The volume, 1939
Town Clerk, Winthrop · from the Internet Archive · 558 pages · 44.8 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'7t^
R-301A
f
1 <
Suffolk
(County)
o 13.5... Pleasant st„
QCtjc CommontDcaltf) of iHafifiacfju setts
OFFICE OF THE SECRETARY
DIVISION OF VITAL STATISTICS
STANDARD
CERTIFICATE OF DEATH
To bo filed for burial permit
with Board of Health
or it* Afrat.
Registered No _JL
I (If death occurred in a hospital or institution.
Ward \ Bjve ;ts NAME instead of street and number)
2 full name G© Q.rge. ...Smi.th..±).o.llQf f
(If deceased is a married, widowed or divorced woman, give also maiden name.)
( (If u. s.
j War Vet,
l specify 1
Veteran
WAR)
(a) Residence. No PlSaSant St.,
(Usual place of abode)
Length of residence in city or town where death occurred 13 years Q months
...Ward,
(If nonresident, grive city or town and state)
days.
How long in U.S., if of foreign birth?
months
days.
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
Kale
4 COLOR OR RACE
White
6 SINGLE
MARRIED
WIDOWED
•r DIVORCED
(write the word)
Married
6a II narrisd, vidowed.Ar-direrctd , ,
HUSBAND of ....JjilJ. ©n...iiUSiXtU§'ll
(Give maiden name of wife in full)
(or) WIFE of
(Husband’s name in full)
6 IF STILLBORN, enter that fact here.
7
AGE
70
.Years...'. Months
23
Days
If less than 1 day
Hours Minutes
8 Trade, profession, or particular
« w ‘etc—.: Superintendent
8 Industry or business in which
work was done, as silk Bill, RactOry
•aw Bull, bamk, etc
lO Date deceased last worked
at
this occupation (month and T)gn
year)
1 X Total time (years)
1938??!.n!iKt!!is 50
occupation..
(State or country)
Massachusetts
13 NAME OF . _ _ _ _ _
father Abner Dolloff
C/5
14 BIRTHPLACE OF
FATHER (City) ..
Exeter
►-
Z
(State or country)
Hew Hampshire
UJ
or
<
a.
15 MAIDEN NAME
OF MOTHER
Emeline Cogswell
10 BIRTHPLACE OF
MOTHER (Citv)
(State or country)
Nova Scotia
lo'omast .Hi
(Address) 125
Relation, if any
,._iiA...J)..0.11.otf.f.....w.if.e )
St V/inthrop Mass
dard certificate of death was
Sit permit was issued:
^'4tMZEE.
MEDICAL CERTIFICATE OF DEATH
18 DATE OF
DEATH ...
(Month) f
/ ...
(Day)
/Ml
(Year)
19 . i h ee eby OEHTiFY, That I attended deceased from
/....., 19.-^
I last saw h/m.... alive on ..., 19.3/?., death Is said
to have occurred on the datwfated above, at
The principal cause ol death and related causes ot Importance In order of onset
were as follows: oat* of OaMt
IMPORTANT
Cootribatory cum of importance not related to principal cause:
Importance not related I
/.fM.
Name of operatlon^.^r^r...fr^^^* .m. Date of y
What test confirme^d^gnosj^7^TTf^r.^-.^r>-:. y'..Was there an autopsy^^^..
20 Was disease or l^u^n^nyw^'reiated )^occupation of deceased
If so, specify...
(Signed) ..
(Addri
, M. D.
iurit-w
Place of Burial, Cremation or Removal. (City or lown)
DATE OF BURIAL J&HU&.IX...4: 19-39
22 name of Charles R. Bennison
UNDERTAKER .
address .V/.int.hrop ...Mass.
Received and filed..
(Registrar)
.19.. —
•WK.11E. I , Wliri Ul'IfAUIl'il., bLALPw UNIS. — 1 nlo IS A 1't.KM AIN t-IN 1 KtUUKU. river y item of
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
1 R-301 A
g S.uf f.QlJk
< (County)
..'iZirLt.Jbx.Qp.
(City or Town)
^ (Euraouimoralth of fSJaafiartfURPtta
.1<& : j, 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.
(If death occurred in a hospital or institution,
give its NAME instead of street and number)
N0...;zint.hr..Qp.....Q.9muai.t.y„..E.P„§pitait ward {
, , _ _ r df u. s.
2 FULL NAME JEaXXX..E.d^^X....^.Wt WarVet.ru.,
(If deceased is a married, widowed or divorced woman, give also maiden name.) I specify WAR)
(a) Residence. No .&.9.0....B.QXKLD. JUKI St.,
(Usual place of abode) r>r n A
Icnfth of residence in dty or town where death occnrrcd
26 ^ 7
days.
Ward,
(If nonresident, give city or town and state)
How Ion* ia U. S., if of foreign birth? yri. moi. days.
PERSONAL AND STATISTICAL PARTICULARS
4 COLOR OR RACE
White
5 SINGLE
MARRIED
WIDOWED
or DIVORCED
(write the word)
Married
S^^^ff^earson
(Give maiden name of wife in full)
(or) WIFE of
(Husband’s name in full)
IF STILLBORN, enter that fact here.
x pa
Years..^". Months .V.Days
If less than 1 day
Hours Minutes
8 Trade, profession, or particular
t ruct ural engineer
sawyer,
9 Industry or business in which
work was done, as silk mill. Oil iC6
saw mill, bank, etc
lO Date deceased last worked at
this occupation (month a
year)
"San..
1 1 Total time (years)
1 Q r< C spent in this
XaOO occupation
12 BIRTHPLACE (City) ....XQ.Q.jHQ.
(State or country) New Hampshire
13 NAME OF . ~ -i . TT i n *i
father Albert Henry Sawtell
14 BIRTHPLACE OF
FATHER (City)
Rindge
(State or country)
New Hampshire
15 MAIDEN NAME
OF MOTHER
Abbie Ann McClanathan
16 BIRTHPLACE OF
MOTHER (City)
Weston
(State or country)
Vermont
17 m ^ - Relation^ any
bfaurt .M.r.s.....Cora...P, Sawtell wife J
(Address) ft Q Bowdom ot /inthron Mass
rd certificate of death was
peemit was issued:
(Official Designations "(/
MEDICAL CERTIFICATE OF DEATH
18 DATE OF
DEATH
^5
(J (Month)
(Day)
'(Yea?)
19 i hereby certify, Thai I attended deceased from
. , IShiJh., t0....1^<fe?*i 3. , 19.??.^,
' I last saw Ila**».... alive on .jHdUw 3 194.$.., Heath Is said
to have occurred on the date slated above,
The principal cause oi death and related causes ot importance In order of onset
were as follows:
Date of Onset
IMPORTANT
C^tt/M****, . . .
.1
JZi (
SL
Contributory causes of importance not related to principal cause:
Name of operation « Date of k/ "
What test confirmed diaonnsi Was there an autopsy?/K®..
jr
20 Was disease or injury in any way related to occupation of deceased?
If so, speedy ./).... ‘ GS Gri
21 PLACE
CRi
) .lAj'lMjZZZyt. DateXu^.-V:.. 19
lit. Auburn oambrldga
(Cemetery) (City or town)
January 5 .193.9 19 ....
DATE OF BURIAL .
22 UNDERTAKER
ADDRESS
Received and filed..
pr
432a.
.19
(Registrar)
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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.
IU0m I I -'36. No. 9080 F
R-3Q1A
Suffolk
(County)
Winfchrop
(City or Town)
QTf jc Commontoealtf) of itlassarfjugettg
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.
3
N<
117 Locust st.,_
Registered No. ...
f (If death occurred in a hospital or institution.
Ward ^ give its NAME instead of street and number)
2 FULL NAME J. Q.1?R. . . M& dd Olill i
(If deceased is a married, widowed or divorced woman, give also maiden name.)
f (If U. S.
•j W.r Vet.
I specify 1
Veteran
WAR)
(a) Residence. No.... 1.17..1.oc.us.t;.,. st.,
(Usual place of abode)
I
Length of residence in city or town where death occorred \
months
days.
Ward,
(If nonresident, f?i^e city or town and state)
How long in U.S., if of foreign birth? years months days.
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
Mai e
4 COLOR OR RACE
Whi 1 9
(write the word)
5 SINGLE
MARRIED ,, .
widowed Married
•r DIVORCED
5a If curried, widowed, or divorced
husband of -tiiig.e lina ....D-iV-i-ta...
(Give maiden name of wife in full)
(or) WIFE of ...»
(Husband’s name in full)
0
IF STILLBORN, enter that fact here.
7
AGE ...U..9 Years Months
Days
If less than 1 day
Hours
Minutes
z
o
8 Trade, profession, or particular
kind of work done, as ipiaoe..
Builder
H-
<
Q.
3
9 Industry or business in which
work was done, as silk Bill,
O
o
lO Date deceased last worked at
this occupation (month and
year)
1933
1 1 Total tima (years)
spent In this OK
occupation nT.*rr.
13 BIRTHPLACE fCitv)
(State or country) X tci ly
13 NAME OF
FATHER
Pas quale Maddolini
14 BIRTHPLACE OF
FATHER (City) .
(State or country)
Italy
1 5 wMomER^ng elina Grasso
16 BIRTHPLACE OF
MOTHER (City)
(State or country) Italy
2 Y *VfcU»WWU, AA cut/
lowers, .A^ wife....)
(Address) 1 17 Locust St .lint hrou - rasa
Relation, if any
HEREBY CERTIFY that a satisfa
1 wjUtme B^fORE/Ihe bi
A2A.; :JZ...U
t of
certificate of death was
it was issued:
MEDICAL CERTIFICATE OF DEATH
18 DATE OF
DEATH ...
CS (Month)
z,
(Day)
/ 9J.9,
(Year) '
is I hereby CERTIFY, That I attended deceased from
, U.3J?.., lo^a^-..-. 7 19.#.:
“ . 7/7 ,19.?^... Heart It old
twti
I last saw Ii.a-Ah.. alive
to have occurred on the date stated above, at rpJL.ra.-
The principal came of death and related causes of Importance lo order of onset
were as follows:
odfrtbatory earner of ll
SnuOxMrAJ....
m
It.fy
/.iJ.L
Codfrftatory caoaee of Importance not related to principal cause:
Pete of Onset
IMPORTANT
/.Ula.
Name of operation 7yu?V!rWr?~...rr.. Data of
What test confirmed diagnosis? Was there an autopsy?.^-^.'..
20 Was disease or Injury in any way related to occupation of deceased? ...1 lo
If so, specify.**
(Signed) , M. D.
(Address)
Datelfort(*r,jf'..19
2 , Winthrop ' Wlnthrop
Place of Burial, Cremation or RemoyaL (City or Town) _
DATE OF BURIAL ? .1 19?.9..
22 UNDERTAKER .C.fa$:.rX§S Oft..
address ^iiit.hr..op....Mas.s
Received and filed..
.19..
rv 10^°
— •'
(Registrar)
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Suffolk
Sllje Qlommrmuipaltfj of UJaooarlfUBftJfl
OFFICE OF THE SECRETARY
DIVISION OF VITAL. STATISTICS
STANDARD
_ „ „ , CERTIFICATE OF DEATH
Bo3pltel
Chelsea
(City or town makinjjrjjgum)
Registered No
No.
( (If death occurred in a hospital or institution,
St., Ward | give its NAME instead of street and number)
2 FULL NAME.
Charles Fdgar Brooks
(If dfece. ... . 1 is a married, widowed or (Jivorced woman, give also maiden name.)
or Id
(IIU.S.
l Ww Veteran,
I specify WAR)
(a) Residence. No M...T.® ??&.?©... AV0 . St., Ward, .... Wjnthrpp.^.Ma S S«
(Usual place of abode) 0 5 25 (If nonresident, give city or town and state)
Length of residence in city or town where death occurred yrt. mos. days. How lone in U. S., if of foreign birth? yrs. mos. days.
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
M
4 COLOR OR RACE
w
5 SINGLE
MARRIED
WIDOWED
or DIVORCED
(write the word)
Married
5a If married, widowed, or fictaa Mack
HUSBAND of
(Give maiden name of wife in full)
(or) WIFE oi
(Husband's name in full)
6 IF STILLBORN, enter that fact here.
7 46 4 0
AGE Years
Months Days
If less than I 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
Vatch Maker
Ovm Business.
10 Date deceased last worked at
this occupation (ipp(!)lf7and J 90Y
year)
.eaxs)
spent in this Xo
occupation
12 BIRTHPLACE (City).
(State or country)
Nyack, New York
13 NAME OF
FATHER
Charles C.
CO
14 BIRTHPLACE OF
FATHER (City) .
h-
Z
(State or country)
jsoaxon ss#
LU
cn
<
CL
15 MAIDEN NAME
OF MOTHER
cannot be learned
10 BIRTHPLACE OF
MOTHER (City) .
(State or country)
Brookf iOld,Mass.
1 7
• Terrace Ave .•-inthrop^ Maas 4
A TRUE COPY.
ATTEST:
DATE FILED .
(Registrar of city or town where death occurred)
Jan. ?,1959
19-
18 DATE OF
DEATH
MEDICAL CERTIFICATE OF DEATH
Jen.7,1939
(Month)
(Day)
(Year)
10 CE58iFY-J^tt!tt7,d deceased f 199
lm *ffanri°- 7 ^ -39 * 19
I last saw h alive on
jt-W', 19 death is said
11.48 A -II.
to have occurred on the date stated above, at m.
The prindpsJ esuse of death and related causes of importance in order of
onset were as follows:
Datiofonsst
Generalized carclncanat-oslff uhknov/n
Contributory causes of importance not related to principal cause:
J
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? .. H
If so, specify.
(Signed)
(Address). USN H0sp . CllG Is 30 Date 1/Y 19 .3.9
2 f Winthr op ,, Ma s a .
Place of Burial.
(City or Town)
DATE OF BURIAL *?w # ~ 1#
22 NAME OF Fichard I'.irby'
UNDERTAKER ""fltriSWt Bj|WlrOtt
ADDRESS
Received and filed 19..
— ~:a
M R-303B
M.[x. «
°o S
f«3
i&JU
-Zu.
fcZ 0 •
S-fi
>5 0*;
U«S-- B
.s
Q<£*s
/y ^ «
o“«SS
. u c *5
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2 « C o
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1
2 FULL NAME
®1jp (Humuimuopaltlj of fflaBflarljuaPtta
OFFICE OF THE SECRETARY
DIVISION OF VITAL STATISTICS
MEDICAL EXAMINER’S
CERTIFICATE OF DEATH
To be filed, for burial
permit with Board of
Health or its Agent.
Registered No
( (If death occurred in a hospital or institution,
\ give its NAME instead of street and number)
(If deceased is a married, widowed or divorced woman, <5
(a) Residence. No St., Ward,
(U U. S.
War Veteran,
„ ( .necify WAR)
(Usual place of abode) ,
Length of reiidence in city or town where death occnrred -3 yra.
days.
(If nonresident, gyFe city or town and state)
How long in U. S., if of foreign birth? yra. not. day..
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
4 COLOR OR RACE
5 SINGLE
MARRIED
WIDOWED
or DIVORCED
5a
HUSBAND
If married, widowed,/!. di^rced „ /
band of
/ (Give maiden name of wife (n full)
(or) WIFE of
(Husband’s name in full)
(write the word)
6 IF STILLBORN, enter that fact here.
AGE Years.../. Months .(.'pr... Days
£.
If less than 1 day
Hours Minutes
8 Trade
rade, profession, or particular . J _ /
kind of work done, as .pinner, /V sMAi •
lawyer, bookkeeper, etc QS'l
lawyer,
9 Industry or business in which
work was done, as .ilk mill,
•aw mill, bank, etc
10 Date deceased last worked at
this occupation (month and
year)
12 BIRTHPLACE (City) ft
(State or country)
1 1 Total time (years)
spent in this
occupation..
13 NAME OF
FATHER
1 (h'i.
y)£^
CO
14 BIRTHPLACE OF
FATHER (City) ....
f
h-
z
(State or country)
UJ
Q1
<
15 MAIDEN NAME /)/] / Oft /7
OF MOTHER /tf
16 BIRTHPLACE OF
MOTHER (City) ....
(State or country)
Informant
, cJL}.
(Official Designation)
MEDICAL CERTIFICATE OF DEATH
19 I HEREBY CERTIFY that I have investigated the death
of the person above-named and that the CAUSE AND MANNER thereof are
as follows: (If an injury was involved, state fully.)
(See reverse side for description for unknown person )
20 IN WHAT
21 PLACE OF BURIAL,
CREMATION OR REMOVAlf.f.'
(Cemetery) (City or towt()
iftfff...
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
phvsician. 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, Set. 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, Chop. 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 writh the circumstances when these are known.
For example : 4 4 Compound fracture of the femur with ensuing septicemia
(gas bacillus) caused by a steam railway accident. ” 44 Pistol shot wound
of the chest with associated hemorrhage, homicidal.” 44 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. 33, Sec. 14.
THIS CERTIFICATE CONSTITUTES SUCH PERMIT
tion should be carefully supplied. Age should be stated LX AC I LY. 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 dh back of certificate.
100m-12-’3S. No. 61S6E
R-30T
V
1 <
2 FULL NAME
je Commontoealtf) of jfHaSfiacfiugettsl
OFFICE OF THE SECRETARY
DIVISION OF VITAL. STATISTICS
STANDARD
CERTIFICATE OF DEATH
(City or town making return)
6
Registered No.
^ / (If death occurred in a hospital or institution,
St., Ward (give its NAME instead of street and number)
(If deceased is a married, widowed or divorced woman, give also maiden name.)
(a) Residence. No. ..St., Ward,
(Usual place of abode) * * df norm
{(If U. S.
War Veteran
specify WAR)
Length of residence in cit/ or town where death occurred
£
years
months
days.
(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 ,
4 COLOR OR RACE
6C IMP I C
OlnUlift
M i nnirrt
luiuniLi/
WIDOWED
or -DIVORCED
(write the word)
5a If Darned, widowed, or divorced
HUSBAND of
(or) WIFE of .
((jiveifaai^ga-Bamp «Lsvi£e in full) 77
&?ZA.
(Husband's name in full) j,
6 IF STILLBORN, enter that fact here. /£• /f^C/
~n ~P~Z. ~7z *U ^ J-..
L
.. Years..
/....Months.™..... Days
If less than 1 day
Hours Minutes
lO
Trade, profession, or particular
kind of work done, as spinner,
sawyer, bookkeeper, etc
Industry or business in which
work was done, as silk mill,
sew mill, beak, etc
Date deceased last worked at
this occupation (month and
year)
11 Total time (years)
spent in this
occupation..
12 BIRTHPLACE (City)
(State or country)
14 BIRTHPLACE OF
FATHER (City)
(State or country)
15 MAIDEN NAME
OF MOTHER
16 BIRTHPLACE OF
MOTHER (City)
N
I HEREBY CERTIFY that d satisfactory standard certificate of death was
filed with me BEFORE the biuial or transit pe/mit was issued:
(Offii
rued witn me t^i-UKt tne burial or transit pe/mit was issui
. sJLJLiJXAtx^ . . . . . t . . . .
(Signature of Agent of Board of Health or other;
J
lCiaJJDesignation) / (Date of Issue «f Permit)
I HEREB^ CERTIFY,
19.S.R., 19.3<?
I last saw IlwIxV... .alive on . * 19.$..?., death Is said
{/ <7 3S-
to have occurred on the date stated above, at 10.... .*>... m.
The principal cause of death and related causes of Importance In order ot onset
MEDICAL CERTIFICATE OF DEATH
18 DATE OF
DEATH
(Month)
=9-
./..<> “ /iai
(Day) (Year)
19
That I attended deceased from
*L
were as fallows:
Date of Onset
.
Contributory causes of Importance not related to principal cause:
/
What test confirmed diagnosis?..?:.™.1 ™. •.$: ...Was there an autopsy?.
20 Was disease or injury in any way related to occupation of deceased? .
If so, specify..
(Signed) .4
(Address) Datei^. '**19.
M. D.
a*.
Jz.,
21
Place of Buj’fal, Cremation o y Rwneval. (City or Town)
DATE OF BURIAL 73..#*, hr. /.3P. '
22 NAME OF
UNDERTAKER/
e SLkU
ADDRESS .
Received and filed ....
A TRUE COPY ATTEST:
(Registrar)
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Suffolk
(County)
g Vint hr op
ui (City or Town)
®fjc Commontoealtf) of iflassadjugfttg
OFFICE OF THE SECRETARY
DIVISION OF VITAL STATISTICS
STANDARD
CERTIFICATE OF DEATH
To bo filed for burial permit
with Board of Health
or iu Agent.
7
No. 90. Washingt on Ave nue
Registered No. ...,
yV , J Of death occurred in a hospital or institution,
■***>- Ward ^ give its NAME instead of street and number)
2 full name . Ellen Louise. ,.(l).a.vis. ). .. Hay.war d ,.
(If deceased is a married, widowed or divorced woman, give also maiden name.)
f (If u. s.
•J War Vet,
l specify 1
Veteran
WAR)
, i.;-
(a) Residence. No .9Q.-7/&&hing.tOll.. A-Yfinil£ SEf Ward, I™...'
(Usual place of abode) (If nonresident, grive city or town and state)
Lengrtb of residence in city or town where death occurred 40y«.ra months days. How lone in U.S., if of foreign birth? years months days.
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
Female
4 COLOR OR RACE
Whit e
6 SINGLE
MARRIED
WIDOWED
•r DIVORCED
(write the word)
Widowed
5a If curried, widowed, «r divorced
HUSBAND of
_ (Give maiden name of wife in full)
(.,) wife of . JlaoEge.. JlM.uiOiay:i7a.rd
(Husband’s name in full)
0 IF STILLBORN, enter that fact here.
7
AGE.
83
..Years .A.. ...Months ... Days
17,
If less than 1 day
Hours Minutes
8 Trade, profession, or particular
kindofwork done, as spinner. Tlnnoo wnv»V
sawysr, bookkeeper, etc
9 Industry or business in which
work was done, as silk sill,
tow mill, bonk, etc
lO Date deceased last worked at
Own home
this occupation (month an<l933
1 1 Total time (years)
spent in this Kf)
occupation y..Y„
12 BIRTHPLACE (City). FiLcMuEg.......
(State or country) M& S Sa CxlUS e utS
13 NAME OF _ , . , _
father Frederick: Hiram Davis
C/5
14 BIRTHPLACE OF
FATHER (City)
(State or country)
2it..Q.hhurg
►-
Z
Massachusetts
UJ
cr
<
Q_
15 MAIDEN NAME
OF MOTHER
Seriza Veronica Younglovci
10 BIRTHPLACE OF
MOTHER (City)
(State or country)
Vernon
Vermont
17io<otuou Florence M. Joel / 'sister
(AdSb3TiigHmhd""Ave'-; Fitdhbuyg i.!a-s
Relay on, if any
IS
actory ’standard certificate of death was
* ansit permit was issued:
Board of Health cfr'othaf)
&kL ,,
(Date of Issue of Pe
MEDICAL CERTIFICATE OF DEATH
18 DATE OF
DEATH ...
1.7.
(J (Month) Q (Day) (Year)
is I hereby okrtifx, Ttiat I attended deceased from
i».3<£, to i9.~
I last saw tL&^.illv# on 19V/., I*
to have occurred on the date tilted above, at .2. ra.
said
The principal cause of death and related causes of Importance In order ot onset
were as follows:
Contribntory causes of Importance not related to principal cause:
Daft of OoMt
I IMPORT AWT
ff/k/yj
,xH,r
Name of operation
What test confirmed diagnosis
Date of 7r....rrrz
L*~ Was there an autopsy?l&jv.
20 Was disease or Injury in any way related to occupation of deceased?^-.,...
If so, specify.®
(Signed) ..j ....... M. D.
(Addr Date
2 1 lint hr op Winfnr
Place of Burial, Cremation or Removal. (City or Town)
DATE OF BURIAL 19....?.9
22 undertaker fife&rle s . R. ...B eirni s on
address :iin.tbrop.jass
Received and filed—
(Registrar)
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5m-12-'34. No. 2938-g
\J (County)
I (City or Town)
2 FULL NAME i-xtr.
2; lie (Eummmuuealtfi of ffluaaarijuHPttH
OFFICE OF THE SECRETARY
DIVISION OF VITAL STATISTICS
MEDICAL EXAMINER’S
CERTIFICATE OF DEATH
I'o be Jiled for burial
permit with Board of
Health or its Afgent.
Registered No.
R
St., Ward
is a married, widowed or diyorced woman, give also maiden name.)
(a) Residence. No Ward,
(If death occurred in a hospital or institution,
give its NAME instead of street and number)
(Usual place of abode) l
Length of residence in city or town where death occurred
(If 0. s.
War Veteran,
specify WAR)
(If nonresident, give city or town and state)
days. How long in U. S., if of foreign birth? yrs. mos. days.
PERSONAL AND STATISTICAL PARTICULARS
5 SINGLE
MARRIED
WIDOWED
or DIVORCED
(write the word)
(or) WIFE of
0 IF STILLBORN, enter that fact here.
4?
AGE /..../ ...Years..
Months.
If less than 1 day
Days I Hours..
Minutes
lO
rafle, profession, or particular
hind of work done, as spinner,
sawyer, bookkeeper, etc
Industry or business in which
work was done, as silk mill,
saw mill, bank, etc
Date deceased last worked at
this occupation (month and
year)
M.e.Lovvi£......
1 1 Total time fyears)
spent in this
occupation
12 BIRTHPLACE (City) ^
(State or country)
13 NAME OF ft
FATHER jL
14 birthplaceTof)
FATHER (Ci
t -lr+ti 1...,..* A
(State or country)
VQlaoOLTUA. CttMr
15 MAIDEN NAME
OF MOTHER
Ua^.VL/^Uul
10 BIRTHPLACE OF »
MOTHER fCitv) ~ i. ... A
(State or country)
vychuuM, Cow/i-
1EBY CERTIFY that a satisfactory standard certificate of death was
wjif) me BEFORE the bukjal or transit permit wajjjsstied:
SK^dkotHeaith or o^fcr) v <wiuw'
(Drfte drtssrafef Permit)
MEDICAL CERTIFICATE OF DEATH
18 DATE OF
DEATH
(Month)
7 - nil
7 (Day) ( (fear)
19 I HEREBY CERTIFY that I have investigated the death
of the person above-named and that the CAUSE AND MANNER thereof are
as follows: (If an injury was involved, state fully.)
u > 3 |
(See reverse side for description for unknown person )
DATE OF BURIAL
22 NAME OF 1
UNDERTAKER
20 IN WHAT CITY ORTDWI'
WAS INJURYSUST^.
(Signed)
(Address>
21 PLACE OF BURIAL,
CREMATION OR REMOVAL ,w. LLLLtX
ADDRESS
0.
Received and filed
JAN 20 1939
.19..
(Registrar)
EXTRACTS
FROM THE LAWS OF THE
COMMONWEALTH OF MASSACHUSETTS
OOVERNING 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, Chop. 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 mapner 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 OP 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 ansesthetic. ” “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 ip 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
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.
R-3Q1A
2 (County)
i « s .imsEfiE
hi (City or Town)
®j)c Commo?TtDea(t1) of i^lassarini setts
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 v}..
No.StatiQn..Haspital,£or.t..Bariks,llass... St., Ward { KnS e' 2«ead
f (If u. s.
2 FULL NAME
.BAND OL.PH. . G ILL j W»r Vdnu
(If deceased is a married, widowed or divorced woman, give also maiden name.) v. ipeciiy WAR)
£
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
Male
4 COLOR OR RACE
Colored
6 SINGLE
MARRIED
WIDOWED
•r DIVORCED
(write the word)
Single
5a II curried, 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.
.20. ...Years.. ..3 Months /.Days
If less than 1 day
Hours Minutes
z
8 Trede, profession, or particular
klndofwork done, as tpinnei.
CCG
►—
<
a.
Z>
9 Industry or business in which
work was done, as silk mill.
CGG
O
o
10 Date deceased last worked at
this occupation (month and.
year) Jan# lo«..-l,
11
939.
Total time (years)
spent in this
occupation
1Q f’.IRTHPt ACF fCitvl
..... Unknown
(State or country)
13 NAME OF
FATHER
Unknown
CO
14 BIRTHPLACE OF
FATHFR rr.itvl
unknown
I-
z
(State or country)
LU
CE
<
0_
15 MAIDEN NAME
OF MOTHER
Unknown
10 BIRTHPLACE OF
MOTHER fCitvl
.Unknown
(State or country)
1 7 Relation, if any
(Address)
(a) Residence. No £81..Lalnu.t St., Ward,.. Pall.-Piiveiv-Massa
(Usual place of abode) . / (If nonresident, give city or town and state)
Leodb of residence in city or town where death occorred years months r A. days. ” ~ How Ion* in U.S., if of foreign birth? years months "“days.
MEDICAL CERTIFICATE OF DEATH
18 DATE OF — ,r~r
death J&miarjr. 2.1 133.9..
(Month) (Day) (Year)
is I hereby oertify. That I attended deceased from
....Jsn.«...l6. , 19.3.3., to .<l3.iia...21 i9.. 3v
I last saw h.. is..... alive on Jan. ...20 19.3.9., death Is said
to have occurred on the date stated above, at At 55.3m.
The principal cause of death and related causea of Importance In order of onset
were as follows:
liib.er.c.ulO£is^....piLlainnar5r:,...ac.u.tar...
r3.1iap„',...r.i^.lm..limg,....c:hr.QnlG.,
a.Q.tlxe.,...la2t.l.w>.t
Costribatory ceases of importance not related to principal cause:
...Eulmonary..heRQrrhage.A Js
Date of Oottf
IMPORTANT
Unknown
n
..16/59.
Name of operation ~.T. Date of “ ....
What test confirmed diagnosis? Was there an autopsy? I. O...
20 Was disease or Injury in any way related Uroccupation of deceased?
If so, specify.
(Signed) Charlefi....¥.e...^£Lla,....Ll*....Gole ... m. d.
(Addressj.F.P.r.t.^ank.Sj I.. ass.. Date Jan 2119.J.9.
Received and filed....
19...—.:
(Registrar)
riling
it im
.... *Sf|l...
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®l)c Cornmontocaltf) of i^asefacfjusettg
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
.Ward
/ (If death occurred in a hospital or institution,
U
2 FULL NAME
give its NAME instead of street and number)
(If U. S.
War Veteran
(If deceased Is a" married, widowed or divorc£i_woman, give also maiden name.) ^ l it>ecify WAR)
(a) Residence. No t. , Lxajs^L .Ward,.... .» ■ . '.c^
(Usual place of abode) ^ (If nonresident, give city or town and/' state)
Length of residence in dty or town where death occurred xa ear* — — months — days. How long in U.S., if of foreign birth? - Months •*. days.
’“Vj,
PERSONAL AND STATISTICAL PARTICULARS
4 COLOR OR RACE
L
iiitorced
6 SI
M.
W
•D
VORCEff
i v(wnt« the word)
hjuLc
? \jlK £,
6a If narried, widowed, or divorced ~~yO :
HUSBAND of
[ / . (Give maiden name of wife in full)
(or) WIFE of y. V...„£&£X..W.
(Husband’s name in full)
wa <"1
'..■■•..pa ,M>I ,....
6 IF STILLBORN, enter that fact here.
7
AGE Years Months Days
If less than 1 day
Hours Minutes
m&tim
I last saw h-A<t<, alive on ...
’ to have occurred on the date st|_
The principal cause of death and related causes of Importance In order of onset
8 Trade, profession, or particular
kind of work done, as «pinner,
sawyer, bookkeeper, etc
9 Industry or business in which
work was done, as silk Dill,
saw mill, beak, etc
lO Date deceased last worked at
this occupation (jponUi and
year) .
1 1 Total time 4ms)
Spent in this
occupation..,
12 BIRTHPLACE (City)
(State or country)
13 NAME OF
FATHER
IP
14 BIRTHPLACE OF
FATHER (City)
(State or country)
<- e A ^
rc lie Fn
15 MAIDEN NAME
OF MOTHER
&
16 BIRTHPLACE OF
MOTHER (City) .
(State or country)
1
tl
MEDICAL CERTIFICATE OF DEATH
18 DATE OF
DEATH
\1 ^(A. •
(Month)
^ I
(Day)
1
/m
I attended deceased from
. * ./ 19.19.
3L.JL..., 19.5. .^, death Is said
were as follows:
Cocjai^utory cypes of importance not ri
>id3l
\ i f i .el ■ i / I) 1 1
v Am
iij ,3,49 ^ .
/?3i
“Date of
Name of operation,.
What test confirmed diagnosis? Was there an auti
fc.
20 Was disease or injury in any way related to occupajjdft of deceased?^
If so, specify
(Signed) ' 4 f M. D.
(Address) Date... . 19
Place of Burial, Crre#
DATE OF BURIAl \l...
22 NAME OF / H f ,
UNDERTAKER ..kLXJJi
. , yt
'or Hem ova IT (City or Town) _ L
,..19 3.‘&
ADDRESS Q
Received and filed
.19
24
(Registrar)
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OFFICE OF THE SECRETARY
DIVISION OF VITAL STATISTICS
STANDARD
TJFICATE OF DEATH
To be filed for burial permit
with Board of Health
or it* Agent.
11
Registered No.
.Ward
f (If death occurred in a hospital or institution,
leiv
.give its NAME instead of street and number)
2 FULL NAME
'ort^d woman, give also maiden name.)
(a) Residence. No..
(Usual place or abode
Length of residence in city or town where death occarred
months
days.
Ward
(If nonreCidentT give city or town and state)
How long in U.S., if of foreign birth? years months days.
32
PERSONAL AND STATISTICAL PARTICULARS
r(vmte the word)
6a If curried, widowed, or divorced
HUSBAND of
(Give maiden name of wife in full)
(or) WIFE of ...
6 IF STILLBORN, enter that fact here. t-fr'X'V*
7
AGE Years Months Days
If less than 1 day
Hours Minutes
8 Trade, profession, or particular
klndofwork done, as .pinoei.
uwytr, bookkeeper, etc
9 Industry or business in which _
work was done, as silk still,
saw mill, buk, etc -
lO Date deceased last worked at —
this occupation (month and
-••••*
1 1 Total time (years)
spent in this
occupation..
18 DATE OF
DEATH \
ICAL CERTIFICATE OF DEATI
(Day)\/ ' ''(Year)
he r e B y EB'l' i p y , That I attended deceased from
nj.%, to. .Mts*c...2-2 iUl.f
IW alive on ^ * 19 i ?. death Is said
to have occurred on the date
The principafyuuie
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le stated above, at m
of death and relateocaus8* of Importance In order of c
onset
were as Mows: J
Daft of Ootti
IMPORTANT
^ /
Contributory uuh of importance not related to principal cause:
Name of operation..
What test confirmed diagnosis?
..Date of rrrr.
AWas there an autopsy?.
:fe
20 Was disease or Injury i
If so, specify
(Signed)
(Addresi
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(Registrar)
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3T1 je Commontoealtf) of ifflaggatfjusettg
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.
'.VlnthroD
(City or Town)
No 3.8...Reade„.^.t
r (u u
. Anle.Mj,... Buckley j w«
(If deceased is a married, widowed or divorced woman, give also maiden name.) v spedf
Registered No.
IS..
^ death occurred in a hospital or institution,
^ard \give its NAME instead of street and number)
2 FULL NAME
(a) Residence. No
(Usual place of abode)
Lenr»h of residence in city or town where death occurred years
s.
Veteran
specify WAR)
months
days.
.St., Ward,
(If nonresident, give city or town and £tate)
How long in U.S., if of foreign birth? years months days.
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
Male
4 COLOR OR RACE
’.Vhite
(write the word)
mvoRCEii^arr i e d
5 SINGLE
MARRIED
WIDOWED
•r
6a If married,
HUSBAND
rf carte fTiie Shea
(Give maiden name of wife in full)
(.r) WIFE ol ! ..
(Husband's name in full)
0 IF STILLBORN, enter that fact here.
7
AGE.
.6.1.
•Years Months
• Days
If less than 1 day
Hours Minutes
8 Trade, profession, or particular
Kind Of work done, as spinner, 4 y»©/4
saw yer, bookkeeper, etc
9 Industry or business in which
workwasdone, as silk mill, -r>_ t 4 „ _ „
saw mill. buk. etc
IO Date deceased last worked at 11 Total time (years)
this occupations. (month and spent in this
year) ...Ms? p.U X^z.J.C— occupation....
3.2
(State or country)
Ire land
13 NAME OF
FATHER • . ^
L’licnae
1 Buckley
00
14 BIRTHPLACE OF
FATHER (Citvl
h-
z
(State or country)
Ireland
LU
cc
<
CL
15 MAIDEN NAME
OF MOTHER^ len
Sweeney
10 BIRTHPLACE OF
MOTHER (Citv)
(State or country)
Ireland
h|r.lne Bukley ( Httg
17
I
(Address)
if any
I HEREBY CERTIFY that a satisfactory standard certificate of death was
filed with me BEFORE the burial Oj^trarystt permit was*issued:
jo ! 1 1
MEDICAL CERTIFICATE OF DEATH
18 DATE OF
DEATH
(Month)
hde?
(Day)
/ Qf
(Year)
19 x h E ke by certify. That I attended deceased from
./ , «*/.., \o/pl£^...)rA . i>4£
\ last uw h..*r^rr..all»e on , f , death Is said
to have occurred on the date sta^M above, at f
The principal cause of death and related causes of Importance In order of onset
were as follows:
IMMf
In 1
r "
I** -1 -f T ■ _
/
Contributory causes of importance not related to principal cause:
Name of operation Date of
What test confirmed diagnosis? Wasthere an autopsy?. ...**=
20 Was disease or injury in any way related to occupation of deceased?
If so, specify
(Signed) Zy ^ , M. D.
(Address) .^1. "Date^.™.^?.... lSflJ.yf..
1 Holy. Cr.aaa....Ma.lde.n
Place of Burial, Crei rfjatip n or Kemoy
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50m-2»’30. No. 7997-d
M
Norfolk
(City or Town)
Qllje GlotmtumtoraUi} of fHaaflartiuarttfl
OFFICE OF THE SECRETARY
DIVISION OF VITAL. STATISTICS
STANDARD
CERTIFICATE OF DEATH
Quinoy
(City or town making return)
Registered No 43
tu (Lity or 1 own;
5 No Quinoy City Hospital
Axel J* Potorson
r (If death occurred in a hospital or institution,
■St., Ward \ give its NAME instead of street and number)
2 FULL NAME.
(If u. s.
War Veteran,
(If deceased is a married, widowed or divorced woman, give also maiden name.) [ specify WAR)
(.) Residence. No.?0...?.®.l..l.O™6 JVCnUe St Weed, ... jVinfcfePOp,. ...*» .
13
(Usual place of abode)
Length of residence in city or town where death occurred
(If nonresident, give city or town and state)
days. How long in U. S., if of foreign birth? yrs. mos. day*.
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
Male
4 COLOR OR RACE
White
(write the word)
5 SINGLE
MARRIED
widowed Harried
or DIVORCED
5a If married, widowed,
HUSBAND of
O&Bb 01 BOB
(Give maiden name of wife in full)
(or) WIFE of
(Husband's name in full)
6 IF STILLBORN, enter that fact here.
7 74
AGE
Years
Mont
A..
Days
If less than 1 day
Hours Minutes
8 Trade, profession, or particular
sawyer^ 'bo okke ep er , etc!*” . .
9 Industry or business in whicji
work was done,
saw mill, bank,
10 Date deceased last worked at___. 1 1 Total time (years,
this occupation (month and ly 24 spent in this J;
year) occupation
isiness in which
l e’tc.as ,ilk mSllip Cfenncller store
12 BIRTHPLACE (City)
(State or country) Sweden
13 NAME OF
father Andrew p# Peterson
14 BIRTHPLACE OF
FATHER (City)
(State or country)
Sweden
15 MAIDEN NAME _ «, _ -
of mother Connot be loomed
16 BIRTHPLACE OF
MOTHER (City) .
(State or country)
17
, , _Yr8» Ii’ene Peterson/^Da filter
(Idd^:
A TRUE COPY.
ATTEST:
(Registrar of city or town where death occurred)
Jan, 27
DATE FILED 19..
39
MEDICAL CERTIFICATE OF DEATH
18 DATE OF „ _ n
death J mu^Ty . ,...S6 * 19.0.9.
(Month) (Day) (Y ear)
19 I HEREBY CERTIFY, That I attended deceased from
Jen* 2 .19.39 to Jan* 29 - §9
I last saw gjyj alive on Jan* 25 > death is said
to have occurred on the date stated
"ft™- J,f
The principal canse of death and related causes of importance* in order of
onset were as follows:
• 4 iypertonslve hear fc d i se« a© 1«
Ur-a-emia
Dataof onset
1-69
Contributory causes of importance not related to principal cause:
Hyoeer&itis
€hr onlc • nophr it I s
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,
CRE ‘
^Taholc'-H*--Hurke natB
mihoy, Haas,
y or town)
DATE OF BURIALjy,^ . O0
22 NAME OF , .. M , ,
UNDERTAKER IliGXl£2’.&. , , .hit©-
ADDRE^lnthrOPj
Received and filed 19-
, M. D.
(Registrar of City or Town where deceased resided)
FE3— !939 AH
R-301 A
(City or Town
3?
t ULonfttrtmtofaltf) of itlaggarfyugettg
OFFICE OF THE SECRETARY
DIVISION OF VITAL STATISTICS
STANDARD
F DEATH
CERTIFICATE
No.
FULL NAME
1 o be filed for burial permit
with Board of Health
or its Agent.
14
Registered No.
married, widowed or divorced woman, give also maiden name.)
death occurred in a hospital or institution,
ve its NAME instead of street and number)
(If U. S.
War Veteran
specify WAR)
{:
Residence. No. St,,..../'.. Ward,
I I Toil'll nl'li'O r*.t ' ( T f nnnrooi/lonl mtra /.it /vr fr\mn on/1 ctofn^
(Usual place of abode)
Lnr*h of residence in city or town where death occurred —
year* — months •— days.
(If nonresident, give city or town and state)
How long in U.S., if of foreign birth? years •— • months days.
PERSONAL AND STATISTICAL PARTICULARS
4 COLOR Oft RACE
6 SINGLE (write the word)
MARRIED t . »
WIDOWED A />>/
:eiK -
or DIVORCE
6a If married, widowed, or dirorced ” —
HUSBAND of A
(Give maiden name of wife in fi
(or) WIFE of ..7......
(Husband's name in full)
0 IF STILLBORN, enter that fact here. c-
..Years Months.
..Days
If less than 1 day
Hours Minutes
8 Trade, profession, or particular
kind of work done, as spinner,
sawyer, bookkeeper, etc
6 Industry or business in which
work was done, as silk mill,
law mill, beak, etc. i.U.
lO Date deceased last worked at
this occupation (month and
year)
X 1 Total time (years)
spent in this
..v ^occupation...
12 BIRTHPLACE (City).
(State or country)
13 ^
14 BIRTHPLACE OF
FATHER (City) .
:3 £Z<2 /*
(State or country)
15 MAIDEN NAME
OF MOTHER
10 BIRTHPLACE OF
MOTHER (City) .
(State or country)
17
Informant
(Address) /
MEDICAL CERTIFICATE OF DEATH
18 DATE OF
DEATH
(Month)
"4 .-iFf
10 I HEREBY CERTIFY,
t I attended deceased from
to . 19 -3y
tM,ie on itl 19.1/., death 1$ said
nn tho data otitari ohnwo^nt // , \A A m
I last sawh ..L^^alhfe i
to have occurred on the date stated aboverat //.Udfc.m.
The principal cause of death and related causes ot Importance In order ot onset
were as follows:
Date of Onset
IMPORTANT
f 7 /7 /
p\ ( A (/ 1/
Contributory causes of importance not related to principal cause:
Name of operation Date of
What test confirmed diagnosis? Was there an autopsy?
20 Was disease or Injurydifi any way ^plated to occypdtjon of dgc^ased? -
if so, specify...™.
(Signed) ..<
(Address)..
....... M. D.
. , 6^..^ , /§.£*>*
Place of Burial, Cremati
DATE OF BURIAL
22 NAME OF
FUNERAL DIRECTOR £
nnoval^ (City or Town) ~>0
' - -*
(Registrar)
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5m-12-’34. No. 2938-g
I
J
uy
®l;p (Eommoiuiipaltlj of fHaBaariiaaPtta
OFFICE OF THE SECRETARY
DIVISION OF VITAL. STATISTICS
MEDICAL EXAMINER’S
CERTIFICATE OF DEATH
(If death occurred in a hospital or institution,
give its NAME instead of street and number)
“j (City oaTowd) ,
2 Ward { J
TJLL ^r.CZ..., { War Veteran,
(tf deceased is a married, widowed or divorced woman, give alsc* maiden name.) " ”r‘
(a) Residence. No...l. tJ . CfkJdsfL . . .V^V^r. . . . .Sfr-. ..... W a r d ,
To be filed, for burial
permit with Board °f
Health or its Agent.,
Registered No
(Usual place of abode)
Length of residence in city or town where death occurred
•pecify WAR).
days.
(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
Male
4 COLOR OR RACE
White
(write the word)
5 SINGLE
HURRIED
WIDOWED
or DivoRCEPVarrled
"ftfey^orrow Doucette
(Give maiden name of wife in full)
(or) WIFE of
(Husband's name in full)
0
IF STILLBORN, enter that fact here.
7 36
AGE Years..
Months
Days
If less than 1 day
Hours Minutes
z
8 Trade, profession, or particular
kind of work done, as spinner.
Shipper.
H-
<
Q.
Z5
9 Industry or business in which
work was done, as (ilk mill.
Howe. &Pre.ne.h
O
o
10 Date deceased last worked at
tye^?CC^^.tm(^TaniSt^
1 1 Total time (years)
spent in this^™ - „
occupation... W.f.W.W.w..
12 BIRTHPLACE (Citv).
Yarmouth
(State or country)
N.
s.
13 NAME OF
father Theodore
Doucet^.,
00
14 BIRTHPLACE OF
FATHER fCitv)
1—
z
(State or country)
Nova
Scotia
UJ
Cd
<
15 MAIDEN NAME
OF MOTHER,
iOt 3e
Learned
10 BIRTHPLACE OF
MOTHER (Citv*
(State or country)
Nova
Scotia
17
inWm.nf n. .mi 1 v . Do.uc.ette
(Address)
143 Sewall
ii /6
MEDICAL CERTIFICATE OF DEATH
18 DATE OF
DEATH
(Month)
VL\
. 2, P -
(Day)
19 I HEREBY CERTIFY that I have investigated the death
of the person above-named and that the CAUSE AND MANNER thereof are
a* follows: (If an injury was involved, state fully.)
-i „
'
(See reverse side for description for unknown person )
20 IN WHAT CITY OR TOWN ^
WAS INJURY. SUSTAlNEI^^^^^c^
(Signed)
(Address)
%
iu
... M. D.
21 !
(Cemetery) (City or town)
&.B 2.1 12;, 9.
■Tih
Dale •2r.0...r....l
t
DATE OF BURIA
22 NAME OF
UNDERTAKER
address ./. Wlnthr.o.p
Received and filed- „ 19.
f£i3
(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
phvsioian. 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 ? G. L.
(7 cr centenary 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. 114,5ec. 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 peisons round 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, nresumablv coronary sclerosis. fSudden 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
I
R-301 A
(City or Town)
<£^tnfafaeam) 0f iJlaggarijusetts;
OFFICE OF THE SECRETARY
DIVISION OF VITAL. STATISTICS
STANDARD
CERTIFICATE OF DEATH
2 FULL NAME
(If deceased is^i mar
No./^C &(JL*
To be filed for burial permit
with Board of Health
or it* Agent.
Registered No.
/■*
/(If death occurred in a hospital or institution.
Ward | gjve its NAME instead of street and number)
(a) Residence.
(Usual place of abode)
Length of residence in city or town where death occurred
divorced woman, ^ive also maiden name.)
months
days.
Ward,
(If nonresident, give
How long in U.S., if of foreign birth?
town and state)
onthi dart.
PERSONAL AND STATISTICAL PARTICULARS
5a If curried, widowed, or divorced
HUSBAND of
(Give maiden name of wife in full)
(or) WIFE ef
(Husband's namt In fell)
6 IF STILLBORN, enter that fact he
band's narpCrn fell)
AGE .1CT. Years..
Months Days
If less than 1 day
Hours Minutes
8 Trade, profession, or particular
kindofwork done, as tpioaei,
uwytr, bookkeeper, etc
0 Industry or business in which
work was done, as silk Bill,
saw mill, bamk, etc
lO Date deceased last worked at
this occupation (month and
1 1 Total time (years)
spent in this
12 BIRTHPLACE fCitv)
(State or country)
13 NAME OF
FATHER
CO
14 BIRTHPLACE OF
FATHER (City)
(State or country)
K
Z
UJ
cr
<
a.
15
16 BIRTHPLACE OF
MOTHER (City)
(State or country)
MEDICAL CERTIFICATE OF DEATH
<39, /£ S?
(Month) (Day)
(Year)
'EjB, y o e r f y , That I attended deteaied from
/, t0 „ 19
' * 7T., 19 death la said
to have occurred on the date stated above, at // /v,.m.
related causes ot I
I last saw h...
were as follows: /
Doto of Oot«t
IMPORTANT
/ ^/... f] /Jr)
\ xf fJ/J
y' U yf v
(1
Cootribatory cabfct of importance not related to principal cause:
"Tiame of operation Data 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)
(Add res
, M. D.
19 aS(^r
Place of Burial,
1 .tflsr
c<vaL (City or Town)
'A jBATE OF BURR
w.*:.
22 NAME OF ^ —
UNDERTAKER ...
ADDRESS
Received and filed...
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QTfjf Commontoealtl) of Jflaggacfjugettg
OFFICE OF THE SECRETARY
DIVISION OF VITAL STATISTICS
STANDARD
CERTIFICATE OF DEATH
To be filed for burial permVv'5
with Board of Health
or its Agent.
Registered No.
b-F-
St.,.. Ward
f (If death occurred in a hospital or institution,
lei
.give its NAMIC instead of street and number)
2 FULL NAME
(a) Residence. Nc
(Tisual place of abode)
CL
/it j ised is a married, widowed or d!
divorced woman,
also maiden name.)
f (If U.
< War V
( specify
S.
Vetera*
WAR)
Z. -St., Ward,
(If nonresident, give city or ta
Length of residence in city or town where death occurred
nonths
days.
How long in U.S.V if of foreign birth?
n and state)
ionths days.
i *
1 U
i£
li
, V
PERSONAL AND STATISTICAL PARTICULARS
3 SE
SEE. 4 COLOR, OR RACE
I f rh
6 SINGLE '
MARRIED
WIDOWED
•r DIVORCED
(write the word)
6 a If curried, 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
a
Years Months Days
If less than 1 day
Hours Minutes
8 Trade, profession, or particular
kind of work done, as tpinnn,
towytr, bookkeeper, etc
9 Industry or business in which
taustry or Dusiness in wnicn _ a /•
work was done, as rilk uill, f ,-&■ 4 1 , . /*
u> Bull, book, etc -.HA
10 Date deceased last worked at
this occupation (month and
year) -
12 LIRTHPLACE (City).....
(State of country)
. ■ • L/C
1 1 Total time (years)
spent in this
occupation.
13 NAME OF
FATHER
14 BIRTHPLACE OF
FATHER (City)
//
(State or country)
15 MAIDEN NAME
OF MOTHER
GO ' n
^ & 0+*dL*l
10 BIRIHPLACE OF
MOTHER (City) .
(State or country)
? Wfca/ .
17 ;
InloraoBt
(Address)
. . (
Relation
rd certificate of death was
permit was issued:
MEDICAL CERTIFICATE OF DEATH
18 DATE OF
DEATH
'Jcuwazy M*. >‘/33
(Monti# (Day) (Year)
19 I hereby oertify, That I attended deceased from
OmQaaaZ. , ibM.., \o.^CLn/.Alf , 1*39..
I last saw ti.&Xd... alive on 19.^?., death la said
to have occurred on the date stated above, at ..vr^m.
The principal cause of death and related causes of Importance It
were as follows:
order of onset
Oafs of Oasat
JMPORTANT
.5
/?33.4
'
/cfe>6'±
Contributory causes of Importance not related to principal cause:
' | •- - v..- ’ 5 -
Name of operation- r.v ...Date of............
What test confirmed diagnosis
autopsy?..
20 Was disease or Injury rn any way related to occupation of deceased? 14jd..
If so, specify ...... ^
(signed) ~ ft- - M- D-
(Address)/^ 19^^^..
21
^'Mot/vC'C
Place of liuriai, fit elation or R^ovaL (City or Town) /
DATE OF BURIAL .
22 NAME OF
UNDERTAKER
ADDRESS
19#..?
lit
M.J/3brUr2 1
'7...
Received and filed -
7
.19
(Registrar)
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5m-12-’34. No. 2938-g
1
-f,
own)
(EommDmm'altlj of fHaBBarljuapUB
OFFICE OF THE SECRETARY
DIVISION OP VITAL. STATISTICS
MEDICAL EXAMINER’S
CERTIFICATE OF DEATH
Jh£h...
. J J (County)
JVvolpC j
(City or "L
No..!22..£...yS£^^
2 FULL NAME
(If deceased-is a mameti, wflowed or divojted woman, give a
/rag-
To be filed for buriul
permit with Board of
Health or its Agent.
Registered No '......Si,.
St Ward {
(If death occurred in a hospital or institution,
give its NAME instead of street and number)
(a) Residence. No
(Usual place of abode)
Length of residence in city or town where death occurred / yn.
(If U. S.
War Veteran,
specify WAR*
' e22m£-
(If nonresident, give city or town and state)
dayi. How long in U. S., if of foreign birth? yrs. mot. dayt.
owed or dijVqjted wonjan, givp also maiden name.)
Ward,..'
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
4 COLOR OR RA<E
5 SINGLE
MARRIED
WIDOWED
or DIVORCED
5a If married, widowed, or divorced
HUSBAND of
(Give maiden name of wife in full)
(or) WIFE of
(Husband’s name in full)
(writhe the word)
0 IF STILLBORN, enter that fact here.
/£
AGE /.../ Years
Months Days
If less than 1 day
Hours Minutes
8 Trade, profession, or particular
kind cf work done, as spinner,
sawyer, bookkeeper, etc
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) -A
12 BIRTHPLACE (City)
(State or country)
1 1 Total time (years)
pent in this _
'peculation
13 NAME OF
FATHER
14 BIRTHPLACE OF
FATHER (City)
jXLtZL tyfs.
I HEREBY CERTIFY that a satisfactory standard certificate of deatK was
filed with me BEFORE the burial or transit permit was issuesk-
S>f* Agent of Board of Health or oth
(Official Designation)/ ' '
al Desigi *'
(Date of Issue of Permit)
MEDICAL CERTIFICATE OF DEATH
JM. 21 ~ t
(Month) \ (Day)
ear)
19 I HEREBY CERTIFY that I have investigated the death
of the person above-named and that the CAUSE AND MANNER thereof are
illows: (If an injury was involved, sta^e fully.)
ChrJ (
O 0 ft ^
(See reverse side for description for unknown person )
20 IN WHAT CITY OR TOW
WAS 1NJURY-SUSTAIN
(Signed)
(Address)
21 PLACE OF BURIAL,
CREMATION OR REMOVAL
DATE OF BURIAL ff IS
(City or town)
g;^2 NAME OF
UNDERTAKER .
ADDRESS
Received and filed 19
FEB 6 i9#'s'r‘,r
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 gTave 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.
( Tercentenary Edition.)
DESCRIPTION (for unknown person)
No undertaker or other peison 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
bv 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. 3H, Sec. 14.
THIS CERTIFICATE CONSTITUTES SUCH PERMIT
RM R-302
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<F,tyDr3a^ist Hosp
5Itje (Snmnumujpaltlj nf maflBarlfaartta
OFFICE OF THE SECRETARY
DIVISION OF VITAL. STATISTICS
STANDARD
CERTIFICATE OF DEATH
(City or town makg^return)
Registered No
No..
St., Ward
Mildred II Barry
( (If death occurred in a hospital or institution,
\ give its NAME instead of street and number)
19
(If u. s.
2 FULL NAME I i War Vetera.,
(a) Residence. No St., Ward,
(Usual place of abode) (If nonresident, give city or town and state)
Length of residence in dty or town where death occurred yr*. mos. day*. How long in U. S., if of foreign birth? yrs. mo*. days.
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
F
4 COLOR OR RACE
(write the word)
6 SINGLE
MARRIED
widowed Liar riff?
or DIVORCED ■v-rrlCa
5a If married, widowed, or divorced
HUSBAND ol
tat) wife .i Jo.eph <lWf
(Husband’s name in full)
den name of wife in full)
0 IF STILLBORN, enter that fact here.
7 34
AGE
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
housewife
at home
10 Date deceased last worked An
this occupation (month mv/ *3°
year)
1 1 Total time fyears^
spent in this u
occupation
(State or country)
Lynn
13 NAME OF . . . .
father i artin Hines
co
14 BIRTHPLACE OF
FATHER fCitvt —
h-
Z
(State or country)
ireianci
LU
OZ
<
Q_
15 MAIDEN NAME*--—,
OF MOTHER •
yol'anus
10 BIRTHPLACE OF
MOTHER i'C.itvi
(State or country)
Ireland
1 7
Informant
.Relation, if any
^xusbahd ,
( Address)
A TRUE COPY.
ATTEST:
(Registrar of city or town where death occurred)
DATE FILED 19„
18 DATE OF
DEATH
MF.D1CAL CERTIFICATE OF DEATH
Jan 3/39
(Month)
(Day)
(Year)
19 J HEREBY CERTIFY. ThaU attended deceased from
T/3/.3®
I last saw ft?. alive on 1 , 19 , death is said
to have occurred on the date stated abo7^§^P m.
The principal cause of death and related causes of importance in order of
onset were as follows: ” : :
Dattsfonsit
... 19..
lobar pneumonia type 3
neutropenia
12/:
x/v
Contributory cause* of importance not related to principal cause:
nQnrvsI.dollYsi.ry. 1/ i/39.
transfusion Dl/2/S9
d diagnosis?
51/36
LO/3.9
Name of operation
What test confirmed diagnosfsf 7. .77.7.7.7. Was therVan iutopsy?
20 Was disease or injury in any way related to occupation of deceased? .
If so, specify
(Signed) AAHornor • M- D-
(Addres%19Lorip?ok Ave "tftfzv 19
2 1
Place of Burial, d^ati^ryaieml^nn
DATE OF BURIAL
22 NAME OF ,, . Vr-l 1
UNDERTAKER .ail.
1/7/39
(City or Town)
19
ADDRESS
1/6/39
Received and filed 19
(Registrar of City or Town where deceased resided)
25m I I •'36. No. 9080-h
>RM R-305
Jjsueeqlk
\ bo^TO’n
(City or Town)
Qttft (Spmnummraltti of AtouraarlinBrttH
OFFICE OF THE SECRETARY
DIVISION OP VITAL. STATISTICS
MEDICAL EXAMINER'S
CERTIFICATE OF DEATH
BOSTON
{City or town making return)
No
Bo ston ’ C ItyTTosp '
2 FULL NAME
decei
(a) Residence. No .,«»
(Usual place of abode) fSillXIijrOp
La|ti of resideace in city or town where death secured j
is a married, widowed or divorced woman, give also maiden name.)
St., Ward,
Registered No. 215
tirred in a hospital or institution,
give its NAME instead of street and number)
m
j (If death occurred in a hospital or institution,
St., Ward |
(If V. s.
War Veteran,
specify WAR)
, give city or town and state)
day*. How Ions in U. S„ if of fareisn birth? yr>. not. daym.
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
4 COLOR OR RACE
&a If married, widowed, or divorced
HUSBAND of
5 SINGLE
MARRIED
WIDOWED
or DIVORCED
(write the word)
Divorced
(Give maiden name of wife in full)
(or) WIFE of
C-oralc &'&&&£&&
in full)
6 IF STILLBORN, enter that fact here.
7
AGE Years Months
a3f$sde, profession, or particular
kind of work done, as i
Days
If less than 1 day
Hours Minutes
OCCUPATIOI
sawyer, bookkeeper, etc.
6 Industry or business in which
work was done, as iBk Bill,
at hone
10 Date deceased last worked at
this occupation (month and
year)
11
Total time (years)
spent in this
occupation
mm
12 BIRTHPLACE fCitv)
(State or country)
13 NAME OF
FATHER
Boston
14 BIRTHPLACE Or
FATHER (Citv)
F Dolan
(State or country) _ .
15 MAIDEN NAME
OF MOTHER
DUS tUU
10 BIRTHPLACE oK>uiBe XHOL7as
MDTUFB fCitv)
(State or country)
Boa-hem
1 7 Relation, if any
Informant ( - )
(Addr««);Irs L Shorrin .lother
A TRUE COPY.
ATTEST
(Registrar of city or town where death occurred)
DATE FILED 19
MEDICAL CERTIFICATE OF DEATH
18 DATE OF
DEATH
6/S9
(Day)
(Year)
19 I HEREBY CERTIFY that I have investigated the death
of the person above-named and that the CAUSE AND MANNER thereof are
as follows: (If an injury was involved, state fully)
ic .-cnoral' pe^ an
ab sed ss— foil owing abortion— saic to have
been e-elf induced
2.0 If death was due to external causes (VIOLENCE) fill in the following:
Accident,
Suicide or Date of Injury t. 19
Homicide?
Where did
Injury occur?
and State)
Manner of
Nature of i&pfirOtCHiy "with exteriorization
Injury
Was there
12/28/38
21 Was disease or injury in any way related to occupation of deceased?
If so, specify
(Signed) M. D.
(Address) ff. -Ti jlMTy Date.* .* 19..
Boston
22
l/c/Z9-
Place of Burial. Crem
DATE OF BURIAL
23 NAME OF
UNDERTAKER
Ufol f ' SLl&e#
l/s/SO
or Town)
19
ADDRESS :L -4rhy
Received and filed l/lO/&9 19
fRegistrar of City or Town where deceased resided)
V1'
WRITE PLAINLY, WITH UNFADING 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. Exact statement of OCCUPATION is very
R-302
1
]
BOSTON
(City or town making retugij^ ^
Registered No
Qlfjp (EmtrounuttpalHj of MaBBarljuBrtlH
/ OFFICE OF THE SECRETARY
1 SUFFOLK 901 DIVISION OF VITAL. STATISTICS
S / BOSTON CERTIFICATE OF DEATH
^ HOSp r (If death occurred in a hospital or institution,
St., Ward ^ give its NAME instead of street and number)
Robert B Hyslop r (UU.S. 2X
2 FULL NAME . j War V«t.r«,
(|fi c[ec^aSB^yTi vddpyred or divorced woman, give also maiden name.) Win
Ward,
(If nonresident, give city or town and state)
No,.
(a) Residence. No St.,
(Usual place of abode)
Length of residence in city or town where death occurred yrs. Dos.
days. How lone in U. S., if of foreign birth?
days.
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
H
4 COLOR OR RACE
V/
6 SINGLE
MARRIED
WIDOWED
or DIVORCED
(write the word)
M&rriod
5a If married, widowed, or divorced Ilarv Chisholm
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 64
AGE 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
lO Date deceased last worked at 12/3S
this occupation (month and •
year)
o&rponter
11 Total time (yearsVlQ
spent in this
occupation
12 BIRTHPLACE (City).
(State or country)
Few Srunstdc'k
13 NAME OF
FATHER
George Hyslop
14 BIRTHPLACE OF „ _
FATHER (City) Smf Jnrwi&wlok
(State or country)
16 MAIDEN NAME - , ~ , , ,
of mother mMy Softw
16 BIRTHPLACE OF
MOTHER (City) .
(State or country)
C g
s
1 7
Bosp Records
Informant (
( Address)
Relation, if any
H 7
o z
a
E~o
«*\
A TRUE COPY.
ATTEST:
egistrar of city or town where death occurred)
DATE FILED 19.
MEDICAL CERTIFICATE OF DEATH
18 DATE OF
DEATH
Jan 7/39
(Month)
(Day)
(Year)
19
BY CERT
lm
I last saw h alive on
ll.ISp
to have occurred on the date stated above, at ....
ifv /r-TIjat A attended deceased from
lyr/zti ’ 19
’ ' , 19 death Is said
perforated • duodenal orlc or
••pulm#«aboltts-
•12/1
Vs,
Contributory causes of importance not related to principal cause:
post opr puln.atelectasis
Name of operation repair . Oi......tl.P.O.?*. Jf-.-/.Ar.§...
What test confirmed diagnosis? Was there an autopsy?
( Ad d ress) . Y. . . . . y.Y:*r. D
.19 .
? 1
YTinthrop-adinthrop
Place of Burial, CrematiJi/jfjR^fival. (City or Town)
DATE OF BURIAL, 19
22 NAME OF
UNDERTAKER
n — r —
ADDRESS
Received and filed
l/H/39
19..
(Registrar of City or Town where deceased resided)
The principal cansa of death and related causes of importance in order of
onset were as follows:
Datiafonsit
e/36
%9"
20 Was disease or injury in any way related to occupation of deceased?
,fso- speei,y C'R-Sduders
(S,gned) 605' Cdm^re nl/8/59 D'
z
—
ftM R-305
6 IF STILLBORN, enter that fact here.
7
If less than 1 day
— -1 crQ
<£. ©Ijp ffiammonajpalUj of fllaoBarljaBrttB
1 SIIKRnr V OFFICE of the secretary
|l J\ DIVISION OF VITAL. STATISTICS
BOSTON tw# MEDICAL EXAMINER’S
CERTIFICATE OF DEATH
(City or Town)
BQ3! 'Q*. .
(City or town making return)
Registered No.
ise
- No Boston Gity Eo«p
2 FULL NAME
, widowed or divorced woman, give also maiden name.)
St., Ward,
Leafth of residence in cilr or town where death occurred yrt. mot.
( (If death occurred in a hospital or institution.
•St., Ward ^ give its NAME instead of street and number)
22
(If u. s.
War Veteran,
specify WAR)
(,) "sans, "ss ise sowdoin
’ (?f^nSYn7^Tn?fit, give city or town and state)
dayt. How loa( ia U. S., if o( foreign birth? yrs. mot. dayv
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
4 COLOR OR RACE
5 SINGLE
MARRIED
WIDOWED
or DIVORCED
6a If married, widowed, or divorced
husband .f .Mary Gavin
(Give maiden name of wife in full)
(or) wife of
(Husband’s name in full)
(write the word)
harried
8 Trade, profession, or particular
13 NAME OF
FATHER
Chelsea’
14 BIRTHPLACE Sfrael "errV
FATHER (City)
(State or country)
16 MAIDEN NAME
OF MOTHER
16 BIRTHPLACE OF
MOTHER (City) .
(State or country)
Hova Scotia
^ligftbeth Ilurburt
1 7
Relation, if any
Informant
- < - >
(Addreee)
A TRUE COPY
ATTEST:
Registrar of city or town where death occurred)
DATE FILED 19
MEDICAL CERTIFICATE OF DEATH
18 DATE OF
DEATH
Jan 8/39
(Month) (Day)
(Year)
19 I HEREBY CERTIFY that I hare investigated the death
of the person above-named and that the CAUSE AND MANNER thereof are
as foDows: (If an injury was involved, state fully)
0
F-
<
CL
3
sawyer, bookkeeper, etc
9 Industry or business in which
work was done, as silk mill.
motornan
O
O
10 Date deceased last worked at
this occupation (month and
year)
B E RY n
Total time (years)
spent in this
occupation
12 BIRTHPLACE fCitv)
17^9
30
(State or country)
cor e, hemorrhage -treated ’’for"
admitted -in -const died "ii* -4- hoars
20 If death was due to external causes (VIOLENCE) fill in the following:
Accident,
Suicide or Date of Injury .19
Homicide?
Where did
Injury occur?
Manner of
Injury
Nature of
Injury
Was there an autopsy?
/City or town and State)
21 Was disease or injury in any way related to occupation of deceased?
If so, specify
(Signed) , M. D.
(Address) -I- I-OWfjP. Date 19
22
DATE OF BURIAL
23 NAME OF
UNDERTAKER
Boston l/c/3 9
or Town)
i/n/39
Place of Burial. Cremation or Removal. _ . (City <
-ff£nfaroP4finthro?
ADDRESS
R E Whit©
Received and filed
■ant hr op
T/Vj/oT
(Registrar of City or Town where deceased resided)
19
[s/iR-9i939 M
WRITE PLAINLY, WITH UNFADING 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. Exact statement of OCCUPATION is very
(M R-302
I SUFFOLK,
a BOSTON
Qltfp (EtmutununraWii of fHasBartfuartJfl
OFFICE OF THE SECRETARY
DIVISION OF VITAL. STATISTICS
STANDARD
CERTIFICATE OF DEATH
oral Hospt
BOSTON
(City or town making return)
„ 426 23
Registered No
( (If death occurred in a hospital or institution,
No St., Ward ^ give its NAME instead of street and number)
Robert Bean [ «fu.s.
2 FULL NAME j W« Vet.mn,
ggcgceg^J^eJnpjpied, widowed or divorced woman, give also maiden name.) (3^^^
(a) Residence. No St., Ward,
(Usual place of abode) (If nonresident, give city or town and state)
Length of residence in city or town where death occnrred yrs. mos. days. How long in U. S., if of foreign birth? yTS. mos. days.
te
. o
o
s *
t! o
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
4 COLOR OR RACE
Cblored
6 SINGLE (write the word)
MARRIED , .
widowed harried
or DIVORCED
5a If married, widowed, or divorcedBlanch® Snith
HUSBAND of
(Give maiden name of wife in full)
(or) WIFE of
(Husband’s name in full)
6 IF STILLBORN, enter that fact here.
^ 65
AGE
9 10
Years Months
Days
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 mil),
saw mill, bank, etc
lO Date deceased last worked at 11/58
this occupation (month and /
year)
Janitor
building’
11 Total time (years)!")
spent in this
occupation
12 BIRTHPLACE (City).
(State or country)
Hajiii ton Bermuda
13 NAME OF
FATHER
Richard Boon
14 BIRTHPLACE OF
FATHER (City) ..
(State or country)
lia-d 1 ton-Bomuda
15 oFAMEoN™rEAbilona Smith
10 BIRTHPLACE OF
MOTHER (City) ..
(State or country)
Ira Hilton Bermuda
17
if any
Informant (
( Address )
A TRUE COPY.
ATTEST:
..«&*«**
* A pS — n — C p i ♦ , . P— f p n.L J . . S L — n n . J
tegistrar of city or town where death occurred)
DATE FILED 19.
If less than 1 day
Hours Minutes
MEDICAL CERTIFICATE OF DEATH
18 DATE OF
DEATH
Jan 13/59
(Month) (Day)
(Year)
19 / THEREBY CERTIFY, That I attended deceased from
MM. B 1/WS9 .9
I last savijP. alive on 1/... 1.3/59 , 19 death is said
to have occurred on the date stated atuhel&p m.
The principal cause of death and related causes of importance in order of
onset were as follows: - . , ,
nttef onset
... oa? d iao hyp. ertr.o p hy . . d i lat at i on
syp.b i .1 i t i s . . a o rt % t . i .$ . . vrt t.h . . c. ong .
failure
Contributory causes of importance not related to principal cause:
pulm .inf ar.c.tion . .bilateral 4dys
^rs.
Name of operation Date of
What test confirmed diagnosis? Was there an autopsyfeg
20 Was disease or injury in any way related to occupation of deceased?
If so, specify
(Sigr$0 Baker • M- D-
(Address) »« o ■». Daje /. ... 19
■ays' "m.iidsp
2 1
Place of Buria (City or Town)
DATE OF BURIAL l/l
22 NAME OF R IT Whit®
UNDERTAKER
rfinthrop
ADDRESS x
1/17/39
Received and filed 19
(Registrar of City or Town where deceased resided)
VI R-302
v -
« ■*
s.™
« ft
! ob. e
■30.5
l
Cambridge
(City or town mairing return)
Registered No 45
Middle sex £ QIt|p (CommotuopaUli of ilafiBarljuBPtJH
OFFICE OF THE SECRETARY
« «■ V -s SKhMI DIVISION OF VITAL. STATISTICS
Cambridge Mp standard
CERTIFICATE OF DEATH
(ShaiTfcefl gate Hoap • (If death occurred in a hospital or institutioni
No St., Ward | give its NAME instead of street and number)
Kasonof r(Itu.s.
2 FULL NAME I WurVet.run,
(JL&ceI«l ipEtifl’ v2^Vecii>r divorced woman, give also maiden name.) V /fYft fi^bp
(a) Residence. No St., Ward,
(Usual place of abode) (If nonresident, give city or town and state)
Length of resilience in city or town where death occurred yr». mo«. day*. How long in U. S., if of foreign birth? yr». mm. day».
PERSONAL AND STATISTICAL PARTICULARS
r
4 COLO^OR RACE
6 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.
7
AGE
Years Months Days
If less than 1 day
Hours Minutes
10
Trade, profession, or particular
kind of work done, as spinner,
sawyer, bookkeeper, etc
Industry or business In which
work was done, as silk mill,
saw mill, bank, etc
Date deceased last worked at
this occupation (month and
year)
12 BIRTHPLACE (City).
(State or country)
1 1 Total time (years)
spent in this
Cambridge ■-CT-*g=
Mass
13 NAME OF
FATHER
Lewis
14 BIRTHPLACE OF
FATHER (City) ...
Cambridge
(State or country)
Mass •
15 MAIDEN NAME
OF MOTHER
Ethel Herman
10 BIRTHPLACE OF
MOTHER (City) ....
Cambridge
(State or country)
Mas 8 •
17
, , Lewis Kasonof xa’tneF
Informant ( )
(Address)
A TRUE COPY.
ATTEST:
Jan 17 1939
(Registrar of city or town where death occurred)
DATE FILED ...V. 19.
18 DATE OF
DEATH
MEDICAL CERTIFICATE OF DEATH
Jan 15 1939
(Month)
(Day)
(Year)
10 J^aff^EBY CER^Y
SI
deceased fr^i^
19
13
19 *r death is s
MM.
,19..—..., to...._._ •«•>«•. 19
r*? 19 V>$ath is said
I last saw h alive on-
to have occurred on the date stated above,
The principal cause of death and related causes of importance in order of
onset were as follows: , , .
Daft ef onset
Ate 1 e Ota a "e's 2‘days
Contributory causes of importance not related to principal cause:
Prema.turi.ty. 2....d.ay
8.
Name of operation Date of
What test confirmed diagnosis? Was there an autopsy? no
20 Was disease or injury in any way related to occupation of deceased? .
If so, specify
(signed) Joeeph H Meyer
M. D.
(Address) g70 Commonwealth l
21 Kennesetty Israel Cem. IV o burn
Place of Burial, Carnation or RernovaL (City or Town)
DATE OF BURIAL^^ ^ ^ 19T 9 19
22 NAME OF
UNDERTAKER
ADDRESS
Manuel Stanetsky
10 WaSMhgtdri St. Dor .
Jan' '17 I
Received and filed 19.
(Registrar of City or Town where deceased resided)
a EC El V i. '
FEB±<Ti!930 Ml
<
IM R-302
<o
£ 3 *
No..
Wife GJmnmimuipaltfj of fUJaaBadjuartifl
OFFICE OF THE SECRETARY
DIVISION OF VITAL STATISTICS
STANDARD
CERTIFICATE OF DEATH
(Cit5U$!rc& City Hospital
i SUFFOLK
] BOSlW
' l
(City or town making return)
6G1
Registered No
Augusta Porter
(If death occurred in a hospital or institution,
number
25
St., Ward { give its NAME instead of street and number)
(If U. S.
2 FULL NAME I i V.t.r«n,
(If deceased is a married widowed or divorced woman, give also maiden name.) I specify WAR)
(.) Residence. No J™..™*.™. S,„ W„d
(Usual place of abode)
Length of residence in city or town where death occurred yrs. mos.
(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
Female
4 COLOR OR RACE
White
6 SINGLE
MARRIED
WIDOWED
or DIVORCED
(write the word)
Isiarrio 1
5a If married, widowed, or divorced
HUSBAND of
(Give i
(or) WIFE of
(Husband’s name in full)
,u)
6 IF STILLBORN, enter that fact here.
7
AGE
50
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 at0 . JL 1
this occupation (month andoepU itfSo
year)
Housewife
At Home
12 BIRTHPLACE (City).
(State or country)
Bouton L3a ss
Total time
spent in this
occupation
13 NAME OF
FATHER
Theodor© Hellberg
14 BIRTHPLACE OF
FATHER fCitv)
Sv/odon
(State or country)
15 MAIDEN NAME
OF MOTHER
Augusta Anderson
10 BIRTHPLACE OF
MOTHER ( Oitv)
Sweden
(State or country)
1 7
(Address)
Harry Porter
Rel!r‘i§"ooM
Informant gll £l 1 f f AW YfillthlrOp >
A TRUE COPY.
ATTEST:
'(Registrar of city o'r town wYlere”'3?ath
rred)
DATE FILED 19„
MF.D1CAL CERTIFICATE OF DEATH
18 DATE OF _
death .«Ievu^2O.*.lS50.
(Month) (Day)
(Year)
19 i HEREBY CERTIFY, That I attended deceased from
September. ..-9 ,19.3.3, to JaruSQ , 19. .3.9
I last saw h alive on ■ , 19 death Is said
to have occurred on the date stated above£at.j.gp...];T...m.
The principal cause of death and related causes of importance in order of
onset were as follows: . , , .
Oaftaf onset
Yr
<Jareinrjna of eorvix
Contributory causes of importance not related to principal cause:
Metastasis
3’io-s
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)
. irw o«CMeii n : ::M-D-
Hoston urty — 1-51 3©
21
Place of Qkl'MlK&T Removal.
DATE OF BURIAfr^
(City or Town)
lflS9
22 UNDERTAKER ^WETd , M Fits ^bbOZI
address 142S -Hor-cHostor .ATO^HoroIicstor.
Received and filed 1?9.
tJ.a3no.s...A..Eurk0.
(Registrar of City or Town where deceased resided)
(County)
<*L Cdpmmxnmtralttf of ^aBBarljoarttB
OFFICE OF THE SECRETARY
DIVISION OF VITAL STATISTICS
MEDICAL EXAMINER’S
CERTIFICATE OF DEATH
(City or Town)
No. E&Rout B to Boston &ity liosp St., Ward
^City or town making return)
Registered No. . .0.2.6.. ..2,^7S„
( (If death occurred in a hospital or institution,
(_ give its NAME instead of street and number)
„ (BU.S.
2 full name Gosorge leoisley jwarv.i„«.
(If deceased is a married, widowed or divorced woman, give also maiden name.) [ tpeafy WAR)
(,) J'SA)? Shore Drive
St., Ward,
Leafth of readeace ia city or town where death occurred
■Wte; give city or town and state)
1*1*. How loaf ia U. S., if of foreicn birth? yn. not. doyt.
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
5 SINGLE
MARRIED
WIDOWED
or DIVORCED
(write the word)
8 Trade, profession, or particular
kind of work done, as epinaer
lawyer, bookkeeper, etc.
6 Industry or business in which
work was done, as silk mill,
saw aiill, baak, etc.
lO Date deceased last worked at
this occupation (month and
year)
Hfi r'aehinist
1 1 Total time (years)
spent in this
occupation.. 3 ..
12 BIRTHPLACE (City)
(State or country)
13 NAME OF
FATHER
Ungland
14 BIRTHPLACE OF
FATHER (City)
John T&nsley
(State or country)
Ifoglond
15 MAIDEN NAME
OF MOTHER
16 BIRTHPLACE OF
MOTHER (City) .
Harriet Judkins
(State or country)
finf1
17
Relation, if any
Informant «/4 #»-r
(Addreae) Wlx 6
A TRUE COPY.
ATTEST:
(Registrar of city or town where death occurred)
DATE FILED 19
5a U married, widowed, or
HUSBAND •<
divorced
Ur) WIFE of
(Give maidAt'riMnelot-wife^ft^ull)
(Husband’s name in full)
0 IF STILLBORN, enter that fact here.
7
If less than 1 day
AGE __ Yearv
Months,, Days
Hours Minutes
57 ... "’1
MEDICAL CERTIFICATE OF DEATH
18 DATE OF
death ... Jen 26/39
(Month) » (D;
(Day)
(Year)
19 I HEREBY CERTIFY that I have investigated the death
ol the person above-named and that the CAUSE AND MANNER thereof are
as foDows: (If an injury was involved, state fully)
cerebral fryfaaTg
C.Q.l.l.&p.S.Q.d;....§udc]erJ,y -natural.. ..causes
20 If death was due to external causes (VIOLENCE) fill In the following:
Accident,
Suicide or Date of Injury .19
Homicide?
Where did
Injury occur?
Manner of
Injury
4 City or town and State)
Nature of
Injury
Was there an autopsy?
21 Was disease or injury in any way related to occupation of deceased?
If so, specify
(Address) .c....^..0fIeary D 19
Boston i/26/39
22
or Town)
Place of Burial.
DATE OF BURIAL i /rvr> A»« 19
23 NAME OF
UNDERTAKER ....
■1/23/39
ADDRESS
Received and filed .
irratr
1/30/33
rinthrop
.19
(Registrar of City or Town where deceased resided)
tM R-305
6 IF STILLBORN, enter that fact here.
7
AGE
Years Months Days
If less than 1 day
Hours Minutes
e 1 SUFFOLK
a ) Bosfm
Qlpmaumuipalttj of ^aaBarlfuartta
OFFICE OF THE SECRETARY
DIVISION OF VITAL STATISTICS
MEDICAL EXAMINER’S
CERTIFICATE OF DEATH
(City or Town)
No ' SaJlout e Sost on ■City Heap
BOSTON
V'-ity or town making return)
Registered No.
St., Ward
2 FULL NAME or
Honc^,deL^ur8a!Tied
, widowed or divorced woman, give also maiden name.)
St., Ward,
Leafth of readeoce is dty or lows where death occarred yn. mot.
(If death occurred in a hospital or institution,
give its NAME instead of street and number)
(If U. S.
War Veteraa,
ipedfy WAR)
nonresicrent, give city or town and state)
day*. How loaf ia U. S., if of foreisa birth? yr*. bos. day*.
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
4 COLOR OR RACE
I 5 SINGLE
MARRIED
WIDOWED
I or DIVORCED
5 J-if Barriod, widowed, or divorced
HUSBAND of
(Give
(or) WIFE of .TZr.
(Husband’s name in full)
(write the word)
arrled
8 Trade, profession, or particular
kind of work done, as tpiaoer,
lawyer, bookkeeper, etc
9 Industry or business in which
work was done, as alk auD,
saw Bill, haah, etc.
lO Date deceased last worked at
this occupation (month and
year)
•■eaTa'firw
12 BIRTHPLACE (City)
(State or country)
1 1 Total time (years)
spent in this
occupation.
ZQ-
13 NAME OF
FATHER
Montreal
Canada
14 BIRTHPLACE OF'fr&FjLOS i*8COttT8
FATMFB CCitv)
(State or country)
15 MAIDEN NAME
OF MOTHER
vy€L. .ncifi.
16 BIRTHPLACE OF
MOTHER (City)
'lisa Dunont
(State or country)
waria^a
1 7
Informant
(Addres)
wiff
Relation, if any
A TRUE COPY.
ATTEST:
J
(Registrar of city or town where death occurred)
DATE FILED «
MEDICAL CERTIFICATE OF DEATH
18 DATE OF
DEATH
"(Mg&i 27/CO
(Day)
(Year)
19 I HEREBY CERTIFY that I have inveitiga ted the death
of the person above-named and that the CAUSE AND MANNER thereof are
as foDows: (If an injury was involved, state fully)
!oronaz%'solerosis
natural causes
20 If death was due to external causes (VIOLENCE) fill in the following:
Accident,
Suicide or Date of Injury .10
Homicide?
Where did
Injury occur?
Manner of
Injury
Nature of
Injury
Was there an autopsy?
fCity or town and State)
21 Was disease or injury in any way related to occupation of deceased?
If so, specify
(Signed) , M. D.
(Address) Date 19
22 Boston
Place of Burial. Cremation or Removal.
DATE OF BURIAL T » 7
1/28/S9
(City or Town)
23 NAME OF
UNDERTAKER
1/31/59
ADDRESS J-gL.Q.!.-,; aloy
Received and filed 11®®**!!*®..
1/S1/39
19
(Registrar of City or Town where deceased resided)
MAR— 9;93g m
A R-301A
3 taO
5-oS
"’TDu
» »u
>to°
iL°
io c
5- 2
jto g .
J>* 8 •
5= 3 g
J?* RJ <U
J J * «
jgjl
« -Ji
I’SSg
,-s « g
) fl) 4) *"""*
!-fi a S
It. S-
3 aS
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< J5 -2 b
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i 4J *
_• « ©
* ^ -C T3
,® * c
0,0*
. a w »
! “ s!
. 4* y
!S <D 3
I?
S.uf.f.o.lk
(County)
...lin.t.hr.o..p
(City or Town)
No. ..r^T^Pr.a^pStf
©I}? Cdammottnipaltlj of HIa0Barl]UEPttB To be filed for burial permit
OFFICE OF THE SECRETARY '> with Board cf Health
DIVISION OF VITAL STATISTICS
" >\
STANDARD
CERTIFICATE OF DEATH
or its Agent.
Registered No,.. 2.3.....
%{£ ( (If death occurred in a hospital or institution,
.V.i.?....;.Ward ^ give its NAME instead of street and number)
2 full name I. s aa c. . . . F ... . . P.Q il a.t*d I War Veteran,
(If deceased is a married, widowed or divorced woman, give also maiden name.) I *pecif7 WAR)
(a) Residence. No....7Q....PP.Q.SP.fi.C.ti St., Ward,
(Usual place of abode) * (If nonresident, give city or town and state)
Lenjth of residence in rily or tews where death occurred J Jjyrs. nos. days. How long in U. S., if of foreign birth? yrs. mos. days.
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
Male
4 COLOR OR RACE
White
(write the word)
Widowed
5 SINGLE
MARRIED
WIDOWED
or DIVORCED
5a If married, widowed, or divorced^ . Ac |
husband of Soph i a Me-fae.Q . d. ■. . .fer.Ll artl
(Give maiden name of wife in full)
(or) WIFE of
MEDICAL CERTIFICATE OF DEATH
18 ddeaattehof Feburary. .1. * 1939.
(Month) (Day)
(Year)
(Give i
(Husband’s name in full)
0 IF STILLBORN, enter that fact here.
7
AGE 7 7 Years . Months. .1.3. Days
If less than 1 day
Hours Minutes
8 Trade, profession, or particular
kindof work done, as spinner, p-i - _•»_
sawyer, bookkeeper, etc v..l..v..r.l\
8 Industry or business in which
work was done, as silk Dill, ,,
saw mill, bank, etc Dry LrQ.Q O. S
10 Date deceased last worked at 11 Total time (years)
this occupation (month and -r _ __ _ spent in this,
year) Jan.. lU l'J
12 BIRTHPLACE (Citv) . .
Rockland.
(State or country)
Massachusetts
13 NAME OF
FATHER
Isaac Pollard
00
14 BIRTHPLACE OF
FATHER (City) ..
Rockland
h-
Z
(State or country)
Massachusetts
UJ
cz
<
CL
15 MAIDEN NAME t . . , .
of mother Lydia otmston
10 BIRTHPLACE OF
MOTHER (City) ...
(State or country)
Rockland
Massachusetts
17
Informant Florence S. Pollard (.Daughter
(Address) 7Q Prospect Ay Cr W j TT tVTOT) Ma. r ^
I HEREBY CERTIFY that a satisfactory standard certificate of death was
filed with me BEFORE the bucipl or transit, permit was issued:
19, 1 HEREBY C E RT I E Y* That I attended deceased from
JO, gj/'to /...., igj£.
I last saw h.*r**7. alive on ■■/■■■ , 19.3y£., death is said
to have occurred on the date stated above, at
The prindp&I came ol death and related causes of importance in order of
onset were as follows: z~. : :
Catsof onset
<sl/j 7m d-
. > ,..., sJjDate / a AS
cremau6n“or removal Winthr op Wi n thr o p
(Cemetery) (City or town)
date of burial Feb u r a ry 3 . 19 59 - 19 .
21 PLACE OF BURIAL,
22 NAME OF
UNDERTAKER
address 147 Winthr op S t W i n t hfpp. Ma.s.s
Received and filed
MJ
I93f
.19
(Registrar)
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GTfjc CornmontDcaltf) of JfflaBgarfjuBettB
OFFICE OF THE SECRETARY
DIVISION OF VITAL. STATISTICS
STANDARD
IF1CATE OF DEATH
No.
2 FULL NAME
(City or Town) r -■> CERTIFICA1
(If deceased is a married, j^idfSwed^tf divoi^fed ^romaru^ve also
To be filed for burial permit
with Board of Health
or its Agent.
29
Registered No.
(a) Residence. No
(Usual place of abode)
Length of residence in city or town where death occurred // yean
d yoman^fve also maiden name.)
f (If death occurred in a hospital or institution,
-Ward|give its NAME instead of street and number)
(If U. S.
ar Veter
Ward,
(If nonresident, grive city or
months
days.
How long in U.S., if of foreign birth?.
and state)
oaths days.
U
©
- ©
2 to
2 « •
J.s|
M U t
C 0- 0.
.2 e c
PERSONAL AND STATISTICAL PARTICULARS
4 COLOR 0R RACE
6 SINGLE
HARRIED
WIDOWED
•r DIVOR
(write the word) ,
5a II Darned, widowed, or dirorctd
HUSBAND of
(Give maiden name of wife in full)
(er) WIFE of
(Husband’s name in full)
0 IF STILLBORN, enter that fact hare.
7
AGE
..Years Months Days
If less than 1 day
Hours Minutes
8 Trade, profession, or particular
klndofwork done, as tpiaoci,
uwycr, bookkeeper, etc.
0 Industry or business in which
work was done, as silk Bill,
uw mill, buk, etc
lO Date deceased last worked at
this occupation (month and
year)
11 Total time/years)
spent in this
occupation..
12
BIRTHPLACE (City)
(State or country
13 HAHE OF
FATHER
l£
,^j4/Z4/vyusyi
14 BIRTHPLACE OF
FATHER (City) .
(State or country)
15 MAIDEN NAME
OF MOTHER
10 BIRTHPLACE OF
MOTHER (City)
(State or dluntry)
<rr-
I HEREBY CERTIFY that a satisfactory standard certificate of death was
filed with me BEFORE the burial or transit permit was issued:
Ra
BEFORE the buria
(Signature of Agent of Board of H^lth or <
3/
(Official Designation) (Dafe of Issue of ^Permit!
MEDICAL CERTIFICATE OF DEATH
18 DATE OF
DEATH
(Month)
<3
(Day)
M3jL
(Year)
is I hereby certify. That I attended deceased from
were as follows:
Data of Oaut
IMPORTANT
7
Contributory eisiei of importance not related to principal cause:
f?3f:
What test confirmed diagnosis
'JZRRRRg. *-
Was there an autopsy?.
20 Was disease owlnjury in any way relatedl^occupation of deceasetT7T^.....
If so, specify _
(Signed) . . . .. ...
(Addt^....S^^..^..-
Received and filed..,
(Registrar)
-
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Suffolk
(County)
Iin.tiir.op
(City or Town)
®f)e Cornmontoealtt of iHafigarijugetts!
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.
No 9.Q....Washingt. a
2 full name Charles .H-fakkJga. Squires
(If deceased is a married, widowed or divorced woman, give also maiden name.)
(a) Residence. No. .V..Q...jV.&.S.h.iXl§tDJ!l..A.Y.©Xl.ll©.
(Usual place of abode)
Lenirtk of residence in city or town where death occurred*- C years months days.
Registered No SO-
rurred in
ilE inste
f (if u. :
j War V.
I specify
f (i( death occurred in a hospital or institution,
Ward | give ;ts NAME instead of street and number)
S.
Veteran
specify WAR)
S££. Ward,
(If nonresident, give city or town and state)
How long in U.S., if of foreign birth?
months
days.
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
Male
4 COLOR OR RACE
7hi te
(write the word)
6 SINGLE
MARRIED
widowed insle
•r DIVORCED ‘■>J-I1e-LO
6a If curried, 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.
AGE i?. Years Months . Days
If less than 1 day
Hours Minutes
2
O
8 Trade, profession, or particular
kind of work done, as »»*“B'Qh.XSi
sawyer, bookkeeper, etc .T. J
Quartermaster
9 Industry or business in which
**Jg\3y,*i* United States ifavy
10 Date deceased last worked at 11 Total time (years)
this occupation (month and spent in this
year) occupation
JSA.
12 BIRTHPLACE (City) -D.aHV.il.la..
(State or country) IT 0V7 TTOrll
13 NAME OF /ri
FATHER
0*0
00
14 BIRTHPUCE OT
FATHER (CiV)
Unable to obifain
h-
Z
(State or country)
LU
CC
<
a.
15 MAIDEN NAME
OF MOTHER
10 BIRTHPUCE OF
MOTHER (City)
.nna.b.l&-t-0--d3-taTn
(State or country)
MEDICAL CERTIFICATE OF DEATH
18 DATE OF
DEATH
(Month) f
(Day)
(Yew)
I HEREBY OERTIF
Thai I attended deceased from
I last saw b.D^ttallve on ytf: 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: oat* of Oout
Place of" mi rial. Cremation or Removal. (City or Town)
DATE OF BURIAL Zs.~b.rmry...-?. 19..59.
22 NAME OT ft lq ..n ri rs •
UNDERTAKER L/.LlQ.r.lSD.....lla D.Sim.DS.QlL
address -.wiuD^-Qp La.ss
Received and filed..
.19..
(Registrar)
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GTfje ComrnontDcalrt) of iBlafisfadju^ctts
OFFICE OF THE SECRETARY
DIVISION or VITAL. STATISTICS
(City or town making return)
STANDARD
CERTIFICATE OF DEATH
:Sfcr.
Ward
Registered No 3.1.
[cath occurred in a hospital or institution,
its NAME instead of street and number)
a married, widowed or divorced woman, give al:
X
abode) /
(a) Residence. No,
(Usual place of
length of residence in city or town where death occurred 30 year*
...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
4 COLOR OR RACE
6 SINGLE (write the word)
MARRIED
WIDOWED
•(-DIVORCED
5a If married, widowed, or di reread
HUSBAND of „
(or) WIFE of ... .
(Hugband's name in full)
0 IF STILLBORN, enter thaWact here
AGE.
ILL
..Years
...../?...Months»^..£)...Days
If less than 1 day
Hours Minutes
8 Trade, profession, or particular
kindof work done, as (pinner,
sawyer, bookkeeper, etc y -
9 Industry or business in which
work was done, as silk mill,
■aw mill, bank, etc !0>fel«3rTCk'.'.l
lO Date deceased last worked at 11 Total time (years)
this occupatioi^Ttnonth and I q v . spent in t^i:
year) yv. occuflatioi
12 BIRTHPLACE (City)..
(State or country)
13 NAME OF
FATHER
GO
14 BIRTHPLACE OP
FATHER (CThe text goes on. The rest is in the file.