. 8, 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:

nterstitial nephritis ete
Cerebral hemorrhage

ro2r

reer

July 5, 1927

MTT aTeseeeseeses

cecraccereceoccssccsensscccnspassseccsscsceeess aeevcncccvecccnssccvcconsces| ssecenscccacganonacsasecee

copavusqndanponcsusuanasessoonetuncscenecsenecsvonpecceneceese seveeeses | ceeseeerseenteceensesesens

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 TH
COMMONWEALTH OF MASSAC
GOVERNING THE

RETURN OF CERTIFICATES OF DEATH

No undertaker or other person shall bury or otherwise dispose
of a human body in a town, or remove therefrom a human body
which has not been buried, until he has received a permit from
the board of health, or its agent appointed to issue such ermits,
or if there is no such board, from the clerk of the town where 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 attending physician, or if, for
sufficient reasons, his certificate cannot be obtained early enough
for the pee or is insufficient, a physician who is a member of the
board of health, or employed by it or by the selectmen for the purpose,
shall upon a plication make the certificate required of the attendin
physician. If death is caused by violence, the medical examiner Shall
make such certificate. Tf such a permit for the removal of a human body,
not previously interred from one town to another within the common-
wealth cannot be obtained early enough for the purpose, the certificate
of death made as above provided and in the possession of the undertaker
desiring to make such removal shall constitute a permit for such re-
moval; provided, that such body shall be returned to the town from
which it was removed within thirty-six hours after such removal, unless
a permit in the usual form for the removal of such body has been sooner
obtained hereunder. If the death certificate contains a recital, as re-
quired by section ten of chapter forty-six, that the deceased served in
the army, navy or marine corps of the United States in any war in
which it has been engaged, such recital shall appear upon the permit.
The board of health, or its agent, upon receipt of such statement and
certificate, shall forthwith countersign it and transmit it to the clerk
of the town for registration. The person to whom the permit is so
given and the physician certifying the cause of death shall thereafter
furnish for registration any other necessary information which can be
obtained as to the deceased, or as to the manner or cause of the death,
which the clerk or registrar may require. — Chap. 114, Sec, 45, G. 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.

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.

nie SE ee

RULES OF PRACTICE

The fulfillment of the purpose of these laws calls for the observance
of the following rules of practice: 2

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

Every item of =

PHYSICIANS should state
Exact statement of OCCUPATION:

AGE should be stated EXACTLY.

10)
Zz
Qa
Zz
oO
o
Tm
1]
ul
>
4
ay
hl
ye) a
pi
HZ
Ae
n<
1

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

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

formation should be carefully su

CAUSE OF DEATH in plain
is very important.

-9-"33.

bg
w
L
>

No. 9321-a

“ ae ee

eeeaenee

Tesbeeereenseeeeeees

(a) Residence. No. B§. fA

(Usual place of abod
Length of residence in city or town where death/occurgedy "i oyna

PERSONAL AND STATISTICAL PARTICULARS

E) 5 SINGLE (write the word)
> : 4 COLOR , RA CE MARRIED ,
Sessate. Jt AAL or DIVORCEN YA ZpAC So

5a If married, widowed, or divorced

G IF STILLBORN, enter that fact here.

*
ee 3. Pees ated sists A waitin ....Days

8 Trade, profession, or particular
kind of work done, as spinner,
sawyer, bookkeeper, CtC.........ssssscssessssoceressbereleeees
9 Industry or business in which
work was done, as silk mill,
Sea MemanI NAN AMER AI REs Pe sae yep oobi c caves daltsavs'bdsab ru ipcsbcgets viene hadesousi cosevacua asesddegauatesvesndeucesaes4
10 Date deceased last worked at 11 Total time (years)
this occupation (month and spent in this
3: seas BRS Ee ener ee OCCUPATION...........00ceeeeees

If less than 1 day

OCCUPATION

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

13 NAME OF |
FATHER Bi

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

(State or country)

15 MAIDEN NAME
OF MOTHER

PARENTS

16 BIRTHPLACE OF~
MOTHER (City) ...........

(State or country)

w-8 ee

~~ The Commonweal
OFFICE OF THE SECRETARY
DIVISION OF VITAL STATISTICS
STANDARD
CERTIFICATE OF DEATH

days.

She, oe
of Massachusetts

cx a

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

Registered No................. 7 Whats

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

(lf U. S.
War Veteran,

BHRAELER, WATE ic hasessctvavecnecsanensreschtlpteceod

PrPeee Pert rite e rrr tee t errr rrr irri rir rit i

“(dE nonresident, give city or town “and state)
days.

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

MEI ICAL CERTIFICATE OF DEATH

18 DATE OF
DEATH...

Aten nnneeneneeeeenseeeeesenenrnenseeenwenennne

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

Date of Onset
IMPORTANT

WANG OF GPOTALION: scsconccccvavssvsue-ence-ncva-tebsaeneetertitcdvouts caect DAG) OF. ois vs inccncoayeae ate cnet cenee {
What test confirmed diagnoSis?..............:cssesseececeeseeeeee

20 Was disease or injury in any way related to occupation of deceased? Bi xe Aes
If so, specify.....
(Signed)
(Address)......... 14

21 PLACE OF BURIAL,
CREMATION OR RE

ALT... pr

DATE OF BURIAL <,tbQlh bbe BAd 4 ics... Gea Dovesscsersircvee 1335
22 NAME OF / / =)
UNDERTAKER (lo la Te Be eve
__ADDRESS soo IBA AW read oss ccve
Received and filed.csessnenennen i? 4-9-9 3B PR a: Wire
‘ v7
svectneenesnenetnenetnetneeneeneevennnennenenneenernerseegsciceesascccenene

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 houseke:per—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
ean 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

r "i Date of onset
of importance in order of onset were as follows: <

Arteriosclerosis rors

pereeerennrprrrrrrrrrr rrr rrr rrr

Chronic interstitial nephritis 1g92r

peeererrernrrrerrerrrrerrrrrrrrrertrrrrr rrr rir irr ey

Cerebral hemorrhage Jul

Contributory causes of importance not related to
principal cause:

seeerecesbuceenceeceeessecsecesesnssesecssecseusecusescsausssessceuscaeuarassnuessncasacessser|sssees
coon eee eee ee eee eee ee ee eee Se ESE EEE EEE EE eee

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.

Standard Certificate of Death -

COMMONWEALTH OF MASSACHUSETTS
GOVERNING THE

RETURN OF CERTIFICATES OF DEATH

ody and remove it from a town, from one cemetery to another, or
from one grave or tomb other than the receiving tomb to 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 of a human body,
not previously interred from one town to another within the common-
wealth cannot be obtained early enough for the purpose, the certificate
of death made as above provided and in the possession of the undertaker
desiring to make such removal shall constitute a permit for such re-
moval; provided, that such body shall be returned to the town from
which it was removed within thirty-six hours after such removal, unless
a permit in the usual form for the removal of such body has been sooner
obtained hereunder. If the death certificate contains a recital, as re-
quired by section ten of chapter forty-six, that the deceased served in
the army, navy or marine corps of the United States in any war in
which it has been engaged, such recital shall appear upon the permit.
The board of health, or its agent, upon receipt of such statement and
certificate, shall forthwith countersign it and transmit it to the clerk
of the town for registration. The person to whom the permit is so
given and the physician certifying the cause of death shall thereafter
furnish for registration any other necessary information which can be
obtained as to the deceased, or as to the manner or cause of the death,
which the clerk or registrar may require. — Chap. 114, Sec. 45, G. L.,
as amended by Chap. 48, Acts of 1927 and Chap. 414, Acts of 1931.

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

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 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 diseaze,
and those of persons found dead.

Every item of 3

PHYSICIANS should state
Exact statement of OCCUPATION

AGE should be stated EXACTLY.

and extracts from the laws on back of certificate.

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

ions

truct

See ins

ortant.

information should be carefully su
is very imp

CAUSE OF DEATH in plain

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

a
@
2
>

No. 9321-a

100m-9-"33.

The ee Maseacineetis To be filed for burial permit
x wo s¢
Fe sesssvecssse end 2 UELOLE, DIVISION OF VITAL STATISTICS bee Tea ie iia
ent.
3 STANDARD 5 an
. = J
11S ...uMinthron CERTIFICATE OF DEATH Registered Now. deed
ta (City or Town) : : ,
2 (If death occurred in a hospital or institution,
my Nob....s.2 81... Main. SuiauducsssPasersenboasppusksucdecddecsoventinnaiestas ea Ses gecsavestectsczsceszes Ward { give its NAME instead of street and number)
(If U.S.
2 FULL NAMES AS 7IAG. ALMA..PAD TANG er.... OWNS. .ccsccsccccsssssesesssussssssssseessen War Veteran,
(If deceased is a married, widowed or divorced woman, give also maiden name.) specaly WAM) ssccsisicscescssscsossssnrgretectsieres
(a) Residence. No......c.cccsessee0s Ped ee See eet SE een san Ward tc) cteatetil cle eich ameodee eeeae
(Usual place of abode) (If nonresident, give city or town and state)
Length of residence in city or town where death occurred 14 yrs. mos. days. How long in U. S., if of foreign birth? yrs. mos. days.
PERSONAL AND STATISTICAL PARTICULARS EDICAL CERTIFICATE OF DEATH
3 SEX 4 COLOR OR RACE | © SINGLE write eer]

IED
FPemale| White yeaa ~Angse

5a If married, widowed, or divorced

NMEA T BEM ree fee Sey Stet a osc cai atb ec ndencievcsednsuussoneshetvakehesocanttnvaveeshnvsssvaxadshonivancreteadesesehoxanaceesies
(Give maiden name of wife in full) by ress
(or) WIFE of ORE MR SOR ee CR SER AT arvasasehousdsscuuabuveanssceeapaneap siipiapanan I last saw ae live ona Z.. 2 rete | 19. ee death is said
6 IF STILLBORN, enter that fact here. to have occurred on date stated above, at.. ST nds £77
7 himenirarctu., The principal cause of death and related causes of importance in order of
ess than 1 day onset were as follows: Date of Onset
AGE...... iP 4 L ercnac de Years..... 8 Hesse Months...&’7..Days meat baiaes HOUPS.<20:...2002 Minutes ee ales
8 meet pean. or particular S
ind of work done, as spinner, 5
5 sawyer, bookkeeper, as spinser, pb vudent wlaapncunsouatearsbevounssvounstey
SAE) poets or eal en
a work was done, as si ill, S
= saw mill, bank, @tC........:scsecssssssecssessseseee, 0 chool BA. tee ee, seca fee
© | 10 Date deceased last worked at CRUE ouch 1 ROSE | EA) Oe ee co Sek aera TES ae
a ONS. IS 8 Contributory causes of importance not related to principal cause:
12 BIRTHPLACE (City) ecco VEIAC LOD oo ccssmmnaemnnnne
(State or country) Ma. ssa ch use + e Ss
13 NAME OF Ts *
ratHER Charles William Johnson
14 BIRTHPLACE OF Name of operation........&c..
a FATHER (City) ........ esaeneneenee eraser aS Ramee ere ce ocacalgear casrondahlestcd eae deerczor ah arstonve hat test confirmed diagnosi
z (State or country) owed en
lu
«/15 pauutiee N a ae Ih
<
oa wee eee Fehlender (Signed) .. ‘sha Mf A AB ore re, B
16 BIRTHPLACE OF :) AAA
MOTHER’ (city) ee ee tarce rer (Address) <4. Ecce
Stat t weden 21 PLACE OF BURIAL, fi Hn4
eee oy) CREMATION OR REMOVAL ‘Winthrop essen det, gosy ba S.:
17 d (Cemetery) (City or town)
baformant ... CHET LES...a.. LOBNS. ON. cnnsnnnnnnnne DATE OF BURIAL... SO LUALY Spies nnnvnnnnnnnnien 19.09)
(Address) ‘Ts } Le
c 22 NAME OF -
UNDERTAKER neece LEAT nD. etn AA OTATLA SOD ccccscscsceonsn
| HEREBY CERTIFY that a sgtisfactory standard certificate of death was linthr O i) fa a
filed/with me a t ial ansit permit was issued: ADDRESS ....... W mii: LOYp oD. OGM RON n wee Seon
‘a mg ips W gent of Board ck Gealth of other) 777 || Received and ee Sones ett vee
2s alli LA. tA Chex AAT REE A ee A Jee 1, SONALI RO oes) 2 fatale 3 La) sedan alent ereee aeemerene nt:
cial Designation) / Boa. . of Issue kY lds a 19: iy (Registrar)

Revised United Seftes Standard Certificate of Death

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

To be complete, an occupation return must state:

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

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

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

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

Distinguish carefully the different kinds of engineers by stating
the full descriptive titles, as civil engineer, mechanical engineer, mining
engineer, stationary engineer, etc. Avoid the term ‘‘laborer’’ when a
more precise statement of the occupation can be secured. Do not
use the word ‘‘mechanic,’’ but give the exact occupation, as carpenter,
painter, machinist, etc. Distinguish carefully between retail merchanis
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
of importance in order of onset were as follows: abe orionast

TOIS

1o2t

July §, 1927

Arteriosclerosis

Chronic interstitial nephritis

Cerebral hemorrhage

neat aneneeeeneeesneneseaeeeneeesneenenueneasenecsenaessnansneansseenenananseenseasesneasssenua| seaenessansseeaseenucssiee

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 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 attendin
physician. If death is caused by violence, the medical examiner sha
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
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 res
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. é ‘

... Fe 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.

Every item of ¢
'
8

PHYSICIANS should state
ified. Exact statement of OCCUPATION

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

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

is very important.

100m-9-'31,

nformation should be carefully supplied.

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

No, 3385-f

The Commonwealth of Massachusetts

C1, 26,71, OBRBICE OF THE SECRETARY (i vvvcccoccccosccsee...;
= Su Ol ie ee ee ORME OP RE SECRETARY cecsseascocussasdanseiveoesrsscceserscasocenscosisotestececepeued
< ae, = eosensececessccccccccsee EE DIVISION OF VITAL STATISTICS (City or town making return)
. Se STANDARD
WS Eee ar OD LR CERTIFICATE OF DEATH Registered No.
(City or Town)
g 1 Ss. 8 acs = fe (If death occurred in a hospital or institution,
> No. ....: Bat ccd eis dow of 0 ie ie laa i i St... War give its NAME instead of street and number?
Sy Ae (If U. S.
2 FULL NAME......011.4.2....E.. (Haley). oot EE Sede erm ee War Veteran,
(If de I, Team ns ee
J,
a esidence. Niet ee a ean oo anetien Sa aakee mann ale dens odessa dua sd sok eb eae aun sD CPlanetcssessenecs WW RRREMD, snvensesevsanclesaedundsucspevcveccessusacycsmpuntncsbdvedugnbosaadee
(a) Resid No...2:5

(Usual place of abode)

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

(If nonresident, give city or town and state)

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
aa Ee WIDOWED ‘ee ee
ema Le nite er DIVORCED i1qaowed

5a If married, widowed, or divorced

UNMMDRMNN MNase cat at cnc p= chnt-nann cases sdete ac tocnuoe MaacSancceeseeugienicahaseh ceadeendctagtedce
An wn4 BS phi nner ame of wife i in ‘ee +.
(or) WIFE of... ODL Be oie th 2 = 2 (alee epee ae

(Husband 3 ater in full)
6 IF STILLBORN, enter that fact here.

7 “£7 If less than 1 day
TEs esecee MbaTE ioc Months............ Days | «2... Hours..........-. Minutes
ie Trade, profession, or particular
kind of work done, as spinner, ty... ...,2 ©.
sawyer, eeper, CfC.......-....00:t nee Wer deveerresk leon ereinceWtsatbe dutacurass assed: cuorenaccesrs'sp

9 Industry or business in which
work was , fone, as silk mill, ~___ tT

OCCUPATION,

saw mill, bank, etC......-..-.....-..-.--e 1G 1O1 iS So ee ee
10 _ deceased last beri at 11 Total oie Ts)
is oct oe spent inthis 22>
year) Set = occupation......“.&.... ;

12 BIRTHPLACE (City)
(State or country)

13 NAME OF
FATHER

14 BIRTHPLACE OF
FATHER (City)

(State or country)

15 MAIDEN NAME la
OF MOTHER : U

16 BIRTHPLACE OF
Mi (City)

PARENTS

(State or country)

Vif j

(Address)

“Wate of Issue of Permit

MEDICAL CERTIFICATE OF DEATH

18 DATE OF

(Month)

oie me ;

aaa Co Jonvessseeeesevens ,1935..., dea

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