The volume, 1937

Town Clerk, Winthrop · from the Internet Archive · 530 pages · 53.1 MB
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J. L. FAIRBANKS & CO.

Stationers
43 FRANKLIN STREET
—BOSTON—

i |
a |

Gls eadhuarts |
RY Pee eee eee eee eee eee eee ee eee eee eee
(City or town making return) ;
14
1 Registered Now... ;
(If death occurred in a hospital or institution,
give its NAME instead of street and number)
y (lf U.S.
ee Cg SS: br cc a War Veteran,
(If deceased is a married, widowed or divorced woman, give also maiden name.) ; SPECI SPER Chek gcinscosesueesinelsinacaeee
(a) Residence. No..67.. OekeLand.. Road, b eval MO Nsitershe@echschdeseckete bese Ward, East. Braintraay. ~MOS6&......:......
(Usual place of abode) (If nonresident, give city on town and state)
ry Length of residence in city or town where death occurred yrs. mos. days. How long in U. S., if of foreign birth? yrs. mos. days.
oe) Ca erawwwOWWWWWWWWWWmmm?——_OO—————————
| PERSONAL AND STATISTICAL PARTICULARS MEDICAL CERTIFICATE OF DEATH
e : pare Dts
3 3 SEX 4 COLOR OR RACE | © co ae (write the word) |] 18 DATE OF
$ WIDOWED DEATH...... January... AM |S oes Loree a area a9 <a
= Male | White ___or DIVORCED Married onth) Day) cary
3 is 5a If married, — os, ae oe a name ior HEREBY CER TIE YN, That | attended deceased from
HUSBAND of . S...dane. ee See csasincses.
3 i (Give modes Murphy, unknov. in full) Necember..31, ‘oeereneesate ,1996., to... J... UAL LS 19.0.0
a ¢ (or) WIFE of ee ee ee Ei pasa ieee igers Seal RTE» Su Ma poedacssuech I last saw h.-LM...alive onJanuary..lst Seay ae : 19, Oo death is said
4 6 IF STILLBORN, enter that fact here. to have occurred on the date stated above, at...2.3.58Pm.
Fs : : = The principal cause of death and related causes of importance in order of
Cj 7 Iflessthan 1day | onset were as follows: Date of Onset
2 SAGE: e.g... Years...mm.......Months....e.....Days | oc... Hours.....--.---- Minutes 1Hemorrhage,cerebral,acute, sever: Dee Bl,
ft) 8 Trade, profession, or particular
kind of work done, as spinner, 2eArterial...hypertension,moderate. own:
£E || sawyer, bookkeeper, etc... Warrant..0fficer,U.S.A yP 7 “—
4 | 9Q Industry or business in. which
a a work was done, as ft pill
3 2 saw mill, bank, etc... Headguarters...lst...Cor pie Area
¥ | 10 Date deceased last worked at 11 Total time (years) .
4 nis Fig wombe rey 836 ran eS tale Contributory causes of importance not related to principal cause:
© : »
3 || 12 BIRTHPLACE (City)... a ries 1D Se pce Eee BaObesity generalized, SeVeree |e
§ Te LEDGE i aS Boats ckcupenecesnsece cccapevpcdeseublascotecabtndetvrcas Dasastesons | ee
£ re ET Uh et nr my) ener we TN Ge ee ei ee eeeats | ec ee
8 H FATHER, mc TD aetettensteentecetenestnnnettanesncssescssecseteeneensnnessasanssnenscaneecaneans
a) 14 BIRTHPLACE OF Name of operation.............-cceseceeeees Se iapetest cs ceavsws aceon DAO Of se ccccesscheatstrndteses =
.2 - . FATHER (City) .. Unknown... 7 coe OE es oe ie eee What test confirmed diagnosis? .............0..ccccecccecceceenenee Was there an autopsy?...NO
re (State or country) _U: own 20 Was disease or injury i ion of deceased? ...NQ...........
«| 15 MAIDEN NAME enact
< OF MOTHER Unknown ’ é
a (Signed) .. of Rit eC tm |
gh ee ee (Address). Fort..Banks.y
| 21 PLACE OF BURIA
(State or country) — Unimown CREMATION OR REMOVAL”...

17
EGISTRAR..Ste..Hosv..Fort..Banks.Masarl| DATE OF BURIAL............ SEY
ci REGISTRAR, Sta.,Hosp.,Fort. Banks, Mass == = - BURIAL. .

UNDERTAKER “0.22. (ITF 2,4 6 oC
| HEREBY CERTIFY that a satisfactory standard certificate of death was

filed with me BEFORE the burial Diy pk Dgmit yas ipsved: __ADDRESS OAS bf

ee AS nn! © Sa errr reer ree rere Oe ee NN SI | ee) ee PCCP CPPCC OSC Eee Cree ec

ignation) (Registrar)

Statement of occupation.—Precise statement of occupation is
very important, so that the relative healthfulness of various pursuits
can be known. Make some entry in this section for every person
agedi0yearsorover. 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 houseworl
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 “tse of such general
terms as ‘‘store,'’ “‘factory,’’ “‘mill,’’ etc. State the particular
rind store, factory, mill, etc., as grocery store, soap factory, cotton

ish carefully the different kinds of engineers by stating
escriptive titles,as civil engineer, mechanical engineer, mining
stationary engineer, etc. Avoid the term ‘‘laborer’’ when a
ecise statement of the occupation can be secured. Do not
word ‘‘mechanic,”’ but.give the exact oecupation, as-carpenter,
‘machinist, etc. Distinguish carefully between retail merchants
jolesale merchants. A person who sells goods should be called a
and not a clerk.

ent of cause of death.—Cause of death means the disease,
ication 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

y 2 Date of onset
of importance in order of onset were as follows:

IOIS

Arteriosclerosis

Chronic interstitial nephritis

Cerebral hemorrhage

Contributory causes of importance not related to
principal cause:

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

Gen. Laws, Chap. 46, Sec. 9.

ywhich it was removed within thirty-six hours after such removal, unless

a permit in the usual form for the removal of such body has been sooner
obtained hereunder. If the death certificate contains a recital, as re-
quired by section ten of chapter forty-six, that the deceased served in
the army, navy or marine corps of the United States in any war in
which it has been engaged, such recital shall appear upon the permit.
The board of health, or its agent, upon receipt of such statement and
certificate,-shall forthwith countersign it and transmit it to the clerk
of the town for registration. The person to whom the permit is so
given and the physician certifying the cause of death shall thereafter
furnish for registration any other necessary information which can be
obtained as to the deceased, or as to the manner or cause of the death,
which the clerk or registrar may require. — Chap. 114, Sec. 45, G. L.,
as amended by Chap. 48, Acts of 1927 and Chap. 414, Acts of 1931.

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

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

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

RULES OF PRACTICE

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

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

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

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

ee Wenn Bis -
The Commonwealth of Massachusetts To be filed for burial permit ~

R-301A me Suffolk OFFICE OF THE SECRETARY with Board of Health
- < seeneseesceeeseccesssscecs ( county) vsvevaccccccssavececssee DIVISION OF VITAL STATISTICS or its Agent.
2 & Winthrop STANDARD a
Fat abet. wn nam CERTIFICATE CF DEATH Registered No............. annotate
(City or Town)
= < 3 138 Bartlett Road (If death occurred in a hospital or institution,
5 = STEERS SS RRS AR A an a paces ee Ward give its NAME instead of street and number)
8 Sains eee Emerson Frank Harding (adoption) as 4
mee, BN Bete SNE RAV ERs «occ c nce nn cee nnceee esas sess eee ean teense eeees tenes eee easeeeESE EES SEOEEEEHEE EER HHE EH EE EOE nse EEE EH EEE EE HEE EEE EE EEEE SEES EEE EEEESOEESS EES EEEES eter ,
S (If deceased is a married, widowed or divorced woman, give also maiden name.) epecily WAR) cos sccks acs tecisses twa cesvoreumeea
~
Us (a) Residence. No.......: 138 Bar tiett Road = | a Sts eee Werle. Fite nat erect Cape es Cte cr,
£ (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.
8 eee eae beer ae erred ieee ys, How leg in V.S.,ifcfforeigm birth? yrs, ume ares
$ PERSONAL AND STATISTICAL PARTICULARS MEDICAL CERTIFICATE OF DEATH
4 3 SEX 4 COLOR OR RACE | © SINGLE ae eo
. os WIDOWED / - ct fe oi RPE RPE Oe
g Male Whi te or Divorce angle

5a If married, widowed, or divorced

6 IF STILLBORN, enter that fact here.

> 2 Soe del ptr sesne DAP Bs oe, 7 193.1.
‘a (or) WIFE of : 8 ADR MS! BET ee , 1958.2. death is said
(Husband’s

to have occurred on the date stated above, at.7... One.

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Re The principal cause of death and related causes of peice in order of
ey Ap 11 23 If less than 1 day onset were as follows: Date of Onset
3 2 AGE cess: Years......... Months... Days | .......--..- Hours........... Minutes 1! IMPORTANT
wee 8 Trade, profession, or particular DNChmm Mois. 1936
Q & = aaa ara ied atari acre crear eras MP MNT evse ca cant tne cratered see ctne_ canvas foosvt anne es coaeeesene ee Asters cco PPbassconalasvensnentecste| tek Map MeN ere
5 3 5 S sawyer, bookkeeper, CtC,......-..-.-0-0000-0+ See ee
i | 9 Industry or business in which
>. Ds work was done, as silk mill hool
: £3 = saw mill, bank, a Sisie ES RE or ee!
a © | 10 Date deceased last worked at 11 Total time (years)
om < this occupation (month and spent in this Contributory causes of importance not related to principal cause
#69 ‘ occupation...............000
Gig " ;
=i i toe Io) aes RS | Oe ea oe
r 9 q (State or country) NaS ssacmy setts
. n eS
as || | Mier af i
| own a
; 3 r = ~ Name of operation........ n Che oh, Rhepoveee: Date of... ee
4) P al PTH cite) nanown What test confirmed dlagnosis?Cedcntaaad-wae—...... Was there an autopsy? “2.
¢ ms Ee ae anata
kg £ Z| (State or country) 20 Was disease or injury in any way related to ei of deceased? i
me om
> D, a 15 MAIDEN NAME If so, nett oa Ph Sh eee Lae ie,
r ed OF MOTHER Unknown (Signed) ....~...1. cya seed Pru it SaeaW par eavucu ecb sasatas vss s engi cate Rurmnen PETERS tees oie nee , M.D.
+3 . 16 BIRTHPLACE OF Unknown (Address)... A/ LU one... . Date iia shea aa
- *
on eee ie .
: 21 PLACE OF BURIAL, Tw 3 r
: eid (State or country) CREMATION OR REMOVAL..UMdOn Harwich Mass
ts) J x ae y) 7 (City or town)
VEO 8 g i Mrs.Josephine Harding 2 DATE OF BURIAL...» 4 9. fo) ee 19
2 - (Address) 158 Bartlett Road Qe 22 NAME OF Richard H White
= F 2 ee Pe. Ren a oe
5 a8 I HEREGY CERT: that a satisfactory standard certificete of death was ‘147 be stelil st ” tnthy sail
- £6 a it! t/Dermit was issued: ADDRESS... daa paae du Phin cove eases Shuseacesnecscosivaccseanse
aUs © Z. >f/- aia =
fi t i, fp vanadherevencns bet Messsessctvcace whee Gasp corcvccveccsesesesess Received and filed...............: SAN... ere 4 Oe aT: the
: E é
ia
ie G aevvcscsosssocssstessoopoeges eee ee ee ee ee ee TOE tee names e stews POTEET EE EERE EEE EEE EEE REE RH ee ee rr oleae A

(Registrar)

(/ |

ANC VISTU UMMTU VLaALTd VlaAlUGrU UCIilIcaLle Ul VAL

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 whkose
only occupation was that of home housework, write housework
in answer to Question 8 and own home in answer to Question 9.
For a person engaged in domestic service for wages, however, designate
the occupation by the appropriate terms, as housekeeper—private
Jamily, cook—hotel, etc. For a person who had no occupation what-
ever write none.

To be complete, an occupation return must state:

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

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

In stating the occupation, avoid the use of such indefinite terms
as ‘“‘employee,”’ ‘‘worker,’’ ‘‘operative,’’ etc. Find out the parti-

cular kind of work done and return that, as spinner, weaver, etc.

In stating the industry or business, avoid the use of such general
terms as ‘‘store,” “‘factory,’’ ‘“‘mill,’’ etc. State the particular
yind 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 car penier,
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
telated to principal cause, name other important diseases.

Example

The principal cause of death and related causes

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

Arteriosclerosis

Chrontc interstitial nephritis

Cerebral hemorrhage July 5, 1927

Contributory causes of importance not related to
principal cause:

tee receneessacenersnecsnsseansnuccucesssssacnstrcescnsescnsrseesnsssee GS eeeeeeceessecsavescscees|ssseceascsseressases

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.

COMMONWEALTH OF MASSACHUSETTS
GOVERNING THE

RETURN OF CERTIFICATES OF DEATH

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

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

...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.

Bevery 40882 OF
a
8
>

PHYSICIANS should state
Exact statement of OCCUPATION

CTLY.

ified.

AGE should be stated
; be properly class
ctions and extracts from the laws on back of certificate.

ully lied.
= ga ings. it may
stru

PARENTS

should be caref
See

100m-12-'34. No, 2938-f

\owten

ih hee 4 Massachusetta To be filed for burial permit

4 CFFICE OF THE SECRETARY with Board of Health
Ps SUELO i eran DIVISION OF VITAL STATISTICS or its Agent. 2
i STANDARD My
145] OF) ok i CERTIFICATE OF DEATH Registered NBQ'2Q oc vccsccseeun
g tas eae ad (If death di hospital or instituti
eath occurred in a hospital or institution,
a No........ Winthrop.Community.Hospit*el pvascussee swe Ward give its NAME instead of street and number)
(Lf U. 8.
2 FULL NAME.............. ATMEStANE... Fre... D." EMbMOMOMN GE once csccesssesssssssssssssessssssssssonene War Veteran,
(I£ deceased is a married, widowed or divorced woman, give also maiden name.) SHOEI GA WAND) isiscsssscsacscsocessssstecsnucesceivey
im) Residence. No....dbedan RIOR OM. Sitio. cccccncnscssccsesserenee SUES Ward,........] ned CO ae ea ae
(e) (Usual place of abode) ss) : i ? (If Bag b-- BOSton and state)
Lengih of residence in city or towa where death occurred yrs. mos. (Ways. How long in U. S., if of foreign birth? 41 () yrs. mes. days.

PERSONAL AND STATISTICAL PARTICULARS MEDICAL CERTIFICATE OF DEATH

5 SINGLE (write the word)
S SEX 4 COLOR GR RACE MARRIED
Sa WIDOWED
ema Le ide or DIVORCE apr} eg
5a If married, widowed, or divorced
RS MND eerste te caster nnn cto poe cot ides cops SvesesutcnsivoUassveevsespnsnngusataudoebaopeesiaanepesesccesiupe ie

(or) WIE of essen Geopge 0 intremont, eS ioe onal id

“sband’s name in fu
6 IF STILLBORN, enter that fact here.

The principal cause of death and related causes of fmporlance in order of onset
were as follows: Late of Gnsct
IMPORTANT

lf less than 1 day

8 Trade, profession, or particular
kind of work done, as spinner,
sawyer, bookkeeper, etC..........0.0

9 Industry or business in which
work was done, as sitk

OCCUPATION

saw mill, bank, etc................s000 OTLO-- ea ieAaiseANGRWMncsiscpedions sucsnantaartiveadaees
10 Daie deceased last worked at 8 11 Total time (years)

this occupation (month and spent in this

“Ee eS, Ee eS Scent ea oe OCCUPATION.........00.20--.s0000-

(State or country)

12 BIRTHPLACE (City MidAle... West... Pubnie@o...nccc
ee ewe Seetig

13 NAME OF
FATHER Peter Deon tee OE ey eee
14 BIRTHPLACE O Name of operation |
FATHER (City), _Mest...Pubnico este ttiascieles What test confirmed di ETP casein eek ae,
(State or country

15 MAIDEN NAME
OF MOTHER

es ye,
10 MOTHER Ci MLGdLe. West..Pubnico..........

(State or coun

21 PLACE OF BURIAL,

CREMATION OR REMOVAL .HOLY.... Cross.,..Malden........
metery) (City or town)

DATE OF BURIAL. 8 (ei eee

22 NAME OF
UNDERTAKER .... hed A i £ . )

Uiewtsec 7 =

Relation, if any

Pre yar...D....D.' Entremoft......son.....

os
aleve aT Oo Ay
a et et et ee St It Se

Anes heneeceneensdOON Nes Ned seee cnet eneenesscceterreeeseseeneeee nanan amen en ene

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 tetms
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
ai of store, factory, mill, etc., a8 grocery store, soap faclory, coiton
mill, etc.

Distinguish carefully the different kinds of engineers by stating
the full descriptive titles, as civil engineer, mechanical engincer, niining
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 cerpenier,
painier, machinist, etc. Distinguish carefully between refail tnerchants
and wholesale merchanis. A person who sells goods should be called a
salesman and not a clerk,

Statement of cause of death.—Cause of death means the disease,

T complication which causes death, not the mode of dying, ¢. g., heart

ailure, asphyxia, asthenia, etc. As principal cause name the disease

Causing death. As related causes, name earlier morbid conditions,

if any, related to the principal cause and any important complication

of the principal cause. Under contributory causes of importance not
related to principal cause, name other important diseases.

Example

The principal cause of death and related causes

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

_ Arteriosclerosis 101g

Chronic interstitial nephritis

ePrrrietrriiitirterttitter titted

Cerebral hemorrhage

anna weneeeneecnsesncecnssewasstesenasssesteasstssassunsssessneensneneneesesenesensensesaaasuns |ussone segs eeAPasneneee nase

Contributory causes of importance not related to
principal cause:

In a group of causes containing the principal cattse 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 priricipal cause in the above example
happens to be the second cause given.

ONMMONWEA HO ~~

Sat do AYA VE Ne DN im.

RETURN OF CERTIFICATES

A physician or registered hospital miogical 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 gupposed
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 reinove 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 set 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 puree: oris 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 bpp isatida make the certificate required of the attendin
physician. If death is caused by violence, the medical examiner shal
make such certificate. If such a permit for the removal of a human body,
not previously interred, from one town to another within the 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 male 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 shail 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.

...He shallin all cases certify to the town cleric or registrar in the
place where the deceased died his name and residence, if known;
otherwise a desctiption as full as may be, with the cause and manner
of death.— Gen. Laws, Chad. 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.

ed,

er ths Initeshational Classification of Causes

ed under

le properly classi

side for extracts from the laws relative to the return of certificates of death.

terms, so that it may

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

The Commoumealth of Massachusetts To be filed for burial

OFFICE OF THE SECRETARY permit with Board of
DIVISION OF VITAL STATISTICS

MEDICAL EXAMINER’S 4
CERTIFICATE OF DEATH Registered No..........2—

Health or its Agent.

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

oan (If U. S.
soe rene d cee See Soro ertAc.csesseves fae hanetberers Seer heal Kew He Sp CEO Ah Oo Bee en War Veteran,
(If deceased is a married, widowed or divorced woman, give also maiden name.) SPECHY: WAR) iccsucossccssstecsvorscvseociceeene
(SS PE NESETD SE aaicds bere th oo hh A Sti ue. hie ms Bs SRP A ACR Woet yee Bao PR Pe ee
(Usual place of abode) 0 (If nonresident give city or town and state)
Length of residence in city or town where death Sceerned yrs. mos. days. How long in U. S., if of foreign birth? yrs. mos. days.

PERSONAL AND STATISTICAL PARTICULARS
3 SEX 4 COLOR OR RACE 5 SINGLE (write the word)
MARRIED <
Male te wibowepD Single

or DIVORCED
5a If married, widowed, or divorced
UCT RINE IT een ca coos eee eo eee al aon Rete phe OM choy susstacoasadekeebevineesshinesraconeend

EDICAL CERTIFICATE OF DEATH

18 DATE OF ~S/ i C
SE | oe OP = aa al Mate ee ae
if (Month) (Day)

“(Ye
19 4 HEREBY CERTIFY that I have investigated the death

of the person above-named and that the CAUSE AND MANNER thereof are
Srp TVET eee p ONS Oe 90 a ag Pa Ye as follows: (If an injury was involved, state fully.)

8 Trade, profession, or particular

kind of work done, as spinner, Carpenter CM NASAL.

SRWVER DOOKKORDOR: CLG: j0'snuiiacedsasavcaskesissvenaetavunsdavesevesbaossaroncdasenuencoccsdassoevaesdees

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

OCCUPATION

ny mill, bank, aaa rater gr atenent a giaacbeatann-naeiePeeegpucstanscea AB oN DN i Deca Racha asteetescesyilons sabcdaeogioussende mate
10 Date deceased last worked at 11 Total time (year) O eR Seta, 8 GET
this occupation (month and 19 6 _ Spent in this ,
ee ae eee OCCUPALION.. .--s.cccccccseece. | [cocccect ec eecee eee te rete estes ee teen eee ee eee eceeeeseneneseebensteseeeeresesteeeacersesecerseaeearenseneets
12 BIRTHPLACE (City)..... WA OD rece etg| [OPT ettesesennnncenenevnnsnrnansssessessnstonaresnunnansensuionnseesunnngnensinnanenenneeei
(State or country) NOW eot 1a

(See reverse sjde for degcripti known person)
WY, 4, ia
HAT" OR TO ‘
rae USTAI Y fe A icesnay incre enn cectnerecesnusepstnesiossnecrntaes

1S THER’ LeVi A. Dimock

2 fe eT Py a
FATHER (City) fiorko | AW aE a, a
eam eeve peetie 0

.. i a a aor Suey i Y aie I, <A ME f Y . gy vie

20 INW
W.

PARENTS

16 BIRTHPLACE OF
E 21 PLACE OF BURIAL,
MOTHER (City) CREMATION OR REMOVAL Win

thr
(C

eme

MAI BU Dick chino 1907.

op...... Wint
(State or country) NoVa Seotia tery)

n
i ty standard certificate of death was
bos Rabid gtd yy Be eerie arm SBN WRDDRRS: Scryers tesstdtocter ese oneeyersenacsicoptirs Pnerbge: oaieapiie lined
Seirarme Y Oe BO) eS Oe
i

ys ent of Board of Heal

D ccc cccrerccccenncsce Gy ssrcssssssessusevsrecsssasssessaes

Ngee ll [LOA ALS.

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

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

Medical examiners shall make examination upon the view of the
dead bodies of only such persons as are supposed to have died by violence.
If a medical examiner has notice that there is within his county the
body of such a person, he shall forthwith go to the place where the body
lies and take charge of the same;...—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
Bee parca is absent from home when the certificate of death is
needed.

STATEMENT OF CAUSE OF DEATH

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

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

Every item of =
a
wo
S

PHYSICIANS should state
Exact statement of OCCUPATION

cea EXACTLY.
y classified

's on back of certificate.

2
2}
2
4
be
fi
Zz
:
fs
<
2
a8
;
zi
S
e)
=
Zz
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3

“AGE...

d extracts from the

that it may be pro

lly supplied
so

MEREE should be careha
is very important. See instructions an

YY,

No. 7070-h

im-12-'32.

(Ci
No... Sta..Hospital,..Fort...Banks.,...Mass...Stey..... ce Ward

or Town)

a
PLACE OF DEATH

2 FULL NAME......

(Usual place of abode)

OFFICE OF THE SECRETARY
DIVISION OF VITAL STATISTICS

STANDARD
CERTIFICATE OF DEATH

MOSBPH. Ma... MATSON 00.2 cccsescsscsssssccsssen

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

(a) Residence. No.....8:5...Brow..Stre0%... ees

eae, St.,................Ward,

(City or town making returpy

Registered No..

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

(If U. S.

War Veteran,

specify. WAR) ccscccsssiscteassbcseaspsceneestess
an Braintree.,....Mass.... lie

(If nonresident, give city or town fendi State)

Length of residence in city or town where death occurred yrs. mos. days. How long in U. S., if of foreign birth? yrs. mos. days.
; PERSONAL AND STATISTICAL PARTICULARS MEDICAL CERTIFICATE OF DEATH
3 SEX | 4 COLOR OR RACE | © SINGLE (write|/the word) "1/18 DATE OF
| | WIDOWED DEATH se SMAMALY.. My Bg ert 1987...
5a If married, widowed, or divorced 19 I HEREBY CERTIFY, That | attended deceased from
Bea oh amet. Jouise, lesson. madden. name fl Way 20 enmmnnnn 19.36, to... Sopa See 19.89
(or) WIFE Of .eeccrnjntcsen Bi RH VINCROWN || ast saw h. AM. alive on... SANUALI. 4... 3 Jaeath is said

6 IF STILLBORN, enter that fact here.

| If less than 1 day

<4
AGE... peer Pet Months.........

Days

3 | sawyer, bookkeeper, etc........... Of ficer...U.S. ee
Ee! 9 2 or plied he
work was done, as silk mi 2
he saw mill, bank, CtC....+..:-.cceseeece0see--- Captain QMC Msstsacek saeeeeat pect?
8) 10 or deceased pect worked = 11 Total ee
is Sccup: n spent in this
year).. a kta eee occupation.......... 18...
12 BIRTHPLACE (City)... ccc. eS ae
(State or country) Ma $5
) 13 NAME OF
FATHER =~ Unknown
14 BIRTHPLACE OF
~d FATHER (City) .... Unknow...
~ (State or country)
Ww
«| 15 MAIDEN NAME nknown
< OF MOTHER U
a
16 BIRTHPLACE OF
| MOTHER (City) ..... Unknowne
(State or country)
17
Informant .. Rogiatrer,SatHosp.Fort. Banks.,.....
(Address) Vinth .
‘ HEREBY CERTIFY Mg a satisf ey, sta
h B Arans

e purists

ard gertificate of death was
Misi kp issu DZ

sth of Health

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

. Coranary..OCCLUSE ON... 5/20/36
es Myocarditis shone marers.... ‘10/36
“Contributory causes of importance not related to principal cause: | =
a9 Arteriosclerosis,generalized,........ | -- Unkmown
BM MOT.) oS es! Sea) et aa ye tee
Name of operation.......2% St, 2” een a Date of........ erevalvalaenndtts <p heeh
What test confirmed diagnosis?.... HCG» vesssecconssssesseseseWas there an autopsy?...... Vo e
20 Was disease or inj elated 13 oc Of deceased? mre
If SO, SPOCifYy..... <M ipest ag Mince Sia vos ie a gem...

(Signed) ...... Rohert.. £. Thomas. Ta jor.. MG.-USA.---. M. D.

(Address)... Rox'k... Banks shlasss........ Date.. Jan.4.9 BT
“21 PLACE OF BURIA
CREMATION OR ee Nhs gtrae.... Mg
Tcoters) Ci = Bi
DATE OF BURIAL.. ee ee tide mee AOR 193.7.

22 NAME OF
UNDERTAKER . Mz. eM:

___ AppRESS an ae

Revised Uni .

Statement of occupation.—Precise statement of occupation is
very important, so that the relative healthfulness of various pursuits
can be known. Make some entry in this section for every person
aged 10 yearsorover. Iftheoccupation had been given up or changed
on account of the disease causing death, report the occupation prior
to illness. If the deceased had retired from business, report the
occupation prior to retirement. Children not gainfully employed
may be returned as at school or at home. For a woman whose
only occupation was that of home housework, write housewor?
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—privata
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, professisn, 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 termg
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 noty
use the word ‘‘ mechanic,’ but give the exact occupation, as carpenter,
painter, machinist, etc. Distinguish carefully between retail merchants
and wholesale merchants. A person who sells goods should be called a
salesman and not a clerk. "

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

Example

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

Date of onset

Contributory causes of importance not related to
principal cause:

esa ee = “T=

EXTRACTS FROM THE LAWS OF IHE
COMMONWEALTH OF MASSACHUSETTS
GOVERNING THE

RETURN OF CERTIFICATES OF DEATH

A physician or registered hospital medical officer shall forth-
with, after the death of a person whom he has attended during
his last illness, at the request of an undertaker or other
authorized person or of any member of the family of the deceased,
furnish for registration a standard certificate of death, stating to the
best of his knowledge and belief the name of the deceased, his supposed
aye, 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 whiere the
person died; and no undertaker or other person shall exhume a human
body and remove it from a town, from one cemetery to another, or
from one grave or tomb other than the receiving tomb to anotherin the
same cemetery, until he has received a permit from the board of health
or its agent aforesaid or from the clerk of the town where the body
is buried. No such permit shall be issued until there shall have been
delivered to such board, agent or clerk, as the case may be, a Satis-
factory written statement containing the facts required by law to
be returned and recorded, which shall be accompanied, in case of an
original interment, by a Satisfactory certificate of the attending
physician, if any, as required by law, or in lieu thereof a certificate
as hereinafter provided. If there is no attending physician, or if, for
sufficient reasons, his certificate cannot be obtained early enough
for the purpose, or is insufficient, a physician who is a member of the
board of health, or employed by it or by the-selectmen for-the purpose,
shall upon application make the certificate required of the attendin
physician. If death is caused by violence, the medical examiner shal
make such certificates If such a permit for the removal of a human body,
not pe wansly interred, from one town to another within the common-
wealth cannot be obtained early enough for the purpose, the certificate
of death made as above provided and in the possession of the undertaker
desiring to make such removal shall constitute a permit for such re-
moval; provided, that such body shall be returned to the town from
whichit was removed within thirty-six hours after such removal, unless
a permit in the usual form for the removal of such body has been sooner
obtained hereunder. If the death certificate contains a recital, as re-
quired by section ten of chapter forty-six, that the deceased served in
the army, navy or marine corps of the United States in any war in
which it has been engaged, such recital shall appear upon the permit.
The board of health, or its agent, upon receipt of such statement and
certificate, shall forthwith countersign it and transmit it to the clerk
of the town for registration. The person to whom the permit is so
given and the physician certifying the cause of death sha!l thereafter
furnish for registration any other necessary information which can be
obtained as to the deceased, or as to the manner or cause of the death,
which the clerk or registrar may require. — Chap. 114, Sec. 45, G. L.,
as amended by Chap. 48, Acts of 1927 and Chap. 414, Acts of 1931.

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

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

RULES OF PRACTICE

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

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

and those of persons found dead. f

aesvwey svwess Ws

PHYSICIANS should state

Exact statement of OCCUPATION

BR SeBwsVe sas veut &

AGE should be stated EXACTLY.

hat it may be properly classified.

y supplied.

ain terms, so t

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

information should be carefull
CAUSE OF DEATH in pl

is very important.

Pe VV INE Ese EF BePRSENEZ SED VUE SER WEN SEEMS SSE SENSE SEP ON
100m-12-'34. No. 2938-e

AZ The Commonwealth of Massachusetts

OFFICE

ee OL

DIVISION OF VITAL STATISTICS

OF THE SECRETARY

(City or town making return)
,

4 (County) =
er ares STANDARD 6
a ae SS | CERTIFICATE OF DEATH Registered Noeisscssscssssssnesne
g sea lle aig (If death Ba ep Moupitellor instats
e a ca occurred in a Dospitai or institution,
a No..Jinthrop Community Hospitadé.:: Satadenusuneuveercas Ward give its NAME instead of street and number)
(If U. S.
2 FULL NAME.......2AMGT..BLL SWOPE. DAWSON cccsssssssssssssssssesssssssssssssesssssssssneese War Veteran,
(If deceased is a married, widowed or divorced woman, give also maiden name.) BOC, WAR) os20.cccvesessresecenssessoazs-cennasnes
(a) Residence. No.......... 28 Washington. Avenue er ose SE age cceccoeenns Me Espen UR OO EN EE SRERy AA Ear aie beer Or
(Usual place of abode) (If nonresident, give city or town and state)
Length of residence in city or town where death occurred 40 yrs. mos. days. How long in U. S., if of foreign birth? yrs. mes. days.
PERSCNAL AND STATISTICAL PARTICULARS MEDICAL CERTIFICATE OF DEATH
3 SEX 4 COLOR OR RACE | © SINGLE (write the word) || 18 DATE OF
Male White woowen Married 17 ee ee pe ae hkl ee Bi J ams
or DIVORCED (Month) (Bay) (Year) ant
5a If ied, widowed, or di d 1 , ed deceased from
HUSBAND of... V2881e Coburn. ae gee Re Po ee ae
(Give maiden name of wifeinfull) st eve y bp yay 3.0 Metra dsewsenessouts AGS 02, 10s ies besetcs qd a ccarceches dees ; 194...
aie) WP IIRE: GE sansssecvescanscesovecor: Giese ca GS enaee ctishisansdveonstecssnosstzesesipavaedanace’ I last saw h..8 _allve on......... fere.....f. sy; Pi i 193-4. death Is sald

6 IF STILLBORN, enter that fact here.

to have occurred on the date stated above, at...)..: 8 oy
The principal cause of death and related causes of importance in order of onset

7 If less than 1 day s . ——
AGE... 12 Sodan Years.....A#r.... Months..ecte Days | ccssssssenes Hours:....:...... Minutes oe Ditech
Bae SOIT, or particular wesennrecnnsefenecsienes fecngeennaernnene
= kindof work done, as spimeyJHOLESale flour bechaeecore res.
° OB gt MORENO raga pes exaccoesencauedzccuenadaMlcisutouasnansstaesicslaZsasacsussboathdonsedee}
E| 2 aay or pleiions [Pater Pee Me ge a a) a, ee
a work was done, as ks ffiee
>
Fa} Seana aa Ret ena eevee ne NM, ne eet | [fina cancer ont Uasseusastaconbadapuxavastexavenasesescactacnsdacdeenvscecssavadessncsnssaxeej)-taneHdatssaunasush
S| 10 Date deceased last worked at 11 Total time (years)
ro) e seg n ‘
t t th d Few OY tt ence ween eee eee eee ee eee eee eee EEE EEE EERE EEE EE EEE EEE EEE EE EEE EEE EEE EEE EEE EEE HEHE EEEEE! THHEEEEEEEEEE SEES
Co een ROOD Setup ane Ovu|| Contebtory ease of importance nat related to principal cause
12, BIRTHPLACE (City)... POTAZW OTE RY oo cccnmmnnnsnnnnne HAs. Se oT. eg CPR ~ x SORE METER RRS Sveti
Gate or country) Lowa oe & a a
Ea! | eee =I haha: Partly fe
, jee Ee
14 BIRTHPLACE OF Date of... AGLaAk.. Zoro
Ms DPN NUN asa pte a tcowessctocasevsdccbenndec nsesedpeanonctycncsizesoscodevnsesescanasapaccsdessoonsh Was there an autopsy ont PW)
z| (State or country) owa
w 20 Was disease or injury in any way related to occupation of deceased? ...... Ltd...
= 15 pg Margaret Jane Clark BFiSOs SPIGCI EY 5. sce Rea sag bist ccstasscessesenu conecaghatsocons Meee
a (Signed) J...
ys EN Oe eee (Address) ..n
(State or count un rt D CE OF BURIAL, we re /
vy) Mereer Co ty, e. ommayi MATION OR REMOVAL inthe Qa \ ldmt b K.P... 248
elation, if any tery ity or town
of: Pts )||__DATE oF suman SOMBRE Bec 19.9.2
Winthrop 22 NAME OF

| HEREBY CERTIFY t nda
_ BEF nsit '

certificate of death was
Jermit/was issued:

tenes

UNDERTAKER

Received and filed

1 Ee SER Re. | RT a Se \ el

A TRUE COPY, ATTEST:

Statemont 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 10yearsorover. 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 ome. 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 worl done.

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

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

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

Distinguish carefully the different kinds of engineers by stating
the fuil descriptive titles, as civil enginecr, mechanical engineer, mining
engineer, Siationary engineer, etc. Avoid the term ‘‘laborer’’ when a
more precise statement of the occupation can be secured. Do not
use the word ‘‘mechanic,”’ but give the exact occupation, as carpenter,
Painter, machinist, etc. Distinguish carefully between retail merchants
and whelesale merchanis. A person who sells goods shouid 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,

Ezemple

The principal cause of death and related causes

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

rorg

Cerebral hemorrhage

July 4, 192

AU epee aseeeneenacenncesaseserenerseteresesseensesnussenessnesesasseeaesheseseeesssssesensasenoss| <ssesHneaeseSSeeeeE sees

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 onse%, 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.

WW IVEIVE WIN EVE Sk tv ewe eee

GOVERNING THE

RETURN OF CERTIFICATES OF DEATH

A nbyalcten 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
ef 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
pee died; and no undertaker or other person shall exhume a human

ody and remove it from a town, from one cemetery to another, or
from one grave or tomb other than the receiving tomb to another in the
Same cemetery, until he has received a permit from the board of health
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 oflientth, 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 exarhiner 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, unles3
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 ccrps 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, 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 shall thereafter
furnish for registration any other necessary information which can ba
obtained as to the deceased, or as to the manner or cause of the death,
which the clerk or registrar may require. — Chap. 114, Sec. 45,G. L.,
(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. :

...Ee shallin ali 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 causé 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 cr burial ground in which the interment is made....Chap. 114,
Sec. 46, G. £., (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
iliness from disease unrelated to any form of injury.

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

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

caref

tion should be

DEATH in
of Death.

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veigpthowoamey se

No. 7070-i

peal
PLAINLY,

The Commonmealth of Massachusetts To be filed for burial permit
OFFICE OF THE SECRETARY with Board of Health
DIVISION OF VITAL STATISTICS or its Agent
MEDICAL EXAMINER’S 4 ay

CERTIFICATE OF DEATH Registered No........./

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

(If U.S.
A a Ae War Veterar,

(If deceased is a married, widowed or ed formes. Bes also maiden name. )

; ae et dye SUECICTWANIR haciss a5 ace sadeeancracsssceseedne se
f - rs Oe
(a) Residence. Noe. YELLED SOT Og cbesccccssesssees SEs | pif are EMD cr renee A AS Ga RUA c1, als. e NU aa
(Usual place of abode) (If nonresident, give city or town and state)
Lezsth of residence im city er tewm where death occurred yrs. mos. days, How long in U. S., if of foreign birth? yrs. mos. days.

PERSONAL AND STATISTICAL PARTICULARS MEDICAL CERTIFICATE OF DEATH
5 SINGLE (write the word) 2 ee eS
3 SEX | 4 COLOR OR RACE Saeed) 18 DATE OF Z ; 2 v7 F “>

" Sa IPO] eR ANDRE af ell 0! G7 ORRIN AY eM Ar PRED A oe
Femalg White Prone Wt LELowed. (Month) (Day) ha
Feo Lh Seas, Sk ee 19 1 HEREBY CERTIFY that I have investigated the death

: ie 15 te ppaiden name of wife in full) of the person above-named and that the CAUSE AND MANNER thereof are
or ot papper eg ate ee ga tee car eee nee eee Uae Mer ea cS TG oo Sa ceive hen tne nkehreeveneeenenanie ae +o

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

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

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

z
= “ Industry or busines in which cceubrrigar tien ~ (See reverse side for description for unknown person)
oa work was done, as si > aE. ae If death was due to external causes (VIOLENCE) fill in the following: 3
= saw mill, bank, | SS Sree eh Ge Sie oy seed Aocident, ‘ytd oo
8/10 da) “occupa ont at 11 Total fing Cea Suicide or Date of injury ae Pd 19.257
is occupa ion . a Biot spent in this. EA id a elt, oreo ies evcatnal Deets
year)... if Hany 24194 occupation.......2........ Homicide ? ‘
. id
ES SED Bai Se ORT Si Rie eeied
(State or country) Treland
er Manner of
13 NAME OF Ele Ng pen TTR RAR a al op SR roe ree a
FATHER ewww ewe OULLIVan Nature of
14 BIRTHPLACE ee = i appari Be agement a na aa a
wed Were (Cag ee ee tne
", ve i a 7) qd
z (State or country) Lt Lat
ui
{| 15 MAIDEN NAME
<| OF MOTHER Connot be learned: '
a seb Sig lle cots /
16 BIRTHPLACE OF
Cou ile es Roehs 62 ae rere ain Re: Oe ee
ates tas 22 PLACE OF BURIAL, Rate
Canin ne Souaety) -reland CREMATION OR REMOVAL ...cdQ. V0. IQ coral didn GID serene
17 (Cemetery). ___§City or town)
Inormant 52 Ss» DATE OF BURIAL... =a oS sh Donttad
Vision 23 NAME OF vot Otten bed
rae UNDERTAKER ..... f..! Sees pRCaES, « avaheaten vent atents tod FR Heaths soi ccdew caver teashovebsbssehcs
| HEREBY CERTIFY thet i seteectow standard certificate of death was i eee ian a ?

filed with me BEFORE ¢!

Md,

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

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

DESCRIPTION (for unknown. person). hcicscn sess esetesisvsssessssagggeslipends Wy eatiatedittare oe tetas tee ne

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 cemetery or burial ground
in which the intermentis made... .—Chap. 114, Sec. 46, G. L. as amended

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

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

RULES OF PRACTICE

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

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

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

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

STATEMENT OF CAUSE OF DEATH

Medical Examiners in certifying to a death will state the cause and
manner thereof, and will specify: (1) Under cause, the nature of an
injury and of its consequences; and (2) under manner, the mode of
its production together with the circumstances when these are known.
Forexample: ‘*Compound fracture of the femur with ensuing septicemia
(gas bacillus) caused by asteam 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 presumable nature; and (2) under manner, indicate the
circumstances leading to medico-legalinquiry. 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

(County)

js Us| ee

(City or Town)

Every item or =
=
PLACE OF DEATH

PHYSICIANS should state 7

(Usual place of abode)

Pe. a oe Call
_ The Commonwealth o 1 lll

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

(City or town making return)

Registered No.................... as

¥ (If death occurred in a hospital or institution,
No. St8..Hospitel,..Fort.. Banks Mass ook STE og oe eee Ward { give its NAME instead of cccey aed sare
Q, \
(lé U. S. OD yidarcegr«
Pe | RTGS os ORS A ec War Veteran, VA Matra
(If deceased is a married, widowed or divorced woman, give also maiden name.) specify WAR) :
(a) Residence. No....999.. BAST... BU. occ ccccccsccsssescessessssstsessseeeees beget cscs, Ward, South... Bas. ton,...Mass....

(If nonresident, give Aa or town and State)

Exact statement of OCCUPATION

Taw

If less than 1 day

fd
iC aS 5 a ee VearSoic.ccc..: Months......... ;

AGE should be stated EXACTLY.

Wilm UNPFAUVING BLACK INN-—-IFIS [5 A FERMANENT KRECURD,

oo DAYS e-seshe--/HOUTS: 202-24 Minutes
£5 | 8 Seat, «jabs Sa or particular
Ind Of work Gone, as spinner, . * .
2 E 5 sawyer, bookkeeper, etc............. Warrant...0fficer,USAr
me | 9 Industry or business in which
F = = work was done, +) mee
e {ls saw mill, bank, etc. adquar ters,1st- -Corps--Area-
2a S| 10 Date deceased last fone 11 Total time (years)
#5 | this occupation (month and spent in this
3 6 x year) .. Jame Ck A Si AY Apes ees occupation. ......0......
25, PME ESE RUN (SEP Scat easy gcvace nae spats sakes eapgh yb nabeviaceccacaceeaddbbalgabtuesincsean
a8 5 (State or country) New York
3 ou Fa, is
a@e | 13 NAME OF
b> : a) FATHER U
—_ ”
3+ g 0 14 BIRTHPLACE OF N
é FATHER (City) .. Fee ae ea ta
£ z / (State or country)
‘yo ww
| 15 MAIDEN NAME
SES ||<| OF MOTHER re)
a
16 BIRTHPLACE OF W
MOTHER (City) ........ oN

(State or country)

OF DEA
important.

No. 7070-h

So aR sFort..Banks.......

certificate of death was
rmit was issued:

Official Designation)

100m-12-"32.

oO Length of residence in city or town where death occurred yrs. mos, 4 days. How long in U. S., if of foreign birth? yrs. mes. days.
2 ‘
& PERSONAL AND STATISTICAL PARTICULARS MEDICAL CERTIFICATE OF DEATH
one 5 SINGLE (write the word) Waay.
ie fee | RARRED age > nee eee 1937.....
"3 Male White or DIVORCED Married (Month) (Day) (Year)
aS 5a If married, Soe or socal ne Maiden name 19 1 HEREBY CERTIFY, That | attended deceased from
HUSBAND of ....... oe: en... ERNE... PUNE scs<..cpeesspserensrecs-
rE (Give maiden name of wife in full) Januar Rua 6 Perantuctavgertessuiettes pi | 9.9. to.. SAaNMaLY.....LO Uoshcnctsvie 19.00.
Mamie NPN Mea see ce ceteris celeste nada ansncasineseocasests cusavoasesiusadesnastaelecedisnsee ibovarssceonssed . . .
4 g ~2 2 Wire's aecae in fall) ! last saw h-LM....alive on... JANMALY...LO Bs catty - 19.2....., death is said
pe ‘6 IF STILLBORN, enter that fact here. to have occurred on the date stated above, at.5.2.50P.m.

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

ePellagra........ A: ei ge SR ae 8/10/36
#oeliver,cirrhosis. of ,severe................

%ehneumonie, broncho,acute,termin=
al,severe,bilateral. 3

RREII Gl ORTOP E CATON ctecteacannnsptonnssacteRtoenics>sanoncsusasececdtests avs)
What test confirmed diagnosis?...
20 Was disease or vase in_any way felated to pccupation of deceased? ........ To dae
If SO, SPOCifY......cseeeriehey/ Moone” 4 smi Ie aera LMA REN aaexonas0 eau ancraieats sessilis <anresiconnaserertaanreree
(Signed) .. pages M.Arnett.,.1lst...Lieyt,] * ¥ .

21 PLACE OF BURIAL
CREMATION OR L noval IRMA CAAT ON

ie pial Se eee

DATE OF BURIAL...

22 NAME OF
UNDERTAKER

ADDRESS _ 254. oat lek ot &

Received and filed

A TRUE COPY, ATTEST:

(Registrar)

hOvVised United otates Standard Certilicate of Veath —

Statement of occupation.—Precise statement of occupation is
very important, so that the relative healthfulness of various pursuits
can be known.
aged 10 years or over.
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 ort 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—privaiz
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.

Make some entry in this section for every person,
If the occupation had been given up or changed ©

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

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

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

Example

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

Art

Date of onset

IQms
ts I92r

Chronic interstitial nepi

Cerebral hemorrhage ,

principal cause: ‘

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

happers to be the second cause given.

EXT RACID Prryum 6mm eA Se tee
COMMONWEALTH OF MASSACHUSETTS
GOVERNING THE

RETURN OF CERTIFICATES OF DEATH

No undertaker or other person shall bury or otherwise dispose
of a human body in a town, or remove therefrom a human body
which has not been buried, until he has received a permit from
the board of health, or its agent appointed: to issue such permits,
or if there is no such board, from the clerk of the town where the
person died; and no undertaker or other person shall exhume a human
body and remove it from a town, from one cemetery to another, or
from one grave or tomb other than the receiving tomb to another in the
Same cemetery, until he has received a permit from the board of health
or its agent aforesaid or from the clerk of the town where the body
is buried. No such permit shall be issued until there shall have been
delivered to such board, agent or clerk, as the case may be, a satis-
factory written statement containing the facts required by law to
be returned and recorded, which shall be accompanied, in case of an
original interment, by a satisfactory certificate of the attending
physician, if any, as required by law, or in lieu thereof a certificate
as hereinafter provided. If there is no attending physician; or if, for
sufficient reasons, his certificate cannot be obtained early enough
for the purpose, or is insufficient, a physician who is a member of the
board of health: or employed by it or by the selectmen for the purpose,
shall upon application make the certificate required of the attendin
physician. If death is caused by violence, the medical examiner 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 re-
moval; provided, that such body shall be returned to the town from
«which it.was.romeved 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
farnish for registration any other necessary information which can be
obtained as to the deceased, or as to the manner or cause d@the death,
which the clerk or registrar may require. — Chap. 114, Sec. 45, G. L.,
as amended by Chap. 48, Acis of 1927 and Chap. 414, Acts of 1931,

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

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

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

RULES OF PRACTICE

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

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

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

ivery item or introrma- ~

PHYSICIANS should state CAUSE OF DEATH

be carefully supplied. Age should be stated EXACTLY.
terms, so that it may be properly classified. Date of onset and exact statement of OCCUPATION are very

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

"36. No. 9080-F

PLAINLT, Wiiti UNPAUING BDLAUNR INK-——IFIS 1D A PFERMIANENT RECORD,

N. B.——-WRIIE
tion should
in plain
impo

100m 11

The Commontwealth of HMlassachusetts To be filed for burial permit
OFFICE OF THE SECRETARY *
DIVISION OF VITAL STATISTICS with Board of Health
or its Agent.

STANDARD
CERTIFICATE OF DEATH Registered No. ___.............----.--4]

(If death occurred in a hospital or institution, |
LU EEE hd ed ha LE Es a give its NAME instead of street and number)

(If U.S.
ih fen a A On en, ae ae ae War Veteran

SRV EWAR)) <3... |

shes
(a) Residence. ne eo Lo I ELA ABE Ls AN ee ht eh On del} ge) ee eee Warden 82 2 Ok ee eS
(Usual place of abode) (If nonresident, give city or town and state) |

h death o

Length of residence in city or town

PERSONAL AND STATISTICAL PARTICULARS MEDICAL CERTIFICATE OF DEATH |
3 SB 4 COLOR QR RACE | © SINGLE write the word) | [ ri i> ;
EA Ty gene ee eee EN Oh SE, | A! Gk ESET cxecconscannoffs Ncouctivassancnaceseeiecassacdedevavoteesceosesasisestscasvednesndontatrevesaftunamiasess / sesong

or DIVORCED (Day) (Year)

5a If married, widowed, or divorced

HUSBAND 68 22s scicscomsce, nd Se ie re
(Give maiden name of wife in full) Loe
on) HIER wih oo te it ee eS eee ee ee kt se
(Husband’s name in full) —
6 IF STILLBORN, enter that fact here. to have occurred on the date stated above, at. 7... ¢7m. |
SS" TS ie) i a a a aaa The principal cause of death and related causes of Importance In order of onset —

If less than 1 day were as follows:

eines Hours............Minutes Pace
SSS Op 2 Mm Deca RP MN | neater gees ccleaner ry ny Di ene Wa a |
z= kind of work done, as spines, Cede. Sorbet 2
=) Senn an RR TI ses ccgueinsoaacrshnsns as iausacansansansoxasneddpecastonsepsignasoicasee/ /
| 9 Industry or business in which Fy , §- <I te anceenentsecesenseeccrsseenscnnssssencnenecassauessnnansccensncsssnanssesnnnssennuce] sesesssesensseeses |
a work was done, as silk mill, “Aone,
= cates I OUI rae cs eet cee ee. dR CEN cece cosine senbedadnoseduarcossssssncseduansseecnoprdeacsbscasscensarcvecssrecncaundbaned/fisevsostinsepnns tam
©&| 10 Date deceased last worked at 11 Total time (years)
this occupation (month and —— Spent in this |] warerseareeceseeeeeeeeeeeceseseecesenssneesenenananeeseseseneenacnenenensenescssecsensnae) sanananenenezeness }
RGN) oo ivcesiddeegstatedsteevvie chen OCCUPATION........00.0.eeeeeees
AEP LACE, (G16 Y) cic scsnturecece MRC Ma seven love cd tee ou toy Lecter eve eet a xsabsncssidesarecnasenei
(State or coufitry)
13 NAME OF ge
FATHER A? o 22)
oe P IN MPAIG) Ol OPO PMID co vs sy och s-ncbe cone ph ccnbecnsttenscesdadinicasvinvene¥zncd Date, Of. ica:ccscassersitvconctvsrs olteee
‘= What test confirmed diagnosis?.....0.....c..ccccececneeeeeeeee Was therean aufopay?. Atos
z
wi 20 Was disease or Injury in any way related to occupation of deceased? By oe ee:
« ,
BTSs LO DBCAEY: <<: cepckcccmgstechonteces a srsulvovenercase ella vu teste veep tacos touieadtpuescee .daeels cokcaiomeaseeeee
<
a (Signed) Pe Sor } is roseaprene ills Cunaviignl dautngspets say SSsCavekTS cuMK ont ufsuah lay yo gen omdakon ri

ry Se a VAP Aa

Place of Bfial, G

DATE OF @URIAL......<...7-%&1
Say
22 NAME OF i :
UNDERTAKER eens 2G ol errs corse dave, PELE

cate of death was
si ued;

Statement of occupation.—l’recise statement of occupation is
very important, so that the relative healthfulness of various pur-
suits 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 bus-
iness, 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 whatever 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 partic-
ular kind of work done and return that, as SPINNER, WEAVER, etc.

In stating the industry or business, avoid the use of such gen-
eral 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 ENGIN-
EER, MINING ENGINEER, STATIONARY ENGINEER, etc. .\void 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, ete. 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, nor 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 cause€s| pate of Onset

of importance in order of onset were as follows:

Arteriosclerosis 1915

Cerebral hemorrhage

Contributory causes of importance not related to
principal cause:

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

RETURN OF CERTIFICATES OF DEATH

A physician or registered hospital medical officer shall forth-
with, alter 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 sup-
posed 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. ... Grn, Laws, Cuap. 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 nave been delivered to such board, agent
or clerk, as the case may be, a satisfactory written statement con-
taining 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 re-
quired by law, or in lieu thereof a certificate as hereinafter pro-
vided. If there is no attending physician, or if, for sufficient rea-
sons, his certificate cannot be obtained early enough for the pur-
pose, or is insufficient, a physician who is a member of the board
of health, or employed by it or by the selectmen for the purpose,
shall upon application make the certificate required of the attend-
ing 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 an-
other within the commonwealth 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 a
removal shall constitute a permit for such removal; provided, that
such body shall be returned to the town from which it was re-
moved 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. Tf the death certificate contains a recital.
as required by section ten of chapter forty-six, that the deceased
servec in the army, navy or marine corps of the United States
in any war in which it has been engaged, such recital shall ap-
pear upon the permit. The board of health, or its agent, upon
receipt of such statement and certificate, shall forthwith counter-
sign it and transmit it to the clerk of the town for registration.
The person to whom the permit is so given and the physician cer-
tifying 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.—Cnap, 114, Sec. 45, G. L.. (Ter-
CENTENARY 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, Cuap. 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.— Gren. Laws, Cuap. 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 cemetery or burial ground in which the interment
is made, . . .—Cuap. 114, Sec. 46, G. L. (TERcENTENARY EDITION.)

RULES OF PRACTICE

The fulfillment of the purpose of these laws calls for the ob-
servance of the following rules of practice:

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

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

(3) Medical Examiners will investigate and certify to all deaths
supposably due to injury. These include not only deaths caused
directly or indirectly by traumatism (including resulting septi-
cemia), 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 deathe of persons not disabled by recognized disease, and
those of persons found dead.

Every item of informa- ™

PHYSICIANS should state CAUSE OF DEATH %

UNFAUDING BLACK INBK—IHIS Ib A PERMANENT RECORD.

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

No. 9080-F

Jain terms, so that it may be properly classified. Date of onset and exact statement of OCCUPATION are very

tion should be carefully supplied. Age should be stated EXACTLY.

WRITE PLAINLY, Wilkt

O1A

100m I1-"36,

The Commontwealth of Massachusetts 7° be filed for burial permit

OFFICE OF THE SECRETARY with Board of Health
DIVISION OF VITAL STATISTICS or its Agent.
STANDARD |
CERTIFICATE OF DEATH Registered No. 4 .(} |

jae death occurred in a hospital or institution, i
give its NAME instead of street and number) |

(If U.S.
a“ OC War Veteran

specsty GWAR)! .:..2..... 2. 0.5 eee

(a) Residence.
(Usual place of abode)

(If nonresident, give city or town and state)

Length of residence in city or town where death occurred years months days. How long in U.S., if of foreign birth? years months days.
PERSONAL AND STATISTICAL PARTICULARS MEDICAL CERTIFICATE OF DEATH
8 SEX 4 COLOR RACE | 5 cen (write the word)
aA

18
ear SB cnn nnn B om
(Month) (Day) (Ydar)

HERE BY CERTIF/(Z{ That | attended decedsed from

MARRIED Lt
WIDOWED
or DIVORCED

(Give mdiden of wife in full) : om |. sags !
(or) LO eee Gide Ch eoeudcncouccensescdsenevsssonscosscogee. 1 las saw bh is ....allve Cee AS nnn A = - 182. death | -gald |

6 IF STILLBORN, enter that fact here. {have occurred on the JE 3 0 AK.
principal cs ¢felated causes of Importance In order of onset
lowsyy “De

5 sawyer, bookkeeper, €tC.........-.-s0-+-
| 9 Industry or business in_ which
& work was done, as silk mill,
2 saw mill, bank, €t0...........000000- AER Pa sl tle oR
| 10 Date deceased last worked at
this occupation (month and spent in this
ee ee Sar 4 occupation........H....-
ey PRIMES RBC (CIES) concovescoscarcecasesschtcastareeteo MEIN Me Arhninsnsdecscovoveccecscubuppusdidivessesses
(State or country Btt222.
13 NAME OF pee ;
FATHER ssf BFE . . wadgecccccccvensesecccensnaccanscssessnsssusssccsnse |rsrsesscsesessseen®
14 BIRTHP p KZ. Gitbia Name of operation.........040...-\mieespeery sees See ee Date Of: jccet tte
= PIRI ccna eon Rac cho encoraet PER LotasneSccdusvovescs sp ctintbsvaasaleosnnne> What test confirmed diagnosis?......A¢<Z#<Sc___......Was there an autopsy?............
z (State or country) ‘ Ztage °
w
| 15 MAIDEN NAME
< OF MOTHER
a

16 BIRTHPLACE OF
MOTHER (City) ccc MMP DPT ec cannillasesessnseseee

@tate oF country) Letada .

22 NAME OF an
UNDERTAKER ...ovoscce-ugeeeseee 22 a

Statement of occupation.—I’recise statement of occupation is
very important, so that the relative healthfulness of various pur-
suits 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 bus-
iness, 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 whatever 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 partic-
ular kind of work done and return that, as SPINNER, WEAVER, etc.

In stating the industry or business, avoid the use of such gen-
eral 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 ENGIN-
EER, MINING ENGINEER, STATIONARY ENGINEER, etc. .\void 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 onder of onset were as follows:

Artertosclerosis ; 1915

Chronic interstitial nephritis

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 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 nave been delivered to such board, agent
or clerk, as the case may be, a satisfactory written statement con-
taining 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 re-
quired by law, or in lieu thereof a certificate as hereinafter pro-
vided. If there is no attending physician, or if, for sufficient rea-
sons, his certificate cannot be obtained early enough for the pur-
pose, or is insufficient, a physician who is a member of the board
of health, or employed by it or by the selectmen for the purpose,
shall upon application make the certificate required of the attend-
ing 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 an-
other within the commonwealth 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 a
removal shall constitute a permit for such removal: provided, that
such body shall be returned to the town from which it was re-
moved 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. Tf 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 ap-
pear upon the permit. The board of health, or its agent, upon
receipt of such statement and certificate, shall forthwith counter-
sign it and transmit it to the clerk of the town for registration.
The person to whom the permit is so given and the physician cer-
tifying 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—Cnap. 114, Sec. 45, G. L. (Trr-
CENTENARY 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. .. .—GeEn. Laws, Cuap. 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.— Grn. Laws, Cuap. 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 cemetery or burial ground in which the interment
is made, . . .—Cuap. 114, Sec. 46, G. L. (Tercentenary Epition.)

RULES OF PRACTICE

The fulfillment of the purpose of these laws calls for the ob-
servance of the following rules of practice:

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

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

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

The Commonwealth of Massachusetta To be filed for burial permit

F -301A = Suffolk OFFICE OF THE SECRETARY with Board of Health
s oz 3 Perret errr rs ( County) nnn Renee enn nnennnnee DIVISION OF VITAL STATISTICS or its Agent.
026 a W inthrop STANDARD A
Ese 22 BES bonne Ore ees CERTIFICATE OF DEATH Registered No...... BB. encse
° < ww (City o) anee
“toy < é Road (If death occurred in a hospital or institution,
> 3 3 = 1s. inccheces oh cree eee A ae Ee I eee ccesedeesd Che eee Ward give its NAME instead of street and number)
on
5°35 Susan Wonson Pope (If U.S.
n SNe Nea naa NESS eee ey a a Ee ec fA Te ee cps cve bee conde et eaantes'Suavesvccvesctlvdvtccececereses War Veteran,
) 2 S (If deceased is a married, widowed or divorced woman, give also maiden name.) GCA GY WANE) isk. os csscesescscchesodeuensstadeee
2 F Ro
ZOE (a) Residence. No. FOArt | ad EE. OR an ee ae Cee rel ea NET LMS So Re RIO ll day co en ME
On (Usual place of abode) 35 (If nonresident, give city or town and state)
g oO 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.
2 a ee
J Ye]
ee PERSONAL AND STATISTICAL PARTICULARS MEDICAL CERTIFICATE OF DEATH
5 ne 5 SINGLE (write the word)
B.. 3 = 3 SEX 4 COLOR OR RACE MARRIED
, 9 ne F wh
Aes Female White or DIVORCED Married
: 0 +4 5a If married, widowed, or divorced
3 9 a eae Papen pe eg oT a a
Wye 6 e@ mal wife in fu
Be 8. || (or) WIFE of... AnrefiS’ Tar". G 2 SR ae eee
PH a Oo (Husband's name in full) =e 3 aie ah ‘ 0A
ae 0 have occurred on the date stated above, at..././:50Am.
ws cf OIF STILLBORN, enter that fact here, The principal cause of death and related causes of importance in order of
Meot™ 7 63 If less than 1 day onset were as follows: _ \ Date of Onset
= 32 2 (Sata: 8 Wear ies. ce, 7) Months............ Days c HOUTS......000-0 Minutes IMPORTANT
°
zz ae 8 Trade, profession, or particular
3 > ind of work done, as spinner,
| 3 a) S sawyer, bookkeeper, etc...............0.-- At. Home bE RA cin d ae tees eats
Se & | 9 Industry or business in which
> <=
= 09 8 work was done, as silk mill,
td) E 3] Fs Same I NET env Sor coicee sce cosenaaeathelte apnea dueipashaifeevsacaversncohaeppranieatvsivered
%g S 6 | 10 Date deceased last worked at 11 Total time (years)
esr Se $ this occupation (month and spent in this
is a 3 C1 ee To 9 tee aaa seers sree eae occupation..................--..
OS S2 || 12 pintuptace (city)... loucester. Pe sE eo... Ceeek
2% 9 a (State or country) Vass veal
aA"%~e
52 a§ 13 NAME OF ea be. ea ci A ne ae RS ot Ce eS
| was FATHER Benj. Wonson a
Pe Name of operation.. HOS SG nate Oe? ey er oe ee Dalfar ahi aksncihanosid ae
Z25+2 «| 14 BIRTHPLACE OF Gloucester What test confirmed diagnOSis? .........ssssssssssssseeeeccsserees Was there an sutopsy?..42a%
Pacs | FATHER (City) ..........°
. Ee £ z=! (State or country) Vass 20 Was disease or injury in any way related to occupation of deceased? .29@2.....
wares w
| ef «| 15 MAIDEN NAME sreseneesggMenvscesensssucneenscnestenseussucassnsenuenenuneneencence4ss
BSS < F MOTHER Mary Allerton wiley, 9 righ AMMA AAAAD. ,M. D.
. I
SSE. 16 BIRTHPLACE OF (Address) WY. Aeraty fF 2ypoq date HA AY. 1927.
<) e Eo : >
pea ype Cone - 21 PLACE OF BURIAL, Y YY, WA
Zs (State or country) CREMATION OR REMOVAL —f7 ALK GLGR...4 MMA LA.
; Qa (Cemetery) (City or town) f
|| 17
Sse $ Ae al. Pope we | -gpagpans.. fs DATE OF BURIAL... Bh rfay- WBi.2
(Address) curt Road n mre Boag Bepbarep 22 NAME OF . Bes
ae g UNDERTAKER.......... paechard HO hi te. Boas
Iv 5 4
3 A. EBY CERT!“ ( that a satisfactory standard certificate of death was pi ry dar certificate ~ ai was ADDRESS... 147 Winthr op... St. i other ss
Saf I) oe gh
4 4 or AMS. Y.. Px oo a Pere Os rere A |, pe yh (A BOM
Fd 02 VL, "4,
rw 2 C ial gues tion) Ory tee Soe See es oe) a ee . Cite i eeemen ms erm ee ~~"

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
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 showd be called a
salesman and not a clerk.

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

Example

The principal cause of death and related causes

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

IQIs

July 5, 1927

Cerebral hemorrhage

Contributory causes of importance not related to
principal cause:

GOVERNING THE

RETURN OF CERTIFICATES OF DEATH

ody and remove it from a town, from one cemetery to another, or
from one grave or tomb other than the receiving tomb to another in the
same cemetery, until he has received a permit from the board of health
or its agent aforesaid or from the clerk of the town where the body
is buried. No such permit shall be issued until there shall have been
delivered to such board, agent or clerk, as the case may be, a satis-
factory written statement containing the facts required by law to
be returned and recorded, which shall be accompanied, in case of an
original interment, by a satisfactory certificate of the attending
physician, if any, as required by law, or in lieu thereof a certificate
.as hereinafter provided. If there is no attending physician, or if, for
sufficient reasons, his certificate cannot be obtained 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. [f such a permit for the removal of a human body,
mot 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
iby violence... .Gen. Laws, Chap. 38, Sec. 6.

No undertaker or other person shall bury a human body or the
lashes 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
jappointed 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
lis to be held, or from a person appointed to have the care of the ceme-
tery or burial ground in which the interment is made....Chap. 114,
Sec. 46, G. L. as amended.

i RULES OF PRACTICE

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

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

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

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

‘RECORD. Every item of informa- |
PHYSICIANS one state CAUSE
CUPATION is very

Exact statement of

hould be stated EXACTLY.

lied.

tion eoukl be carefully tat
OF DEATH in plain terms, so that it may be properly classified.

(City or Town)

No UsSe%aval Hospital

~
PLACE OF DEATH

Poll SA) ELGG aS PNY 0 DARI eR te ea a ae A RL ii
(a) Residence. No........ 77, Court Rds Sea ratsuestts

(Usual place of abode)

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

5 SINGLE
MARRIED
WIDOWED
or DIVORCED

3 SEX 4 COLOR OR RACE

Mal 5
5a If married, widowed, or divorced
HUSBAND of

(or) WIFE of

If less than 1 day
Months 18 pays

8 Trade, profession, or particular

kind of work done, as spinner, .

9 Industry or business in which
work was done, as silk
saw mill, bank, et
10 Date deceased last worked 11 Total time (years)
this occupation (month spent in this
j fp occupation

13 NAME OF
FATHER

Franklin Ws«Brown

14 BIRTHPLACE OF F,
FA St OVW»

THER (City)
(State or country)

15 MAIDEN NAME

PARENTS

16 BIRTHPLACE OF
MOTHER (City)

(State or country)

‘wea Cheties HyBrown Brother...
(Addre: bur Road ,Winthrov Jase

A TRUE COPY,» Z*
CTL A ta £4

" (Registrar of city or town where death occurred)

Jane 165 én.

chon” Susan Louise Wonson

PudieintonpHillietus wvius ick pitee pss tobndscudevenesstvane Pa

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

STANDARD
CERTIFICATE OF DEATH

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

(If U.S. iat
War Veteran, ‘* orad

19 I HEREBY CERTIFY, That | attended deceased from

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

rteriosclerosis of kidneyea............|............
Parciac hypertrophy... fa

Name of operation....... Hone Bo vse Areceniaunculauseaeenbute Fis aichn cat Datecofscins...itdackes
‘]..... @gWas there an autopsy77.6.8

20 Was disease or injury in an
UC TSS NINi vec,» Sta ea oicg Vinca 6 dae bivnstockaxacvccnaveccnceadtacze chavhudeectwoatovévonaned siscsai¥eancecstavetnecueattert

(Signed) -DdebeNorne °

(Addres® OL pate Nt, str Sh gel
@1 PLACE OF BURIAL, j ;
CREMATION OR REMOVAL........ oN. Lntprgge.-
(Cemetery) (City on bb °
DATE OF BURIAL. ...........- pe) = Sr SOE:
22 NAME OF 4 ~ OR
UNDERTAKER ... ‘ichard Heh:
avpress.... -Lnthrop st. PODeMaaN »
Received and filed......cccccccscccccsesesseneeeeees J=5........ bs -
nade sseseeraneen t oo

Me 4 f; ; “ r .
(Registrar of City or Town where decdpshresided), P- J
\ «a? . — p

PHYSICIANS should state CAUSE OF D

ACTLY.
the laws on back of certificate.

ctions and extracts from

so that it may

See instru

No, 6156F

in plain terms,
important.

100m 12-'3S.

The Connnontwealth of PMassachusetts To be filed for burial permit

Sete SU tO be... OFFICE OF THE SECRETARY with Board of Health
Py (County) DIVISION OF VITAL STATISTICS or its Agent.
a epee STANDARD q if
1 Cpe ee ei Wei Pen : a
= (City or Town) CERTIFICATE OF DEATH Registered No. -...............--------
< ; b Mg oe
a re ee ATE (If death occurred in a hospital or institution,
Now 90.6 an -58 AUINey..AV. Fie oenene nen nnnnnnnnnnnenn enn nnnnns NOE AS Ee Ward \ give its NAME instead of street and number)
(If U.S.
mere MaMa Lac eo! MeCarthy oe War Veteran
(If deceased is a married, widowed or divorced woman, give also maiden name.) specify WAR) ................0....0..... =
(a) Residence. No......... Bowe w Amey Ave, F220 gs ce Sel tee ues Wardd . teeter eb eee
(Usual place of abode) (If nonresident, give city or town and state)
Length of residence in city or town where death occurred years months days. How long im U.S.., if of foreign birth? years months days.
PERSONAL AND STATISTICAL PARTICULARS MEDICAL CERTIFICATE OF DEATH
5 SINGLE (write the word)
eae sy | DEATH f H7 ps Suh 37 |v
al rite wo eplarried (Month) ay) (Year)
5a If married, widowed, or divorced a: 19 I HHREBY CERTIFY, That | attended deceased from
HUSBAMD of... FETE EUG SCA MIOL L . ervrssenenerieene Le /, 2.
(Give inaitien same of wife in full) eo 8 +§ PALLET nee OR See
FN Di I ces tote Fderrescarusiete nae tean an stissoiecasoncssaspieesaieons scovnesdeworencnsavcsvercesevensdaassanssessendesoases 5
Giusband’s name in fui) YA ast saw n. £22... allve on
6 IF STILLBORN, enter that fact here. to a occurred = the date A oe 4 2 ere
ie and r causes mportance In order o onse
vf Wa If less than 1 day ose cause of dea 0 ——————
eee, Oe veers... onthe. eave | Les Hous 2 Sante |] POO Fen et ee
Sasveesece VOBLS.sseeeesseseeeMOMEHS ..ececceeeDAYS | ceseese-ee-HOUPS.ceeeeeeeees IMPORTANT
8 — prem opt or particular
ndof wo @, aS spinner, res ee ee
5 sawyer, bookkeeper, CtC..........s.sse:sssssseztes Aas)! a ee
| © Industry or business in which
a work was done, as silk mill, ato Me, te ie re. tat
S saw mill, . cpoetecaes mec 084 ON Ea RY 8 2° RE a
$|10 thi deceased last San, ie 11 Total ig eli
is ae on spent in =
wis) is g Ceeupation.caed Semssensateies

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

a oo
FATHER

14 BIRTHPLACE OF

nd “i ES Ss A Ee Sener 1 > 001 ©) @ eee a ee What test confirmed diagn&iggZ f a. Y........Wasther&an autopsy SL,
Z| (State or country) f oF j— ;
w 20 Was disease or injury in any way related to occupation of deceased? ,2#..,.........
| 15 MAIDEN NAME | 180, SBC ong CREE: ee PERE feats | T
2 y po Se (Signed) so, “ae M.D.
BE EE BOS (Addre ries Joe. Spe J at. Date fe hoy on

21..

17 Relation, if any

P lace or ‘Barks
E.G... Me Carthy... (oe PALM...) DATE OF BURIAL..
} {VE 22 NAME OF
1 HEREBY CERTIFY that a satisfa veer ndard certificate of death was ry. ger,
Sy, ith me BEFOR parmit was issued: ADDRESS...

et hat Md,
leet

sees ee eeeeeneneee:

Statement of occupation.—l’recise statement of occupation is:
very important, so that the relative healthfulness of various pur-
suits 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 bus-
iness, 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

uestion 9. Tor a person engaged in domestic service for wages,
oe designate the occupation by the appropriate terms, as
HOUSEKEEPER—PRIVATE FAMILY, COOK—HOTEL, etc. For a person
who had no occupation whatever 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 partic-
ular kind of work done and return that, as SPINNER, WEAVER, etc.

In stating the industry or business, avoid the use of such gen-
eral 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 ENGIN-
EER, 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, nor 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:

pa ed ae ee | ae eee
Chiraeileciebar sitll ep BUA ae Bebe cease snnernsaes ee es occ
Cerebral hemorrh July 5, 1927

Contributory causes of importance not related to
principal cause:

densnsesecrceesnstcsssccsesssesnessesesennssssces steenseccesesesscsses seetesecsesseene anne |cescccesescesecessssccesecsens

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.

Saaew Sweet we

A physician or registered hospital medical officer shall forth-
with, aiter the death of a person whom he has attended during his
last illness, at the request of an undertaker or other authorized
person or of any member of the family of the deceased, furnish
for registration a standard certificate of death, stating to the best
of his knowledge and belief the name of the deceased, his sup-
posed 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, Cuap. 46) Src. 9.

which shall be accompanied, in case of an original interment, by a
satisfactory certificate of the attending physician, if any, as re-
quired by law, or in lieu thereof a certificate as hereinafter pro-
vided. If there is no attending physician, or if, for sufficient rea-
sons, his certificate cannot be obtained early enough for the pur-
pose, or is insufficient, a physician who is a member of the board
of health, or employed by it or by the selectmen for the purpose,
shall upon application make the certificate required of the attend-
ing 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 an-
other within the commonwealth 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 a
removal shall constitute a permit for such removal; provided, that
such body shall be returned to the town from which it was re-
moved 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 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 ap-
pear upon the permit. The board of health, or its agent, upon
receipt of such statement and certificate, shall forthwith counter-
sign it and transmit it to the clerk of the town for registration.
The person to whom the permit is so given and the physician cer-
tifying 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——Cnap. 114, Sec. 45,, G. L. (TrErR-
CENTENARY 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, Cuap. 38, Sec. 6.

Spas es 2S wee 8 eee ae 8 SS ae

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 cemetery or burial ground in which the interment
is made. . . .—Cuap, 114, Sec. 46, G. L. (TeErcenTENARY EDITION.)

RULES OF PRACTICE

The fulfillment of the purpose of these laws calls for the ob-
servance of the following rules of practice:

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

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

Exact statement of OCCUPATION

stated EXACTLY.
ws on back of certificate.

— classified.
a

AGE should be
hat it may be pro
d extracts from the

BLA’
*

ould be carefully suppli

sot

lain terms,
See instructions an

CAUSE OF DEATH in p

B.—WRITE PI
information

is very important.

No. 7070-h

100m-12-'3?.

TE | 4 COLOg 0 Bente
\ A WIDO
er DIVORC

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

STANDARD

(City or town making me

Registered Now...
irae gsi aes or institution,
give ifs } instead of street and number)

(If U. S.
War Veteran,

(a) Residence. No.....,4.. ta RR rd ok A oa: Sess, SRaarra e i J ‘t . F ee hor

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

days. How loag in U. S., if of pare birth?

yrs. mos, days.

5a If married, ‘ibewed, or divorced
HUSBAND of ............ yO ae (5 Ue ae See apenas snc crsaeriaa Me tasan sn isBocoe cus icdeessnascvocserens riod

ET I eR A a nal Coal Sat Pe, on A ote cee een Rare Reteiavna seater
(Husband's name in full) ud OA
6 IF STILZBORN, enter that fact here. to have occurred on the date/ftated above, at seemrhcneve
Pe sre ae + The principal cause of death and related causes 7 frites in order of
|| Ifless than 1 day onset were 2s follows: “Date of Onset
ie as Ce Months........ DayS | .c-.0-..--HOUPS: 201-0400 Minutes
8 Trade, profession, or particular
Z| kind of work done, as spinner, OD
o| sawyer, bookkeeper, €tC............c00ccceeeee Sette tela sec iah cn daibenvons<sacMatraaceodseoatat
| Q industry or business in which
a work was done, 2s silk mill,
S BUT a IR TO lacs 2 ova cs th oes 05a nonvar tonne dsos Oe ee DO aaa meson oensucameende nis vni ra Praned seep wowne clase Meine emadprins areas
=| 10 Date deceased = a # 11 Total ine vee
ie Gcrapatboa “(nninth An: Mount in TicM Cee) oo ee ee
ER Ta : antZT $7 occupation......%@. Wr.
12 BIRTHPLACE (City)... WwW PALTVAPI ooo ccccctnssseseenennees
(State or country) Onan
13 NAME OF Peer ereer eee rere eee ee . Terre TOL Cee errr eT eee Ter reeeerrrrrerrrerr rer er rrr rr rrr | Cees reeewsereres
FATHER 0 Ka. 3 :
| 14 BIRTHPLACE OF : Mame OF OPOPatOn ies 25 oar: occssecancys-peonsn-nyosmnentecastnep-oecies-aoed Date Off. .:2.200.)-covenscaesensny sfas=
= FATHER (City) . GQoawe ns ; What test confirmed diagnosis?....................2-+- .Was there an autopsy?. —-
=| (State or country) 7 aes : ‘
us pees, & Sbienty, 20 Was disease or injury in any way related to occupation of deceased? ..................
. 15 MAIDEN NAME i
. GF MOTHER —~ vv If so, nA Aga Ce Se OER a RE ee SE EE a he
“| (Signed) ...d.....00 a 4
16 BIRTHPLACE OF a
MOTHER (City) CRU GEGES) 5 cag dc Boek mano rttenceannrc cave ceveuss

| SATE Pes 21 PLACE OF BURIAL, —_. ;
wun ee,“ Yule ne CREMATION OR reeeee TT BE
17 9 - Cemete (City or town)
£ AMADA 19.5...

\)
Inlormast .VAAA re) « = Ry Qe A+| _ DATE _ OF BURIAL...........

(Address) @G Ya native 22 NAME OF

ss UNDERTAKER .... x
| HEREBY CERTIFY that a satisfactory standard pryphange of death was

filed with me BEFORE the burial or t it yasgissued: __appress DUES: Weiarnedlt WL aha

Bete Ss, AGIA

y (Signature of "Agent of

- ngs

(Official Designation) A TRUE COPY, “ATTEST: ’ (Registrar)

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

90,—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 part
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
aoe of store, factory, mill, ete., as grocery store, soap factory, cotion
mill, etc.

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

Statement of cause of death.—Cause of death means the disease,
or complication which causes death, not the mode of dying, 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. Wnder contributory causes of importance not
related to principal cause, name other important diseases.

—————

Example

— ————————

Date of onset

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

Iors

192i

Contributory causes of importance not related to
principal cause:

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

GOVERNING THE

RETURN OF CERTIFICATES OF DEATH

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 por 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 Shall
make such certificate. If such a permit for the removal of a human body,
not promaues 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, suc 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 ermit 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, Gra
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.

is to be held, or from a person appointed to have the care of the ceme-

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

RULES OF PRACTICE

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

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

a
w
c
>

EATH ©

CAUSE OF D
CCUPATION are very

the laws on back of certificate.

ons and extracts from

ree ti

terms, so th
important. See

No, 6156F

100m 12-'35.

The Commonwealth of Massachusetts To be filed for burial permit

i eat One OFFICE OF THE SECRETARY with Board of Health
P| (County) DIVISION OF VITAL STATISTICS or its Agent.
1 be Minthrovo We STANDARD Fa
ae STE (City or Town) a a CERTIFICATE OF DEATH Registered No. _..........°= bez
3 2 : : Res iy
= 26 Lo eus “ (If death occurred in a hospital or institution,
Now ee = beaches wd Beton AE J ee eh eae tcc Eee ee S t-y-------------- Ward give its NAME instead of street and number)
= DU he (If U.S.
2 FULL NAME ....- Margaret B. (_ McKean } tome OST, 2) A en LO ae |W Veteran
(If deceased is a married, widowed or divorced woman, give also maiden name.) epecity WAR) «.. .<..<.2.sdc-cchceneeee ES
(ah (Radinace. No..cO Locus, Sirect es on Spucredei ee Weekes: cote ica, | Dena
(Usual place of abode) (If nonresident, give city or town and state)
Length of residence in city or town where death occurred years months days. How long in U.S., if of foreign birth? years months days.

PERSONAL AND STATISTICAL PARTICULARS M p ICAL CERTIFICATE OF DEATH

5 SINGLE (write the word ¥ ;
lo bee We ee eee Bef ase 73.7.
Fema le Whit wpvoRcED i dowed (Month) ayy 7" Wear)
6a If married, widowed, or divorced 19 HHXEBY CERTIFY, That | attended deceased from
USRAMD Of jo... Ss ccceccn... CORE ae eM riskon tteReaweccains yy L 19.2
ne: 3 J Size one aL |) RT vo icsbenept puns Pemcctmnamst ics frcveseesesenenent LOA, GAay 10, Je ET ccreerneale geeneeees » 19.2.
WIFE <i. A ee ee be EEE es eadaneselsscdenceds calsiupeasamunecss ss t saw b. E*...allve On... 2 as 2 13. ie death Is-sald
6 IF STILLBORN, enter that fact here. have occurred on the date a{dted above, at 6...
= Flesa than id The principal cause eath and related causes of Importance In order of onset
COA eee ae were as follows: “Date of Onset
(VL ied SES Wearso=...-.. Months............ RYE cnssetsace,: HOUFS........+04 Minutes IMPORTANT
iat = a fie a oe ee
ea NB COTTE iB MRM | i ae a Vi
E 9 <r or a a ie Snsepansdedavunetvenns Arccun vanes sous dageeasveus sansuextosrakuanndesusabeselanevndaunauiue‘ausbond 2shuNeuames
a. work was done, as i. a moO
= saw mill, bank, GtC............:.:::scsscseseresseeees Or é Hi ee Meee ee NN aa reveca so sg cBiincbe cae peeemevawhcuscedendvacveccandunnanvesevencbacerasnacanq=ahsavasen [axdeneancemmansnia
6| 10 = deceased last worked at = 11 Total pen \veatal
Apoxn 5 ee reine Mee PUN estab tue tics 2M aga stot o aechwsstncnstoranun isonussiuvvscnseapiebosordudronernkenuectla#Obaame nang
eatlatt oh Aciieeas net 19.36: Geenpation.. fae BO. | oe of importance gs ag to principal cause: "ii
SEE RN Mee a Ma ig rae oe cca cased ctyfocctcnvsnenrcncacesvopnccencotanetiit ae rod role geil ie ee
tate or country) PES Ya SO MR ONE) Se Se Re RO hs Ae ROE, be SBN

a 14 BIRTHPLACE OF PUM TaT ER CN CODBT AN LAND ooo cigs ss ces tks cbarebencesceasoceruaxpsclpacadteascl

vt FATHER (City) What test confirmed diagnosis?

w 20 Was disease or Injury in any way related to occupation of deceased? ............-....++
a Ti RN ONT ee ake ate a RE Se lie oe ee Rta ea A

od (Signed) .......¢.

(Address) 564... 6r2.7..¢

+ \t.]
hast 9 PEGs patchrrerowericuaraleeubcbed natedek secede deaneadoandvdtrod bers abanyechaseeshporass Castlbottataate fapeseemnaze WWicevavdhs Ci eenebae
Place of Burial, Cremation or Removal. (City_ or Town)
DATE OF BURIAL. on euf/f-t).taI Liki Ae Eo ccdanss tha wedel cssnssrsessse AQnesenon
22 NAME OF Wr £57 y
UNDERTAKER ........2 0 i hat on
cate of death was avs ’ chyvsetts
$ jpsued: ADDRESS........... Pia scntrvales: 71058 LE IE Th DCA DOE i A CLO fA :

Received and filed GP | ca RE ite A 6 IR fa 3

A tAe een eeeeeneneneeeenpereeeeeeesereene rrerteeereriteritirerrc iter stttg

Statement of occupation.—lrecise statement of occupation is:
very important, so that the relative healthfulness of various pur-
suits 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 bus-
iness, 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 whatever 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 partic-
ular kind of work done and return that, as SPINNER, WEAVER, etc.

In stating the industry or business, avoid the use of such gen-
eral 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 ENGIN-
EER, MINING ENGINEER, STATIONARY ENGINEER, etc. Avoid the term
“Jaborer’ 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|~ ate of Onset
of importance in order of onset were as follows:
Arteriosclerosis , 1915

Chronic interstitial nephritis

Cerebral hemorrhage

Contributory causes of importance not related to
principal cause:

ae ceensecneceeeenserscsecensenscaerensesenenes

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.

oc neces tt A EC
= resi

RETURN OF CERIIPIVA PES wor eeernsss

A physician or registered hospital medical officer shall forth-
with, atter the death of a person whom he has attended during his
last illness, at the request of an undertaker or other authorized
person or of any member of the family of the deceased, furnish
for registration a standard certificate of death, stating to the best
of his knowledge and belief the name of the deceased, his sup-
posed 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, Cuap. 46, Src. 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 nave been delivered to such board, agent
or clerk, as the case may be, a satisfactory written statement con-
taining 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 re-
auired by law, or in lieu thereof a certificate as hereinafter pro-
vided. If there is no attending physician, or if, for sufficient rea-
sons, his certificate cannot be obtained early enough for the pur-
pose, or is insufficient, a physician who is a member of the board
of health, or employed by it or by the selectmen for the purpose,
shall upon application make the certificate required of the attend-
ing 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 an-
other within the commonwealth 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 a
removal shall constitute a permit for such removal; provided, that
such body shall be returned to the town from which it was re-
moved 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 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 ap-
pear upon the permit. The board of health, or its agent, upon
receipt of such statement and certificate, shall forthwith counter-
sign it and transmit it to the clerk of the town for registration.
The person to whom the permit is so given and the physician cer-
tifying 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.—Cnap. 114, Sec. 45,, G. L. (Trr-
CENTENARY 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, Cuap. 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, Cuap. 38, Src. 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 cemetery or burial ground in which the interment
is made, . . —Cuap. 114, Sec. 46, G. L. (TERcENTENARY EDITION.)

RULES OF PRACTICE

The fulfillment of the purpose of these laws calls for the ob-
servance of the following rules of practice:

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

(2) Board of Health physicians will certify to such deaths only
as those of persons who, though disabled by recognized disease
unrelated to any form of injury, have died without recent medical
attendance or whose physician is absent from home when the
certifioate 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 septi-
cemia), and by the action of chemical (drugs or poisons), thermal.
or electrical agents, and deaths following abortion, but also deaths
from disease resulting from injury or infection related to occupation,
the sudden deaths of persons not disabled by recognized disease, and
those of persons found dead.

The Commonwealth of Massachusetta Te be filed for burial permit

NRE MMS CRORE Ysa fale torent Reda Rent ies Ur a¥ ys oie Srtsasbainaspaveuadvosoesseaesdaivdvownsvvaregazee
(State or country) :

13 NAME OF
FATHER i, ; e Z, 4 ‘

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

(State or country)

Name of opsraiion................
What test confirmed dlagnosis?...

DCL On | CS co SSRNNG I a, os A shcsiaas dua dehosXndboeatncanegrca hate tepreia
(Signed) .... A020 QIN... pect LAM OLE, LS ;

16 BIRTHPLACE OF 3 * veeey Fodeses Sr sf) y) See Cf Bue. fh...

OTHER (City) ......
M (City) 21 PLACE OF BURIAL,
(State or country) CREMATION OR REMOVAL

Wife. 1A RS ee rats 1 oe 9: ne aa \5

(Address) 7 feof 22 NAME OF
c Leer Chia fo Za AME O
= = UNDERTA

301A OFFICE OF THE SECRETARY with Board of Health
e. E DIVISION OF VITAL STATISTICS or its Agent.
‘62% a STANDARD 4e
e a. "FP
£35 ai OW (> oy CERTIFICATE OF DEATH Registered No............. NS ath
oO we (City or Town)
7S g 4 (If death occurred in a hospital or institution,
i a = No. Z& Khe Bat: give its NAME instead of street and number)
ee
ee oo Bes & (If U. S.
; pa Pe TEU SUNY Se 2 og a a oe a el a OS, Sa War Veteran,
F A 0 kag decefsed is a married, widowed or divorced woman, give also maiden name.) specify WAR). “77 O7.4L_, aS tas
ml jet <
MOE (a) Residence. EE a Aad ae ieee euen 1 ERTS OM RO Oot se BES 00 Piece cree eee Oe ae
n g (Usual place of abode) (If nonresident, give city or town and state)
ne oO 2 ___ Length o} of residence in city or town where death occurred 2S yrs. mos, days. How long in U. S., if of foreign birth? 42 yrs. mos, days.
wots i
"A Sg PERSONAL AND STATISTICAL PARTICULARS MEDICAL CERTIFICATE CF DEATH
B..3% SEX 4 COLOR OR RACE | 5 SINGLE Greite Hpeore) | 1S DATE OF 37
be . $ WIDOWED DEATH......... Yew 5, St Ar! SNEED <I ee eee Goel Oa LO Bone
2rd. a. or DIVOR! WY a sales (Month) (Year)
; 2.5 4 5a If married, wide i 19 17H EREBY CERTIFY, That | attended deceased from
7: 433 HUSBAND of .....0 M00 ae oe eae A GO ar aaa a Ses | MD 2 BM 4 ae ee Ser} fe eae 192.7...
3. (or) WIFE of : | las saw h.4em....alive on..... A. 5 , 193.7..., death is said
3 3 } 6 (Husband's name in full) 3 P
eS 6 IF STILLBORN, enter that fact here to have occurred on the date stated above, ee mee 0../.m.
vg § ae 2 The principal cause of death and related causes of importance in order of
4 o= 7 z, If less than 1 day onset were as follows: Date of Onset
= 32 g || AGE.....0.Z... YVOArS..oeoenes Months... Days | ooecroo Hours......-..- Minutes | IMPORTANT
I actin sensiggp rence nneranncrennere office sve osensna ding satbynsnnsnnonscsensnncersenteail veetcteastgeites
on 8 Trade, profession, or particular _ f
| 5m £ = kind of work done, as spinner, ° A 18/22.
woto 3S sawyer, bookkeeper, €tC..........0000 S00. ALO PEI oc ccccctecrscecnees
pers Te ST SSeS TR STS | ret | eran (Ok aaa “ai aa Lia > ia (YL | *
| a a work was done, as silk mill, 1/22]? /
JAS 9 saw mill, bank, etc..................... 7000. 7ee nest)... LL a ae eee ee eee one ee Lae ea ce
BOE g &| 10 Date deceased last worked at cH ‘Total PEEpIT GSC Gare re ase cece ccc rsa cM aace trends Mansa aes on casrtacgay san augh caidtteatatacatastconstostvacc | Salsa.) Seetter ea
< 4 month and spent in this 80
o Sgt eae ire castids Wi adepisateasntztacnidsan occupation.....@.........
as]
£
|
a
£
°
-
-
3)
]
4
£
-

15 MAIDEN NAME
OF MOTHER

PARENTS

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

is very important.

information

1 HEREBY CERT!" /¢ that a satisfactory standard certificate of death was
ed with me BLFOR 6 or transi sae was | issued:

i rs f ny

very eperent: 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
ylad of store, factory, mill, etc., as grocery store, soap factory, colton
mill, etc. ri

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

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

Example

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

Date of onset

. Arteriosclerosis

Chronic interstitial nephritis I92r

July 5, 1927

a | s.ceceneaeccesccee Wenveeee

Cerebral hemorrhage

Contributory causes of importance not related to
principal cause:

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.

ealth 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 rabienede 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, of 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.

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

RULES OF PRACTICE

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

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

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

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

~ COMMONWEALTH OF MASSAGNUDETIDS

Very ster OF

PHYSICIANS should state
Exact statement of OCCUPATION

RANE OR BRAD EP FR BS SBN AVESAIN EUAN A BN AUNU OREN EY)

AGE should be stated EXACTLY.

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

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

00m-12-'34. No. 2938-e

AN a Derr VV INA EEL FP EAPREINES Eg VR RES

& She Commonwealth of Massachusetts

Cee Fer MEA OELCE REMI AR ROM, a ccucheoccncencteapcesevidsavoneess oeeecetr Het EE
= Tee a) uttole — yes saeeeme DIVISION OF VITAL STATISTICS (City or town making return)
P| , STANDARD “Aig
is. Wank hrop. i CERTIFICATE OF DEATH Registered No.cccsccsccsenntre fe
g fap eagle (if death din a hospital
x eath occurred in a hospital or institution,
a No... 62. pleas sant ee ee aes pee ES) ee ...Ward give its NAME instead of street and number)
t (lf U. S.
SRE TNE ee OM re ae cacsussetsccrcrteqnnmtenncoe War Veteran,
(If deceased is a married, widowed or divorced woman, give also maiden name.) SPECIEG? WALD sscsnncsctseccececsssuscvssccconnatete
(a) Residence. No.......... 262. kleasant Bi asachsananbecsenseeuacseectoes SEs ter As cea. Wrardwe ei 20 eet Ba eles Al BRL, casctacevsapeennn tee
(Usual place of abode) (If nonresident, give city or town and state)
Length of residence in city or town where death occurred 4 0 yrs. mos. days. How long in U. S., if of foreign birth? yrs. mos. days.

PERSONAL AND STATISTICAL PARTICULARS MEDICAL CERTIFICATE OF DEATH

3 SEX 4 COLOR OR RACE | 5 SINGLE (write the word) 18 DATE OF yy
, MARRIED ’ a3 LI3 7
a DEATH -.cssssess COREE ELPA, SP gp rrcccrrhef 2. Lecce
Male | White wipoweD | Married Month) Dat (year)
5a If married, widowed, or divorced 19). 71) FA REBY CERTIF That | allended deceased from

HUSBAND of .. 22.92

sn agPresevcsnesesereceePareccreccreseesl) PWrreefae

to have occurred on the date
The principal cause of death and related causes of importa ¢ in order of onset
were as follows:

6 IF STILLBORN, enter that fact here.

i i
AGE....... re 9 Weceovee Years. LL....Months doe Days

8 Trade, profession, or particular

if fess than 1 day

kindof work done, as spinzer, i)
2 . Pe prec it Sea ee ae MS ae
ie Svein Bievator | |
Sit akecnin aaa sn 2026) °° woute this
SSRN I es basic tolbasny Gioveseal Teton stonc avoeteans dashoners anne OCCUPATION.....cccereeeeeeseenes

12 BIRTHPLACE (City) VRAD oc cccssessessssnntnnnnsesmene
(State or country) “Ve: rm ont

13 AMF Jason Dow

14 BIRTHPLACE OF Name of operatio

° FATHER (City) ..cscsccrromatcreetsecree essence Monee eM RE cesscssnecersnesee What test confirmed diagnosis
z (State or country) at
w 20 Was disease or injpry in any way related to occupation of deceased? ww,,.........
«
<| OF MOTHER MArtha (Unable $0 ob ta inh] !f 80, specity.csceplerevesssenen
a SS (Signed) ...... aA Rx orale egg latinas RM
(Addresef #0 ZS 12 ore A
a wash, Uneble-to~-obtatnr ar att eae Lhe. Yoeag
or country 1 —
CREMATION OR REMOVAL .. a [00 0. Law Trae
Sette) zi
DATE OF BURIAL. DIRE ery AGP as
22 NAME OF Sri.
UNDERTAKER ore fas, feet Bev er Seni ig ¥
ADDRESS.........0 E22’ z MSS So") Z|

j re t/of Board of He: Adty er) hea emt ani: Received and filed.........0+++ bret ao a vi, Deron

(Date of Issue of

-—

ROVIsed United oratles Viahdara Veruricare Of Peat

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
eged 10 yearsorover. If the occupation had been given up or changed
on account of the disease causing death, report the occupation prior
to illness. If the deceased had retired from business, report the
occupation prior to retirement. Children not gainfully employed
may be returned as at school or at home. For a woman whose
only occupation was that of home housework, write housework
in answer to Question 8 and own home in answer to Question 9.
For a person engaged in domestic service for wages, however, designate
the occupation by the appropriate terms, as housekeeper—private
family, cook—hotel, etc. For a person who had no occupation what-
ever write 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
kind of store, factory, mill, etc., as grocery store, soap faciory, cotion
miil, etc.

Distinguish carefully the different kinds of engineers by stating
the full descriptive titles, as civil engineer, mechanical enginecr, mining
engineer, Sialtionary enginee7, etc. Avoid the term ‘‘laborcr’’ 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 retai merchanis
and wheiescle 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 Ceath, noi 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
rélated to principal cause, name other important diseases.

Example

The principal cause of death and related causes

: : soe Date of onse?
of importance in order of onset were as follows:

Arteriosclerosis

rorg

interstitial nephrélis

ro2r

hag

SNDOAROE Ae caeneneeneeneranenaaeereesaseeneceunceeeenes

AO ANON ARO e ee EOeeEre Hee eeeee ante sEEReEED SERB OE AES eE ES ee EREE ARSE EROS SEED ERNE GHENSBEEE EEE SEESSENS cus HassESEBESDESEBEEEESSOS

SEE ES ROE a eee i ae a ee | op sc

Contributory causes of importance not zelated to
principal cause:

In a group of causes containing the principal cause and related
Causes, the causes shouid 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.

ee SOVERNING THE
RETURN OF CERTIFICATES OF DEATH

A saps egy or registered hospital medical officer shall forth-
with, er 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 2 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
eg 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 tom) other than the receiving tomb to another in the
Same cemetery, until he has received a permit from the board of health
or its agent aforesaid or from the clerk of the town where the body
is buried. No such permit shall be issued until there shall have been
delivered to such board, agent or clerk, as the case may be, a Satis-
factory written statement containing the facts required by law to
be returned and recorded, which shall be accompanied, in case of an
original interment, by a satisfactory certificate of the attending
physician, if any, as required by law, or in lieu thereof a certificate
as hereinafter provided. If there is no attending physician, or if, for
sufficient reasons, his certificate cannot be obtained early enough
for the purpose, or is insufficient, a physician who is a member of.the
board of health, or employed by it or by the selectmen for the purpose,
shall upon application make the certificate required of the attendin
physician. If death is caused by violence, the medical examiner shal
make such certificate. If such 9 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
Gesizing 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 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 shail appear upon the permit.
The board of health, or its agent, upon receipt of such statement and
certificate

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