The volume, 1941

Town Clerk, Winthrop · from the Internet Archive · 544 pages · 41.7 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. S 3 *T

-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.

RM R -30 1 A

Suffolk

(County)

.Vinthrot)

(City or Town)

No ii5.....3anks___St_v

®!|e (ffcr.tuumfiTraltb of (^Massachusetts

OFFICE OF THE SECRETARY

DIVISION OF VITAL STATISTICS

STANDARD

CERTIFICATE OF DEATH

To b« filed for burial permit
with Board of Health
or its' Agent.

Registered No

.St.

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

2 FULL NAME Maria Ottonello Martini )

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

(a) Residence. No....{r...< .? .?*. ht.'.? §.1d.» St. .

(Usual place of abode)

Length of stay: In hospital or institution.

(Specify whether)

years

months

days.

(If nonresident, give city or town and state)

In this community 2 5 yrs- mos. days.

PERSONAL AND STATISTICAL PARTICULARS

3 SEX

Female

4 COLOR OR RACE

■Shite

5 SINGLE
MARRIED
WIDOWED
or DIVORCED

(write the word)

'.V idowed

5a If married, widowed, or divorced
HUSBAND of

fiiye maidejijiame pf.wife.in full)

(or) WIFE of

(Give maiden name of wife in

August ino Martini

(Husband’s name in full)

6 Age of husband or wife if alive years

7 IF STILLBORN, enter that fact here.

AGE

Years Months

Days

If less than 1 day
Hours Minutes

Occupation: SSj&lESSL

Industry
iO or Business:

Housewi fe

11 Social Security No..

12 BIRTHPLACE (City)
(State or country)

"Italy

13 NAME OF
FATHER

Giacomo Ottonello

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

Italy

15 MAIDEN NAME

of mother Domonica Oddone

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

Italy

7 ^ Relation, if any

Informant. ..Maria C..iQ..m daughter...)

.(Addresser ^ Vo > V ft)).

I^HERJSBY CERTIFY that a satisfactory standard certificate of death was
vith mo BEFORE thpsfiyiriai pr transit permit was issued:

nature or ^gent of BoarcMjy Heamror other)

... //S.

(Official Designation) / (Date of Issue /f Perm;*

MEDICAL CERTIFICATE OF DEATH

/ , Itll

(Day) ' (Year)

19 I H ET? EBY CERTIFY, / That I attended deceased from

, 19.#/.

I last saw h~&tH’.... alive on •..../. death is said

to have occurred on the date seated above, at/^.'.j £.377.#?-.. .m.

Immediate cause of death..

Other conditions r...

(Include pregnancy within 3 months oi death)

Major findings :

Of operations 77777.

Date of...

Of autopsy hr..

What test confirmed diagnosis? T7777..

PHYSICIAN

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

20 Was diseasa ar Injury In any way related te occupation el deceased? . .

If so, specjJ

(Sign ■ M. D.

(Address)//yyh^.h7r,.Luy7.u tf/u&iZiU 19.4^./.

21 Si... Michaels. B.as.lan -

Place of Burial, CrematiM.^or R^moyfl. j. (City or Town) t

DATE OF BURIAL UU&r.Y — > 19 Gl

FUNERAL DIRECTOR JFZV..'T'.

ffintnrab Massachusett

22 NAME OF
FUNERAL

ADDRESS

Received and filed

.19..

(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 emploj'ed 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.)

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„ ( 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 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

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.

RM R-301 A

(City or Town)

0ljr (ttninmmtuiraltfj nf IHasBarljnartta
OFFICE OF THE SECRETARY
DIVISION OF VITAL STATISTICS

STANDARD

certificate OFJDEATH

2 FULL NAME.

^ C.

To be filed for buri&l 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)

Length of stay: In hospital or institution

( Lfyieceasedfe'a married, widowed or divorced woman, give also maid,

£ ; t s>

/X months A

iden name.)

(If U. S.

War Veteran,
specify WAR)..

(Specify whether)

days.

(If nonresident, give city or town and state)

In this community ^ yrs. mos. days.

PERSONAL AND STATISTICAL PARTICULARS

3 SEX

4 COLOR OR RACE

5 SINGLE (write the word)

MARRIED /

WISOWED UASL-4-J

or DIVORCED

5a If married, widowed, or divorced
KUS3AND of -

(Give maiden name of wifeTn full)

(or) WIFE of

(Husband’s name in full)

6 Age of husband or wife if alive .

7 IF STILLBORN, enter that fact here.

8 ^7 7 J S' ( I If less than 1 day

s Af-A- / J - I

AGE..

..Years ^TT^Months Days| Hours Minutes

9 Occupation : ^ ]

or Business:....

11 Social Security No.

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

13 NAME OF
FATHER

5V . Q-'-cZ^&^Z

14 BIRTHPLACE OF

FATHER (City)

(State or country)

IS MAIDEN NAME,
OF MOTHER

Z/t '> .c-t >t^t«

16 BIRTHPLACE OF ^2^

MOTHER (City)
(State or country)

Informan

(Address) /A f

I HEREBY CERTIFY that a satisfactory standard certificate of death
^w^s^iled witl^^^-BEF^^^Hi^^uria^or transit permit was issued:

(Official Designation)

(Date of Issue of Permit)/

MEDICAL CERTIFICATE OF DEATH

19 I H &* EBY CERTIFY, That 1 attended deceased from

, 19 , to , 19

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

have occurred on the date stated above, at
Immediate cause of death..

Duration

IHP0ITAN1

Due to

Major findings: ^
Of operations ...

Of autopsy .

What test confirmed diagnosis?.

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

(Signed)

Dat 19.:

Place of Burial, Cremation or^Removal. ^ , (City orTown)

DATE OF BURIAL

rf.i9..V?.

22 NAME OF

FUNERAL DIRECTOR

ADDRESS

Received and filed..

.19..

(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 registration a standard
certificate of death, stating to the best of his knowledge and belief the
name of the deceased, his supposed age, the disease of which he died,
definded 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 receiv-
ing tomb to another in the same cemetery, until he has received a permit
from the board of health or its agent aforesaid or from the clerk of the
town where the body is buried. No such permit shall be issued until
there shall have been delivered to such board, agent or clerk, as the case
may be, a satisfactory written statement containing the facts required by
law to be returned and recorded, which shall be accompanied, in case of an
original 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 in-
sufficient, a physician who is a member of the board of health, or em-
ployed by it or by the selectmen for the purpose, shall upon application
make the certificate required of the attending physician. If death is caused
by violence, the medical examiner shall make such certificate. If such a
permit for the removal of a human body, not previously interred, from
one town to another within the commonwealth cannot be obtained early
enough for the purpose, the certificate of death made as above provided
and in the possession of the undertaker desiring to make such removal
shall constitute a permit for such removal; provided, that such body shall
be returned to the town from which it was removed within thirty-six
hours after such removal, unless a permit in the usual form for the re-
moval 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.,
( 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., ( Tercentenary
Edition).

RULES OF PRACTICE

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

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

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

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

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

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 business, 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

-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.

RM R-301 A

/5....s.ur.i:.i.o.s.

\q (County)

1 \o Ji^nDhrop

/ w (City or Town)

<Av fEIie dmujnan(tt?altl| of JiNassacljusetts

-SSU 'office of the secretary

- ^ DIVISION OF VITAL STATISTICS

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

Registered No

STANDARD

CERTIFICATE OF DEATH

^ No .W.in.txir.Q.P.^ St. { give its NAME instead of st'ree

2 full name Anna ,(.K&<iey.) .Qampfeell > War Veteran,

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

or institution,
street and number)

(a) Residence. Nj?.Sl..Shirlej, st.

(Usual place of abode)

Length of stay : In hospital or institution..

(Specify whether)

months

days.

(If nonresident, give city or town and state)

yrs. mos. days.

In this community 1

PERSONAL AND STATISTICAL PARTICULARS

3 SEX

Female

4 COLOR OR RACE

Minis

(write the word)

5 SINGLE
MARRIED
WIDOWED ,

or DIVORCED -VOLdOW

5a If married, widowed, or divorced

HUSBAND of

(Give maiden name of wife in full)

(or) wife of Robert. . ..M Campbell

(Husband's name in full)

6 Age of husband or wife if alive years

7 IF STILLBORN, enter that fact here.

AGE

.18.

Year;

Months ..Cl... Days

If less than 1 day
Hours Minute*

9 Occupation: ..Housewife..

Industry
10 or Business:

Own Home

11 Social Security No.

12 BIRTHPLACE (City)
(State or country)

St. Johns

13 NAME OF

father if/nnam Kedev

14 BIRTHPLACE OF
FATHER (City) .

St.

Johns

(State or country)

New

Brumswick

15 MAIDEN NAME

OF MOTHER

Jane

Siz.e

16 EIRTHPLACE OF
MOTHER (City) ...

St .

J unns

(State or country)

New BrumswiCK

17 Relation, if any

Informant tfl.lHam...JilQ.rrl.S..Qn (Son....l.n...La

(Address) CM t SnlrlSV S L . .LllU ; _ i'C VJ

I HEREBY CERTIFY that a satisfactory standard certificate of death was
filed v^ith me BEFORE the hurkfl or tyinsjA permit was issued:

/Signature .^rjAgent of Board of Hea

Y__ _ , k&,. /jS/f/

(Official Designation)/ J (Date of Issue of Bermit)/ ‘

MEDICAL CERTIFICATE OF DEATH

18 DATE OF . c\ . f\A a

death January 2, 1941

(Month)

(Day)

(Year)

19 I HEREBY CERTIFY. That 1 attended deceased from

U»roh...ll#....19.4Q9 to..J..€«iWftry....2^...1.9.41i3

I last saw b.er. alive on.. aaauary...2>194i ..., death is said

to have occurred on the date stated above, at... 2;.3.Q....p. .m.

Immediate cause of death

Duration

ihportaht

o inam .. .p. e r f q rated to.v..4?os

Due to
Due to

Other condition^.ter.iP.§5.1e.ro.si.§j...nyper.tei^i.gQ..iPyr
(Include pregnancy within 3 months of death)

Major findings :

Of operations

Date ofl2.^2S/r4Q..

Of autopsy

What lest confirmed diagnosis?

PHYSICIAN

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

20 Was disease orjdfury In any way related tn occupation of dseaased? .
If so, spec/

(Signed) '

3 1941

21 F»**nwww»tiaa»wi«:iew BruMsvlejt

1 (City or Town)

DATE OF BURI

Received and 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 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 ether 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, 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) 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 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 Occupation. — Precise statement of occupation is very
Important, so that the relative healthfulness of various pursuits
can be known. Make some entry in thi3 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

M R-301 A

“ ® Z

5 *• ~

a O

a ~ «
3 “t,

:*o •<
■3 n
* oD
3*5 u
: u

Jtn O

< °

y 0

50 c
>. c

I -

£2

>? 25

J x *•
HU g

0 «

yTJ 0
r> v
U<e Jd

1 *5 «

iTJ « S

1 41 rt

3 0 g

* ►» _

h >

o j
aJS

2 •

aj=

> ® -
: us S
* o

►» Si

1 <d u*

.m o
— ci
44 J3

2 x
•5 o

*• N

c .2

A "B

S'-S

.2 2

a.S

(i c o
®

tjj -

-2h .

j g< -s
sjgu g
?“Q:
J gU g.
^•20 |

d 2 UT

« a to £

l . — . r*

r ~ ••

t.Su.2

(City or Town) /

I no 4a ^

tJljr QInmmnmuraltlj of JHojiBarffHiiftljB
OFFICE OF THE SECRETARY
DIVISION OF VITAL STATISTICS

2 FULL NAME

(a) Residence. No

(Usual place of abode)

-j£seS^Ci

^ (If deceased is a married, widowed_Qr divossed women, g

6ul

STANDARD

CERTIFICATE OF DEATH

6o<a-^

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

Registered No

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

'omen, give also maiden name.)

OUdL<>_^

.St.

(If u. s.

War Veteran
specify WAR)

,• ha.

Length of stay: In hospital or institution .

(Specify whether)

years

months

days.

(If nonresident, give city <^town and state)

In this community^^' yrl. mos. days.

PERSONAL AND STATISTICAL PARTICULARS

3 s:

4 colo;

OR RACE

5 SINGLE (write the word)
MARRIED '

WIDOWED
or DIVORC1

yvvutt tuv. nui'

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.

If less than 1 day

ours Minutes

16 BIRTHPLACE OF

MOTHER (City)

(State or coi

MEDICAL CERTIFICATE OF DEATH

18 DATE OF
DEATH

((Month)

...3.

(Day)

(Year)'

I HEREBY CERTIFtY, That I attended deceased from

... wv/, , 19 y/

list saw h...L4a^live on , 19,'j/, death is said to

&ve occurred on the date state® above, at....J..!..tyLi.~T../k

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?..

IMPORT ANT

PHYSICIAN

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

20 Wu disease or injury in any way related to occupation of deceased?..

If so, specify... ■An

(Signed) .j. M. D.

(Address). 4L(.4jfc ,19...ty

Received and filed..

.19..

(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 registration a standard
certificate of death, stating to the best of his knowledge and belief the
name of the deceased, his supposed age, the disease of which he died,
defined as required by section one, where 6ame 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 receiv-
ing tomb to another in the same cemetery, until he has received a permit
from the board of health or its agent aforesaid or from the clerk of the
town where the body is buried. No such permit shall be Issued until
there shall have been delivered to such board, agent or clerk, as the case
may be, a satisfactory written statement containing the facts required by
law to be returned and recorded, which shall be accompanied. In case of an
original 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 In-
sufficient, a physician who is a member of the board of health, or em-
ployed by it or by the selectmen for the purpose, shall upon application
make the certificate required of the attending physician. If death is caused
by violence, the medical examiner shall make such certificate. If such a
permit for the removal of a human body, not previously interred, from
one town to another within the commonwealth cannot be obtained early
enough for the purpose, the certificate of death made as above provided
and in the possession of the undertaker desiring to make such removal
shall constitute a permit for such removal; provided, that such body shall
be returned to the town from which it was removed within thirty-six
hours after such removal, unless a permit in the usual form for the re-
moval 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. 4 5. 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 burled 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 observance of
the following rules of practice :

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

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

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

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

SPACE FOR ADDITIONAL INFORMATION

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.

RM R-301 A

(County)

21?* CSnmmnnujealtf? uf fflaatiartjuflrtta
OFFICE OF THE SECRETARY

DIVISION OF VITAL STATISTICS

STANDARD
RT1F1CATE OF DEATH

No.

2 FULL NAME...'

(If deceaL— ^

(a) Residence. No...^!.^.

(Usual place of abode)

Length of stay: In hospital or institution

(City or ^ CERT1FI

roman, give alsi

...'t:**. . . years

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

Registered No.

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

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

(If u. s.

War Veteran,
specify WAR)..

months

(Specify whether)

days.

(If nonresident, give city or town and state)

In this community? ^ yrs. mos. days.

PERSONAL AND STATISTICAL PARTICULARS

4 COLOR OR RACE

5 SINGLE
MARRIED
WIDOWEJ
or DIVO:

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.

Usual
9 Occupation:

I If less than 1 day

onths Days! Hours Minutes

’■Sty...

S&S7-. <jQ»

11 Social Security No. I

12 BIRTHPLACE (i

(State or country)

14 BI&PHPLACE OF |
FATHER (City) ....
(State or country)

MEDICAL CERTIFICATE OF DEATH

1J9 (] \ HEF&EBY CERTI Y Y . That I attended deceased from

i9.y..d to Q-&A*****y <3 , ia y/

I last saw hrrrd?(L.. alive on. death is said to

have occurred on the date stated above, at //....• /dr. m. '

Immediate causo of death .a

Due to

Other conditions

(Include pregnancy within 3 months of death)

Major findings: -

Of operations.„^?^I?l^f..

IMPOITAN?

PHYSICIAN

Of autopsy

What test confirmed

ny way related Je eccupslion of deceased?.

y - n

bZat+ttA \%%/

(Registrar)

EXTRACTS FROM THE LAWS OF THE
COMMONWEALTH OF MASSACHUSETTS
GOVERNING THE

RETURN OF CERTIFICATES OF DEATH

A physician or registered hospital medical officer shal I forthwith,
after the death of a person whom he has attended daring his last illness,
at the request of an undertaker or other authorized person or of any
member of the family of the deceased, furnish for registration a standard
certificate of death, stating to the best of his knowledge and belief the
name of the deceased, his supposed age, the disease of which he died,
definded 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 receiv-
ing tomb to another in the same cemetery, until he has received a permit
from the board of health or its agent aforesaid or from the clerk of the
town where the body is buried. No such permit shall be issued until
there shall have been delivered to such board, agent or clerk, as the case
may be. a satisfactory written statement containing the facts required by
law to be returned and recorded, which shall be accompanied, in case of an
original 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 in-
sufficient, a physician who is a member of the board of health, or em-
ployed by it or by the selectmen for the purpose, shall upon application
make the certificate required of the attending physician. If death is caused
by violence, the medical examiner shall make such certificate. If such a
permit for the removal of a human body, not previously interred, from
one town to another within the commonwealth cannot be obtained early
enough for the purpose, the certificate of death made as above provided
and in the possession of the undertaker desiring to make such removal
shall constitute a permit for such removal; provided, that such body shall
be returned to the town from which it was removed within thirty-six
hours after such removal, unless a permit in the usual form for the re-
moval 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„
( 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., ( Tercentenary
Edition).

RULES OF PRACTICE

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

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

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

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

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

50m-10-’39. No. 8427-f

302

5 1.Q.r.G.e.s..t..ar..

W (County)

©fje ©ommortfDealtlj of <i!Haseacl]usetts
OFFICE OF THE SECRETARY
DIVISION OF VITAL STATISTICS

COPY OF

CERTIFICATE OF DEATH

Gxa.tb.QM

(City or town making return^

Registered No

o Grafton

U (City or Town)

| No Gr.af.ton...S.ta.ta....Ho.s.pxt.al. St. { i” IS*1 name" o^t

2 FULL NAME Aly.§.h...A*.....3.0.1.C.har. ] (If U. s.

(If deceased is a married, widowed or divorced woman, give also maiden name 1 ) War Veteran,

! specify WAH)

(a) Residence. St. ... &T.Q..p.,L....I.Ia § S •

(Usual place of abode) p a tt g n - -

Length of stay: In hospital or institution.™.*. I?.?.. ..7..* years

(Specify whether)

^ months ^ ^ days.

(If nonresident, give city or town and state)

In this community yrs. mos days

PERSONAL AND STATISTICAL PARTICULARS

3 SEX 4 COLOR OR RACE 5 SINGLE

I MARRIED

« I . i WIDOWED

Hale White ! or divorced

5a If married, widowed, or divorced
HUSBAND of

(Give maiden name of wife in full)

(or) WIFE oi

(Husband’s name in full)

(write the word)

.Single

6 Age of husband or wife ii alive years

7 IF STILLBORN, enter that fact here.

AGE.7.8 Years Months..

Days

If less than 1 day
Hours Minutes

9 Occupation:

10 or^Budness: U.Q.t L&arH£.i.

11 Social Security No.

.item.

12 BIRTHPLACE (City) .Ain t&P.Q.g

(State or country) i'.TS S S •

13 NAME OF
FATHER

Samuel Belcher

14 BIRTHPLACE OF
FATHER (City) .

Winthrop

(State or country)

Mass.

15 MAIDEN NAME
OF MOTHER

Not learned

16 BIRTHPLACE OF
MOTHER (City) .

....Hammond

(State or country)

New Hampshire

<*dto“> Sreftnn. >

(Registrar of city or to

DATE FILED 7..*..

.19

..41..

MEDICAL CERTIFICATE OF DEATH

18 dea!hof January. 3, 1941

(Month) h<hay) (Year)

I9 I H EREBYCERTIFY. That I attended deceased from
19.4.0., to Jmu&xxJS.* 19.il

I last saw h...l.m.aiive on...sI.a.&» §.a death is said

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

^‘Ukration

Hr.emia

Due to Hydro nephrosis

Many

yrs .

Due to Hy.P.e.r.t.x.Q.phy.....o.f ....pro.s.tat.e.

Many....
v rs .

Other conditions

PHYSICIAN

(Include pregnancy within 5 months of death)

Major findings :

Of operations -...QP.S.

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

Of autopsy N.Q.n$

What test confirmed dia miosis ^

If so, specify

(Signed) . H e - Patt on ... „

(Address)ir.Q.,..ar.a.f .t.Q.n...MaLL..s..e. Datn 1 /4 i9 41

M. D.

21 PLACE OF BURIAL, Hi

CREMATION OR REMOVAL ... : l.llP.^S.h.t .* NO, Grafton
(Cemetery) (City or Town)

date of burial January. 7. 19. ...41

22 NAME OF

FUNERAL DIRECTOR l.emplfi

ADDREssiI.Q..r.th Graft o n

Received and filed

(Registrar of City or Town where deceased resided)

.19.

Middl.e.s.e.x

(County)

(Hlje (Ennuttcmhiealtlf of (iHass;tcI|ttsetts
OFFICE OF THE SECRETARY

DIVISION OF VITAL STATISTICS

COPY OF

CERTIFICATE OF DEATH

Melrose

(City or town making return)

Registered No.

o Melrose

W (City or Town)

„ / (If death occurred in a hospital or institution,

MelrOSe .JlO SJD1 taJ. St. I give Its NAME instead of street and number)

i No,

2 FULL NAME

j ron

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

. . D . , M 60 Cliff Ave.

(a) Residence. IMo

(Usual place of abode) q wppvt.

Length of stay: In hospital or institution .S....v.£.5«k.s....

(Specify whether)

.St.

Winthron

years

months

days.

(If nonresident, give city or town and state)

In this community yrs. mos. days.

PERSONAL AND STATISTICAL PARTICULARS

3 SEX

Female

(write the word)

4 COLOR OR RACE 5 SINGLE
| MARRIED

White i ^'divorced Single

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

(Give maiden name of wife in full)

(or) WIFE of

(Husband’s name m full)

6 Age of husband or wife if alive years

7 IF STILLBORN, enter that fact here.

8 a q e c If less than 1 day

AGE .3.5... Years Months Y...Day3 Hours Minutes

9 Occupation: Sch.Q.Q.l . Je^.cMr..

Industry
10 or Business:

11 Social Security No.

12 BIRTHPLACE (City)
(State or country)

Boston

Mass ,

13 NAME OF
FATHER

Adolph Grobe

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

Germany

15 MAIDEN NAME
OF MOTHER

Carrie L. DeMond

1G BIRTHPLACE OF
MOTHER (City)

(State or country)

Boston

Mass .

^Informant Adplph GfObe (

(Address) xi Derr i ng Ave. . Braihtree, Mass.

A TRUE COPY.
ATTEST:

(jbjfrrU)Hx£ $

(Registrar of city or town where death occurred)

DATE FILED Jan. ?.., 1.94.1 19..

MEDICAL CERTIFICATE OF DEATH

18 death°F Jan...... 4.,... 1941

(Month)

(Day)

(Year)

19 I HEREBYCERTIFY, That 3 attended deceased from

IS.??.. 39 to...Jaa.t...4/4l 19

I last saw h....vL?...alive on 19 death is said

to have occurred on the date stated above, a d". . i .Vr. . . A. .’. H
Immediate cause of death

C.arcinpma ..of ..the stomach

Due to

Other conditions

(Include pregnancy within 3 months of death)

Duration

PHYSICIAN

Major findings: - - _

Of operalions .ji?2.L9.?T.Ol9.:C.y....L.~d?.

Date of...Q.C.t;....?.9/4.0

Of autopsy

What test confirmed diagnosis?. ..Clinical

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

If so, specify

(Signed) R.* Layton

(Address ) M.o.l.r.o.s.e..,....M.as.s..,. Date.

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

21 PLACE OF BURIAL. w. .. i. r . , ,

cremation or removal Wintnrop « lnthrpp

T (Cemetery) (City or Town)

Jan. 6, 1941

DATE OF BURIAL..

.13

22 funeral director A*.....?.* Ballantyne

address M.e..ir.o..s.e..,....M.c:

Received and filed

(Registrar of City or Town where deceased resided)

.19..

?M R-301 A

®t?r GJnmmnnroraltb of fHuaaarljuflptt*
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

mr vj / in m p , f death occurred in a hospital or institution,

Ko.XJ.A St. {give its NAME instead of street and number)

2 FULL NAME ) _

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

(a) Residence. N St

(Usual place of abode) (If nonresident. ^ive city or town and state)

Length of stay: In hospital or institution, Tlamsisf sir,... years months days. In this community^ o' yrs, mos. days.

(Specify whether) '

PERSONAL AND STATISTICAL PARTICULARS

3 SEX

4 COLOR OR RACE

^ DIVORCED

S SINGLE
MARRIED

(write the word)

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

(Give maiden

(or) WIFE of

in name opwife in full)

(Husband’s name in full)

6 Age c£ husband or wife if alive years

7 IF STILLBORN, enter that fact here.

8 **7/1 I than 1 day

AGE... Years Month* Days! Hours Minutes

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)

1±!±Z

IS MAIDEN NAME
OF MOTHER

16 BIRTHPLACE OF

MOTHER (City)

(State or country)

Relation, if any

)

Informant w

(Address)

MEDICAL CERTIFICATE OF DEATH

18 DATE OF
DEATH

(a li£.l

/] (Month)/] (Day) (Year)

19- I HEREBY CERTIFY, That I attended deceased,from

.Jfy^rl dl, 1*27 ^....1^2^..^ 19

I last saw fc.^L.alive on 1^^/ death is said to

have occurred on the date statoi above, at.... m.f

lediate yause of death. J. /.

Due to..

Due to.

Other wwMoii^^ — -

(Include pregnancy within 3 months

Major findings:

Of operations. .Z^d^T...

Date of.

Of autopsy..

What test confirmed diag

PHYSICIAN

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

20 Wu disea,, or injury in any way related te aecupalion of deceased?..

If so, specify...

(Signed) „ M. D.

ADDRESS

22 NAME OF

FUNERAL DIRECTOR

Received and filed..

.19..

(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 registration a standard
certificate of death, stating to the best of his knowledge and belief the
name of the deceased, his supposed age, the disease of which he died,
definded 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 receiv-
ing tomb to another in the same cemetery, until he has received a permit
from the board of health or its agent aforesaid or from the clerk of the
town where the body is buried. No such permit shall be issued until
there shall have been delivered to such board, agent or clerk, as the case
may be, a satisfactory written statement containing the facts required by
law to be returned and recorded, which shall be accompanied, in case of an
original 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 in-
sufficient, a physician who is a member of the board of health, or em-
ployed by it or by the selectmen. for the purpose, shall upon application
make the certificate required of the attending physician. If death is caused
by violence, the medical examiner shall make such certificate. If such a
permit for the removal of a human body, not previously interred, from
one town to another within the commonwealth cannot be obtained early
enough for the purpose, the certificate of death made as above provided
and in the possession of the undertaker desiring to make such removal
shall constitute a permit for such removal; provided, that such body shall
be returned to the town from which it was removed within thirty-six
hours after such removal, unless a permit in the usual form for the re-
moval 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.,

( 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., (Tercentenary

Edition).

RULES OF PRACTICE

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

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

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

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

SPACE FOR ADDITIONAL INFORMATION

?M R-301 A

(Sc ..S.Ur.r.lO.K

u
\q
Jtu

(County)

o Winthrop

[4 (City or Town)

Slfr fflnmtnmtuiralll) nf HaBHarljujrrttB
OFFICE OF THE SECRETARY

DIVISION OF VITAL STATISTICS

STANDARD

CERTIFICATE OF DEATH

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

Registered No .1

\3 M 40 Thornton Park c. f (If death occurred in a hospital or institution.

No rr.V. . . . J-. Af-W .+. “ .V. XAt:.. ± i . AV St. {give its NAME instead of street and number)

2 FULL NAME I^UC^...Hppe....(JH.aWS.S.)....CM.Ce j

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

Veteran,
specify WAR)..

(a) Residence. No .4.Q...T^0.mt.Qa....?.ark 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 f £yrs. mos. days.

3 SEX

Female

PERSONAL AND STATISTICAL PARTICULARS

(write the word)

4 COLOR OR RACE

White

S SINGLE
MARRIED

widowed Yo r»md

or DIVORCED ^0.1 I It

5a If married, widowed, or divorced

HUSBAND of

(Give maiden name of wife in full)

tor) wife of....F.mcLrl.c.k...B Chace

(Husband’s name in full)

6 Age of husband or wife if alive..

7 IF STILLEORN, enter that fact here.

8 . .. , I If less than 1 day

AGE./..U Years..... TT... Months |^.....Days| Hours Minutes

9 Occupation : HOUSeWire.

10 or B^sYness: O.W.n....H.QUIS

Social Security No —

19 RTRTHPT.AP.F. (CAUr)

Chatham

(State or country)

Mass .

13 NAME OF
FATHER

Daniel Howes

14 BIRTHPLACE OF
FATHER (City)

Chatham

(State or country)

Mass-.

«
<
c u

15 MAIDEN NAME
OF MOTHER

Hope Atkins

16 BIRTHPLACE OF
MOTHER (City)

Chatham

(State or country)

Mass .

Informant

(Address)

or transit permit was issued:
of Bo^j^Tf 'tie^h or other) /
e of Perm ft) *

MEDICAL CERTIFICATE OF DEATH

18 DATE OF
DEATH

1 H e"r e BY CERflFY, That Uttended deceased from

19 ...tf.A

I last saw h.*&rr. ..alive 19.$#.., death is said to

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

Immediate cause of death...

(Month)

I2Z

(Day) 1

lt±L

(Year)

Due to

Due to .fti..

Other conditions..

(Include pregnancy within 3 months of death)

Of autopsy.

What test confirmed diagnosis?.

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

(Signed) , M. D.

(Address) . Date A .19.*/..

21..^^ Chattiaiii

Place of Burial, Cremation or Removal.

DATE OF BURIAL 9..

(City or Town)

.19

22 FUNERAL DIRECTOR.^OW&.F^....,?. Y.^5?.."!^.^.?..

ADDRESS Winthrop Mass.

Received and filed..

..19..

(Registrar)

■4

EXTRACTS FROM THE LAWS OF THE
COMMONWEALTH OF MASSACHUSETTS
GOVERNING THE

RETURN OF CERTIFICATES OF DEATH

A physician or registered hospital medical officer shall forthwith,
after the death of a person whom he has attended during his last illness,
at the request of an undertaker or other authorized person or of any
member of the family of the deceased, furnish for registration a standard
certificate of death, stating to the best of his knowledge and belief the
name of the deceased, his supposed age, the disease of which he died,
definded 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 receiv-
ing tomb to another in the same cemetery, until he has received a permit
from the board of health or its agent aforesaid or from the clerk of the
town where the body is buried. No such permit shall be issued until
there shall have been delivered to such board, agent or clerk, as the case
may be, a satisfactory written statement containing the facts required by
law to be returned and recorded, which shall be accompanied, in case of an
original 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 in-
sufficient. a physician who is a member of the board of health, or em-
ployed by it or by the selectmen for the purpose, shall upon application
make the certificate required of the attending physician. If death is caused
by violence, the medical examiner shall make such certificate. If such a
permit for the removal of a human body, not previously interred, from
one town to another within the commonwealth cannot be obtained early
enough for the purpose, the certificate of death made as above provided
and in the possession of the undertaker desiring to make such removal
shall constitute a permit for such removal; provided, that such body shall
be returned to the town from which it was removed within thirty-six
hours after such removal, unless a permit in the usual form for the re-
moval of such body has been sooner obtained hereunder. If the death
:ertificate 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
t to the clerk of the town for registration. The person to whom the permit
s so given and the physician certifying the cause of death shall thereafter
:umish 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, Sec. 46, G. L., (Tercentenary
Edition).

RULES OF PRACTICE

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

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

(3) Medical Examiners will investigate and certify to all deaths
supposably due to Injury. These include not only deaths caused
directly or indirectly by traumatism (including resulting septicemia),
and by the action of chemical (drug3 or poisons), thermal, or electrical
agents, and deaths following abortion, but also deaths from disease
resulting from injury or Infection related to occupation, the
sudden deaths of persons not disabled by recognized disease,
and those of persons found dead.

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

SPACE FOR ADDITIONAL INFORMATION

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-301 A

®lfp ®nmmomnealtlj of dJaonarljujSfttjB
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 7......

2 FULL NAME

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

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

(a) Residence. No. tfc/1. St

(Usual place of abode)

Length cf stay: In hospital or institution. .

(Specify whether)

years

months

days.

fO...

(If nonresident, give city or ywn and state)

In this community ) raos. days.

PERSONAL AND STATISTICAL PARTICULARS

4 COLOR OR RACE

(write the word)

5a If married, widowed, or divorced

husband of

(Give maiden same 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.

8 / I If lees than 1 day

AGE. A. 5. Years Months Days! Hours Minutes

Usual
9 Occupation:

Industry
10 or Business:,

11 Social Security No.

XX ijutiai ouLuiity

12 BIRTHPLACE (City) ’.

(State or country) j *>. ..

13 NAME OF
FATHER

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

15 MAIDEN NA
OF*MOTHER

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

(Address)

Rdation, if any

standard certificate of death
r transit permit was issued:

u /

(Date of Issue of Permit)

That I attended deceased from

*rr.A, 19...#/

'if//, death is said to

t.m.

. i&B

CL jl,

Due to f> ’

3ICAL CERTIFICATE OF DEATH

18 DATE OF
DEATH

■.(/f/rr. :

(Month)

Tgfir...

VT) I H E R E BY C E

r.t lL#

I last s^y alive on...

have occurred on the date sta|
Immediate cause of death ...

Due to..

Other conditions

(Include pregnancy within 3 months of death)

Major findings:
Of operations .

Date of...

What test confirmed diagnosis?.

Duration

IMPOKMN!/-

IliPOITANf

PHYSICIAN

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

No undertaker or other person shall bury or otherwise dispose of a
human body in a town, or remove therefrom a human body which has
not been buried, until he has received a permit from the board of health,
or its agent appointed to issue such permits, or if there is no such board,
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 receiv-
ing tomb to another in the same cemetery, until he has received a permit
from the board of health or its agent aforesaid or from the clerk of the
town where the body is buried. No such permit shall be issued until
there shall have been delivered to such board, agent or clerk, as the case
may be, a satisfactory written statement containing the facts required by
law to be returned and recorded, which shall be accompanied, in case of an
original 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 in-
sufficient, a physician who is a member of the board of health, or em-
ployed by it or by the selectmen for the purpose, shall upon application
make the certificate required of the attending physician. If death is caused
by violence, the medical examiner shall make such certificate. If such a
permit for the removal of a human body, not previously interred, from
one town to another within the commonwealth cannot be obtained early
enough for the purpose, the certificate of death made as above provided
and in the possession of the undertaker desiring to make such removal
shall constitute a permit for such removal; provided, that such body shall
be returned to the town from which it was removed within thirty-six
hours after such removal, unless a permit in the usual form for the re-
moval 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„
( 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., ( Tercentenary
Edition).

RULES OF PRACTICE

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

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

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

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

SPACE FOR ADDITIONAL INFORMATION

N. B. WRITE PLAINLY, WITH UNFADING BLACK INK — THIS IS A PERMANENT RECORD. Every item of

200m-10-’39. No. 8427-d

DRM R-301

(County) '

®Ijc Contmnnfuealilj of iilaosacl]UB*tl*
OFFICE OF THE SECRETARY

DIVISION OF VITAL STATISTICS

STANDARD

CERTIFICATE OF DEATH

(City or town making return)

Registered No.

o '.A/|

W (City or Town/

«C t i / jJ I “~~t — — l , J f) ( (If death occurred in a hospital or institution,

gj No.Y^.i.hu(LM.)C Tiy\ St. I give its NAME instead of street and number)

FULL NAME - j

(If dec«sed» is a married, widowid or divorced woman, give also maiden name.) (

ecase

(a) Residence. No..

(Usual place of abode)

.englh of stay: In hospital or institution

(Specify whether)

Veteran.

WAR)

St. .

months days.

(If nonresident, give city or town and state)

In this community yrs. mos. days.

PERSONAL AND STATISTICAL PARTICULARS

3 SEX

4 COLOR OR RACE
vc/ W tVr,

5 SINGLE
MARRIED
WIDOWED C | vi c. (,
or DIVORCED ** ^

(write the word)

5a If married, widowed, or divorced

HUSBAND of v

(Give maiden name of wife in full)

(or) WIFE of

(Husband’s name in full)

G Age of husband or wife if alive ...yearn

7 IF STILLBORN, enter that fact here. g i H q y

AGE

..Years Months..

If less than 1 day
Days Hours Minutes

Usual

9 Occupation: .

Industry
10 or Business:

11 Social Security No.

12 BIRTHPLACE (City)
(State or country)

s^.v.vv F,.V5..)r.r.'^..

13 NAME OF
FATHER

14 BIRTHPLACE OF
FATHER (City) ..

(State or country)

IS MAIDEN NAME
OF MOTHER

1G BIRTHPLACE OF
MOTHER (City)

(State or country)

17 Vkt. D rCi Relation, if any

(Address) -3~ Oy^ 1 ’

I HEREBY CERTIFY that a satisfactory xtftandard certificate of death was
filed wi|a me BEFORE tl^ burial^ transit perrr.it v

(Official Designation)

mipi.! /Jr/ f/..

ignation) u J (Date of Issue 'of ^Permit./ *

MEDICAL CERTIFICATE OF DEATH

18 DATE OF
DEATH ....

(Month)

(Day) (Year)

19 I HEREBY CERTIFY, That I attended deceased from

19 to 19

I last saw h alive on 19 death is said

to have occurred on the date stated above,

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?.

Duration

PHYSICIAN

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

20 Was disease or Injury lo any way related to oceopatloo ol deceased ? .

If so, specify

(Signed) , M. D.

(Address) .(IrSi-t^.(>tiO*vt.Date 19

21 ....Kcow^..6

Place of Jlurial, Cremation or

or Removal.

DATE OF BURIAL

(City or Town)

19**/

FUNERaT D1RECTOR7 . .)** ?**t.**J

ADDRESSES 3

Received and filed

.19..

A TRUE COPY ATTEST:

(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,
ifter the death of a person whom he has attended during his last
llness, at the request of an undertaker or other authorized person
>r of any member of the family of the deceased, furnish for regis-
ration a standard certificate of death, stating to the best of his
cnowledge and belief the name of the deceased, his supposed age,
he disease of which he died, defined as required by section one,
vhere same was contracted, the duration of his last illness, when last
leen alive by the physician or officer and the date of his death . . .
Jen. Laws, Chap. 46. Sec. 9.

No undertaker or other person shall bury or otherwise dispose of a
luman body in a town, or remove therefrom a human body which
tas not been buried, until he has received a permit from the board
if health or its agent appointed to issue such permits, or if there
s no such board, from the clerk of the town where the person died :
md no undertaker or other person shall exhume a human body and
■emove it from a town, from one cemetery to another, or from one
frave or tomb other than the receiving tomb to another in the same
■emetery, until he has received a permit from the board of health or
ts agent aforesaid or from the clerk of the town where the body is
juried. No such permit shall be issued until there shall have been de-
ivered to such board, agent or clerk, as the case may be, a satisfac-
ory written statement containing the facts required by law to be
■elurned and recorded, which shall be accompanied, in case of an
iriginal interment, by a satisfactory certificate of the attending
jhysician, if any, as required by law, or in lieu thereof a certificate
is hereinafter provided. If there is no attending physician, or if. for
lufficient reasons, his certificate cannot be obtained early enough for
he purpose, or is insufficient, a physician who is a member of the
>oard of health, or employed by it or by the selectmen for the pur-
jose, shall upon application make the certificate required of the at-
ending physician. If death is caused by violence, the medical exam-
ner shall make such certificate. If such a permit for the removal of
i human body, not previously interred, from one town to another
vithin the commonwealth cannot be obtained early enough for the
jurpose, the certificate of death made as above provided and in the
jossession of the undertaker desiring to make such a removal shall
constitute a permit for such removal ; provided, that such body shall
>e returned to the town from which it was removed within thirty-
;ix hours after such removal, unless a permit in the usual form for
he removal of such body has been sooner obtained hereunder. If the
leat.h certificate contains a recital, as required by section ten of
chapter forty-six, that the deceased served in the army, navy or
narine corps of the United States in any war in which it has been
mgaged, such recital shall appear upon the permit. The board of
lealth, or its agent, upon receipt of such statement and certificate,
ihall forthwith countersign it and transmit it to the clerk of the
own for registration. The person t,o whom the permit is so given
ind the physician certifying the cause of death shall thereafter fur-
lish 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, See. 46,
G. L., (Tercentenary Edition.)

No undertaker or other person shall bury a human bodv 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„ (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 pei’sons 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) Medical Examiners will investigate and certify to all deaths
snpposably 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. o.,
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

100m-2-’40-D-729-a

QUj r (Inmmomuraltli of MaBflarfjiiBeltfl
OFFICE OF THE SECRETARY

DIVISION OF VITAL STATISTICS

STANDARD

CERTIFICATE OF DEATH

g (CityorTowu^ CERTIFICATE OF DEATH

^ N {

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

„ . _N 12

Registered No

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

(a) Residence. No...

2 FULL NAME.

(Usual place of abode)

Length of stay: In hospital or institution A-

specify

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

(If U. S.

War Veteran,
specify WAR)..

whether)

years

months

days.

(If nonresident, give city or town and state)

In this community yrs. mos. J days.

PERSONAL AND STATISTICAL PARTICULARS

3 SEX

4 COLOR OR RACE
) / / —

5 SINGLE (write the word)

MARRIED

18 DATE OF V .
DEATH

L±!f.±

WIDOWED
or DIVORCED

(Monthy

(Day)

(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.

8 I If

AGE Years Months Days)..

Usual

9 Occupation:..

Industry

10 or Business:

than 1 day
Hours Minutes

11 Social Security No 1.

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

13 NAME
FATHER

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

15 MAIDEN 1
OF MOTH

16 BIRTHPLACE OP
MOTHER (City)...,
(State or country)

MEDICAL CERTIFICATE OF DEATH

19 I HEREBY CERTI , That I attended deceased from

, 19 0. , 19 ILL..

I last saw h.w^Mv alive on uui.r. A. , 19 ..H.L, death is said to

have occurred on the date stated above, at m.

Immediate cause of death.. '

...X&dr.

Due to

Due to..

Other conditions

(Include pregnancy within 3 months of death)

Major findings:

Of operations

....... .Date of

Of autopsy. nr^r.

What test confirmed diagnosis?..

Duration

IMP0RUN1

mroiTANi

THYSICUN

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

20 Was disease or injury in any way related to occupation o{ deceased? ...

Place of Burial, Cremation or

DATE OF BURIAL

tymr Towjl

i9.*y

Received and filed...

19.

(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 registration a standard
certificate of death, stating to the best of his knowledge and belief the
name of the deceased, his supposed age, the disease of which he died,
definded 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 receiv-
ing tomb to another in the same cemetery, until he has received a permit
from the board of health or its agent aforesaid or from the clerk of the
town where the body is buried. No such permit shall be issued until
there shall have been delivered to such board, agent or clerk, as the case
may be, a satisfactory written statement containing the facts required by
law to be returned and recorded, which shall be accompanied, in case of an
original 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,
bis certificate cannot be obtained early enough for the purpose, or is in-
sufficient, a physician who is a member of the board of health, or em-
ployed by it or by the selectmen for the purpose, shall upon application
make the certificate required of the attending physician. If death is caused
by violence, the medical examiner shall make such certificate. If such a
permit for the removal of a human body, not previously interred, from
pne town to another within the commonwealth cannot be obtained early
:nough for the purpose, the certificate of death made as above provided
ind 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
lours after such removal, unless a permit in the usual form for the re-
moval of such body has been sooner obtained hereunder. If the death
sertificate 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
ippear upon the permit. The board of health, or its agent, upon receipt of
such statement and certificate, shall forthwith countersign it and transmit
t to the clerk of the town for registration. The person to whom the permit
s so given and the physician certifying the cause of death shall thereafter
urnish for registration any other necessary information which can be
obtained as to the deceased, or as to the manner or cause of the death,
vhich 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, Sec. 46, G. L., ( Tercentenary
Edition).

RULES OF PRACTICE

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

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

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

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

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 business, report the usual occupation
prior to retirement. ChBdren 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

-WHITE PLAINLY, WUH UlNrADlNLi BLACK. INK. — I HIS 15 A 1 EKMAIMEIN 1 KtLUKU. Every item ot
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 hack of certificate.

!M R-301 ^

bounty)

(City or Town)^^»— ^

No S.O..

Qtie ffimttmomtiealll| nf iSanaarljuiirtlJS
OFFICE OF THE SECRETARY

DIVISION OF VITAL STATISTICS

STANDARD

CERTIFICATE OF DEATH

2 FULL NAM

(a) Residence. No....^Z..r?..&....

(Usual place of abode)

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

Registered No.

.13..

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

days.

(If nonresident, give city or town and state)

In this community y yrs. mos. days.

PERSONAL AND ST ATISTI CAL PARTICULARS

4 COLOR OR RACE

5 SINGLE
MARRIED,
WIDOWS
or DIVA

3 SEX

5a If married, wiftoJ^ed.^gr^iv^gcejl
HUSBAND of..

(Ofi^ maiden name of wife in full)r

(or) WIFE of

(Husband’s name in full)

6 Age of husband or wife if alive .

7 IF STILLBORN, enter that fact here.

0k,

Usual

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

1*,.

Relational any

16 BIRTHPLACE OF

MOTHER (City)

(State or country)

Inform <S

(Address) /c> a

I HEREBY CERTIFY that a satisf»tory^tandard certificate of death
w^87fi}ed_with meBEEORE tly^bytial jtj/ trg^i^it permit was issued:

* ‘

Future of Aacnl/of Board of Healt

(Official Designation)

MEDICAL CERTIFICATE OF DEATH

(write the word!

18 DATE OF
. DEATH

(Month)

(Day)

(Year)

19 I HEREBY CERTIFY, That 1 attended deceased from

Am...: 3 » 19 * “> , 19 :t.

I last saw h alive on , 19 ...L., death is said to

have occurred on the date stated above, at...’X r.

Immediate cause of death. S

Duration

IMPSITUn

| If less than 1 day

onths Days | Hours Minutes

Due to..

Other conditions

(Include pregnancy within 3 months of death)

iiiraiTun

Major findings:

Of operations....

Of autopsy

What test confirmed diagnosis?..

..Date of...

Was disease or injury in any way related le accusation of deceased?..

If so, specify..

Received and 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 registration a standard
certificate of death, stating to the best of his knowledge and belief the
name of the deceased, his supposed age, the disease of which he died,
definded 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 receiv-
ing tomb to another in the same cemetery, until he has received a permit
from the board of health or its agent aforesaid or from the clerk of the
town where the body is buried. No such permit shall be issued until
there shall have been delivered to such board, agent or clerk, as the case
may be, a satisfactory written statement containing the facts required by
law to be returned and recorded, which shall be accompanied, in case of an
original 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 in-
sufficient, a physician who is a member of the board of health, or em-
ployed by it or by the selectmen for the purpose, shall upon application
make the certificate required of the attending physician. If death is caused
by violence, the medical examiner shall make such certificate. If such a
permit for the removal of a human body, not previously interred, from
one town to another within the commonwealth cannot be obtained early
enough for the purpose, the certificate of death made as above provided
and in the possession of the undertaker desiring to make such removal
shall constitute a permit for such removal; provided, that such body shall
be returned to the town from which it was removed within thirty-six
hours after such removal, unless a permit in the usual form for the re-
moval 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.,
(.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., (Tercentenary
Edition).

RULES OF PRACTICE

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

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

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

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

SPACE FOR ADDITIONAL INFORMATION

M R-301 A

®1 fr CCnmmnnmralli? of fifaasar4u»rtl*

OFFICE OF THE SECRETARY

DIVISION OF VITAL STATISTICS

2 FULL NAME

married,

STANDARD

CERTIFICATE OF DEATH

■ divorce# woiHan, give also maiden name.)

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)

(If U. S.

War Veteran,
specify WAR)..

(a) Residence. No

(Usual place of abode)

Length of stay: In hospital or institution

(If nonresident, give city or town ai

In this community £ £) yrs.

and state)

(Specify whether)

years

months

days.

PERSONAL AND STATISTICAL PARTICULARS

3 SEX

4 COLOR OR RACE

5 SINGLE (write the word)
MARRIED i t . /> -i
WIDOWED
or DIVORCED

5a If married, widowed, or divorced

HUSBAND of

(Give maidpa-^iame of wife in full)

(or) WIFE of..

(Husband’s namepn fifll)

6 Age of husband or wife if alive years

7 IF STILLBORN, enter that fact here.

8 7 O I If les* than 1 day

AGE. ...L.rZ... Years Months Days! Hours Minutes

Usual
9 Occupation:

Industry
10 or Business:.

11 Social Security No.

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

13 NAME OF
FATHER

<-^L/

14 BIRTHPLACE OF

FATHER (City)

(State or country)

JDL

IS MAIDEN NAME
OF MOTHER

16 BIRTHPLACE OF ■

MOTHER (City)

(State or country) /

(State or country)

Informant

(Address) /

Region, if any

!=JI

I HEREBY CERTIFYthat a satisfactory standard certificate of dearth
was (Usd with m^-^BrORETKe burial Q/ transit permit was issued:

MEDICAL CERTIFICATE OF DEATH

18 DATE OF
DEATH

....La* 9... Lfi#:/:

(Month) J ' (Day) (Year)

19- I HEREBY CERTIF/iY, That I attended deceased from
1*3.4. to.Jh&z^ *■</../?:.., 19 ft/.....

I last saw h alive on . death is said to

have occurred on the date statM above, at Q...C(...> m. '

Immediate cause of death .y.

Due to...

Dae to

Other conditions

(Include pregnancy wifljfn 3 months of death)

SBBfa

Duration

20 Wat disease or injury in any way related to occupation of deceased?

If so, specify...

(Signed). M. D.
(Address). .. ..^ 19^/

DATE OF BURIAL..

(City or Town)

.0 19.^.(

22 NAME OF

FUNERAL DIRECTOR

ttt ^ ^

ADDRESS / 6 Hi. */. L&P-4~*

Received and filed..

.19..

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

No undertaker or other person shall bury or otherwise dispose of a
human body in a town, or remove therefrom a human body which has
not been buried, until he has received a permit from the board of health,
or its agent appointed to issue such permits, or if there is no such board,
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 receiv-
ing tomb to another in the same cemetery, until he has received a permit
from the board of health or its agent aforesaid or from the clerk of the
town where the body is buried. No such permit shall be issued until
there shall have been delivered to such board, agent or clerk, as the case
may be, a satisfactory written statement containing the facts required by
law to be returned and recorded, which shall be accompanied, in case of an
original 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 in-
sufficient, a physician who is a member of the board of health, or em-
ployed by it or by the selectmen for the purpose, shall upon application
make the certificate required of the attending physician. If death is caused
by violence, the medical examiner shall make such certificate. If such a
permit for the removal of a human body, not previously interred, from
one town to another within the commonwealth cannot be obtained early
enough for the purpose, the certificate of death made as above provided
and in the possession of the undertaker desiring to make such removal
shall constitute a permit for such removal; provided, that such body shall
be returned to the town from which it was removed within thirty-six
hours after such removal, unless a permit in the usual form for the re-
moval 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.,
(.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., (Tercentenary
Edition).

RULES OF PRACTICE

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

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

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

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

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 business, 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

-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.

RM R-3Q1 A

SEX

3,SE

®f}c (Eoimtnmfnealilj nf (JHitssncIutsctis
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

Jo // I I r ILA l c. SJr UtAl n Jrvegistered INo

L & ( c. f (If death occurred in a hospital or institution,

YTTir/) '■ rr: ...r. at. ) give its NAME instead of street and number)

d, widowed or divorcecKwoman, give

2 FULL NAME

(a) Residence. No.

(Usual place of abode)

also maiden name.)

\ (If u. s.

• •( War Veteran,
i specify WAR)

Length of stay : In hospital or institution..

(Specify whether)

years

months

(If nonresident, give city or town and state)
days. ~hi In this community / >-S”"yrs. mos. days.

PERSONAL AND STATISTICAL PARTICULARS

(write the word)

4 COLOR OR RACE : 5 SINGLE
MARRIED

WIDOWED CWJ • /

I '^A'C^Us/aD 1 or DIVORCEL^CgZ^^c^^-C^

5c If married, widowed, or divorced

HUSBAND of

(or) V/IFE of

* (Give rn^idciy-name of wife in f

rz£&yJL..L

full)

(Husband’s name in full)

MEDICAL CERTIFICATE OF DEATH

18 DATE OF
DEATH

7 (»

(Month)

(Bay)

J?4/

(Year)

9J HEREBY CERTI RY , Thai 1 attended deceased Lots

19.#:/

[ last saw Oil L-4r . (' 1 T\ <*/ l„«L

6 Age of husband or wife if alive =a/=, , years

7 IF STILLBORN, enter that fact here.

1 last saw lu^rL... alive on. . .l^SfdrbMr. . .(/ 12.#/., death is said
to have occurred on the dat^tated above, (t\^L.3.SS..(C,'.ra.

Immediate cause of /death,

AGE

E kL Years io

Occupation:

| If less than 1 day

Months Sr? JK.Dcys | Hours Minutes

Industry
10 or Business:

nscediate cause ofwjeath a

Due to
Due to

11 Social Security No

12 BIRTHPLACE (City)
(State or country)

13 NAME OF /C\
FATHER

Other conditions-
(Include pregnancy within i mouths of death)

Major findings :
Of operations

Date of....

Of autopsy sta.

What test confirmed diagnosis

Duration

PHYSICIAN

Underline
the cause to
which death
hould be

;rrr:.. rustically.

28 W as disease or Injury In any way related tn occupation ol deceased?
If so,

(Signed

21 ...

Place of Burial, Cremation or Removal. ' (City or T3wn)

DATE OF BURIAL.C^tS^ /../ ... 19 l

22 NAME OF ^ /P » ff / Q /

FUNERAL DIRECTOR

ADDRESS 1 7 .

I HEREBY CERTIFY that a s^isfaotor^ standard certificate of death was
me^&fiFQRE lto/y\wfcty or/rcansit permit was issued:

dtCrA’

(Official Designation

Received and filed .

.19.

(Registrar)

EXTRACTS FROM THE LAWS OF TH2
COMMONWEALTH OF MASSACHUSETTS
GOVERNING THE

RETURN OF CERTIFICATES OF DEATH

A physician or registered hoipitnl medical officer shall forthwith,
fter the death of a person whom he has attended during hio last
lness, at the request of an undertaker or other authorised person
r of any member of the family of the deceased, furnish for regis-
ration a standard certificate of death, stating to the best of his
nowlcdge and belief the name of the deceased, his supposed age,
le disease of which he died, defined as required by section one,
'here same was contracted, the duration of bis last illness, when last
?en alive by the physician or oificer and the date of his death . . .
'■en. Laws. Chap. 46, See. 9.

No undertaker or other person shall bury or otherwise dispose of a
uraan body in a town, or remove therefrom a human body which
as net been buried, until he has received a permit from the beard
f health, or its agent appointed to issue such permits, or if there
s no such hoard, from the clerk of the town where the person died ;
nd no undertaker or other person shall exhume a human bodv and
amove it from a town, from one cemetery to another, or from one
rave or tomb other than the receiving tomb to another in the same
smetery, until he has received a permit from the board of health or
;s agent aforesaid or from the clerk of tile town where the body is
uried. No such permit shall be issued until there shall have been (le-
vered to such board, agent or clerk, as the case may be, a satisfao-
iry written statement containing the facts required by law to be
eturned and recorded, which aha!! be accompanied, in case of an
riginal interment, by a satisfactory certificate of the attending
hysician, if any, as required by law, or in lieu thereof a certificate
a hereinafter provided. If there is no attending physician, or if. for
□ ificient reasons, his certificate cannot be obtained early enough for
Se purpose, or is insufficient, a physician who is a member of the
oard of health, or employed by it or by the selectmen for the pur-
ose, shall upon application make the certificate required of the at-
mding physician. If death is caused by violence, the medical exnni-
ler shall make such certificate. If such a permit for the removal of

human body, not previously interred, from one town to another
■ithin the commonwealth cannot be obtained early enough for the
urpose, the certificate of death made rj above provided sad in the
ossessicn of the undertaker desiring to make such removal shall
Destitute a permit for such removal ; provided, that such body shall
e returned to the town from which it was removed within thirty-
Ix hours after such removal, unless a permit in the usual form for
re removal of such body has been sooner obtained hereunder. If the
eath certificate contains a recital, as required by section ten of
hap ter forty-six, that the deceased served in the army, navy or
rarine corps of the United States in any war in which it hai been
ngaged. such recital shall appear upon the permit. The board of
ealth, or its agent, upon receipt of such statement and certificate,
hall forthwith countersign it and transmit it to the clerk of the
□wn for registration. The person to whom the permit is so given
Dd the physician certifying the cause of death shall thereafter fur-
ish for registration any other necessary information which can be
btained as to the deceased, or as to the manner or cause of the
eath, which the elerk or registrar may require. — Chap. 114, See. 45,
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 tile 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 ns thoRe
of persona 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) Medical Examiners will investigate and certify to ail 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, hut also deaths
from disease resulting from injury or infection reluted to occupa-
tion, the sudden deaths of persons not disabled by recognised
disease, and those of persons found dead.

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

or complication which eauses death, nof 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.

Statement of Occupation. — Precise statement of occupation is very
Important, so that the relative healthfulness of various pursuits
can tie 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 iiiness. If the deceased had retired from busi-
ness. report the usual occupation prior to retirement. Children not
gainfully employed may be returned as of school or at homo. 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, took — hotel, ete. For a person who had
no occupation whatever write none.

SPACE FOR ADDITIONAL INFORMATION

WKllfc. rLAIINLT, WUH UlNi-AUiiNU dLAL\ iinn — I nio a rturaAntni KEtUKU. t-very item or
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-301 A

3 SEX

Female

Suffolk

(County)

o Winthrop

U (City or Town)

3ljr (Cnmmnnuipaltlj of fHasBarfyuiirttH
OFFICE OF THE SECRETARY

DIVISION OF VITAL STATISTICS

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

1 fi

Registered No

STANDARD

CERTIFICATE OF DEATH

t No M...£owd.Qia St. {

FULL NAME Mtie (Wheeler) Qrcut t (

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

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

(a) Residence. No 4'.8...B.Q.W.$-.Q.ih St.

(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 41 yrs. raos. days.

PERSONAL AND STATISTICAL PARTICULARS

4 COLOR OR RACE

White

5 SINGLE (write the word)

MARRIED s 1

widowed wiaowecj

or DIVORCED

5a If married, widowed, or divorced

HUSBAND of

(Give maiden name of wife in full)

William 3. Or cut t

(Husband’s name in full)

(or) WIFE of

6 Age of husband or wife if alive years

7 IF STILLBORN, enter that fact here.

8 Q *7 I If less than 1 day

AGE O.. I ..Years Months Days| Hours Minutes

9 Occupation : M hOOie

Industry
10 or Business:

11 Social Security No. ......

12 BIRTHPLACE (City).... Mll.f O.r.4

(state or country) New Hampshire

13 NAME OF TTT, _

father Gilman Wheeler

14 BIRTHPLACE OF TTo w.rt

FATHER (City)

(state or country) jjew Hampshire

15 MAIDEN NAME _ _ . _ . , . ,

of mother Graoia Kitridge

16 BIRTHPLACE OF TJo ^

MOTHER (City) Hail COCK

(State or country) New Hampshire

Relation, if any

Informants* E t hel... Wurt z... (daughter)

(Address) 4 8 Bowdoin St Winthron iiass

I HEREBY CERTIFY/hat a satisfactory standard certificate of death
was filed with jne BJt^r ORE, the huri^T^r transit pafmif was issued:

signature of Agen
(Official ^Designation)

msit permit was issued:

of- Health or o^her)

^,/tf + '

ate of Issue of Permit)

MEDICAL CERTIFICATE OF DEATH

I last saw h.-/fr^.. alive
have occurred on the date stab
Immediate cause of death.

19y.fi, itoyT\..

t a

on J

vW#

death

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.

20 Was disease or injury in any way related lo occupation of deceased?

If so, specify

(Signed) A. ,C. J..... M. D.

(Address )

21 Winthrop cemetery ^...Wint.h?.9P....Mss

Place of Burial, Cremation or Removal. OCity or Town)

DATE OF BURIAlJ.aiIUary . .l.2.^ 1.94.1 19

22 name of Charles R. Bennlson

FUNERAL DIRECTOR

address Wint hrop Mass

Received and filed. 19

(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 registration a standard
certificate of death, stating to the best of his knowledge and belief the
name of the deceased, his supposed age, the disease of which he died,
definded 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 receiv-
ing tomb to another in the same cemetery, until he has received a permit
from the board of health or its agent aforesaid or from the clerk of the
town where the body is buried. No such permit shall be issued until
there shall have been delivered to such board, agent or clerk, as the case
may be, a satisfactory written statement containing the facts required by
law to be returned and recorded, which shall be accompanied, in case of an
original 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 in-
sufficient, a physician who is a member of the board of health, or em-
ployedby it or by the selectmen for the purpose, shall upon application
make the certificate required of the attending physician. If death is caused
by violence, the medical examiner shall make such certificate. If such a
permit lor 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 re-
moval 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..
(.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„ (Tercentenary
Edition).

RULES OF PRACTICE

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

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

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

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

SPACE FOR ADDITIONAL INFORMATION

WKlIfc, rLAlWLl, W11M unrAUinu unis. — ima la a rr.RiviAnr.i'i i klluku. tvery item or

M R-301 A

Suffolk

(County)

1 <o Iint.hr op

(City or Town)

<2Hjp (ffmnntmtuiealtff of fUtuuiarliuarttii
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

No .7....M^rtle. .Avenue

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

2 FULL NAME Marguerite (Harley.) Seymour $£?v!Ur.n,

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

(a) Residence. No L.MyT.t 1.6.. Aveftlie .

(Usual place of abode)

Length of stay: In hospital or institution .

.St.

months

(Specify whether)

days.

(If nonresident, give city or town and state)

In this community 15 yrs. mos. days.

PERSONAL AND STATISTICAL PARTICULARS

3 SEX

Female

4 COLOR OR RACE

Colored

5 SINGLE (write the word)

MARRIED . . * s

widowed Mar r i e a

or DIVORCED

5a If married, widowed, or divorced

HUSBAND of

(Give maiden name of wife in full)

(or) wife of Albert Mward... Seymour

(Husband’s name in full)

6 Age of husband or wife if alive..

full)

7 IF STILLBORN, enter that fact here.

8 c Q | If less than 1 day (

AGE... J3. .*.... Years Months Days| Hours Minutes

9 Occupation: -A..fc

Industry
10 or Business :

11 Social Security No.

13 NAME OF

father Hichard Harley

14 BIRTHPLACE OF

FATHER (City)

(State or country) (J Q Q Tg la

15 MAIDEN NAME
OF MOTHER

Unable to

Tamerobtain

16 BIRTHPLACE OF

MOTHER (City)

(State or country) Georgia

firs1
- naan

Relation, if any

informant Albert . Seymour (husband )

(Address Myrtle .ive Jin t far op Mass

I HEREBY CERTIFY that a satisfactory standard certificate of death
wasTiled with me BEFORE/ theburial e'r transit permit was issued :

MEDICAL CERTIFICATE OF DEATH

18 DATE OF
DEATH

Q (Mo

(Month) f

(Day)

iiii

(Year)

X? I HEREBY CERTIFY. That I attended deceased from

19#4 to £ , 19#/

L*fa.L.aIive on , 19.*^/., death is said to

I last saw hL

have occurred on the date stated above, at /ft.. m.

Immediate cause of death.. .......

Due to..

Due

Other conditions

(Include pregnancy within 3 months of death)

Major findings:
Of operations..

..Date of..

Of autopsy

What test confirmed diagnosis?..

IMPORTANT

PHYSICIAN

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

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

"(sVnedT ^.1^^

(Address)f \j/}j 19^//

21 lin.t..hr..Qp......C.emeLery^^

Place of Burial, Cremation or Removal. _ (Citv or Town)

J.a.nmry...l3.,....lMl

DATE OF BURIAL

19.

22 NAME OF

FUNERAL DIRECTOR ?.*

address w^n v hro p Mh s s

Received and filed..

.19..

(Registrar)

Duration

IMPORTANT

ir/rfyo

EXTRACTS FROM THE LAWS OF THE
COMMONWEALTH OF MASSACHUSETTS
GOVERNING THE

RETURN OF CERTIFICATES OF DEATH

A physician or registered hospital medical officer shall forthwith,
after the death of a person whom he has attended during his last illness,
at the request of an undertaker or other authorized person or of any
member of the family of the deceased, furnish for registration a standard
certificate of death, stating to the best of his knowledge and belief the
name of the deceased, his supposed age, the disease of which he died,
definded 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 receiv-
ing tomb to another in the same cemetery, until he has received a permit
from the board of health or its agent aforesaid or from the clerk of the
town where the body is buried. No such permit shall be issued until
there shall have been delivered to such board, agent or clerk, as the case
may be. a satisfactory written statement containing the facts required by
law to be returned and recorded, which shall be accompanied, in case of an
original 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 in-
sufficient, a physician who is a member of the board of health, or em-
ployed by it or by the selectmen for the purpose, shall upon application
make the certificate required of the attending physician. If death is caused
by violence, the medical examiner shall make such certificate. If such a
permit for the removal of a human body, not previously interred, from
one town to another within the commonwealth cannot be obtained early
enough for the purpose, the certificate of death made as above provided
and in the possession of the undertaker desiring to make such removal
shall constitute a permit for such removal; provided, that such body shall
be returned to the town from which it was removed within thirty-six
hours after such removal, unless a permit in the usual form for the re-
moval 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„
(.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„ (Tercentenary
Edition).

RULES OF PRACTICE

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

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

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

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 business, 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
Jiome 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

M R-30I A

0 L'.in.#i.\r..Q.p

Ju (City or Town)

1 <

\n.

01|r (ftamtnmtwrallif of ^aHsarljuartta
OFFICE OF THE SECRETARY
DIVISION or VITAL STATISTICS

STANDARD

CERTIFICATE OF DEATH

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

Registered No.

14. . Egle ton ..Park st.

2 FULL NAME..<

(If dece;

(a) Residence. No.../

(Usual place of abod

Length of stay: In hospital or institution

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

Tan ere d ) Sfu\,si

••••• / War Veteran,

married, widowed or divorced woman, give also maiden name.) J specify WAR)..

.St.

(Specify whether)

years

months

days.

(If nonresident, give city or town and state)

In this community J yrs. ^ mos. days.

PERSONAL AND STATISTICAL PARTICULARS

3 SEX

'emale

4 COLOR OR RACE

White

5 SINGLE (write the word)

MARRIED

WIDOWED pf J.,,.
or DIVORCED W1QOW

5a If married, widowed, or divorced

HUSBAND of

(Give maiden name of wife in full)

(or) wife of P..e..t.e.r T.an.cred.

(Husband’s name in full)

6 Age of husband or wife if alive years

7 IF STILLBORN, enter that fact here.

AGE.... <

..Months..

I If less than 1 day
..Daysj Hours Minutes

9 Occupation : HQUSeWife..

Industry
10 or Business:

Own Plorae

13 NAME OF
FATHER

14 BIRTHPLACE OF

FATHER (City)

(State or country)

15 MAIDEN NAME
OF MOTHER

16 BIRTHPLACE OF

MOTHER (City)

(State or country)

Relation, if any

Informant Charles Tancred( Son \

?£%£) t^T"TgTgTQn"TK'7rrfithT-Q-p ;

I HEREBY CERTIFY that a satisfactory standard certificate of death
was/filed witb-Urte BEFORE the burial or transit permit was issued :

LAsc..

. (Signature <

ft / A

.-go

: Agent of Board

(Official Designates

^MzJL

1th or other)

(Date of IssuC of

Peri

l/fcu

•mit)

MEDICAL CERTIFICATE OF DEATH

18 deathof January 12.1941

(Month) (Day)

(Year)

4 ft

l/uL . , 19 */ , death is said to
--

EREBY CERTIFY,

20 , 19^0, to

I last saw h alive on

have occurred on the date stated above, at m.

Immediate cause of death

Due to..._ .7

That I attended deceased 1

JpJb , 19*/

Due to..

Other conditions..

Occlude pregnancy within ^months of, death)

Major findings:
Of operations .

Date of..

Of autopsy

What test confirmed diagnosis?..

Duration

IMPORTANT

PHYSICIAN

.Eoxiest„„K.Ills.

Place of Burial, Cremation or Removal.

DATE OF BURIAL ^

hoc ton

(Cifly or Town)

m, 14 y

22 NAME OF

FUNERAL DIRECTOR.1

ADDRESS '.n.

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

20 Was disease or injury in any way related to occupation o( deceased! .rsL-^v'.-

If so, specify. ...L . ....V .Q

(Signed)^.,. , m. d.

(AddJiss) Date/jf/./-.'. 19..#

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

No undertaker or other person shall bury or otherwise dispose of a
human body in a town, or remove therefrom a human body which has
not been buried, until he has received a permit from the board of health,
or its agent appointed to issue such permits, or if there is no such board,
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 receiv-
ing tomb to another in the same cemetery, until he has received a permit
from the board of health or its agent aforesaid or from the clerk of the
town where the body is buried. No such permit shall be issued until
there shall have been delivered to such board, agent or clerk, as the case
may be, a satisfactory written statement containing the facts required by
law to be returned and recorded, which shall be accompanied, in case of an
original 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 in-
sufficient, a physician who is a member of the board of health, or em-
ployed by it or by the selectmen for the purpose, shall upon application
make the certificate required of the attending physician. If death is caused
by violence, the medical examiner shall make such certificate. If such a
permit for the removal of a human body, not previously interred, from
one town to another within the commonwealth cannot be obtained early
enough for the purpose, the certificate of death made as above provided
and in the possession of the undertaker desiring to make such removal
shall constitute a permit for such removal; provided, that such body shall
be returned to the town from which it was removed within thirty-six
hours after such removal, unless a permit in the usual form for the re-
moval 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.,
( 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., ( Tercentenary
Edition ) .

RULES OF PRACTICE

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

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

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

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

SPACE FOR ADDITIONAL INFORMATION

M R-302

a Q
*.s

°'S

U 8

VTJ

C S

.*5-0

K.20

•j a c*
a r:

<u IS
•X3 e .

a,: «

■a

v i*'®

aoT

u„2-

.■•si

q^.O

l.*<x

t n"S

:at

S<V1

°5

27 «

.*3

fiT3

k«.a

'Sc

S'?

« 5

c O

« 5 *7

5 |

5 « *0

(County)

•

* )

(City or Town)

®hc Cottmtonfuealllf of ,iKaaBacIju*ett0
OFFICE OF THE SECRETARY
DIVISION OF VITAL STATISTICS

COPY OF

CERTIFICATE OF DEATH

(City or town making return)

Registered No 5-7-7

3 No Bo.s.to.n...Jui.ty....Ho.s.pltal St. I S*ve its NAME instead of street ^'d number)’

2 FULL NAME

Francis... o .Ball } m us.

(If deceased is a married, widowed or divorced woman, give also maiden name.) J Wai.i !»?!»'

y / specify WAR)

(a) Residence. No 2?2Jtein. St Wlnthrop

(Usual place of abode)

Length of stay: In hospital or institution years

(Specify whether)

months

days.

(If nonresident, give city or town and state)

In this community yrs. m0s. days.

PERSONAL AND STATISTICAL PARTICULARS

4 COLOR OR RACE;

5 SINGLE
MARRIED
WIDOWED
or DIVORCED

(write the word)

married

5a If married, widowed, or divorced

HUSBAND of

(Give maiden name of wife in full)

(or) wife of Frances .W-~ ...

(HuabantT s name in full)

6 Age of husband or wife If alive..

full)

years

7 IF STILLBORN, enter that fact here.

AGE .6. 6. Years... .1 Months B-.Days

If less than 1 day
Hours Minutes

Usual

8 Occupation:

Industry
10 or Business:

--a.r.terl.os.clera.tl.c...he.ar.t..
Insurance retired dls.eas.e

Due to

11 Social Security No .Q.f>.l>.i..C.€L

12 BIRTHPLACE (City)
(State or country)

13 NAME OF
FATHER

-Hyde Park Mass

Francis 0 Ball

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

15 MAIDEN NAME
OF MOTHER

Eunice Rogers

18 BIRTHPLACE OF
MOTHER (City) ..

(State or country)

3Ss“t'Sn'''l!Ias8'

inionnaM....Eeixr.y E....Xeo.ugh ( ^'friend)

*v0-^-throP-

A TRUE COPY,
ATTESTi

-x . / ^Lwr/»tX,

T-..,

(Registrar of dty or town where death

1/17/40 is

DATE FILED

rred)

MEDICAL CERTinCATE OF DEATH

death°F Jan 13 194-1

(Month) (Day)'

(Year)

19 I HEREBYCERTIFY, That I attended deceased from

1/7-Al 19 to X/13/Ikl 19

I last saw h...lm..alive on l/l^Al 19 death is said

to have occurred on the date stated above, at 9/5^^°

Immediate cause of death

G-er.ebral...heraar.rha.g.e

Other conditions

(Include pregnancy within 3 months of death)

Duration

..dys..

yr.a.

Major findings:
Of operations

Date of

Of autopsy

What test confirmed diagnosis?

2 1 Was disease er injury In any way related te occupation ol deceased 1
Ii bo, specify . .

(Signed)

rarsiciAK

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

(Address) BOStOH Dat.l/l3/l9 4'

21 PLACE OF BURIAL.

CREMATION OR REMOVAL

Wlnthrop Mass

DATE OF BURIAL

(Cemetery) (City or Town)

van 15-1941 ». .....

22 NAME OF

FUNERAL DIRECTOR

ADDRESS

C R Bennlson

Received and Sled

(Registrar of City or

Town where deceased resided)

M R-301 A

o .'.Vint hr op

U (City or To1

tUijr Qlmnmonmralth of fHaanar^ufirtta
OFFICE OF THE SECRETARY
DIVISION OF VITAL STATISTICS

Suffolk

(County) _ _

STANDARD

(City or Town) CERTIFICATE OF DEATH

2p....^agampre..Avexijfte st

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

Registered No.

a 0

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

2 FULL NAME.....4^Pnira.m„J.ft<ifiPh....y.Q.lUlg VI or Veteran ,

) specify WAR)

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

(a) Residence. No ?0 ^.Jagamore ...Avenue st .'.

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

Length of stay: In hospital or institution years months days. In this community 66 yr3. mos days.

(Specify whether)

PERSONAL AND STATISTICAL PARTICULARS

3 SEX

Male

4 COLOR OR RACE

White

(write the word)

S SINGLE

MARRIED .

WIDOWED jjarneffl
or DIVORCED

5a If married, tSTtflida RObertS OH

HUSBAND of.,
(or) WIFE of..

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

6 Age of husband or wife if alive..

J59

7 IF STILLBORN, enter that fact here.

AGE

OQ K / I If less than 1 day

Sf..T.. Years Months /*... Days| Hours Minutes

9 occupation: Real Estate (retired.)..

Office

Industry
10 or Business

11 Social Security No. ^

12 BIRTHPLACE (City)

(State or country) MStl.116

13 NAME OF

father Alvin Young

14 BIRTHPLACE OF IMqnOQpof

FATHER (City) “..V..

(State or country) JJQ, 6

15 MAIDEN NAME. r . , . ,

of mother Ma rtha Winchester

16 BIRTHPLACE OF

MOTHER (City)

(State or country) q

St Albins

Relation, if any

(Address)2Q Sagamore nve Winthron

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

as filed with me |3EFORE tl^e burial or transit

/ / - (Signature of/Agfent of Bogri£)8f flomrh or other)

///r/ff

(Official Designation) / (Date of Issue <

MEDICAL CERTIFICATE OF DEATH

18 DATE OF
DEATH

(Month)

12 UM

(Day) (Year)

19 I HEREBY CERTIFY- That I attended deceased from

LKUM...Z0.. , , 19..4V

I last saw h .feirrs . alive on Z&Uvx.../.£. , 19#/.., death is said to

have occurred on the date stated above, at /&....m

Immediate cause of death.. m

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.

20 Was disease or injury in any way related to occupation of deceased? - '-V.

If so, specify. ..Q.Trr^i. ** xcy...

(Signed). M. D.

(Address) 19

2i li.n.throp G0me..t..«.ry.....W.i.n.tlir..op...

Place of Burial, Cremation or Removal. _ — (Citvor Town)

January 19 .......19.41

DATE OF BURIAL

.19.

22 NAME OF

FUNERAL DIRECTORp.fea S R# B 0 1111 A 8 Oil

address Jlnt..hr.op....Ma.ss

Received and filed 19..

(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 registration a standard
certificate of death, stating to the best of his knowledge and belief the
name of the deceased, his supposed age, the disease of which he died,
definded 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 receiv-
ing tomb to another in the same cemetery, until he has received a permit
from the board of health or its agent aforesaid or from the clerk of the
town where the body is buried. No such permit shall be issued until
there shall have been delivered to such board, agent or clerk, as the case
may be, a satisfactory written statement containing the facts required by
law to be returned and recorded, which shall be accompanied, in case of an
original 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 in-
sufficient, a physician who is a member of the board of health, or em-
ployed by it or by the selectmen for the purpose, shall upon application
make the certificate required of the attending physician. If death is caused
by violence, the medical examiner shall make such certificate. If such a
permit for the removal of a human body, not previously interred, from
one town to another within the commonwealth cannot be obtained early
enough for the purpose, the certificate of death made as above provided
and in the possession of the undertaker desiring to make such removal
shall constitute a permit for such removal; provided, that such body shall
be returned to the town from which it was removed within thirty-six
hours after such removal, unless a permit in the usual form for the re-
moval 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.,
( 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., ( Tercentenary
Edition).

RULES OF PRACTICE

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

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

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

SPACE FOR ADDITIONAL INFORMATION

M R-301 A

®Ijp (Sumnimiuiraltf) nf fHaniiarbnnrtljs
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

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

(I^y^ceased is a married, widowed or divorced woman, give also maiden name.)

(a) Residence. St

(Usual place of abode)

(If U. S.

War Veteran,
specify WAR).

Length of stay: In hospital or institution .

(Specify whether)

years / months days.

(If nonresident, giv^city or town and state)

In this community yrs. mos. days.

PERSONAL AND STATISTICAL PARTICULARS

3 SEX

4 COLOR OR RACE

5 SINGLE
MARRIED
WIDOWED
or DIVORCE

(write the word)

5a If married, widowed, or divorced

HUSBAND of

(Give maiden name of wife in full)
.yf ‘ ' '

(or) WIFE of.

f (.Give maiden name ol wite in lull)

(Husband's name in full)

6 Age of husband or wife if alive .

, ■ raC

7 IF STILLBORN, enter that fact here.

8 *7$ I If less than 1 day

AGE.. Years Months DayeJ Hours Minute

Usual

9 Occupation:..

Industx-y

10 or Business:

11 Social Security No.

12 BIRTHPLACE (City)

(State or country)

13 NAME OF
FATHER

( -V.

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

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

17 Relation, if any

I HE 3Y CERTIFY that a satisfactory standard certificate of death
wasj i with mp BEFORE >iiib'burial or transit permit was issued:

nature pi

’(Official Designation) J

MEDICAL CERTIFICATE OF DEATH

18 DATE OF , <■

DEATH vyy. 9^i jf y

(Month)*

(Day)

(Year)

That I attended deceased from

/.£i, i9 y/

19 I HEREBY CERT!

'hsrvr .Jo , 19 */P, jo

I last saw Ii Xsl. alive on Jf? 19 death is said to

have occurred on the date stateaabove, at «?.•" J ‘0... d.r...a

Immediate causa of death.

*/ ■

Due to '

Due to..

Other conditions

(Include pregnancy within 3 months of death)

Major findings:

Of operations.-.

..Date of

Of autopsy.

What test confirmed diagnosis?..

Duration

IMPMTAin

wrtttun

PHYSICIAN

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

20 Was disease or injury in any way related te occupation ol deceased!

Place of Burial. Cremation or

DATE OF BURIAL .

Removal. (City or 1

Town)

.19

22 NAME OF

FUNERAL DIRECTOR-

ADDRESS.

Received and filed 19..

(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 registration a standard
certificate of death, stating to the best of his knowledge and belief the
name of the deceased, his supposed age. the disease of which he died,
definded 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 receiv-
ing tomb to another in the same cemetery, until he has received a permit
from the board of health or its agent aforesaid or from the clerk of the
town where the body is buried. No such permit shall be issued until
there shall have been delivered to such board, agent or clerk, as the case
may be, a satisfactory written statement containing the facts required by
law to be returned and recorded, which shall be accompanied, in case of an
original 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 in-
sufficient, a physician who is a member of the board of health, or em-
ployed by it or by the selectmen for the purpose, shall upon application
make the certificate required of the attending physician. If death is caused
by violence, the medical examiner shall make such certificate. If such a
permit for the removal of a human body, not previously interred, from
one town to another within the commonwealth cannot be obtained early
enough for the purpose, the certificate of death made as above provided
and in the possession of the undertaker desiring to make such removal
shall constitute a permit for such removal; provided, that such body shall
be returned to the town from which it was removed within thirty-six
hours after such removal, unless a permit in the usual form for the re-
moval 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

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