The volume, 1938
Town Clerk, Winthrop · from the Internet Archive · 520 pages · 44.2 MB
open the file ↗ · original at the source ↗
’:*> — :
J. L. FAIRBANKS DIV.
Thomas Groom & Co.
Stationers
105 State St., Boston
To duplicate this book order
No. *, 7 *7^ ^
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3 SEX I 4 COLOR OR RACE
Ht <4-^. a_*r k lH
5 SINGLE
MARRIED
WIDOWED
or DIVORCED
(write the word)
Si u^K
18 DATE OF
DEATH
r iur
[ J (Month) j
(t)ay) ! (Year)
5a If married, widowed, or divorced
la, i h e’re b y CERTIFY
1 That 1 attended deceased froja.
i
g 3.u..fefcelU
5 (County)
Wiht ity<4^:
^-(City or Towny /
<o. .C.X/VH. MML .V. Mr*£l l.fayplAyJ
®f|p (Hot^tnonuura4..f . /^HJaHsarljuBi
OFFICE OF THE SECRETARY
DIVISION OF VITAL. STATISTICS
STANDARD
CERTIFICATE OF DEATH
To be filed for burial permit
with Board of Health
or its Agent.
Registered No.
1
....St., Ward
2 FULL
NAME ...\/<4..VW.<f3. 4 ; / t V v ':v
■A ^ sJ<W«M^(
(If death occurred in a hospital or institution,
give its NAME instead of street and number)
(« U. S.
War Veteran,
•peril? WAR)
(a) Residence. No...
(Usual place of aboi
Length of residence in city or town wherr death occurred
(If nonresident, give city or town and state)
i. g days. How long in U. S., it of foreign birth? yre. mot. days.
PERSONAL AND STATISTICAL PARTICULARS
HUSBAND of
(or) WIFE of
(Give maiden name of wife in full)
(Husband's name in full)
6 IF STILLBORN, enter that fact here.
7
AGE
Years Months
Days
If less than 1 day
Hours Minutes
8 Trade, profession, or particular
kind of work done, as spinner,
•awyer, bookkeeper, etc.
9 Industry or business in which
work was done, as silk mill,
saw mill, bank, etc.
10 Date deceased last worked at
this occupatit)
year) .
1 1 Total time (years)
spent in this \9> «
- ,, — . O
occupation.
(State or country)
13 NAME OF
FATHER
14 BIRTHPLACE OF
FATHER (City)
(State or country)
u
15 MAIDEN NAME
OF MOTHER
Sb J Q**jX*.
10 BIRTHPLACE OF
MOTHER (City)
(State or country)
17
Informant
(Address)|^ y
I HEREBY CERTIFY that a satisfactory standard certificate of death was
filed with me BEFORE the burial or transit permit, was issued:
fa/jr?A
(Signature of Agent/51 Board of Health mother) ,
/jfea..
/ / (Date of Issue of Permit)
is 7
(Official Designation)
MEDICAL CERTIFICATE OF DEATH
to
I last saw h.A-uv-alive on..^r^tv(/...y. , !%£>¥■■. death is said
to have occurred on the date' stated above, at
The principal cause of death and related causes ot importance in order of
onset were as follows:
Contributory causes of importance not related to, principal
l&xiAiaJ!
Name of operation
What test confirmed diagnosis!!
t ... Date of
Vss there an autopsy? Jk*(j
20 Was disease or injury in any way related to occupation of deceased?.
(Signed) S SJSKrf <7^ ■ M.J),
(Address! SoS&UL*- Oat
21 PLACE OF BURIAL,
CREMATION OR REM0VA1
DATE OF BURIAL
c^rr- , M.D.
at</'‘X
, /44o^
{Cemetery) (City or town)
J9 M
22 NAME OF
UNDERTAKER
ADDRESS
Received and filed
S*. •(*
Jan*. 1.2, 19 ...30
(Registrar)
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.S.uf.f.olk...
(County)
1 <
s Y/inthrop
bd (City or Town)
®bc Commontoealtf) of iWasteacfrtigettg
OFFICE OF THE SECRETARY
DIVISION OF VITAL. STATISTICS
To be filed for buri&l permit
STANDARD
CERTIFICATE OF DEATH
with Board of Health
or ita Agent.
No.
140 Shore Drive / (If death occurred in a hospital or institution,
... ....... .... St., ... V/ ard i
Registered No ft*1..
: cur red in a hospital or insti
give its NAME instead of street and number)
2 FULL NAME
CL,
(If decea/
tied,
-Solai-ne
also meiderr nai
name.)
ved or divorced woman, give ai
(a) Residence. No ' St., Ward,
5 months day!.
f (If u. s.
-j War Vet.
I specify I
Veteran
WAR)
(Usual place of abode)
Length of residence in city or town where death occurred
(If nonresident, give city or town and state)
How long in U.S., if oi foreign birth? years months days.
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
i’emale
4 COLOR OR RACE
5S1MP-I R
a# 1 HUUT>
MAIUHEB
WIDOWED
o, DIVflBrEB
(write the word)
6a U named, widowi
HUSBAND of
(or) WIFE of
: divorc
— -
(Give maiden name of wifq
(Husband’s name in full)
6 IF STILLBORN, enter that fact here.
7
AGE..
3S
..Years.
If less than 1 day
Months Days Hours Minutes
8 Trade, profession, or particular
kind of work done, as spinner,
sawyer, bookkeeper, etc
9 Industry or business in which
work was done, as silk mill,
saw mill, bank, etc
10 Date deceased last worked at
this occupation (month and
year)
12 BIRTHPLACE (City)...!
(State ox country)
.*7 ^ occu
1 1 Total time (years)
spent in this
occupation...
I HEREBY CERTIFY that a Satisfactory standard certificate of death was
filed with i
maJKFORE the burial or trpnsrt* permit w qs issued:
(Signature of Agent of Bo^rd of Health or other)
(OOdi/^^itioi ' . 7 "...
MEDICAL CERTIFICATE OF DEATH
18 DATE OF
death J.anuary.....Z,.1.93S
(Month) 7 (
(Day)
(Year)
That I attended deceased from
<...! .7. 19^a
19 r\ X HBSRBY OEETIF'
19.3.7... 10 •
I last saw lk>*£r:. alive 193.^ death Is said
to have occurred on the date sfhfed above, at.jZ’.irLtn.
The principal cause of death and related causes of Importance in order of onset
were as follows:
Name of operation of..
What test confirmed diagnosis? Was there an autopsy?.*
20 Was disease or Injury in any way related tooccupation of deceased/^^p..
If so, specify..
(Signed)
(Adduss)^.j£?...
fit Date
r. , M. 0.
21 k yjl^fJULa^. — —
Place ofABurial, Cremation or Removal. (City or Town)
DATE OF BURI,
22 NAME OF
UNDERTAKER
,L....r.J.^u.^g^l.Q.r1938 ^ r
mMOAb Wmk
ADDRESS 1.
3.0. .w . it. Q a .C: .G S. .
Received and filed....
- .sI.QH.a 1.9.* 19...3.S
(Registrar)
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Revised United States Standard Certificate of Death
A R-301
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,„.S.u£f..Q.lJL.
(County)
o Wint hr op
(City or Town)
3tjp (Eommomupalll? of iSaaaadjttSBila
OFFICE OF THE SECRETARY
DIVISION OF VITAL STATISTICS
STANDARD
CERTIFICATE OF DEATH
(City or town making return)
3
Registered No
< tt . , _ f (If death occurred in a hospital or institution,
2 No.alnt.nrOp c :onuaaiuJt;£.Jla&^ . ward \ give its NAME instead of street and number)
2 full name Beniamin l&.Ms.on .. .
(If deceased is a married, widowed or divorced woman, give also maiden name.)
(a) Residence. No St.,
(Usual place of abode) _ _
Length of residence in city or town where death occurred ' ' yrr. mos.
(If U. S.
War Veteran,
specify WAR).
days.
Ward
(If nonresident, give city or town and state)
How long in U. S., if of foreign birth? yrc. mos. days.
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
Male
4 COLOR OR RACE
>7hi t e
5 SINGLE
MARRIED
WIDOWED
or DIVORCED
(write the word)
Married
5.*..“ ” '“S'Bha ( Dahl ) -SsHtfrMW
(Give maiden name of wife in full)
(or) WIFE of
(Husband’s name in full)
6 IF STILLBORN, enter that fact here.
7
AGE..
78
..Years
Mon
Months D.... Days
II less than 1 day
Hours Minutes
Sexton
Trade, profession, or particular
kind of work done, as spinner,
sawyer, bookkeeper, etc
Industry or business in which ,
work was done, as silk mil!, OiTlirCn.
saw mill, hank, etc
lO
Date deceased last worked at 1 1 Total time (years)
this occupation (month andjan 1938 spent in this
year) occupation
12 EIRTHPLACE (City)
(State or country) Norway
13 NAME OF T_ , _ ,
father ivnute Knuds on
14 BIRTHPLACE OF
FATHER (City)
(State or country ) 1 ' ^ ^ 1 a J
15 MAIDEN NAME
OF MOTHER
Unable to obtain
10 BIRTHPLACE OF
mother (City) unable fc.o--ebbal-n--
(State or country)
17 _ Relation, if any
Informant ^^..9.11 ( SO 31 )
(Address) 9 Lincoln 3 t int hr op rass
I HEREBY CERTIFY that
Kith
ifeiu«ith n^-HEFORE
signat-
(Official Designatic
factory standard certificate of death was
' ansit permit was issued:
of Boart^df HSkTth or other)
/ ///
(Date of Issue of Pr^'"' "
MEDICAL CERTIFICATE OF DEATH
18 DATE OF
DEATH .
<
Af (Month)
J.A /Ml
(Day) (Year)
19
keby certify .Jhat I attended deceased from
Uc^» / , 19»^ to ~rt%+. ,
I lasMaw h./4/..allve on... .rfJfa.-U.f.. , 195^ death is said
to have occurred on the data stated goove, at^r-yft.m.
The principal cause of death and related causes of importance In order of onset
were as fGilows:
Date of Onset
J \u0L.J..
WAX'
Contributory causes of importance not related to principal cause:
Name of operation
What test confirmed diagnosis?
4. .*y..
iagnosis 1
20 Was disease or injury in any
If so, specify.
(Signed) ... i
(Address)
related .^occupation nf deceased? ...j
, M. D,
1 Date J&i./$.190u£.
2 1 CREMAT10NB0RIARLEM0VAL -.L rop...
,/t (Cemetery) (City or town)
DATE OF BURIAL J.^.n.'(Mry....l2.<....l-9.3.8 19..
22 NAME OF yO /f, /
UNDERTAKE
ADDRESS.. 2^..
Received and filed. ........
A TRUE COPY, ATTEST:
(Registrar)
..Date of
..Was there an autopsy?. M .
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®bc Commontoealtf) of jftlastfarinigettg
OFFICE OF THE SECRETARY
DIVISION OF VITAL STATISTICS
STANDARD
CERTIFICATE OF DEATH
To be filed for burial permit
with Board of Health
or it* Agent.
Registered No.
4
Nc
565 Shirley St
St., Ward
J (If death occurred in a hospital or institution,
l B'v
2 FULL NAME
Myra Williams Jackson
(If deceased is a married, widowed or divorced woman, give also maiden name.)
(a) Residence. No St.,
(Usual place of abode)
Length of residence in city or town where death occurred TO year* months days. How Ion* in U.S.. if of foreign birth?
give its NAME instead of street and number)
S.
Veteran
specify WAR)
f (If U.
< War V
V specify
Ward,
(If nonresident, give city or town and state)
months
days.
PERSONAL AND STATISTICAL PARTICULARS
4 COLOR OR RACE
White
5 SINGLE
MARRIED
WIDOWED
or DIVORCED
(write the word)
Widowed.
Sa II curried, widowed, or divorced
HUSBAND of
John Xo of wUo in fuU)
(Husband's name in full)
(or) WIFE of
0 IF STILLBORN, enter that fact here.
7
AGE
U4
.Years. ...i Months
16
Days
if less than 1 day
Hours Minutes
8 Trade, profession, or particular
klndofwork done, as spinnei,
sawyer, bookkeeper, etc
0 Industry or business in which
work was done, as silk aiiU,
taw mill, bank, etc
10 Date deceased last worked at
this occupation (month and
year)
House wife
At Home
1 1 Total time (years)
spent in this
occupation
12 BIRTHPLACE (City) kOM...Z9.h.<L
(State or country) Maine
13 NAME OF
FATHER
Asa Williams
14 BIRTHPLACE OP
FATHER (City) .
(State or country)
ureat Pond
Maine
15 MAIDEN NAME
OF MOTHER
Jirexa Dunn
10 BIRTHPLACE OF . .
mother (City) j^haEryxi.ala.
Maine
(State or country)
17
Relation, if any
In.nr.an. ,_Jk ...HftJsI&JK y.JMioon ( Son# )
(Add,-) ™ 85 River fit Host
■ on ima a s
ndard certificate of death was
it permit was issued:
r other)
j Jj (Date of Issue of Permit
MEDICAL CERTIFICATE OF DEATH
18 DATE OF
DEATH
19
/...o y.
(MontM) (Pay)
(Year)
hereby certify. That I attended deceased from
Lj , U , 19 ?.2r
stated above, at JZ. Y^sa.
I wst saw h.r^lX . alive
on
., death la said
to have occurred on the date
The principal cease of death and related causes ol Importance In order of onset
were
Oat* of Onaat
TflNT
ere as Mows: ^ — -
^
. '/C/
Contributory cause* of Importance not related to principal cause:
1
Name of operation Date of
What test confirmed diagnosis? Was there an autopsy?
20 Was disease or Injury in any way related to occupation of deceased?
If so, specify.
(Signed) M. D.
(Address) i
2 , Wlnthrop Wlnbarop
Place of Burial, Cremation or Removal. (City or Town)
DATE OF BURIAL W.&U* 1.2 19.36 19..
22 NAME OF X)
UNDERTAKER
I4y Winthrop Wiuwurop
ADDRESS
Received and filed..
1 t W*
.19...—
(Registrar)
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jgffifiMfr
(County)
Winthrop
(City or Town)
58 Birch Road
<Hh? (tfummomuraltl? of Massnt^uBtUa
OFFICE OF THE SECRETARY
DIVISION OF VITAL. STATISTICS
STANDARD
CERTIFICATE OF DEATH
To be filed for burial permit
with Board of Health
or its Agent.
o • 5
Registered No
No.
St., Ward
(If death occurred in a hospital or institution,
give its NAME instead of street and number)
(If U. S.
War Veteran,
speciiy WAR)
2 FULL NAME
(If deceased is a married, widowed or divorced woman, give also maiden name.)
, . D . . m 58 Birch Road ,
(a) Residence. No... St., Ward,
(Usual place of abode) _ (If nonresident, give city or tov/n and state)
Length of residence in city or town where death occurred AO yrs. mos. days. How long in U. S„ if of foreign birth? yrs. mos. days.
PERSONAL AND STATISTICAL PARTICULARS
feeale Wt?
3R OR RACE
18
5 SINGLE
MARRIED
WIDOWED
or DIVORCED
(write the word)
Widowed
5a If married, widowed, or divorced
HUSBAND of
Winf i e if
(Husband’s name in full)
(or) WIFE of
0 IF STILLBORN, enter that fact here.
L ?o
AGE
8 8
Years Months Days
If less than 1 day
Hours Minutes
8 Trade, profession, or particular
kind of work done, as spinner,
sawyer, bookkeeper, etc.
9 Industry or business in which
work was done, as silk mill,
saw mill, bank, etc.
10 Date deceased last worked at
this occupation (month and
year)
Housewife
Own Home
1 1 Total time (years)
spent in this
occupation
12
(State or country)
Massachusetts
13 NAME OF
FATHER
Lewis Abbot
00
14 BIRTHPLACE OF
FATHER (City)
(State or country)
Andover
h-
z
Massachusetts
LU
CC
<
Q_
15 MAIDEN NAME
OF MOTHER
Nellie Evens
10 BIRTHPLACE OF
MOTHER (City)
(State or country)
l&ine
1 ^Informant WillfiS
Id Scott Kendrick Jr (Son)
(Address) 58 Birch Rd Winthron Mass
dard certificate of death was
permit was issued:
other)
(Date of Issue of Permit)
MEDICAL CERTIFICATE OF DEATH
18 DATE OF
DEATH
January
(Month)
13
(Day)
1938
(Y ear)
Contribatory caoses of importance not related to principal cause:
Name of operation Date of
What test confirmed diagnosis? Was thera an autopsy?/ ^ ^
20 Was disease or injury in any way related to occupation of deceased?
If so, specify ^....
(Signed) ./ m. D.
w
(Address )
19/^r-
21 CREMATiONBORIARLEMOVAL SwaiDp S C 0 1 1 SwampSCOt t }J&8
(Cemetery) (City or town)
DATE OF BURIAL
January 15
iwn)
Am
22 NAME OF
UNDERTAKER/
7£/:W'
address ^47 Wintnrop St Winthrop Mass.
Received and filed
S0
19
(Registrar)
CERTIFY, That I attended deceased from |
“ Yv* ■■ '3, vif
I last saw h .^^alive on J death is said
to have occurred on the d stated above, at
The principal came of death and related causes of importance in order cf
onset were as follows: ~ : :
Datesf onset
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Suffolk
(County)
Winthrop
(City or Town)
®bc Commontoealtf) of iWaggarijusSetts
OFFICE OF THE SECRETARY
DIVISION OF VITAL STATISTICS
STANDARD
CERTIFICATE OF DEATH
To be filed for burial permit'
with Board of Health
or its Agent.
6
Registered No.
No 5? Ingle side Ave Winthrop
Susie Mills Sarto y
St., Ward
I”
U'>
(If death occurred in a hospital or institution,
give its NAME instead of street and number)
f (If U. S.
FULL NAME , W., V,™
(If deceased is a married, widowed or divorced woman, gfive also maiden name.) I specify WAR)
5S Ingleside Ave
(a) Residence. No..!,.T...**^.TT"*.^...*'" St., Ward,
(Usual place of abode) (If nonresident, give city or town and state)
Length of residence in city or town where death occorred3S yean month* day*. How long in U.S., if of foreign birtll?/ 5 yean month* days.
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
Female
4 COLOR OR RACE
hits
(write the word)
6 SINGLE
MARRIED »*
widowed wiaovea
or DIVORCED
6a If curried, widowed, or divorced
HUSBAND of
VtillU%vert£tf^ of wife in fuU)
(Husband's name in full)
(or) WIFE of
0 IF STILLBORN, enter that fact here.
7 80 5 29
AGE Years Months Days
if less than 1 day
Hours Minutes
8 Trade, profession, or particular
klndofwork done, as tpinnei,
aawyar, bookkeeper, etc
9 Industry or business in which
work was done, as *ilk mill,
•aw mill, baek, etc
10 Date deceased last worked at
this occupation (month and
year)
Housewife
Own Home
1 1 Total time (years)
spent in this
occupation
Bradford.
CO * -r *
e t Z
X
d L-lIV 1 nrLALL
(State or country)
Ontario Canad%
W "T U. K
z< o i
5 a 2
i flil
*
3 E =
13 NAME OF
FATHER
James Mills
00
\-
Z
14 BIRTHPLACE OF
FATHER (City)
(State or country)
Not known
"uts;x;
I ** 0
UJ
cr
<
CL
15 MAIDEN NAME
OF MOTHER
Catherine Watt
.'%■£ »
>. v. a
10 BIRTHPLACE OP
MOTHER (City) .
Not known
=! u * *
£ v
(State or country)
U.5.A.
17
lo'
Mrs Helen Lstson
(Address) "5 7 Trig Te side " X' e" W i nt riroN
Relation, if any
ughter
MEDICAL CERTIFICATE OF DEATH
18 death°F January 15
(Month)
(Day)
1938
(Year)
is i hereby certify. That I attended deceased frqB 1
, 19//.,
last saw h..th£,.... alive on , death la said
to have occurred on the date stawr above, at .7/ m.
The principal cause of death and related causes ot Importance In order of onset
weraas follows:
mrT. . . . .
Contributory aim pf Importance not related to principal cause:
.S tkJtsJL*.
Name of operation .7. Date of
What test confirmed diagnosis? Was there an autopsy?.
20 Was disease or injury in any way related to occupation of deceased?
If so, specify. .?. .rt .... .K, K' f}
(SlgnedL^r— ....lAffL/Vt.
moot 1 l l (i.. * Date 19
(Address)
21 Winthrop l Winthrop Mass
Place of Burial, Cremation or Remov^^ (City or Town)
Cremation or Rem oval. (Cit
January 18 1938
22 NAME OF
UNDERTAKEI
address .st,,,m..nthr.Qp....i^ja.a
Received and filed..
.19..
S
(Registrar)
5m-12-,34. No. 2938-g
1
S<JUl.
< % | / (County)
3
b.
O
(ttflmuumujfalttj of MasaarijuaPttH To be filed for burial
permit with Board of 0
u (City or [Town) .. . / /I
2
2 FULL NAME fcA.OTU^S.
OFFICE OF THE SECRETARY
DIVISION OF VITAL STATISTICS
MEDICAL EXAMINER’S
pERTIFICATE OF DEATH
Health or its Agent.
Registered No..
( (If death occurred in a hospital or institution,
..Ward | give its NAME instead of street and number)
(a) Residence.
(Usual place of abode)
Length of residence in city or town where death occsrred
(If deceaseds a/married, wic
No...!. £
(If u. s.
War Veteran,
specify WAR).
.Ward,
(If nonresident, give city or town and state)
days. How long in U. S., if of foreign birth? yrs. mos. days.
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
5a If married
5 SINGLE .
MARRIED
WIDOWED
or BIVQRCED
(write the word)
5a III married, widowed, or divorced
HUSBAND of
(Give maiden name of wife in full)
(or) WIFE of
(Husband’s name in full)
0 IF STILLBORN, enter that fact here.
7
AGE.
,..Z
Years.. ..Months *?/ Days
If less than 1 day
Hours Minutes
8 Trade, profession, or particular
kind of work done, as spinner,
sawyer, bookkeeper, etc
9 Industry or business in which
work was done, as silk mill,
saw mill, bank, etc.
10 Date deceased last worked at
this occupation (month and
year)
1 1 Total time fyears)
spent in this
occupation
12 BIRTHPLACE (City).
(State or country)
13 NAME OF
FATHER
14 BIRTHPLACE OF
FATHF-R (City) ....
fJ.L ..
^
.zc:x*v^r:.X
(State or country)
15 MAIDEN NAME
OF MOTHER
r
10 BIRTHPLACE OF
MdTHPB rC.it.v)
(State or country)
I HEREBY CERTIFY that a satisfactory standard certificate «f dea
filed with me BEFORE the burial or transit permit was issued:
(^}ii#naneYdf' Xgent of Board of Health or other)
(Official Desi^n^ioj^) rjl (Date of Issue of Permit)
MEDICAL CERTIFICATE OF DEATH
18 DATE OF
DEATH
r
- /&- tf'JJf
f (Month) (Day) ( (Year)
19 1 HEREBY CERTIFY that I have investigated the death
of the person above-named and that the CAUSE AND MANNER thereof are
as follows: (If an injury wa^involved, state fully.)
ivea, state tuny.)
r.
(See reverse side for description for unknown person )
20 IN WHAT CITY
WAS INJU
22 NAME OF
UNDERTAKER
ADORESS
Received and filed 19..
1 ....k ...1.93.B
(Registrar)
EXTRACTS
FROM THE LAWS OF THE
COMMONWEALTH OF MASSACHUSETTS
GOVERNING THE
RETURN OF CERTIFICATES OF DEATH
A physician or registered hospital medical officer shall forth-
with, after the death of a person whom he has attended during his
last illness, at the request of an undertaker or other authorized
person or of any member of the family of the deceased, furnish for regis-
tration a standard certificate of death, stating to the best of his knowledge
and belief the name of the deceased, his supposed age, the disease of
which he died, defined as required by section one, where same was con-
tracted, the duration of his last illness, when last seen alive by the
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 'aused by violence, the medical examiner shall
make such certificate. If such a permit for the removal of a human body,
not previously interred, from one town to another within the common-
wealth cannot be obtained early enough for the purpose, the certificate
of death made as above provided and in the possession of the undertaker
desiring to make such removal shall constitute a permit for such re-
moval; provided, that such body shall be returned to the town from
which it was removed within thirty-six hours after such removal, unless
a permit in the usual form for the removal of such body has been sooner
obtained hereunder. If the death certificate contains a recital, as re-
quired by section ten of chapter forty-six, that the deceased served in
the army, navy or marine corps of the United States in any war in
which it has been engaged, such recital shall appear upon the permit.
The board of health, or its agent, upon receipt of such statement and
certificate, shall forthwith countersign it and transmit it to the clerk
of the town for registration. The person to whom the permit is so
given and the physician certifying the cause of death shall thereafter
furnish for registration any other necessary information which can be
obtained as to the deceased, or as to the manner or cause of the death,
which the clerk or registrar may require. — Chap. 114, Sec. 45, G. L.
( Tercentenary Edition.)
DESCRIPTION (for unknown person)
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.. . . — Chap. 114, Sec. 46, G.L. ( Tercenten-
ary 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.
If a medical examiner has notice that there is within his county the
body of such a person, he shall forthwith go to the place where the body
lies and take charge of the same;.. . — General Laws, Chap. 38, Sec. 6.
. . .He shall in all cases certify to the town clerk or registrar in the
place where the deceased died his name and residence, if known; other-
wise a description as full as may be, with the cause and manner of death.
■ — General Laws, Chap. 38, Sec. 7.
. . . The medical examiner certifies the cause and manner
of death to the best of his knowledge and belief.
RULES OF PRACTICE
The fulfilment of the purpose of these laws calls for the observance
of the following rules of practice:
(1) Attending physicians will certify to such deaths only as those
of persons to whom they have given bedside care during a last illness
from disease unrelated to any form of injury.
(2) Board of Health physicians will certify to such deaths only
as those of persons who, though disabled by recognized disease unrelated
to any form of injury, have died without recent medical attendance or
whose physician is absent from home when the certificate of death is
needed.
(3) Medical Examiners will investigate and certify to all deaths
supposably due to injury. These include not only deaths caused
directly or indirectly by traumatism (including resulting septicemia),
and by the action of chemical (drugs or poisons), thermal, or electrical
agents, and deaths following abortion, but also deaths from disease
resulting from injury or infection related to occupation, the
sudden deaths of persons not disabled by recognized disease, and
those of persons found dead.
STATEMENT OF CAUSE OF DEATH
Medical Examiners in certifying to a death will state the cause and
manner thereof, and will specify: (1) Under cause, the nature of an
injury and of its consequences; and (2) under manner, the mode of
its production together with the circumstances when these are known.
For example: " 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 anaesthetic. ’’ “Fracture of the skull with
associated internal injury sustained under circumstances unknown.”
If disease or injury was related to occupation, specify. If investigation
shows the death to have been due to disease, specify: (1) Under cause,
its known or presumable nature; and (2) under manner, indicate the
circumstances leading to medico-legal inquiry. For example: “Hemorr-
hage spontaneous, of the brain (basal ganglia) (found dead in bed).”
“Heart disease, presumably coronary sclerosis. (Sudden death.)”
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
1 -<
Suffolk.
(County)
2-im.t.li22QpL.,
(City or Town)
®jjc Commontoealtf) of iWagfiarfjusiettg
OFFICE OF THE SECRETARY
DIVISION OF VITAL STATISTICS
STANDARD
CERTIFICATE OF DEATH
To be filed for burial per'
with Board of Health
or its Agent.
Registered No jQ
No 387 Shirley St
St., Ward
{(I
Igi
(If death occurred in a hospital or institution,
give its NAME instead of street and number)
2 full name ... Ha
(If deceased is a married, widowed or divorced woman, give also maiden nan e.)
r (if u. s.
t War Vet«
V specify \
Veteran
WAR)
(a) Residence. No S.t_.
(Usual place of abode)
Lenftli of residence in city or town where death occurred years
months
days.
.St., Ward,...
(If nonresident, give city or town and state)
How long in U.S., if of foreign birth? years months days.
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
Hal<
4 COLOR OR RACE
In its
6 SINGLE
MARRIED
WIDOWED
or DIVORCED
(write the word)
.ed.
6a II curried, widowed, or direr ced
HUSBAND of L11.SH...A.. Re.SLfl.
(Give maiden name of wife in full)
(or) WIFE of
(Husband’s name in full)
6 IF STILLBORN, enter that fact here.
7
AGE..
52
..Years Months.
..Days
If less than 1 day
Hours Minutes
8 Trade, profession, or particular
kindof work done, as spinner, rs * 4-
uwytr, bookkeeper, etc
O Industry or business in which
work was done, as silk mill,: tp r> D n ^
saw mill, bank, etc .«v....£a...i,\...iw,..Q
IO Date deceased last worked at 11 Total time (years)
spent in this na
occupation- .fe.i...
i&rfsisjss!!^
12 PIRTHPI ATF (Citv)
Mllle.rsvlll.fi
(State or country)
Penn
13 NAME OF
FATHER
Harry lerth
CO
14 BIRTHPLACE OF
FATHER (City)
(State or country)
Miller. sv.H 1 e
F-
Z
Penn
LU
Q :
<
Q_
15 MAIDEN NAME
OF MOTHER c
usan .71 tee r
16 BIRTHPLACE OF
MOTHER (City)
(State or country)
PftTrn -
17
Informant
(Address)
Relation, if any
SllenJL- JjbsLrilL. ( JBtlf.fi, )
-.V -12-1.’.. . 2,t
factor^ standard certificate of death was
I OFYrabaypejrnit was issued:
lo^fo^^^^o^^ier,
(Date of Issue of Per £it}
MEDICAL CERTIFICATE OF DEATH
18 DATE OF
DEATH
n
(Month)
j J> ! % 3 Jr
(Day) . (Year)
4****>S-r
That I attended deceased from
.A. 11
19 I HEREBY CERTIFY,
■K*v»C""" " 19 * t0
I l»<saw tii***... alive on 19 death is said
to have occurred on the date stated above, at X. & ...in.
The principal cause of death and related causes of importance In order of onset
were as follows: _ (J _ Date of Onset
IMPORTANT
The principal canse of death and related 1 causes ot importance
;ere as follows: _ iTk)
z:$:zz:z:
Contributory causes of importance not related to principal cause:
Name of operation YSrflfcy**: : Date of .j.-r-
What test confirmed diagnosis?.)*^^^.)A|;.*...y^r^,Was there an autopsy?.. .cl/0
20 Was disease or injury in any way related to occupation of deceased? A/p
(Signed) , M. D.
If so, specif;
Signed) .
(Address]
./Si
occupation of <
3
i ftthrop W ill throp..
Place of Burial/|Crematwi|i or Re
(Registrar)
O
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ommon#eaitt) ' of ffleWacyuflettg
OFFICE OF THE SECRETARY
DIVISION OF VITAL. STATISTICS
STANDARD
OF DEATH
To be filed for burial p
with Board of Health
or it» Agent.
Registered No 9
ard
J (If death occurred in a hospital or institution.
.give its NAME' instead of street and number)
FULL NAME
a married, y widowed or divorced woman, give also maiden name.)
(a) Residence. Nc
(Usual place of abode)
Length of residence in city or town where death occurred
IM.U a llld.1 ULUy WIUUWl'U t
( (If u
■j War
. s.
Veteran
WAR)
St., Ward,
(If nonresident, give city or town and state)
years months days.
How long in U.S., if of foreign birth? years
months ^ days.
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
4 COLOR OR RACE
6 SINGLE
MARRIED
(write th,e word)
WIDOWED I jy.y
•r DIVORCED'*®^^*’^'
6a If curried, widowed, or divorced — —
HUSBAND of
(Give maiden name of wife in full)
(or) WIFE of rrCT. ..
(Husband’s name in fuip /
6 IF STILLBORN, enter that fact here.
AGE Years .
..Months Days
If less than 1 day
...Hours.. .err:.. Minutes
8 Trade, profession, or particular
kindofwork done, as spumei,
lawyer, bookkeeper, etc
9 Industry or business in which
work was done, as silk mill,
uw mill, bank, etc
10 Date deceased last worked at
this occupation (month and
year)
12 LIRTHPLACE (City)
(State or country)
X 1 Total time (years)
spent in this -
occupation..
14 BIRTHPLACE OF
FATHER (City)
(State or country)
15 MAIDEN NAME
OF MOTHER
S':
16 BIRTHPLACE OP
MOTHER (City) .
(State or country)
DICAL CERTIFICATE OF DEATH
Jr /Mt
/(Day) / CYeai
(Year)
That I attended deceased fro®
.19.4/, 19^f
saw h...**rrr... alive on. , 19?*/, death Is said
* to have occurred on
.m.
were as foilsws:
fruu^tu**. jr hurwuL* ,
Date of Oottf
IMPORTANT
ZlnM
7
t
CoDtribotofy csoiei of Importance, notarelated to principal cause:
R.
Name of operation Date of
What test confirmed diagnosis? Was there an autopsy?./!
y ?//....
20 Was disease or Injury in any way related to occupation of deceased? ... u.
If so, specify..*.
Received end filed.
(Registrar)
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^ ^flje (Eommumncaltlj of iUaosdrljua?!
OFFICE OF THE SECRETARY
DIVISION OF VITAL STATISTICS
STANDARD *
CERTIFICATE OF DEATH
Tc be Hied for burial permit
with Board of Health
or its Agent.
>3 A
Registered No ilsH
..Ward {
(If death occurred in a hospital or institution,
give its NAME instead of street and number)
2 FULL
(If deceased is a m
(a) Residence. Nc.
(Usual place of abode)
Length of residence in c!Ey or town where death occurred
(If u. s.
<*f. j War Veteran,
i€d, widowed or divorced woman, give also maiden name.) — . I specify WAR).
^ — , i specny wiuu
*>3
days.
..St., Ward,
(If nonresident, give city or town and state)
Kow long in U. S., if of foreign birth? yrs. mos. days.
_ a
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PERSONAL AND STATISTICAL PARTICULARS
3 SEX
4 COLOR OR RACE
5 SINGLE
MARRIED
WIDOWED
or DIVORC!
(write the word)
5 a If married, widowed, or dirorctd
HUSBAND of
(Give maiden name of wife in full)
(or) WIFE of
(Husband's name in full)
0 IF STILLBORN, enter that fact here.
7 ^
AGE Years Months Days
If less than 1 day
Hours Minutes
8 i rade, profession, or particular
kind cf work done, as spinner,
eawyer, bookkeeper, etc
9 Industry or business in which
work was done, as silk mill,
ssw mill, bank, etc
10 Date deceased last worked at
this occupation (month and
year)
1 1 Total time (years)
spent in this
occupation..
14 BIRTHPLAi
FATHER (City)
(State or country)
15 MAIDEN NAME
OF MOTHER
MEDICAL CERTIFICATE CF DEATH
18 DATE
DEATH •
i.
(Month)
IflEi
(Day)
(Year)
19 I hereby CERTIFY. Thai I attended deceased from
Qfai./U , \o....$Axc tit , isj£
n last saw lLr*»r~... alive on.. ,13.3.. t~, death Is said
to have occurred on the date stared above, at-2.r/S'/=>m.
The principal cause of death and related causes ot Importance In order of onset
Were as fOllCWS: Date of Onset
IMPORTANT
Contribntory canses of importance not related to principal cause:
z>
'.{(ltJ.Ot
Name of operation
What test confirmed diagnosis?../.
„...Date of._
astherean autopsy?..
20 Was disease oj^injury in any way related to occupation of deceased? .
If so, sg
(Sis /. , m. d.
(Addrcss).../^^^ Date.4^..*?. . 19
21 PLACE OF BURIAL,
CREMATION OR REMQVAL .. tie
DATE OF BURIAL
22 NAME OF
UNDE
ADDRE3
5E
(City or town) _
« 19.^?..T
Received and filed
'TIW
,.19..
(Registrar)
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N. 11. WKIlfc, KLAIINLT, WMM UN1AU11NU ULAtN 11NN — 1HI3 13 A rtKIVlAINU'l I RLLVJaU. LVery Item OI
information should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state
CAUSE OF DEATH in plain terms, so that it may be properly classified. Exact statement of OCCUPATION
is very important. See instructions and extracts from the laws on back of certificate.
100ra-12-’34. No. 293S-e
[ R-301
g J3.u££filk
^ (County)
I JirLt.Jir..Qp. —
w (City or Town)
3 No
^ (Ulje (Commatnm'ultlj of flaeoadjitotlis
OFFICE OF THE SECRETARY
DIVISION OF VITAL STATISTICS
STANDARD
CERTIFICATE OF DEATH
(City or town making return)
Registered No
ii
f (If death occurred in a hospital or institution,
Ward ^ give its NAME instead of street and number)
2 full name JlQh.e.r.t-..Kem.pi.Q.n... J.armar. j war veteran.
(If deceased is a married, widowed or divorced woman, give also maiden name.) I specify WAR).
(If U. S.
(a) Residence. No,....
(Usual place of abode) ^
Length of residence in city or town where death occurred yrs.
2£.5....dh.irle.y. st., Ward,
(If nonresident, give city or town and state)
tnos. days. How long in U. S., if of foreign birth? yrs. moc. days.
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
Male
4 COLOR OR RACE
Thite
(write the word)
5 SINGLE
MARRIED
widowed Carried
or DIVORCED ' ° L X c
5a If married, widowed, or divorced , _ _ _ _ _
husband of
(Give maiden name of wife in full)
(or) WIFE of
(Husband’s name in full)
6 IF STILLBORN, enter that fact here.
7
AGE.
81
Q ^
-Years..:: Months ...V- Days
If less than 1 day
Hours Minutes
8 Trade, profession, or particular
kind of work done, as spinner,
sawyer, bookkeeper, etc
Eer airman
9 Industry or business in which - 3 -sn
work was done, as .ait mm, ilevated railroad
saw mill, bank, etc..
10 Date deceased last worked at -
this occupation (month and tJ6C«
year) .
, J. U Jpta! time (years)- „
193 Vspent in this 3 7
occupation..
IQ PIRTHPIATF
Roxbury
(State or country)
Massachusetts
13 NAME OF
father Robert Kempt on Jenner
CO
14 BIRTHPLACE OF
FATHF.R (Citvi
H-
Z
(State or country)
England
UJ
q:
<
CL
15 MAIDEN NAME
OF MOTHER
Safronia Miller
10 BIRTHPLACE OF
MOTHER (City) .
Yarmau-th.
(State or country)
Maine
17
In(oraaat M£JL» ...JL?. £§2®®*.
(Address) Q3 g 5 hi T 1 G ’7 8 t .71 II t h -
Relation, if any
wi xe )
inthrop Mass
te of death was
issued:
MEDICAL CERTIFICATE OF DEATH
18 DATE OF
DEATH
H !k ft 3.
Vj (Month) (Day) (Year)
19 - x hereby certxey, Ilia! I attended deceased from
3 i if?., lo.JMfv/.t. , 19J ....
I last saw &.vidKt..aliY® on 19 XC, death is said
;Ja!ed above, at.Jt //*..... m.
to have occurred on the date s'
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:
.Lr?t/.
7
-.*n
Name of operation Date of .• ...
What test confirmed diagnosis?. Was there an autopsy?.. ■■/»/'"
20 Was disease or injury in any way related to occupation of deceased? .
If so, specify .
(Signed) M. D.
(Add ress) Pate,^/ft-19-y.r. '
21 place of burial, J yradle''" Maine
CREMATION OR REMOVAL £1.7T.^.±..Y.i X.
(Cemetery) (City or town)
DATE OF BURIAL JanU&Xy„.../5.I..t 19 . 2.8
22 UNDERTAKER .Ch&£.l.$..S....Jl.« ;i©.HU.i.£..Qll
address ^in.throp....Ma.ss
Received and filed 19-
(Registrar)
A TRUE COPY, ATTEST:
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| Suffolk
25 (County)
Q
© C3ae.ls.ea
u (City or Town)
3 No. U..*.^..«.Mai‘lne...H.o.s.p.- st.,
©tfp (Eommcnuipaltlj of llaoaarliuartta
OFFICE OF THE SECRETARY
DIVISION OF VITAL. STATISTICS
STANDARD
CERTIFICATE OF DEATH
...Qhee.ls.ea
(City or town making return)
Registered No..
.12....
( (If death occurred in a hospital or institution.
Ward ^ give its NAME instead of street and number)
[ (IfU. S.
2 FULL NAME KfeSXl.. H.Q.r.t.Qn. WuVa.™,
(If deceased is a married, widowed or divorced woman, give also maiden name.) [ specify WAR)
85..Heman.,.^t.,. st., Ward^'in t.hr op, Mg, as... .
(a) Residence. No.
(Usual place of abode)
Length of residence in city or town where death occurred -
(If nonresident, give city or town and state)
s. 7 days. How lonf in U. S., if of foreign birth? 20 yrs. mos. days.
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
Male
4 COLOR OR RACE
white
5 SINGLE
MARRIED
WIDOWED
(write the word)
or DIVORCED
married
la.
5a If married, widowed, or -divorced
husband of B.er.tha agnus.sen.
(Give maiden name of wife in full)
(or) WIFE of
(Husband's name in full)
Q IF STILLBORN, enter that fact here.
7
AGE
54
Years 8 Months
15
Days
If less than 1 day
Hours Minutes
8 Trade, profession, or particular
kind of work done, as spinner, f' . _ „ j
sawyer, bookkeeper, etc V.U.S.t.0m.....7ha.P.Cl..
9 Industry or business in which _
Guard
work was done, as silk miU,r<,",o o +-
MW mill, hank, etc r.YY: 53 Y.
10 Date deceased last worked at
1 1 Total time (years)
this occupation, (month .and t ^ n o -z o spent in this
year) January 15 , 1958 occupation
12 BIRTHPLACE (City) ..QUy.S.b. OP 0 , N .* £>.+..
(State or country)
13 NAME OF
FATHER
David
14 BIRTHPLACE OF
FATHER (City)
(State or country) Guvsboro, N,0
15 MAIDEN NAME
OF MOTHER
10 BIRTHPLACE OF
MOTHER (City)
riebecca — J one s
(State or country) GuySbO V O , ^ , b
17
Informant 'PS C.S.aS.0CL.
(Address)
&
A TRUE COPY.
,<$
attest: Mary E. Keoan -
(Registrar of city disown where death occurred)
date filed ..Qlerk Jan. 24 , 1938
MEDICAL CERTIFICATE OF DEATH
18 DATE OF T
death Jm.uar.y. 23.., 1.938
(Month) (Day) (Year)
19
1 HEREBY CERTIFY. That I attended deceased from
January .17 ,19 .38 to Januar..y....23.,., 19 38.
I last saw h llll alive on JanUH.P.y.....2.3.,.., 19 38., death is said
to have occurred on the date stated above, at4..
The principal cause of death and related causes of importance in order of
onset were as follows:
.. Pneumonia,.. ..lo.bar....lef.t
. .vPh.e.ump c q c cus... . t. yp.e. . . . 1.). 1 -1.3-36 .
Contributory causes of importance not related to principal cause:
Datcofontet
Name of operation Date of
What test confirmed diagnosis? X.— my Was there an autopsy? HO.
20 Was disease or injury in any way related to occupation of deceased? ..hP
If so, specify..
(Signed) u . Jlitchell , M. D.
(Address) U ..Marine hp-sp-. Date l/25 19 38
21 PUCE OF BURIAL, „ t. km u
CREMATION OR REMOVAlf.OPr.0 S t nlii s ,.L>OS t-On
(Cemetery) (City or town)
date of burial January 2.6., 195.8 19
22 undertaker V-.ill.iam . Spencer
address 4.0.8. Broadway Boston
Received antMlle
(Registrar of City or Town where deceased resided)
N B. — WRIT.E PLAINLY, WITH UNFADING BLACK INK— THIS IS A PERMANENT RECORD. Every item of informa-
tion should be carefully supplied. Age should be stated EXACTLY. PHYSICIANS should state CAUSE OF DEATH
in plain terms, so that it may be properly classified. Date of onset and exact statement of OCCUPATION are very
important. See instructions and extracts from the laws on back of certificate.
00m I I 36. No. 0080 F
M R-301A
1 i
SUFF
(County)
ntoealtf) of ifflagsfarfjusettg
OFFICE OF THE SECRETARY
DIVISION OF VITA L STATISTICS
WIETHRO:
(City or To
STANDARD
CERTIFICATE OF DEATH
To be filed for burial permit
with Board of Health
or its Agent.
Registered No.
_o
' f (i
No Station. .HQS.pi.tal»Fort...Bank3.#Masa, Ward ( gi
2 FULL NAME
(a) Residence.
ROSE- - -MARY- . _S HQRE . . - ; ,
(If Heceased is a married. • widowed or divorced woman, give also maiden name.)
Ward,
(If death occurred in a hospital or institution,
give its NAME, instead of street and number)
( (if u. s. (
j War Veteran ' ^
l specify WAR) *
(Usual place of abode)
Lenrtb of residence in city or town where death occurred
months
days.
(If nonresident.
How long in U.S., if of foreign birth'
ye city or town
years months
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
Female
4 COLOR OR RACE
White
5 SINGLE
MARRIED
WIDOWED
•r DIVORCED
(write the word)
6a If curried, vi cloved, or divorced
HUSBAND of
(Give maiden name of wife in full)
(or) WIFE of
(Husband's name in full)
6 IF STILLBORN, enter that fact here.
7
AGE
..Years "“.....Months.
Days
If less than 1 day
...” Hours ”... Minutes
8 Trade, profession, or particular
kind of work done, as spinnei, T_r>— e.
sawyer, bookkeeper, etc
9 Industry or business in which _ „ ,
work was done, as idle mill, "’YHT&Wfy* —
uv mill, book, etc -
lO Date deceased last worked at 11 Total time (years)
this occupation (month and spent in this
year; occupation m.
12 lirthplace (City)..Winfc3xr.o.p*JlfekSS.«
(State or country)
13 NAME OF
FATHER
Marshall Ray Shore
14 FATHER^tc.w yadk±nville.,lIor.th....Car.Qlim...
(State or country)
15 MAIDEN NAME
OF MOTHER
Renee Cecils Bfisgun
10 SffraER^ityf F.i t ohb.urg. s s. ». . .
(State or country)
17
le'ormoot
(Address)
Relation, if any
R.«gi.s.trar..,S.ta..lIo.s.p...F.t...RafikG,Masso )
on standard certificate of death was
r /Transit permit was issued:
HEREBY CERTIFY that* rftisfi
FORE >fjal/uuriai
lealth or ol
idLl U.X
(Date of Issue of Permit)
MEDICAL CERTIFICATE OF DEATH
18 DATE OF _
death .January 24 19.3.8. *1
(Month) rriavi fYenrt
(Day)
(Year)
19 i hereby certify. That I attended deceased from
rr.rr. , 19 rr, io ”- 19.-. ...
I last saw h allva on. .Stillbarn...Jan..24j&8 ..., death Is said
to have occurred on the data stated above, at m.
The principal cause ol death and related causes of Importance In order of onset
were as follows:
Bro Qch..£r e s entati on
Contributory uun of Importance not related to principal cause:
Nona
Data of Ontat
IMPORTANT
Name of operation KoH& Date of
What test confirmed diagnosis? Was there an autopsy? Ho- -
20 Was disease or Injury in any way related to occupation of deceased?
If so, specify—^^*
(Signed)
(Address) ••Port'-'-Bankg-b'Mfta-s*
... M. D.
Date
19.
21 Fort Devons ,Mass«
Place of Burial, Cremation or Removal.^ (City or Town)
DATE OF BURIAL ^ ^ ^ 19
Received and fll
(Registrar)
)RM R-303B
<#
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1* «
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5 « B
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* *■■£
d o *•
P ’0 0
3 C *<
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l’5«
* JL fa flifz
< ySAyy^
6 IF STILLBORN, enter that fact here.
AGE ...Years / Months .-rZ^T) ays
If less than 1 day
Hours Minutes
®1jp dlmnmamm'altlj of fflaBaarljuHPtta
OFFICE OF THE SECRETARY
DIVISION OF VITAL STATISTICS
MEDICAL EXAMINER’S
CERTIFICATE OF DEATH
“ (City or Town)
£ St., Ward {
To be filed for burial
permit with Board of
Health or its Agent.
A '
Registered No
(If death occurred in a hospital or institution,
give its NAME instead of street and number)
2 FULL NAME
(If deceased is a married, widowed
(a) Residence. No....^4..^f..(/....!!l
(Usual place of abode) .
idowed or divorced yraman, give also maiden name.)
S't'. /
(If u. s.
War Veteran,
specify WAR)
, ^^7 *£
t:^/^....Ward
/ / (If nonresident, give city or town and state)
Length of residence in city er town where death occurred /O yrs. V moi. Jays. How long in U. S., if cf foreign birth? G yrs. ^ moi. injt.
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
4 COLOR OR RACE i 5
(write the word)
MARRIED /yj , y _ ff
widowed LASu actvZoK
or DIVORCED
5a if married, widowed, or divorced
HUSBAND of .
(or) WIFE of ii
(Husband’s rtame in full)
enname of wife Mull)/}
8 Trade, profession, or particular
kind of work done, as spinner,
sawyer, bookkeeper, etc
9 Industry or business in which
work was done, as silk mill,
saw mill, bank, etc,
10 Date deceased last worked at
this occupation (month ani
year)
. tAS v~y.
1 1 Total time (years)
spent in this
occupation C frA ?...
I HEREBY CERTIFY that a satisfactory standard certificate of death was
r/n^it permit was issued:
filed with ma BEFORE the bur)
UQld4
(Signature of Ar
If*
cial Desig
(Official Designation)
of Health orotherT^
( -2c ^[3
Issue of Perryt)
MEDICAL CERTIFICATE OF DEATH
18 DATE OF
DEATH
fj&ie,. - 2 ..A
(Month) (Day)
(■/3L
Zr
(Year)
L>v- ilA^VKL
(See reverse side for description for unknown person )
20 IN WHAT CITY
WAS INJURY
ITY OR TOWN yViA^pb
:Y. sustained^..... , !k„
Traterr
19 I HEREBY C E R T I F Y that I have investigated the death
of the person above-named and that the CAUSE AND MANNER thereof are
as follows: (If an injury was involved, state fully.)
c^c%Z?sx^dt, o-^x^xxax. \
■ m
(Signed) /■.y.....„*/V«...'T.f1.". , M. D.
(Address) Q.lhZZL LUfaL-lXis 2.F1
21 PLACE OF BURIAL,
CREMATION OR REMOVAL
DATE OF BURIAL
(Cemetery/ , / (i
7\ City or town/ ,
Received and filed
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 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.
(Ter centenary Edition.)
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. .. . — Chap. 114, Sec. 46, G. L. ( Tercenten-
ary 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.
If a medical examiner has notice that there is within his county the
body of such a person, he shall forthwith go to the place where the body
lies and take charge of the same; . . . — General Laws, Chap. 38, Sec. 6.
. . .He shall in all cases certify to the town clerk or registrar in the
place where the deceased died his name and residence, if known; other-
wise a description as full as may be, with the cause and manner of death.
— General Laws. Chap. 38, Sec. 7.
. . . The medical examiner certifies the cause and manner
of death to the best of his knowledge and belief.
RULES OF PRACTICE
The fulfilment of the purpose of these laws calls for the observance
of the following rules of practice:
(1) Attending physicians will certify to such deaths only as those
of persons to whom they have given bedside care during a last illness
from disease unrelated to any form of injury.
(2) Board of Health physicians will certify to such deaths only
as those of persons who, though disabled by recognized disease unrelated
to any form of injury, have died without recent medical attendance or
whose physician is absent from home when the certificate of death is
needed.
(3) Medical Examiners will investigate and certify to all deaths
supposably due to injury. These include not only deaths caused
directly or indirectly by traumatism (including resulting septicemia),
and by the action of chemical (drugs or poisons), thermal, or electrical
agents, and deaths following abortion, but also deaths from disease
resulting from injury or infection related to occupation, the
sudden deaths of persons not disabled by recognized disease, and
those of persons found dead.
STATEMENT OF CAUSE OF DEATH
Medical Examiners in certifying to a death will state the cause and
manner thereof, and will specify: (1) Under cause, the nature of an
injury and of its consequences; and (2) under manner, the mode of
its production together with the circumstances when these are known.
For example: “Compound fracture of the femur with ensuing septicemia
(gas bacillus) caused by a steam railway accident. ” “Pistol shot wound
of the chest w'ith associated hemorrhage, homicidal." “Asphyxiation
by suspension, suicidal.” “Syncope while under the influence of ether
administered as a surgical anaesthetic." "Fracture of the skull with
associated internal injury sustained under circumstances unknown.”
If disease or injury was related to occupation, specify. If investigation
shows the death to have been due to disease, specify : (1) Under cause,
its known or presumable nature; and (2) under manner, indicate the
circumstances leading to medico-legal inquiry. For example : ' ‘ Hemorr-
hage spontaneous, of the brain (basal ganglia) (found dead in bed).”
“Heart disease, presumably coronary sclerosis. (Sudden death.)”
DESCRIPTION (for unknown person)
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
L
DM R-301
I -
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Suffolk:
(County)
Winthrop
(City or Town)
No> 26 Pluiajiier Avenue
#
©tjT CSommtmuiTaltlj of fHaooarljusrna
OFFICE OF THE SECRETARY
DIVISION OF VITAL STATISTICS
STANDARD
CERTIFICATE OF DEATH
( CiAy or town making retumL,
Registered No
•St.,.,
Ward
(If death occurred in a hospital or institution,
give its NAME instead of street and number)
2 FULL NAME..
Janas Reid
(If deceased is a married, widowed or divorced woman, give also maiden name.)
26 Plumper Avenue
(If u. s.
War Vetcran9
specify WAR)-
(a) Residence. No
(Usual place of abode)
Length of residence in city or town where death occurred
PERSONAL AND STATISTICAL PARTICULARS
OflOR RACE
5 SINGLE
MARRIED
WIDOWED
or DIVORCED
(write the word)
Widowed
HandaforA
(Give maiden name of wife in full)
(or) WIFE ol
(Husband’s name in full)
6 IF STILLBORN, enter that fact here.
7 84
AGE.....®’ Years.
11 14
Months Days
If les« than 1 day
Hours Minutes
(State or country) Newf oundland
13 NAME OF
FATHER
James Reid
14 EIRTHPLACE OF
FATHER (City) .
(State or country)
E&nds . . .Harbor
Newfou dlarid
15 MAIDEN NAME
OF MOTHER
Diana King
16 BIRTHPLACE OF
MOTHER (City) .
(State or country)
Hands Haroor
Newfoundland
17
Informant ...
Willis J Reid
R^i^.ifany
(A5CT"35-"T&ra^ }
I HEREBY CERTIFY that a satisfactory standard certificate of death was
filed with me BEFORE the burial o(\transi^erg>it was is^ed:
Jrrf.Ci
Uesign&tu
(Signa^ue^^ of Heal^M^jtti
(Official Designation)
days.
.St., Ward, :
(If nonresident, give city or town and state)
How long is U. S., if or foreign birth? yrs. mss. days.
z
o
8 Trade, profession, or particular
kind of work done, as spinner.
Boat builder
b-
<
Q
ZD
9 Industry or business in which
work was done, as silk null.
Shipyard
O
O
10 Date deceased last worked at
1 1 Total time (years)
spent in this p.
occupation
12 BIRTHPLACE (City)...
MEDICAL CERTIFICATE OF DEATH
18 DATE OF
DEATH
January 26
(Month) (Day)
1938
(Year)
HEREBY CERTIE
Thai I attended deceased from
y J9f / to JkfiX , 19r?.^n.
saw h...L-~... alive on ... . . . L/^-.rT. , 19.^7.., death is said
to have occurred on the date staled above, at!&; A Q.$..\n.
The principal cause of death and related causes of importance in order of onset
were as follows:
Contrihatcry causes of importance not related to principal cause:
Name of operation .
What test confirmed diagnosis^2ta**>«V~
Date of Onset
.Date of
Was there an autopsy?./Zf.A
20 Was disea
\sease-Q,
If so, specify../:..
iMA
r injury in any way related tooccupation of deceased?
Q-Gl
(Signed) — * , M. D.
Dat^trfk...<-.^...19..J..y.
(Address).
21 PLACE OF BURIAL, Wt nfhwnn W-i
CREMATION OR REMOVAL .Wi£. Y.h.rOp
(Cemetery) (City or town)
DATE OF BURIALJ^.OU^Xy....J8.9... .19.38
22 NAME OF
UNDERTAKE
19..
ADDREssl^?....W.iQ.^fer.9jo....st....wl.^lirQp...Ma.ftfl
Received and filed 19
7EB 1 193fc^«>
A TRUE COPY. ATTEST:
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OFFICE OF THE SECRETARY
DIVISION OF VITAL STATISTICS
STANDARD
CERT5FICATE OF DEATH
(Ciiy or town making return)
16
Registered No.
(If death occurred in a hospital or institution.
( (If death occurred m a hospital or institution,
..St.» Ward | give its NAME instead of street and number)
2 FULL
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(If U. S.
War Veteran,
specify WAR).
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(Usual place of abode)
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days.
.St., Ward, :
(If nonresident, give city or town and state)
How long in U. S., if of foreign birth? yrs. mos. days.
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
Fe.ua le
4 COLOR OR RACE
Vfn _ ; e
5 SINGLE
MARRIED
WIDOWED
or divorced Sin le
(write the word)
5a If married, widowed, or divorced
HUSBAND of
(Give maiden name, of wife in full)
(or) WIFE of ....
(Husband’s name in full)
V
0 IF STILLBORN, enter that fact here.
7
AGE .
..«i9 ...Years.. ..2 Months.. ...22d
ays
It les* than 1 day
Hours Minutes
8 Trade, profession, or particular
kindofwork done, as spinner,
sawyer, bookkeeper, etc
9 Industry or business in which
work was done, as silk mill,
saw mill, bank, etc
10 Date deceased last worked at
this occupation (month and
year) .
..Maab.
laxi..
Concert
1 1 Total time fyears)
1936
spent in this
occupation..
20
12 RIRTHPI.AfF. ICitv)
....He.x..C.i.ty
(State or country)
Penn,
13 NAME OF
father Eraeat Sinclair
GO
14 BIRTHPLACE OF
FATHER (City) .
....5jalt.cn.
f-
z
(State or country)
Maine
LU
CH
15 MAIDEN NAME
life, r gar et Murphy
<
CL
OF MOTHER
10 BIRTHPLACE OF
MOTHER (City) .
Pl.t-t-flb.urgk.
(State or country)
Penn.
1 informant .J&g.s )
(Address) o Orlando Ave . , Wincnrop
Relation, if any
I HEREBY CERTIFY that a satisfactory standard certificate of death was
filed with me BEFORE the buWl orTt ran sit-permit was issued:
(Signature of Agent
- r..,
(Official Designation)
7
MEDICAL CERTIFICATE OF DEATH
18 DATE OF
DEATH
.Jan:
xAcary...
tMonth)
..26l.
(Day)
..1938..
(Year)
ic/ i hereby c e r t i e Yy That l alien
J Q'Wr r ( J y, laS.A,
That I attended deceased fjoi
,19’
1 from
Jo
I last saw h.Jfh alive on. , death Is said
to have occurred on the date stated above, at J.
The principal cause of death and related causes of importance in order of onset
were :
i as toMvs:
(t
Contributory cause* of importance not related to principal cause:
Date of Onsot
ipT,
Name of operation Date of
What test confirmed diagnosis? Was there an autopsy?
20 Was disease or injury in any way related to occupation of deceased?
If so, specify..
(Signed)
(Address)....'!?^..
21 PLACE OF BURIAL,
CREMATION OR REMOVAL
DATE OF BURIAL
Mt. Auburn Cambridge
(Cemetery) (City or town)
Jan.. ..29..»....19.3.6. „ 19...
22 NAME OF
UNDERTAKE
ADDRESS .
147 interop jft'/'l WIno*nrop , !&
Received and filed . 19...—
:....
A TRUE COPY, ATTEST:
.egistrar)
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OFFICE OF THE SECRETARY
DIVISION OF VITAL STATISTICS
STANDARD
CERTIFICATE OF DEATH
To be filed for burial permit
with Board of Health
or its Agent.
Registered No TUT
(If death occurred in a hospital or institution,
give its NAME instead of street and number)
2 FULL NAME
(If deceased is a married, widbiv^d or divorced woman, give also maiden name.)
(a) Residence. No \rXSZrr.~. - J... .... Ward,
(Usual place of abode) (If nonresident, gi1
Length of residence in city or town where death occurred yr». mas, Jays, How long in U. S., if of foreign birth? .^/.j * yr>
)city or town and state)
mos. days.
PERSONAL AND STATISTICAL PARTICULARS
4 C0L0R0R RACE
5 SINGLE
MARRIED
WIDOWED
or DIVORCED
(write the word)
5a If married, widowed, or divorced
HUSBAND of
(Give maiden name of wife in full)
(or) WIFE of
(Husband's name in full)
6 IF STILLBORN, enter that fact here.
AGE
JXC Years Months ^ Days
If less than 1 day
Hours Minutes
8 Trade, profession, or particular
kind of work done, as spinner,
sawyer, bookkeeper, etc,
9 Industry or business in which
idustry or business in which C/
work was done, as silk mill, / s A J'
saw mill, bank, etc
10 Date deceased last worked at
this occupation (month an
year)
12 BIRTHPLACE (City).
(State or country)
1 1 Total time fyears)
spent in this ^
occupation vjr U
13 NAME OF /?
FATHER
14 BIRTHPLACE OF
FATHER (City) .
(State or country)
15 MAIDFN NAME yr
OF MOTHER / L
10 BIRTHPLACE OF
MOTHER (City) ..
(State or country)
X
_ _ . Jr )
UU^._
I HEREBY CERTIFY that a 'satisfactory standard certificate of death was
filed with me BEFORE the burial or ^ransitopertnit vyasissued:
, <Signature of Agent of ifkafcl of Health or oi her) y
10-:, J*X
1 Designation) f (0ate of Issue of Peimit)
(Official
MEDICAL CERTIFICATE OF DEATH
18 DATE OF
DEATH
(Month)
(Day)
/?3f
(Year)
19 I HERE J3 Y CERTIFY, That I attended deceased from
/ Y- >9.3.1 ,.-3 f
I last saw h-rtyW.. alive on...,i£?k^vr •st*40pZrr?..tct ,19..-::....-!., death is said
date stated above, at (..... m.
^uses? of importance in order of
to have occurred on the date stated above,
The principal
onset were
Contributory causes of importance not related to principal cause:
X
Name of operation .
What test confirmed diagnosis? T
Date of —
Was there an autopsy?
,w
20 Was disease or injury in any way related to occupation of deceased?
If so, specif:
(Signed) V. ... r). ‘ . w.-r*.
*)<u,
ffmz,
A
M. D.
Date
ZtklyzXX
21 PLACE OF BURIAL,
CREMATION OR REMOVAL
DATE OF BURIAL
XCemetery) /(City or town)
30j 190*^.
22 NAME OF
UNDERTAKER
Received and filed 19
fE'BT 1938' ww
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R-301 A
1 -<
Suffolk
(County)
...Mass
(City or Town)
Gftjc Commontoealtf) of jfWasgarfjusiettsi
OFFICE OF THE SECRETARY
DIVISION OF VITAL. STATISTICS
STANDARD
CERTIFICATE OF DEATH
To be filed for burial permit
with Board of Health
or its Agent.
No 94 . Wa sMngt on .. Av.t st., ward{”f dcath occurred in a hospital or inRtitution’
2 full name Ka^.l Goetz.. .
(If deceased is a married, widowed or divorced woman, give also maiden name.)
Registered No.
:curred in a hospital or instituti
give its NAME, instead of street and number)
{(If U. S.
War Vetei
specify ^
Veteran
WAR)
(a) Residence. No 94...WaSifringtan-- AV-e St., Ward,
(Usual place of abode) (If nonresident, give city or town and state)
Length of residence in city or Iowa where death occurred 0 year, monthi day,. How long in U.S., if of foreign birth? ^^ye«r» month, da y»-
I. 3
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
(Mala.
4 COLOR OR RACE
Vfhite
6 SINGLE
MARRIED
WIDOWED
or DIVORCED
(write the word)
■Harried-
6a If cumed, widowed, or divoretd _ . _ -
husband of j^xxzabaiJbL...Lrauss..
(Give maiden name of wife in full)
(or) WIFE of ,
(Husband’s name in full)
Q IF STILLBORN, enter that fact here.
AGE .60 Years Months Days
If less than 1 day
Hours Minutes
8 Trade, profession, or particular
hind of work done, as spinne, ’D.aViCjv*
aowyar, bookkeeper, etc _V..ajtl£Uu.
9 Industry or business in which
work was done, as >ilk Bill, t-. . ,
tow null, bank, etc .'.2. xLQ ^ 27 . . . 72 X* O JX «
lO Date deceased last worked at 11 Total time (years)
this occupation (month andjyj^g 193*7 sPent ‘n. tflis
12 LIRTHPLACE (City).
(State or country)
13 NAME OF
FATHER
Germany
Karl Goetz
14 BIRTHPLACE OF
FATHER (City) .
(State or country) Qg.rrrig'py
15 MAIDEN NAME
OF MOTHER
16 BIRTHPLACE OF
MOTHER (City)
(State or country)
Elizabeth Framer
17
latormAnt
(Address)
Gprmany
Relation, if any
2.A.„.Ellzabeth....Go(etz wife)
fth jnr*tr,n iiinthrof
MBDICAL CERTIFICATE OF DEATH
EREBY OERJIF
/S
*
I last snHu.fr*... alive on
to have occurred on the dat&4tated above, at
The principal cause oi death and related cau:
>9 /?3jr
(Day) (Year)
That I attended deceased from
1 193*7
I&jfl death Is said
sear of Importance In order of onset
were as follows:
Oit« of Oot«t
IMPORTANT
/f3 cl
%r/23/
— - A
Contributory cun of importance not related to principal cause:
Name of operation .
What test confirmed du
..Date of niv.
..Was there an autopsy?.^^
20 Was disease or Injury in any way related to ocdGpation of deceased?
If so, specify ..+\ J
(Signed) , M
2 1 Mt t ... .Hope * Boston
Place of fsurial, Cremation or Removal. (City or Town)
y/3,EL938
DATE OF BURL
22 NAME OF
UNDERTAKER
oston -
address MetrMo.litan...Ei&isral....S.firvi.c.e
Received and filed
.19.......
— -FtBl-1328
atrar)
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information should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state
CAUSE OF DEATH in plain terms, so that it may be properly classified. Exact statement of OCCUPATION
is very important. See instructions and extracts from the laws on back of certificate.
100m-12-'34. No. 2938-e
R-301
Qftj? JlammmmtraUl? of fHasaarfmsetta
OFFICE OF THE SECRETARY
DIVISION OF VITAL. STATISTICS
STANDARD
CERTIFICATE OB*DEA£H
(If death occurred in a hospital or institution,
give its NAME instead of street and number)
2 FULL NAME
IS
(a) Residence. No.
(Usual place of abode)
Length of residence in city or town where death occurred
Registered No
,„:...Ward {
(If deceased is a married, widowed or divorced woman, gjye also ipaiden name.) ^ l specify
^ " 7a
>c
V
(If u. s.
War Veteran,
WAR)
’(If nonresident, give city or town and state)
days. How long in U. S., if cf foreign birth? yrs. mol, day».
PERSONAL AND STATISTICAL PARTICULARS
4C^0^AKl_eS|(!=LEEc
widowed
&
e the word)
or DIVORCED
5a If married, wt.Inwed, nr ffenirrd _
HUSBAND of
(or) WIFE of .
(Give maiden name of wife in full)
(Husband’s name in full)
6 IF STILLBORN, enter that fact here
-G-tVc/lA-
7
AGE..
}s: Years .^F... Months XT.Days
If less than 1 day^.
..-^r...Hours...-<St... Minutes
8 Trade, profession, or particular
kind of work done, as spinner,
sawyer, bookkeeper, etc
0 Industry or business in which
work was done, as silk mill,
saw mill, baak, etc
10 Date deceased last worked at
this occupation (month am
year)
12 BIRTHPLACE (City).
(State or country)
1 1 Total time (years)
it in t
occflpatioi
13 NAME OF
FATHER
spent in thiju-. — ,
14 BIRTHPLACE OF
FATHER (City)
(State or country)
13^
15 MAIDEN NAME
OF MOTHER
16 BIRTHPLACE OF
MOTHER (City) .
(State or
V2
3 W
I HEREBY CERTIFY that a satisfactory standard certificate of death was
filed with me BEFORE the botial or tidn*it pewniUtotas Issued:
(Official
MEDICAL CERTIFICATE OF DEATH
18 DATE OF
DEATH ....
-2^ dr
F/' (Month) ir (Day)’ A "(Year)
is I hereby oertify. That I attended deceased from
,19 , to ,19
I fast saw h alive on 19 , death Is said
to have occurred on the date stated above, at m.
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:
Name of operation... .FT _
What test confirmed diagnosis^^^^^yy^j^Ti....
20 Was disease or injury
If so, specify,
(Signe
(Address)
21 PLACE OF BURIAL, , - ^
CREMATION OR REMOVAL
^ (Cemetery) ' (City of town)
i9...
•••**•-
A TRUE COPY, ATTEST:
139.
(Registrar)
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Q IF STILLBORN, enter that fact here.
AGE 5.G. Years Months Days
If less than 1 day
Hours Minutes
l <
Suffolk
(County)
..Winthrop
(City or Town)
Wl)l Commtmtoealtf) of To be filed for burial permit
OFFICE OF THE SECRETARY with Board of Health
DIVISION OF VITAL STATISTICS
or its Agent.
STANDARD
2378
No IDO. . .7 ar.r.ac.e. . Av*
CERTIFICATE OF DEATH
f (If dt
St.f Ward \give i
Registered No.
death occurred in a hospital or institution,
its NAME instead of street and number)
fUMJ.S.
2 full name Ir.ene...A*....T.ucker--- - jw.rv.te™.
(If deceased is a married, widowed or divorced woman, give also maiden name.) I specify WAR)
(a) Residence. No JL0.G...Ter3>.aCfi. -JiV*
(Usual place of abode)
Length of residence in city or town where death ocenrred f j Qyears months
St., Ward,
(If nonresident, give city or town and state)
days.
How long in U.S., if of foreign birth?
months
days.
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
Female
4 COLOR OR RACE
wh il
(write the word)
6 a If curried, widowed, or divorced
HUSBAND of
6 SINGLE
MARRIED
WIDOWED
.orDIVpRCED^p.^^.
(Cyve maiden name of wife in full)
(or) wife of LfiMi£....G.*.Ea.,.T.uc.ker.
(Husband's name in full)
8 Trade, profession, or particular
klndofwork done, as ipinnet tt_ „ •
UV)V, bookkeeper, etc iiO.U£.eWiJ..e
9 Industry or business in which
work was done, as silk mill, » TT__
•aw mill, bamk, etc ....
10 Date deceased last worked at 11 Total time (years)
this occupation (month and -r _ _ _ r_, spent in this
year) ■fci.&n— I occupation
12 L1RTHPLACE (City).
(State or country)
lleaL-York-i
13 NAME OF
FATHER
TT v
-i — • — •-
14 BIRTHPLACE OP ,T ,r ,
FATHER (City) KeW- YOPk
Joto A«- -Thompson
(State or country) V
15 MAIDEN NAME
OF MOTHER
4v argar e-t Ke e le y
16 BIRTHPLACE OP .
MOTHER (City) .KeW -YOPk^ •
(State or country) JT QY/ Voj’k
17
Ia*i
(Address)
Relation, if any
.Lewis--G*H*.~T.ucker ( husband )
.100. . .Terrace Av, . Viirvt.hrop
MEDICAL CERTIFICATE OF DEATH
18 DATE OF
DEATH
1 2
(Month) (Day) CYear)
19
) i hereby oertif y,» That I attended deceased from
ISi+A. ~..Lr. .^93A., 19i3.^.
last saw b...£.Y*....allve on. ..f^<5Wvt.S..^v.*A..'r...‘!Si..)....,.,'f9.^.Sr., death Is said
said
I last saw h... O.*... .alive on....?si.*Mvt.8..1^!A,
to have occurred on the date stated above, ain:.20nLP.M,
The principal cause of death and related causes ot Importance In order of onset
were as follows
Contribatory caom of importance not related to principal cause:
Date of Onset
IMPORTANT
Name of operation
What test confirmei
20 Was disease or Injury in jny i
If so, specify..
(Signed),
(Address). ...’Las k
^ 4/r i j <aij • i>
ij diagnosis? av'Sjji ~ Was there an autopsy? Wa
ted to occupation of deceased? ... /.¥..«
.1 , M. D.
Date|r«b..^..l9AC'..
21 Winthrop, Winthrop
1’laci- of liurial, (_ ret nation or Removal. (City or Town)
,,.1.93.8 19..
DATE OF BUR
22 NAME OF
UNDERTAKE
ADDRESS ...Ml
topo.liban
...B.O.S.tOH
.^.Funeral.. ..Sarvic.e
Received and filed
T53F
.19
(Registrar)
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a
®Ijb (Eummmuuraltlj of iHasoarfjusBtta
OFFICE OF THE SECRETARY
DIVISION OF VITAL. STATISTICS
STANDARD
CERTIFICATE OF DEATH
(County)
Tint hr op
(City or Town)
No...l9.„yXila„AveirdG §£&, Ward {
(City or town making return)
Registered No
(If death occurred in a hospital or institution,
give its NAME instead of street and number)
2 FULL NAME (JA®.). j War Veteran,
(If deceased is a married, widowed or divorced woman, give also maiden name.) I specify WAR) .
,&£. Ward,.
(If U. S.
O l
,+aJ JL
(a) Residence. No
(Usual place of abode)
Length of residence in dty or town where death occurred 2 D yr».
(If nonresident, give city or town and state)
days. How long in U. S., if of foreign birth? yrs. ffios. days.
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
Female
4 COLOR OR RACE
T7hi te
5 SINGLE
MARRIED
WIDOWED
or DIVORCED
(wnte the word)
7/ id owed
5 a If married, widowed, or divorced
HUSBAND of ... .
(Give maiden.name of wife in full)
(or) WIFE of ii.LlX6.d....FJllIlIlS.Y
(Husband’s name in full)
0 IF STILLBORN, enter that fact here.
AGE L.l. Yea rs.. . X.Q.. . Months ..tJ.Q... Days
If less than 1 day
Hours Minutes
<
Q-
5
8 Trade, profession, or particular
kindof work done, as spinner, Ilnnon wm»V
sawyer, bookkeeper, etc
9 Industry or business in which ,
work was done, as rilk mill, 0 T1 h 01116
saw mill, bask, etc
10 Date deceased last worked at _ .Tl Total time (year:
this occupation (month and Join . 1 ydb spent in thi:
yea r) occupation
12 BIRTHPLACE (City) £X.QjQklyiL..
(State or country) New York
13 NAME OF . .
father 2awin Iae
14 BIRTHPLACE OF
FATHER (City)
, /rent ham
(State or country)
Massachusetts
15 of^mother^ Ab ia 1 V . P on&
10 BIRTHPLACE OF
MOTHER (City)
(State or country)
Pondvill
Massachusetts 0
17
Alice Phirmey ^ ^ i
I HEREBY CERTIFY that a satisfactory standard certificate of death was
filed with me BEFORE the burial or transit permit waYissued:
(Official Designat:
MEDICAL CERTIFICATE OF DEATH
18 DATE OF
DEATH
2.
(Month)
(Day)
/f3lr
(Year)
is x hereby oertify. That I attcntiad deceased from
J. , 19^ 7-.-, & 19 3 ^
I mst saw h.rrf?r.... alive on ~hP. 13.3..^ death is said
to have occurred on the date slated above,
The principal cause of death and related causes oi importance in order of onset
were as follows: Date of Onset
Contributory canses of importance not related to principal cause:
UP r
Name of operation. .. Date fy.. ./.ft.. ^ ^
What test confirmed diagnosis? Was thercan autopsy?. 'Z^c
20 Was disease or injury in any way related to occupation of deceased?
If so, specif) a..../?) ft
(Signed) S:.^Urn.r*r^rr
(Address).(^/.h<t^t^tw*l^> D:
, M. D.
Date 9r/.. ...^.....19.nJ’.6l
21 PLACE OF BURIAL.
CREMATION OR REMOVAL
DATE OF BURIAL.
Center V.rrentham I,?asa
. (Cemetery) (City or town)— -
February 5, 19 3 8
22 nave of Charles K. Bennison
UNDERTAKER ...... .T....7.
address Yinthrop Mass
Received and filed
A TRUE COPY, ATTEST:
tii.
(Registrar)
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OFFICE OF THE SECRETARY
DIVISION OF VITAL. STATISTICS
STANDARD
CERTIFICATE OF DEATH
To be filed for burial permit
witb Board of Health
or it* Agent.
Registered No
No.
O/i T'Vn ~ 11 -^4 . a. f (If death occurred in a hospital or institution,
- ernii4E.„ai!r.e.S»., Ward \ gjve it
its NAME instead of street and number)
f (If U. S.
-j War Vet.
I specify I
Veteran
WAR)
22
2 full name : .Hov/ard.„GiQ.uJL.cl
(If deceased is a married, widowed or divorced woman, give also maiden name.) ^
(a) Residence. No ward,......'.
(Usual place of abode) (If nonresident, give city or town and state)
Length of residence in city or town where death occorred years months days. How long in U.S., if of foreign birth? years months days.
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
male
4 COLOR OR RACE
white:
5 SINGLE
MARRIED
WIDOWED
or DIVORCED
(write the word)
. ido ed
Sa II married, widowed, or divorced _
husband of .Lsn.3 L...alli..„h.e.e...
(Give maiden name of wife in full)
(or) WIFE of
(Husband’s name in full)
6 IF STILLBORN, enter that fact here.
7
AGE..
74
..Years.. ...IQ. Months
..Days
If less than 1 day
Hours Minutes
8 Trade, profession, or particular
kindof work done, as spinner, A r* + r\-n
sawyer, bookkeeper, etc £V.
9 Industry or business in which
work was done, as silk mill,
saw mill, bank, etc
lO Date deceased last worked at
this occupation (month and
year)
19-
1 1 Total time (years)
Spent in this
occupation
12 E1RTHPLACE (City).’..
(State or country)
.. .tr. . .'K... n^i . S, (. r.ni^n) n.... .
13 NAME OF
FATHER
Hiram ’./.Gould
14 BIRTHPLACE OF
FATHER (City) ..
(State or country)
■>ortl -r / I..
15 MAIDEN NAME
OF MOTHER
Elizabeth I. Libby
10 BIRTHPLACE OF ^ + -i 7-
MOTHER (City)
(State or country)
17
Inh
(Address)
Relation, if any
. shrola Gould ( ion )
17 L-keviTTe ze J . ? . '
MEDICAL CERTIFICATE OF DEATH
18 DATE OF
DEATH FS.D.....a..™l9.s3.3.
(Month) (Day)
(Year)
19; i hereby oertify. That I attended deceased from
,
I last saw b.h~!... alive 11^7 death Is said
to have occurred on the date stated above,
The principal cause of death and related cause* ot i
principal
were as follows:
Contributory coses of importance not_ related to principal cause:
Name of operation
What test confirmed dia
Importance In order ot onset
Date of Onset
IMPORTANT
.^Ilate oJ....Tr:...r>w...., — ^....
autopsy^..
20 Was disease or Injury in any way related to occupation of decs
If so, specify... j
(Signed) V - .y M. D.
2t r
JM.tcc of Burial, Cremation or Removal, (City or Town)
DATE OF BURIAI 1. .Fb b 5 193Ba r\
19..
22 NAME OF
UNDERTAKER
ADDRESS
.AW.L.
-4 B.Qh.l.Q.n..
Received and filed...-
TT^!“T
'WVA':
(Registrar)
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e o- o.
ig SUFFOLK. ....
(County)
s WINTHROP
w (City or Town)
5
O'
/mt CornmontoealH) of iHagsarfjusicttsi
' OFFICE OF THE SECRETARY
DIVISION OF VITAL STATISTICS
STANDARD
CERTIFICATE OF DEATH
To be filed for burial permit
with Board of Health
or it* Agent.
Registered No
_ , ,. tt. __.,_ / HI death occurred in a hospital or institution.
No. O tatlQI1.4iO.Spital^ ^.Or-t --BankS,^^iaS St., Ward | give its NAME instead of street and number)
2 FULL NAME CECELIA . . CLARE . . ilBLCH
(If deceased is a married, widowed or divorced woman, give also maiden name.)
f (If U.
j War V
l i pacify
S.
Veteran
. ipecify WAR)
o o
(a) Residence. No. ... 431-TLanieS— S±.,NeW--Port -rRX St., Ward,
(Usual place of abode) (If nonresident, give city or town and state)
Lenirth of residence in city or town where death occurred years months dnys. How long in U.S., if of foreign birth? years months day*.
PERSONAL AND STATISTICAL PARTICULARS
3 SEXFema
Female
% COLOR OR RACE
White
6 SINGLE
MARRIED
WIDOWED
or DIVORCED
(write the word)
married
5a If curried, widowed, or divorced
HUSBAND of
(or) WIFE
ue.
(Husband's name in full)
Q IF STILLBORN, enter that fact here.
AGE ..2.1 Years 8. ..Months 26. ..Days
If less than 1 day
Hours Minutes
8 Trade, profession, or particular
kindofwork done, as apinnei, TIrtll«5AVft«OPr
sawyer, bookkeeper, etc C.Q.US. » A.5?. S.p. V. X.
9 Industry or business in which
work was done, as silk mill. Own h0ITl6
saw mill, bank, etc -
lO Date deceased last worked at 11 Total time (years)
this occupation (month and spent in this
year) occupation
12 BIRTHPLACE (City).
(State or country)
Eall...RiY.«r
Mas sachusetts
13 NAME OF, " /-
father (fjtftp .fa f.h Madden
i "'}
14 BIRTHPLACE OP TT ,
FATHER (City) ....UaJOlJOMin.
(State or country) TTn lm OWTI
15 MAIDEN NAME
of mother Unknown
10 BIRTHPLACE of it ,
MOTHER (City) ^Xl2n 0)5(11..
(State or country) Unknown
j 7 Relation, if any
u<ormant Sgt...Edi«ard....X^..We.lAh. ( ..husband )
13th 1nf ..Ft Adams. RI
Isfactory standard certificate of death was
al Or transit permit was issued:
MEDICAL CERTIFICATE OF DEATH
18 DATE OF
death F.ebr..uar.y....5.,....1.9.38
(Month) (Day)
(Year)
is i hereby oertify, That I attended deceased from
.F.eh...5. , 19.3.8., io...E.b.bx.uary...5. , 1938...
I last saw h..er alive on F.ehr.uar.y 5 19. 38., deith l* uid
to have occurred on the date stated above, atJ.U.A fl.in.
The principal caote of death and related causes ot Importance in order of onset
were as follows:
L»J3ar.bmcle.#ac.ufce>ae.yer.«#.lfif.t
saa.pulftr...r.sgiQfl fan. . .2.3/38
2 ♦Br. onahjopne unuani a , a cut r , .s error a .,. . .
inmlTin g . . a 1 1 . . lahe.s >r i gh.t . . I.un/>
...Typ.e...IV. L.. |:an...3.Q/38
Contributory eanses of Importance not related to principal cause:
Data of Oout
IMPORTANT
Name of operation Date of
What test confirmed diagnosis? No Was there an autopsy?
20 Was disease or Injury in any way related to occupation of deceased? ... Ho.
"S2T -d&m&it/r ~ iT
(Signed) Char le s h « ; - Ms c Laugh lln^L/S tLt " ‘
(Address). ...station Pete 19..%.#^
"Ft" Banks
21
1'Iace of B u rial ,£j£i Ration or RcmovaLy (City Town)
DATE OF BURIAL v-*V~ — ^
:.Tu4r..^..
(City Mr Town)
\ 19..Q5CT
22 undertaker ,C.jL„.R*...B.S3Mii.8.o.ii*....17.0...’iYiiithr.o.p..
address 2.t.<....Wia.thr.o.p.>....]yiaas..
Received and filed
—
44B.-I — .
.19.. —
(Registrar)
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3 SEX
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4 COLOR OR RACE
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5 SINGLE (wnte the word)
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in * v
>* g «
r i u
5a If married, widowed, or divorced ,
husband of Cora, E o Hob ens on Viwr
£-oS
£ t
£ 4)
« V
(or) WIFE of . ..
(Give maiden name of wife in full)
(Husband's name in full)
1 -<
Suffolk
(County)
Wiflthrop
^City or Town)
Wf )t CommontDcaltf) of Jfflafigaritusiettg
OFFICE OF THE SECRETARY
DIVISION OF VITAL STATISTICS
STANDARD
CERTIFICATE OF DEATH
To be filed for burial permit
with Board of Health
or its Agent.
Registered No.
.8.1
No.
II Adams St. Winthrop
f (If death occurred in a hospital or institution,
\ give its NAME' instead of street and number)
2 FULL NAME _We*t
(If deceased is a married, widowed or divorced woman, give also maiden name.)
r (if u.
-j War V.
I specify
S.
Veteran
. specify WAR)
(a) Residence. No I I..AdamS..St . . .Wlnthrfip..JUiaR||.fl St., Ward, .
(Usual place of abode) (If nonresident, give city or town and state)
Length of residence in city or town where death occurred I 7 years months days. How Ion* in U.S., if of foreign birtli?O v/ years months days.
PERSONAL AND STATISTICAL PARTICULARS
Q IF STILLBORN, enter that fact here.
AGE £9 Years ^...Monthrf? Days
If less than 1 day
Hours Minutes
8 Trade, profession, or particular
kind of work done, as spinnet, Prorinf’f1
sawyar, bookkeeper, etc T..„.r:„..T:..
9 Industry or business in which
work was done, as silk mill,
saw mill, btak, etc.
10 Date deceased last worked at
this occupatipc^ jggonth and
I4arket
1 1 Total time (years)
spent in this cq
occupation..
13 [UBTHPlifF fCitvl
Del Eaven
(State or country)
Ncv4ra Scotia
13 NAME OF
FATHER
Ei jan West
CO
14 BIRTHPLACE OF
FATHER (City)
(State or country)
Del Haven
h-
z
Ncv-ia Scotia
LU
cr
<
Q_
15 MAIDEN NAME
OF MOTHER
Harriett Rand
16 BIRTHPLACE OF
MOTHER (City)
Del Haven
(State or country)
No via Scotia
U.
G
17
I sac £. Robinson/
Jlelation, if any
Nephew ^
CC.
G
c-
(Address)
TI Adaiiis St. V. intinrop '
/
I H&REBY CERTIFY that a satisf;
, li) ti with me BEFORE the '
(Official Deaignation)
certificate of death was
issued:
MEDICAL CERTIFICATE OF DEATH
18 OATE OF
DEATH
February
(Month)
7
"(Day)'
1938
(Year)
is. i hereby oertify. That I attended deceased from
^ , 19 to ...
last 8avM.f#*t... alive on 19..*?.<Ttotli la aald
to have occurred on the date slated above, at
The principal cause of death and related causes ot Importance In order of onset
were as follows:
Date of Qntit
IMPORTANT
..
Caapjbatory pause, of Importance not related to principal cause:
/933~
'/JZ
/
Name of operatloirrr.r^r^^^>TN_-. -fj-g Date of....1
What test confirmed dia2na&£c^*«^oe^C^_/£ Was there an autopsyT
20 Was disease or Injury in an^wSiy^efeteifto ocw/^on of deceased
If so, specify ■■/)— ’/yitf'
(Signed) , M. D.
(Address)^x^.J Date"y^
2 , Ceder Grove Bostcif f.^ass
Place of Burial, Cremation J^emoyal. (City or Town)
DATE OF BURIAL 19..
22 NAME 0F
UNDERTAKER
Lfl Jrirr.C. jL . ... .2
address
Received end filed..
.19..
Jl
(Registrar)
y,
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.S.ufXQ.Ih.
(County)
.Vinthrop
No.
(City or Town)
4 6 "5 Vinthrop St
Commontoeattf) of iHasffiatfjuSetts!
OFFICE OF THE SECRETARY
DIVISION OF VITAL STATISTICS
STANDARD
CERTIFICATE OF DEATH
To be filed for burial permit
with Board of Health
or its Agent.
25
-St., Ward
Registered No.
:curred in a hospi
give its NAME instead of street and number)
J (If death occurred in a hospital or institution,
Igi
2 full name Daniel Joseph Danahy
(If deceased is a married, widowed or divorced woman, give also maiden nar e.)
(a) Residence. No.— Ijj2.ltll32D.pL--j3.1l
(Usual place of abode)
Length of residence in city or town where death occurred year*
r (if u. s.
-j War Veti
l specify \
Veteran
WAR)
St., Ward,
(If nonresident, give city or town and state)
months
days.
How long in U.S., if of foreign birth?
months
days.
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
Male
4 COLOR OR RACE
White
6 SINGLE (write the word)
MARRIED
or^ DIVORCED < - ' C -
6a If married, widowed, or divorced _ s
husband of ...Ua.iT.-.e.r:j.iis O.....C.Q.nn.Qi?
(or) WIFE of .
(Give maiden name of wife in full)
(Husband’s name in full)
6 IF STILLBORN, enter that fact here.
7
AGE..
.1.6...
..Years Months.
..Days
If less than 1 day
Hours Minutes
8 Trade, profession, or particular
kind of work done, as spinaer,
•ewytr, bookkeeper, etc
0 Industry or business in which
work was done, as silk mill,
tew mill, beak, etc
10 Date deceased last worked at
this occupation (month and
year) ±.i?..J.5:..
Retired
xsajiiThe text goes on. The rest is in the file.