The volume, 1940

Town Clerk, Winthrop · from the Internet Archive · 492 pages · 37.4 MB
open the file ↗ · original at the source ↗

J. L. FAIRBANKS DIV.
Thomas Groom & Co.

Stationers

105 State St., Boston

To duplicate this book order

No. % 0 -3 ^ V*

information should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state
CAUSE OF DEATH in plain terms, so that it may be properly classified. Exact statement of OCCUPATION
is very important. See instructions and extracts from the laws on back of certificate.

M R -30 1 A

S-u£.£aIk

\q (County)

1 ,o ’Ylntlirnn.

®be (Entturtonfoealth of i^lossticluisctfs
OFFICE OF THE SECRETARY

DIVISION OF VITAL STATISTICS

STANDARD

CERTIFICATE OF DEATH

(City or Town)

'2 No st.

2 FULL NAME

(If deceased is a married, widowedor aTVori

To be filed for burial permit
with Board of Health
or its Agent.

Registered No

reed woman, give also maiden name.)

(a) Residence. No Ji.U-0.....V/IlXtlnj2Qp...-Sfc St

(Usual place of abode)

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

(If U. S.

War Veteran,
specify WAR)

Length of stay: In hospital or institution..

(Specify whether)

years

months

daj'S.

(If nonresident, give city or town and state)

In this community yrs. mos. days.

PERSONAL AND STATISTICAL PARTICULARS

3 SEX

I.!al e

4 COLOR OR RACE

5 SINGLE
MARRIED
WIDOWED
or DIVORCED.

(write the word)

5a If married, widowed, or divorced

husband of Susan j . Sheeky

(Give maiaen name oi wire :

Widowed-

(or) WIFE of

in full)
(Husband’s name in full)

6 Age of husband or wife if alive years

7 IF STILLBORN, enter that fact here.

If less than 1 day

Days Hours Minutes

AGE

Years Months.

Usucl

9 °ccupation: Laborer

Industry __

10 or Business: JP

11 Social Security No.

.None..

12 BIRTHPLACE (City)
(State or country)

13 NAME OF
FATHER

Ireland

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

.James Sheer In

Ireland

15 MAIDEN NAME
OF MOTHER

Catherine-

16 BIRTHPLACE OF

MOTHER (City)

(State or country) Tt»p1 ^Hd

Relation, if any

( daughter

(Official Designation)

Winter

standard certificate of death was
it permit was issued:

■

of Board of Hearth |or other

(Date of Issue of yermit)

MEDICAL CERTIFICATE OF DEATH

18 DATE OF
DEATH

(Month)

(Day)

(Year)

19 1 HEREBY CERTIFY. That I attended deceased from

/..2r....r..i 19 J.ljr., to 19...#.#.....

I last saw h...V*r»... alive on 19.JJ. ., death is said

to have occurred on the date stated above, at.... m.

Immediate cause of death

.L.^£tWjfc

Due t'

Due to

Other conditions!

(Include pregnancy within 3 months of death)

Major findings :
Of operations

•Date of..

Of autopsy

What test confirmed diagnosis?..

Duration

MP9RTANT

PHYSICIAN

Underline
the cause to
which death
should be
charged sta-
tistically.

29 Was disease nr Injury In any way related te occupation nl deceased?
If so, specify .. A.„,

(Signed)

(Adds «S3) .

Received end filed

(Registrar)

EXTRACTS FROM THE LAWS OF THE

COMMONWEALTH OF MASSACHUSETTS

GOVERNING THE

RETURN OF CERTIFICATES OF DEATH

A physician or registered hospital medical officer shall 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 regis-
tration a standard certificate of death, stating to the best of his
knowledge and belief the name of the deceased, his supposed age,
the disease of which he died, defined as required by section one.
where same was contracted, the duration of his last illness, when last
seen alive by the physician or officer and the date of his death . . ,
Gen. Laws, Chap. 46, Sec. 9.

No undertaker or other person shall bury or otherwise dispose of a
human body in a town, or remove therefrom a human body which
has not been buried, until he has received a permit from the board
of health, or its agent appointed to issue such permits, or if there
is no such board, from the clerk of the town where the person died ;
and no undertaker or other person shall exhume a human body and
remove it from a town, from one cemetery to another, or from one
grave or tomb other than the receiving tomb to another in the same
cemetery, until he has received a permit from the board of health or
its agent aforesaid or from the clerk of the town where the body is
buried. No such permit shall be issued until there shall have been de-
livered to such board, agent or clerk, as the case may be, a satisfac-
tory written statement containing the facts required by law to be
returned and recorded, which shall be accompanied, in case of an
original interment, by a satisfactory certificate of the attending
physician, if any, as required by law, or in lieu thereof a certificate
as hereinafter provided. If there is no attending physician, or if, for
sufficient reasons, his certificate cannot be obtained early enough for
the purpose, or is insufficient, a physician who is a member of the
board of health, or employed by it or by the selectmen for the pur-
pose, shall upon application make the certificate required of the at-
tending physician. If death is caused by violence, the medical exam-
iner shall make such certificate. If such a permit for the removal o t
a human body, not previously interred, from cne 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 registration. The person to whom the permit is so given
and the physician certifying the cause of death shall thereafter fur-
nish 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.)

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

RULES OF PRACTICE

The fulfillment of the purpose of these laws calls for the observ-
ance of the following rules of practice :

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

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

(3) Modical 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 septice-
mia), 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 occupa-
tion, the 6uddon deaths of persons not disabled by recognized
disease, and those of persons found dead.

Statement of Cause of Death. — Cause of death means the disease,
or complication which causes death, not the mode of dying, e. g.,
heart failure, asphyxia, asthenia, etc. As principal cause name the
disease causing death. As related causes, name earlier morbid con-
ditions, if any, related to the principal cause and any important
complication of the principal cause.

Statement of Occupation. — Precise statement of occupation is very
Important, so that the relative healthfulness of various pursuits
can be known. Make some entry in this section for every person
aged 10 years or over. If the occupation had been given up or
changed on account of the disease causing death, report the usual
occupation prior to illness. If the deceased had retired from busi-
ness, report the usual occupation prior to retirement. Children not
gainfully employed may be returned as at school or at home. For a
woman whose only occupation was that of home housework, write
housework. 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

is very important. Sec instructions and extracts from the laws on back of certificate.

301 A

/£

l w

Svdrfolk

(County)

o Winthrop

(City or Town)

©Ije (Enttintotiftiealth af JlilasBacIjuscttB
OFFICE OF THE SECRETARY

DIVISION OF VITAL STATISTICS

STANDARD

CERTIFICATE OF DEATH

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

Registered No !

255 Pleasent ffr^rWtxxtttrop

.St.

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

2 FULL NAMETr.M^.*r^^^„WiV^£e** J ^Veteran.

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

specify WAR)..

(a) Residence. No St.

(Usual place of abode)

Wtorl&rop

(If nonresident, give city or town and state)

Length of slay : In hospital or institution..

(Specify whether)

months

days.

In this commun ityl6 yrs. mos. days.

PERSONAL AND STATISTICAL PARTICULARS

3 SEX

Male

4 COLOR OR RACE

White

5 SINGLE
MARRIED
WIDOWED

(write the word)

divorced Widowed.

5a If married, widowed,_jor divorced- . , . - -

husband of Jennie Grant Wither ell

(Give maiden name of wife in full)

(or) WIFE of

(Husband’s name in full)

6 Age of husband or wife if alive years

7 IF STILLBORN, enter that fact here.

AGE Years 2 Months... 2

Days

If less than 1 day
Hours Minutes

Usual

9 Occupation:

Arbitrator

IC or

Business: Wholesale Fi ah P.i.i.?..

11 Social Security No..

None.

12 BIRTHPLACE (City)
(State or country)

..Cambr

as.

13 NAME OF
FATHER

William Witherell

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

So.Wel^lasS^

Mass

15 MAIDEN NAME
OF MOTHER

1G BIRTHPLACE OF
MOTHER (City) .
(State or country)

st\yj>

eer

.So. WelKA«c*t
Maas.

Relation, if any

Lucille H. Brown , None \

_5 ( *'**>*■ ;

Informant 7.7..;.....—..®.-...-.;

iid±!!!i_j?Y..Plfia.8ent St.

Winter qll

Y CERTIFY that a
me BEFORE

7 standard certificate of death was
isit permit was issued:

(Signature^

UJ..

(Official Designation)

MEDICAL CERTIFICATE OF DEATH

18 DATE OF
DEATH

Jem*

(Month)

(Day)

194Q

(Year)

19 I HER E B Y CERTIFY, That 1 attended deceased from

19.3y to^jpcM^ 3L- 19 MO

..alive on. / , 19. </Q, death is said

I last saw h

to have occurred on the date stated above, at.../^;.'..f.P.Am.

Immediate cause jpf death...-

Due to

Other conditions

(Include pregnancy within 3 months of death)

Major findings :
Of operations

Of autopsy
What test confirmed diagnosis?.

•Date of.

Duration

IMMRTAHT

drQtfl.

PHYSICIAN

Underline
the cause to
which death
should be
charged sta-
tistically.

20 Was disease er Injury In auy way related te occupation el deceased?

I! so, specify
(Signed)^
(Address)

M. D.

Date ' / 3. 19.y..<?

Jan. 4 194Q.

DATE OF BURIAL 1

iation or Removal. (City or I own)

Cambridge Cambridge,

22 NAME OF

FUNERAL DIRECTO^-^l^r^<r<?L^tVV<^...../(r®...^L(<wrjfrlKdirri

address “47 Win c hr op $t . Winthrop.

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 regis-
tration a standard certificate of death, stating to the best of his
knowledge and belief the name of the deceased, his supposed age,
the disease of which he died, defined as required by section one,
where same was contracted, the duration of his last illness, when last
seen alive by the physician or officer and the date of his death . . .
Gen. Laws, Chap. 46, Sec. 9.

No undertaker or other person shall bury or otherwise dispose of a
human body in a town, or remove therefrom a human body which
has not been buried, until he has received a permit from the board
of health, or its agent appointed to issue such permits, or if there
is no such board, from the clerk of the town where the person died ;
and no undertaker or other person shall exhume a human body and
remove it from a town, from one cemetery to another, or from one
grave or tomb other than the receiving tomb to another in the same
cemetery, until he has received a permit from the' board of health or
its agent aforesaid or from the clerk of the town where the body is
buried. No such permit shall be issued until there shali have been de-
livered to such board, agent or clerk, as the case may be, a satisfac-
tory written statement containing the facts required by law to be
returned and recorded, which shall be accompanied, in case of an
original interment, by a satisfactory certificate of the attending
physician, if any, as required by law, or in lieu thereof a certificate
as hereinafter provided. If there is no attending physician, or if, for
sufficient reasons, his certificate cannot be obtained early enough for
the purpose, or is insufficient, a physician who is a member of the
board of health, or employed by it or by the selectmen for the pur-
pose, shall upon application make the certificate required of the at-
tending physician. If death i? caused by violence, the medical exam-
iner shall make such certificate. If such a permit for tlie""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 registration. The person to whom the permit is so given
and the physician certifying the cause of death shall thereafter fur-
nish 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.)

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

RULES OF PRACTICE

The fulfillment of the purpose of these laws calls for the observ-
ance of the following rules of practice :

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

(2) Boned of Health physicians will certify to such deaths only
as those of persons who, though disabled by recognized disease un-
related to any form of injury, have died without recent medical
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
•upposably due to injury. These include not only deaths caused
directly or indirectly by traumatism (including resulting septice-
mia), and by the action of chemical (drugs or poisons), thermal,
or electrical agents, and deaths following abortion, hut also deaths
from dicease resulting front injury or infection related to occupa-
tion, the sudden deaths of persons not disabled by recognized
disease, and those of persons found dead.

Statement of Cause of Death. — Cause of death means the disease,
or complication which causes death, not the mode of -dying, e. g.,
heart failure, asphyxia, asthenia, etc. As principal cause name the
disease causing death. As related causes, name earlier morbid con-
ditions, if any, related to the principal cause and any important
complication of the principal cause.

Statement of Occupation. — Precise statement of occupation is very
Important, so that the relative healthfulness of various pursuits
can be known. Make some entry in this section for every person
aged 10 years or over. If the occupation had been given up or
changed on account of the disease causing death, report the usual
occupation prior to illness. If the deceased had retired from busi-
ness, report the usual occupation prior to retirement. Children not
gainfully employed may be returned as at school or at home. For a
woman whose only occupation was that of home housework, write
housework. 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

information should be carefully supplied. should be stated tAAl-lLl. rnuii.iAi'iiJ snouia state

CAUSE OF DEATH in plain terms, so that it may be properly classified. Exact statement of OCCUPATION
is very important. See instructions and extracts from the laws on back of certificate.

R -30 1 A

3 SEX

jftiite

/jjj SUFFOLK

..WINIHROP

(City or Town)

®hc (£arnmonftmtltl| of ,JHtt5sai:l|U0£lt0

OFF-ICE OF THE SECRETARY

DIVISION OF VITAL STATISTICS

(County)

STANDARD

CERTIFICATE OF DEATH

NoSta.tion>..l^.Q^.ltaI>...For.t...3anka.,...)^a«.5.^ st. !

To be filed for burial permit
with Board of Health
or its Agent.

Registered No.

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

2 FULL NAME CliAPJI S KD MB STSVKtgCK )

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

(a) Residence. Nol&.Ca&OT. . .Place St. Canton* J^.s,

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

Length of stay: In hospital or institution Hospital ... years 1 months 11

(Specify whether)

days.

PERSONAL AND STATISTICAL PARTICULARS

4 COLOR OR RACE

White

(write the word)

5 SINGLE
MARRIED
WIDOWED

or DivoRCEDi .arriffia

5a If married, wicLawad-or divorced

husband of aHageti K. Keane.

(Give maiden name of wife in full)

(or) WIFE of

(Husband’s name in full)

6 Age of husband or wife if alive

7 IF STILLBORN, enter that fact here.

years

AGE 88 Years 8 Months 23 Days

If less than 1 day
Hours Minutes

9 Occupation: Retted.. .Ciuarte

Industry

10 or Business: ... U,.S....,...Jj!^yy.(.I.ietired)..

11 Social Security No.

12 birthplace (CitjGormra3. 11s ^'iava... Scotia ,

(State or country)

13 NAME OF

father ^111^ Ftevenson

(State or country

15 MAIDEN NAME

OF mother Anriie , ^ arshall

16 birthplace of Cornwallis -Nova Scotia,

MOTHER fGitvl ^ ^ * *

Canada

MOTHER (City)
(State or country)

7 Relation, if any

Informa nRegistrar^ta Hosp ...Ft. 3a^iks.,I^ass* )

I HEREBY CERTIFY that a satisfrffctory^tandard certificate of death was
filed, wjtth me BEfiOQE the or/ttansft permit was issued:

18 DATE OF
DEATH

MEDICAL CERTIFICATE OF DEATH

January 2nd

(Month)

(Day)

(Year)

HfevcratEff e ££ c3fM t i«Januanyat2 attended decc 49 from

im i9....Jsjftir&y...2 40 19

I last saw h alive on .3:.5®d.P..., death is said

to have occurred on the d£^j^a^p!^|li»ve^{t^;0j.^.0M....m.

UrtlOTCwn

Due to

Unknown

Due to

“nTrflau^jrTj

Arter ioselerotie heart ^ —

tions

gnancy within 3 months of death)

Major findings Amputation* M toird*thidi
16ift%erations ftov- 24/39

No- Date of.

of autopsy Uone-

What test confirmed diagnosis? m:

Duration

PHYSICIAN

In this community yrs. mos. days. I1

Received and filed

.19..

(Registrar)

EXTRACTS FROM THE LAWS OF THE

COMMONWEALTH OF MASSACHUSETTS

GOVERNING THE

RETURN OF CERTIFICATES OF DEATH

No undertaker or other person shall bury or otherwise dispose of a
human body in a town, or remove therefrom a human body which
has not been buried, until he has received a permit from the board
of health, or its agent appointed to issue such permits, or if there
is no such board, from the clerk of the town where the person died ;
and no undertaker or other person shall exhume a human body and
remove it from a town, from one cemetery to another, or from one
grave or tomb other than the receiving tomb to another in the same
cemetery, until he has received a permit from the board of health or
its agent aforesaid or from the clerk of the town where the body is
buried. No such permit shall be issued until there shall have been de-
livered to such board, agent or clerk, as the case may be, a satisfac-
tory written statement containing the facts required by law to be
returned and recorded, which shall be accompanied, in case of an
original interment, by a satisfactory certificate of the attending
physician, if any. as required by law, or in lieu thereof a certificate
as hereinafter provided. If there is no attending physician, or if, for
sufficient reasons, his certificate cannot be obtained early enough for
the purpose, or is insufficient, a physician who is a member of the
board of health, or employed by it or by the selectmen for the pur-
pose. shall upon application make the certificate required of the at-
tending physician. If death is caused by violence, the medical exam-
iner 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 registration. The person to whom the permit is so given
and the physician certifying the cause of death shall thereafter fur-
nish 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, Sac. 45,
G. L„ ( Tercentenary Edition.)

RULES OF PRACTICE

The fulfillment of the purpose of these laws calls for the observ-
ance of the following rules of practice :

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

(3) Medical Examiners will investigate and certify to all deaths
supnosably due to injury. These include not only deaths caused
directly or indirectly by traumatism (including resulting septice-
mia), 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 occupa-
tion, the sudden deaths of persons not disabled by recognized
disease, and those of persons found dead.

Statement of Cause of Death. — Cause of death means the disease,
or complication which causes death, not the mode of dying, e. <7.,
heart failure, asphyxia, asthenia, etc. As principal cause name the
disease causing death. As related causes, name earlier morbid con-
ditions, if any, related to the principal cause and any important
complication of the principal cause.

Statement of Occupation. — Precise statement of occupation is very
Important, so that the relative healthfulness of various pursuits
can be known. Make some entry in this section for every person
aged 10 years or over. If the occupation had been given up or
changed on aocount of the disease causing death, report the usual
occupation prior to illness. If the deceased had retired from busi-
ness, report the usual occupation prior to retirement. Children not
gainfully employed may be returned as at school or at home. For a
woman whose only occupation was that of home housework, write
housework. For a person engaged in domestic service for wages,
however, designate the ecsupation by the appropriate terms, as
honsekoepci — private family, cook — hotel, ete. For a person who had
no occupation whatever write none.

SPACE FOR ADDITIONAL INFORMATION

\A R-301 A

(Enmmanfoealilf of (iSilassacIjnsetta

OFFICE OF THE SECRETARY

DIVISION OF VITAL STATISTICS

STANDARD

CERTIFICATE OF DEATH

T* W filed for burial permit
with Board of Health
er its Agent.

Registered No

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

(If U. S.

War Veteran,
specify WAR)

months

(If nonresident, give city or town and state)

In this community yrs. mos. days.

PERSONAL AND STATISTICAL PARTICULARS
4 COLOR /OR RACE

5a If married, widowed, or divorced
HUSBAND of

|(Give maiden nama of'wife in full)

Due to

MEDICAL CERTIFICATE OF DEATH

18 DATE OF
DEATH

(Month)

tf¥0

(Day)

(Year)

19 IHEREBY CERTIF

S , 19 J.,%, to

1 last saw 'h-.C/Jii'... alive on

That 1 attended deceased from

Aj 1 9.Sk.d

...i./. 19 death is said

to have occurred on the date stated above,

Immediate cause of death „

Other conditions

(Include pregnancy within 3 months of death)

Major findings :
Of operations

.Date of..

Of autopsy
What test confirmed diagnosis?.,

20 Was disease or injury In any way related to occupation ot deceased?
If so, specify
(Signed)

(Address)

.71*

Duration

PHYSICIAN

Underline
the cause to
which death
should be
charged sta-
tistically.

ADDRES;

Place of

DATE OF BURIAL

22 NAME OF

FUNERAL DIRECTOR

Received and filed

(Registrar)

EXTRACTS FROM THE LAWS OF THE

COMMONWEALTH OF MASSACHUSETTS

GOVERNING THE

RETURN OF CERTIFICATES OF DEATH

No undertaker or other person shall bury or otherwise dispose of a
human body in a town, or remove therefrom a human body which
has not been buried, until he has received a permit from the board
of health, or its agent appointed to issue such permits, or if there
is no such board, from the clerk of the town where the person died ;
and no undertaker or other person shall exhume a human body and
remove it from a town, from one cemetery to another, or from one
grave or tomb other than the receiving tomb to another in the same
cemetery, until he has received a permit from the board of health or
its agent aforesaid or from the clerk of the town where the body is
buried. No such permit shall be issued until there shall have been de-
livered to such board, agent or clerk, as the case may be, a satisfac-
tory written statement containing the facts required by law to be
returned and recorded, which shall be accompanied, in case of an
original interment, by a satisfactory certificate of the attending
physician, if any, as required by law, or in lieu thereof a certificate
as hereinafter provided. If there is no attending physician, or if, for
sufficient reasons, his certificate cannot be obtained early enough for
the purpose, or is insufficient, a physician who is a member of the
board of health, or employed by it or by the selectmen for the pur-
pose. shall upon application make the certificate required of the at-
tending physician. If death is caused by violence, the medical exam-
iner 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 registration. The person to whom the permit is so give*
and the physician certifying the cause of death shall thereafter fur-
nish 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.t ( Tercentenary Edition.)

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

RULES OF PRACTICE

The fulfillment of the purpose of these laws calls for the observ-
ance of the following rules of practice :

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

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

Statement of Occupation. — Precise statement *f occupation is very
Important, so that the relative healthfulness of various pursuits
can be known. Make some entry in this section for every person
aged 10 years or over. If the occupation had been given up or
changed on account of the disease causing death, report the usual
occupation prior to illness. If the deceased had retired from busi-
ness, report the usual occupation prior to retirement. Children not
gainfully employed may be returned as at school or at home. For a
woman whose only occupation was that of home housework, write
housework. 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

N. B.— WRITE PLAINLY, WITH UNFADING BLACK INK— THIS IS A PERMANENT RECORD. Every item of
information should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state
CAUSE OF DEATH in plain terms, so that it may be properly classified. Exact statement of OCCUPATION
is very important. See instructions and extracts from the laws on back of certificate.

200m-10-’39. No. 8427-d

RM R-301

So £fo\K;

(County)

1 \ o y°, ft

I W (City or Town}.

©Ij* Canimonfriealtlj of (JHsssacIjtMdia
OFFICE OF THE SECRETARY

DIVISION OF VITAL STATISTICS

STANDARD

CERTIFICATE OF DEATH.

(City or town making return)

Registered No.

(Ifrdeath occurred in a hospital or institution,
ive its NAME instead of street and number)

2 FULL NAME.

A..'0.X).\S. j wl?'v®£,an.

(if deceased is a married, widowed or divorced woman, give also maiden name.) (Bpe city WAR)

St '

. . (If nonresident, gi._ — , .

/ days. In this community'

' ££

(a) Residence. No .£?>• .fct.*.

(Usual place of abode) j/ J / ,

I ength of stay : In hospital or institution years

' (Specify /whether)

months

(If nonresident, give city or town and state)

In this community' Wt/yn. mos. days.

PERSONAL AND STATISTICAL PARTICULARS

3 SEX

4 COLOR OR RACE

5 SINGLE

IsmaA £

(wtite the word)

5a If married, widowed, or divorced
HUSBAND of

(or) WIFE

full)

(Husband’s name in full)

6 Age of husband or wife if alive yeore

7 IF STILLBORN, enter that fact her*.

AGE.

.Years Months Days

If lose than 1 day
Hours Minutes

Usual

9 Occupation:

Industry
10 or Business:

11 Social Security No.

12 BIRTHPLACE (City)
(State or country)

13 NAME OF
FATHER

14 BIRTHPLACE
FATHER (City)

(State or country)

E OF ^fT' \ V

15 MAIDEN NAME
OF MOTHER

16 BIRTHPLACE OF
MOTHER (City)

(State or country)

^l^UL

I HEREBY CERTIFY that a aatisfact
hied, ynth me BEFORj^Ihe bui

ard certificate d! death was
>euait was Issued:

ture

(Official Designation)

MEDICAL CERTIFICATE OF DEATH

18 DATE OF
DEATH ....

(Month)

(Day)

(Year)

I HEREBY CERTIFY. Thai I attended deceased from

19«jb..y., .'....w 19r.^.

h...£..\.... alive on...Tl:..k.(J..-.'..ir.<r. /. 13. -sr,...*, death is said

I last saw

to have occurred on the date stated above, at..^Ay. .m
Immediate cause of death

Due to

: 1

Other conditions Sr..!...»h...r.'..t..T'.

(Include pregnancy within 3 months of death)

Major findings:
Of operations

..Date of..

Of autopsy

What test confirmed diagnosis?.

20 Was disease or Injury In any way related to occupation ol deceased ? (...

If so, specify.

(Signed)

Idress)

Duration

£<u\j‘

PHYSICIAN

Underline
the cause to
which death
should be
charged sta-
tistically.

» < ynrOLAA 1 M. D.

Received and filed

A TRUE COPY" ATTEST:

(Registrar)

EXTRACTS FROM THE LAWS OF THE

COMMONWEALTH OF MASSACHUSETTS

GOVERNING THE

RETURN OF CERTIFICATES OF DEATH

A physician op 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 regis-
tration a standard certificate of death, stating to the best of his
knowledge and belief the name of the deceased, his supposed age,
the disease of which he died, defined as required by section one,
where same was contracted, the duration of his last illness, when last
seen alive by the physician or officer and the date of his death . . .
Gen. Laws, Chap. 46, Sec. 9.

No undertaker or other person shall bury or otherwise dispose of a
human body in a town, or remove therefrom a human body which
has not been buried, until he has received a permit from the board
of health or its agent appointed to issue such permits, or if there
is no such board, from the clerk of the town where the person died ;
and no undertaker or other person shall exhume a human body and
remove it from a town, from one cemetery to another, or from one
grave or tomb other than the receiving tomb to another in the same
cemetery, until he has received a permit from the board of health or
its agent aforesaid or from the clerk of the town where the body is
buried, 'jm such permit shall be issued until there shall have been de-
livered/*such board, agen40or clerk, as the case may be, a satisfac-
tory Sfirten statement containing the facts required by law to be
returned arrd-recorded, which shall be accompanied, in case of an
original interment, by a satisfactory certificate of the attending
physician, if any, as required by law, or in lieu thereof a certificate
as hereinafter provided. If there is no attending physician, or if, for
sufficient reasons, his certificate cannot be obtained early enough for
the purpose, or is insufficient, a physician who is a member of the
board of health, or employed by it or by the selectmen for the pur-
pose, shall upon application make the certificate required of the at-
tending physician. If death is caused by violence, the medical exam-
iner 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 a 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 registration. The person to whom the permit is so given
and the physician certifying the cause of death shall thereafter fur-
nish 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. 46,
G. L., (Tercentenary Edition.)

RULES OF PRACTICE

The fulfillment of the purpose of these laws calls for the observ-
ance of the following rules of practice :

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

Statement of Cause of Death.— Cause of death means the disease,
or complication which causes death, not the mode of dying, e. g.,
heart failure, asphyxia, asthenia, etc. As principal cause name the
disease causing death. As related causes, name earlier morbid con-
ditions. if any, related to the principal cause and any important
complication of the principal cause.

Statement of Occupation. — Precise statement of occupation is very
important, so that the relative healthfulness of various pursuits
can be known. Make some entry in this section for every person
aged 10 years or over. If the occupation had been given up or
changed on account of the disease causing death, report the usual
occupation prior to illness. If the deceased had retired from busi-
ness, report the usual occupation prior to retirement. Children not
gainfully employed may be returned as at school or at home. For a
woman whose only occupation was that of home housework, write
housework. For a person engaged in domestic service for wages,
however, designate the occupation by the appropriate terms, as
housekeepei — private family, cook — hotel, etc. For a person who had
no occupation whatever write none.

SPACE FOR ADDITIONAL INFORMATION

M R-3Q1 A

s £Z
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► JJ «i

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•fls

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-1 gw*

oO «
:< >

-H,

> fl rj « o'

. PO

a--

2 FULL NAME

®l|c (Eumntcmfoealtlf of (iSflassacljuscits
OFFICE OF THE SECRETARY

DIVISION OF VITAL STATISTICS

STANDARD
CERTIFICATE OF DEATH

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

. . JM 8
Registered No.

. y/7, s ( (If death occurred in a hospital or institution,

••••■•- «j.....y..... Ot. ( give its NAME instead of street and number)

(a) Residence. No...C

(Usual place of abode)

Length of stay: In hospital or institution.

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

r'/) / 2

: 4r

\ (If u. s.

• < War Veteran,
J specify WAR)

.St.

(Specify whether)

months

days.

(If nonresident, give city or town and state)

In this community [p yrs. mos. days.

PERSONAL AND STATISTICAL PARTICULARS

MEDICAL CERTIFICATE OF DEATH

3 SEX

4 COLOR OR RACE | 5 SINGLE

(write the word)

Owes i

18 DATE OF
DEATH

ff (Month)

(Day)

/f¥o

(Year)

5a If married, widowed, or divorced
HUSBAND of

(Give maiden name of wife in full

(or) WIFE of

(Husband’s name in full)

6 Age of husband or wife if alive years

7 IF STILLBORN, enter that fact here.

Major findings :
Of operations

19 A HEREBY CERTIF That I attended deceased from

L6..x , i9.,3U ,

I last saw alive ox\.....Qaj2L 19„fl death is said

to have occurred on the date Hated above, at....4*...af!L«....

Immediate cause of death...

Duration
IMPORTANT

Due to

i(v^r7> • .

Other conditions

(Include pregnancy within 3 months of death)

•Date of..

PHYSICIAN

Underline
the cause to
which death
should be

0f aU,°PSy >•; charged s

What test confirmed diagnosis ?.'fLr&y«rfc3s<Sfwi^£^^^4Ustically.

sta-

20 Was disease cr Injury In any way related to occupation of deceased?

If so, specify „ uYY%. .

(Signed) D.

(Addro^.Z.^7.iy^^.w*bf£^r....£*^^

. OJ....

(City or Town)

Received and filed

19 Saras'

(Registrar)

EXTRACTS FROM THE LAWS OF THE
COMMONWEALTH OF MASSACHUSETTS
GOVERNING THE

RETURN OF CERTIFICATES OF DEATH

A physician or registered hospital medical officer shall 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 regis-
tration a standard certificate of death, stating to the best of hiy
knowledge and belief the name of the deceased, his supposed age,
the disease of which he died, defined as required by section one,
where same was contracted, the duration of his last illness, when last
seen alive by the physician or officer and the date of his death . . .
Gen. Laws. Chap. 46, Sec. 9.

No undertaker or other person shall bury or otherwise dispose of a
human body in a town, or remove therefrom a human body which
has not been buried, until he has received a permit from the heard
of health, or its agent appointed to issue such permits, or if there
is no such hoard, 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 de-
livered to such board, agent or clerk, as the case may be, a satisfac-
tory written statement containing the facts required by law to be
returned and recorded, which shall be accompanied, in case of an
original interment, by a satisfactory certificate of the attending
physician, if any, as required by law, or in lieu thereof a certificate
as hereinafter provided. If there is no attending physician, or if, for
sufficient reasons, his certificate cannot be obtained early enough for
t'ne 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 pur-
pose, shall upon application make the certificate required of the at-
tending physician. If death is caused by violence, the medical exam-
iner 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 hotly 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 registration. The person to whom the permit is so given
and the physician certifying the cause of death shall thereafter fur-
nish for registration any other necessary information which can b#
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«e. 45,
G. L., (Tercentenary Edition.)

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

RULES OF PRACTICE

The fulfillment of the purpose of these laws calls fsr the observ-
ance of the following rules of practice:

(1) Atiending physicians will certify to such deaths only as those
of persons to whom they have given bedside care during a last ill-
ness from disease unrelated to any form of Injury.

(3) Medical Examiners will investigate and certify to all deaths
supposably due to injury. These include not only deaths caused
directly or indirectly by traumatism (Including resulting septice-
mia), 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 orcupa-
tlon, the sudden deaths of persons not disabled by recognised
disease, and those of persons found dead.

Statement of Canse of Death. — Cause of death means the disease,

or complication which causes death, not the mode of dying, e. g.,
heart failure, asphyxia, asthenia, etc. As principal cause name the
disease causing death. As related causes, name earlier morbid con-
ditions, If any, related to the principal cause and any important
complication of the principal cause.

Statement «f Occupation. — Precise statement of occupation is very
important, so that the relative healthfulness of various pursuits
can be known. Make some entry in this section for every person
aged 10 yearn or over. If the occupation had been given up or
changed on account of the disease eauslng death, report the usual
occupation prior to illness. If the deceased had retired from busi-
ness, report the usual occupation prior to retirement. Children not
gainfully employed may be returned as at school or at home. For a
woman whose only occupation was that of home housework, writs
housework. For a person engaged in domestic service for wages,
however, designate the occupation by the appropriate terms, as
housekeeper — private family, took — hotel, etc. For a person who had
no occupation whatever write none.

SPACE FOR ADDITIONAL INFORMATION

A R-301 A

(City or ^rown)

N„..4r.

2 FULL NAME

®lfe (Eaminoitfacaltl; of (iMassacljuseits

OFFICE OF THE SECRETARY

DIVISION OF VITAL STATISTICS

STANDARD

CERTIFICATE OF DEATH

To be filed for burial permit
with Board of Health
or its Agent.

Registered No.

St.

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

sed is a married, widowed or durorc

(a) Residence. No.

(Usual place of abode)

ijrorced woman, give also maiden name.)

(If U. S.

War Veteran,
specify WAR)

Length of stay : In hospital or institution..

(Specify whether)

years

months

days.

(If nonresident, give city or town and state)

In this commur.il yrs. mos. days.

PERSONAL AND STATISTICAL PARTICULARS

3 SEX

4 COLOR OR RACE

5 SINGLE
MARRIED

(write the word)

WIDOWED

or DIVORCED*

5a If mairied, widowed, or divorced
HUSBAND of

(Give maiden name of wife m full)

(or) WIFE of

(Husband’s name in full)

6 Age of husband or wife if alive

7 IF STILLBORN, enter that fact here.

years

Years

Months Days

If less than 1 day

Hours Minute:

12 BIRTHPLACE (City) Zfc.Oi-

(State or country)

16 BIRTHPLACE OF
MOTHER (City)
(State or country)

Informant

(Address) -?JF<

Sj * . Relation, if any

(.rtr+rtf*, )

•2S~ C

I HEREBY CERTIFY that a satisfactory standard certificate of death was
filed i^itjx-^ne BEFORE t^ &Urial /ar tjdnait permit wa3 issued:

^'7/XyfSS £?) ►

(§jf nature of/hfe nt of Bogrj^epj^iltll orofher)/' ^
icial Designation^ U // (Date of Issfie^f Veignit)'

MEDICAL CERTIFICATE OF DEATH

18 DATE OF ,,, , .

DEATH ^ iRJ A\ l\ - Q.

iffi)

(MonF

(Day)

> ^ 4 4.

(Year)

That 1 attended deceased from

19 I. HEREBY CERTIFY. 1 hat 1 attended deceased trom

19^? .... to MaM.HM 19-a^L

I last saw h..LftU... alive on Afij.lbWlY.T.&L.ehi?., IS.vfcl.., death is said

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

Immediate cause of death.....-.,.

. . .9A.1 .l .>!^ a H .^.C. ^ «..-h aI) ’.

Due to !r.

Due to

Other conditions

(Include pregnancy within 3 months of death)

Major findings :

Of operations

Date of....,

Of autopsy

What test confirmed diagnosis?

Duration

IMPORTANT

PHYSICIAN

Underline
the cause to
which death
should be
charged sta-
tistically.

-fits

28 Was disease or Injury In any way related to occupation al deceased? .

If so, specify ...f... ., „A v

(Signed) AT.V'ALtf M. D.

(Addr«a»).,^g3ft^..afe&^ '

21 Q&tf ?%».

Place of Burial, Gniinatiun/Sy-Bomownl. y>*(City or Town) tM

DATE OF BURIAL xC /..Y.. 19 L9 P

22 NAME OF

FUNERAL DIRECTOR

ADDRESS

Received and filed

JUL i3^

(Registrar)

EXTRACTS FROM THE LAWS OF THE

COMMONWEALTH OF MASSACHUSETTS

GOVERNING THE

RETURN OF CERTIFICATES OF DEATH

or of any member of the family of the deceased, furnish for regis-

tration a standard certificate of death, stating to the best of his
knowledge and belief the name of the deceased, his supposed age,

the disease of which he died, defined as required by section one,

where same was contracted, the duration of his last illness, when last
seen alive by the physician or officer and the date of his death . , .
Gen. Laws, Chap. 46, Sec. 9.

No undertaker or other person shall bury or otherwise dispose of a
human body in a town, or remove therefrom a human body which
has not been buried, until he has received a permit from the board
of health, or its agent appointed to issue such permits, or if there
is no such board, from the clerk of the town where the person died ;
and no undertaker or other person shall exhume a human body and
remove it from a town, from one cemetery to another, or from one
grave or tomb other than the receiving tomb to another in the same
cemetery, until he has received a permit from the board of health or
its agent aforesaid or from the clerk of the town where the body is
buried. No such permit shall be issued until there shall have been de-
livered to such board, agent or clerk, as the case may be, a satisfac-
tory written statement containing the facts required by law to be
returned and recorded, which shall be accompanied, in case of an
original interment, by a satisfactory certificate of the attending
physician, if any, as required by law, or in lieu thereof a certificate
as hereinafter provided. If there is no attending physician, or if, for
sufficient reasons, his certificate cannot be obtained early enough for
the purpose, or is insufficient, a physician who is a member of the
board cf health, or employed by it or by the selectmen for the pur-
pose, shall upon application make the certificate required of the at-
tending physician. If death i3 caused by violence, the medical exam-
iner 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 ha3 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 registration. The person to whom the permit is so given
and the physician certifying the cause of death shall thereafter fur-
nish 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.t ( Tercentenary Edition.)

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

RULES OF PRACTICE

The fulfillment of the purpose of these laws calls for the observ-
ance of the following rules of practice:

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

(3) Medical Examiners will investigate and certify to all deaths
eupposably due to injury. These include not only deaths caused
directly or indirectly by traumatism (including resulting septice-
mia), 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 occupa*
tion, the sudden deaths of persons not disabled by recognized
disease, and those of persons found dead.

Statement of Occupation. — Precise statement of occupation is very
Important, so that the relative healthfulness of various pursuits
can be known. Make some entry in this section for every person
aged 10 years or over. If the occupation had been given up or
changed on account of the disease causing death, report the usual
occupation prior to illness. If the deceased had retired from busi-
ness, report the usual occupation prior to retirement. Children not
gainfully employed may be returned as at school or at home. For a
woman whose only occupation was that of home housework, write
housework. 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

R-301 A

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®lje (Utmtmtmfrrealfff of ^assarljuscttB
OFFICE OF THE SECRETARY

DIVISION OF VITAL STATISTICS

STANDARD

CERTIFICATE OF DEATH

To be filed for burial permit
witb Board of Health
or its Agent.

Registered No.

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

(a) Residence. No

(Usual place of abode)

Length of stay: In hospital or institution.

is a married, widowed or divorced woman, give also maiden name.)
.^1. . ;.

\ (If u. s.

)War Veteran,
specify WAR)

(Specify whether)

years

months

days.

(If nonresident, give city or town and state)

In this community yrs. mos. days.

PERSONAL AND STATISTICAL PARTICULARS

3 SEX

4 COLOB OR RACE

5 SINGLE
MARRIED
WIDOWED
or DIVORCED

(write the word)

5a If married, widowed, or divorced

HUSBAND of

(Give maiden name of wife in full)

(or) WIFE of

(Husband’s name in full)

6 Age of husband or wife if aliv® . /.y. -j-j-f -w yoars

7 IF STILLBORN, enter that fact here. sfAstY/

8 | If less than 1 day

AGE Years Months Days ( Hours Minutes

Usual

9 Occupation:

Industry
10 or Business:

12 BIRTHPLACE (City)

13 NAME OF *

0 /■) ' *

FATHER (L

C fi

14 BIRTHPLACE /

FATHER (CiXy)

/7 /

c~*

(State or country)

15 MAIDEN NAME

or Mother A,

16 BIRTHPLACE OF

MOTHER (City)

(State or country)

Relation, if *«y

I HEREBY CERTIFY that a satisfactory standard certificate of death was
, filec^yafh meMLESORE /purip^7 or^fransit permit was issued:

WM ' ^ . a ^ ,

(SijrtJhture of AjTee^of Board oI^rt«!tn or other)

///r/YO

(Official Designation) t/Y / / f (Date of Issue /f Permit'

18 DATE OF
DEATH

MEDICAL CERTIFICATE OF DEATH

7*-

Y3^JJ.UA

(Month) /

(Day)

(Year)

19 THEREBY CERTIFY. That i attended deceased from •

19 to 19.

I last saw h alive on ^ , 19 , death is said

to have occurred on \}$ dab

Immediate cap fie/ of

Due 'to

Due to

Other conditions

(Include pregnancy within 3 months o( death)

Major findings :

Of operations

Date of.....

Of autopsy

What test confirmed diagnosis?..

Duration ^

PHYStClAH

Underline
the cause to
which death
= hp uj[ d be
■Sta-
tistically.

20 Was disease or Injury In any way related to occupation ol deceased? .

It so, specify.^? f

(Signed) . M. D.

( Address).. Di 2t*7r..!..7._....i9.V-6-

Place of Burial

DATE OF BURIAL,

22 NAME OF

FUNERAL DIRECTO:

ADDRESS

ia), Cremation or Removal. * (City or .Town)

......\s4r.r'

^..jdazz

Rocoivod and filed .. 13..

(Registrar)

EXTRACTS FROM THE LAWS OF THE
COMMONWEALTH OF MASSACHUSETTS
GOVERNING THE

RETURN OF CERTIFICATES OF DEATH

No undertaker or other person shall bury or otherwise dispose of a
human body in a town, or remove therefrom a human body which
has not been buried, until he has received a permit from the board
of health, or its agent appointed to issue such permits, or if there
is no such board, from the clerk of the town where the person died ;
and no undertaker or other person shall exhume a human body and
remove it from a town, from one cemetery to another, or from one
grave or tomb other than the receiving tomb to another in the same
cemetery, until he has received a permit from the board of health or
its agent aforesaid or from the clerk of the town where the body is
buried. No such permit shall be issued until there shall have been de-
livered to such board, agent or clerk, as the case may be, a satisfac-
tory written statement containing the facts required by law to be
returned and recorded, which shall be accompanied, in case of an
original interment, by a satisfactory certificate of the attending
physician, if any, as required by law, or in lieu thereof a certificate
as hereinafter provided. If there is no attending physician, or if. for
sufficient reasons, his certificate cannot be obtained early enough for
the purpose, or is insufficient, a physician who is a member of the
board of health, or employed by it or by the selectmen for the pur-
pose, shall upon application make the certificate required of the at-
tending physician. If death is caused by violence, the medical exam-
iner 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 registration. The person to whom the permit is so given
and the physician certifying the cause of death shall thereafter fur-
nish 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 .)

RULES OF PRACTICE

The fulfillment of the purpose of these laws calls for the observ-
ance of the following rules of practice:

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

(3) Medical Examiners will investigate and certify to all deaths
supposablv due to injury. These include not only deaths caused
directly or indirectly by traumatism (including resulting septice-
mia), 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 occupa-
tion, the sudden deaths of persons not disabled by recognized
disease, and those of persons found dead.

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

or complication which causes death, not the mode of dying, e. g.,
heart failure, asphyxia, asthenia, etc. As principal cause name the
disease causing death. As related causes, name earlier morbid con-
ditions, if any, related to the principal cause and any important
complication of the principal cause.

Statement of Occupation. — Precise statement of occupation is very
important, so that the relative healthfulness of various pursuits
can be known. Make some entry in this section for every person
aged 10 years or over. If the occupation had been given up or
changed on account of the disease causing death, report the usual
occupation prior to illness. If the deceased had retired from busi-
ness, report the usual occupation prior to retirement. Children not
gainfully employed may be returned as at school or at home. For a
woman whose only occupation was that of home housework, write
housework. 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

R-303 B

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®fye ©ommonfaealtfj of <j8!IaB0ae{juaett»
OFFICE OF THE SECRETARY

DIVISION OF VITAL STATISTICS

MEDICAL EXAMINER’S

CERTIFICATE OF DEATH

To be filed for bnrlal permit
with Board of Health
or it* Agent.

Registered No.

2 FULL NAME

(a) Residence. No

(Usual place of abode)

Length of stay: In hospital or institution

M4&M.

(If deceased is a>Hktied, widowed or divqriecf womap, give also maiden name.)

XkdL^^

node) <j

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

(If U. S.

War Veteran,

I specify WAR) .

(Specify whether)

years

months

...St.

days.

(If nonresident, give city or town and state)

In this community ifO yrs. mos. days.

PERSONAL AND STATISTICAL PARTICULARS

A LCE

5 SINGLE
MARRIED
WIDOWED
or DIVORCED

5a I! married, widowed, or divorced
HUSBAND of

(or) WIFE

°1 OlXuJdO.

(Husband’s

6 Age of husband or wife if alive years

7 IF STILLBORN, enter that fact here.

AGE.. Years Months D'

Usual

9 Occupation:

Industry
!0 or Business:

Months DayM

/4vUAMirr\&

If loss than 1 day
Hours Minutes

II Social Security No,

MEDICAL CERTIFICATE OF DEATH

18 DATS OF
DEATH

JX Month) I (Day) / ' (Year)

19 I HERf?BY CERTIFY that 1 have investigated the death
of the person above-named and that the CAUSE AND MANNER thereof
t«£ as follows: (If an injury was involved, state fully.) „ . ' "~yL

fhus\^? ...7J ^

Was there an autopsy? .\ftwt?.

(See reverse sid% for description for unknown person)

20 Where did
injury occur?

(Cfty"

or town and State)

21 Was dlseasa or Injury In any way rclatcd^to occupation e! deceased?..

If so, specify .^j

(Signed)..

Received and Bled.

(Registrar)

EXTRACTS

FROM THE LAWS OF THE

COMMONWEALTH OF MASSACHUSETTS

GOVERNINC THE

RETURN OF CERTIFICATES OF DEATH

or of any member of the family of the deceased, furnish for regis-

tration a standard certificate of death, stating to the best of his
knowledge and belief the name of the deceased, his supposed age,

the disease of which he died, defined as required by section one,

■where same was 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.

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 registration. The
person to whom the permit is so given and the physician certifying
the cause of death shall thereafter furnish for registration any other
necessary information which can be obtained as to the deceased, or
as to the manner or cause of the death, which the clerk or registrar
may require. — Chap. 114. Sec. 45, G. L., as amended.

DESCRIPTION (for unknown person)

No undertaker or other person shall bury a human body or tba
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 cara
of the cemetery or burial ground in which the interment is made. . . .
Chap. 114, Sec. 46, G. L. as amended.

Medical examiners shall make examination upon the view of the
dead bodies of only such persons as are supposed to have died by
violence. If a medical examiner has notice that there is within his
county the body of such a person, he shall forthwith go to the place
where the body lies and take charge of the same ; . . . — Genual
Laws. Chap. 68, Sec. 6.

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

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

RULES OF PRACTICE

The fulfillment of the purpose of these laws calls for the observ-
ance of the following rules of practice :

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

(3) Medical Examiners will investigate and certify to all deaths
supposably due to Injury. These include not only deaths caused
directly or indirectly by traumatism (including resulting septice-
mia), 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 occupa-
tion, the sudden deaths of persons not disabled by recognised
disease, and those of persons found dead.

STATEMENT OF CAUSE OF DEATH
Medical Examiners in certifying to a death will state the cans*
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
ere known. For example : "Compound fracture of the femur with
ensuing septicemia (gas bacillus) caused by a steam railway ac-
cident." "Pistol shot wound of the chest with associated hemor-
rhage, homicidal.” "Asphyxiation by suspension, suicidal.” "Syn-
cope 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 Inves-
tigation shows the death to have been due to disease, specify : ( 1 )
Under cause, its known or presumable nature: and (2) under man-
ner, 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)."

NOTICE TO UNDERTAKERS: No embalming fluid, or nny substitute therefor, shall be injected inlo the
body of any person supposed to have met bis death by violence, until a permit, signed by the Medical
Examiner, has first been obtained. — General Laws, Chap. 38, Sec. 14.

THIS CERTIFICATE CONSTITUTES SUCH PERMIT

200m-10-’39. No. 8427-d

?M R-30I

< Suffolk

M (County)

tElje 3Itnnmon£uealil| of ,iSta*sacIpta*tt*
OFFICE OF THE SECRETARY

DIVISION OF VITAL STATISTICS

STANDARD

CERTIFICATE OF DEATH

(City or town making return)

Registered No

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

o t hr op

W (City or Town)

§ No....;.i..:..t.]a.r..Q.E

) / l (if n s

..El,0:ra-...G..has5..e....{j.Ql.fc.Qnl....Y.exnfiz

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

./ St

days.

2 FULL NAME.

(a) Residence. No S.H.. J.£L

(Usual place of abode)

ength of stay : In hospital or institution Q....LL.;!,.TZS..:

(Specify whether)

(If nonresident, give^ity or town and state)
In this community - yrs. mo:

days.

PERSONAL AND STATISTICAL PARTICULARS

3 SEX

Femal e

4 COLOR OR RACE

White

(write the word)

5 SINGLE

MARRIED .

widowed Married

or DIVORCED *'* '

5a If married, widowed, or divorced

HUSBAND of

(or) WIFE of

(Givn maiden name of wife in full)

Sewell Verne. v

(Husband’s name in

full)

6 Ago of husband or wife if alive

71 lyoars

7 IF STILLBORN,

enter that fact here.

AGE .0.8. Years Months.'TT: Days

If leas than 1 day

Hours Minutes

Usual

9 Occupation:....

House wife

Industry

10 or Business: .

Own home

11 Social Security No.

12 BIRTHPLACE (City)
(State or country)

roxbut:

rra-s'ga'elmg'ett'g'

13 NAME OF
FATHER

Benjamin Felton

inform«miArthttr... F. Verney Wft if “7 >.

(Addiees) I47 Cottage Pk« Rd iNlnthrop '

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

MEDICAL CERTIFICATE OF DEATH

18 DATE OF
DEATH

UL , .

(Day) ’ (Year)

19, I H

I last saw h~&XT!...aIive on.
to have occurred on the date stated

ImmediateySsuse of death

IFY

to..

That I attended deceased from

LI.., i9.fL.iP

Vjfiltf..., death is said

Duration

14 BIRTHPLACE OF
FATHER (City)

Unable to obtain

(State or country)

lew Hampshire

15 ofmothk12 Angeline Moore

16 BIRTHPLACE OF
MOTHER (City)

(State or country)

Boston

Ma s s a chus efts

20 Was disease or injury In any way related to occupation o( deceased ?

If so, specil

M. D.

(Address): Date../..//..?

2i /int hrop Ge

Place of Buriai, Cri
DATE OF BURIAL

Place of Burial, Cremjig^ , g (City or Town) ^ q

22 FUNERAL DIRECTOR GhSr.rlSS.

address '.vinthron Mass

Received and filed _..I9

A ' TRUE ' COPY ATTEST: (Registrir)"'

EXTRACTS FROM THE LAWS OF THE

COMMONWEALTH OF MASSACHUSETTS

GOVERNING THE

RETURN OF CERTIFICATES OF DEATH

No undertaker or other person shall bury or otherwise dispose of a
human body in a town, or remove therefrom a human body which
has not been buried, until he has received a permit from the board
of health or its agent appointed to issue such permits, or if there
is no such board, from the clerk of the town where the person died ;
and no undertaker or other person shall exhume a human body and
remove it from a town, from one cemetery to another, or from one
grave or tomb other than the receiving tomb to another in the same
cemetery, until he has received a permit from the board of health or
its agent aforesaid or from the clerk of the town where the body is
buried. No such permit shall be issued until there shall have been de-
livered to such board, agent or clerk, as the case may be, a satisfac-
tory written statement containing the facts required by law to be
returned and recorded, which shall be accompanied, in case of an
original interment, by a satisfactory certificate of the attending
physician, if any, as required by law, or in lieu thereof a certificate
as hereinafter provided. If there is no attending physician, or if, for
sufficient reasons, his certificate cannot be obtained early enough for
the purpose, or is insufficient, a physician who is a member of the
board of health, or employed by it or by the selectmen for the pur-
pose, shall upon application make the certificate required of the at-
tending physician. If death is caused by violence, the medical exam-
iner 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 a 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 registration. The person to whom the permit is so given
and the physician certifying the cause of death shall thereafter fur-
nish 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.)

RULES OF PRACTICE

The fulfillment of the purpose of these laws calls for the observ-
ance of the following rules of practice :

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

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

Statement of Occupation. — Precise statement of occupation is very
important, so that the relative healthfulness of various pursuits
can be known. Make some entry in this section for every person
aged 10 years or over. If the occupation had been given up or
changed on account of the disease causing death, report the usual
occupation prior to illness. If the deceased had retired from busi-
ness, report the usual occupation prior to retirement. Children not
gainfully employed may be returned as at school or at home. For a
woman whose only occupation was that of home housework, write
housework. 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

I R-301 A

®ffc (Hammort&rcalilj of .JHaseacIjusettB

OFFICE OF THE SECRETARY
DIVISION OF VITAL STATISTICS

STANDARD

CERTIFICATE OF DEATH

To be filed for burial permit
with Board of Health
or its Agent.

Registered No.

2 FULL NA

(If deceased is

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

(a) Residence. No

(Usual place of abode)

rried, widowed or divorced woman, give also maiden name.)

(If U. S.

War Veteran,
specify WAR)

.St.

Length of stay : In hospital or institution.

(Specify whether)

years

months

days.

(If nonresident, give city or town and state)

In this community /€> rs. mos. days.

>6EX

PERSONAL AND STATISTICAL PARTICULARS
4 COLOR OR RACE

5a If married,
HUSBAND

5 SINGLE (write ttfe word)

MARRIED. y~\ >. .

V/IDOWE

or DIVORCED . "

(or) WIFE of

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

6 Age of husband or wife if alive years

7 IF STILLBORN, enter that fact here.

If less than 1 day

Hours Minute

12 BIRTHPLACE (City)
(State or country)

13 NAME
FATHER

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

15 MAIDEN II.
OF MOTH!

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

I HEREBY CERTIFY that a satisfactory standard certificate of death was
file£b v$tJi_^mo B£ZP#E the yb^u sigtf or,,*1j&nsii/pormit was issued:

(Official Designation)

of Board of HeaklrXr o*ner)

^ //€

(Date of Issue of'PermiO

/? C

of/Permit") / '

EDICAL CERTIFICATE OF DEATH

( 1 to

(Year)

Y CERTIFY.

That I attended deceased from

?. 19 J..&, .. *T.Sn..., 19..^:*

I last saw h...?rr*rv,alive 19..S^Q death is said

to have occurred on the date Hated above, at. yi.Yxa.

Immediate cause of death

Due to

Other conditions

(Include pregnancy within 3 months of death)

Major findings :
Of operations

..Date of..

Of autopsy

What test confirmed diagnosis?.

PHYSICIAN

Underline
the cause to
which death
should be
charged sta-
tistically.

Was disease or Injury in any way related to occupation ol deceased? ■...tijaumliS..
so, specify.

(Signed)

(i*f*ress )'~t^

21 S

Received and filed

.19.

(Registrar)

EXTRACTS FROM THE LAWS OF THE

COMMONWEALTH OF MASSACHUSETTS

GOVERNING THE

RETURN OF CERTIFICATES OF DEATH

No undertaker or other person shall bury or otherwise dispose of a
human body in a town, or remove therefrom a human body which
has not been buried, until he has received a permit from the board
of health, or its agent appointed to issue such permits, or if there
is no such board, from the clerk of the town where the person died ;
and no undertaker or other person shall exhume a human body and
remove it from a town, from one cemetery to another, or from one
grave or tomb other than the receiving tomb to another in the sami
cemetery, until he has received a permit from the board of health o:
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 de-
livered to such board, agent or clerk, as the case may be’, a satisfac-
tory written statement containing the facts required by law to be
returned and recorded, which shall be accompanied, in case of an
original interment, by a satisfactory certificate of the attending
physician, if any, as required by law, or in lieu thereof a certificate
as hereinafter provided. If there is no attending physician, or if, for
sufficient reasons, his certificate cannot be obtained early enough for
the purpose, or is insufficient, a physician who is a member of the
board of health, or employed by it or by the selectmen for the pur-
pose, shall upon application make the certificate required of the at-
tending physician. If death is caused by violence, the medical exam-
iner 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 registration. The person to whom the permit is so given
and the physician certifying the cause of death shall thereafter fur-
nish 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.)

RULES OF PRACTICE

The fulfillment of the purpose of these laws calls for the observ-
ance of the following rules of practice :

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

(2) Board of Health physician? will certify to such deaths only
as those of persons who, though disabled by recognized disease un-
related to any form of injury, have died without recent medical
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 septice-
mia), 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 occupa*
tion, the sudden doaths of persons not disabled by recognized
, disease, and those of persons found dead.

Statement of Cause of Death. — Cause of death means the disease,
cr complication which causes death, not the mode of dying, e. g.,
heart failure, asphyxia, asthenia, etc. As principal cause name the
• disease causing death. As related causes, name earlier morbid con-
ditions, if any, related to the principal cause and any important
complication of the principal cause.

^ » Statement of Occupation. — Precise statement of occupation is very
Important, so that the relative healthfulness of various pursuits
p\can be known. Make seme entry in this section for every person
I aged 10 years or over. If the occupation had been given up or
P changed on account of the disease causing death, report the usual
' occupation prior to illness. If the deceased had retired from busi-
ness, report the usual occupation prior to retirement. Children not

F 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,
nowever, 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

R-303 B

M [v. «

OS o
Q «

Sjwu

Zwj;

>i» 0

. ^ s
“< G 41

“.S’0

iS;

Q 3*o

5 5 •- **
5< S £

ujs g

!?Uc

D-*a

< a &

U J «

O <4*

*£ o

(Q rj

t; £ c

4» h
"0^3

"3 *■* «

J • *•

“■5JS

® 0
•V *J

3 «

3 ►

TJ ’£
«i i«

5 •

3 SEX

Female

.3. '.Us J iJj£.

(County)

° yVUUTlwl

w (City or Tot

s no jaku I

®lje CorntiTon&realllj of ,JSiiaszacl\uBeH»
OFFICE OF THE SECRETARY

DIVISION OF VITAL STATISTICS

MEDICAL EXAMINER’S

CERTIFICATE OF DEATH

To ba filed for burial permit
with Board of Health
or ita Agent.

Registered No.,

A o

JLw

| 1 | death occurred in a hospital or institution.

2 FULL NAME

(a) Residence,

(Usual place of abode)

Length of stay: In hospital or institution

give its NAME instead of street and number)

(If U. S.

War Veteran,
specify WAB) ..

(If nonresident, giye^ity or town and state)

In this community6 6 yrs. mos. days.

(Specify whether)

PERSONAL AND STATISTICAL PARTICULARS

4 COLOR OR RACE

Whit e

5 SINGLE
MARRIED
WIDOWED
or DIVORCED

(write the word)

,7 id owed

5a If married, widowed, or divorced
HUSBAND of

(or) WIFE

_ i j (Give maiden name of wife in full)

oi Albert .Grlgas lacks on...

(Husband’s name in full)

6 Age of husband or wife if alive. .. years

7 IF STILLBORN, enter that fact here.

AGE.

M '

Years ...10

Months

Days

If less than 1 day
Hours Minutes

9 Occupation: .H.P.US 0. WQXk

Industry
10 or Business:

...Qm. home

11 Social Security No..

12 BIRTHPLACE (City)

13fa™erof Unable to

obtain

14 BIRTHPLACE OF
FATHER (City) ...

Unable

obtain

(State or country)

Unable

obtain

15 MAIDEN NAME
OF MOTHER

Unable

1 0

obtain

16 BIRTHPLACE OF
MOTHER (Citv) ..

Unable

obtain

(State or country)

Informant flSXl L#......I.elS OB

(Address! q Marshall St Uinthr

gtiST’ i( any

°£_

)

I HER
hied.

Y CERTIFY that a satisfactory standard certificate of death was
u me BEFORE the bjxfigt^ox trqq&it permit was issued:

(Official Designation)

18 DATE OF

DEATH

%1~ r J..}

4/0

/ (Month) l

(Day)

(Year)

19 I HEREBY CERTIFY tbrat I have investigated the death
of the person above-named and that the CAUSE AND MANNER thereof
are as foiiov/s : (If an injury was involve^ stat^ fully.)

MEDICAL CERTIFICATE OF DEATH

. % volvad? state^

. ^ ^

V|aa^i

WsiidL £ 4* -....Tr. fv.

(..

\\M>

Was there an autopsy?

(See reverse side for description for unknown person)

20 Where did
injury occur?..

(City or town and State)

21 Was disease or Injiiftja Li fay relatW to s^upa'.lan ol deaeased?..

If so, specify '•'*

(Signed) a

(Address)

Auburn.

fcwwH, Cremation e».44«wowal. (City or Town)

date of burial, ..J.an.ua.ry.....2..4 19..AQ.

22 Ivl.t..*...

Place of

23 NAME OF

FUNERAL DIRECTOR

address..: 'in throp^JTass

Charles R. Bennison

deceived and filed..

.19.

(Registrar)

EXTRACTS

FROM THE LAWS OF THE

COMMONWEALTH OF MASSACHUSETTS

GOVERNING THE

RETURN OF CERTIFICATES OF DEATH

A phyticlan 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 regis-
tration a standard certificate of death, stating to the best of his
knowledge and belief the name of the deceased, his supposed age,
the disease of which he died, defined as required by section one,
where same was contracted, the duration of his last illness, when last
seen alive by the physician or officer and the date of his death . . .
Gen. Laws, Chap. 46. Sec. 9.

No undertaker or other person shall bury or otherwise dispose of a
human body in a town, or remove therefrom a human body which
has not been buried, until he has received a permit from the board
of health, or its agent appointed to issue such permits, or if there
is no such board, from the clerk of the town where the person died ;
and no undertaker or other person shall exhume a human body and
remove it from a town, from one cemetery to another, or from one
grave or tomb other than the receiving tomb to another in the same
cemetery, until he has received a permit from the board of health or
Its agent aforesaid or from the clerk of the town where the body is
buried. No such permit shall be issued until there shall have been de-
livered to such board, agent or clerk, as the case may be, a satisfac-
tory written statement containing the facts required by law to be
returned and recorded, which shall be accompanied, in case of an
original interment, by a satisfactory certificate of the attending
physician, if any, as required by law, or in lieu thereof a certificate
as hereinafter provided. If there is no attending physician, or if, for
sufficient reasons, his certificate cannot be obtained early enough for
the purpose, or is insufficient, a physician who is a member of the
board of health, or employed by it or by the selectmen for the pur-
pose, shall upon application make the certificate required of the at-
tending physician. If death i3 caused by violence, the medical exam-
iner 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 tbe
deceased served in the army, navy or marine corps of the United
States in any war in which it has been engaged, such recital shall
appear upon the permit. The board of health or its agent, upon
receipt of such statement and certificate, shall forthwith countersign
It and transmit it to the clerk of the town for registration. The
person to whom the permit is so given and the physician certifying
the cause of death shall thereafter furnish for registration any other
necessary information which can be obtained as to the deceased, or
as to the manner or cause of the death, which the clerk or registrar
may require. — Chap. 114, Sec. 45, G. L„ as amended.

DESCRIPTION (for unknown person)

No undertaker or other person shall bury a human body or tbe
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 ihe care
of the cemetery or burial ground in which the interment is made. . , .
Chap. 114, Sec. 46, G. L. as amended.

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

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

RULES OF PRACTICE

The fulfillment of the purpose of these laws calls for the observ-
ance of the following rules of practice :

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

(3) Medical Examiners will Investigate and certify to all deaths
•nppotably due to injury. These include not only deaths caused
directly or indirectly by traumatism (including resulting septice-
mia), 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 occupa-
tion, the sudden deaths of persons not disabled by recognised
disease, and those of persons found dead.

STATEMENT OF CAUSE OF DEATH
Medical Examiners in certifying to a death will state the cans*
and manner thereof, and will specify: (1) Under cause, the natura
of an injury and of its consequences; and (2) under manner, tha
mode of its production together with the circumstances when thesa
are known. For example: "Compound fracture of the femur with
ensuing septicemia (gas bacillus) caused by a steam railway ac-
cident.” “Pistol shot wound of the chest with associated hemor-
rhage, homicidal," "Asphyxiation by suspension, suicidal." "Syn-
cope 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 inves-
tigation shows the death to have been due to disease, specify: (1)
Under cause, its known or presumable nature: and (2) under man-
ner, 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)."

NOTICE TO UNDERTAKERS: No embalming fluid, or any substitute therefor, shall be injected into the
body of any person supposed to have met his death by violence, until a permit, signed by the Medical
Examiner, has first been obtained. — General Laws, Chap. 38, Sec, 14,

THIS CERTIFICATE CONSTITUTES SUCH PERMIT

CAUSE OF jjfrEATH in plain terms, so that it may be properly classified. Exact statement of OCCUPATION
is very important. See instructions and extracts from the laws on back of certificate.

R-301 A

©he ©cmttrtmthmtlib uf (JHassacliitsetts
OFFICE OF THE SECRETARY
DIVISION OF VITAL STATISTICS

(City or Town)

No.

2 FULL NAME

STANDARD

CERTIFICATE OF DEATH

To bo Usd far burial permit
with Beard of Health
er its Agent.

Jr- ~

Registered No

| War^ Veteran.

(If deceased is a rnarngd. widowed or divorced woman, give also maiden name.) ) specify WAR) ^lyV '

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

(a) Residence. No

(Usual place of abode)

^rre,

St.

Length of stay: In hospital or institution..

-^9-

(Specify whether)

months

days.

(If nc

In this community yrs

5«sr...

(If nonresident, give city or town and state)

days.

PERSONAL AND STATISTICAL PARTICULARS

DICAL CERTIFICATE OF DEATH

3 SEX | 4 COLOR SR RAC

Tt/aA ksXitL

RACE | 5 SINGLE
MARRIED
WIDOWED
or DIVORCED

(write the word)

5a If married, widowed, or divorced,

HUSBAND of

(Give mai3en name of wife in full)

]'§Uc4<U( A, hf?. /

oidon nomn of nnfo ' r* full l * * *,

(or) WIFE of

(Husband’s name in full)

6 Age of husband or wife if alive

7 IF STILLBORN, enter thai fact here.

..years

AGE

&/■

Years

Months Days

If less than 1 day
Hours Minutes

Usual

9 Occupation:

Industry
10 or Business:

11 Social Security No.

12 EIRTHPLACE (City)
(State or country)

.7^

13 NAME OF,
FATHER

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

t<TK.

15 MAIDEN NAME
OF MOTHER

O' Am

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

'JZ7/*P

(Date of Issue of /hermit)

(Month)

CERTIFYi

(Day)

(Year)

,,yr0

last saw h...4rrVn»f»Iive on......

to have occurred on the date

Immediate cause of death

ate

That 1 attended deceased from

■ ^ S . 19 .fa, death is said

above, at

Due to

Other conditions -

(Include pregnancy within 3 months of death)

Major findings :
Of operations

.Date of..

Of autopsy

What test confirmed diagnosis?.

Duration

IMPMTMT

PHYSICIAN

Underline
the cause to
which death
should be
charged sta-
tistically.

20 Was dise3S8 or injury^ any *ay roiated to occupation of jtsceascc? .

If so, specif;

(Signed)

(Address)!"

UJ.

fCitv_or_Xown)

&& ,

22 NAME OF ' — ' "'2-^' LJ

FUNERAL DIRECTOR < { .... ...

ADDRESS • SZJSL.

Place of Burial, Crerr^noitY)i^Rem6val.
DATE OF BURIAL

Received end filed .

.19..

(Registrar)

EXTRACTS FROM THE LAWS OF THE

COMMONWEALTH OF MASSACHUSETTS

GOVERNING THE

RETURN OF CERTIFICATES OF DEATH

No undertaker or other person shall bury or otherwise dispose of a
human body in a town, or remove therefrom a human body which
has not been buried, until he has received a permit from the board
of health, or its agent appointed to issue such permits, or if there
is no such board, from the clerk of the town where the person died ;
and no undertaker or other person shall exhume a human body and
remove it from a town, from one cemetery to another, or from one
grave or tomb other than the receiving tomb to another in the same
cemetery, until he has received a permit from the board of health or
its agent aforesaid or from the clerk of the town where the body is
buried. No such permit shall be issued until there shall have been de-
livered to such board, agent or clerk, as the case may be, a satisfac-
tory written statement containing the facts required by law to be
returned and recorded, which shall be accompanied, in case of an
original interment, by a satisfactory certificate of the attending
physician, if any, as required by law, or in lieu thereof a certificate
as hereinafter provided. If there is no attending physician, or if, for
sufficient reasons, his certificate cannot be obtained early enough for
the purpose, or is insufficient, a physician who is a member of the
board of health, or employed by it or by the selectmen for the pur-
pose, shall upon application make the certificate required of the at-
tending physician. If death is caused by violence, the medical exam-
iner 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 registration. The person to whom the permit is so given
and the physician certifying the cause of death shall thereafter fur-
nish 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. 46,
G. L., ( Tercentenary Edition.)

RULES OF PRACTICE

The fulfillment of the purpose of these laws calls for the observ-
ance of the following rules of practice:

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

(2) Board of Health physician* will certify to such deaths only
as those of persons who, though disabled by recognized disease un-
related to any form of injury, have died without recent medical
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
•upposably due to injury. These include not only deaths caused
directly or indirectly by traumatism (including resulting septice-
mia), 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 occupa*
tion, the pudden deaths of persona not disabled by recognized
disease, and those of persons found dead.

Statement of Cause of Death.— -Cause of death means the disease,
or complication which causes death, not the mode of dying, e. g.,
heart failure, asphyxia, asthenia, etc. As principal cause name the
disease causing death. As related causes, name earlier morbid con-
ditions, if any, related to the principal cause and any important
complication of the principal cause.

SPACE FOR ADDITIONAL INFORMATION

information should be carefully supplied. AL»ii should be stated LaALILY. rHYolUAINo should state
CAUSE OF DEATH in plain terms, so that it may be properly classified. Exact statement of OCCUPATION
is very important. See instructions and extracts from the laws on back of certificate.

R-301 A

l< duf.lQlk

Vq (County)

< % / in t hr op

/w (City or Town)

®be donntumfnsaltlf of <i${a5sac{jusetts
OFFICE OF THE SECRETARY

DIVISION OF VITAL STATISTICS

STANDARD

CERTIFICATE OF DEATH

No 23... Almont St. {

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

Registered No

\ 4

Aw..-*-..

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

2 FULL NAME J.§^.©.(...^§.yl.P..9.f.S ) War Veteran,

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

specify WAR)

(a) Residence. No

(Usual place of abode)

Length of stay: In hospital or institution..

(Specify whether)

months

St.

days.

(If nonresident, give city or town and state)

In this communit y20

yrs. mos. days.

PERSONAL AND STATISTICAL PARTICULARS

3 SEX

Female

4 COLOR OR RACE

'./hit e

5 SINGLE (write the word)

MARRIED 7 4 r1

WIDOWED K 10- ow e a

or DIVORCED

5a If married, widowed, or divorced

HUSBAND of

(Give maiden name of wife in full)

(or) wife of _r.nd.re.YL Doig

(Husbands

s name in full)

6 Age of husband or wife if alive

years

7 IF STILLBORN, enter that fact here.

Days

If less than 1 day

9 Occupation: . House work

Industry
10 or Business:

Own home

11 Social Security No.

12 BIRTHPLACE (City)
(State or country)

Dundee
S q o't'land

13 NAME OF
FATHER

Thomas Gray

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

'Scotland''

lsSr Annie Sharpe

16 EIRTHPLACE OF
MOTHER (City) .
(State or country)

"Scotland'

Informant Y/illiam DOig /SUI1 \

(Address)^ Timoht S t •• /Tint hi^p imss >

Relation, if any

/ son

rd certificate of death was
penfeit was issued:

MEDICAL CERTIFICATE OF DEATH

18 DATE OF
DEATH

(Month)

s* 7 /f&A

(Day)r (Year)

19 InJHEREBY CERTIFY., That 1 attended deceased from

j .T., 19.Jf.dS, ^...7 19...V...4?....

I last saw h JtA alive ~n ffn 19..Vf..f, death is said

to have occurred on the date Ttated above, at

Immediate cause of death -

Due to

Other conditions'

(Include pregnancy within 3 months of death)

Major findings :

Of operations L_..

Date of

Of autopsy Aid

What test confirmed diagnosis

Duration

IMPORTANT

/ O

PHYSIClAit

29 Was disease ei injury In any nay related te tccnpatlen of deceased?

If so, specify^*. ...

(Sign

(Address ) 7*10.

finthroi Qemet'ery Zinthrop.

t>. r' __ r> i re:.., nr \

Date

,1 ■ M. D.

fh 1 19 fff

Place of Burial, Cremation or Removal.

DA1T OF BURIAL ^ , l/40

(City or Town)

.19

22 FUNERAL DIRECTOR 0hfl>rl88 Re BOIlIliSOll

address Win.thro.p.....Mas.s

Received and Sled

.19..

(Registrar)

EXTRACTS FROM THE LAWS OF THE

COMMONWEALTH OF MASSACHUSETTS

GOVERNING THE

RETURN OF CERTIFICATES OF DEATH

No undertaker or other person shall bury or otherwise dispose of a
human body in a town, or remove therefrom a human body which
has not been buried, until he has received a permit from the board
of health, or its agent appointed to issue such permits, or if there
is no such board, from the clerk of the town where the person died ;
and no undertaker or other person shall exhume a human body and
remove it from a town, from one cemetery to another, or from one
grave or tomb other than the receiving tomb to another in the same
cemetery, until he has received a permit from the beard 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 de-
livered to such board, agent or clerk, as the case may be, a satisfac-
tory written statement containing the facts required by law to be
returned and recorded, which shall be accompanied, in case of an
original interment, by a satisfactory certificate of the attending
physician, if any, as required by law, or in lieu thereof a certificate
as hereinafter provided. If there is no attending physician, or if, for
sufficient reasons, his certificate cannot be obtained early enough for
the purpose, or is insufficient, a physician who is a member of the
board of health, or employed by it or by the selectmen for the pur-
pose, shall upon application make the certificate required of the at-
tending physician. If death is caused by violence, the medical exam-
iner 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 registration. The person to whom the permit is so given
and the physician certifying the cause of death shall thereafter fur-
nish 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.)

RULES OF PRACTICE

The fulfillment of the purpose of these laws calls for the observ-
ance of the following rules of practice:

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

(3) Medical Examiners will investigate and certify to all deaths
vupposably due to injury. These include not only deaths caused
directly or indirectly by traumatism (including resulting septice-
mia), 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 occupa-
tion, the sudden deaths of persons not disabled by recognized
disease, and those of persons found dead.

Statement of Cause of Death. — Cause of death means the disease,
or complication which causes death, not the mode of dying, c. g.,
heart failure, asphyxia, asthenia, etc. As principal cause name the
disease causing death. As related causes, name earlier morbid con-
ditions, if any, related to the principal cause and any important
complication of the principal cause.

SPACE FOR ADDITIONAL INFORMATION

R-303 B

S2S § ?

S-o

"5 # #

2 &Ei

< h

U, — 2 o

2 £ 0-5

2$ I «
^•V Z >

E S
3

xJnl

f“ rco.

(County)

O V

W (City or (Toi

®Jje (EotninortfercaItf| of (dStassadfUBetta

OFFICE OF THE SECRETARY

DIVISION OF VITAL STATISTICS <

MEDICAL EXAMINER’S
CERTIFICATE OF DEAjTF

2 FULL NAME.

(a) Residence,

(Usual place
Length of stay: In hospital or institution

To be filed for bnrial permit
with Board of Health
or its Agent.

Registered No

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

(If U. S.

War Veteran,
specify WAR)

(Specify whether)

years

months

(If nonresident, give city or town and state)

In this community yrs. mos. days.

PERSONAL AND STATISTICAL PARTICULARS

3 SEX 4 COLOI

% to

4 COLOR OR RACE

5 SINGLE
MARRIED
WIDOWED
or DIVORCED

yhwrite the word)

D T

5a If married, widowed, or divorced

HUSBAND of

(Give maiden name of wife in full)

(or) WIFE of

(Husband’s name in full)

6 Age of husband or wife if alive year3

7 IF STILLBORN, enter that fact here.

If less than 1 day

Hours Minutes

11 Social Security No.

(State or country)

13 NAME OF f

FATHER f

14 BIRTHPLACE OF
FATHER (City) ....

%. A

(State or country)

v> AJUta** d

15 MAIDEN NAME u
OF MOTHER f

W If. ^

16 BIRTHPLACE OF
MOTHER (City) .

(State nr country)

^aZ£ssi

Relation, if sjw

I HEREBY CERTIFY that a sarisfacjary standard certificate of death was
filed /-r.h me REF/1RE tJr^/Vurial or transit permit was issued:

MEDICAL CERTIFICATE OF DEATH

18 DATE OF
DEATH

I ^ ^ $ (4

t (Month) l n

(Day)

(Year)

19 1 HEREBY CERTIFY that 1 have investigated the death

of the person above-named and that the CAUSE AND MANNED thereof
are as follows: .(If an injury was invaded, state fully.) j jC 1 ,

^errTp Vfr^rrr. . . .

*«

^yu

A^^rr!*rrrr?....„<^

'“S'

w*rr.

Was there an autopsy?..

(See reverse side for desfription for unknown person)

20 Whero
injury

escriplioi

(Cit;

ity or town and State)

21 Was disease or Injury In an; way related to eccnpatlon a! dsesasti?..

If so, specify ...i

(Signed) /Ifc* M. D.

(Address) | . (jUtf* ■—/•••-- -»

Place ol Bu/ial, erefrtatioif'ot^Kempval. (City or Town)

DATE OF BURIAL 3^-^C,. >2...... L 19.^...

23 V8&8S. director

ADDRESS

, DIRECTOR^

leceived and filed.

.19.

(Registrar)

EXTRACTS

FROM THE LAW 3 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 regis-
tration a standard certificate of death, stating to the best of hi*
knowledge and belief the name of the deceased, his supposed ugc,
the disease of which he died, defined as required by section one,
where same was contracted, the duration of his last illness, when last
seen alive by the physician or officer and the date of his death...
Gen. Laws, Chap. 46. Sec. 9.

No undertaker or oilier peron 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 cierk 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 i*
buried. No such permit shall be issued until there shall have been de-
livered to such board, agent or clerk, as the case may be, a satisfac-
tory written statement containing the facts required by law to be
returned and recorded, which shall be accompanied, in case of an
original interment, by a satisfactory certificate of the attending
physician, if any, as required by law, or in lieu thereof a certificate
as hereinafter provided. If there is no attending physician, or if. for
sufficient reasons, his certificate cannot be obtained early enough for
the purpose, or is insufficient, a physician who is a member of the
board of health, or employed by it or by the selectmen for the pur-
pose, shall upon application make the certificate required of the at-
tending physician. If death is caused by violence, the medical exam-
iner 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 registration. The
person to whom the permit is so given and the physician certifying
the cause of death shall thereafter furnish for registration any other
necessary information which can be obtained as to the deceased, or
as to the manner or cause of the death, which the clerk or registrar
may require. — Chap. Ill, Sec. 45, G. L., as amended.

DESCRIPTION (for unknown person)

No undertaker or other person shall bury a human body or the
ashes thereof which have been brought into the commonwealth until
he has received a permit so to do from the board of health or its
agent appointed to issue such permits, or if there is no such board,
from the clerk of the town where the body Is to be buried or tha
funeral is to be held, or from a person appointed to have the cura
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 tha
dead bodies of only such persons as are supposed to have died by
violence. If a medical examiner has notice that there is within his
counly the body of such a person, he shall forthwith go to the place
where the body lies and take charge of the same ; . . . — General
Laws, Chap. 38, Sec. 6.

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

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

RULES OF PRACTICE

The fulfillment of the purpose of these laws calls for the observ-
ance of the following rules of practice:

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

(3) Modieai Examiners will investigate and certify to all death*
■upposably due to injury. These include not only deaths caused
directly or indirectly by traumatism (including resulting septice-
mia). and by the action of chemical (drugs or poisons), thermal,
or electrical agents, and deaths following abortion, but also death*
from disease resulting from injury or infection related lo occupa-
tion, the sudden deaths of persons not disabled by recognised
disease, and those of persons found dead.

STATEMENT OF CAUSE OF DEATH

Medical Examiner* in certifying to a death will state the cans*
and manner thereof, and will specify: (1) Under cause, the nalura
of an injury and of its consequences; and (2) under manner, tho
mode of it* 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 ac-
cident.” "Pistol shot wound of the chest with associated hemor-
rhage, homicidal.” “Asphyxiation by suspension, suicidal." "Syn-
cope 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 Inves-
tigation shows the death to have been due to disease, specify: (1)
Under cause, its known or presumable nature: and (2) under man-
ner, 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)."

NOTICE TO UNDERTAKERS: No embalming fluid, or any substitute therefor, shall be injected into the
body of any person supposed to have met his death by violence, until a permit, signed by tlie Medical
Examiner, has first been obtained. — General Laws, Chap. 38, Sec. 14.

THIS CERTIFICATE CONSTITUTES SUCH PERMIT

a^vairioJJteK

®lfe ®0mman{neaIt!{ of <fKasaacltusclt6
OFFICE OF THE SECRETARY
COPY OF

MEDICAL EXAMINER’S
CERTIFICATE OF DEATH

BOSTOSi y

(City or town making return)

W (County)

u, Boston

W (City or Town)

O ((If death occurred in a hospital or institution,

3 No Boston City h.O.SD St. I give its NAME instead of street and number)

Registered No 1.5.

2 FULL name Sunmer .. For.t.e.r. \ War Veteran,

specify WAR)

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

(a) Residence. No il.l,.Shtxley st.

(Usual place of abode)

t usual place ot aooae,> Unont fol

Length of stay: In hospital or institution.. ...(A.Q.S.pj-.uUj... years

(Specify whether)

months

~J days.

.Wln.thiLQ.p

(If nonresident, give city or town and state)

In this community 2 yrs. mos. days.

PEBSONAL AND STATISTICAL PARTICULARS

3 SEX

(write the word)

4 COLOR OR RACE 5 SINGLE
! MARRIED

WIDOWED ni.-i -

or divorced single

5a It married, widowod. or divorced

HUSBAND oi . , „

(Give maiden name of wife in full)

(or) WIFE oi

(Husband’s name in full)

6 Age of husband or wile ii alive years

7 IF STILLBORN, enter that fact here.

AGE

Years Months

| H less than 1 day
Days j Hours Minutes

9 Occupation: .Chauffeur. W*.P...A.

Industry
10 or Business:

11 Social Security No.

12 BIRTHPLACE (City)
(State or country)

Russia

13 NAME OF
FATHER

Abraham Porter

14 BIRTHPLACE OF
FATHER (Hitvl

(State or country)

Russia

15 MAIDEN NAME
OF MOTHER

Fannie Goldberg

IB BIRTHPLACE OF

MOTHER (Citv)

(State or country)

Russia

Nathan Goldberg

(Address)

\JL Of '. -- . r ^ V ,<r ■ /\ cL,

A TRUE COPY
ATTEST: ....

"Rei

DATE FILED

Registrar ef-eity or tewr. wfecre-deatb uu .Wnflft
19

MEDICAL CERTIFICATE OF DEATH

18 DATE OF

DEATH

J anuary 2, .19.40....

(Month) (Day)

(Year)

19 I HEREBY CERTIFY that 1 have investigated the death
of the person ebove-named and that the CAUSE AND MANNER thereof
are ns follows: (If an injury was involved, state fully.)

Asphyxiation., by. suspension...
Paranoid ps yc.ho sis -previous
attempts...

20 Accident, suicide, or homicide (specify).. Sul.qjdfil

Date of occurrence I9..4.Q

occur? Boston

(City or town and State)

Did injury occur in or about the home, on farm, in industrial place, or in

public place?

(Specify type of place)

Manner of
Injury

Nature oi

Injury

While at work ? Was there an autopsy ?. ...Jtfo..

21 Was disease or Injgry la aay way related to nccapaticn ol deceased ?

If so, specify

(Signed) T Leary

(Address) BOStOn Date.

22 He rt sol- Everett

Place of Burial, Cremation or Removal.

DATE OF BURIAL

1/3.3$

or Town)

.19

“J FUNERAL" DIRECTOR M Stanets.ky

address Dorch e s.t e r

Received and tiled mm.

(Registrar of City or Town where deceased resided)

- C £ I \/ jr

FEB 17131,0 ui

in I,,

50m-10-’39. No. 8427-f

302

(8Nx«*oi2fe

®I|c Ottommtm&iealtlj of ^asBacIjuscitB

OFFICE OF THE SECRETARY
DIVISION OF VITAL STATISTICS

COPY OF

CERTIFICATE OF DEATH

(County)

Boston

(City or Town)

P0+-V1 To>oo/-n ,. f Of deat!) occurred in a hospital or institution,

No .S.§..W.il....fIf.S.P.S..6.J.....AiQ.S.p St. I 8‘ve its NAME instead of street and number)

(City or town maWng return) -

f (

Registered No 1..V.&

2 FULL NAME .)

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

70 Beach Road _

(a) Residence. No St.

(Usual place of abode) —

Length of stay: In hospital or institution years months c. days.

(Specify whether)

Winthrop

(If nonresident, give city or town and state)

In this community^ [jrs. mos. days.

PERSONAL AND STATISTICAL PARTICULARS

3 SEX

4 COLOR OR RACE 5 SINGLE (write the word)

MARRIED

W widowed Marrl piI

I or DIVORCED MarrleU

5a If married, widowed, or divorced

HUSBAND of .............. ....

(Give maiden name of wife in full)

(or) WIFE of

(Husband’s name in full)

6 Age of husband or wife if alive - ti ... years

7 IF STILLBORN, enter that fact here.

8 (- 0 If less than 1 day

AGE. ..pci.. ..Years Months Days Hours Minutes

Usual

9 Occupation:

Industry
10 or Business:

Retail store

11 Social Security No.

12 BIRTHPLACE (City)
(State or country)

"Russia"'

13 NAME OF
FATHER

Louis Freedman

14 BIRTHPLACE OF
FATHER (City) ..
(State or country')

Russia

15 MAIDEN NAME „ _ .

OF mother Louise J Levitas

16 BIRTHPLACE OF
MOTHER (City) ..

(State 01 country)

Russia

Informant..

(Address)

Wife

Relation, if any

A TRUE COPY,
ATTEST:

(Registrar of city or town where death occurred)

DATE FILED

.19.

MEDICAL CERTIFICATE OF DEATH

dea?hof January 7f 19*K)

(Month) (Day) (Year)

19 I

ceased from

19..

TAWCER,VF\: plM.

I last saw h..iXn...alive on.. IWM > 19 , death is said

to have occurred on the date stated above,

Immediate cause of death

Cerebral thrombosis

Congenital

Due to

heart failure

Due to

Other conditions

(Include pregnancy within 3 months of death)

Duration

"wFs

mos".

Major findings:

Of operations

Date of

Of autopsy

What test confirmed diagnosis?

20 Was disease or Injury in any way related to occupation of deceased ?

If so. specify

(Signed) L... Eo..a.e.nie.il’ZZ. .. , ....

(Address) B.e.t.h 4.S.P.&P.1 -.-.QS.Ijbato .1/ 7.. 19 "IQ.

PHYSICIAN

Underline
the cause to
which death
should be
charged sta-
tistically.

M, D.

21,jpRESym^Uo|^ Beth El

/e st

DATE of

Koxoury (Cemetery) _ /w /). ~(City or Town)

BURIAL 1/°/ 19

22 NAME OF T LI

FUNERAL DIRECTOR ^ ^6 Vine

address Dor cTie s "ter

Received and filed l/10/40

(Registrar of City or Town where deceased resided)

‘‘ * £fV . ;

C i)

x;9#,f -.' .
(cl':. #3.;?-

cf4.

&/?/]?.

f£B* 7/940 M

‘- . -s-i . „ .

;- - .

v- . ... ,

—

MldjjfeliisijBex-

(c^wni®a);.ge

COPY OF

CERTIFICATE OF DEATH

Cambridge

(City or town making return)

Registered No

w o.l iv d?thx-ACxC,uJred in » ^ospilal or institution.

Holy Ghout Hospital

2 FULL NAME

Hdv^^tffsclj|iW¥r8'^iidi6ow^8tiilS'lcfiS;,man' Eive also maiden name-)

(if a. s.

Wat Veteran,
specify WAR)..

(a) Residence. No

(Usual place of abode) 1^0 35? tlett lid.

Length of stay: In hospila! or institution years

1 J2-.

.St.

months

days.

(If nonr^jk^Jrjejeityrjr town and state)

In this community yrs. mos. days.

^SB-

personal AND STATISTICAL PARTICULARS

3 SEX ! 4 COLOR OR RACE 5 SINGLE

MARRIED

WIDOWED

j|_| ! or DIVORCED

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

(write the word)

widowec

(or) WIFE of

(Give maiden jSafifiL tSfe 6 0>lL) 6]Ti&n
(Husband’s name in full)

MEDICAL CERTIFICATE OF DEATH

18 DATE OF
DEATH

T«5#»n lg 1940

(Year)

6 Age of husband or wife if alive years

7 IF STILLBORN, enter that fact here.

AGE

Usual
9 Occupation;

rs Months Days

If less then 1 day
Hours Minutes

Industry
10 or Business:

Waiter 'Retired"

11 Social Security No.

Hotel

12 BIRTHPLACE (City)
(State or country)

13 NAME OF
FATHER

none

st -j-q-rh; •-

Hewi'oundi -nd

14 BIRTHPLACE O!
FATHER (City) .
(State or country)

^fearer ence Cousins

IS MAIDEN NAME
OF MOTHER

s t J oim

Hew fa 'in cl i ittcL

16 BIRTHPLACE OF
MOTHER (City) .

(State or country)

Ellen Nugent

(Address) Helen "Ccmwtn

St John
-tfew founding

A TRUE COPY.
ATTESTi

tion, if any

v danght^

ISO Circuit Hu~vrintLrop

J.anD 14 1S40

(Registrar ot city or town where death occurred)

MTE “■

I HEREBY CERTIFY. That I attended deceased from

Jct-n- 19 4G Jan...XS> , 19.....40

to have occurred on the date stated above, at '

Immediate cause of death

Due to

Hyp.aa..tJa.t.i.o....2ne.umanla.

Onrottxc-ivlyocardit'i-e

Ghro-me ir'aes-ive -oongoa-t

Other conditions

(Include pregnancy within 3 months of death)

Duration

l.wk

yr«-

iv^-yr

PHYSICIAN

Major findings:
Of operations

•none

Underline

j the cause to

Date of jwhich fif3*-11

should be

0f au,°Psy I charged sts-

What test confirmed diagnosis? M

•"Sxa

tistically.

20 Was disease or lojory In any way related to occupation o! md.

If so, specify _ nO

(Signed) , M- D

(Address) (31ir i stfl-fihAY! T2. TZkrtarn 19

21 crema tion ^or ' vaiF ,l1PF. ~ ® Rd. Bel* l/l4 40

r Hr, t a jjj£ xaSStt or Town)

J-in 16 1940

date or Holy»fer^a

.19

22 NAME OF

FUNERAL DIRECTOR

ADDRESS

Received and filed .

J ohir F G Muley

Wintfaro-p —

.19

(Registrar of City or Town where deceased resided)

(County)

(City or Town)

®I]e Commonfoealtli af ,i$tassaclfuseits

OFFICE OF THE SECRETARY
DIVISION OF VITAL STATISTICS

COPY OF

CERTIFICATE OF DEATH

BOSTON

(City or town making return)
Registered No j.

NoAu.dub.on...Ho.8.p.i.t*l ^ st. I & ft naSSIL&J SS

2 FULL NAME ..M.aM...Maren/Mrl.A j

a matjied, widow,*! r~ J: J — ^

(If deceased is

or divorced woman, give also maiden name.)

(If U. S.

i War Veteran,
t specify WAR).,

(Usual place of abode) 'T* --

Length of stay: In hospital or institution years months days.

(Specify whether)

(U^nonrefidJnt, gi^city or town and state)

In this community yrs. m0s. days.

PERSONAL AND STATISTICAL PARTICULARS

3 SEX

female

4 COLOR OR RACE 5 SINGLE
i MARRIED
! WIDOWED

wnlte or DIVORCED

5a If married, widowed, or divorced

HUSBAND of

(Give maiden name of wife in full)

(or) WIFE of

(Husband’s name in full)

(write the word)

single

S Ago of husband or wife if alive years

7 IF STILLBORN, enter that fact here. Stlllbom

AGE.

Years Months.

Days

If less than 1 day
Hours Minutes

Usual

9 Occupation:

Industry
10 or Business:

11 Social Security No.

(State or country)

Mass.

13 NAME OF
FATHER

Domenick Amarpna

14 BIRTHPLACE OF
FATHER (City)

.8.o..s..t.an

(State or country)

Maes.

15 MAIDEN NAME
OF MOTHER

Mary Dente

16 BIRTHPLACE OF
MOTHER (City)

Boston

(State or country)

Mass.

I“»f5rmant Poni.eni.ck....Araar.ena....(' .F.a.tbe.r..any

4 — V/inthrop

(Address)

11 Pi

DATE FILED

(Registrar of city or town where death occurred)

MEDICAL CERTIFICATE OF DEATH

18 DATE OF T

death Jan...

(Month)

...20....

(Day)

(Year)

Due to

Other conditions

(Include pregnancy within 3 months of death)"

19 I HEREBYCERTIFY. That I attended deceased from

> 19 to , 19

1 Iast saw h aIive on , 19 , death is said

to have occurred on the date stated above, at

Immediate cause of death

frama&ixfi

.Stillborn (6 ths)

Due to

Duration

Major findings:
Of operations

•Date of..

PHYSICIAN

Underline
the cause to
which death
should be
charged sta-
tistically.

Of autopsy

What test confirmed diagnosis?

20 Was disease or injury In 2ny way related to occupation ol deceased T

If so. specify

(Signed).....—..?. ...Y.* CanePOpifl vr D

(Address) 1.9.5..J.M gtate n-.-l/gO Aft

21 PLACE OF BURIAL. Tlf. 0 ^ _

cremation or removal Bgnediet Cem.

(Cemetery) B$gTOn(dty or Town)

22 NAME OF

FUNERAL DIRECTOR

ISrt.U..

Tbomns D* JELlS&I 1

ADDRESS

Iff.Q.9. .Par.* Ay.e. Do.r...

Received and filed

..J.an....2.3._ lakrv

7 — r-W

. .

DECEIVE :

4«3> "'l^C

,'u?/ 'v A, VA**

H 1-3??-

O S

FEB17I94Q AH

(County)

®!je Cdontmonfeealtlj of (Massachusetts

OFFICE OF THE SECRETARY
DIVISION OF VITAL STATISTICS

COPY OF

CERTIFICATE OF DEATH

OJV

(City or town making return)-^

* y 3

Registered No

(City or Town)

tst Beth Israel Hospital ~ de4at^T?c^HTed in ? h,0SPitaI or institution,

Tv f*. ^ t. ( give its NAME instead of street and number)

2 full name .Q9lA?tein j (Ii_U.S.

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

Residence. No St

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

months days. In this community yrs. mos. days

Wai Veteran,
specify WAR).,

(a)
Length of stay

In hospital or institution years

(Specify whether)

PERSONAL AND STATISTICAL PARTICULARS

3 SEX

Male

4 COLOR OR RACE 5 SINGLE (write the word)

i MARRIED

! widowed Married

or DIVORCED HarrleU

White

ba it married, widowed, or divorced r\_ __ t -i _ . • _i_

HUSBAND of P.Q.rft....h.e.D.0.Y1.0h..

(Give maiden name of wife in full)
(or) WIFE of

(Husband’s name in full)

6 Age of husband or wife if alive years

7 IF STILLBORN, enter that fact here.

AGE 53 Years Months Days

If less than 1 day
Hours Minutes

Usual _ ,

9 Occupation: aJr.QiC.en..

Industry
10 or Business:

Insurance.

II Social Security No..

12 BIRTHPLACE (City) s B.P.St.OQ...MaS.S.

(State or country)

13 NAME OF
FATHER

Samuel Goldstein

14 BIRTHPLACE OF
FATHER (Citv)

Russia

(State or country)

15 MAIDEN NAME
OF MOTHER

Ida Goldstein 0.K

18 BIRTHPLACE OF
MOTHER (City) ..

(State or country)

Russia

orman. M Goldstein R$i?«W3i«r

(Address) ^ V 2

(Registrar of city or town where death occurred)

DATE FILED 19

MEDICAL CERTIFICATE OF DEATH

is date of Jan. 25,1940

DEATH.

(Month)

(Day)

(Year)

19 1 HEREBYCERT.FY. That I attended deceased from

1t.1Q.-4Q 19 to. 1-25-40

to....+.-.V.«.T’M , 19

I last saw h fcUalive on 1.T.2.5.T4Q jg f death ;s sa;d

to have occurred on the date stated above, at..l.!j.l.QA.m.

Immediate cause of death

QY.$.orhfilfflihs..lar.e.Q.t.i.Q».

Due to ..P..f.^.?lchii

Due to

Duration

2 Days

. . . .with . . me ta s t as .es . . . .5.0. . . .li.ver . . . an a

SICIAN

Major findings: mesentery I Underline

of operations Lar^noiaa..o.f..-.reoto --si gnioit(i cause to

M..mas.s.nfcar.i...nadas.... ...Dale of. 1-2.3-40...... Fwliicb death

should be

0f au,°Psy charged sta-

What test confirmed diagnosis? tistically.

20 Was disease or Injnry In any way related to occupation ol deceased ?

If so, specify ...

(Signed) D Kopans ~ . M A

Beth Israel Hosrvfc 1—25 40

(Addross).°6t5. .Israel ..Hps.pt

Date.

PLACE OF BURIAL, Flo A fra _ Cu , .

CREMATION OR REMOVAL Ua ,1(1 VlCUJ4 hOUlim-

(Cemetery) (City or Town)

DATE OF BURIAL Jail .. 2fi .T.Q4D 19

22 NAME OF D p „

FUNERAL DIRECTOR 5.....I S.OlOElOIl .

ADDRESS

_ Brookline Maas:

Received and filed J.an ...2.7,1940

(Registrar of City or Town where deceased resided)

. . •

K^^hRG?^y

FEB17I3M m

■

®fje (Eontmanfoealflj of .JHassacIjuscfts
OFFICE OF THE SECRETARY
DIVISION OF VITAL STATISTICS

COPY OF

CERTIFICATE OF DEATH

BOSTON

(City or town making return?

^ *■

(City or Town) Registered No

< w Mass General Hospital ( lilLd;e5hxiAC^trrcci or institution,

2 full name Ric h ar d Dana Carp enter ' (u u. s.

/ T f a m a > 1 J nt | #1 AtlVA/1 A >• /IllfAtAAfl VITA MA AM mLba • 1 _ ’ 1 \ W Cl 1 V P t F

(If deceased is a married, widowed or divorced woman, give also maiden name ) ) ^a,.y° J?trSS;

t cpecily WAH)..

(a) Residence. No S. WigthrOp

(Usual place of abode)

Length of stay: In hospital or institution years months £ days.

(Specify whether)

(If nonresident, give city or town and state)

In this community g^rrs. mos. days.

PERSONAL AND STATISTICAL PARTICULARS

3 SEX

Male

4 COLOR OR RACE 5 SINGLE (write the word)

i MARRIED

White* i widowed Married
vmiue or djvorced "*** 1 xou'

MEDICAL CERTIFICATE OF DEATH

Lottie M Kewton

5a If married, widowed, or divorced
HUSBAND of

(Give maiden name of wife in full)

(or) WIFE of

(Husband’s name in full)

6 Age of husband or wife if alive 58 years

7 IF STILLBORN, enter that fact here.

8 aa a i o If less than 1 day

AGE Py. Years. ...s Months.-“.~ Days Hours Minutes

9 Occupation: Printer Retired)

Industi^

10 or Business:

Pr.i.at.i».£...Business.

II Social Security No,.

12 BIRTHPLACE (City) .!....S.0.Utb.....B.Q,5.tpn.,MaSS..

(State or country)

13 NAME OF
FATHER

Jerome B Carpenter

14 BIRTHPLACE OF
FATHER (City)

—Maine

(State or country)

15 MAIDEN NAME
OF MOTHER

Lesina - —

16 BIRTHPLACE OF
MOTHER (City)

Maine

(State or country)

Informant..

(Address)

Wife

Relation, if any

( )

A TRUE COPY.
ATTEST:

(Registrar of city or town where death occurred)

DATE FILED

1 8 death°f Jan • 26,1940

(Day)

(Month)

(Year)

1 HEREBY CERTIFY , That I attended deceased from

1*0...., to £tm, ...Z& , 19...$o

I last saw h..ijH...alive on > l940 ..f Jeaf| Ja;d

to have occurred on the date stated above, at.l.Q.;.Q8F...m.r Duration
Immediate cause of death

Hypertensive heart disease 2 Yrs

Due to

Other conditions

(Include pregnancy within 3 months of death)’

PHYSICIAN

Major findings:
Of operations

Underline
the cause to

£)aje Qf i which death

should be
charged sta-

Of autopsy

What test confirmed diagnosis? tistically.

28 Was disease or Injury In any way related to occupation of deceased ?

If so. specify

(Signed) “ Y FheeS

(Address).. M.»5.s....G.eneml...H.Q.^t.Dgte. .l» .. . » .40

M. D.

21 PLACE OF BURIAL

CREMATION OR REMOVAL

Forest Dale Malden Mass

T . (Cemetery) (City or Town)

DATE OF BURIAL V.®"?*... 29*1940

22 NAME OF a *«r j e o

FUNERAL DIRECTOR ... AJN .^ard & Soil

. address Malden -Mass

Received and filed Jan,... 31, .1940

(Registrar of City or Town where deceased resided)

.19

\ I

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&8B9X

(County)

Danvers

(City or Town)

®{]c (Eantmonfacaltlj cf jiftassncljuseitg
OFFICE OF THE SECRETARY

DIVISION OF VITAL STATISTICS

COPY OF

CERTIFICATE OF DEATH

Denvers

(City or town making return)

Registered No ......0?..

( (If death occurred in a hospital or institution,
St. ( g>ve its NAME instead of street and number)

2 FULL NAME 9Mls^Xn§...2aLt^ra.Qn )

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

(a.) Residence. No 44......>.i-Ll.QYJ St.

(Usual place of abode)

Length of stay: In hospital or institution - years month<) daysJ5

(Specify whether)

Hlnthroo.

(If nonresident, give efty or town and state)

In this community yrs. mos. days.

PERSONAL AND STATISTICAL PARTICULARS

3 SEX 4 COLOR OR RACE 5 SINGLE

MARRIED

fenalje white widowed

(write the word)

or DIVORCED • STF-ieCl

So I! married, widowed, or divorced

HUSBAND of .... ......

(Give jqaiden name of wife in full)

(or) wife of ... hi Hiata ^ahteraon,

(Husbands name m Fu!

Tull)

6 Age ol husband or wile il alive^ oannotb-e learned ars

7 IF STILLBORN, enter that fact here.

MEDI

13 DATE OF
DEATH

(Month)

(Day)

(Year)

8 f. j. If less than 1 day

AGE Q%ars Months Days Hours Minutes

Usual

9 Occupation:

housewife

Industry
10 or Business:

11 Social Security No bO X.e.SSf

12 BIRTHPLACE (City)
(Slate or country)

rrova-'seotla"

13 NAME OF
FATHER

VJiiiiur, P.oraAt

14 BIRTHPLACE OF
FATHER (Citv) ....

Ijovq ^cotla

(State ot country)

15 MAIDEN NAME
OF MOTHER

Christina Or ay

15 BIRTHPLACE OF
MOTHER (Citv) ....

Mrvtrsa. •»*/■» o

(State or country)

Informant •

(Address)

A TRUE COPT.
ATTEST:

--Dim (

DATE FILED

(Registrar of city or town where death occurred)

2/5/40

19.

is I H Eglt^y cg^T I FT0.9 Th5^8n%ndS^*eased fro^P

-s-2? > 19 -h—. r .40. 19

1 Iast saw k «!*▼« 0“ .140?., death is said

fo have occurred on the date stated above, at m. 1 Duration

•u-i-’-vr......

I..’....::::..; .;. □.*?

Due to

Other conditions

(Include pregnancy within 3 months of death)

PHYSICIAN

Major findings: Underline

Of operations | the cause to

Date of...- 'Thich drath

r\r t i„ should be

Of autopsy CULAU.a ! charged sta-

What test confirmed diagnosis? £LG tisticsHy-

20 Was disease or iojory lo any waj related to occupatien ol deceased T

" *p*"17 Melvin Caortaorr —

(Address) Date

21 CREMATCO^^^felkcVAL '. iinthrop

(Cemetery) , J . • / .{City or Town)

_ DATE OF BURIAL ^ .w.J3.

22 NAMF OF L • -1* '* t; X C/Ll £t iZrisll

FUNERAL DIRECTOR

ADDRESS

Received and filed

(Registrar cf City or Town where deceased resided)

.19.

100m-10-’39. No. 8427-e

■S No

2 FULL NAME

■ vO

(City or Town)

®l }t (Eonutttmfacalllj of ^Hassarhuseiia
OFFICE OF THE SECRETARY
DIVISION OF VITAL STATISTICS

To be filed for burial permit
with Board of Health
or its Agent.

STANDARD

CERTIFICATE OF DEATH Registered No

*— \M \T~r — vf , C. f (M death occurred in a hospital or institution,

bt. i give its NAME instead of street and number)

r-P 1 \ (If u- s-

. . _ J War Veteran,

(If deceased is I married, widowed or divorced woman, give also maiden name.) j spscify WAR)

(a) Residence. No.... St. .

(Usual place of abode) (If nonresident, give city or^own and slate)

days.

Length of stay: In hospital or institution..

(Specify whether)

months

In this

community £(p> "

mas. days.

PERSONAL AND STATISTICAL PARTICULARS

3 SEX

4 COLOR OR RACE | 5 SINGLE
MAHRIED
WIDOWED
i or DWORCEE

(write the, word) Ij 18 DATE OF T’f
|| DEATH

MEDICAL CERTIFICATE OF DEATH

5a Ii married, wido
HUSBAND ol

(or) WIFE of

ojl divorced

( Give ma!r%n name of wife inlull)
(Husband's name in full)

G Age of husband or wife if alive

7 IF STILLBORN, enter that fact hers.

..Tears

AGE .

•Sty Years

If less than 1 day

Months Days j Hours Minutes

9 Occupation: ^ - -»■ ~

Industry
10 or Business:

11 Social Security No

12 BIRTHPLACE (City)
(State or country)

13 NAME OF
FATHER

14 BIRTHPLACE OF
FATHER (City)
(State or country)

15 MAIDEN NAME
OF MOTHER

AJU^L

18 BIRTHPLACE OF

MOTHER (City)

(State or country)

ME D
5

^Due Cfil

Informant..

(Address)

Relation, if nay

)

ndard certificate o £ dsath was
it/permit wers issuedi

(Month Nj (Day) (Year)

i fast saw b...f.m... alive on .. 1S.U/?, d

to have occurred on the date stated aboveMt..jC«^/^^.m.

Irajnediatea cause pf de^jM 1 t

.S..crr»..):.«.[ ^hr.d/S.bA£/S

Due

to jy\

Other conditions . . . . & T.A i . . . .C AT ft / Af.eS .

(Include pregnancy within 3 mnnllis of death)

Major findings : * I - , "

Underline
the cause to

..Date of which death

'should be
'charged sta-

What test confirmed diagnosis? ! tistically.

Of operations'-?!,
Of autopsy

Duration

IMPORTANT

<L Mt.Jis -

ESS. 9 '

PHYSICIAN

20 Wss disease er Injury In <
If so, specify..
(Signed)

(Address).^..

21 Wj _

Place of Burial, Cremation

DATE O]

i related to occupation

EXTRACTS FROM THE LAWS OF THE
COMMONWEALTH OF MASSACHUSETTS
GOVERNING THE

RETURN OF CERTIFICATES OF DEATH

No undertaker or other person shall bury or otherwise dispose of a
human body in a town, or remove therefrom a human body which
has not been buried, until he has received a permit from the board
of health, or its agent appointed to issue such permits, or if there
is no such board, from the clerk of the town where the person died :
and no undertaker or other person shall exhume a human body and
remove it from a town, from one cemetery to another, or from one
grave or tomb other than the receiving tomb to another in the same
cemetery, until he has received a permit from the board of health or
its agent aforesaid or from the cleric of the town where the body is
buried. No such permit shall be issued until there shall have been de-
livered to such board, agent or clerk, as the case may be, a satisfac-
tory written statement containing the facts required by law to be
returned and recorded, which shall be accompanied, in case of an
original interment, by a satisfactory certificate of the attending
physician, if any, as required by law, or in lieu thereof a certificate
as hereinafter provided. If there is no attending physician, or if, for
sufficient reasons, his certificate cannot be obtained early enough for
the purpose, or is insufficient, a physician who is a member of the
board of health, or employed by it or by the selectmen for the pur-
pose, shall upon application make the certificate required of the at-
tending physician. If death is caused by violence, the medical exam-
iner 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 registration. The person to whom the permit is so given
and the physician certifying the cause of death shall thereafter fur-
nish 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.)

RULES OF PRACTICE

The fulfillment of the purpose of these laws calls for the observ-
ance of the following rules of practice:

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

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

or complication which causes death, not the mode of dying, e. g.,
heart failure, asphyxia, asthenia, etc. As principal cause name the
disease causing death. As related causes, name earlier morbid con-
ditions, if any, related to the principal cause and any important
complication of the principal cause.

Statement of Occupation. — Precise statement of occupation is very
important, so that the relative healthfulness of various pursuits
can be known. Make some entry in this section for every person
aged 10 years or over. If the occupation had been given up or
changed on account of the disease causing death, report the usual
occupation prior to illness. If the deceased had retired from busi-
ness, report the usual occupation prior to retirement. Children not
gainfully employed may be returned as at school or o£ 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

Z''

1 R-301 A

(I S.n££.Ql]fe

(County)

i -jo V/int hrop

(City or Town)

®l?c (Eontmnnfncaltfj of JHassttclfusetis

OFFICE OF THE SECRETARY

DIVISION OF VITAL STATISTICS

STANDARD

CERTIFICATE OF DEATH

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

Registered No

No 2.E....U.plaM...Iload st.

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

2 full name Ralp.h...S.lie.rman...J..Q.hns..cn J War Veteran,

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

(a) Residence. No St.

(Usual place of abode)

Length of stay: In hospital or institution..

(Specify whether)

months

days.

(If nonresident, give city or town and state)

In this community O 2 yrs. mos. days.

PERSONAL AND STATISTICAL PARTICULARS

3 SEX

Male

4 COLOR OR RACE

Y/hite

5 SINGLE
MARRIED
WIDOWED
or DIVORCED

(write the word)

Married

husband^' widowed; or diria^rie J3imock

(Give maiden name of wife in full)

(or) WIFE of

(Husband’s name in full)

6 Age of husband or wife if alive 69 years

7 IF STILLBORN, enter that fact here.

AGE

74Yb_8

Years .V Months

Days

If less than 1 day
Hours Minutes

MEDICAL CERTIFICATE OF DEATH

18 DATE OF
DEATH

' ' (Month) /

(Day)

(Year)

I H E R E B.Y.

to Ik

ave occurred on

Usual

9 Occupation:

Manufacturing dept (ret ire { )

EBYTE R.T I F , /That I attended deceased frc

r 9# . ..2r. ., i9..£r.£?.

I last saw h.k^j^dalive on. death is said

the date stated above, at...^....6C.>...m.

Immediate cause oLdeath .y. ,...

.Due to

or Business: .11.#. .§.* Rubber Co

11 Social Security No.

12 BIRTHPLACE (City>Q.._.£<m
(State or country) l«icA SbclC

13 fatmherof John Johnson

14 SETtatyf .Unable to obtain

(State or country)

15 MAIDEN NAME .

of mother Ma ry Thompson

16 mottherA9c::°f Una b l e t o ... Ob t a in

(State or country)

Informc:

(Address

Relation, if .any

^ Barbara Johnson /laugnterx
&2 Upland Hd :7ihtErW " }

I HEREBY CERTIFY thpt a satisfactory standard certificate of death was
filed .v^th me BErCRE the b>raia^6i^tr^sit/permit was issued:

lealth .

Board

.. k'/J /f.A

(Date of Issue oN/’ermit) / '

Due to

Other conditions
(Include pregnancy within

'months of death)

Major findings
Of operations •

.Date of..

Of autopsy

What test confirmed diagnosis

2G Was disease or injur/ In any way related to occupation of deceased?
If so, specify/

(Signed)

(Adds

Duration

liiPfimHT

PHYSICIAN

Underline
the cause to
which death
sjiould be
arged sta-
tistically.

lint. hr op. (..tomb) ‘^Tii^irop.

SS OFBOTl!^^

22 FUNERAL DIRECTOR OhUX.X.Q.S R.« B.Snn IS .011..

address ,.lrin.t..hr..Q.p....lla.s..s

Received and filed .

.19..

(Registrar)

EXTRACTS FROM THE LAV/S 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

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