The volume, 1956

Town Clerk, Winthrop · from the Internet Archive · 532 pages · 37.9 MB
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ACCOUNT BOOK
MANUFACTURERS

, . hX^O STON

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S-J97f

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https://archive.org/details/townofwinthropre1956wint

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♦, '%

bof FOLii

^ (Eommomupaltl) nf maBHarliiwpttjB

EDWARD J. CRONIN

(County) ,

^;N

2 FULL NAME..

(City or Town)

Veterans A
RALPH I M

No.

Secretary of the Commonwealth

DIVISION OF VITAL STATISiyj^^^T^J^fJ^

COPY OF

30ST0N

(City or Town making this return)

CERTIFICATE OF DEATH

Registered No.

Dr» IFoT f(If death occurred in a hospital or institution,

i give its name instead of street and number)

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

9^9 i:i^nnlnt;ton St. E Bos ton

(Was deceased a
L^ S. War Veteran,
if so specify WAR)..

(a) Residence. No.

(Usual place of abode)

St..

23.

Length of stay: In place of death years months .trdays. In place of residence ...TrJ^ears months days.

11,

WW I

(If nonresident, give city or town and State)

3 DATE OF
DEATH ....

MEDICAL CERTIFICATE OF DEATH

iTanuc^ni:7~I956“

(Month)

(Day)

4 I HEREBY C E RT I F Y. ThatVAattended

Dee 22 Jan £, 1956

have occurred on the date stated above, at „ ll:50p

(Year)

deceased from

death is said to

DEATH WAS CAUSED BY: IMMEDIATE CAUSE

(a)

(TerleiTlc aortic stenosis

Due To
(b)

Due To

(c)

OTHER

SIGNIFICANT

CONDITIONS

INTERVAL
BETWEEN
ONSET AND

DEATH

yrs

Was autopsy performed?

What test confirmed diagnosis?..

autopsy

-no-

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

If so, specify

,. Eric Sharton
VAH, Bos ton 30

(Address) Date.

iZg/gS

Wlnthrop Cem«, Wlnthr op ^ Ma s s •

M. D
19

Place of Burial or Cremation
PATE OF BU R I AL r..'..^C.Y. 1 9..

"January

7 NAME OF
FUNERAL DIRECTOR..

ADDRESS..

Richard C, Klr^

^..3..t.gnj, Ss.s......

Received and filed..

jee:

.135b..

..19..

(Registrar of City or Town where deceased resided)

8 SEX

9 COLOR

PERSONAL AND STATISTICAL PARTICULARS

10 SINGLE (write the word)
MARRIED
WIDOWED

or DIVORCED iHarrl ed

?usBArD"S’ Hansen

(Give maiden name of wife in full)

(or) WIFE of..

(Husband’s name in full)

11 IF STILLBORN, enter that fact here.

AGE.

S8v

ears ,.<.Months.._~.'.rDays

If under 24 hours
Hours Minutes

13 Usual

Occupation :

Salesman

(Kind of work done during most of working life)

14 Industry
or Business:

15 Social Security No.

Shoe

16 BIRTHPLACE (City).
(State or country)

Masa

17 NAME OF
FATHER

Frank I Anderson

18 BIRTHPLACE OF

FATHER (City)

(State or country)

Gloucester

Mass

19 MAIDEN NAME

OF MOTHER •^lllian V i/ithara

20 BIRTHPLACE OF
MOTHER (City)....-..
(State or country)

Gloucester
Hass.

Informant.

(Address)

, Hospital Records

150 B* HuntiTigtron Aw. '^' BOs"

TRUE ^ 37 . 2^ O. ^.Jf . ",

ATTEST:

DATE FILED

(Registrar of City or Town where death occurred)

Janus ry 11, 1956

!♦ £ r. r : V r*‘

FEB “9 All

Jan 28, 1918
Dec 21, 1918
QM 2/c
US Uavy
Kone

RM R-301A

iSnUCTIONS

FOR

CAL CERTIFICATE

In (ivinc
SE OF DEATH

o not enter
are than one
UM for each
.), (b) and (c)

his does not mean
7de of dying, such
■I failure, asthenia, •
means the disease,
nplications which
death.

'orbid conditions, ,
giving rise to the ’
cause (a) stating
nderlying cause

mditions contrib- ■
0 the death but not
to the disease or
on causing death.

2 FULL NAME .

(dommomopaUtf of fnaBaadfuartta

EDWARD J. CRONIN

Secretary of the Commonwealth

DIVISION OF VITAL STATISTICS

To bo filod for burial pormlt
with Board of Hoalth
or its Afonte

STANDARD

CERTIFICATE OF DEATH

Registered No.

.a.

s Suf f olk Y..

- (County)

Winthro

(City or Town)

RX T A "P t. ^ A V & /(If death occurred in a hospital or institution,

No St. \ give its NAME instead of street and number)

Edith M (Maddick) Huhy

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

6 Myrtle St#

(If nonresident, give city or town and State)

Length of stay: In place of death years months days. In place of residence years months days.

(a) Residence. No. ..

(Usual place of abode)

St.

, PHYSICIAN — IMPORTANT

I (Was deceased a

I U. S. War Veteran.

I if so specify WAR)

Boston

MEDICAL CERTIFICATE OF DEATH

3 DATE OF
DEATH ..

(Month)

(Day)

(Year)

41 HEREBY CERTIFY, That I attended deceased from

19 /J 9.. to . 3^.,

1 last saw h .^.h^.aUve oo \9Vi'^., death is said to

have occurred on the date stated above, at

DISEASE OR CONDITION

DIRECTLY LEADING^ /

TO DEATH (a) .C...42.

ANTE Due To
CEDENT (b)
CAUSES

Due To
<c)

OTHER
SIGNIFICANT
CONDITIONS

P & lT~ 9^ a/

IRTERVU BE-
TWEEN ONSET
MO OEATH

Major findings;

Of operations

Date of operation Was autopsy performed?..

What test confirmed diagnosis?..

^^n t l .

Place of Burial orT^remation
DATE OF BURIAL

Winthrop.

(City or Town)

J.^n * , 6 19 .5.6

PERSONAL AND STATISTICAL PARTICULARS

8 SEX

Female

9 COLOR OR RACE

V/hite

10 SINGLE
MARRIED
WIDOWED
or

(write the word)

gPv^l^Eri^Iarried

10a If married, widowed, or divorced

HUSBAND of

(Give maiden name of wife in full)

(or) WIFE of .Char.ls.e ... ..G:,..,Huhy;

(Husband's name in full)

11 IF STILLBORN, enter that fact here.

AGE

Years Months . Days

If under 24 hours
Hours Minutes

13 Usual

Occupation :

Housewife

(Kind of work done during most of working life)

14 Industry
or Business:

15 Social Security No.

Own home

^0-1B~033B'

16 BIRTHPLACE (CityV_..

(State or country) ^ng lanO.

Huir

17 NAME OF
FATHER

Henry Maddick

18 BIRTHPL.4CE OF

FATHER (City)

(State or country) SnP^ land

19 MAIDEN NAME

OF MOTHER Ellen Florence Hill

20 BIRTHPLACE OF

MOTHER (City) ?.h..a.^’.at.9.)l..

(State or country) Enffj land

Informant

(Address)

;"'Ave V Wiht;hrdh7MaRa

I HEREBY CERTIFY that a satisfactory st^dard certificate of death was
file^^ith ^e^EFORE tl^ ^rial o^-t^ansit^rmit was issued:

(SiAa^re of Agm^f Board of Heattn/or other) y y

. /./A/.£'.^

(Official Designation) ^ 1/ jj (Date of Issue of Permit) /

EXTRACTS

FROM THE LAWS OF THE

COMMONWEALTH OF MASSACHUSETTS

GOVeRNING THE

RETURN OF CERTIFICATES OF DEATH

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

death certificate contains a recital, as required by section ten of chapter forty-six.
that the deceased served in the army, navy or marine corps of the united States
in any war in which it has been engaged, such recital shall appear upon the permit.
The board of health, or its agent, upon receipt of such statement and certificate,
shall forthwith countersign it and transmit it to the clerk of the town for registra-
tion. The person to whom the permit is so given and the physician certifying
the cause or 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).

Medical examiners shall make examination upon the view of the dead bodies
of persons as are supposed to have died by violence, or by the action of
chemical, thermal or electrical agents or following abortion, or from diseases
resulting from injury or infection relating to occupation, or suddenly when not
^ disabled by recognizable disease, or when any person is found dead. .. — General
i t4ws, Chap. 38. Sec. 6., as amended by Chap. 632, Sec. 4, Acts of 1945.

A physician or officer furnishing a certificate of death as required by tii^j
preceding section or by section forty-five of chapter one hundred and four^^
teen, shall, if the decea^d. to the best of his knowledge and belief, served ip the
army, navy or marine corps of the United States in any war in which it has been
engaged, insert in the certificate a recital to that effect, specifying the war.’ apq,,
shall also certify in such certificate both the primar>' and the secondary or irpme^*'
diate cause of death as nearly as he can state the same. For neglect togomply '
with any provision of this section, such physician or officer, shall forfeit ten dollars.
For the purposes of this section and of sections forty-five, forty-six and fortyw^gvert
of said chapter one hundred and fourteen, the word “war” shall include the China
relief expedition and the Philippine insurrection, which shall, for said purposes«;be
deemed to have taken place between February fourteenth, eighteen hundred^aotL
ninety-eight and July fourth, nineteen hundred and two. and the Mexican. b^dy^'
service of nineteen hundred and sixteen and nineteen hundred and seve'nj^n.
G. L. Chap. 46. Sec. 10. ' ^

No undertaker or other person shall bury or otherwise dispose of a human body-
in a toVn. 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
person died; and no undertaker or other person shall exhume a human bo(|j/444
remove it from a town, from one cemetery to another, or from one grave or tomb
other than the receiving tomb to another in the same cemetery, until he has
received a permit from the board of health or its agent aforesaid or from the clerk
of the town where the body is buried. No such permit shall be issued until there
shall have been delivered to such board, agent or clerk, as the case may be,
a satisfactory written statement containing the facts required by law to be
returned and recorded, which shall be accompanied, in case of an original inter-
ment, 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 w’ithin the commonwealth cannot be obtained early enough for the
purpose, the certificate of death made as above provided and in the possession of
the undertaker desiring to make such removal shall constitute a permit for such
removal; 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

_ No undertaker or other persons shall bury a human body or the ashes thereof
■ f which have been brought into the commonwealth until he has received a permit
' ^ 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
I or the funeral is to be held, or from a person appointed to have the care of the
•‘••ceMeteir or burial ground in which the interment is made.

■— . V'. . Chap. 114, Sec. 46, G. L., (Tercentenary Edition).

r- : RULES OP PRACTICE

The'fulfilltnent of the purpose of these laws calls for the observance of the follow-
IKitteniles of practice:

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

I' 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
{«m home ^Vfen 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. — Physicians: see explanatory instructions
on face side of standard certificate of death.

Statement of Occupation. — Precise statement of occupation is very import-
ant, so that the relative healthfulness of various pursuits can be known. Make
some entry in this section for every person aged 10 years or over. If the occupa-
tion had been given up or changed, or if the deceased had retired from business,
report the kind of work done during most of working life even if retired. Children
not gainfully employed may be returned as at school or at home. For a woman
whose only occupation was that of home housework, write housework. For a
person engaged in domestic service for wages, however, designate the occupation
by the appropriate terms, as housekeeper — private family, cook — hotel, etc. For
a person who had no occupation whatever write none.

SPACE FOR ADDITIONAL INFORMATION

DATE OF ENTERING MILITARY SERVICE

DATE OF DISCHARGE

RANK, RATING

ORGANIZATION AND OUTFIT

SERVICE NUMBER.

RM R-301A

UTRUCTIONS

FOR

CAL CERTIFICATE

In ffivinf
SE OF DEATH

o not enter
>re than one
use for each
i), (b) and (c)

his does not mean
xfe of dying, such
I failure, asthenia, ■
means the disease,
splications which
death.

orbid conditions, ,
giving rise to the '
cause (a) slating
nderlying cause

mdilions conirib- ■
} the death but not
to the disease or
on causing death.

' QlammonniFaltt; of AaBoadfOBrllB

y\A EDWARD J. CRONIN

ft- Secretary OF THE Commonwealth

DIVISION OF VITAL STATISTICS

STANDARD

CERTIFICATE OF DEATH

To be 61ed for burial permit
with Board of Health
or Its A^nt.

Registered No. .

Suffolli

(County)

"fintiirop

(City or Town)

. I , • j • L _ n I (If death occurred in a hospital or institution.

No St. I give its NAME instead of street and number)

13 (X ■ (j ' ^ ^ ‘ ' PHYSICIAN — IMPORTANT

2 FULL NAME 0. I (Was deceased

(If deceased is aonarried, widowed or divorced woman, give also maiden name.) | U. S. War Vet<

Veteran. lyo
I if so specify WAR)

(a) Residence. No X2....LJjn>.Qlj..Tl.G....x\.Y.9.Aji St

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

Length of stay: In place of death years months days. In place of residence years months

days.

MEDICAL CERTIFICATE OF DEATH

3 DATE OF , , ,/ t L

(Month)

DEATH

(Day)

(Year)

HEREBY CERTIFY,

19 to

J — 7-" \1 \ ^ ^

1-_a. h J\ y _i: 1 1/ r. -w- J

That I attended deceased from
19.?^ ^

-'T' i-f-

I last saw h_A-:\/^.alive on 19 ?. death is said to

have occurred on the date stated above, at ‘.T. rfn.

DISEASE OR CONDITION
DIRECTLY LEADINCf^

TO DEATH (a)

Y^e wto-

Yu r Y

ANTE Due To
CEDENT (b)
CAUSES

Due To
(c)

OTHER

SIGNIFICANT .
CONDITIONS

linitllAL BE
TWEEN ONSET
MD DEATH

If under 24 hours

AGE

Years

Months

Days

0 Hours Minutes

Major findings:

Of oi>erations

Date of operation Was autopsy performed?

What test confirmed diagnosis?

5 Was disease ps injury in any way related to occupation of deceased?.

If so, specif;^./.^ ,

(Signed) M. D

(Address) . Date ..CTft.YV...19X..4

Place 01 Bunal or Cremation

DATE OF BURIAL ..January

•Aldeji ^

(City or Town)

D, 195.G 19..

^ FUNERAL DiRECTOR.Artiiur,..._;.......E.o.3::<s.ell.a

ADDRESS

Received and filed 19..

(Registrar)

PERSONAL AND STATISTICAL PARTICULARS

8 SEX

F'omle

9 COLOR OR RACE

Yrhite

10 SINGLE (write the word)
MARRIED

WIDOWED _ . ,

or DIVORCED Slllj.le

10a If married, widowed, or divorced

HUSBAND of

(Give maiden name of wife in full)

(or) WIFE of

(Husband's name in full)

1 1 IF STILLBORN, enter that fact here.

13 Usual

Occupation:..

i 'ion t^.

(Kind of work done during most of working life)

14 Industry
or Business:..

15 Social Security No

16 BIRTHPLACE (City) .

(State or country) ^

,ass*

17 NAME OF

FATHER Qt Brian

18 BIRTHPLACE OF

FATHER (City)

(State or country)

..ZlG.ir.er.e..

19 MAIDEN NAME

OF MOTHER Caz^roll

20 BIRTHPLACE OF
MOTHER (City) ....
(State or country)

..iio.s.tan..

I . ‘ ty #

Informant .Yj_l.XiQJ.1...0.|..3j?X.QJl„

(Address) IS UnQine Ave»» Reversj .asso

I HEI^BY CERTIFY that a ^tisfactory standard..^rtificate of death was
fil^vfah m^^^^FORE the buTf&l,^ tragsit^permit^was issued:

\Official Designation)

'of.Boaraof Health oc^tmer]
./ (Da

(Date of Issue of P;

EXTRACTS

FROM THE LAWS OF THE

COMMONWEALTH OF MASSACHUSETTS

GOVERNING THE

RETURN OF CERTIFICATES OF DEATH

A physician or registered hospital medical officer shall forthwith, 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 deceas^. furnish for registration a standard certificate of death, stating to the
oest of his knowledge and belief the name of the decea^d. his supposed age. the
disease of which he died, defined as required by section one. where same was
contracted, the duration of his last illness, when last seen alive by the physician
or officer and the date of his death. . .Gen. Laws, Chap. 46, Sec. 9.

A physician or officer furnishing a certificate of death as required by the
preceding section or by section forty-five of chapter one hundred and four-
teen. shall, if the decea^d. to the best of his knowledge and belief, served in the
army, navy or marine corps of the United States in any war in which it has been
eng.aged. insert in the certificate a recital to that effect, specifying the war. and
shall also certify in such certificate both the primar>' and the secondary or imme-
diate cause of death as nearly as he can state the same. For neglect to comply
with any provision of this section, such physician or officer, shall forfeit ten dollars.
For the purposes of this section and of sections forty-five, forty-six and forty-seven
of said chapter one hundred and fourteen, the word “war” shall include the China
relief expedition and the Philippine insurrection, w'hich shall, for said purposes, be
deemed to have taken place between February fourteenth, eighteen hundred and
ninety-eight and July fourth, nineteen hundred and two. and the Mexican border
service of nineteen hundred and sixteen and nineteen hundred and seventeen.
G. L. Chap. 46, Sec. 10.

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 satisfactory written statement containing the facts required by law to be
returned and recorded, which shall be accompanied, in case of an original inter-
ment, 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 oi a human body, not previously interred, from one town
to another within the commonwealth cannot be obtained early enough for the
purpose, the certificate of death made as above provided and in the possession of
the undertaker desiring to make such removal shall constitute a permit for such
removal ; prov^ed, 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 required by section ten of chapter forty-six.
that the deceased served in the army, navy or marine corps of the United States
in any war in which it has been engaged, such recital shall appear upon the permit.
The board of health, or its agent, upon receipt of such statement and certificate,
shall forthwith countersign it and transmit it to the clerk of the town for registra-
tion. 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, S^. 45.
G. L.. (Tercentenary Edition).

Medical examiners shall make examination upon the view of the dead bodies
of persons as are supposed to have died by violence, or by the action of
chemical, thermal or electrical agents or following atKirtion, or from diseases
resulting from injury or infection relating to occupation, or suddenly when not
disabled by recognizable disease, or when any person is found dead. .. — General
Laws, Chap. 38. Sec. 6., as amended by Chap. 632, Sec. 4, Acts of 1945.

No undertaker or other persons shall bury a human body or the ashes thereof
which have been brought into the commonwealth until he has received a permit
^ to do from the board of health or its agent appointed to issue such permits, or
if there is no suc^bpa^Klyfrom tjie clerk of the town where the body is to be buried
or the funeral is icAo'n^d.W, from a person appointed to have the care of the
cemetery or burial ground in which the interment is made.

. . . (5hap. 114, S^. 46, G.^^L., (Tercentenary Edition).

, 'I 0;<;

. \ ' 7"". vRULES of practice

The fulfillmentlof p{friI)o?e pf these laws calls for the observance of the follow-
ing rules of practice: \* ■

( 1 ) Attending physicians will certify to such deaths only as those of persons

to whom they have given bedsijJe’Care during a last illness from disease unrelated
to any form of injury. ..“r ‘

(2) Board o#. 'Health phye|ciaris will certify to such deaths only aS those of
persons who. thoui^)!. disalil^d.by recognized disease unrelated to any form of
injury, have died f^th^Mtir^ent* medical attendance or whose physician is absent
from home when^JJe c^ifioaxe^f'death is needed.

(3) Medical investigate and certify to all deaths supposably

due to injury. IrlcTiiqe not only deaths caused directly or indirectly by

traumatism (ind'udini_iig^ulting 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 diAtfe^of parsons not disabled by recognized disease, and those of
persons fouiWaianT^ ^ t-,!

Statement qf Cause of Death. — Physicians: see explanatory instructions
on face side of standard certificate of death.

Statement of Occupation. — Precise statement of occupation is very import-
ant, so that the relative healthfulness of various pursuits can be known. Make
spme entry in this section for every per^n aged 10 years or over. If the occupa-
tion had been given up or changed, or if the deceased had retired from business,
report the kind of work done during most of working life even if retired. Children
not gainfully employed may be returned as at school or at home. For a woman
whose only occupation was that of home housework, write housework. For a
person engaged in domestic service for wages, however, designate the occupation
by the appropriate terms, as housekeeper — private family, cook — hotel, etc. For
a person who had no occupation whatever write none.

SPACE FOR ADDITIONAL INFORMATION

DATE OF ENTERING MILITARY SERVICE

DATE OF DISCHARGE

RANK, RATING

ORGANIZATION AND OUTFIT

SERVICE NUMBER

< ,3.yur.fQ.ik

1 g (County)

I o

I W (City or Town)

No..

ulljp (Emnmoniufaltlj nf HJaHHarljuartla

EDWARD J. CRONIN " Ghl^lse*

Secretary of the Commonwealth (City or^wn m^ing thi

DIVISION OF VITAL STATISTICS

COPY OF

CERTIFICATE OF DEATH Registered No.

.Home Hospl.,tal

ing this return)

.St.

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

2 FULL NAME ^.•.£'192.^.

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

-J (Was deceased a

I U. S. War Veteran,

_ „ -in. L if so specify WAR)

(a) Residence. No St

nonresident, give city or town and State)

Length of stay: In place of death..* years...??. months .*?..days. In place of residence.* years..* months .iwdays.

MEDICAL CERTIFICATE OF DEATH

3 DATE OF
DEATH ....

Jan.7,1.956

(Month) (Day)

(Year)

4 I HEREBY CERTIFY, That

to , 19.56-

I last saw himiiHve on Jan.*..?- 1^6 ., death is said to

6;10p,

8 SEX

9 COLOR

Male

White

have occurred on the date stated above, at

DEATH WAS CAUSED BY: IMMEDIATE CAUSE

(a) Acute mype ar dl a Infarc.tl dn

Due To
(h)

Due To
(c)

skinWicant Chronic bronchial asthma

CONDITIONS

INTERVAL
BETWEEN
ONSET AND

Was autopsy performed? ...

What test confirmed diagnosis? .C..JLXni..C.a.X..

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

1 f so, specify

(.sig.,d)..I.l«anor S.Wang

Home

...Date.._ 1/7/56

M. D.

WintJ^Qp. ...C Wlntihrrtp.Mfl $

— (City or Town)

19....

Place of Burial or Cremation
DATE OF BURIAL

’’ FUNEkAL DIRECTOR. ...Alllr.e.d... B

ADDRESS.

Received and filed..

(Registrar of City or Town where deceased resided)

PERSONAL AND STATISTICAL PARTICULARS

10 SINGLE (write the word)
MARRIED
WIDOWED

or DIVORCElMflT»rtt

lOa If married, widowed, or divotc^

HUSBAND of XO.UIlg

(Give maiden name of wife in full)

(or) WIFE of...

(Husband’s name in full)

11 IF STILLBORN, enter that fact here.

60 11 16

AGE Years !Months..» Days

If under 24 hours
Hours Minutes

13 Usual

Occupation

.Bpgkk..eepe.r

(Kind of work done during most of working life)

14 Industry

or Business:..

not known.

IS Social Security No._.. not kaown..

16 BIRTHPLACE (City)_.
(State or country)

Winthropimss;'

17 NAME OF T,

FATHER Charles P«

18 BIRTHPLACE OF

FATHER (City)

(State or country)

19 MAIDEN NAME

OF MOTHER £ Rlchardfipn

20 BIRTHPLACE OF

MOTHER (City).....

, (State or country)

Bj^bklyaiN,Y«

Informant .EQ..3.p.l.tal....JB.e.c.or.dw-

(Address)

A TRUE COPY
ATTEST:

DATE FILED

gar of City or Town where death occurred)

Jan« 7.1956 jg

/.A

Enlisted 2/14/15
Discharged 6/6/19
Pvt. l/c

Co. 101st Inf,
62890

RM R-303 A

•n *
3Su

'•E

111

•8

ihd I
f

oSrrS

3?’« 5

I
I

l| 2

11 ^

]l .

I: I

|] s

»2 6

• 8 o

=■

a >

12 «
S? t;
" C ^

■S. "

•.! a

» -

s S

•o ■"

^(County)

dli;r Cdammomoralttr of fflaasarlruertta
EDWARD J. CRONIN
Secretary of the Commonwealth

DIVISION OF VITAL STATISTICS

MEDICAL EXAMINER’S ,
CERTIFICATE OF DEATH

To bo fiUd for burial parmlt
with Board of Hoalth
or Its A^nt.

* Registered No. .

jHktJL

Q (City or To^) r l~

. PULL N*MEllli<^i^lllQl

(If decease! is a married, w^wed or divorced woman, give also mmden name.) | M- S.

of abode) (IfVionn

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

PHYSICIAN — IMPORTANT

deceased a

. War Veteran, „ _
specify WAR) B.Q

(a) Residence. No.
(Usual place (

Length of stay: In place of death years months days. In place of residence ..kO... .years months days.

onresident, give city or town and State)

MEDICAL CERTIFICATE OF DEATH

3 DATE OF
DEATH ....

(Month)

tPay) t (Year)

41 HEREBY CERTIFY that I have investigated the death
of the person above-named and that the CAUSE AND MANNER thereol

r.) '

are as foUows: (If. an injury was iiuralved, statefltllhr.) *

S Accident, suicide, or homicide (specify) :rT.

Date and hour of injury 19..

Where did
Injury occur?

(City or town and State)

Did injury occur iii^jtpabout home, on farm, in industrial place, or in public
place?

Manni
Injury

& 1

While at work? ? Was autopsy performed?

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

(Address)

7 IVinthr.QT2....C.ein.ig.l$.iy.,...>....Im

Place of Burial, or Cremation. (City or Town)

DATE OF BURIAL J.®nii.«?T3r....l.ljL 19SA

* FUNERAL DIRECTOR .E.n).5..5.t....r..a....CiLEgi.'9Xl.O..

ADDREss..lk7.....t¥inthr.Q.p....S.t.».»....i.fiatJirQp..

Received and filed .rrJ.

(Registrar)

.19..

PERSONAL AND STATISTICAL PARTICULARS

9 SEX

T'.'ale

10 COLOR OR RACE

'JThite

11 SINGLE (write the word)
MARRIED

WIDOWED married

or DIVORCED

11a If married, wi(^wed-oi divorced

HUSBAND of ^teTla jean

(or) WIFE of

(Give maiden name of wife in full)
(Husband’s name in full)

12 IF STILLBORN, enter that fact here.

AGE

.6.k.

Years..

Months.?.3i Days

If under 24 hours
Hours Minutes

14 Usual

Kation:....Truck,..Drive^

(Kind of work done during most of working life)

or‘^Bl\mess:....TpTm,.Of.Jiyl^^^

16 Social Security No Q.15?.T.l.§!rQQ.(?.$

17 BIRTHPLACE (City)...,EaS.t...BpS.tQn

(State or country) j g SS? CHUSe ttS

18 NAME OF
FATHER

19 BIRTHPLACE OF f J -/

FATHER (Citv)

(State or country)

20 MAIDEN NAME

OF MOTHER

21 BIRTHPLACE OF ,T . . .. . / /

MOTHER (City) .

(State or country)

Informant M?.?..?....

(Acfdr^) [ k Pij

Stella Mamilton

c'h^lrn St. 'Tintt.rnr'

I HEREBY CERTIFY that a satisfactory standard pertificate of death was
filed Mtb me BEFORE the burial or tranaThermit^as issued:

t of Board of Health or^dmer)

(Date of Issue of Pern

EXTRACTS

FROM THE LAWS OF THE

COMMONWEALTH OF MASSACHUSETTS

GOVERNING THE

RETURN OF CERTIFICATES OF DEATH

A phN'sician or registered hospit«il medical officer shall forthwith, after the
death of a person whom he has attended durinR 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 reRistration a standard certificate of death, stating to the
best of his knowledge and belief the name of the decea^d, his supposed age. the
disease of which he died, defined as required by section one, where -same was
contracted, the duration of his last illness, when last seen alive by the physician
of officer and the date of his death. . .Gen. Laws. Chap. 46. Sec. 9.

A physician or officer furnishing a certificate of death as required by the
preceding section or by section forty-five of chapter one hundred and four-
teen, shall, if the deceased, to the best of his knowledge and belief, served in the
army, navT or marine corps of the United States in any war in which it has been
engaged, insert in the certificate a recital to that effect, specifying the war, and
shall also certify in such certificate both the primary' and the secondary or imme-
diate cause of death as nearly as he can state the same. For neglect to comply
with any provision of this section, such physician or officer, shall forfeit ten dollars.
For the purposes of this section and of sections forty-five, forty-six and forty-seven
of said chapter one hundred and fourteen, the word “war” shall include the China
relief expedition and the Philippine instirrection, which shall, for said purposes, be
darned to have taken place between February fourteenth, eighteen hundred and
ninety-eight and July fourth, nineteen hundred and two, and the Mexican border
service of nineteen hundred and sixteen and nineteen hundred and seventeen.
G. L. Chap. 46. Sec. 10.

N’o undertaker or other person shall bury or otherwise dispose of a human body
in a to\vn, 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 to^yn. from one cemetery to another, or from one grave or tomb
other than the receiving tomb to another in the same cemetery, until he has
received a permit from the board of health or its agent aforesaid or from the clerk
of the town where the body is buried. No such permit shall be issued until there
shall have been delivered to such board, agent or clerk, as the case may be,
a satisfactory written statement containing the facts required by law to be
returned and recorded, which shall be accompanied, in case of an original inter-
ment, 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 commonwealth cannot be obtained early enough for the
purpose, the certificate of death made as above provided and in the possession of
the undertaker desiring to make such removal shall constitute a permit for such
removal; 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 required by section ten of chapter forty-six,
that the deceas^ served in the army, navy or marine corps of the United States
in any w'ar 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 registra-
tion. The person to whom the permit is so given and the physician certifying
the cause of death shall thereafter furnish for registration any other necessary
information which can be obtained as to the deceased, or as to the manner or
cause of the death, which the clerk or registrar may require.— Chap. 114, Sec.
45. G. L. as amended by Chap. 48. Acts of 1927 and Cnap. 414. Acts of 1931.

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 w'here 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-cr burial -groxmd in which the interment is made Chap. 114,

Sec. 46. G. L., as amended.

Medical examiners shall make examination upon the view of the dead bodies
of persons as are supposed tq have died by violence, or by the action of
chemical, thermal or eledtrlcaLagVnts or following abortion, or from diseases
resulting from injury or infection relating to occupation, or suddenly when not

disabled by recognizable diseasa, or when any person is found dead — General

Laws, Chap. 38, Sec. 6., as anpepded by Chap. 632. Sec. 4, Acts of 1945.

The medical e.xaminer certifies the cause and manner of death to the best

of his knowledge and belief. ■ ,

r!uLES i&F PRACTICE

The fulfillment of the* purpose of.thea laws calls for the observance of the follow-
ing rules of practice:

(1) Attending physicians will cerlSfy to such deaths only as those of persons
to whom they have giv^ bedside care.dqring a last illness from disease unrelated
to any form of injury,

(2) Board of Health certify to such deaths only as those of

persons who. though dis^lyea W' r^doghiied disease unrelated to any form of
injury, have died without attendance or whose physician is absent

from home when the certificate of death is needed.

(3) Medical ExamineVs Will iriwStigate and certify to all deaths supposably
due to injury. These include-rrot only deaths caused directly or indirectly by
traumatism (including resulting septicemia), and by the action of chemical
(drugs or poisons) thercruL o^lectrical agenf and deaths following abortion, but
also deaths from dis^^Winud|timsfrom injury or infection related to occupation,
the sudden deaths orT^sflns mm 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, hom-
icidal.” “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: (l)Under cause its known
or presumable nature; and (2) under manner, indicate the circumstances leading
to medico-legal inquiry. For example: “Hemorrhage spontaneous of the brain
(basal ganglia) (found dead in bed).” “Heart disease, presumably coronary
sclerosis. (Sudden death.)’ ’

SPACE FOR ADDITIONAL INFORMATION

DATE OF ENTERING MILITARY SERVICE

DATE OF DISCHARGE

RANK, RATING

ORGANIZATION AND OUTFIT

SERVICE NUMBER

M R-301A

nuaioNS

FOR

il CERTIFICATE

n tivinc
i OF DEATH

not enter
e than one
le for each
, (b) and (c)

does not mean
e of dying, such
failure, asthenia, ■
iran^ the disease,
dications which
eath.

rbid conditions, .
living rise to the *
use (a) staling
ierlying cause

ditions conirib- •
the death but not

0 the disease or

1 causing death.

.Suffolk

(County)

o '7 1 n t op

/ 142 Pleas

(SammoniDpalttf of AasBartiuartta
EDWARD J. CRONIN
Secretary OF THE Commonwealth

DIVISION OF VITAL STATISTICS

To bo filed for burial permit
with Board of Health
or it* Agent.

STANDARD

CERTIFICATE OF DEATH

7 x7

No St. \ give its NAME instead of street and number)

TS a »» It-. a ^PHYSICIAN-IMPORTANT

Den n 1 s M , 0 . B r i e n /

Registered No

I (If death occurred in a hospital or institution.

2 FULL NAME .‘.V..* .V. .f.f , I (Was deceased a

(If deceased is a married, widowed or divorced woman, give also maiden name.) | C. S. War Veteran,

I if so specify WAR)

8l Sunny s i de^^^ A

(a) Residence. No St. ,

(Usual place of abode)

Length of stay: In place of death years ....5.. ..months..

(If nonresident, give city or town and State)

..days. In place of residence years ...T.. . months days.

MEDICAL CERTIFICATE OF DEATH

^ DEATH°^. January 8, .195.6

(Month) (Day)

(Year)

4 I H ER

I ERE BY CERTI

lLU..%l£i 19

F Y . That 1/ ^tten^ed deceased

19-

I last saw h .'.T^T.?’..^... alive on 19 death is said to

-7 /^'7>

have occurred on the date stated above, at

DISEASE OR CONDITION
DIRECTLY LEADING

TO DEAJTH (a) ,, ?....

7i 7ro A

cedInt 7b) MX7.^.tlh:j.L,\

CAUSES

Due To
(c)

OTHER

SIGNIFICANT .
CONDITIONS

'T'

Major findings:

Of operations

Date of operation Was autopsy performed?

What test confirmed diagnosis?

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

If so. specify

(Address)fS^.^.4^-<^^r^.Y!r:i(^^ .-^4/ Date 19

6 ....Mtf., C,aiva.ry Bo.S:.t.pn..„Ma.i3.a

Place of Burial or Cremation (City or Town)

..January 1.1.., iq.5.6

DATE OF BURIAL

^ FUNERAL DIRECTOR .Ar.t-.b.ur.....J... .Q..’.Ma.l.'5.y...

ADDRESS I.ln..t..h.r.Q.p......M.as.g..*

Received and filed JAN...10....19.5.6 19..

(Registrar)

PERSONAL AND STATISTICAL PARTICULARS

8 SEX

Male

9 COLOR OR RACE

White

10 SINGLE (write the word)
MARRIED

^oPyoRCEMdoweci

10a If married, widowecLpr diyorcecL

HUSBAND of liP na yea

(Give maiden name of wife in full)

(or) WIFE of

(Husband's name in full)

1 1 IF STILLBORN, enter that fact here.

AGE

Years

Moiyths

Days

If under 24 hours
Hours Minutes

Occupation: O.P.er.a.tQ T

(Kind of work done during most of working life)

‘^or'^Sess:....M.*. T....A.. Rai.l.w.ay..

15 Social Security No..

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

Ire I'an'fi’

17 NAME OF
FATHER

Denni 3 0 *3r1 en

18 BIRTHPLACE OF

FATHER (City)

(State or country)

T re land

19 MAIDEN NAME
OF MOTHER

20 BIRTHPLACE OF
MOTHER (City) ..
(State or country)

Mary Minihane

^ — Ireland

Informao 3Mrs.....C.ha.r.l.e.s. W.i.l.l.ia33.s.,

(Addres^X ounnvsTae Ave Tinthron

I HEREBY CERTIFY that a satisfactory s^ndard certificate of death was
fil§d,^ith 9EFORE th^^rial^^trans^permit was issued:

: of Board of Il^th or othe^ /

official Designation) ///; (Date of Issue of .Permi))

EXTRACTS

FROM THE LAWS OF THE

COMMONWEALTH OF MASSACHUSETTS

GOVERNING THE

RETURN OF CERTIFICATES OF DEATH

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

A physician or officer furnishing a certificate of death as required by the
preceding section or by section forty-five of chapter one hundred and four-
teen. shall, if the decea^. to the best of his knowledge and belief, served in the
army, navy or marine corps of the United States in any war in which it has been
engaged, insert in the certificate a recital to that effect, specifying the war. and
shall also certify in such certificate both the primar>' and the secondary or imme-
diate cause of death as nearly as he can state the same. For neglect to comply
with any proWsion of this section, such physician or officer, shall forfeit ten dollars.
For the purposes of this section and of sections forty-five, forty-six and forty-seven
of said chapter one hundred and fourteen, the word “war” shall include the China
relief expedition and the Philippine insurrection, which shall, for said purposes, be
deemed to have taken place between February fourteenth, eighteen hundred and
ninety-eight and July fourth, nineteen hundred and two. and the Mexican border
service of nineteen hundred and sixteen and nineteen hundred and seventeen.
G. L. Chap. 46, &c. 10.

No undertaker or other person shall bury or otherw'ise 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 satisfactory written statement containing the facts required by law to be
returned and recorded, which shall be accompanied, in case of an original inter-
ment. 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 commonwealth cannot be obtained early enough for the
purpose, the certificate of death made as above provided and in the possession of
the undertaker desiring to make such removal shall constitute a permit for such
removal; 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 required by section ten of chapter forty-six.
that the deceased served in the army, navy or marine corps of the United States
in any war in w hich 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 forthw ith countersign it and transmit it to the clerk of the town for registra-
tion. 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 .b^oht^iped as to the deceased, or as to the manner or
cause of the death. w’hi«ih theixletk or registrar may require. — Chap. 114, ^c. 45.
G. L.. (Tercentenary Edition).

Medical examiners shall make examination upon the view of the dead bodies
of persons as are supposed to have died by violence, or by the action of
chemical, thermal or elecjtrical agents or following abortion, or from diseases
resulting from injury or infection relating to occupation, or suddenly when not
disabled by recognizable disease, or when any person is found dead. .. — General
Laws. Chap. 38, Sec; 6,, as amended by Chap. 632, Sec. 4, Acts of 1945.

No undertaker or other |persons 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, trqnv^e clerk of the town where the body is to be buried
or the funeral is to be n^ld, or from a person appointed to have the care of the
cemetery or burial ground irf ^hich the interment is made.

. . . (2hap. 114, Sec. 46, G. L., (Tercentenary Edition).

RULES OF PRACTICE

The fulfillment oflphjiijicpei of these l^wre calls for the observance of the follow-
ing 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. — Physicians: see explanatory instructions
on face side of standard certificate of death.

Statement of Occupation. — Precise statement of occupation is very import-
ant, so that the relative healthfulness of various pursuits can be known. Make
sqme entry in this section for every person aged 10 years or over. If the occupa-
tion had been given up or changed, or if the deceased had retired from business,
report the kind of work done during most of working life even if retired. Children
not gainfully employed may be returned as at school or at home. For a woman
whose only occupation was that of home housework, write housework. For a
person engaged in domestic service for wages, however, designate the occupation
by the appropriate terms, as housekeeper — private family, cook — hotel, etc. For
a person who had no occupation whatever write none.

SPACE FOR ADDITIONAL INFORMATION

DATE OF ENTERING MILITARY SERVICE

DATE OF DISCHARGE

RANK, RATING

ORGANIZATION AND OUTFIT

SERVICE NUMBER

tM R-301A

STRUaiONS

FOR

RL CERTIFICATE

n (ivinc
E OF DEATH

> not enter
re then one
*e for each
), (b) and (c)

II does not mean
le of dying, such
failure, asthenia, ■
nrani the disease,
plications which
ieath.

<rbid conditions, .
giving rise to the ’
luse (a) stating
derlying cause

editions contrib- ■
the death but not
to the disease or
n causing death.

I Suffolk

Q (County)

^ ¥inthrop

U (City or To

(EammamoFaltti of AaBaact^uartlB

EDWARD J. CRONIN

Secretary of the Commonwealth

DIVISION OF VITAL STATISTICS

STANDARD

CERTIFICATE OF DEATH

To bo filed for burial permit
with Board of Health
or its A(ent.

Registered No

(City or Town)

No. :^.inth.rOP....C Hospital St. NANiTlnsTead

2 FULL rU'WE .

T, , ^ T , PHYSICIAN — IMPORTANT

Frank G ^BalC Oil - J <Was deceased a

(If deceased is a married, widowed or divorced woman, give also maiden name.) j U. S. War Veteran,

c I if so specify WAR)

(a) Residence. No ^ ?.H®.?..t’..?..?’.....Ay'6 e St. .

(Usual place of abode)

(If nonresident, give city or town and State)
Length of stay: In place of death . . . .^^^ars months. IB. days. In place of residence 32 years months

MEDICAL CERTIFICATE OF DEATH

3 DATE O.
DEATH

« m Qi ^ f I ( 9*!^ V*

^2/ (Month) (Day) (Year)

41 HEREBY CERTIFY.

OCb 9-p 19AS...

That I attended deceased from

I last saw h i Hrt. alive on .

to^^^diAA

19 5 t

/.O , death is said to

have occurred on the date stated above, at v~..‘.....m.

DISEASE OR CONDITION
DIRECTLY LEADING . .

TO DEATH (a) >

CEDENT ^b)
CAUSES

Due To
(c)

SIGNIFICANT t...

CONDITIONS MycAW

Major findings:
Of operations..

V\fVOL.V<^>ftCA.Wg\

IRTERVAL BE
TWEEN ONSET
MD DEATH

Date of operation ”7” Was autopsy performed?. .^1.®

What test confirmed diagnosis? ^ Voa^ cA<\e»u{

5 Was disease or injury in any way related to occupation of deceased? NlO

(Signed) c - M- D

(Address), Date V U 19

(City or Town)

DATE OF BURIAL ^ 1^ .,./.l5.6

7 NAME OF ^ "

FUNERAL DIRECT)

ADDRESS
Received and filed..

(Registrar)

PERSONAL AND STATISTICAL PARTICULARS

8 SEX

Male

9 COLOR OR RACE

V/hite

10 SINGLE (write the word)
MARRIED

"D?voRCED‘iai’rled

L yerrlll

(Give maiden name of wife in full)

(or) WIFE of

(Husband’s name in full)

11 IF STILLBORN, enter that fact here.

AGE

Years Months . _ Days

If under 24 hours

Hours Minutes

(Kind of work done during most of working life)

14 Industry

or Business:

Self

J ,T. ...‘JT

IS Social Security No M.Q.nP..

16 BIRTHPLACE (City) ,... ,T,l.lt,Qn

(State or country) NCV^ HampShirS

17 NAME OF _ _ ,

FATHER George Balcom

18 BIRTHPLACE OF tt t-t

FATHER (City) t/.P.. ...Pfet. .4.1.0, .

(State or country) Connecticut

19 MAIDEN NAME

OF MOTHER Ells Chase

20 BIRTHPLACE OF

MOTHER (City) ...l.l.l'Vf.P.?^

(State or country) JlJeW HamDflh1r>ft

21 ng

Informant ... — •

(Address) ^

.l..a....L...B.a.l.c.Qm

Ave ... WinthroD. 14^^

I HEREBY CERTIFY that a satisfactory stand^d certificate of death was
\ with^me^EFORE the^unal or jtnansit perfnit was issued:

EXTRACTS

FROM THE LAWS OF THE

COMMONWEALTH OF MASSACHUSETTS

GOVERNING THE

RETURN OF CERTIFICATES OF DEATH

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

death certificate contains a recital, as required by section ten of chapter forty-six,
that the deceased served in the army, navy or marine corps of the United States
in any war in which it has been engaged, such recital shall appear upon the permit.
The board of health, or its agent, upon receipt of such statement and certificate,
shall forthwith countersign it and transmit it to the clerk of the town for registra-
tion. 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, S^. 45,
G. L., (Tercentenary Edition).

Medical examiners shall make examination upon the view of the dead bodies
of persons as are supposed to have died by violence, or by the action of
chemical, thermal or electrical agents or following abortion, or from diseases
resulting from injury or infection relating to occupation, or suddenly when not
disabled by recognizable disease, or when any person is found dead. .. — General
Laws, Chap. 38. Sec. 6., as amended by Chap. 632. Sec. 4. Acts of 1945.

A physician or officer furnishing a certificate of death as required by the
preceding section or by section forty-five of chapter one hundred and four-
teen, shall, if the decea^d. to the best of his knowledge and belief, served in the
army, naN'^’ or marine corps of the United States in any war in which it has been
eng.aged. insert in the certificate a recital to that effect, specifying the war. and
shall also certify in such certificate both the primary* and the secondary or imme-
diate cause of death as nearly as he can state the same. For neglect to comply
with any pro\nsion of this section, such physician or officer, shall forfeit ten dollars.
For the purposes of this section and of sections forty-five, forty-six and forty-seven
of said chapter one hundred and fourteen, the word “war” shall include the China
relief expedition and the Philippine insurrection, which shall, for said purposes, be
deemed to have taken place between February fourteenth, eighteen hundred and
ninety-eight and July fourth, nineteen hundred and two, and the Mexican border
ser\ice of nineteen hundred and sixteen and nineteen hundred and seventeen.
G. L. Chap. 46. Sec. 10.

No undertaker or other person shall bury or othen^ ise 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 recei\*ing tomb to another in the same cemetery, until he has
received a permit from the board of health or its agent aforesaid or from the clerk
of the town where the body is buried. No such permit shall be issued until there
shall have been delivered to such board, agent or clerk, as the case may be,
a satisfactory written statement containing the facts required by law to be
returned and recorded, which shall be accompanied, in case of an original inter-
ment. 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 commonwealth cannot be obtained early enough for the
purpose, the certificate of death made as above provided and in the possession of
the undertaker desiring to make such removal shall constitute a permit for such
removal ; 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

SPACE FOR ADDITIONAL INFORMATION

DATE OF ENTERING MILITARY SERVICE

DATE OF DISCHARGE

RANK, RATING

No undertaker or other persons 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.

. . . (^hap. 114, Sec. 46, G. L., (Tercentenary Edition).

RULES OF PRACTICE

The fulfillment of the purpose of these laws calls for the observance of the follow-
ing 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.

Statement of Cause of Death. — Physicians; see explanatory instructions
on face side of standard certificate of death.

Statement of Occupation. — Precise statement of occupation is very import-
ant, so that the relative healthfulness of various pursuits can be known. Make
some entry in this section for every person aged 10 years or over. If the occupa-
tion had been given up or changed, or if the deceased had retired from business,
report the kind of work done dunng most of working life even if retired. Children
not gainfully employed may be returned as at school ^^/hpme. For a woman
whose only occupation was that of home hou^w6i^^_^rite^ bQti$ework. For a
person engaged in domestic service for occu^tion

by the appropriate terms, as •hEWsekeepe^^orti^rtfr. f amlvt:T^Ok-/^otel. For

a person who had no ___

ORGANIZATION AND OUTFIT
SERVICE NUMBER

:M R-301A

TRUCTIONS

FOR

a CERTIFICATE

n Kivins

I OF DEATH

not enter
e than one
le for each
, (b) and (c)

■j does not mean
e of dying, such
failure, asthenia, .
leans the disease,
tlications which
eath.

'bid conditions. .
iving rise to the
use (a) stating
ierlying cause

ditions contrib- ■
the death but not

0 the disease or

1 causing death.

Suffolk

(County) •

(City or Town)

(lit;? (tiammamiiEaltl; of MaBoactiuartto

EDWARD J. CRONIN

Secretary of the Commonwealth

DIVISION OF VITAL STATISTICS

STANDARD

CERTIFICATE OF DEATH

To b« filod for burial pormit
with Board of Haalth
or its Agante

Registered No. .

,8.

2 FULL NAME

4--^ ,r% Ct

Jpj

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

il 3t . St

I (If death occurred in a hospital or institution.
St. \ give its NAME instead of street and number)

(a) Residence. No

(Usual place of abode)

PHYSICIAN — IMPORTANT

((Was deceased a
U. S. War Veteran,
if so specify WAR)

Length of stay: In place of death years months..

. days.

(If nonresident, give city or town and State)
In place of residence years months days.

MEDICAL CERTIFICATE OF DEATH

^ DEATH°^....January 14. 1.956..

(Month)

(Day)

(Year)

41 HEREBY CERTIFY.

That I attended deceased from

..Jan*l6 1947. to...Janmry...l4 19...5.6

I last saw le.Jl alive on «J.r;.Il'U3.3;iy....l4 1956-. death is said tc

have occurred on the date stated above, at 7i5-53ru. IRTERVAL BE

TWEEB ONSET

BND DEATH

DISEASE OR CONDITION
DIRECTLY LEADING

TO DEATH (a) Ur.e.mia..

cedInt °b) .^°... Nephrosclerosis...

CAUSES GeneralizeTi: Arte rib sclero'sig I

SIGNIFICANT .J)i.v.e.rtimAlitis....af....SigraQic

CONDITIONS g Rjpht Hip

Hypertension-

Hypertensive Heart Disease

• 12

If under 24 hours

AGE

. Months

.. Days

Hours Minutes

3 Mos,

2 yrs

3 jrs

3 yrs

4 mos
Severe'

Major findings: ,, VeaTS

Of operations XxOHe

Date of operation None Was autopsy performed?. ..No

What test confirmed diagnosis?.. ...X-Ray;...&...Ia.l?.o.3

5 Was disease cu^I^jui^ in any wayr^l

.ted to occupation of^ec^a^d? No

6 -;.c.lTr....y.r.Q

Place of Burial or Cremation
DATE OF BURIAL .

(City or Town)

PERSONAL AND STATISTICAL PARTICULARS

8 SEX

■ 2

9 COLOR OR RACE

^•'hi tft

10 SINGLE
MARRIED
WTDOWED
or DIVORCED

(write the word)

lOa If married, widowed, or divorced

HUSBAND of

(Give maiden name of wife in full)

(or) WIFE of

(Husband's name in full)

1 1 IF STILLBORN, enter that fact here.

13 Usual

&tion:I-l.,..Q.r„:.r£.tP.n

(Kind of work done during most of working life)

14 Industry - -,r- Vp 1

or Business:

IS Social Security No Q.;^.l.r'..Q.9.m .fci.’liQ.y.

16 BIRTHPLACE (City)

(State or country) n , i± «

17 NAME OF
FATHER

Timothy Olifforcl

18 BIRTHPLACE OF

FATHER (City)

(State or country)

‘i'3

19 MAIDEN NAME
OF MOTHER

T oh

F^rt' ;f»tt

20 BIRTHPLACE OF
MOTHER (City) ....
(State or country)

Ireland

Informanp..„.._M4rE.;i43.j;i.^5liI£OF<3

(Address) j .Q V m*~’ 1 t , . 1>~>V O V '

I HBkEBY CERTIFY that a satisfactory stan^rd certificate of death was
fije^ with p)e^®EFORE thcylsurial or traxait permit was issued:

EXTRACTS

FROM THE LAWS OF THE

COMMONWEALTH OF MASSACHUSETTS

GOVERNING THE

RETURN OF CERTIFICATES OF DEATH

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

A physician or officer furnishing a certificate of death as required by the
preceding section or by section forty-five of chapter one hundred and four-
teen. shall, if the deceased, to the best of his knowledge and belief, served in the
army, navy or marine corps of the United States in any war in which it has been
engaged, insert in the certificate a recital to that effect, specifying the war. and
shall also certify in such certificate both the primar\* and the secondary or imme-
diate cause of death as nearly as he can state the same. For neglect to comply
with any pro\dsion of this section, such physician or officer, shall forfeit ten dollars.
For the purposes of this section and of sections forty-five, forty-six and forty-seven
of said chapter one hundred and fourteen, the word ‘'war” shall include the China
relief expedition and the Philippine insurrection, which shall, for said purposes, be
deemed to have taken place between February fourteenth, eighteen hundred and
ninety-eight and July fourth, nineteen hundred and two. and the Mexican border
service of nineteen hundred and sixteen and nineteen hundred and seventeen.
G. L. Chap. 46. Sec. 10.

No undertaker or other person shall bury or othen^ ise dispose of a human body
in a to^m, 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 satisfactory written statement containing the facts required by law to be
returned and recorded, which shall be accompanied, in case of an original inter-
ment. 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 commonwealth cannot be obtained early enough for the
purpose, the certificate of death made as above provided and in the possession of
the undertaker desiring to make such removal shall constitute a permit for such
removal; 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

Medical examiners shall make examination upon the view of the dead bodies
of persoiw as are supposed to have died by violence, or by the action of
chcmica^' (hje^m^l or electrical agents or following abortion, or from diseases
resuUir^g from injury or infection relating to occupation, or suddenly when not
disabl^by recognizable disease, or when any person is found dead. .. — General
Laws, Sec. 6., as amended by Chap. 632. Sec. 4. Acts of 194.S.

• No' undertakdf or. other persons shall bur>’ a human body or the ashes thereof
jx’blbh hajfe^heen'-brpdght into the commonwealth until he has received a permit
^.io dp trom’thet board of health or its agent appointed to issue such permits, or
If therein no syth'b'oard. from the clerk of the town where the body is to be buried
ortJte funeral isjt» be held, or from a person appointed to have the care of the
cefnfefpre or biinalwronnd in which the interment is made.

‘C^p.^ Ij4^6ec. 46, O. L.. (Tercentenary Edition).

RULES OF PRACTICE

The fulfillment of the purpose of these laws calls for the observance of the follow-
ing rules of practice:

I 'lA^nding phsnicians will certify to such deaths only as those of persons
U^wlJb Uivy have ^ven bedside care during a last illness from disease unrelated
to any form of injury.

Statement of Cause of Death. — Physicians: see explanatory instructions
on face side of standard certificate of death.

SPACE FOR ADDITIONAL INFORMATION

DATE OF ENTERING MILITARY SERVICE

DATE OF DISCHARGE

RANK, RATING

ORGANIZATION AND OUTFIT
SERVICE NUMBER

>RM R-301A

NSTRUCTIONS

FOR

ICAL CERTIFICATE

In givinf
jSE OF DEATH

lo not enter
ore than one
lUee for each
• ). (b) «nd (c)

'his does not mean
ode of dying, such
rl failure, asthenia, •
means the disease,
mplications which
death.

forbid conditions. .
, giving rise to the "
cause (d) slating
mderlying cause

ondilions conirib-
'o the death but not
lo the disease or
ion causing death.

ote:- Chapter 137.

I of 1954, require*
■iciana to print or
the cause or cauae*
death on death
ificatea.

(SammomtiFaltl; of MaeBaclfaBettB

A EDWARD J. CRONIN

Secretary OF THE Commonwealth

DIVISION OF VITAL STATISTICS

STANDARD

CERTIFICATE OF DEATH

To ba 6l«d for burial

with Board of HoaJtla
or it* A(ont.

Registered So.

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

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

I PHYSICIAN — IMPORTANT

2 FULL NAME /.. ' . CCfH-eieGysrr I (Was deceased a

1 U. S. War Veteran.

^ I if s^pecify V^)

(a) Residence. No. ,2r.^ (e St

(Usual place of abode) /f (If nonresident, give city w town and State)

/ 7 7 /

Length of stay: In place of death years months days. In place of residence years ...r’... months days.

MEDICAL CERTIFICATE OF DEATH

3 DATE OF
DEATH

/MA

(Year)

'6^

Ihax^ I attended deceased
19 to e) ^ 19^ *lC?

I last saw h C-/

alive on sH ^ ^ . 19jj^ Cftath is said tc|

have occurred on the date stated above, at

DISEASE OR CONDITION
DIRECTLY LEADIN
TO DEATH (a)

ANTE Due To
CEDENT (b)
CAUSES

-1(5.9,//,'/.

Due To

(c)

OTHER

SIGNIFICANT

CONDITIONS

J\/

IRTERm BE
TWEEN ONSET
UO DEATH

Major findings;
Of operations,.

K OlV'^

Date of operation

What test confirmed diagnosis?.

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

Was autopsy performed?.

•? h A c. o

If so. specify.
(Signed)
(Address)

PERSONAL AND STATISTICAL PARTICULARS

8 SEX

9 COLOR OR RACE

M-

10 SINGLE
MARRIED
WIDOW '
or DIVO:

(write the word)

t,U /,

10a If married, widowed, or divorced

HUSBAND of

f] (Give maid/n/name of wife in full)

(or) WIFE of

(Husband’s name in full)

1 1 IF STILLBORN, enter that fact here.

AGE Years Months

Days

If under 24 hours

Hours Minutes

Occupation:

(Kind of work done during most of working life)

14 Industry
or Business:

IS Social Security No.

‘l.ctnoji..

16 BIRTHPLACE ,
(State or country)

17 NA.ME OF
FATHER

^ -

18 BIRTHPLACE OJ

FATHER (City)

(State or country)

OF MOTHER

EXTRACTS

FROM THE LAWS OF THE

COMMONWEALTH OF MASSACHUSETTS

GOVERNING THE

RETURN OF CERTIFICATES OF DEATH

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

Medical examiners shall make examination upon the view of the dead bodies
of persons as are supposed to have died by violence, or by the action of
chemical, thermal or electrical agents or following abortion, or from diseases
resulting from injury or infection relating to occupation, or suddenly when not
disabled by recognizable disease, or when any person is found dead. .. — General
Laws, Chap. 58, Sec. 6.. as amended by Chap. 632, Sec. 4, Acts of 1945.

A physician or officer furnishing a certificate of death as required by the
preceding section or by section forty-five of chapter one hundred and four-
teen. shall, if the deceased, to the best of his knowledge and belief, served in the
army, navy or marine corps of the United States in any war in which it has been
eng.Tged, insert in the certificate a recital to that effect, specifying the war, and
shall also certify in such certificate both the primary and the secondary or imme-
diate cause of death as nearly as he can stale the same. For neglect to comply
with any provision of this section, such physician or officer, shall forfeit ten dollars.
For the purposes of this section and of sections forty-five, forty-six and forty-seven
of said chapter one hundred and fourteen, the word "war” shall include the China
relief expedition and the Philippine insurrection, which shall, for said purposes, be
deemed to have taken place between February fourteenth, eighteen hundred and
ninety-eight and July fourth, nineteen hundred and two. and the Mexican border
service of nineteen hundred and sixteen and nineteen hundred and seventeen.
G. L. Chap. 46, ^c. 10.

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 satisfactory written statement containing the facts required by law to be
returned and recorded, which shall be accompanied, in case of an original inter-
ment. 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 commonwealth cannot be obtained early enough for the
purpose, the certificate of death made as above provided and in the possession of
the undertaker desiring to make such removal shall constitute a permit for such
removal; 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

No undertaker or other persons shall bury a human body or the ashes thereof
which have been brou^tJat^ the commonwealth until he has received a permit
so to do from the2j|o^rq oSt-Hea1tn 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 grpund iinl^hich the interment is made.

. . . Chap. 114, Sec. 46^, (i.*L., (Tercentenary Edition).

1 ^ T-“

•'RUtiS.OF PRACTICE

The fulfillment of the pur^o^ of these laws calls for the observance of the follow-
ing rules of practice: • , i . *

( 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 injuiV^ ^ \

(2) Board of Heal^h’*iihysician^ will certify to such deaths only as those of
persons who. though^disabl^d b^ recognized disease unrelated to any form of
injury, have died without'raeehtTrhedical attendance or whose physician is absent
from home when the cer^ifici^te of death is needed.

(3) Medical Examm^ts 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 poisotis) thermalt gj electrical agents, and deaths following abortion, but
also deaths from di^Msjif ^Jtiag from injury or infection related to occupation,
the sudden deaths ot persons not disabled by recognized disease, and those of
persons found dead.

Statement of Cause of Death. — Physicians: see explanatory instructions
on face side of standard certificate of death.

SPACE FOR ADDITIONAL INFORMATION

DATE OF ENTERING MILITARY SERVICE

DATE OF DISCHARGE

RANK, RATING

ORGANIZATION AND OUTFIT

SERVICE NUMBER

tM R-301A

tnUCTIONS

FOR

RL CERTIFICATE

n giving
E OF DEATH

not enter
re than one
M for each
i, (b) and (c)

is does not mean
'e of dying, such
failure, asthenia, .
seans the disease,
Plications which
eath.

'bid conditions, .
riving rise to the "
use (a) slating
lerlying cause

dilions conirib-
the death but not

1 0 the disease or

11 causing death.

-I

2 FULL NAME

Town)

CHommamoFalttf of iflaBaactfuartta

EDWARD J. CRONIN

Secretary of the Commonwealth

DIVISION OF VITAL STATISTICS

STANDARD

CERTIFICATE OF DEATH

To b« filed for burial permit
with Board of Health
or It* A^nt.

Registered No.

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

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

I (Was deceased a

PHYSICIAN — IMPORTANT

v'o ^A.X

ce of abode) Q

Length of stay; In place of death years months ... z ..days.

(a) Residence. No
(Usual place i

St. ..<

tU. S. War Veteran,
if so specify WAR) .

(If nonresident, give city or town and State)

In place of residence^trr... /(years months days.

MEDICAL CERTIFICATE OF DEATH

3 DATE OF
DEATH

Y CERTIFY

7.. , > 19 to

I last saw h “*

attended deceased from
19

alive on 19 .“...., death is said to

have occurred on the date stated above, at

C ' yoXro.

DISEASE OR CONDITION
DIRECTLY LEADING /)/; .yL
TO DEATH (a)

ANTE Due To

CEDENT (b)

CAUSES

Kicr rose

Due To
(c)

OTHER

SIGNIFICANT .
CONDITIONS

(3 e e c/ r:r.

/jirt^y^ro^e/eirosis

IRTEmi BE
TWEEN ONSET
UO DEATH

Major findings; _

Of operations....<??dP7^rrs.

Date of operation /nxryix .. .Was autopsy performed? .. /yuo
What test confirmed diagnosis?

S Was disease 05A9jury Jn ^y way related to
If so, specil
(Signed)

(Address)

PERSONAL AND STATISTICAL PARTICULARS

10 SINGLE

(write the word)

MARRIED 1 / / , /
WIDOWED

10a If married, widowed, or divorced

HUSBAND of

— ,1 ^ (Give maidea-name of wjf^n fy

(or) WIFE of . . i\

(Husband s name in full)

11 IF STILLBORN, enter that fact here.

AGE

/^iKYears M

Months Days

If under 24 hours

Hours Minutes

13 Usual . ^ j t

Occupation ;...

' ^ (Kind of work done jjuring of working life)

14 Industry
or Business; .

CL^

IS Social Security No.

16 BIRTHPLACE (City) .^...../

(State or country)

17 NAME OF
FATHER

18 BIRTHPLACE OF |

FATHER (City) ..fy...

(State or country)

EXTRACTS

FROM THE LAWS OF THE

COMMONWEALTH OF MASSACHUSETTS

GOVERNING THE

RETURN OF CERTIFICATES OF DEATH

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

disabled by recognizable disease, or when any person is found dead — General

Laws. Chap. 38. Sec. 6.. as amended by Chap. 632. Sec. 4. Acts of 1945.

No undertaker or other persons shall bury a human body or the ashes thereof
which have been brought into the commonwealth until he has received a permit
M to do from the board of health or its agent appointed to issue such permits, or
if there is no such board, from the tterk 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
cemeteiy or burial ground in which the interment is made.

. . . (;hap. 114. Sec. 46. G. L.. (Tercentenary Edition).

RULES OF PRACTICE

For the purposes of this section and of sections forty-five, forty-six and forty-seven , ^ ■>,

of said chapter one hundred and fourteen, the word “war" shall include th^Cbiifa

relief expedition and the Philippine insurrection, which shall, for said purpofcST be i ti r r n

deemed to have taken place between February fourteenth, eighteen hundred and^ — The fulfillment of the purpose of these laws calls for the observance of the follow-

ninety-eight and July fourth, nineteen hundred and two. and the Mexican bordgf.i^'- . . ... , u J I r

service of nineteen hundred and sixteen and nineteen hundred and seventeen. \ ■ > ('> Attending physician, will certify to such deaths only a-s those of peisons
G L Chao 46 Sec 10 .4p *hom they have given bedside care during a last illness from disease unrelated

P' ’ ■ ■ 1 T*9 of 'ttittT’

No undertaker or other person shall bury or otherwise dispose of a human body (J), Powd of Health phyMcians will certify to such deaths only as those of
in a town, or remove therefrom a human body which has not been buried, until he’’ pe.rsoos_ who. though disabled by recognized disease unrelated to any form of
has received a permit from the board of health, or its agent appointed to issue/. died without recent medical attendance or whose physician is absent

such permits, or if there is no such board, from the clerk of the town whe^e the (.. • ® certificate of death is needed. n j ^i. .t

person died; and no undertaker or other person shall exhume a human body, aftd ' Medical Examiners will investigate ^d certi^ to all deaths supposably

remove it from a town, from one cemetery to another, or from one grave or tonib to.lnjury. These include not only deaths caused directly or indirectly by

• 4 L _ ly. traumatietn (including resulting septicemia), and by the action of chemical

other than the receiving tomb to another in the same cemetery, until he. Kas.*-

received a permit from the board of health or its agent aforesaid or from the clei'W';V-\vteVfe55r pqisons) agents, and deaths following abortion but

of the town where the body is buried. No such permit shall be issued until from disease resulting from in jui^ or infection related to occupation

- ... '' - . . tM,.&tfdden deaths of persons not disabled by recognized disease, and those of

shall have been delivered to such board, agent or clerk, as the case may be»

a satisfactory written statement containing the facts required by law to 'bp
returned and recorded, which shall be accompanied, in case of an original inter-. . £
ment. 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 earlj^

pfersons found dead.

enough for the purpose, or is insufficient, a physician who is a member of the boaicAM
of health, or employed by it or by the selectmen for the purpose, shall
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 commonwealth cannot be obtained early enough for the
purpose, the certificate of death made as above provided and in the possession of
the undertaker desiring to make such removal shall constitute a permit for such
removal: provided, that such body shall be returned to the towm 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

Statement of Cause of Death. — Physicians: see explanatory instructions
on face side of Standard certificate of death.

tatement of Occupation. — Precise statement of occupation is very import-
ant, so that the relative healthfulness of various pursuits can be known. Make
some entry in this section for every person aged 10 years or over. If the occupa-
tion had been given up or changed, or if the deceased had retired from business,
report the kind of work done during most of working life even if retired. Children
not gainfully employed may be returned as at school or at home. For a woman
whose only occupation was that of home housework, write housework. For a
person engaged in domestic service for wages, however, designate the occupation
by the appropriate terms, as housekeeper — private family, cook — hotel, etc. For
a person who had no occupation whatever write none.

SPACE FOR ADDITIONAL INFORMATION

DATE OF ENTERING MILITARY SERVICE

DATE OF DISCHARGE

RANK. RATING

ORGANIZATION AND OUTFIT

SERVICE NUMBER

3RM R-303 A

jljl

oSj|

U3U<S

Sdgt

i t^i-

Q • 0

i 25-?:

s ^S»i

u-s e

«d“ •

P UjB

»<gi-

oSgg
^ •'^2
m'U'Z

z ,.i

t Ur: I

Z ag E
B a B J
0 "i
iJsi-
z2^«2

3 •

ES*.?

*iS

^ 0 c ^

z -SJ

3 B a*”

^•|f

tfij

'I ^

J
d

To bo filod for burial parmit
with Board of Hoalth
or it* Agant.

Registered No. .

(Slfr (Dammonmraltif of fflaaaarifUBrtta
EDWARD J. CRONIN
Secretary OF THE Commonwealth

DIVISION OF VITAL STATISTICS

MEDICAL EXAMINER’S
CERTIFICATE OF DEATH

|y^ ^ ^ t A if ^ A r PHYSICIAN — IMPORTANT

2 FULL NAME - I (Was deceased a

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

I if 80 5

, t (ifounty)
(City or To’

No. "

. St

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

(a) Residence. No
(Usual place

1. Jo

of abode) Q •

. War Veteran. _ _
specify WAR) U.Q..

St.

(If nonresident, e city or town and State)
Length of stay: In place of death years.. X months days. In place of residence years X. .months ^ days.

MEDICAL CERTIFICATE OF DEATH

3 DATE OF
DEATH ...

onth)

JJZ.

(Day)

/.p:A.

(Yfar)

41 HEREBY CERTIFY that I have investigated the death
of the person above-earned and that the CAUSE AND MANNER thereol
are as follows: (If an injury .wat involved, state fully.)

nz.

rr*....l^.

5 Accident, suicide, or homicide (specify).

Date and hour of injury.. 19SZ...(S.

(City or town and StaV)

Did injury occur in or abou^hon^ on farm, in industrial place, or in public
place? ..4

Where did
Injury occur?

^ -(Specify type of gjace) / s /

Nature of
Injury

(How did injury occur?)

While at work? ^ Was autopsy performed?

6 Was disease or injury in ^y way related to occupation of deceased?

If so. specify..

(Signed)

(Address)

7 ..Smi.t.hv.l.l.le..'' .y T.exas

Place of Burial, or rramntinn. /f (Gity or Town)

. V >A ri^

DATE OF BURIAL..

8 NAME OF
FUNERAL DIRECTOR

19.1?..;

■TWiievi^ Home

ADDRESS. .':^8.Q QajBt>p-14ge ataC»fep4-d-gft--

Received and filed **AfV4-

(Regi^rar)

PERSONAL AND STATISTICAL PARTICULARS

9 SEX

'emale

10 COLOR OR RACE

oolored

11 SINGLE
MARRIED
WIDOWED

(write the word)

or DIVORCED

single

1 la If married, widowed, or divorced

HUSBAND of

(Give maiden name of wife in full)

(or) WIPE of

(Husband’s name in full)

12 IP STILLBORN, enter that fact here.

AGE

..Yeats

Months.

.1.5

Days

If under 24 hours
Hours Minutes

14 Usual

Occupation:..

(Kind of work done during most of working life)

15 Industry
or Business:.

16 Social Security No

17 BIRTHPLACE (City) Q.P.rpUS Chr l.S.t l.

(State or country)

Texas

18 NAME OP
FATHER

Samuel C. Houston

19 BIRTHPLACE OF

FATHER (City) B afl trop , Tsxas.

(State or country)

20 MAIDEN NAME

OF MOTHER ,E V a May e en

21 BIRTHPLACE OF

MOTHER (City) ... P..o.rp.u.8...,Chr.5a.-{j.i...

(State or country)

Informant ..S.am.ue.l...O-wHous ton

(Address) ^ /• ij

EXTRACTS

FROM THE LAWS OF THE

COMMONWEALTH OF MASSACHUSETTS

GOVERNING THE

RETURN OF CERTIFICATES OF DEATH

A ph\*sician or registered hospital medical officer shall forthwith, after the
death of a person whom he has attended durinj? his last illness, at the request
of an undertaker or other atithorized person or of any member of the family of
the deceased, furnish for reRistration 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 ^ame was
contracted, the duration of his last illness, when last seen alive by the physician
of officer and the date of his death. . .Gen. Laws. Chap. 46, Sec. 9.

A physician or officer furnishing a certificate of death as required by the
preceding s«:tion or by section forty-five of chapter one hundred and four-
teen, shall, if the deceased, to the best of his knowledge and belief, served in the
army. nav>' or marine corps of the United States in any war in which it has been
engaged, insert in the certificate a recital to that effect, specifying the war, and
shall also certify in such certificate both the primary and the secondary' or imme-
diate cause of death as nearly as he can state the same. For neglect to comply
with any provision of this section, such physician or officer, shall forfeit ten dollars.
For the purposes of this sectiqn and of sections forty-five, forty-six and forty-seven
of said chapter one hundred and fourteen, the word “war” shall include the China
relief expedition and the Philippine insurrection, which shall, for said purposes, be
deemed to have taken place t^tween Februar>' fourteenth, eighteen hundred and
ninety-eight and July fourth, nineteen hundred and two. and the Mexican border
serv'ice of nineteen hundred and sixteen and nineteen hundred and seventeen.
G. L. Chap. 46. Sec. 10.

Ko undertaker or other person shall bury or otherwnse 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 satisfactory written statement containing the facts required by law to be
returned and r^orded. which shall be accompanied, in case of an original inter-
ment, by a satisfactory certificate of the attending physician . if any, as required by
law, pr 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 commonwealth cannot be obtained early enough for the
purpose, the certificate of death made as above provided and- in the possession of
the undertaker desiring to make such removal shall constitute a permit for such
removal; 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 required by section ten of chapter forty-six,
that the deceased ser\'ed in the army, navy or marine corps of the United States
in any w'ar 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 forthwnth countersign it and transmit it to the clerk of the towm for registra-
tion. The person to whom the permit is so given and the physician certifying
the cause of death shall thereafter furnish for registration any other necessary
information which can be obtained as to the deceased, or as to the manner or
cause of the death, which the clerk or registrar may require. — Chap. 114. Sec.
45. G. L. as amended by Chap. 48. Acts of 1927 and Chap. 414. Acts of 1931.

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 tjie Xovn where the body is to be
buried or the funeral is to be held, or from a pefsoii jippointed to have the care

of the cemetery-or burial-ground in which the intermenT is made Chap. 114,

Sec. 46. G. L., as amended.

Medical examiners shall make examination upon the .view of the dead bodies
of persons as are supposed to have died by violence, or by the action of
chemical, thermal or electrical agents or following abortion, or from diseases
resulting from injury or infection relating to occupation, or suddenly when not
disabled by recognizable disease, or w'hen any person found dead. .. General
Laws, Chap. 38. Sec. 6., as amended by Chap. 632. Sec. 4, Acts of 1945.

The medical examiner certifies the cause and manner of death to the best

of his knowledge and belief.

RULES OF PRACTICE

The fulfillment of the purpose of these law'S cafts for. the observance of the follow-
ing rules of practice: . . f ' .•• •

(1) Attending physicians will certify to such deeths only as those of persons
to whom they have given bedside care during ^ 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 w'lthout recent medical kttefd^nce or whose physician is absent
from home when the certificate of deat

(3) Medical Examiners will investigate afrd ^«Hify to aU 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, hom-
icidal.” “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.”

SPACE FOR ADDITIONAL INFORMATION

DATE OF ENTERING MILITARY SERVICE

DATE OF DISCHARGE

RANK, RATING

ORGANIZATION AND OUTFIT

SERVICE NUMBER

IM R-301A

ITRUCTIONS

FOR

liL CERTIFICATE

n giving
E OF DEATH

not enter
fe than one
ae for each
. (b) and (c)

it does not mean
te of dying, such
failure, asthenia, •
Mans the disease,
plications which
teath.

rbid conditions, .
liiing rise to the "
tuse (a) stating
derlying cause

\ditions contrib- ^
Ike death but not

0 the disease or

1 causing death.

Chapter 137.
f 1954, requires
ians to print or
cause or causes
ath on death
ates.

(County)'

(City or lown;

No.

dommomnraltt; of iHaBsadiuartto

EDWARD J. CRONIN

Secretary of the Commonwealth

DIVISION OF VITAL STATISTICS

STANDARD

CERTIFICATE OF DEATH

To bo filod for burial pormlt
with Board of Haalth
or its A^nta

Registered No.

:ia„.

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

2 FULL NAME

1/jp- Cuff'

' G o (>p i F£/M MA-fioF l™rf'fc«»dT

ied, widowed or divorced woman, give also maiden name.) . | U. S. War Veteran, fp

1 I if so specify WAR)

nonresident, give city or town and S

(If deceased is a married,

(a) Residence. No. C/.fFF

(Usual place of abode)

Length of stay: In place of death ..sf

years months days. In place of residence

(If nonresidefif, give ?ity i
years months days.

State)

MEDICAL CERTIFICATE OF DEATH

3 DATE OF
DEATH ..

y^jiMonth)
Vy C E RT"

(Day)

TfAk

(Year)

CERTIFY,

19 O., to

That I

4 KH E R E

I Jast saw h . ..alive on

have occurred on the date stated above, at / ^

c4l

attend^ deceased from

.1^^. i9jr%

DISEASE OR CO^'DITION
DIRECTLY LE,

TO DEATH (

19^.P, death is said to

irrERVAL BE
_ TWEEB OBSET
^fijUl DEATH

v/c

ANTE Due To
CEDENT (b)
CAUSES

Due To(

(c)

3/OIV'

OTHER
SIGNIFICANT
CONDITIONS

77od/

Major findings:

Of operations

Date of operation Was autopsy performed?..

What test confirmed diagnosis?

5 Was disease or injury in any way related to occup
It so, specify..

(Signed) .y.:

(Address) .

tion of deceased?..

ate t

place of Burial or Cremation (City or Town) '

M. D

t<^ 19w?!5>

DATE OF BURIAL

niAA/UA^/

ADDRESs/^./i/*

7 NAME OF
FUNERAL DIRECTOR

Received and filed MU..Z

.19.

(Registrar)

PERSONAL AND STATISTICAL PARTICULARS

8 SEX

I 9 COLOR OR RACE

i/:A Uz/i/T/£

10 SINGLE (write the word)
MARRIED
WIDOWED
or DIVORCl

' / Jj K.

) pFVAVl/VJt A

lOa If married, widowed, or divorced

HUSBAND of

(Give n^iden name of wife in full)

(or) WIFE of . “

. , ^uive n^iaen name oi wire in luii;

(Husband’s name in full)

11 IF STILLBORN, enter that fact here.

age/J

Years Months

Days

If under 24 hours
Hours Minutes

Occupation: /^Q uS-Eu^//r£

(Kind of work done durin^Tnc

durin^Tnost of working life)

14 Industry
or Business:

15 Social Security No

16 BIRTHPLACE (City) . viLma, ~ . , .

(State or country) 4 / T’JfjAAf / .4^

17 NAME OF
FATHER

18 BIRTHPLACE OF
FATHER (City) ..
(State or country)

Al D /f (MA^oa/

19 MAIDEN NAME
OF MOTHER

UlFA-

Togc

20 BIRTHPLACE OF
MOTHER (City) ....
(State or country)

VtL/VA

i-l T'/'/leAF/A,

Informant

(Address) y ^ ^

EXTRACTS

FROM THE LAWS OF THE

COMMONWEALTH OF MASSACHUSETTS

GOVERNING THE

RETURN OF CERTIFICATES OF DEATH

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

A physician or officer furnishing a certificate of death as required by the
preceding section or by section forty-five of chapter one hundred and four-
teen. shall, if the deceased, to the best of his knowledge and belief, se^ed in the
army, navy or marine corps of the United States in any war in which it has been
eng.aged. insert in the certificate a recital to that effect, specifying the war. and
shall also certify in such certificate both the primary and the secondary or imme-
diate cause of death as nearly as he can state the same. For neglect to comply
with any provision of this section, such physician or officer, shall forfeit ten dollars.
For the purposes of this section and of sections forty-five, forty-six and forty-seven
of said chapter one hundred and fourteen, the word "war” shall include the China
relief expedition and the Philippine insurrection, which shall, for said purposes, be
deemed to have taken place between February fourteenth, eighteen hundred and
ninety-eight and July fourth, nineteen hundred and two, and the Mexican border
service of nineteen hundred and si.\teen and nineteen hundred and seventeen.
G. L. Chap. 46. ^c. 10.

No undertaker or other person shall bury or otherw ise dispose of a human body
in a town, or remove therefrom a human body w'hich 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
remov'e it from a towm. 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. Xo such permit shall be issued until there
shall have been delivered to such board, agent or clerk, as the case may be,
a satisfactory’ written statement containing the facts required by law to be
returned and recorded, w’hich shall be accompanied, in case of an original inter-
ment, 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 commonwealth cannot be obtained early enough for the
purpose, the certificate of death made as above provided and in the possession of
the undertaker desiring to make such removal shall constitute a permit for such
removal; 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 contaiik a recital, as required by section ten of chapter forty-six.
that the deceased served in the army, navy or marine corps of the United States
in any war in which it has been engaged, such recital shall appear upon the permit.
The board of health, or its agent, upon receipt of such statement and certificate,
shall forthwith countersign it and transmit it to the clerk of the town for registra-
tion. 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, ^c. 45,
G. L., (Tercentenary Edition),

Medical examiners shall make examination upon the view of the dead bodies
of pereons ^ „are supposed to have died by violence, or by the action of
chemical, tlfiftrto^ ^ iel^trical agents or following abortion, or from diseases
resulting from injury or ififecUon relating to occupation, or suddenly when not
disabled by recognizable disease, or when any person is found dead. .. — General
Laws, Chap. as amended by Chap. 632. Sec. 4, Acts of 1945.

Xo undertaker or other persons shall bury a human body or the ashes thereof
which have be(^brbught into the commonwealth until he has received a permit
so to do from tn$.bo*id pf health or its agent appointed to issue such permits, or
if there is no board:.'from the Merk of the town where the body is to be buried
or the funeral is tq be held, or from a person appointed to have the care of the
cemetery orburjal grounetta which the interment is made.

. . . Chajf. 114, Sec. 46,:G/L., (Tercentenary Edition).

0 "-K '

. ' RULES OF PRACTICE

The ful^llra$l»i^t4i^^Urpose of these laws calls for the observance of the follow-
ing rules of priettee; - ) * *

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

(2) Health physicians will certify to such deaths only as those of
personiy^^titl ^jjo^gh disabled- 4>y recognized disease unrelated to any form of
injury, have died \cTthout recent medical attendance or whose physician is absent
from home when the certificate of death is needed.

Statement of Cause of Death. — Physicians: see explanatory instructions
on face side of standard certificate of death.

SPACE FOR ADDITIONAL INFORMATION

DATE OF ENTERING MILITARY SERVICE

DATE OF DISCHARGE

RANK, RATING

ORGANIZATION AND OUTFIT

SERVICE NUMBER.

:M R-^OIA

TRUCTIONS

FOR

iL CEtnFICATE

n givinr

I OF DEATH

not enter
e than one
le for each
, (b) and (c)

is does not mean
e of dying, such
failure, asthenia, •
leans the disease,
dications which
eath.

'bid conditions, .
’iving rise to the '
use (a) stating
ierlying cause

ditions contrib- •
the death but not
0 the disease or
X causing death.

(dammomtiFaltl; of AaaaartiiiaFtla

A EDWARD J. CRONIN

Secretary OF THE Commonwealth

DIVISION OF VITAL STATISTICS

STANDARD
ICATE OF DEATH

To bo filod for biiriol pormlfc
with Board o# Hoalth
or Its Agonte

Re^stered

i. widowed or divorced woman. gi»

Length of stay: In place of death..,./^.. years months days. In place of residence 6

(a) Residence. No.

(Usual place of abode)

{(If death occtifred 'in' a hospital or institution,
give^its NAME instead of street and number)

!/ , PHYSICIAN — IMPORTANT

...I (Was deceased a
I U. S. War Veteran.

I if so specify WAR) .

(If nonresident, give city or town and State)
'years months days.

MEDICAL CERTIFICATE OF DEATH

3 DATE OF
DEATH ...

A-.,.'

(Month)

3^^

(Day)'

(Year)

That I attended deceased from

JY-

41 HEREBY CERTIFY,

3... I9„x!.. to 19

I last saw h ,^:..Y..... alive on 19.:^.^', death is said to

have occurred on the date stated above, at

DISEASE OR CONDITION
DIRECTLY LEADING

UIKECTLY LEAUiNU /V , i ,

TO DEATH

CAUSES

Due To

(c)

SIG^^FICANT/^..‘./^...4.7..

CONDITIONS

IRTERVAl BE-
TWEEN ONSET
MO DEATH

Major findings: /{/ / /

Of operations.

Date of operation Was autopsy performed?.

What test confirmed diagnosis?. ..^'..fr'..(.AY....?../?!.^.Tr.

S Was disease or injury in any way related to occupation of deceased?
If so. specify

(Signed) m. _ d

19.5.4

PERSONAL AND STATISTICAL PARTICULARS

^>-SEX

9 COLOR I

10 SINGLE
MARRIED
WIDOWED
or DIVORCE

10a If married, widowed, or divorced

HUSBAND of

^ (Give mai<ftn nai

(or) WIFE

(Husband's name in full)

ife in full)

1 1 IF STILLBORN, enter that fact here.

Years

Months Days

13 Usual

Occupation :

If under 24 hours
Hours . Minutes

(Kind of work done during most of working life)

14 Industry
or Business:

15 Social Security No.

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

17 NAME OF ^ /y

father

18 BIRTHPL.ACE OF If ^

FATHER (City)

(State or country)

19 MAIDEN NAME
OF MOTHER 1

20 BIRTHPLACE 0
MOTHER (City)
(State or country)

EXTRACTS

FROM THE LAWS OF THE

COMMONWEALTH OF MASSACHUSETTS

GOVERNING THE

RETURN OF CERTIFICATES OF DEATH

A physician or rej?istered hospital medical officer shall forthwith, after the
death of a person whom he has attended during his last illness, at the*request
of an undertaker or other authorized person or of any member of the family of
the deceased, furnish for registration a standard certificate of death, stating to the
b^t 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 %yas
contracted, the duration of his last illness, when last seen alive by the physician
or officer and the date (jf his death. . .Gen. Laws. Chap. 46, Sec. 9.

A physician or officer furnishing a certificate of death as required by the
preceding section or by section forty-five of chapter one hundred and four-
teen. shall, if the deceased, to the best of his knowledge and belief, served in the
army, navy or marine corps of the United States in any war in which it has been
eng.Tged. insert in the certificate a recital to that effect, specifying the war, and
shall also certify in such certificate both the primary and the secondary or imme-
diate cause of death as nearly as he can state the same. For neglect to comply
with any provision of this section, such physician or officer, shall forfeit ten dollars.
For the purposes of this section and of sections forty-five, forty-six and forty-seven
of said chapter one hundred and fourteen, the word “war” shall include the China
relief expedition and the Philippine insurrection, which shall, for said purposes, be
deemed to have taken place between February fourteenth, eighteen hundred and
ninety-eight and July fourth, nineteen hundred and two, and the Mexican border
service of nineteen hundred and sixteen and nineteen hundred and seventeen.
G. L. Chap. 46. Sec. 10.

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, urvtil 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. N*o such permit shall be issued until there
shall have been delivered to such board, agent or clerk, as the case may be,
a satisfactory written statement containing the facts required by law to be
returned and recorded, which shall be accompanied, in case of an original inter-
ment, by a satisfactory certificate of the attending physician, if any, as required by
law. qr 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 commonwealth cannot be obtained early enough for the
purpose, the certificate of death made as above provided and in the possession of
the undertaker desiring to make such removal shall constitute a permit for such
removal: 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

Medical examiners shall make examination upon the view of the dead bodies
of pe^ns as are supposed to have died by violence, or by the action of
chemical, thermal or electrical agents or following abortion, or from diseases
resulting from injury or infection relating to occupation, or suddenly when not
disabled by recognizable disease, or when any person is found dead. .. — General
Laws. Chap. 38, Sec. 6.. as amended by (^hap. 632. Sec. 4, Acts of 1945.

Nqc^ertftir^rotjher persons shall bury a human body or the ashes thereof
which have been broug'ht into the commonwealth until he has received a permit
^ to do from the board of health or its agent appointed to issue such permits, or
if there is no hoard, from the ^erk of the town where the body is to be buried
or the fiinerkl'is to l^e held, or from a person appointed to have the care of the
cemetery or budal ground in which the interment is made.

. . . Ch^p.^i4.'^ec. 46. G. L., (Tercentenary Edition).

• *.w«, '■ 'J

. 'V. l-t* ■

• \ F RULES OF PRACTICE

Theiulfillmcnt of thepurpose of these laws calls for the observance of the follow-
ing rulie'§ of practice; . ^

( 1 ) , Attending.^hyaicians will certify to such deaths only as those of persons
to wh6nj't^^.^Ve.glven bedside care during a last illness from disease unrelated
to anjKfo/m (^‘injufy^' -

physicians will certify to such deaths only as those of
persons disabled by recognized disease unrelated to any form of

injury, have diett without recent medical attendance or whose physician is absent
from home'whenthe certificate of death is needed.

(3) Medical Examiners will investigate and certify to all deaths supposably
due to, i^uiy., .These include not only deaths caused directly or indirectly by
traundtran^including resulting septicemia), and by the action of chemical
(drugslfTTA^feoTis) thermal, dr 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. — Physicians; see explanatory instructions
on face side of standard certificate of death.

SPACE FOR ADDITIONAL INFORMATION

DATE OF ENTERING MILITARY SERVICE

DATE OF DISCHARGE

RANK, RATING

ORGANIZATION AND OUTFIT

SERVICE NUMBER

VI R-301

rnucTiONS

FOR

L CERTIFICATE

1 giving
OF DEATH

not enter
; than one
e for each
(h) and (c)

does not mean
•de of dying,
heart failure,

, etc. It means ^
ase, or compli-
uihich caused

‘tons, if any,
gave rise to
cause (a),
7 the under-
cause last.

iitions contrib- ^
I death but not
to the terminal
condition given

..SUFFOLK

(County)

WINT.HROP.

(City or Town)

WINTHROP

of ilaHHarl|U0FttB

EDWARD J. CRONIN

Secretary of the Commonwealth

DIVISION OF VITAL STATISTICS (City or Town making this return)

STANDARD \

CERTIFICATE OF DEATH 4 ^ Registered No 14

No..

2 FULL NAME __3aLy.....BjBX....M0NTEIM

(If deceased is a married, widowed or divorced woman, gi

Win.tJiro.p....C.o.munliiy...Hos.pi.t\L si

-'Y

,2.08 .Sarat,og,a S.t.#. \ ,.V

abode) ^ \ i\. ' ^

Length of stay: In place of death -....years months days, in H) resiff^cq^

(If ili^h occurred in a hospital or institution,
gig6 Vs NAME instead of street and number!

(a) Residence. No..

(Usual place of abode)

MEDICAL CERTIFICATE OF DEATH

^ DEATI?^... -January. 2.3

(Month)

4 I HEREBY CERTIFY, That I attended deceased from

...J.an.^ 23..., 19561.., to, i9-.-_

I last saw h..rr...alive on —.....ss. , 19—.... , death is said to

have occurred on the date stated above, at .” .“ — m.

DEATH WAS CAUSED BY: IMMEDIATE CAUSE

(a) ... Stillborn.

If under 24 hours

AGE..V

......Years

Months

....Days

Hours Minutes

Pb^-™- -..Fr.ema.t.ur.i.t.y. (.5. .. months..)...

5 mot!

Due To
(c)

OTHER

SIGNIFICANT

CONDITIONS

Was autopsy performed? -Mo...

What test confirmed diagnosis?

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

If so, specify

(Signed)....

(Address)..

. J..Q..s.e.ph .ZainU..e..lIa.., , m. d.

...E.as.t Bo,,s.t.,o.n.....Date 1.-..2.3. 19.5.6.

6 ...n.Q.xjr C.r.Q.s..s Malden^ Mass.

Place of Burial or Cremation (City or Town)

DATE OF BURIAL..

...J.an.uar.y. ZL.......... -.....-;.i56.

7 NAME OF
FUNERAL DIRECTOR.

UlPl-e.tro. ..Ai.-.Ya.sza —

ADDRESS - .E..a.s.t.....B.Q.5.t.Qn.., .Mas.s.„

J.anuar.y....2.4.., 195.6.

Received and filed..

(Registrar)

A TRUE COPY ATTEST:

10a If married
HUSBAND o(-

(or) WIFE.uf..^Tf.

-4i-i —

as deceased a
H S. WaY Veteran, ’
so specify WAR)

ston,. Mass.*..

nt, give city or town and State)

days.

TATISTICAL PARTICULARS

10 SINGLE (write the word)
MARRIED c . ,

WIDOWED V3 ingle

r, ^

or DIVORCED

or divorced

(Give, maiden name of wife in full)
(Husband’s name in full)

11 IF STI

TORN, enter that fact here.

Stillborn

1 3 U suS

Occupation :

(Kind of work done during most of working life)

’14 Industry

or Business:

15 Social Security No.«..

16 BIRTHPLACE (City). jj^lnthrOp.ir

(State or country) Mass* ^

aS-Su

17 NAME OF
FATHER

Joseph Montelro

ji£

18 BIRTHPLACE OF

FATHER (City) BO-8.t.Qn __|1 L-

Mass.

(State or country)

19 MAIDEN NAME
OF MOTHER

Etnely Marcella

20 BIRTHPLACE OF

MOTHER (City) B.O,fi,t.Qn..

(State or country) Mp R8 .

Informant.

(Address)

Joseph M.pn.t.e.ir.o.

208 Saratoga St. ^gt. Bp ston

I HEREBY CERTIFY that a satisfactory standard certificate of death
was filed with me BEFORE the burial or transit permit was issued:

Walter. 0:* Baker...C.ahc.J

(Signature of Agent of Board of Health or other)

Hea.lth._..0f -.Jan. 24.., 1.956

(Officiai Designation) (Date of Issue of Permit)

EXTRACTS

FROM THE LAWS OF THE

COMMONWEALTH OF MASSACHUSETTS

GOVERNING THE

RETURN OF CERTIFICATES OF DEATH

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

A physician or officer furnishing a certificate of death as required by the
preceding section or by section forty-five of chapter one hundred and_ four-
te n. shall, if the deceawd. to the best of his knowledge and belief, served in the
army, navy or marine corps of the United States in any war in which it has been
engaged, insert in the certificate a recital to that effect, specifying the war. and
shall also certify in such certificate both the primary and the secondary or imme-
diate cause of death as nearly as he can state the same. For neglKt to comply
with any provision of this section, such physician or officer, shall forfeit ten dollars.
For the purposes of this section and of sections forty-five,_forty-six and forty-seven
of wid chapter one hundred and fourteen, the word "war" shall include the China
relief expedition and the Philippine insurrection, which shall, for said purposes, be
deemed to have taken place between February fourteenth, eighteen hundred and
ninety-eight and July fourth, nineteen hundred and two. and the Mexican border
service o? nineteen hundred and sixteen and nineteen hundred and seventeen.
G. L. Chap. 46. Sec. 10.

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, the case may be.
a satisfactory written statement containing the fi^ts required by law to be
returned and recorded, which shall be accompanied, in case of an original inter-
ment. 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 commonwealth cannot be obtained early enough for the
purpose, the certificate of death made as above provided and in the possession of
the undertaker desiring to make such removal shall constitute a pennit for such
removal: provided, that such body shall be returned to the town from which it was
removed within thirty-six hours after such removal, unless a pennit in the usual
form for the removal of such body has been sooner obtained hereunder. If the

death certificate contains a recital, as required by section ten of chapter for^-six.
that the deceased served in the army, navy or marine corps of the Unit^ 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 to^ for registra-
tion. The person to whom the permit is so given and tho 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. S^. 45,
G. L„ (Tercentenary Edition).

Medical examiners shall make examination upon the view of the dead bodies
of persons as are supposed to have died by violence, or by the action of
chemical, thermal or electrical agents or following abortion, or from diseases
resulting from injury or infection relating to occupation, or suddenly when not
disabled by recognizable disease, or when any person is found dead. .. — General
Laws, Chap. 38, Sec. 6.. as amended by Chap. 632, Sec. 4. Acts of 1945.

No undertaker or other persons 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 ofthe 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 CTound in which the interment is made.

. . . Chap. 114, Sec. 46. G. L., (Tercentenary Edition).

RULES OF PRACTICE

The fulfillment of the purpose of these laws calls for the observance of the follow-
ing 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
pe^ns 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 Ejuiminers will investigate and certify to all deaths supposably
due to injury. These include not only deaths caused directly or indirectly by
traumatism (including resulting s^ticemia) , 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 disable by recognized disease, and those of
persons found dead.

Statement of Cause of Death. — Physicians: see explanatory instructions
on face side of standard certificate of death.

Statement of Occupation. — Precise stat^ent of occupation is very import-
ant, so that the relative healthfulness of various pursuits can be known. Make
some entry in this section for every penon aged 10 years or over. If the occupa-
tion had been given up or changed, or if the deceased had retired from business,
report the kind of work done dunng most of working life even if retired. Children
not gainfully employed may be returned as at school or at home. For a woman
whose only occupation was that of home housework, write housework. For a
person engaged in domestic service for wages, however, designate the occupation
by the appropriate terms, as housekeeper — private family, cook — hotel, etc. For
a person who had no occupation whatever write none.

SPACE FOR ADDITIONAL INFORMATION

DATE OF ENTERING MILITARY SERVICE

DATE OF DISCHARGE

RANK, RATING

ORGANIZATION AND OUTFIT

SERVICE NUMBER

M R-301A

nUCTIONS

FOR

1 CERTIFICATE

i giving
: OF DEATH

not enter
B than one
e for each
, (b) and (c)

s does not mean
r of dying, such
ailure, asthenia, •
eans the disease,
lications which
rath.

bid conditions, .
iving rise to the "
use (a) stating
'erlying cause

iitions contrib- ^
he death but not
) the disease or
causing death.

Chapter 137.
1954, requires
ans to print or
; cause or causes
ith on death
ates.

..jii.af.f.olJs:

(County)

o ....7/.in.fc.hrpp

u (City or Town)

OIommomDpaltt; of i^aaBaclfUBPtto

EDWARD J. CRONIN

Secretary of the Commonwealth

DIVISION OF VITAL STATISTICS

STANDARD

CERTIFICATE OF DEATH

To be bled for bMrial permit
with Board of Health
or Its Agent.

Registered No. .

..15.

st.

2 FULL NAME

(If deceased

ve also maiden name.)

f.VJ

I (If death occurred in a hospital or institution,

\ give its NAME instead of street and number)

PHYSICIAN — IMPORTANT

(Was deceased a
U. S. War Veteran,

if so specify WAR) iTO-*-

(a) Residence. No ,:i..hv.i..-,.n.’.l..^r,;: St

(Usual place of ab5<K) ^ ^ Vi o cr V nonresident, give city or town and State)

Length of stay: In place of death .g. years months days. In place of residence .7.0 years months days.

MEDICAL CERTIFICATE OF DEATH

3 DATE OF

DEATH i'9^.

41 HEREBY CERTIFY
19

..alive on

have occurred on the date statS3 above, at

dLcx-^.f.

I last saw(ioi_-^ ..£

t I attended deceased from

....'...4^.. 4^.,

19/&..^ death is said to|

Pu rr

DISEASE OR CONDITION
DIRECTLY LEAPiNG
TO DEATH (a)

~^cle)ro

T) t* s e 5 e.

ANTE Due To
CEDENT (b)
CAUSES

Due To
(c)

OTHER
SIGNIFICANT
CONDITIONS

ilp/liiSr

imRVAL BE
TWEEN ONSET
AND DEATH

VS.

/O^YS

Major findings:
Of operations..

Mp)ei<z

Date of operation .^.Was autopsy performed?.

What test confirmed diagnosis?.

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

If so, spec!

(Signed) . . . .*->r M. D
(Address)

pSif KSgfcS.We^e'^y -■ Jr*

DATE OF BURIAL .

Received and filed.

(Registrar)

PERSONAL AND STATISTICAL PARTICULARS

8 SEX

f P.mql P.

9 COLOR OR RACE

whi te

10 SINGLE (write the word)
MARRIED . , ,

WIDOWED widowed

or DIVORCED

10a If married, widowed, or divorced

HUSBAND of

(Give maiden name of wife in full)

(or) WIFE of ..J.^ines •S*

ih'full)

1 1 IF STILLBORN, enter that fact here.

AGE Years ^^ .QMonths Days

If under 24 hours
Hours Minutes

13 Usual

Occupation:

I J

e during most of working life)

‘"o^'^Eess: own. hoiiie.

15 Social Security No.

none.

16 BIRTHPLACE (City) B O S t On

(State or country) ■,

17 NAME OF
FATHER

las S :

18 BIRTHPLACE Of
FATHER (City) ..
(State or country)

eorge 7/. Tatreau

Bwanton

yermont

19 MAIDEN NAME

OF MOTHER Emilia gomp

20 BIRTHPLACE OF

MOTHER (City) P.or.t.l.an.d..

(State or country) ,

:aine

Informant ..sdward G--.-3xg.e.lo.w

(Address)

yj-nthropr

EXTRACTS

FROM THE LAWS OF THE

COMMONWEALTH OF MASSACHUSETTS

GOVERNING THE

RETURN OF CERTIFICATES OF DEATH

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

A physician or officer furnishing a certificate of death as required by the
preceding section or bv section forty-five of chapter one hundred and four-
teen. shall, if the deceased, to the best of his knowledge and belief, served in the
army, navy or marine corps of the United States in any war in which it has been
engaged, insert in the certificate a recital to that effect, specifying the war. and
shall also certify in such certificate both the primary and the secondary or imme-
diate cause of death as nearly as he can state the same. For neglect to comply
with any provision of this section, such physician or officer, shall forfeit ten dollars.
For the purposes of this section and of sections forty-five, forty-six and forty-seven
of said chapter one hundred and fourteen, the word “war'* shall include the China
relief expedition and the Philippine insurrection, which shall, for said purposes, be
deemed to have taken place between February fourteenth, eighteen hundred and
ninety-eight and July fourth, nineteen hundred and two. and the Mexican border
service of nineteen hundred and sixteen and nineteen hundred and seventeen.
G. L. Chap. 46. ^c. 10.

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 satisfactory written statement containing the facts required by law to be
returned and recorded, which shall be accompanied, in case of an original inter-
ment. 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. shaU 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 commonwealth cannot be obtained early enough for the
purpose, the certificate of death made as above provided and in the possession of
the undertaker desiring to make such removal shall constitute a permit for such
removal; 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

Ntedical examiners shall make examination upon the view of the dead bodies
of persons as are supposed to have died by violence, or by the action of
chemical, thermal or electrical agents or following abortion, or from diseases
resulting from injury or infection relating to occupation, or suddenly when not
disabled by recognizable disease, or when any person is found dead. .. — General
Laws, Chap. 38, Sec. 6.. as amended by Chap. 632. Sec. 4, Acts of 1945.

No undertaker or other persons 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 ^erk 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.

. . . (5hap. 114, Sec. 46, G. L., (Tercentenary Edition).

RULES OF PRACTICE

The fulfillment of the purpose of these laws calls for the observance of the follow-
ing 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.

Statement of Cause of Death. — Physicians: see explanatory instructions
on face side of standard certificate of death.

ORGANIZATION AND OUTFIT
SERVICE NUMBER

M R-301A

TRUCTIONS

FOR

ll certificate

n (ivinc

i OF DEATH

not enter
e than one
le for each
, (b) and (c)

s dots not mean
e of dying, such
failure, asthenia, •
Iran j the disease,
dications which
eath.

■bid conditions. .
iving rise to the "
use (a) slating
terlying cause

ditions contrib- ■
fhe death but not
3 the disease or
I causing death.

Suffolk

(County)

Vlnthrop..

(dity or Town)

Olammannipalttf of Aaaoac^narttB

EDWARD J. CRONIN

Secretary OF THE Commonwealth

DIVISION OF VITAL STATISTICS

STANDARD

CERTIFICATE OF DEATH

To bo lilod for burial pormlt
with Board of Hoalth
or Its A^nt.

Registered No. .

No. Tlnthrop Coimiiunrty Hospital s., n°Xm'e lia

2 FULL NAME.

( PHYSICIAN — IMPORTANT

.H.®..S.e.r).i.U.S I (Was deceased a

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

(a) Residence. No .? 5d.g.a r Term 0 6 St. ,

(Usual place of abode)

IU. S. War Veteran,
if so specify WAR) .

(If nonresident, give city or town and State)
Length of stay: In place of death years months days. In place of residence ..4b.5 years months days.

MEDICAL CERTIFICATE OF DEATH

3 DATE OF
DEATH ...

January 24, 1956

'■(M^th) (bay) (Year)'

deceased from

41 HEREBY CERTIFY, ^That I attended

.fy..C..,C: Lk 19 5'^ toJi?r?< .

I last saw h..A./r^. alive ...M.... 19*^... death is said

have occurred on the date s^ted above, at...?J?. '

DISEASE OR CONDITION

DIRECTLY LEADING/..^ J \

TO DBATH (a)

S) >4

rtXll

CEdInT 7b)
CAUSES

C> Zee J.c edi

Due To

(c)

OTHER

SIGNIFICANT

CONDITIONS

irteuhl be-
tween ONSET
MD OUTH

<j^

Major findings:

Of operations

Date of operation Was autopsy performed?..

What test confirmed diagnosis?

5 Was disea9
If so. specify
(Signed)
(Addm

I injury in any way related to occupation of deceased?..

lOuUL.

" ^..l.n thr.op .'.r.. ...yir^hr.o.p

Place of Burial or Cremation _ . , or Town)

^ FUNERAL DiRECTOR.A.r.ti.hup....J.... Q..!.Ma.l.e.y.

ADDRESS th.rop , Ma.ss,*,

Received

and filed ,|Pl...2.0^. .;.19

(Registrar)

PERSONAL AND STATISTICAL PARTICULARS

8 SEX

Female

9 COLOR OR RACE

«Vhl te

10 SINGLE (write the word)
MARRIED

o?D?voRCESidowe(a

10a If married, widowed, or divorced

HUSBAND of

(Give maiden name of wife in full)

<l e c) r g e F . H e s e ro u s

(Husband's name in full)

(or) WIFE of..

11 IF STILLBORN, enter that fact here.

AGE

7.9

-Years Months .

-Days

If under 24 hours
Hours Minutes

13 Usual

Kation: .Hpusewlfe

(Kind of work done during most of working life)

14 Industry
or Business:

Own Home

15 Social Security No-

P 1 A 7 -JS90

16 BIRTHPLACE (City) 5,a S S.t.O.n,.

(State or country) Ma S 3

17 NAME OF
FATHER

18 BIRTHPLACE OF

FATHER (City)

(State or country)

’Vl-l.lJlaTD ..Mulloy

"ova Scotia

19 MAIDEN NAME
OF MOTHER

AcielaMe Gran(3all

20 BIRTHPLACE OF

MOTHER (City) Sa-6..t....3.Q.S..t..0.n

(State or country) Ma 3 9

Informant Mrs Thomas Fulham
(A<Mre^) 22''LaeTi--'"St'-"l^Iro3

I HER-EBY CERTIFY that a satis^ctory standard certificate of death was
fi)ed with me BEFORE the ifuHal/or transit permit was issued:

'd of Health or other) / ✓

(Date of Issue of'-PermitJ'

EXTRACTS

FROM THE LAWS OF THE

COMMONWEALTH OF MASSACHUSETTS

GOVERNING THE

RETURN OF CERTIFICATES OF DEATH

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

death certificate contains a recital, as required by section ten of chapter forty-six.
that the deceased served in the army, navy or marine corps of the United States
in any war in which it has been engaged, such recital shall appear upon the permit.
The board of health, or its agent, upon receipt of such statement and certificate,
shall forthwith countersign it and transmit it to the clerk of the town for registra-
tion. 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 cari be obtained as to the deceased, or as to the manner or
cause of the death, which the clerk or registrar may require. — Chap. 114, Sec. 45.
G. L., (Tercentenary Edition).

Medical examiners shall make examination upon the view of the dead bodies
of pereons as are supposed to have died by violence, or by the action of
chemical, therrnal or electrical agents or following abortion, or from diseases
resulting from injury or infection relating to occupation, or suddenly when not
disabled by recognizable disease, or when any j>erson is found dead. .. — General
Laws, Chap. 38. Sec. 6., as amended by Chap. 632, Sec. 4, Acts of 1945.

A physician or officer furnishing a certificate of death as required by the
preceding section or by section forty-five of chapter one hundred and four-
teen. shall, if the decea^. to the best of his knowledge and belief. ser\»ed in the
army, navy or marine corps of the United States in any war in which it has been
eng.aged. insert in the certificate a recital to that effect, specifying the war. and
shall also certify in such certificate both the primary’ and the secondary or imme-
diate cause of death as nearly as he can state the same. For neglect to comply
with any pro\*ision of this section, such physician or officer, shall forfeit ten dollars.
For the purposes of this section and of sections forty-five, forty-six and forty-seven
of said chapter one hundred and fourteen, the word “war” shall include the China
relief expedition and the Philippine insurrection, which shall, for said purposes, be
deemed to have taken place between February fourteenth, eighteen hundred and
ninety-eight and July fourth, nineteen hundred and two. and the Mexican border
service of nineteen hundred and sixteen and nineteen hundred and seventeen.
G. L. Chap. 46. Sec. 10.

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 satisfactory written statement containing the facts required by law to be
returned and recorded, which shall be accompanied, in case of an original inter-
ment, 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 w'ho 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 commonwealth cannot be obtained early enough for the
purpose, the certificate of death made as above provided and in the possession of
the undertaker desiring to make such removal shall constitute a permit for such
removal; 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

SPACE FOR ADDITIONAL INFORMATION

DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE

. . . (2hap. 114, ^c. 46, G. L., (Tercentenary Edition).

RULES OF PRACTICE

The fulfillment of the purpose of these laws calls for the observance of the follow-
ing 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.

Statement of Cause of Death. — Physicians: see explanatory instructions
on face side of standard certificate of death.

Statement of Occupation. — Precise statement of occupation is very import-
ant, so that the relative healthfulness of various pursuits can be known. Make
some entry in this section for every per^n aged 10 years or over. If the occupa-
tion had been given up or changed, or if the deceased had retired from business,
report the kind of work done during most of working life even if retired. Children
not gainfully employed may be returned as at school or at home. For a woman
whose only occupation was that of home housework, write housework. For a
person engaged in domestic service for wages, however, designate the occupation
by the appropriate terms, as housekeeper — private family, cook — hotel, etc. For
a person who had no occupation whatever write none. •

IT!

-c

vr.

RANK, RATING

ORGANIZATION AND OUTFIT
SERVICE NUMBER

M R-301A

TKUCTIONS

FOR

>L CERTIFICATE

It (ivinc
: OF DEATH

not enter
e than one
le for each
, (b) and (c)

s dots not mean
e of dying, such
'ailure, asthenia, •
eans the disease,
lications which
tath.

bid conditions, .
iving rise to the '
use (a) stating
terlying cause

ditions contrib- ■
he death but not
> the disease or
causing death.

(Qommomocaltt; of MoBoncl^aBttiB

EDWARD J. CRONIN

Secretary OF THE Commonwealth

DIVISION OF VITAL STATISTICS

STANDARD

CERTIFICATE OF DEATH

To bo filod for burial pormlt
with Board of Hoalth
or its A^nte

Registered No.

i No. St.

in, give

a±

2 FULL NAME MAEIA Q/AcWTA I;-

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

(a) Residence. No. /E

(Usual place of abode)

Length of stay: In place of death .....T... years T... months /....days. In place of residence . years —...months .T days.

occurred in a hospital or institution,
NAME instead of street and number)

. PHYSICIAN — IMPORTANT

f I (Was deceased a

I U. S. War Veteran.

so specify WAR)

(If nonresident, give city or town and State)

MEDICAL CERTIFICATE OF DEATH

4 1 H E R B B

3 DATE OF If , -

DEATH JL CKm,

^lonth) (Day)

(Year

E R T I F Y

19.

I last saw h .^.JT... alive on
have occurred on the date statefi/ above, at

■■ on ..ij.

:e stateyal

21 al

..CbrvIL

hr:.

PERSONAL AND STATISTICAL PARTICULARS

8 SEX I 9 COLOR OR RACE

lA//// -nt

attended deceased froi^
19 rc death is said tq

S'urt

10 SINGLE (write the word)
MARRIED ^ iryr,
WIDOWED**^ "

or DIVORCED

DISEASE OR CONDITION

DIRECTLY LEADING >7 , \ J a '

TO DEATH (a) .JT<i|.>aAMt^^

A//j»gp>7-c/ys/ \/B H €Hht

ANTE Due To
CEDENT (b)
CAUSES

Hy/feti T^nsn>A/

Due To
(c)

OTHER

SIGNIFICANT .
CONDITIONS

mniUAL BE
TWEEN ONSET
UD DEATH

Major findings;

Of operations

Date of operation Was autopsy performed?..

What test confirmed diagnosis?

5 Was disease or injury in any way related to occupation of deceased?
If so, specify..

(Signed) If

(Addr^) >~*4. . Date^.lgt)H

: of Burial or Cf

DATE OF BURIAL .

7 NAME OF
FUNERAL DIRECTC

address/ y Es

Received and filed..

own)

19»

t) r-: AC\t- c- '

.19..

(Registrar)

10a If married, widowed, or divorced

HUSBAND of

_ (Give maiden name of wife in full)

(or) WIFE of rASQUALe

* fHusband’s name in fulH

11 IF STILLBORN, enter that fact here.

AGE

Years Months Days

If under 24 hours
Hours Minutes

Usual

Occupation ;

(Kind of work done during most of working life)

Industry
or Business;

15 Social Security No..

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

17 NAME OF
FATHER

/iAFFAEL £ /:/nsl A l^O

18 BIRTHPLACE OF

FATHER (City)

(State or country)

19 MAIDEN NAME

OF MOTHER^/^OO^

20 BIRTHPLACE OF
MOTHER (City)....
(State or country)

Informant

(Address)/^ , ^ Y? >1 ^ -NCW

I HE^ffeBY CEF^IFY that a s^isfacto^ stai^Srd certificate of death was

tl^ ^^FORE the or trailsit pymiit was issued:

'yV / /^Sitoature oFA^nt of Board of HeattiP6r otherV^

(Official Designation? h ,j (Date of Issue of Permit)

EXTRACTS

FROM THE LAWS OF THE

COMMONWEALTH OF MASSACHUSETTS

GOVERNING THE

RETURN OF CERTIFICATES OF DEATH

A physician or rejfistered hospital medical officer shall forthwith, 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 meml>er of the family of
the deceased, furnish for registration a standard certificate of death, stating to the
oest of his knowledge and belief the name of the decea^d, his supposed age. the
disease of which he died, defined as required by section one, where same was
contracted, the duration of his last illness, when last seen alive by the physician
or officer and the date of his death. . .Gen. Laws, Chap. 46. Sec. 9.

A physician or officer furnishing a certificate of death as required by the
preceding section or V>y section forty-five of chapter one hundred and four-
teen. shall, if the deceased, to the best of his knowledge and belief, served in the
army, navy or marine corps of the United States in any war in vyhich it has been
engaged, insert in the certificate a recital to that effect, specifying the war. and
shall also certify in such certificate both the primary and the secondary or imme-
diate cause of death as nearly as he can state the same. For negl^t to comply
with any pro\nsion of this section, such physician or officer, shall forfeit ten dollars.
For the purposes of this section and of sections forty-five, forty-six and forty-seven
of said chapter one hundred and fourteen, the word ‘‘war*’ shall include the China
relief expedition and the Philippine insurrection, which shall, for said purposes, be
deemed to have taken place between February fourteenth, eighteen hundred and
ninety-eight and July fourth, nineteen hundred and two. and the Mexican border
ser\'ice of nineteen hundred and sixteen and nineteen hundred and seventeen.
G. L. Chap. 46, ^c. 10.

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 satisfactory written statement containing the facts required by law to be
returned and recorded, which shall be accompanied, in case of an original inter-
ment. 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 commonwealth cannot be obtained early enough for the
purpose, the certificate of death made as above provided and in the possession of
the undertaker desiring to make such removal shall constitute a permit for such
removal; 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 required by section ten of chapter forty-six,
that the deceased served in the army, navy or marine corps of the United States
in any war in which it has been engaged, such recital shall appear upon the permit.
The board of health, or its agent, upon receipt of such statement and certificate,
shall forthwith countersign it and transmit it to the clerk of the town for rejpslra-
tion. 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, S^. 45,
G. L.. (Tercentenary Edition).

Medical examiners shalkrTMlfe ^an^ination upon the view of the dead bodies
of persons as are suppofeeS -to^av^ died by violence, or by the action of
chemical, thermal or electrical agents or following abortion, or from diseases
resulting from injury or infection relating to occupation, or suddenly when not
disabled by recognizable disease ."or ;wiher> any person is found dead. .. — General
Laws, Chap. 38, Sec. 6.. as amended by Chap. 632, Sec. 4, Acts of 1945.

No undertaker or other persdns^shalf [bury a human body or the ashes thereof
which have been brought into th^ commonwealth until he has received a permit
^ to do from the boaro of heaUh or its agent appointed to issue such permits, or
if there is no such board, from ftlerk of-.the town where the body is to be buried
or the funeral is to be heldjor from 4 ^r^n appointed to have the care of the
cemetery or burial ground in which the interment is made.

. . . (ihap. 114, &c. 46, G.'-L*. (Tercentenary Edition).

J ^ -

kl/LE$, OF 'practice

The fulfillment of the purpose of these laws calls for the observance of the follow-
ing 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. I jT, " j ‘ »

(2) Board of HealtU gikyHpians 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.

Statement of Cause of Death. — Physicians: see explanatory instructions
on face side of standard certificate of death.

SPACE FOR ADDITIONAL INFORMATION

DATE OF ENTERING MILITARY SERVICE

DATE OF DISCHARGE

RANK, RATING

ORGANIZATION AND OUTFIT.

SERVICE NUMBER

RM R-301A

WSTIUCTIONS

FOR

CAL CERTIFICATE

In givinf
SE CF DEATH

o not enter
ore than one
UM for each
a), (b) and (c)

'his does not mean
ode of dying, such
’I failure, asthenia, .
means the disease,
nplications which
death.

\orbid conditions, .

giving rise to the "
cause (a) slating
nderlying cause

onditions contrib- •
0 the death but not
to the disease or
on causing death.

A-

5 SUFFOLK..

Q (County)

W.IN.THE.O.P

(City or Town)

No i.o..9.,.pl.i;asm

(Sammannipaltt; of masoactiuartta

EDWARD J. CRONIN

Secretary of the Commonwealth

DIVISION OF VITAL STATISTICS

STANDARD

CERTIFICATE OF DEATH

To b« fiUd for burial parmlt
with Board of Haalth
or Its Afonte

Registered No. .

,18...

ST y/H'JT.IiR.QP M-A.SS S *" * J'°sp‘tal or institution.

I give its NAME instead of street and number)
^.TT Ar-.TTT-ir^ arr-n->T-,T-t-ir r PHYSICIAN — IMPORTANT

2 FULL NAME AG3N.ES .GALL AQHER ...MUEPHY... j (Was deceased a

(If deceased is a married, widowed or divorced woman, give also maiden name.) | U. S. War Veteran, >,1/^

I if so specify WAR)A1V.

(a) Residence. No 109 ...PLE ASM.T. St. ..W.INTHRQP. MASS

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

2i vears months davs. In place of residence .2.2 ■

Length of stay; In place of death. .^.2 years months days. In place of residence

years months days.

MEDICAL CERTIFICATE OF DEATH

3 DATE OF , I
DEATH

(Month)

(Day)

e^)

iA HE JIL EBYt' CERTIFY, That I attended deceased from

to 19.;

i last gaw h...<?rL,.., alive on 197.;^ death is said to

have occurred on the date stated- Above, at .

DISEASE OR CONDITION
DIRECTLY LEAD^C^ . ,

TO DEATH

r'fy/rL' /Ir'l 0/1/ y /i

ANTE Due To ft- ,

CEDENT (b)

CAUSES

Due To
(c)

OTHER

SIGNIFICANT .
CONDITIONS

IHTERVAL BE-
TWEEN ONSET
MD DEATH

Major findings: ’

Of operations

Date of operation Was autopsy performed?.

What test confirmed diagnosis? .7.

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

If so. specify _ ^

M. p
. 19^:A

If so. specify....^... .^....,^2 ..^...

(Signed) ....^....rt^_<r.S'^....X' ^....

6 .Q.AK... GRQYE MELFOHD. MASS

Place of Burial or Cremation (City or Town)

DATE OF BURIAL (JANUARY 30 1956 19

^ FUNERAL director.FRANIC .H . ..CARR

ADDRESS 79 ELI^ ST CHARLESTOvVN MASS.

Received and filed..

.19 .

(Registrar)

FIMALE

PERSONAL AND STATISTICAL PARTICULARS

8 SEX

9 COLOR OR RACE

WHITE

10 SINGLE (write the word)
MARRIED

WIDOWED .„T-rv^..r
or DIVORCEEtf IIX)W

10a If married, widowed, or divorced

HUSBAND of

(Give maiden name of wife in full)

(or) WIFE of ... WILLIM. JO SEPH MURPHY..

(Husband’s name in full)

1 1 IF STILLBORN, enter that fact here.

rGE78 -Years Months Days

If under 24 hours
Hours -Minutes

13 Usual

Occupation:

HOUSE .WORE.

(Kind of work done during most of working life)

14 Industry

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