The volume, 1936

Town Clerk, Winthrop · from the Internet Archive · 528 pages · 57.4 MB
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J. L. FAIRBANKS & CO.

Stationers
43 FRANKLIN STREET
—BOSTON—

aeee 7

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Every item of
ANS should stat

PHY
Exact statement of OCCUPATIO

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

tlie Aint ae

CK INK—THIS IS A PERMANENT RE

AGE should be stated EXACTLY.

ve,

UNFADING B

carefully supplied.
terms, so that it may be properly clascified.

CAUSE OF DEATH in pla

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rtant.

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No. 2938+

100m-12-'34,

Che Commonwealth of Massarlusetts
OFFICE OF THE SECRETARY
DIVISION OF VITAL STATISTICS

STANDARD
CERTIFICATE OF DEATH Registered Nod...........cccscsseseeeseeee ;

(If death occurred in a hospital or institution,
Nah Met hata nsesbeeslbepccantllsccscunepseces WV AECL give its NAME instead of street and number)

I
PLACE OF DEATH

(lf U.S. a
RNa VIN AIVERS WGA ACN Cofc los ece Loc WAC WWW owe ha Non covetevss G0 id ins A snsboccottscsetinchessesseasesceseasserseincesavcieonsvens ashes War Veteran, 1 é
(If ‘deceased is a married, widowed or divorced woman, give also maiden name.) Specify (WAR) .:<0.=s5:0socensesascsoradutuameonsaiy
(a) Residence. No.. va Hf dae LI 4 iy eee “A ee EAP o) 5 Be Wier a gsc Ae Tabac stuateoercete eas coucac consversocewsnomttaee y
(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

S SEX 4 COLOR OR RACE | © ee (write the word) |] 18 DATE OF
Vale Thite Married DEATH......
5a Lf married, p widewsd 04 divorced ; on EHBY CERTIFY, That | attended deceased from
HUSBAND of ..........b4ndnh..nlh ABEIE | C2540 3 OE OO AR eee

: hake yee name of ‘will in full) wean... %0... £ sh fo... DMMUT UY Pe. ccceee. ; 19:20.
(or) WIFE of SOuDeeDucesworecppsepedycstnscccascccaccasepegensacnscoeconpnccusccencccgecesucdsdavedesccoonencccccccevasneccoescesces I last saw hcan.. allve on.. Pie 1 6r Eas: 197.@.., death Is sald

(Husband’s name in full)

6 IF STILLBORN, enter that fact here.
Thé principal cause of death and relaied | causes of Importance In order of onset

4 i If less than 1 day were as follows: ———
{ . ite of Onset
AGES rad... ERTS) nncsesss-c> Months........... DAYS: | siaconeccss Mours.2,..ccn Minutes sais ae 2
8 eres = pened or particular
indofwork done, aS spinner, 7) Sr Ee Sai peat
5 sawyer, bookkeeper, ‘etc RA abe Manufacty. 0S GU ae We
E| 9 ey or ot ies nas “,
a work was done, as aa dagen) nT. Cc
3 i wht, Ural, GEC sresccvecvnccnosen Mette PURE CO
S| 10 Date deceased fast worked at 11 Total time gen
this occupation (monty ands spent in this ab =
WEAN cee rete tae sic ac tac ade Sart ie osia set necencsvepscousazsens Occupation........-...7% shoes

12 BIRTHPLACE (City)
(State or country)

13 NAME OF
FATHER

CK
14 BIRTHPLACE OF Cannot be earned NAMIE ORO POT AM DMD asescpstbavaseessvesceatnsssol unrusraxebucaseasdancecsponse EPL ENIOE st accsenssscantesced rast ics-raata
és FATHER (City) ceonaeZ 2 DMO’ PD Peaceave ai poet BIL: OO ese ee ae What test confirmed diagmosis?...........:.ccccceseeeeeeeseeeeees
z (State or country)
ES’ EE MF Way Gisease OF Injury In any Way related [O OCCUPATION OF Geceased!s .... 4. geGes......
<| > OF MOTHER Catherine Brown If So, specify...
a (Signed) .&4@Z.
16 BIRTHPLACE OF
MOTHER (City) oo... Canna h...pe.... eR NS Gini (Address) £4
(State or country)
17 ts ey Relation, if any i
Inforant eM a RE MA Ci We) JANUS DY, 6 19.0.
1 HEREBY CERTIFY that a satisfactory standard certificate of death was ” nes (3 Perris : nnee Prrrrrr titi titty 2 rrrerrreertt ete rr
filed with me BEFORE the burial transit permit was issued: ADDRESS.
“atigalle aor 91} (Signature of Agent off Board of Health or other) 7] | Received and filed........csesesercdfosyd dees Mdecsseeenechitessucesnecssussnsnssssssnecenncennecsseceneets hs HOP
(Oiicial Designation) A TRUE COPY, ATTEST: Registrar)

evised ore Standard Certificate of Death COMMONWEALTH 0 ASSACHUSETTS
RETURN OF CERTIFICATZS OF DEATH

A physician or registered hospital medical officer shall forth-!

with, after the death of a Person whom he has attended during;

A his last illness, at the request of an undertaker or other:

Statement of eccupation.—Precise statement of occupation is authorized person or of any member of the family of the deceased, '

very important, so that the relative healthfulness of various pursuits _ furnish for registration a standard certificate of death, stating to the

can be known. Make some entry in this section for every person best of his knowledge and belief the name of the deceased, his supposed

aged 10 yearsorover. Ifthe occupation had been given up or changed age, the disease of which he died, defined as required by section one,

on account of the disease causing death, report the occupation prior where same was contracted, the duration of his last illness, when last
. to illness. If .the deceased had retired from business, report the seen alive by the physician or officer and the date of his death.... :

occupation prior to retirement. Children not gainfully employed Gen. Laws, Chap. 46, Sec. 9.

may be returned as at school or at home. For a woman whose , No undertaker or other person shall bury or otherwise dispose

only occupation was that of home housework, write housework . of a human body in a town, or remove therefrom a human body

in answer to Question 8 and own home in answer to Question 9, which has not been buried, until he has received a permit from

the occupation by the appropriate terms, as housckeeper—private or if there is no such board, from the clerk of the town where the

family, cook—hotel, etc. For a person who had no occupation what- erson died; and no undertaker or other person shall exhume a human

ever write none. »ody and remove it from a town, from one cemetery to another, of

- from one grave or tomb other than the Teceiving tomb to another in the
To be complete, an occupation return must state: 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

8.—The trade, profession, or Particular kind of work done. is buried. No such permit shall be issued until there shall have been

9.—The industry or business in which the work was done. delivered to such board, agent or clerk, as the case may be, a satis«

: factory written statement containing the facts required by law to
10.—The month and year the deceased last worked at the occupation. be returned and recorded, which shall be accompanied, in case of an
11.—The number of years the deceased followed the occupation, orginal interment, by a satisiactory certificate of the attending

physician, if any, as tequired by law, or in lieu thereof a certificate

‘ : 7 F as hereinafter provided. If there is no attending physician, or if, for

In Stating the gccupation, avoid the use of such indefinite terms sufficient reasons, his certificate cannot be obtained early enough
as *‘employee, worker, operative,”’ etc, Find out the parti- for the purpose, or is insufficient, a Physician who is a member of the
cular kind of work done and return that, as spinner, weaver, etc. board of health, or employed by it or by the selectmen for the purpose,
‘ 7 Fi fk shall upon application make the certificate required of the attending

In stating the industry or business, avoid the use of such general Physician. If death is caused by violence, the medical examiner shatt
terms as ‘'store, factory,’ mill,"” etc. State the particular take such certificate. If such a permit for the temoval ofa human body,
kind of store, factory, mill, etc., as grocery store, soap factory, cotton not previously interred, from one town to another within the common
mill, etc. wealth cannot be obtained early enough for the purpose, the certificate

ae 4 : 4 F of death made as above provided and In the possession of the undertaker
Distinguish carefully the different kinds of engineers by stating desiring to make such La eee shail fsastitute a permit for such re-
the full descriptive titles, as civil engineer, mechanical enginecr, mining moval; provided, that such body shall be returned to the town from
engineer, stationary engineer, etc. Avoid the term ‘‘laborer”” when a which it was removed within thirty-six hours after such removal, unless
Hee the wong statement of the occupation can be secured. Do not & permit in the usual form for the removal of such body has been sooner
use the word “mechanic, ” but give the exact occupation, as corpenter, obtained hereunder. If the death certificate contains a recital, as ree
Painter, machinist, etc. Distinguish carefully between retail merchants quired by section ten of chapter forty-six, that the deceased served in
and wholesale merchants. A person who sells goods should be called a the army, navy or marine corps of the United States in any war in

salesman and not a clerk, 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
Statement of cause of death.—Cause of death means the disease, certificate, shall forthwith countersign it and transmit it to the clerk

or complication which causes death, not the mode of dying, ¢. g., heart of the town for registration. ‘The person to whom the permit is so
failure, asphyxia, asthenia, etc. As principal cause name the disease given and the physician certifying the cause of death shall thereafter
causing death. As related causes, name earlier morbid conditions, — fyenish for registration any other necessary information which can be
if any, related to the principal cause and any important complication obtained as to the deceased, or as to the manner or cause of the death,
of the principal cause. Under contributory causes of importance not which the clerk or registrar may require. — Chap. 114, Sec. 45, G. L..

telated to principal cause, name other important diseases, (Tercentenary Edition.) ‘
Medical examiners shall make examination upon the view of
the dead bodies of only such persons as are supposed to have died

by violence... .Gen. Laws, Chad. 38, Sec. 6.
aaa EEEEEee ... fie 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. Lews, Chap. 38, Sec. 7.

PeaePia No undertaker or other person shall bury a human body or the
ashes thereof which have been, tangent Fash ay by Seer pte oe wale
iy incipal f death and related causes : he has received a permit so to do from the oard of health or its agen

dite Gilise pf hematin oe datiowa: Date of onset 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 .
Arteriosclerosis Tors is to be held, or from a person appointed to have the care of the ceme-
SEP eA MAcanbahpaghuiavexes oven sedhicnatepsdaanestesesvuncet| Scuba eodteerecteacentciod tery or burial ground in which the interment mine "Chap. 114,
Chronic interstitial nephritis sansssssccsceresesees| sasseenese ooreensssenee SEE 46, GL, (Tercentenary Edition.)
Cerebral hemorrhage July 5, 1027 RULES OF PRACTICE

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

Nag ampad elu duncn cossaasoncapsp| sasesiingusakocsselsspined (1) Attending physicians will certify to such deaths only as

oo kl eeatgatot. iy 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 recent medical attend-
am ance or whose physician is absent from home when the certificate of
death is needled > a : 4
Wivhowpasdaneqipag¥ eon uctenauieeegisscsivdeccsc tue sven (3) Medical Examiners will investigate and certify to all deaths
supposably due to injury. These include not only deaths caused

directly or sechectly by Noam Sacleding sees peption= a}

In oup of causes containing the principal cause and related _ and by the action of chemica Tugs or poisons), thermal, or electrica

ouuben: the ened should be giien tn Ghaortan oe onset, so thatin a agents, and deaths following abortion, be abe deaths Bort Santee
group of three causes the principal cause May appear in either first, resulting from injury or infection pe the to ee ine oe
second, or third position. The principal cause in the above example sudden deaths of persons not disable y recogniz °
happens to be the second cause given. | and those of persons found dead.

Ghe Cammonwesith of Mansuchusets

oh OFFICE OF THE SECRETARY —___ Cl esssssesseeeee seresessecencaeaseesessanenenenss sacerenenersanere
‘Ss £& E eee (A a ha DIVISION OF VITAL STATISTICS (City or town making return)
© st
£2= - lg STANDARD >
Sof 145 AK CERTIFICATE OF DEATH Registered No.eccsscsce Mesensucs
wry Ba i (City or Town) I : pie ae
| Pp o~ < ; 74 MG (If death occurred in a hospital or institution,
3 a9 2 Noi. Za eee oe. OT a a ee i ol I aed 4 oro ied WME Anatead Of attect and aemilial)
i)
wn : (if U.S.
ZS 2 FULL NAMECA 61-20, beevar hk, Recs clan Gb EI Yaa’ War Veteran,
4 (If deceased is a married, widowed or divor oman, give also maiden name.) epecify WAR) fi: csssvevsosusssdaconuetacenpsteestin
~ | Ue a
OME (a) Residence. Now. dh loo IED ne ee Aaa piaesn WO REN g eas onsc Nee ea doves anal tp ova sadeaen bie nae Geek eee
| ta eo. (Usual place of abode) Z (If nonresident, give city or town and state)
= 3 s Length of residence in city or town where death occurred pi. yrs. mos. : days. How long in U. S., if of foreign birth? yrs. mos. days.
3 bs ve PERSONAL AND STATISTICAL PARTICULARS
ate A 3 3 SEX 4 COLOR OR Race | 5 SINGLE (waite the word)
<5 's Ypule. ply dE Ce ; (Month) ay) (Year)
ess La ae a a. a a
ends euagnn eed ae ssa 3; Ve aa ae ee ae ; 1 eR Sirens 33 sich: A ma oF — a =
ere (Give maiden name of wife in full) Feces ofrerereesenne Seavehanedanicasteere Ali beaten ’ 9...» Mecamanceeesnpaaentennee pe | eee
e (or) WIFE of~.......... Bae ee aes pete acta ane ca iaaeeaict heaeos arb atsaeesh Coe Ie cassonishcn)
n “3 5 4 w (Husband's name in full) | last saw hin...
= >$ || 6 IF STILLBORN, enter that fact here. to cn occurred . the
ri J] $$ 8 princi
23 $= 7 vs S eo If tess than 1 day were as Ph cag oa
3 7° Z OG Ae eee Years. Lovee. Months <.......... Days | -sessseee-- HOULS.....ssssee: Minutes
Loe é
: | 5 a 8 Trade, profession, or particular
vos E = kind Of work done, as spinner, AE Boa
rag) ° i) sawyer, bookkeeper, OtC..........scsceesebleseonoere EI aap lepaaveneesntssuacaied
my el =| 9 Industry or business in which ———— .
io) £ es a work was done, as silk eA" —
8 a 8 2 saw mill, bank, €tC....svesessssseee0 ote AN a <a c
a6 | 10 Date deceased last worked at Az 11 Total time (years)
s oe] = this occupation (month and LP SS- spent in this KO
mos 3 ST 2 ae TY cer t= Al sees Occupation......7..S..cce0
Bed -+=
UROL 12 BIRTHPLACE (City) .ccccscsen GQPYE A ie ce me
Zz a 6 4 (State or country) Zot
—) -
eas 13 NAME OF 4
eas: FATHER JLo Kg Leng é C1.
_— (4) 3
eo a 3 «| 14 BIRTHPLACE OF earn o, OF PQ TABLE <i .cvetscsssncochdbenctincecensjescdnonnnnemantecvoc
2 & 2 ea FATHER (City) Crien ese I reacacupne! FZ spdevsananagiaphcsilens neaciale What test confirmed diagnosis?............cccsesseeseeeserernes
pI z t t i La
5 Be w Piste or country) 20 Was disease or injury in any way related to occupation of deceased? ................00++
SS 3 os 15 petal If-sonspectty ines) isse Aah percccie races MELEE 15: Rone ea MEN a BAe
| = a. (Signed) ....g.0cGiki
Le 16 BIRTHPLACE OF
- 3 4% Ae Re 2 sla atta il ts
% State t 21 PLACE OF-BURIAL,
4 me) A yt tiaras ai CREMATION O@R—-REMOVA
Om a ; 4
SORES then En HEMEL ILE sere (oe DK rs ))[___DATE OF BURIAL nov Eo rnb’ ee ea
Bra? -™
e Eap s a 72 INDERTAKER
= ES 5 Zz EREBY Genii trey AAP CATIS Tet deal das | MC ERTARER. nsannnauvanavsseuasszecssssscctesSven boCeCececroetrorvonnnananananasnvnsanssannaneenetes®
sits iw d wi BEF! he betjavér transit permit was issued:
{ A= | 9 i Sharh (EL
i : ae V. Md i Ba a5 wine i kl |
, mS Z Wate:
Via SS Ts sh 6-82 )
z = (Official Designation) / (/ (Date of Issue of Pormit) A TRUE COPY, ATTEST: & (Registrar)

Revised Unig tates Standard Certificate of Death

Statement of occupation.—Precise statement of occupation is
very important, so that the relative healthfulness of various pursuits
can be known. Make some entry in this section for every person
aged 10 yearsorover. If the occupation had been given up or changed
on account of the disease causing death, report the occupation prior
to illness. If the deceased had retired from business, report the
occupation prior to retirement. Children not gainfully employed
may be returned as at school or at home. For a woman whose
only occupation was that of home housework, write housework
in answer to Question 8 and own home in answer to Question 9.
For a person engaged in domestic service for wages, however, designate
the occupation by the appropriate terms, as housekeeper—private
family, cook—holel, 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, cotton
mill, etc.

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

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

Example

The principal cause of death and related causes

: ‘ Date of onset
of importance in order of onset were as follows: bind -

Arteriosclerosis Iorg

Contributory causes of importance not related to
principal cause:

AFORE AHR AeAE Ree ese eeeeenseensenaseeenessneeseseessuedenensesnauensessseessatanentnsnasseeeenr | osseeeeneeasenasenaneeenes
RAH AA Annee eben sen enemenenenee ene eeneeseeeseneeeehene snes seeneneeaneaRenssnnsenaeeasenansesnessn | eseeeseeOSAR ESOS EEE EE EGES

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

SS SS ae RT eS ey a a eS a

COMMONWEALTH GmisASSACHUSETTS
GOVERNI “THE
RETURN OF CERTIFICATES OF DEATH

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

ody and remove it from a town, from one cemetery to another, or
from one grave or tomb other than the receiving tomb to another in the
Same cemetery, until he has received a permit from the board of health
or its agent aforesaid or from the clerk of the town where the body
is buried. No such permit shall be issued until there shall have been
delivered to such board, agent or clerk, as the case may be, a Satis«
factery written statement containing the facts required by law to
be returned and recorded, which shali 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, cr employed by it or by the selectmen for the purpose,
shall unon 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-
Weaith 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 cape 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

iven and the physician certifying the cause of death shall thereafter
urnish 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.,
(Tercentenary Edition.)

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., (Tercentenary Edition.)

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 bt et 4 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,

Pa St ee eS eee ee ee Te ees iE

Exact statement of OCCUPATION

ified.

INK—THIS IS A PERMANENT RE! very item of neat
AGE should be ee EXACTLY. PHYSICAIAS should state =
perly class:

ully supplied.

caref
CAUSE OF DEAT?i in plain terms, so that it may be pro

UNFADING B

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

is very important.

a
:

No. 3385-f£

100m-9-'31.

The Gommomnesith of Massarhusetts
OFFICE OF THE SECRETARY

E DIVISION OF VITAL STATISTICS
a STANDARD F
1,6 CERTIFICATE OF DEATH Registered No................... 2 2
bl
< (If death occurred in a hospital or institution,
a Ward give its NAME instead of street and number)
LL 2 (If U.S.
NEY SS nd a EL” iy en! ee War Veteran,
(If deceased is a m ae me or divorced woman, give also maiden name.) eppacaiy WAR) 5 0.2 5<05:-5.censasscncnseconethedssseea
(a) Residence. No. LE. age ee eee nee. LE ie ED AE ig cn voc ngsnssacae, WW EAEOlp has anndtandens doce nace danesaeceanssntsnhac cedptagteaza“eae MapMarks
(Usual place of abode) ¢ (If nonresident, give city or town and state)
Length of residence in city or town where death siteeratin 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 J F: ey OR RACE MARRIED ) 3 18 DATE OF
) 4... Va $f WIDOWED » SS s een | ey 6 ATER ER REE Pere epee cee Sd ec crete chs ATT
‘ Tele or DIVORCED~ ee
5a If married, widowed, or divorced 19 1 HEREBY CERTIFY, That! attended deceased from
LUIS) COS a ee ee eoocnticiesnitreanteeetes ee ae nth RR Po eee
(Give maiden name of wife in full) = Prveereveseereennseeevnsnsesrssnsecersneenesenscnnnneeny Bb Freee Fl re BRS ae OR Sm Se Serr onsets PMR TCC ee: Benes
UT ha ie ee eee ee ! last saw h............ MliVGZON nett asc eee ,19 death is said
(Husband’s name in full) ts . mes aah
o have occurred on the date stated above, at.................... m.
G IF STILLBORN, enter that fact here The principal cause of death and related causes of importanoe in order of
Lf ye we Ifless than 1 day _ onset were as follows: Date of Onset
PAIS cziceriocasdscsse- MGAYS coi-202-0-7--! Months... 3)" 3) eee Hours..........-. Minutes
8 Trade, profession, or particular
= kind of work done, as spinner, —
ro} UMAR MAMI N IAL o occ c (ai veces casera. vex vax -vantnsscoyineagdenensasavesznchinessune-asveaerenepeonshard
=| 9 Industry or business in which
a work was done, as silk mill, ——
= con ual Scat cee ee a a ee, ee
©| 10 Date deceased last worked at 11 Total time (years)
this occupation (month and spent in this
MR acs cts nculene cutee cnaveapve-ssevacisacavecteed occupation.....................

7
12 BIRTHPLACE (City).............4 f
(State or country)

13 NAME OF
FATHER

AF
FATHER (City) ..

”
=
z (State or countey)
= 2
«| 15 MAIDEN NAME
<| OF MOTHER xb Ctzce.
a
16 BIRTHPLACE OF ‘
MOTHER (City) ............ ae.
(State or country) Va2g rcJo4 4 rs
~ - / (Comistery) (ity or town)
DATE OF aru Verrea7 Nidae \ ee 1950.6
Ad J, =
22 NAME OF Y LZ
UNDERTAKER Tis sy ko wae Sea cae
ADDRESS........ 224 ARLE. Ate Ah... fd.
MCU EAT EN AMRIT ENEMIES Lives cats sehenpteenttestaparcap cinuieapnie dos nnssetici sicdu ona ninniceve Gus Micagundatotenrcaicche 1.) See
Be |'s EES Sie |: I on
A TRUE COPY, ATTEST Cae

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 Le death, report the occupation prior
to illness. If the deceased had retired from business, report the
occupation prior to retirement. Children not gainfully employed
may be returned as at school or at home. For a woman whose
only occupation was that of home housework, write housework
in answer to Question 8 and own home in answer to Question 9.
For a person engaged in domestic service for wages, however, designate
the occupation by the appropriate terms, as housekeeper—privale
family, cook—hotel, etc. For a person who had no occupation what-
ever write none.

To be complete, an occupation return must state:

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

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

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

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

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

Arteriosclerosis rors

Chronic interstitial nephritis rg2r

Cerebral hemorrh _July 5, 1927

Contributory causes of importance not related to
principal cause:

EXTRACTS FROM TEA: WS OF THE
COMMONWEALTH OF SSACHUSETTS
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.. a4
Gen. Laws, Chap. 46, Sec. 9.

No undertaker or other person shall bury or otherwise dispose
of a human body in a town, or remove therefrom a human body
which has not been buried, until he has received a permit from
the board of health, or its agent appointed to issue such ermits,
or if there is no such board, from the clerk of the town where the
person died; and no undertaker or other person shall exhume a human
body and remove it from a town, from one cemetery to another, or
from one grave or tomb other than the receiving tomb to another in the
Same cemetery, until he has received a permit from the board of health
or its agent aforesaid or from the clerk of the town where the body
is buried. No such permit shall be issued until there shall have been
delivered to such board, agent or clerk, as the case may be, a Satis-
factory written statement containing the facts required by law to
be returned and recorded, which shall be accompanied, in case of an
original interment, by a satisfactory certificate of the attending
Physician, if any, as required by law, or in lieu thereof a certificate
as hereinafter provided. If there is no attending physician, or if, for
sufficient reasons, his certificate cannot be obtained early enough
for the purpose, or is insufficient, a physician who is a member of the
board of health, or employed by it or by the selectmen for the purpose,
shall upon application make the certificate required of the attending
physician. If death is caused by violence, the medical examiner shali
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. 5
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.

iter of 4

{

Every

5S should state

°»

PHYSICIAN
Emact atatement of OCCUPATION

AGE should be stated EXACTLY,

RESERVED FOR BINDING
, 60 that it ay be properly classified.

UNFADING BLACK INK—THIS IS A PERMANENT RE

> ary)” TF \* ¢

refully supplied.

lain termes

netructions and extracts from the laws on back of certificate.

PLAINL
information showld be ca
CAUSE OF DEATH Pe

is very important.
No, 204fee

100-1 20",

OFFICE OF THE SECRETARY = tated, ae ee

oot) ae

= BIVISION CF VITAL STATISTICS (City or town aking cutee
(Comnty)
L 8 STANDARD
143 Winthrop CERTIFICATE OF DEATH cickhantite .. arcane
= (Gity or Town) Gidess 1 zn = Ioapatel or ixatitet
= i9 L el Ward | give its NAME instead of street and numbed)
U.S.
2 FULL NaME 106... (Ricker) Hintze. Sn Can,
dGsceased is widowed of Givorced woman, give also maiden name) a
(a) Residence. 7 Ta te 2
(Usasl piece of bode) nonresident, give Gity of town end stste)
Length of residence in chy or toue where death occurred “ZO rm =o. ar ESTEE ER cs =e. ay
PERSONAL AND STATISTICAL PARTICULARS MEDICAL CERTIFICATE OF DEATH

i
> | 2 coon Om Rc | © SG (wtite the word) !

Female) White WipoweD _, Widowed

(or a an feees Lien
Tat principal cause of death apd reiaied cusses of importance ls oder of ons
Were 85 faloes: Bete of

Uaksiadelereses wae

1S KAEE GF
mmx Cherles Ricker
14 BIRTHPLACE OF iz 5
=| FATHER (City) / y; ts
=| Geter comity) aa 7
—
= 5 et Ee
<| or mom MSTY a
—
16 BIRTHPLACE OF
BOTHER (Cir) FEO: < oy :
(State or comnitry) zZ& Aes, non ox eso. Hinthr , thro
? (Gay of town
DATE OF BURIAL January 6 Saw
23 Re Om Charles R. Bennis
CERTIFY thet a seGsfactory stendesd cerdificete cf Gesci wes & :
vine. “y= perms wes issuet Fin peepee Wek 3
e 3 LZ27-€- . ADDRESS
A, Be ILE Soi ct ed ag 7) Recon n
/ : 2 LOX en = 4 t7 Sé ; | 18

Revised Urigy tates 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
se of store, factory, mill, etc., as grocery store, soap factory, cotlion
mill, etc.

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

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

Example

The principal cause of death and related causes

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

seeesepeeeeeeeeneeneneeneseenareee sen|aee eeeeenecseenenee seeaene

Chronic interstitial nephritis

ae eeeceeeeeeenenens ceucevcncsscecevcceccesccncsdsueovepesspacccnccucnescosscenascccsvceacscsasss | cases

Contributory causes of importance not related to
principal cause:

ateeeersnencneeseencterennenteeseeaneaneusnneneneseeenss

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

ee |" LA Sree

COMMONWEALTH Of 543
GOVERNING THE

RETURN OF CERTIFICATES OF DEATH

A aa rea 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, Chad. 46, Sec. 9.

ody and remove it from a town, from one cemetery to another, or
from one grave or tomb other than the receiving tomb to another in the
same cemetery, until he has received a permit from the board of health
or its agent aforesaid or from the clerk of the town where the body
is buried. No such permit shall be issued until there shall have been
delivered to such board, agent or clerk, as the case may be, a Satis-
factory written statement containing the facts required by law to
be returned and recorded, which shall be accompanied, in case of an
original interment, by a satisfactory certificate of the attending
physician, if any, as required by law, or in lieu thereof a certificate
as hereinafter provided. If there is no attending physician, or if, for
sufficient reasons, his certificate cannot be obtained early enough
for the purpose, or is insufficient, a physician who is a member of the
board of health, or employed by it or by the selectmen for the purpose,
shall upon application make the certificate required of the attending
physician. If death is caused by violence, the medical examiner shail
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 pean for such re-
moval; provided, that such body shall be returned to the town from
which it.was removed within thirty-six hours after such removal, unless
a permit in the usual form for the removal of such body has been sooner
obtained hereunder. If the death certificate contains a recital, as re-
Quired by section ten of chapter forty-six, that the deceased served in
the army, navy or marine corps of the United States in any war in
which it has been engaged, such recital shall appear wpon the permit.
The board of health, or its agent, upon receipt of such statement and
certificate, shail 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.,
(Tercentenary Edition.)

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.

Ele 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. Lews, Chap. 38, Sec. 7.

ote oe ie

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.

Ss eS eee eee es ee. i i tod £6) OCCUPALION, £10

should state

Every item of

PHYSI
Exact statement of OCCUPATION

RVED FOR BINDING

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

_ MARGIN RESE

carefully supplied.

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

N. B.—WRITE PLAINLY,
No. 7070-h

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

i
is very important.

100m-12-"32.

g The Commonwealth ‘o pena 36
OFFICE OF THE s CRETARY 00d endveserecsaset cevsnsccccsncccccsucesasceccsesdedssesnsiuss

DIVISION OF VITAL STATISTICS (City or town making return)

STANDARD 5
CERTIFICATE OF DEATH Registered No............... tha

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

(If U.S.

War Veteran,

epeciky: WARD oo: sciacsceessccccconasscaparateancd
(a) Residence. No...S/.020E54.......44M...... LALYILAL EET Sty. eeceeees Warr orc Frcs sea es ee ae

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

PERSONAL AND STATISTICAL PARTICULARS

S SINGLE (write the word)
Fe | 4 COLOR OR RACE | MARRIED 7
| aoe Lee

5a If married, widowed, or divorced
LOSS ELS) 6 dae Sip Rn Re ee RE od SON ces cach aoins Laka h MMgRancnioncerees
Ww n full)

(or) WIFE of : LUTE N Ah hoon f i OF Aig Ff Os

6 IF STILLBORN, enter that fact here. to have occurred on the

ee The principal cause of death and related causes of importance in order o'
If less than 1 day onset were as follows: Date of Onset
Se Be a Hours............Minutes

7 ==
AGE......... 5 caw fe WEAES 25.Pince.c Months........ f Days

8 Trade, profession, or particular

kind of work done, as spinner, ;

Suwyer, POOKkKeeT|r, GlC.....-2.c00cc-seei esas eteasn cn haWas Menkes tncastcrnassousdscctitavewesnnas® =
9 Industry or business in which

work was done, as silk miil,

COSTE Oe Sa a aa tage eee ee eee he ee

10 Date deceased last worked at 11 Total time (years)
this occupation macaaee and spent in this
23 es ee sete odes cacaays occupation.................000-:

12 BIRTHPLACE (City)... foog35 4 as ee f- ee aie

(State or country)

OCCUPATION

113 Ler OF
FATHER 7 pir 4
14 BIRTHPLACE OF Name of operaplOM.....:.......eeeeeees iy, suottonds Seetepeerenice fe
FATHER (City), 22.2 Qc foccni.. of i S What test confirmed diagnosis?.......................-.. ...Was there an autopsy?..

(State or country)

15 MAIDEN NAME
OF MOTHER

PARENTS

16 BIRTHPLACE OF
TA, Gh CON ee ne CR il

(State or country)

21 PLACE OF BURIAL,
CREMATION OR REMOVAL

17
meet DATE OF BURIAL........ XAe

22 NAME OF

(Address)

tandard certificate’of death was
issued: ADDRESS oscccesnercncvinassavean ig

he a ae ft Zo “A TRUE COPY, ATTEST: 3p (Registrar)

Revised a 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 1n this section for every person
aged 10 years or over. If the occupation had been given up or changed
on account of the disease causing death, report the occupation prior
to illness. If the deceased had retired from business, report the
occupation prior to retirement. Children not gainfully employed
may be returned as at school or at home. For a woman whose
only occupation was that of home housework, write housework
in answer to Question 8 and own home in answer to Question 9.
For a person engaged in domestic service for wages, however, designate
the occupation by the appropriate terms, as housckeeper—privale
family, cook—hotel, etc. For a person who had no occupation what-
ever write none.

To be complete, an occupation return must state:

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

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

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

In stating the industry or business, avoid the use of such general
terms as ‘‘store,” “factory,” ‘mill,’ ete. State the particwlar
ae of store, factory, mill, etc., as grocery store, soap factory, collon
mill, etc.

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

Statement of cause of death.—Cause of death means the disease,
or complication which causes death, not the mode of dying, ¢. 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] Pate of onset
of importance in order of onset were as follows:
Arteriosclerosis rors

ro2r

Chronic interstitial nephriti

Contributory causes of importance not related to
principal cause:

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

EXTRACTS FROM Fg Ns OF THE
COMMONWEALTH O SSACHUSETTS
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
pore 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
same cemetery, until he has received a permit from the board of health
or its agent aforesaid or from the clerk of the town where the body
is buried. No such permit shall be issued until there shall have been
delivered to such board, agent or clerk, as the case may. be, a satis-
factory written statement containing the facts required by law to
be returned and recorded, which shall be accompanied, in case of an
original interment, by a Satisfactory certificate of the attending
physician, if any, as required by law, or in lieu thereof a certificate
as hereinafter provided. If there is no attending physician, or if, for
sufficient reasons, his certificate cannot be obtained early enough
for the purpose, or is insufficient, a physician who is a member of the
board of health, or employed by it or by the selectmen for the purpose,
shall upon application make the certificate required of the attending
physician. If death is caused by violence, the medical examiner shall
make such certificate. If such a permit for the removal ofa human body,
not premoun’ 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 eae 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), Gs Ly
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.

Bh) See

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
thase 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 u)-
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 o 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.

very item of =~
should

ANS
Exact statement of OCCUPATION

PHYSIC

AGE should be stated EXACTLY.

MARGIN RESERVED FOR BINDING
pplied.

UNFADING BLACK INK—THIS IS A PERMANENT REC&€

arefully su

Wi
ca
oyc.

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

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

e .

tant.

CAUSE OF DEAT.

is very impor

B.—WRITE PLAINLY,
nformation should

“A

No. 9321-a°

100m-9-'33.

<Q The Commonwealth of Massachusetts To be filed for burial permit
= ‘ a OFFICE OF THE SECRETARY with Board of Health
E os se oh allan aaa 5 DIVISION OF VITAL STATISTICS on its Agene! ‘
a STANDARD Hy >
iS CERTIFICATE OF DEATH Registered Now........ceccccceeceseceees
ta
o (If death occurred in a hospital or institution,
a Pale MACE ENG chs MA INGE «6050,ecceyscevvccensscosucasees SOEs gretesakecessacaescises Ward { give its NAME instead of street and number)
a (If U.S.
2 FULL NAME... AEE War Veteran,
(If deceased is a married, wid wed or divorced woman, give also maiden name.) punted: WARD woaia iasch seccenssdvnncesscotebeeee
(a) Residence. No... Sacssa Di CPR ND MEME a scassrachoseonesvaces ERP eer ee ACC: GE ee See Pe SE
(Usual place of abode) (If nonresident, give city or town and state)
Length of residence in city or town where death occurred vA 6 yrs. mos, days. How long in U. S., if of foreign birth? 4 vo yrs. mos. days.

MEDICAL CERTIFICATE OF DEATH

PERSONAL AND STATISTICAL PARTICULARS
3 on vie 4 COLOR OR RACE | 5 SINGLE Gate ee)

MARRIED . /

WIDOWED ayes ~ fact

or DIVORCED ‘ ; a (Year)
m If married, _ or divorced

» That | attended deceased from

HUSBAND off ...........cccecesecseecececseerene DAMA SR vce cnc cscs be I RTM rcs pes cceesceeeeeee J
(Give maiden name of wifein full) 9 - Pfr ere - ; 3+, 10in0 Tes ee B scivpey 7. Rosnrede ID | 9.3.6
4 19.54, death is said

ere NMIAE Wem Breet vidas san nga tensoah anste coufaveaptcraans taeda dajvssaevevborhinensansanesovenvercsleitjeMterseersadneed han
to have occurred on the date stated abbye, at. eee Pn.

(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
onset were as follows: “Date of Onset

If less than 1 day

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

z
° sawyer, bookkeeper, etc.............
| 9Q Industry or business in which
a work was done, as silk mill,
= saw mill, bank, tC............0-+004 "
© | 10 Date deceased last worked at 11 Total tine: (Yeaesima Be cats A Ak. Be aR SS onl | Re ee ae
this occupation (month and spent inthis Bo a
OCCUPATION........seeceeeereees
casei Buepsdessenteouen
(State or country)
13 NAME OF
FATHER il: SY C2 auaeal

14 BIRTHPLACE OF

“ SESE Da (CE) BO A le YL aie a
= (State or country)
lu
«|15 MAIDEN NAME
< OF MOTHER Lora K If so, specify....,<7}....
SS (Signed) ......8
16 BIRTHPLACE OF -
MOTHER (City)
Stat t 21 PLACE OF BUR
peert CREMATION OR REMOVAL PS... Cae NEA...
17
aCe ON Oc <h ha a/shis ttiancp senate caved b's reretisahente Shs ianciousencracncennnness geo len! On lee ee DATE OF BURIAL
Jamel £22 22 NAME OF

UNDERTAKER ...........5%.- AMAL RES...

| HEREBY CERTIFY that a satisfattory standard certificate of dea
iled with me BEFORE t urial or transit permit was issued:

a Wpeseee {eo ae
~) 32 Hesgeinss

Revised Uprigpiates 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
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
ashy of store, factory, mill, etc., as grocery store, soap factory, cotton
mill, etc.

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

salesman and not a clerk.

Example

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

Date of onset

Cerebral hemorrhage

Brrr tte Srrererrrrrteeerer .

Contributory causes of importance not related to
principal cause:

Serer neeeeneneeees seeeenneneee eeeeee seeeeee

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.

GOVERNING “THE

RETURN OF CERTIFICATES OF DEATH

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.

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 atiending
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 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 res
moval; provided, that such body shall be returned to the town from
which it was temoved within thirty-six hours after such removal, unless
a permit in the usual form for the removal of such body has been sooner
obtained hereunder. If the death certificate contains a recital, as re+
quired by section ten of chapter forty-six, that the deceased served in
the army, navy or marine corps of the United States in any war in
which it has been engaged, such recital shall appear upon the permit.
The board of health, or its agent, upon receipt of such statement and
certificate, shall forthwith countersign it and transmit it to the clerk

} of the town for registration. The person to whom the permit is so

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

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

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

RULES OF PRACTICE

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

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

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

ut also deaths from disease |

2M R-301A The Commonwealth of Massachusetts To be filed for burial permit
OFFICE OF THE SECRETARY with Board of Health
38 DIVISION OF VITAL STATISTICS or its Agent.
° s STANDARD
S CERTIFICATE OF DEATH Registered NowA2 AT... Yn
3 x (If death occurred in a hospital or institution, -
Pe i iisnreasiaecess bo) 34 | lee Ward { give its NAME instead of street and number)
>a
Bin (if U. S.
ad War Veteran,
: specify, WAR) scsisisscooisssctevucnenesnvensttcadecrs

(a) Residence. No... PP, A ine thn ES ant ee rve PRE ao oe cE Gc osesdsorse cede WW ANG pice ddenciageezdeaenvagsnasnadsessuettssubanterhkapsbrentvackyDbieness0l
(Usual place of abode)

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

days.

PHYSI
Exact statement of OCCUPATION

tructions and extracts from the laws on back of certificate.

PERSONAL AND STATISTICAL PARTICULARS MEDICAL CERTIFICATE OF DEATH

5 SINGLE (write the word)
3 SEY 4 COLOR OR RACE ; MARRIED z 1S DATE OF
| A WIDOWED y DEATH............
~ nn ag ghd or DIVORCES a
5a If married, widowed, or divorced I HEREBY CERTIFY, That! attended deceased from
NI SEIUN RNIN Rest isin desossnsevsneneovescuesdecihcsovessgssvetees
; Te Pe Ee AETV RRR) i MGI 0 |) s WAMOMIMMR OM shecsoyscacesaaserasccsoracepecroceenadés By Ce eee Fuk O basat cadens castes va Weassktarnadeteyeseath reset > ee
(or) eS OT ETT ag AW. Wesssecsaeves ANN. OM: coeesensrte see cncest oeeteaacs ees ties Foiny 19 cssceeene death is said

importance in order of

Date of Onset
IMPORTANT

The principal cause of death and related causes

ney were as follows:

8 Trade, profession, or particular
kind of work done, as spinner,
sawyer, bookkeeper, CtC..........scsseceen eM cesers Mesene Seen Ae PR

9 Industry or business in which
work was done, as silk mill,
saw mill, bank, Ct(...........0---esresseeendee

10 Date deceased la

ate d GF. y: OCI Sa || eae Seah MR Se MPM ACTOR AER eo
is occupation spent in thi i 7 I ;
je ae Meeneesion Wai fas ~sephrne ebay 13 spent in ON 62 Bas :

AGE should be stated EXACTLY.

terms, so that it may be properly classified.

OCCUPATION

FINE MUM U RE CEM CMUNY Yi Mee ce cacao huge gatasteces eee doaba donee asad dus bnwonseranodauavoatunubbessnes4

(State or country)

WITH UNFADING BLACK INK—THIS IS A PERMANENT R

3
=
o
5
“4 13 NAME OF
FATHER. §- \ dene A tg, Sem, oe , J ig "(I greeter tte te ttt ec renee cane neneneecenencnaasanensanae [otereticey
A)
cal «| 14 BIRTHPLACE
‘Sq = COE UIGHCD) Wy, Se Rae A ie CRUD, SY ad MPT ospreceannik
aa ‘ = (State or country)
OB [fu =x
| 15 MAIDEN NAME
AG Z s OF MOTHER SO AS PLEA EM sceccoB vac cuuntonestcs ch cadanre-tan ool saavoosMswann: on vencgabgme.icrmesuaxctsabvonss not azi/<coransenteneeReaaaeoee
¢ = a (Signed) ...
? 16 BIRTHPLACE OF !
hee Op NG UR Se SS Re ee (Address)
caus eee het - ue sn (tly A9>0 “7 tA Loe
-*] Bh 4 17 (City or ge 4
SO S| Informal? y DATE OF BUNA eng SIE aes
es | SEO vg NAME OF CE A j
& Ee i ee LO et ALES, UNDERTAKER .....cs0..s00.. Sweep heescsson _ * eae STE Ie
Ssk55 8 | HBREBY CERTIFY re a satisfactosy standard certificate of death was
wea > = RE t | it permit was issued: _ ADDRESS ... fered Oe Orc tities
#288 | ee
-— — ~”
aul Ed
a a
3 E Dee aeeernicas snenveccessesces
Zz s

Revised Units .Ssutes 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 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
dene 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 engincer, 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 pive the exact occupation, as carpentcr,
painter, machinist, etc. Distinguish carefully between retail merchants
and wholesale merchants. A person who sells goods should be called a
salesmen and not a clerk.

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

Example

The principal cause of death and related causes

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

interstitial nephritis

anepenneeeeees seeegpapeeeeenerenceseeeesseeseeees neeeeeeeneeenenenen

Cerebral hemorrhage

ee ceeaccsesesesrseenenenassnnenenees

anveceresnccassreecsasseseescouassareneses seeneenene

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.

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 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 “Pole 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,
shali upon application make the certificate required of the attending
physician. If death is caused by violence, the medical examiner shall
make such certificate. If sucha permit for the removal of a human body,
not previously interred from one town to another within the common-
wealth cannot be obtained early enough for the purpose, the certificate
of death rnade 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 16 was removed within thirty-six hours after such removal, unless
a permit in the ustial 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. }
as amended by Chap. 48, Acts of 1927 and Chap. 414, Acts of 1931.

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

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

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

Sec. 46, G. L. as amended. ——__.___—.

RULES OF PRACTICE

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

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

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

ean

1
ca

LA
fied under the International Classification of

laws relative to the return of certificates of death.

MEDICAL EXAMINERS should state CAU;

be properly classi

de for extracts from the

y}
;
}
:
0
3
)
_
)
u
>
4
Z
c
;

WITH UNFADING BLACK INK—THIS IS A

information should be carefully supplied.
See reverse s'

DEATH in plain terms, so that it may

of Death.

. B.—WRITE PLAI

a
RM R-303B
=

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

To be filed for burial
hee with Board of
ealth or its Agent.

OFFICE OF THE SECRETARY
DIVISION OF VITAL STATISTICS

MEDICAL EXAMINER’S
CERTIFICATE OF DEATH

Pe ae Caerae Massachusetts

Registered No....................00 005

(If death occurred in a hospital or institution,
Nostaaal give its NAME instead of street and number)
S f : (if U. S.
2 FULL NAME... AAA LI cc cecsssneessnesemeneernnessencesenens War Veteran,
(If deceased is robe e.) Spec WAR) Sos icicessacisevac0croveossdxpsesnnvees
(a) Residence. No... 2. ral V £L (Oe Se... teh AE Ae cI Rell A Eo eee 8
(Usual place of abode) ¢ (If nonresident give city or town and state)

Length of residence in city or town where death occurred “X yrs. mos, days. How long in U. S., if of foreign birth? yrs. mos. days.
PERSONAL AND STATISTICAL PARTICULARS MEDIC AL CERTIFICATE OF DEATH
5 SINGLE (write the word) j ep =
3 SEX 4 COLOR OR RACE MARRIED K 18 DATE OF & ae o, G
WIDOWED DEATH its :cssccevteasteciss fk MMA NS Orton osteatosee A pec ee 7 AU ee ee
: f or DIVORCED (Day) (Year)
Lolincaipry widewed, ox $ Zs, Ge? 19 I HEREBY CERTIFY that I have investigated the death
1e of wifein full) 9 aa of the person above-named and that the CAUSE AND MANNER thereof are
RUIN TUAMNE TORO ceo ke ou g,sc2e nia sr seas ts ccet Pasi osteo cod ost ele peystaoiadbeas soc onsdedtisacrabiccoesoniens as follows: (If an injury wes involved, state fully.) .
(Husband's name in full) : ; ~ “p 4 ft; ‘
Ls CH G (ADe
6 IF STILLBORN, enter that fact here. PO OAM sg PL I SMM as CE MCG ash ES RET Sa ad a Po mie apts sencacesascercccescucsnes
vg £
(0 eh A We@ANS..c73.-:,- Months............Days } ...........-HOUFS......0....

8 Trade, profession, or particular
kind of work done, as spinner,
Sener VeR MORE REPT CL Co. co soncacy centr teescnsasvvousereroverscvocsunsuccrnes
9 Industry or business in which
work was done, as silk mill, PP, 2
saw mill, bank, etc. ............... Berth. Soa RE AY ero ee ts ec
Total time (years)
spent in this
occupation.. ¢

OCCUPATION -

/
12 BIRTHPLACE Cin yh
(State or country)
13 NAME OF
FATHER

2 % (See reverse side for description for unknown person)

14 SorUURLAGE 0 ah el is
72) . 20 IN WHAT CITY OR TOWN j é
eee ie oe CR ae irae wee WTR a WAS INJURY SUSTAINED 2 /........ | Mean tener et bee Wi sh Es. Sie ‘
= (State or country) * , 74 le fl Son
|e Signed) da Saseevatesae ee
oj} 15 MAIDEN NAM ;
E RE POTHER (Add ress)........0-7 5B). fe

16 BIRTHPLACE OF

: 21 PLACE OF BURIAL,
MOTHER (City) .....ccccccsseee(o Je... i ee fea Reiasl asthe MR EON cl CREMATION OR. REMOVAL . ih Ah
(State or country) ° 7 (City or town)
DATE OF BURIAL ju... Soph bAA bane PS Pa 190.6

Ada Cmnee OB ALLY

22 NAME OF
UNDERTAKER ...-
! HEREBY CERTIFY that a satisfactory standard certificate of déath was»*
filed with me BEFORE the burial or transit permit was issued: . ~
¥ O03

panos HEN ei a of Board of Health or other)

JANL

- (CHOSTOMMEALTH DEPT. “ee (Date of Tae ie Permit) ores CoO Eee on

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 bestof 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
aia 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 alee 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 spenaen 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.

DESCRIPTION (for unknown person)............. HAVE Bes 2 i

town where the poy is - be 4 ape or ei funeral is to ipl | or wri |
a person appointed to have the care of the cemetery or burial groun
in which the interment is made... .—Chap. 114, Sec. 46, G. L. as amended

Medical examiners shall make examination upon the view of the
dead bodies of only such persons as are supposed to have died by violence.
If a medical examiner fea 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 | abe bedside care during a last illness
from disease unrelated to any form of injury.

(2) Board of Health physicians will certify to such deaths only
as those of persons who, though disabled by recognized disease unrelated
to any form of injury, have died without recent medical attendance or
whose Shy aaa 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 paca, thermal, or electrical
agents, and deaths following abortion, t
resulting m injury or infection related to oc m, the
sudden deaths of persons not disabled by recognized disease, and
those of persons found dead.

;

STATEMENT OF CAUSE OF DEATH

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

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

THIS CERTIFICATE CONSTITUTES SUCH PERMIT

ut also deaths from disease —

m of
state

Every ite
Ree ade

Exact statemeat of OCCUPATION

ECO
YS<
d extracts from the laws on back of certificate.

R
PH

ly classified.

AGE should be stated EXACTLY.

, so that it may be proper

lain terms

WITH UNFADING BLACK INK—THIS IS A PERMANENT

be carefully supplied.
See instruct

in p

CAUSE OF D
is very important.

informati
100m-9-'31.

NN. B.—WRITE PLA

No. 3385-f

De at. %
E Preis ( esacel tO . DIVISION OF
a
Snare | i TAanthron...
ist (City or Town)
2 No.Winthrop...Community...Hospie.....Stey ccc Ward
2 FULL NAME...........: pony Ur. COfhlan -2)......
(If deceased is 2 married, widowed or divorced woman, give also maiden name.)
(a) Residence. No.....Q.9....00FNb.0N1...: Pare. >.

(Usual place of abode) ~

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

PERSONAL AND STATISTICAL PARTICULARS

5 SINGLE (write the word)
3 SEX 4 COLOR OR RACE MARRIED
Male | White or Divorced Married
5a If married, widowed, or divorced 2 et »
~ rr reaaminds | (aa 00-2)
(Give maiden name of wife in full)
PUNE Rrra Ti hccc nee snide eared cacao ces aovout came chssudstcevenlguseeedensnundiesureesiensince™

(Husband’s name in full)
6 IF STILLBORN, enter that fact here.
If less than 1 day

lg Trade, profession, or particular

= kind of work done, as spinner, nahh, (14 an
i) eenmranme) MMMM Meee Me GLa. cana v sare ccassnctesmesmnaretuenncten neon oversnenecune cute stts caretaccsssbeaiid :
| 9 Industry or business in_ which
a work was done, as silk mill
= taw :
S| 10 Date deceased last worked at 11 Total time «vears)
this occupation (month and spent in this
MMW eo cies alien prec seeasth prs duo pniswositockna occupation... ............0...
12 BIRTHPLACE (City) ....0.c.ceeo-- CAMP PAGES. nsnnsnneinnnen
(State or country) Massachusetts
3
a Patrick J,
om 14 BIRTHPLACE OF
Be BPMN DI CRT cease eve cts etapa re Baas vanish ees Septet abo nocdeniy ath reine ns en nnvb eo yPeniite donewnent
z| (State or country) reland
ud
m=/|15 MAIDFN NAME p
<| OF MOTHER Catherine Horrigan
a
16 BIRTHPLACE OF
ATPAEMM CIE IE ee on clalensshocts piaeemusscell
(State or country) Treland
2 ‘aa fe
Ma. ry...Cag ghlan boas) reeeny eS sti
(addres) Morne on Park Winthrop

s#HEREBY CERTIFY that a satisfactory standard certificate of death was
filed with FO b r transit permit was issued:

eaith or wy VAL

tePtert rite

ee ge / fhad,

(Date of Issue of P:

The Commonwealth of Massachusetts

OFFICE OF THE SECRETARY

STANDARD
CERTIFICATE OF DEATH

VITAL STATISTICS

Registered a: calleaaeeie 4) aa ~

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

(If U.S.
War Veteran,

PPereeeeree treet ieee ier rrr irri ttre eer)

(If nonresident, give city or town and state)

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

MEDICAL CERTIFICATE OF DEATH

19...

.g¢ death is said

| last saw bh...

_to have occurred on the date stated above, a feed -m.

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

ses of importance in order of
Date of Onset

Name of operation........... a2 Pe SP Oe heme ae Date:of...ne eee,
What test confirmed diagnasis?...- 2. ...-Was there an autopsy? 2
20 Was disease or injury in any way related to occupation of deceased?.......-...s-...-.
If SO, SPeCify.u7..f...ccs.soessesseofe. derees C4 rein Gbeccsaavcncttth ieee cil ca ee

(Signed) .. 4. 4A7 4A... hat RA Lee wets sine by Aue in. Rea _ M.D.
(Address) &40....... S Gol. . Date... aw. 19193.6. R)

21 PLACE OF BURIAL,

CREMATION OR REMOVAL .. “aaa LhAPOn... Wénthrov ae
(( femetery) Sea ~ (City or town)_ r
DATE OF BURIAL...J........./90.l dT Forel 2) ccseecscesneeeney Ds

22 NAME OF
UNDERTAKER

ADDRESS....

Received and fiT@G.............ss A AS cen ee a ae cf ee
1 y W

A TRUE COPY, ATTEST;

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 mone.

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

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

Example

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

Date of onset

rors

Io2T

July 5, 1927

Cerebral hemorrhage

Contributory causes of importance not related to
principal cause:

queeescevecescncccceseucesescecscssccccsccacscceccctscssccescscanscccocccsccsssesscensonssccces| -ssccnepeccosensenssse sess

happens to be the second cause given.

COMMONWEALTH OF MAS) 2CHUSETTS

GOVERNING T

RETURN OF CERTIFICATES OF DEATH

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

No undertaker or other person shall bury or otherwise dispose
of a human body in a town, or remove therefrom a human body
which has not been buried, until he has received a permit from
the board of health, or its agent appointed to issue such permits,
or if there is no such board, from the clerk of the town where the
person died; and no undertaker or other person shall exhume a human
body and remove it from a town, from one cemetery to another, or
from one grave or tomb other than the receiving tomb to another in the
same cemetery, until he has received a permit from the board of health
or its agent aforesaid or from the clerk of the town where the body
is buried. No such permit shall be issued until there shall have been
delivered to such board, agent or clerk, as the case may be, a Satis-
factory written statement containing the facts required by law to
be returned and recorded, which shall be accompanied, in case of an
original interment, by a satisfactory certificate of the attending
physician, if any, as required by law, or in lieu thereof a certificate
as hereinafter provided. If there is no attending physician, or if, for
sufficient reasons, his certificate cannot be obtained early enough
for the purpose, or is insufficient, a physician who is a member of the
board of health, or employed by it or by the selectmen for the purpose,
shail 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 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. 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.

Every item of a
S should state 7

Exact statement of OCCUPATION

AGE should be stated EXACTLY.

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

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

"Y, WITH UNFADING BLACK INK—THIS IS A PERMANENT REGC™ —
yid be carefully supplied.

is very important.

information
CAUSE OF D
100m-12-’34, No. 2938-f

N. B.—WRITE PLA

rm
=
>

& She Commonwealth of Massurlwaetts To be filed for burial permit
OFFICE OF THE SECRETARY with Board of Health
E ms DIVISION OF VITAL. STATISTICS or its Agent.
a STANDARD 4 re
145. CERTIFICATE OF DEATH Rapleteted Hote eed
is
g (If death occurred in a hospital or institution,
a No._20) Winthrop St, st, Recseetodceacuapen ... Ward give its NAME instead of street and number)
(if U. S.
B FULL NAME... HOMMAD KOMMOTL Oy oc ccccccareeesctnmeuemesnmeees War Veteran,
(If deceased is a married, widowed or divorced woman, give also maiden name.) SIROEEEG WAR) 5s ccctechesesonmemsortaorsenvesahaane
(a) Residence. No....... 45.2... Winthrop Bt, Pie eh elie Berar BS Begecesecevtscanse Wardens 250 Pe See oceans
(Usual place of abode) (If nonresident, give city or town and state)
Length of residence in city or town where death occurred ir 2 yrs. 9 mos. dayz. How long in U. S., if of foreign birth? 5 yrs. mos. days.

PERSONAL AND STATISTICAL PARTICULARS MEDICAL CERTIFICATE OF DEATH

r S SINGLE (write the word) P
3 SEX 4 COLOR OR RACE | 5 SINGLE 18 DATE OF ' /| FRAG,
WIDOWED 2 DEATH ...+.ees-se00s Ps IS are RR eH) RN Pe as Nin Some — Mate
Fr emal Wh i te or DIVORCED & aowe a / (Month) (Day) (Year)

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

seeeeceneesarsccanauasatersrstensscecsetecntseepentarenarssarcerscsersepeeepansersessrttereensesseeeueeeeeneneneeens

19.8-6., death Is sald

|
te have cscurred on the date ftated above, at.$...20A..m.

Tie principal cause (gt death and related causes of importance In order of onset
were as follows: Date of Cnset
etree toast WET So vectenseves MONEHS ci ssrtacecec DAYS [!scess-sssHOUFS:.ccecoeese IMPORTANT
8 Trade, profession, or particular

kindof work done, as spinner,
SEN MND OODOT = CLC <accincosconconsecactemocktontocnmoete nt stareusesomncrerenss

9 Industry or business in which
work was done, as silk mill,
ARIE RETO MSRM CSL foo ou oe couse ve ozauSoveerecusauenondscdareyunsdenvassevseanash vesenvasalse<nausscavccceosnacees

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

this occupation (month and spent in this A as, |
Nie x Te See ee erie 0 SennaHON: = ene Contributory ceuses of importance not related to principal! cause:

OCCUPATION

TD BIRTHPLACE (City)............cecccssssstessteecssesttescenscsossscncsssecnesesocnecasasncasecescosessvocssancccad | seeeeeesecnscnscccccsscnacansncscsscanscnscensnescesncncnscanccssnsnscscassossececcecsense
(State or country)

13 NAME OF

FATHER John Hughes

14 BIRTHPLACE OF ET EHOT) PSE ct] BAS ae Rae Ee a ae BER aR ee 3: ah) Sees ee Ra
“a FATHER (City) ae Senessoyiscnchvarnsassensbuansdstcacenedeonsneseunaecsoress What test confirmed diagmOsis?...........s.ssscssssseseeseesseeses Was there an autopsy?............
=z Stati ne and (i. a La ak Oe Ean Se Le Se Ee aS
w See) are 20 Was disease or injury in any way related to occupation of deceased? ..Aattm........-
| 15 MAIDEN NAME thee opt
2 , Specify.....
a. Unknown (Signed) ....
4G OTHER (CRY) cn UT (Address)
State or tr 21 PLACE OF BURIAL, ‘
ite ae 7 CREMATION OR REMOVAL Pee: eee mes
17 ation, if any City or town
tmmrercy Kennerle Yon et cut dame te, Lees
Informant *.. Fd nen tte A sana A ranceunaute ne ratte okie maa lable ve 3
(Address) £37 Winthrop St. Winthro

ory standard certificate of death was
nsit permit was issued:

ee Pe cscccncccneses $A Wada vcccsecssccsscsescsssccsefasnesses

(Registrar)

Ee | il bs Sey ye “eats a 7 ee
2

Statement of occupation.—Precise statement of occupation is
very a so that the relative healthfulness of various pursuits
can be known. Make some entry in this section for every person
aged 10 yearsorover. {If theoccupation 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, cotton
mill, etc.

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

Statement of cause of death.—Cause of death means the disease,
or complication which causes death, not the mode of dying, ¢. 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, namie other important diseases.

Examplo

Tho principal cause of death and related causes|” pais of onset
of importance in order of onset were as follows:

Arteriosclerosis
Chronic ¢ A ene LT te aoe
Cerebral hemorrhage be uly 3, 1927

pre pereererter seeeneeaeeeoneeeneneeeessersunsneeeseessecsesnssaesauenenenss nea begneseeennsssneen

ee erenvedsoocccsenecsccnccsesssecccccnsscusccaceacouccescsccccsccccassenscnsssescsaveusesosascns | sescsccesocsouesouooecoel®

” neeeescensceeeaneecsavessceseesssnesseseoanes | ssenneesaensnmenseueenenee

Contributory causes of importance not related to
principal cause:

en ccacccdesesenbeeccesdecccsnccccncecosecccnecccnscccennnsnccoescncccsccsensnccsocenscosscoenene | sescsasseecooooscoenecenee

PTT

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 tho second cause given.

GOVERNING THY,

RETURN OF CERTIFICAT OF DEATH

A Boys rine
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
seon alive by the physician or officer and the date of his death....
Gen. Laws, Chat. 46, Sec. 9.

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

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 Ser gm 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 shail
maize such certificate. [f such a permit for the removal ofa human body,
not previously interred, from one town to another within the conimon~
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-
movel; 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-
Guired 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 aad transmit it to the clerls
of the town for registration. ‘The pee to whom the acres 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.,
(Tercenienary Edition.

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, Scc. 6.

He shallin all cases certify to the town clerk or registrar in the
place where the deceased died his name and residence, if known;
otherwise a description as full as may be, with the cause and manner
of death.—Gen. Lews, 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., (Lercentenary Edition.)

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 tha action of chemical (drugs or penene thermal, or electrica
agents, and deaths following abortion, but also deaths from disease
resulting from injury or infection rolated to occupation, the
sudden deaths of persons not disabled by recognized disease,
and those of persons found dead.

IRM R-303B

Every item of
AND MANNER OF

fied under the International Classification of Causes

MEDICAL EXAMINERS should state CAUS

be properly class

laws relative to the return of certificates of death.

from the

MARGIN RESERVED FOR BINDING
ied.

WITH UNFADING BLACK INK—THIS IS A PERMANENT REC

t may

-
information should be carefully suppl
See reverse side for extracts

DEATH in plain terms, so that

of Death.

c
i;

No. 7997-c

5m-2-'30.

The Commonwealth of Massachusetts To be filed for burial

: OFFICE OF THE SECRETARY permit with Board of
< DIVISION OF VITAL STATISTICS Health or its Agent.
a MEDICAL EXAMINER’S
11% rt Mild} CERTIFICATE OF DEATH Registered No..........J.}........
8 (City or Town) beta t. z : Z oes
< VW c th I fi : — iy- oh (If death occurred in a hospital or institution,
a No.. 4.4.24 DANA. SMa ede capatearenta sass £.St., Fone vtudsaas cawtees Ward { give its NAME instead of street and number)
1 | i. ? _ (If U. S.
2 FULL NAME... es..i..5 PMA. LED... MeN Nc sssscscsgsessncsertssssssecsensenccsansisssssossenstsies War Veteran,
(If 5 sed is a married, widowed or a te fly give also maiden name.) Suecaty: WAR) a 0iixiconscnsisseostecsvasvedvecntoucses
(a) Residence. No... .....0. et & at OT, View Auth, athe M.St., eee eee cle CaM Ms At ON Taide eh) SRD og ATA Os,
(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 married, widgwed,. ivorce Lent
ange eee ‘ tees “in es * Enna King. a DRE, AST ee)

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

S sawyer, bookkeeper, etc. .... ” ..c@Oi ne t.. Mader ee oS eee eee
| 9 Industry or business in which ~ . ; ‘
x work was done, as sik mill, Plano Business
3 RRND Ue Napa Tac ESE CO hoc eigen ns tomaeee a eset ete co ncn «cau svecnnndaptpvneed sueeocaseond
| 10 _— peigees last worked at 11 Total me Bhd
i
am ie tr Occupations An.

PmmNPIN EINER MERIC ALONG Pe pss Covccd scesciavs sac cens pveuncaCe sedecesaewicd oevaesdeciecasincdvocsoveresdamitneueecdisbeshs
(State or country) . Mass,

nas PATHE Elias P Lunt

(See reverse side for Te ieee for unknown person)
$f

5 SINGLE (write the word) ,
eee ey |. See 1 ERT ns AM ei Meme bs a |
Male White or DIVORCED Married (Month) (Day) ¢ (Year)

19 I HERE BY CERTIFY that I have investigated the death
of the person above-named and that the CAUSE AND MANNER thereof are

14 BIRTHPLACE OF De ; 7
) rbyline 20 INWHAT CITY ORTOWN | j
- I a a Vt Ce NR Se a Ne re WAS INJURY SUSTAINED 2%........... reakizcts 7 fale th i eessbs doen acca ds uch apart on iad
= (State or country) bd Ag oa
c| 15 MAIDEN NAME (Signed) , é ile aay. a Dp
oy baleen (Address)... gy PAA Mg ec cccsc een Abe L o@..195.G. |
16 BIRTHPLACE OF
MOTHER (City) oe PP EMATION OR REMOVAL .... BL SIAN. Ma@s eorcenenerercnnenees |
(State or country) (Cemetery) (City or town)
- DATE OF BURIAL. ssccsseccsosene CE <p Jee |. - Poe:
22 NAME OF Whi
j UNDERTAKER Richard H, Rear te 1 i Ay IEAM A arise, Sean sone ea
| HEREBY CERTIFY that a satisfactory standard certificate of death was W 5
tiled with me BEFORE the burial_or transit permit was issued: ADDRESS ie dtnco erase i nthrop Mass. FS eR SEER DS We Koma at
(SR SN oa : Moonta Boawior E ve iit mvsss--7r-" 11 Received and een We Nene a ee
Q 949
Lara eee ge Me). Ue a, NS (RA A hf 0? po Pw calc iaemeeemnes 19ape ke Ss
(Offi i gf Issue of Permi (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
eg 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 pore: 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 pore 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 sup d 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 dec died his name and residence, if known; other-
wise a description as full hs 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 hest 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
hie eda 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 indirectiy 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.

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 ‘onseqtiences; and (2) under manner, the mode of
its production together with the circumstances when these are known.
Forexample: ‘‘Compourid fracture of the femur with ensuing septicemia
(gas bacillus) caused by a steam railway accident.’’ “‘ Pistol shot wound
of the chest with yssociated hemorrhage, homicidal.”” ‘‘Asphyxiation
by suspension, suicidal.”’ ‘‘Syncope while under the influence of ether
administered as a Surgical anzsthetic.’’ ‘‘Fracture of the skull with
associated internal injury sustained under circumstances unknown."’

If disease or injury was telated to occupation, specify. Ifinvestigation
shows the death to have been due to disease, specify: (1) Under cause,
its known or presymable 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.)"

Pree rrrrrrrrrrrrrrrrrerrrremrrrrt i tri tir trite i eerie Stee eee eeeeeeeeee

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

Sell 2 ee e.2 se Ee ee. <2.

“?
4

very item of 1

PHYSICIANS should state

» WITH UNFADING BLACK INK—THIS IS A PERMANENT RECCRD:
properly classified. Exact statement of OCCUPATION

NIAING TIN MEORM VEL? PUN ES LINLIITING
AGE should be stated EXACTLY.
tions and extracts from the laws on back of certificate.

y supplied.
USE OF DEATH in plain terms, so that it may be

See instruc

information should be carefull

is very important.

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

N. B.—WRITE PLAINST

Che Commonwealth of Massarhusetts

Eo SPO ete ee ee
3 (County) DIVISION OF VITAL. STATISTICS (City or town making retarn)
a Winthr STANDARD 2
115 2 TE Aleta Spm Op Fea See CERTIFICATE OF DEATH Registered No.......... a.
= (City or Town) df death 4i Aaeeee ee
eath occurred in a hospital or institution,
A No... 2065. Growers. AGO o.oo... See aS Ward } give its NAME instead of street and number)
(If U.S.
NS Sa ©...) War Veteran,
(If deceased is a married, widowed or divorced woman, give also maiden name.) Spy WEN) cians pmenepcoen gi haccerepecad
(a) Residence. No......205 Grovers Ave a 2a fee & ee Ward, ...... SAAN MI deel ie \ DN api
(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

| & SINGLE (write the word)
eee | | ARR eS ae. 183 eae oe
Female White or DivoRcED Widow (Month
5a If married, widowed, or divorced
> aaa ee os “a
bY aaa ARIS TEEE CL OPCCLIIR APTA OP mf NE mrs erattecierepncrsenntacesteocspesnnenaearasacherzese “Qe
(or) WIFE of ........ Ira..D... rover... | last saw h.4s~alive on..

(Husband’s name jn in full)

6 IF STILLBORN, enter that fact here. to have occurred on the da ated above, at. 7. 4..

If less than 1 day

Ace. 99 Be pacabeases Yeas..9 sae Months...........- BIAS Pe ccanoes Hours...........- Minutes
8 —_ Peace or particular
= ind of work done, as spinner,
S sawyer, beokkeeper, etc............-....00-0--- At...Home Pee veaslei wins tetas
| 9 Industry or business in_ which
a work was —. as silk mill,
= to BS he i :
S| 10 Date deceased last worked at ES 1 Total time (years)
this occupation —— and spent in this
Lill be wee 2 a eee occupation......... :
12 BIRTHPLACE (City)... TRAM ccc ccsseensnsssennenee
(State or country) Massa ch IO an
a ce oe on Se cotansccasecit consoresanabnaaser atapsccuctencaadastgnancoupagenaccnadvcdbazecuscsens|-asocadeauene

FATHER _—
Sebu Dav Nama lofiaperation --<0o ook eden eas eee aa Of ae
s 14 eae} ee Glouce ater x What test confirmed diagnosis? & Was there an autopsy?..........
= (State or country) s 20 Was disease or injuryin any way related 36 occupation of deceased? .............-...0«
w é
«| 15 MAIDFN NAME If =. specify..............
= OF MOTHER Ma rgaret Patterson (Signed) ........<..f L.LA
16 ail Be lfas t (Address)......£..
CTT WE: ae 2 aS" 5 ee ¢
(State or country) Maine CREMATION OR REMOVAL CEOWD.
J { mefery) (City or town
17 anuary
Inf. Faith B Grover. Reena, Daughter... & CN UO: Bap pee casemate Mii RRR S.."S SRO hi SURE 9 Te Sh 19S
(Address) “1 Q 0 ve 2 Winthrop 22 NAME OF eR SeChard H White

1 HEREBY CERTIFY that a satisfactory standard certificate of death was
fil i) — was issued:

me BEFO he OV, of transit ADDRESS......... 4? athe St Winthrop Mas.
Beasaronongt> Asda <A ioe a BUOCORMEE AAO STN: 5 sone cove nssscpeeenatondncy Se tieptznnsauevacocsodens oi tense pean ses tat hecc tee ADs so vonseys

PAN

ntl Stdtes Standard Certificate of Death

Statement of occupation.—Precise statement of occupation is
very important, so that the relative healthfulness of various pursuits
can be own. Make some entry in this section for every person
aged 10 years 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 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,”’ ‘‘factcry,’’ ‘‘mill,’’ etc. State the particular

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

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

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

Example

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

Arteriosclerosis

Chronic interstitial nephritis

Date of onset

Cerebral hemorrhage

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

Automobile accident

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

EXTRACTS
FROM THE LAWS OF THE
COMMONWEALTH OF MASSACHUSETTS
GOVERNING THE

RETURN OF CERTIFICATES OF DEATH

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

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

State cause for which surgical operation was undertaken.

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

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

‘

5
%
Ge
&
i
. 3
2

MARGIN RESERVED FOR BINDING

A PERMANENT REC

MEDICAL EXAMINERS should state
fied under the International Classification of

tive to the return of certificates of death.

be properly classi

lied.
it may

de for extracts from the laws re

WITH UNFADING BLACK INK—THIS IS

information should be carefully supp

DEATH in plain terms, so that

See reverse s

of Death.

Ni /e

yi MOTHER (City) .........4. ve, ee 5 ieee G Mie elite eee 21 PLACE OF BURIAL

f Cow ~The Commonwealth of siidasathusetts To be filed for burial

OFFICE OF THE SECRETARY permit with Board of
DIVISION OF VITAL STATISTICS Health or its Agent
is

MEDICAL EXAMINER’S
Sepia eRe Se CERTIFICATE OF DEATH Registered Now... ne eesseon
‘“ ° le (If death occurred in a hospital or institution,
IO cepathn net aired, cert cere cee) SRO NE EL AN) Ae ee REY ve | { give its NAME instead of street and number)
f. aC iss (If U.S.

War Veteran,

(a) Residence.

(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 ite the word) € —_— |
3 SEX 4 COLOR RACE MARRIED sips 18 ea | : ( § - ¥. =
or DIVORCED - (Month) (Day) { (Year)

5a If married, widowed, or divorced | HEREBY CE F investi
RINNE a AeTeE LAGS 7 eed Morus ee Rit HM FOR LE Miel L Ren see one

(Give maiden name of wife in full) of the person above-named and that the CAUSE AND MANNER thereof are

TI OU au TSR 15g SS te ee a supiebavnsbendasedpusioatl as follows: (If an injury was involved, state fully.)
(Husband's name in full) ~—_ od hare

6 IF STILLBORN, enter that fact here. “E Pees a> ----¥ fowetesstedes yemusscee Wecenee , Perret eet ee eeteneeececscsscensecssecsssas
Iflessthan l day ff weve | gee pbb as ptt ettereceeeecseeeseneeceeeeeeceseerepeensn deans grettterteeeeeseeeee

7
AGE ...... o/ ate MCT a eee Months............ Days

8 Trade, profession, or particular
kind of work done, as spinner :
sawyer, bookkeeper, CtC. .... ..-...-.peet@ece. MRO WA SIG Aon eet eensnesessenssnersnsenseeees

9 Industry or business in which
work was done, as silk mill,
saw mill, [een eae Ae LAB M. LMM veld:

d “ ; 11 Total sg A old

is occupatjo 0 an spent in this
) 3.6 Ms: occupation.. AD.

12 BIRTHPLACE a eee MW Ott Adhen...., on ALT oo) re a ama a a tits ee aN

(State or coufftry) ELLIS EAI SPEND OE PTS a eR So aeee yA SRB PE Sn he EIDE IRE PRN Tr tee Ns Ca

OCCUPATION

13 NAME OF
FATHER PRD As pA J Frm | festtteettcetcececcetstsectctteeeeceetsnereceteensececenneneenesarseeserssceaseaneeesrsneesessrnesentennasens

(See reverse side for description for unknown person)

14 BIRTHPLACE OF
FATHER (City) ........4.. eM AOA 8 Sgr hE ed. a, 20 IN WHAT CITY OR TOWN

WAS INJURYSSUSTAINED ? 0.00.0... eer” 4 Wenp espns tn Soe anc erty are

(State or country) i q
(Signed) wbeleceestanerersnneeeeabend oot aeeprterteta 2b apt eae tf, WS ecunaa

PARENTS

U 44 - (Address).......t.... pt

16 BIRTHPLACE OF
i CREMATION OR REMOVAL
Ct are ee? Vi), MAA Ah SAA 4A fe ofA |

é 22 NAME OF
S01 pike. UNDERTAKER
| HEREBY CERTIFY that a satisé tory standard certificate of death was

filed if me BEFORE the burial or transit permit was issued: ADDRESS...

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
pecan 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 perpose, 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. tt 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.

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

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

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

RULES OF PRACTICE

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

- of persons to whom they have given bedside care during a last illness

from disease unrelated to any form of injury.

(2) Board of Health physicians will certify to such deaths only
as those of persons who, though disabled by recognized disease unrelated
to any form of injury, have died without recent medical attendance or
bl ghee 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 pee thermal, or electrical
agents, and deaths following abortion, but also deaths from disease
resulting from injury or infection related to occupation, the
sudden deaths of persons not disabled by recognized disease, and
those of persons found dead.

STATEMENT OF CAUSE OF DEATH

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

If disease or injury was related to occupation, specify. Ifinvestigation
shows the death to have been due to disease, specify: (1) Under cause,
its known or presumabl 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.)”

THIS CERTIFICATE CONSTITUTES SUCH PERMIT

ery item of
should state

Exact statement of OCCUPATION

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

PHYSICiA

AGE should be stated EXACTLY.
y be properly classified

pplied.

CAUSE OF DEATH in plain terms, so that it ma

is very important.

» WITH UNFADING BLACK INK—THIS IS A PERMANENT RECOR
be carefully su

information shuuld

N. B.—WRITE PLAID

No. 3385-f£

100m-9-'31.

5a If married, widowed, or divorced
HUSBAND

(er) WIFE of .. Wi LLI

6 IF STILLBORN, enter that fact here

OCCUPATION:

12 BIRTHPLACE (City)

The Commonwealth of Massachusetts
OFFICE OF THE SECRETARY

E DIVISION or VITAL STATISTICS AT yee ee eae ech seeeeeere .
a STANDARD 2
11.6 CERTIFICATE OF DEATH Registered No.............. 44 ae
ta
Z a : (if death occurred in a hospital or institution,
z No. Winthrop: Community..Hospitas:., pela cuasnuse ests asner Ward give its NAME instead of street and number)
(If U. S.
2 FULL NAME... 58rah MeDuffy (Hayes) Tasker mun War Veteran,
(If deceased is a married, widowed or divorced woman, give also maiden name.) epseriy WAR) 5 5.02- 500 ccccsecsscaiscorscaseouaies
(a) Residence. No...... Bee IN 5 Pe ORES coe My: ene Se Ean Dee “Ace eB ease Feme BR Ce!
(Usual place of abode) (If nonresident, give city or town and state)
Length of residence in city or town where death occurred 35 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 Ls (write the word) || 18 DATE OF
Female White WIDOWED Wid ow Usa ueoepe sie. op. spears cMtaom covarenrunkorsenunnpvvsonsaptoakpen Seas Wilt ors syuga=siemanahs pnsseek sant aeeeienaastlaleas
or

Am He PARROT ud] (fast sow halve on. f

('
(Husband's name in ful!) V =

to have occurred on the date’ stated above, at....5....7%..m,
The principal cause of death and related causes of importance in order of
If less than 1 day onset were as follows: Date of Onset

8 Trade, profession, or particular
kind of work done, ——— Hous @ wo rk

sawyer, bookkeeper, €tC............0.:.00..SR AEM ee ceeeeey
9 Industry or business in which

work was done, as silk mill, Own home

Siepenipe RMU EAE Sk Se cans ecco chomping sees atc orresorcsergs ssouuhunsaccxbopasepttoaces
10 Date deceased last worked at see mana cAOed INOW ERMIES IME I ANN cean act eso ae onc c ts te cc oboe cates cane rein at paapnet Cetin ana vonos eaearun bese a | ie scnnasrae ee
oe (month and Jan, 1936 hoe Contributory causes of importance not related to principal cause:

(State or country)

a ee Oe eee Name of ODETANON: 5. .é5.0550:0-.» ds Gena Mch aes soe wilh Ownaunatecnce iatangf:. ..:-.cccxtmckon eee
= rs FATHER (City) ir | Lebanon. | ee ———__ | |_ What test confirmed Glagnosis’ ....eneeoemeneeennennnnn Was there an autopsy/..........
= (State or country) Ma ine 20 Was disease or injury in any way related to occupation of deceased? ..................-.
= RLS ee fade eo teee ce ae UR a Ny eS Sean ot UP Cd lta ie orl:

15 MAIDEN NAME .
<| °° Or MommR C@2rOline Ricker (Signed) oeeeesnon; eee ae oe ee ee Pe M. D.
a

== (Address)........ he ALAM yA EO Date. J. f/f. 7.19.36

16 BIRTHPLACE OF

MOTHER (City) .. ebanon poeeatirs 5) 59h, Ata Sr aah icseiiieae ;
(State or country) Maine CREMATION OR REMOVAL Pine..Hill Dover,N.H.....
“S61 93 6 (City or town)
as ,,ciarence E, Tasker. (gen) DATE oF BURLY ENUarY <0. ees. vee Ae ae
(Address) 116 Cottage Pk, Rd. Winthrop || 22 Nave or . Charles R. Bennison
oo WE ERSOG MRSS nnn
ene 8 ee eee Maes titan of death wae nopress... iMbhHTOp, MOSS
y}

Received and filed..............::e00 JAN 22° [ORF Se Ae ccc
EE | Ea eR cee eee cee adh ae pe ccece meee

A TRUE COPY, ATTEST: age nei

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—privale
family, cook—hotel, etc. For a person who had no occupation what-
ever write none.

To be complete, an occupation return must state:

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

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

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

In stating the industry or business, avoid the use of such general
terms as “‘store,’”’ *‘factory,"’ “‘mill,"”” etc. State the particular
ane 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 wholescle merchants. A person who sells goods should be called a
salesinan and not a clerk.

Example

The principal cause of death and related causes

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

Arteriosclerosis Ios

Chronic interstitial nephritis 192r

Cerebral hemorrhage July 5, 1927

Contributory causes of importance not related to
principal cause:

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

group of three causes the principal cause may appear in either first,
second, or third position. ‘The principal cause in the above example

happens to be the second cause given.

EXTRACTS FROM THE LA\ OF THE
COMMONWEALTH OF MAS.) CHUSETTS
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 eafrly 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.

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

RULES OF PRACTICE

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

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

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

|
|

M R-201A The Commonwealth of Massachusetts To be filed for burial permit
ene = OFFICE OF THE SECRETARY with Board of Health
r] : 5 E DIVISION OF VITAL STATISTICS af fiw Agerit
gE = STANDARD
fx< 1s. CERTIFICATE OF DEATH Registered Now... §[3p oui
35> =) : ° F i
3 = (If death occurred in a hospital or institution,
B20 re No.. m2. Dameiinemaaneltaas tl tacter der gaensteeils subeuaescasnasecutsg:huaeeakbacees ra AR ea Ward { give its NAME instead of street and number)
wo
n (If U.S
‘a ° Se
- % ° 2 FULL NAME War Veteran
ia 2 BEG, WHAM) ssbo9sbchysesduatosdsevctectnsthes
< SDECHY WAIN) .ncc-ccccnrecensseeessrenenerenseerecnes
: oe - oO 2
Ou (a) Residence. No...... Ve OD in a a ieee ees Wiad tics. hsitepetooncaecoes thi thasitomnestuipiabraestahanaast®
Li : ; (Usual place of abode) i : (If nonresident, give city or town and state)
m ry 8 g Length of residence in city or town where death occurred ofS yrs. mos. days. How long in U. S., if of forcign birth? yrs. mos. days.
ae
. ee PERSONAL AND STATISTICAL PARTICULARS MEDICAL CERTIFICATE OF DEATH
Te eS 3 SEX 4 COLOR OR RACE | © SINGLE (write the word) |! 18 DATE OF Roe
< re 9 Pa BW : Ze | WIDOWED , DEATH ---so00e cee, SA a1 i ae eB me Vek t fear
=< % ate oA “4. or DIVORCED y; Se 2 y (Month) (Day) Year)
Mis 5a If married, widowed, or divorced 19 “4
nm OM , , b - I HEREBY CERTIFY, That I attended deceased from
eat HUSBAND of ...0...2-.cssecsessecceccse esses Le, AA bh ete
eas (Give maiden name of wife in full) Ame. aeererseeee aS seasecsesseseser ’ 1934, LOPS or Leese . Sk sessseersscoses, . 193.4.
NE ces ecu cach cass av chu naci scan cass otaanpssasesaoishpsatavout aauiabesngdtsacscvbedicesoasesseacore F
" s s c r ° Pe ons eae I last Saw f.cSeme... alive OM ssc Spee errr ceseees Re. Piper , 199.6..., death is said
_ abe 6 IF STILLBORN, enter that fact here. to have occurred on the da ated above, eae
ry The principal cause of death and related causes of importance in order of
Noes 7 If less than 1 da cm = “yi mh
y a :
a Be hes (, Ip eae siciiee onset were as follows Dale of Onset
my oe 8 Trade, profession, or particular ae
VEE £ z kind of work done, as spinner, a 2, (9.26
° °o sawyer, bookkeeper, etC...........- 7 29 WAP NAA Gf Se WT On|
= 4 me | 9 Industry or business in which | neeeseeeteeese ert
[2] £ i Be work was done, as silk mill,
YU < o ORT Eos, oop enn pacar ee ech see Tbanasaacnaasonec ye spacsco es seeiardecveonaf iN “7a ona ne ese senor 2 sae cers =a eden seeders smkann sab ance recen saansarresscsadedgnpess|-Seess 7*t aera
me fo) 1° Pate deceased last worked at 5 SPL IE Rie Pa | ae each oo opine ieee Sameer Seen omen A enn
at year) 3y eupation. tees. Contributory causes of importance not related to principal cause:
tata) 12 BIRTHPLACE (Cit
rs Y) 2. KAAS. Dr cieccscesctessecssesssessnesnesnad] | Seer Jpece etree eeeseeeeeeeee ys eeeeeeeeeeeeerseeeeeceeecrerecaeseeeeneesteneaeaaeas
2 Be 9 5 (State or country)
Zaes Dro 7 LS OE | Wi Sg a a A oo A, a, or OE eee 1
a%e 13 NAME OF
- gs FATHER aE Cie hy EO Teel RRR SR || aaa Ne Ae ea Un ee ne PO DG Mee iar ge Pek Set
Dies
EPEs NHR Chev Crmeybery aeaek Be
Za’ 14 BIRTHPLACE OF ~ Name of operation Dial@ lof ac. be ceuon en
£5 a FATHER (City) .......... =O Te eae ete es Semis ccraaasves What test confirmed diagnosis? Was there an autopsy? 2L.O
7 ie f = (State or country)
= o'E.n Ww 20 Was disease or injury in any way related to occupation of deceased? ase
mo. © | 15 MAIDEN NAME if
Sass 2 OF MOTHER If so, specify.
> :
CSTERIGER) Ge cesct ste nga ss sang cnes ecktvacest ScRmmaDeap conahé aicodssapectaisda/eetico@aaaay maaN
aie 16 BIRTHPLACE OF ;
<8 MOTHER (City) (Address). KL4.
Ci (State or country) 21 PLACE OF BURIAL,
Q = Pere : CREMATION OR REMOV.
° LT
kK &
SE S|] Informant F400. Creweeesan. roeeteey ten DATE OF BURIAL... oe ee Sere ee |
= 5 22. NAME OF i
ae % — UNDERTAKER .....-KA
55 3 ard certificate of death was ‘
a> ermit was issued: ADDRESS ce eae
0.2 ta ce

Pag | Al (Montene jbatdont of Board of tes th Received and filed......s....essecscsssssssnsssocaggerfttooss hades
4

Nkake ee.

(Official Designation (Registrar)

100m-9-'33.

Revised Unityftates 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 cvery 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 :ber—privale
family, cook—hotel, etc. For a person who had no occupation what-
ever write none.

To be complete, an occupation return must state:

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

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

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

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

Distinguish carefully between retail merchants

painter, machinist, etc.
A person who selis goods should be called a

and wholesale merchants.
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
fajlure, 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

E D f t
of importance in order of onset were as follows: mtexetionss

Arteri ERE Se OES oe Ss
Chronic interstitial nephritis , ex 8 || AD
Cerebral hemorrhage J uly 5, 19

ccncevedeevecctenssnccuscnscucccccceussconccsapsescacausteepansssacecnccouscecncccncasouacenss | seesonsccsecsracsces

Contributory causes of importance not related to
principal cause:

ae seeeceseenccepecnenerscucegscensuccsevsssesencssesauscseuscuasssssseesesee seeeeeeee

EXTRACTS FROM THE
COMMONWEALTH OCF MASSA
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 ot 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 healtin
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,
shail upon application make the certificate required of the attending
physician. If death is caused by violence, the medical examiner shall
make such certificate. If such a permit for the removal of a human body,
not previously interred from one town to another within the common-
wealth cannot be obtained early enough for the purpose, the certificate
of death made as above provided and in the possession of the undertaker
desiring to make such removal shall constitute a permit for such re-
moval; provided, that such body shall be returned to the town from
which it was removed within thirty-six hours after such removal, unless
a permit in the usual form for the removal of such body has been sooner
obtained hereunder. If the death certificate contains a recital, as re-
quired by section ten of chapter forty-six, that the deceased served in
the army, navy or marine corps of the United States in any war in
which it has been engaged, such recital shall appear upon the permit.
‘The board of health, or its agent, upon receipt of such statement and
certificate, shall forthwith countersign it and transmit it to the clerk
of the town for registration. The person to whom the permit is so
given and the physician certifying the cause of death sha!l thereafter
furnish for registration any other necessary information which can be
obtained as to the deceased. or as to the manner or cause of the death,
which the clerk or registrar may require. — Chap. 114, Sec. 45, G. 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 poison a: thermal, or electrical
agents, and deaths following abortion, but also deaths from disease
resulting from injury or infection related to occupation, the
sudden deaths of persons not disabled by recognized disease,
and those of persons found dead.

Che Commonwealth of Massarhusetta To be filed for burial permit

MeR-301A

Ee OFFICE OF THE SECRETARY witli board of Moalt

2) 25 DIVISION OF VITAL STATISTICS or its Agent.

Eon STANDARD f . >
fu< CERTIFICATE OF DEATH Registered Now.......ssssisie0 a
PB a (If death occurred in a hospital or institution,
os 5 poe ER) Sy Peo ne ET ge | give its NAME instead of street and number)
ati)

n (If U. S.
ne 8.

:45 CREE os ES: Ze | a A . } War Veteran,

c - oe | gece widowed or divorced woman, give also maiden name.) BO CCU YW AOR). 2 as vostepnaneckacneernnssasngainteda

SAS oO
On £ (a) Residence. No Me Ah Warde ed irc See Seine
= : 25 (Usual place of abode (If nonresident, give city or town and state)

a s 2 Length of residence in city or town where death occurred yrs. mos. days. How long in U. S., if of foreign birth? yrs. mos. days.
0
~ ep es PERSONAL AND STATISTICAL PARTICULARS MEDICAL CERTIFICATE OF DEATH
eae) x Fs 4 COLOR OR RACE | © ren Maowtact” word) || 18 DATE OF
<b Oo H ‘ WIDOWED DEATH | -s3-2252. Kochre. GAA ng AS her ec eae a de ae Nee l.E3 le Ses
ae : = Be, or DIVORCED (Month) (Day) ear)
ae That 1 ee deceased from
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= % > 3 to have occurred on the date s(ited above, atd
ng 58 The principal cause of death and relaied causes of Importance In order of onset
= & 2 4 were as follows: Date of Onset
ued Ace 2-O. atakeriaes
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wv 23 £ = kindof work done, as spinner,
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“an | 9 Industry or business in which
rs) £ i a work was done, as silk mill,
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Ox § = 10 Date deceased last worked at 11 Total time (years)
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Z. a ied m2 (State or country) i
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A*§ 13 NAME OF
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= * 3 bs Name of operation...........-sss-sceessesseessees
| : £ 3 “f What test confirmed diagnosis?
—_= =
ES a ry 20 Was disease or injury in any way related to occupation of deceased? .............--..-+.
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‘ a= = MOTHER (City) (Address) Lt See on eh oe ator “A fi Seth Seaeeee Date. avn! LS. 19té.
is (State or country) 21 PLACE OF BURIAL, 4 y
= ¢ CREMATION OR REMOVALAL LLY ae vee AKAM MA oe
fu BS (City or town)
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a] 5 = UNDERTAKER ......,..4,4¢... <
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Statement of occupation.—Precise statement of occupation is
very sy oh so that the relative healthfulness of various pursuits
can be known. Make some entry in this section for every person
aged 10 yearsorover. Ifthe occupation had been given up or changed
on account of the disease causing death, report the occupation prior
to illness. If the deceased had retired from business, report the
occupation prior to retirement. Children not gainfully employed
may be returned as at school or at home. For a woman whose
only occupation was that of home housework, write housework
in answer to Question 8 and own home in answer to Question 9.
For a person engaged in domestic service for wages, however, designate
the occupation by the appropriate terms, as housckeeper—private
family, cook—hotel, etc. For a person who had no occupation what-
ever Write none.

To be complete, an occupation return must state:

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

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

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

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

Distinguish carefully the different kinds of engineers by stating
the fuil descriptive titles, as civil engineer, mechanical enyincer, 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 velail 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. 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

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

Artertosclerosis

Date of onset

Perret Pee saeeennee

Cerebral hemorrhage July 5,927

rrr POenS Anan eeeeeeeeeaesateneneeeesaeennenawsnsraseuenvenneneneees se eneenneeneeeeneene

se eceecccce cece ecescepeesce cscs conssovescesncooccscccasegnerascnneeeenenes | sanesnanesosvonseseneeses

Aten e ee enennens PPPPeTTTT erred ee

Contributory causes of importance not related to
principal cause:

eeeeenenecccecenennenenceneccncsescnecssccaenseoscngensanesessnssecnens | ssenessnsccucconcoeeooeers

ave neeneeneeceerances | seeensansnenernasevareres®

In a group of causes containing the principal cause and related

causes, the causes should be given in the order of onsct, 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.

GOVERNING TH.
RETURN OF CERTIFICATES7OF DEATH

No undortaker 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
perer died; and no undertaker or other person shall exhume a humar

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 contapning 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 putpote, 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 eppacagon 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 forin for the removal of such body has been sooner
obtained hereunder. If the death certificate contains a recital, as ro-
quired by section ten of chrpter 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.,
(Tercentenary Edition. J :

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. E

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 anes payelsias is absent from home when the certificate of
death is needed. a :

(3) Medical Examiners will investigate and certify to all deaths
suppeosably 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 isons), thermal, or electrica
agents, and deaths following abortion, but also deaths from disease
resulting from injury or infection related to occupation, the
sudden deaths of persons not disabled by recognized disease,
and those of persons found dead.

ery item of FJ
should state a
8

Ev
Exact statement of OCCUPATION

REC °
PHYSICIANS

‘WITH UNFADING BLACK INK—THIS IS A PERMANENT
be carefully supplied. AGE should be stated EXACTLY.
See instructions and extracts from the laws on back of certificate.

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

information sh
is very important.

‘N. B.—WRITE PLAIN

No. 7070-h

-"32.

100m-1

_ ..Winthrop

PLACE OF DEATH

OFFICE OF THE SECRETARY
DIVISION OF VITAL STATISTICS
STANDARD
CERTIFICATE OF DEATH

Registered No..........-*-.: 3

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

(If U. S.

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

If less than 1 day

= =
(1 TS neo ia ) | Months............Days | ...27......Hours.....°%...Minutes
8 Trade, profession, or particular
kind of work done, as spinner, -
sawyer, bookkeeper, etc............... eee Re ce peteee cast aeuodsenns det panusensaccuscnsccystinavdssoasekeases
9 Industry or business in which
work was done, as silk mill, -

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

12 BIRTHPLACE (City)... Fort Banks, Winthrop,............
(State or country) Wassachusetts .

13 NAME OF

_ FATHER + Charles D. Talbert,
14 BIRTHPLACE OF
FATHER (City) ...

(State or country)

15 MAIDEN NAME
OF MOTHER

OCCUPATION

11 Total time (years)
spent in this

Bn | | ee ee
Virginia.

Marie V. Cote,

PARENTS

16 BIRTHPLACE OF
MOTHER (City)... AYE, .

| tate or country) Massachusetts.

17 form MOSe Marie V. Talbert,

cesses, 0 USS ig epg site ee a

19 Prospect St. r, Mass.

| HEREBY CERTIFY that a satisfactory standard certificate of death was
filed with me BEFORE the buriajpor tyans

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