The volume, 1942
Town Clerk, Winthrop · from the Internet Archive · 522 pages · 38.6 MB
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J. L. FAIRBANKS DIV.
Thomas Groom & Co.
Stationers
105 State St., Boston
To duplicate this book order
No
MARGIN RESERVED FOR BINDING
-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 hack of certificate.
ORM R -30 1 A
02
z
\0
fw (City or Town) f
(Ionmton£uealtl| of ffHaasadjiiBetts
OFFICE OF THE SECRETARY
DIVISION OF VITAL STATISTICS
STANDARD
CERTIFICATE OF DEATH
J 7 O
To be filed for burial permit
with Board of Health
or its Agent.
No rrf...
Registered No.,
(If death occurred in a hospital or institution,
give its NAME instead of street and number)
2 FULL NAME
~ (If deceased is a married, widowed or divorced woman, give also maiden name.)
(If U. S. \
War Veteran, 1st
specify WAR) / ... .
(a) Residence. No.....l^.>
(Usual place of abode1
Length of stay: In hospital or institution
.St.
(Specify whether)
years
months
days.
(If nonresident, give city oiyfown and state)
In this commur.itj<_^^!^rs. mos. days.
PERSONAL AND STATISTICAL PARTICULARS
'4 COLOR OR RACE
MEDICAL CERTIFICATE OF DEATH
\3 SEX 4 COLOR OR RA
hiaA LokJhL
(write the word)
18 DATE OF
DEATH
5a If married, widowed, <
HUSBAND of
(or) WIFE of
\J A h •
(Month)
I
(Day)
J9¥2rrr
(Year)
(%ive maiden name of wife in full)
(Husband’s name in full)
6 Age of husband or wife if alive
7 IF STILLBORN, enter that fact here.
I H ER E B Y C ER T I F Y , Thaft I attended deceased from
19&fe, to L
I last saw h.-b***... alive on 1.... f 19.V^^?''death is said
to have occurred on the date statea abovdf at... *]
Immediate cause of death....
I HEREBY CERTIFY thaPa satisfactory standard certificate of death
filed nvith me BpE^RE thpj burial 6r transit permit was issued:
j f . (Signature of \ gent of BoarcLdrL rfealtn <
JfU.aMzu
(Official Designation)
(Registrar)
EXTRACTS FROM THE LAWS OF THE
COMMONWEALTH OF MASSACHUSETTS
GOVERNING THE
RETURN OF CERTIFICATES OF DEATH
A physician or registered hospital modical 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 he 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, Sea. 46,
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
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 he 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
FORM R-301
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FrB 9 1942 ^
Suffolk.
(County)
X
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o Wlnthrop.
g (City or Town)
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m}e (Eoixmt0it&ieal{I| of 4$laasaclju»ett0
OFFICE OF THE SECRETARY
DIVISION OF VITAL STATISTICS
STANDARD
CERTIFICATE OF DEATH
(City or town making return)
Registered No.
(If death occurred in a hospital or institution,
give its NAME instead of street and number)
NoWlnt.hrQP....C.Q.m^ni.t^....HQ5.p.ltal st
A .
K 4 ............. speci}7 WAR)
2 FULL .T. ^ war veteran. hOI16
(If "deceased is a married, widowed or divorced woman, give also maiden name.)
(a) Residence. No \1&£.. S^tiPtMain ' £K££ St. .Attleboro Mass
(Usual place of abode) hnQn-I+al Q <If .nonresident’.8lve Clty or town and^tate)
'.ength of stay: In hospital or institution .9.P.mJ/3ww years months O days. In this community yre. mos. 3^ days.
(Specify whether)
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
4 COLOR OR RACE
Vlh.TL
5 SINGLE
MARRIED
WIDOWED
or DIVORCED
(write the word)
\Ai
5a If married, widowed, or divorced
HUSBAND oi ■;
,,*« AG4v?» maiden -name oi wife in full)
oi William Eastwood
(Husband’s name in full)
18 DATE OF
DEATH
P. ,
L tSJUh.
(Month)
( Day ) *
(Year)
r49 1 HEREBY CERTIFY,
December 30 1(^1
That I attended deceased from
±m...Z
19....42
(or) WIFE
6 Age of husband or wife ii alive years
7 IF STILLBORN, enter that fact here.
AGE?.*? .... Years .7....Monthslf3L Days
Ii less than 1 day
Hours Minutes
Usual
9 Occupation:
Industry
10 or Business:
At home
11 Social Security No.
12 BIRTHPLACE (City)
(State or country)
.Mom
England
13 NAME OF
FATHER
Jalm Soper
14 BIRTHPLACE OF
FATHER fCitvl
England
(State or country)
15 MAIDEN NAME
OF MOTHER
Catherine E Pyne
16 BIRTHPLACE OF
MOTHER (City)
(State or country)
England
17
Tapper sf.
(Address) 60 Babcock St Brookline
if any
I HEREBY CERTIFY that a satisfactory standard certificate of death was
filed with me BEFQRE the^burial or transit permit was issued:
(Official Designation)
MEDICAL CERTIFICATE OF DEATH
er
I last saw h.... alive on..
an !L...
to have occurred on the date stated above, at
Immediate cause of death
":6%Ah
death it said
immediate cause or death
A?.y.t’.®...^P.c^ditls
Due to ™
Due to ....7TT.
Other conditions
(Include pregnancy within 3 months of death)
Major findings:
Of operations 77...
"None
..Date of..
Of autopsy
What lest confirmed diagnosis?.
Duration
.2. Days
PHYSICIAN
Underline
the cause to
which death
should be
charged sta-
tistically.
20 Was disease or injury in any way related to occupation ol deceased I ...~?.Q..
If so, specify I '
(Signed) .jL. ! .0 ..’...y. M. D.
(Address) : „4 Pate i
21 ..Forest. Hi Boston
Place of Burial, Cremation or -r»r r (Qhy or Town) /l O
DATE OF BURIAL .V.5S™.5.QLJ3 19 3?
22 funeraT director ..?I..«.B..e.V/a.i.orman....&.....3.o.iis..
ADDRESS
Received and filed
A TRUE COPY ATTEST :
.19
AN-J
1942
(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 daring his list
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 a removal shall
constitute a permit for such removal ; provided, that such body shall
be returned to the town from which it was removed within thirty-
six hours after such removal, unless a permit in the usual form for
the removal of such body has been sooner obtained hereunder. If the
death certificate contains a recital, as required by section ten of
chapter forty-six, that the deceased served in the army, navy or
marine corps of the United States in any war in which it has been
engaged, such recital shall appear upon the permit. The board of
health, or its agent, upon receipt of such statement and certificate,
shall forthwith countersign it and transmit it to the clerk of the
town for registration. The person to whom the permit is so given
and the physician certifying the cause of death shall thereafter fur-
nish for registration any other necessary information which can be
obtained as to the deceased, or as to the manner or cause of the
death, which the clerk or registrar may require. — Chap. 114, See. 46,
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 3uch permits, or if there is no euch board,
from the clerk of the town where the body is to be buried or the
funeral is to be held, or from a person appointed to have the care
of the cemetery or burial ground in which the interment is made. . . .
Chap. 114, See. 46, G. L., (Tercentenary Edition.)
RULES OF PRACTICE
The fulfillment of the purpose of these laws calls for the observ-
ance of the following rules of practice:
(1) Attending physicians will certify to such deaths only as those
of persons to whom they have given bedside care during a last ill-
ness from disease unrelated to any form of injury.
(2) Hoard of Health physicians will certify to such deaths only
as those of persons who, though disabled hy 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. a..
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 healthfulncss 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 of 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
)RM R-301 A
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“QIljc Cnittnimifaralllj nf <JWas?arbusiiie
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. i3..
I (ft death occurred in a hospital or institution,
give jts jjAME instead of street and number)
2 FULL NAME
(a) ResidSnTie. No,
(Usual place of abode)
PHYSICIAN - IMPORTANT
(Was deceased a
War Veteran,
Length of stay: In hospital or Institution V
(Before death) (Specify whether)
_ years
_jnonths
y WARU..-
(If nonresident, give city or town and State)
In this community yrs. mos. .. ^Rdayi.
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
4 COLOR OR RACE
5 SINGLE (wi
MARRIED
WID
or D
ie the word)
IS DATE OF
DEATH
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
19-0 HEREBV'tERT
WitC* 2>\ , 19
I last saw h...‘V*4 ... alive on.,
have occurred on the date statkK above.
Immediate cause of death A
I attended deceased
" >.y ' ”
, death Is said to
tel
ot. other)
UJ. 't'.l
(Official Designation) j / (Date of Issue/ of Permit)
JAN 6 TMT
(Registrar)
EXTRACTS FROM THE LAWS OF THE
COMMONWEALTH OF MASSACHUSETTS
GOVERNING THE
RETURN OF CERTIFICATES OF DEATH
A physician or registered hospital medioal 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 re-
quired by section one, where same was contracted, the duration of his last
illness, when last seen alive by the physician or officer and the date of his
death ... Gen. Laws, Chap. 46, Sec. 9.
A physician or officer furnishing a certificate of death as required by the
preceding section or by section forty-five of chapter one hundred and four-
teen, shall, if the deceased, to the best of his knowledge and belief, served
in the army, navy or marine corps of the United States in any war in which
it has been engaged, insert in the certificate a recital to that effect, speci-
fying the war, and shall also certify in such certificate both the primary
and the secondary or immediate cause of death as nearly as he can state
the same. For neglect to comply with any provision of this section, such
physician or officer shall forfeit ten dollars. For the purposes of this sec-
tion and of sections forty-five, forty-six and forty-seven of said chapter one
hundred and fourteen, the word “war” shall include the China relief ex-
pedition ami the Philippine insurrection, which shall, for said purposes, be
deemed to have taken place between February fourteenth, eighteen hundred
and ninety-eight and July fourth, nineteen hundred and two, and the Mexi-
can border service of nineteen hundred and sixteen and nineteen hundred
and seventeen. G. L. Chap. 4 6, Sec. 10.
No undertaker or other person shall bury or otherwise dispose of a human
body in a town, or remove therefrom a human body which has not been
buried, until he has received a permit from the board of health, or its
agent appointed to issue such permits, or if there is no such board, from
the clerk of the town where the person died; and no undertaker or other
person shall exhume a human body and remove it from a town, from one
cemetery to another, or from one grave or tomb other than the receiving
tomb to another in the same cemetery, until he has received a permit from
the board of health or its agent aforesaid or from the clerk of the town
where the body is buried. No such permit shall be issued until there shall
have been delivered to such board, agent or clerk, as the case may be,
a satisfactory written statement containing the facts required by law to be
returned and recorded, which shall be accompanied, in case of an original
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 physi-
cian who is a member of the board of health, or employed by it or by the
selectmen for the purpose, shall upon application make the certificate re-
quired of the attending physician. If death is caused bv violence, the medi-
cal examiner shall make such certificate. If such a permit for the removal
of a human body, not previously interred, from one town to another within
the commonwealth cannot be obtained early enough for the purpose, the
certificate of death made as above provided and in the possession of the
undertaker desiring to make such removal shall constitute a permit for
such removal; provided, that such body shall be returned to the town from
which it was removed within thirty-six hours after such removal, unless
a permit in the usual form for the removal of such body has been sooner
obtained hereunder. If the death certificate contains a recital, as required
by section ten of chapter forty-six, that the deceased served fn the armv
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
couiiterngn it and transmit it to the clerk of the town for registration
The pet son to whom the permit is so given and the physician certifying
the cause of death shall thereafter furnish for registration any other neces*
sary information w-hich 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 ashe.
thereof which have been brought into the commonwealth until he has re-
ceived 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 ofP the town
where the body is to be buried or the funeral is to be held, or from a person
appointed to have the care of the cemetery or burial ground in which the
interment is made. . . . Chap. 114, See. 46* O, L., (TeiccuUu^^ Edition)!
examiners shall make examination upon the view of the dead
bodies of only such persons as are supposed to have died by violence
If a medical examiner has notice that there is within his county the body
°Lsu.cb 8 Per,10n> sh»*I forthwith go to the place where the5 body lie*
and take charge of the same;... — General Laws, Chap. 38, Sec. 6.
RULES OF PRACTICE
thJ^ollmWi'^ mfe^of ^practice ;6 °f thMe l8WS CaUs f°r the observ*nc* of
(1) Attending physicians will certify to such deaths onlv as thnso
persons to whom they have given bedside care during a last illness from
disease unrelated to any form of injury. ‘“ness irom
(2) Board of Health physicians will certify to such deaths onlv as those
of persons who, though disabled by recognized disease unrelated to any
form of injury, have died without recent medical attendance or whose* physL
cian is absent from home when the certificate of death is needed. P 5
_.f3A JV16*11,031. Examiners will investigate and certify to all deaths suo-
posably due to injury. These include not only deaths caused directly or "m
directly by traumatism (including resulting septicemia), and by the action
of chemical (drugs or poisons), thermal, or electrical agents, and deaths
inf!e*in'g 8i>0il ti0*’ but a,s.°. deat,ls fl0m disease resulting from injury 'or
nfection 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 faflure
asphyxia, asthenia, etc. As principal cause name the diseas! causing death!
As i elated 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 im-
portant, 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 letired from business, report the usual occupation prior to retirement
Children not gainfully employed may be returned as at school or at home
F“a, 'vhose onl>’ 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
wru!yno!i°e! ’ ’ 8 Pe‘'S°D who had no occupation whatc!e!
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.
IRM R-301 A
I
ri
(County)
No.
#..o &±j.
2 FULL NAME Amc*
(If deceased is I married, widowej
(a) Residence. No .^[..0.
(Usual place of abode)
Length of stay: In hospital or institution .
®fjr CCnmmmtuiealtff of fHaHflnrfjufipttfl
OFFICE OF THE SECRETARY
DIVISION OF VITAL STATISTICS
STANDARD
CERTIFICATE OF DEATH
To be filed for burial permit
with Board of Health
or its Agent.
Registered No.
( (If death occurred in a hospital or institution,
bt. (give its NAME instead of street and number)
or divorced woman, give also maiden name.) Cj] specif
S.
• Veteran,
specify WAR)..
.St.
(Specify whether)
months
days.
(If nonresident, give city or town and state)
In this communityi,^' yrs. mos. - days.
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
4 COLOR OR RACE
5 SINGLE (write the word)
MARRIED , ft
WIDOWED LUv^lL»M>t, . *
or DIVORCED*
5a If married, widowed, or divorced
HUSBAND of..
(or) WIFE of
(Give maiden name of wife in full) .
Cr\.tL*\ A....:. \K/
(Husbana’s name in full)
6 Age of husband or wife if alive years
7 IF STILLBORN, enter that fact here.
8 / Q I If less than 1 day
AGE.. I... Y- Years..... T..... Months **.... Days) Hours Minutes
Usual I /
9 Occupation:
<Jb k.Uv^v<*..
Industry
10 or Business:.
11 Social Security No.
12 BIRTHPLACE (City)..
(State or country)
13 NAME OF
FATHER
j.
C- I 3—
sj <3L-V WUO
14 BIRTHPLACE OF
FATHER (City)
(State or country)
15 MAIDEN NAME
OF MOTHER
16 BIRTHPLACE OF
MOTHER (City)..
(State or country)
Informant..
(Address)
Relation, if any
** )
I HEREBY CERTIFY that a satisfactory standard certificate of death
"l with pae J^EFORf^th4 burial o/ transit permit was issued:
MEDICAL CERTIFICATE OF DEATH
is gsor. k?. — j ' f
♦// (Month) (Efey) (Year)
19 INHERE BY CERT I FA’’, That I attended deceased from
, 19-XU 19.X.*-:
I last saw h .y^v-r.alive on ..kZZ^hsk....Cm , 19.#*, death is said to
have occurred on the date stated above, at L.fe.t.VsjLdfl ro.
Immediatexause of dezlh. ..y....— .’. .
Due to A
Due to
Other conditions ZZ.
(Include pregnancy within 3 months of death)
Major findings:
Of operations Z...
..Date of..
Of autopsy. ;.
What test confirmed diagnosis?..
Duration
IMPORTANT
/ I
'7
..'rdtrcf..';
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? IKT
If bo, specify. ..yo..
(Signed) (.... ../ M. D.
21 w.tr.rrwtr.yttfY.a
Place of Burial, Crematifrv-or Removal. (City or Town)
DATE OF BURIAL 19
22 NAME OF
FUNERAL DIRE
^W^-Vva...
(City or Town)
ADDRESS
E^Vb y^JU^Ua^rrt
* V*f- -
Received and filed..
: U I
.19..
(Registrar)
X
I
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 3hall 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 needed.
(3) Medical Examiners will investigate and certify to all deaths
supposahly 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, a^phypia, 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 pereon 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
m Sufflok
|w (County)
fe Winthrop
(HI)* (Batmmmmraltif of fHanBarfjmirtla
OFFICE OF THE SECRETARY
DIVISION OF VITAL STATISTICS
To be filed for burial permit
with Board of Health
or its Agent.
Registered No z
5...
(If death occurred in a hospital or institution,
give its NAME instead of street and number)
STANDARD
(City or Town) S&gf CERTIFICATE OF DEATH
No 6 5 Loring Road St {
2 FULL NAME M?X...Q.U.Y.§^ ! w«v!i«-an.
(If deceased is a married, widowed or divorced woman, give also maiden name.) i specify WAR) ..
(a) Residence. 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 yrs. mos. days.
(Specify whether)
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
Female
4 COLOR OR RACE
White
S SINGLE (write the word)
MARRIED
WIDOWED 4 _ r
or DIVORCED i IQ OW
5a If married, widowed, or divorced
HUSBAND of
(Give maiden name of wife in full)
(or) wife of C.h2.rl.e.s....F.....Haml.lt.oii..
(Husband’s name in full)
6 Age of husband or wife if alive years
7 IF STILLBORN, enter that fact here.
8 O *2i ^ I ^ 1®** than 1 day
AGE. Years Months .. Days| Hours Minutes
Usual
9 Occupation:
Industry
10 or Business :
Housewife
Own Home
11 Social Security No..
None
12 BIRTHPLACE (City)..
(State or country)
ton...
17
13 NAME OF
father David Barnes
14 BIRTHPLACE OF
FATHER (City)
Boston
(State or country)
Mass .
15 MAIDEN NAME
OF MOTHER
Anna
Maria (Unknown)
16 BIRTHPLACE OF
MOTHER (City)
Unknown
(State or country)
infant Harry L
Relation, if any
Hamilton /Step-Son
(Address) §5 LOring
Pwd. Ojitnrop ..ass'
I HEREBY CERTIFY that a satisfactory standard certificate of death
was filed With me BEFORE t|^i burial or transit permit was issued
£^£££.k....£...h.
(Signature of Agent of Board of Healtttpr o filer)
. _ rtll LLt.
(Official Designation) nil (Date of Issue o^Permil
4=
MEDICAL CERTIFICATE OF DEATH
Immediate cause of death.
Ina Ia ^
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?..
IMPORTANT
PHYSICIAN
Underline
the cause to
which death
should be
charged sta-
tistically.
20 Wll disease or injury in any way related te occupation of deceased? -'l^C
If ao, specify D. ~ p
(Signed M. D.
(Address). 19f»^
9.i Forest Hina
Place of Burial, Cremation or Removal. (City or Town) ,
DATE OF BURIAL J.&nU&X.y. i.Q. 19Z.2
bos1;.
(City or Town)
22 NAME OF
FUNERAL
ADDRESS.
I DiKXCTOR^^^^ff^^. ,'v. . . . ,
X*sns**±...
Received and filed.......
Tl-fTT-
.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 wliich 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 needed.
(3) Medical Examiners will Investigate and certify to all deaths
supposably due to Injury. These include not only deaths caused
directly or indirectly by traumatism (including resulting septicemia),
and by the action of chemical (drugs or poisons), thermal, or electrical
agents, and deaths following abortion, but also deaths from disease
resulting from injury or Infection related to occupation, the
sudden deaths of persons not disabled by recognized disease,
and those of persons found dead.
Statement of Cause of Death. — 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
RM R-301 A
“•8 7
o "5;
a O
E** 2
*>
“"U <
S-So
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WcoO
•5 **■
Q< 0
OJO £
o- S
o£ E
“a, f d
H " «
« M
w>7 Ss
2*J x r
<HW £
5u o
OS3t3 0
.-a 3_g
v it -°
«3’? §
• j? «
- s s I
sc-* g--
H *T> k 0
| "3 °"S
*J§.2 S
5"*&
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(8
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M1l £
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2 £2 0
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►> fe-2
3- *3
Z"3 - o
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H 3 a.g
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<pg — 0)
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>«2h .
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0-.2Of
w « w’“
- Ejn ^
2oD«
£**«
>.Su.s
BOSTON
S rtf’! $ 4942,
5.. : -Suffolk
M (County)
(o Ilnthmp..
(FI je QJnmmmnnraltlj of fflaflfiarfjttaftta
OFFICE OF THE SECRETARY
DIVISION OF VITAL STATISTICS
To be filed for burial permit
with Board of Health
or its Agent.
6
STANDARD
(City or Town) X^J/J CERTIFICATE OF DEATH Registered No
| ?¥(&. . £.t( I?.*}. . J . . . ?.?.££. . .5.3&H.?. A . . iMSSS.t, S£ { g!vedft3thN?ME in3‘t^ad
2 FULL NAME.
(I£ U. S.
War Veteran,
specify WAR)...„
(If deceased is a married, widowed or divorced woman, give also maiden name.)
(a) Residence. Nn 49 rt/mOU ~^}r St ^ClS.t;QXl^....jsJ5.S.«
(Usual place of abode) Of nonresident, give city or town and state)
•— months 3 days. In this community " yrs. mos. > days.
Length of stay: In hospital or institution
(Specify whether)
years
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
Male
4 COLOR OR RACE
White
5 SINGLE (write the word)
MARRIED Mo r*‘P*i pH
WIDOWED
or DIVORCED
5a If married, widowed, or divorced
HUSBAND of .
(Give maiden name of wife in full)
(or) WIFE of
(Husband’s name in full)
6 Age of husband or
wife if alive A-.W.
7 IF STILLBORN, enter that fact here. •m—*
8 AO TO •- I If le»® than 1 day
AGE S'— ....Years Months Days| .77.. ..Hours Minutes
Usual
9 Occupation:
Retired
10 iiip.sr j U. S..Army
-U,
wong-
11 Social Security No
12 BIRTHPLACE (City) Ireland.
(State or country)
13 NAME OF
FATHER
William J. McCartney
14 BIRTHPLACE OF
father (City) w.G.Qtiand.
(State or country)
IS MAIDEN NAME
OF MOTHER _ , , . _ ,
Catherine Redman
16 BIRTHPLACE OF
MOTHER (City)
(State or country)
Ireland
17 Relation, if any
informant..^m. McCartney..^ (...wife )
(Address)
CERTIFY that a satisfactory standard certificate of death
BEFORE ;the buried or transit permit was issued:
natui
(Official Designation^
MEDICAL CERTIFICATE OF DEATH
18 deathOF January 9 j 1942..
(Month) (Day) (Year)
19 I HEREBY CERTIFY, That 1 attended deceased from
.January...^., , 19.42, to ...Jamiary....9.., , 19.42
I last saw h .im.... alive on JS.IUia.ry....9.j.., 19 .42, death is said to
have occurred on the date stated above, at 2.:45 . p.e tn.
Immediate cause of death QS.T6.byr 1 “ ’ .d. S .QU far _
acciaerrt 3 cerebral thrombo sis ^manz.
.fes.t.ed...by....p.a.r..t.ial...ri.ght
j^^L....md....temiml....ur.em.i.a...
t
to
O^er conditions...l2.^§^^5.^§^^^.^?-^.?.J..?-^—
(Include pregnancy within 3 months of death)
Major findings:
Of operations ...
Of autopsy .77.“
What test confirmed diagnosis?..
..Date of 77“.
20 Was disease
If so, specify.
(Signed]
(Ad.
Duration
IMPORTANT
PHYSICIAN
Underline
the cause to
which death
should be
charged sta-
tistically.
:upation of deceased? G.9
V/U<ca-
. .C.alaT..c.Q..y..C.ajp.b.*.^.M.A.....C..p..>..^ m. d.
MSjJmiL.* Date.J.an. Jl19^. 2.
2i jnUcWf
Place of Burial, Cremation oi Removal.
DATE OF BURIAL. .JfGCs'WfW i..
22 NAME OF
FUNERAL DI
(City or Town)
t
address iz»..s:.s4 £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,
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.
(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 i9 needed.
(3) Medical Examiners will Investigate and certify to all deaths
supposably due to Injury. These include not only deaths caused
directly or indirectly by traumatism (including resulting septicemia),
and by the action of chemical (drugs or poisons), thermal, or electrical
agents, and deaths following abortion, but also deaths from disease
resulting from injury or Infection related to occupation, the
sudden deaths of persons not disabled by recognized disease,
and those of persons found dead.
Statement of Cause of Death. — Cause of death means the disease,
or complication which causes death, not the mode of dying, e. f 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 non*.
SPACE FOR ADDITIONAL INFORMATION
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<Ul; p (ttnntmnnniraltli of j93aBoart;nartto
OFFICE OF THE SECRETARY
DIVISION OF VITAL STATISTICS
?..^ri. l*dl£
IW (County)
1 \o iW MEDICAL EXAMINER’S
m (City or Town) VjgZf CERTIFICATE OF DEATH
\l No
2 FULL NAME.
(If deceased is a married, widowed or divorced woma
(a) Residence. No... St
(Usual place of abode) >»
r."T.?rr ^'-~-rr.. — years —
To be filed for burial permit
with Board of Health
or its Agent.
Registered No.
St.
[ (If death occurred in a hospital or institution,
I give its NAME instead of street and number)
1 woman, give also maiden name.)
(If U. S.
War Veteran,
specify WAR)
(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 yrs. a* mos. *» days.
3 .
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
4 co:
OB) RACE
ite the word)
IS DATE OF
DEATH
I
(Month)
i.l..rr 1
(Day) \ (Year)
5a If married, widowed, or divorced
HUSBAND of
(Give maiden name of wife in full)
(or) WIFE of
(Husbandjs name in full)
6 Age of husband or wife if alive
7 IF STL
BORN, enter that fact here.
19 I HEREBY CERTIFY that I have investigated the death
of the person above-named and that the CAUSE AND MANNER thereof are
as follows: (If an injury was mvplved, State fully.)
14 BIRTHB2ACE OF
FATHER (City) ..
(State or country)
20 Accident, suicide or homicide (specify)
Date of occurrence 19 f/.. 2—
K occur?
(City or Town anp State)
Did injury occur in or about home, on farm, in industrial plac^, in public place;
.....
O ' (Specify type of place) y I
Injury...
lie at work? <rr rTTT Was there an autopsy?.../../.uVw£>
Injury.
While
•±L
15 MAIDEN NA
of mothe:
16 BIRTHPLACE OF
MOTHER (City)
(State or country)
21 Was disease or injury in any way related to occupation of deceased? .
If so, specify..
(Signed) .Trr^^TT. j , M. D.
J..?. 19.V.2-
I HEREBY CERTIFY that a satisfactory standard certificate of death
was fi^ed with me BEFORE the burial or transit permit was issued
US
dERBBY CERTIFY thi
is filed with me BEFO!
C&ct
, / jCSig^ture of Ag^nj^of Board of H'
' (Official Designation) {J II (Date of Issuer of Permit
ADDRESS.
r of- other)
Received and filed y. ......t...
..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, 3uch 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 ).
Medical examiners shall make examination upon the view of the dead
bodies of only such persons as are supposed to have died by violence.
If a medical examiner has notice that there is within his county the body
of such a person, he shall forthwith go to the place where the body lies
and take charge of the same; . . . — General Lows, Chap. 38, Sec. 6.
. . . He shall in all cases certify to the town clerk or registrar in the
place where the deceased died his name and residence, if known; other-
wise a description as full as may be, with the cause and manner of death.
— General Laws, Chap. 38, Sec. 7.
. . . The medical examiner certifies the cause and manner
of death to the best of his knowledge and belief.
RULES OF PRACTICE
The 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
diseasp unrelated to any form of injury.
(2) Board of Health physicians will certify to such deaths only as
those of persons who, though disabled by recognized disease unrelated to
any form of injury, have died without recent medical attendance or whose
physician is absent from home when the certificate of death is needed.
(3) Medical Examiners will investigate and certify to all deaths
supposably due to Injury. These include not only deaths caused
directly or indirectly by traumatism (including resulting septicemia),
and by the action of chemical (drugs or poisons), thermal, or electrical
agents, and deaths following abortion, but also deaths from disease
resulting from injury or infection related to occupation, the
sudden deaths of persons not disabled by recognized disease,
and those of persons found dead.
STATEMENT OF CAUSE OF DEATH
Medical Examiners in certifying to a death will state the cause and
manner thereof, and will specify: (1) Under cause, the nature of an
injury and of its consequences; and (2) under manner, the mode of its
production together with the circumstances when these are known. For
example: “Compound fracture of the femur with ensuing septicemia
(gas bacillus) caused by a steam railway accident.” “Pistol shot wound of
the chest with associated hemorrhage, homicidal." “Asphyxiation by
suspension, suicidal." “Syncope while under the influence of ether
administered as a surgical anaesthetic.” "Fracture of the skull with asso-
ciated internal injury sustained under circumstances unknown-”
If disease or injury was related to occupation, specify. If investigation
shows the death to have been due to disease, specify: (1) Under cause
its known or presumable nature; and (2) under manner, indicate the cir-
cumstances leading to medico-legal inquiry. For example: "Hemorrhage
spontaneous, of the brain (basal ganglia) (found dead in bed)." “Heart
disease, presumably coronary sclerosis. (Sudden death.)”
DESCRIPTION (for unknown person)
1
NOTICE TO UNDERTAKERS: No embalming fluid, or any substitute therefor, shall bo injected into the
body of any person supposed to have met his death lay violence, until a permit, signed by the Medical
Examiner, has first been obtained. — General Laws, Chap. 38, Sec. 14.
THIS CERTIFICATE CONSTITUTES SUCH PERMIT
tChr Coimttcutforalfli ot .itTnssarlmsrtts
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.
3.
((If death occurred in a hospital or institution.
St. | give its NAME instead of street and number)
PHYSICIAN -IMPORTANT
2 FULL NAME
(a) Residence. No
(Usual place of abode)
Length of stay: In hospital or Institution
(Before death) (Specify whether)
years months
days.
(If nonresident, give city or towq
In this community 'W yrs.
State)
daya.
PERSONAL ANO STATISTICAL PARTICULARS
3 SEX
4 COLOR OR RACE
5 SINPL
MARRIE
WIDOW
or OIVO
e the word)
(or) WIFE of
(Give maiden name of wife in full)
(Husband's name in full)
6 Age of husband or wife if alive
7 IF STILLBORN, enter that fact here.
year
8
AGE
Years ....TTT... Months
Days
If less than 1 day
Hours Minutes
Usual
9 Occupation :
Industry
10 or Business:
11 Social Security No.
12 BIRTHPLACE (City)
(Slate or country)
i
13 NAME OF
FATHER
14 BIRTHPLACE^ //
FATHER (City) //...pdf'
#
r!
(State or country) L^J'<!
tZSL.
15 MAIDEN NAMEs^Z? / n — ^
OF MOTHER ft
j 16 BIRTHPLACE OF «
MOTHER (City) M-J „....#
.A
(State or country) J {J ^
V
I HEREBY CERTIFY that a satisfactory standard certififate of death was
BEFORE the/buttaJ oF'tMnsit permit was issued:
r -
^j^^^^^^^natu^o^A^ent^of Board^ or cither)
(Official Designation) J J (Date of Issue of fermit) ,
MEDICAL CERTIFICATE OF DEATH
IS DATE OF
DEATH
//.
sy (Month) f (Day) (Year)
That I attended deceased from
.// , i9
I HEREBY CERTIFY,
19.!. f
I last saw ... alive on.. 19 Y^^death Is said to
have occurred on the date stated above, at... .£.... m. f
Imraadiate cause of death..
mmadiate cause of death
Due
Due to .
Other conditions T..
(.Include pregnancy within 3 months of death)
Of autopsy.. .„.
What test confirmed diagnosis?!
Duration
iMfOBTANT
Important
Physician
Underline
the cause to
which death
should b e
barged »ta-
listically.
20 Was disease or injury in any wayj’elated to occupation of ^e<jeased?r«^<
If so, specify.,
Received and filed..
■J T"3""19#"
(Registrar)
EXTRACTS FROM THE LAWS OF THE
COMMONWEALTH OF MASSACHUSETTS
GOVERNING THE
RETURN OF CERTIFICATES OF DEATH
A physioian 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 tile name of the
deceased, l.is supposed age, the disease of which he died, defined as re-
quired bv 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 ... Celt. Laws, Chap. 4G, Sec. 9.
A physician or officer furnishing a certificate of death as required by the
preceding section or by section forty-five of chapter one hundred and four-
teen. shall, if the deceased, to the best of his knowledge and belief, served
in the army, navy or marine corps of the 1'nited States in any war in which
it has been engaged, insert in the certificate a recital to that effect, speci-
fying the war. and shall also certify in such certificate both the primary
and the secondary or immediate cause of death as nearly as he can state
the same. For neglect to comply with any provision of this section, such
phvsician or officer shall forfeit ten dollars. For the purposes of this sec-
tion and of sections forty-five, forty-six and forty-seven of said chapter one
hundred and fourteen, the word “war” shall include the China relief ex-
pedition and the Philippine insurrection, which shall, for said purposes, be
deemed to have taken place between February fourteenth, eighteen hundred
and ninety-eight and July fourth, nineteen hundred and two, and the Mexi-
can border service of nineteen hundred and sixteen and nineteen hundred
and seventeen. G. L. Chap. 40, Sec. 10.
No undertaker or other person shall bury or otherwise dispose of a human
body in a town, or remove therefrom a human body which has not been
buried, until he has received a permit from the board of health, or its
agent appointed to issue such permits, or if there is no such board, from
the clerk of the town where the person died; and no undertaker or other
person shall exhume a human body and remove it from a town, from one
cemetery to another, or from one grave or tomb other than the receiving
tomb to another in the same cemetery, until he lias 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, ot 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 physi-
cian who is a member of the board of health, or employed by it or by the
selectmen for the purpose, shall upon application make the certificate re-
quired of the attending physician. If death is caused by violence, the medi-
cal examiner shall make such certificate. If such a permit for the removal
of a human body, not previously interred, from one town to another within
the commonwealth cannot be obtained early enough for the purpose, the
certificate of death made as above provided and in the possession of the
undertaker desiring to make such removal shall constitute a permit for
such removal; provided, that such body shall be returned to the town from
which it was removed within thirty-six hours after such removal, unless
a permit in the usual form for the removal of such body has been sootier
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 l’ lilted States in any war in which it has heeu
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 ami the physician certifying
the cause of death shall thereafter furnish for registration any other neces-
sary information which can be obtained as to the deceasetl, or as to the
manner or cause of the death, which the clerk or registrar may require. —
Chap. 111. 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 re-
ceived a permit so to do from the board of health or its agent appointed to
issue such peimits, or if there is no such board, from the clerk of the town
where the body is to be buried or tile funeral is to be held, or from a persou
appointed to have the care of the cemetery or burial ground in which the
interment is made. ... Chap. 114. Sec. 40. C. L., (Tercentenary Editiou).
Medical examiners shall make examination upon the view of the dead
bodies of only such persons as are supposed to have died by violence.
If a medical examiner lias notice that there is within his county the body
of such a person, he shall forthwith go to the place where the body lies
and take charge of the same;... — General Laws, Chap. 38, Sec. 0.
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 6uch 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 physi-
cian is absent from home when the certificate of death is needed.
(3) Medical Examiners will investigate and certify to all deaths «up-
posably due to injury. These include not only deaths caused directly oi in-
directly by traumatism (including resulting septicemia), and by the action
of chemical (drugs or poisons), thermal, nr electrical agents, and deaths
following aiiortion, 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 motle of living, 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 im-
portant, 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 retireineuL
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 persou engaged in domestic service for wages, however,
designate the occupation by the appropriate terms, as housekeeper — private
family, cook — hotel, etc. For a persou who had no occupation whatever
write none.
SPACE FOR ADDITIONAL INFORMATION
DRM R-3<
gx'S'S
£1
c u* rv
^ .20 £
w «w*r
H Scfl £
^ ^ (U
$>*;< >
>.Su.s
V/E
SEVERE NOTine
bounty)
(
(City or To^n)
llje Ctnnmunftifaltli of ^fla8sarf]u*»tl*
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.
Noi.Z./
FULL NAME
Registered No.
9
(a) Residence
(Usual place of abode.)
(If death occurred in a hospital or institution,
' ve its NAME instead of street and number)
(I! U. S.
, War Veteran,
f specify WAH)
Length of stay: In hospital or institution..
3
•f
(Specify whether)
- years - months
days.
(If nonresident, give city or town and state)
In this community yrs. mos. days.
PERSONAL AND STATISTICAL PARTICULARS
5a If married, wic
HUSBAND of
(or) WIFE of
(Give maiden- name of wife in full)
(Husband’s name in full)
S Age of husband or wife if aliy® — 7 year#,
7 IF STILLBORN, enter that fact here.
m
8 /■ y- jlf less than 1 dey
AGE Z? . Year3 T. Months ..TT.... Days ' Hours Minutes
Industry
10 or Business:
11 Social Security No - ~
12 BIRTHPLACE (City)
(State or country)
| 13 NAME OF
FATHER
14 B IRTHPL&CEG?*'
FATHER (Cj/f) ,
: Irrj.. , '
(State OLeduntry)
1
i 15 MAIDEN NAME-
OF MOTHER^/-
16 BIRTHPLACE OF
MOTHER (City)
(State or country)
t '' /
I HEREBY CERTIFY that a satisfactory si
Elect, w/th me BEFQRE /he buri^ cr tri
ignature of Agent
iard certificate of death was
permit was is3uodi
MEDICAL CERTIFICATE OF DEATH
18 DATE OF
DEATH
?F /£>
CMonth) (Day) (Year)
That 1 attended decease
isga i/om
••^rTrcCT.^.J 19.Y(..„ 19.Z....S....
1 last saw h...WHr...aIive on.y^.T3kVS-../..(f.. death is said
to have occurred on the date sti^4 above, at
Immediate cause of death..
mmediate cause or death 1 w
/y4
to
Due to
Other conditions
(Include pregnancy whbin 3 months of death)
Major findings :
Of operations the cause to
Date of .. Iwh!ch death
j should be
0f autopsy ;charj:ed st3.
What test confirmed diagnosis tistically.
Hscoired end filad 19
J.AN 1.9. ...1942
(Regis ti&r)
EXTRACTS FROM THE LAWS OF THE
. COMMONWEALTH OF MASSACHUSETTS
GOVERNING THE
RETURN OF CERTIFICATES OF DEATH
A physician or registered hospital medical officer shall 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 perron shall bury or otherwise dispose of a
human body in a town, or remove therefrom a human body which
has not been buried, until he has received a permit from the board
of health, or its agent appointed to issue such permits, or if there
is no such board, from the clerk of the town where the person died ;
and no undertaker or other person shall exhume a human body and
remove it from a town, from one cemetery to another, or from one
grave or tomb other than the receiving tomb to another in the same
cemetery, until he has received a permit from the board of health or
its agent aforesaid or from the clerk of the town where the body is
buried. No such permit shall be issued until there shall have been de-
livered to such board, agent or clerk, as the case may be, a satisfac-
tory written statement containing the facts required by law to be
returned and recorded, which shall be accompanied, in case of an
original interment, by a satisfactory certificate of the attending
physician, if any, as required by law, or in lieu thereof a certificate
as hereinafter provided. If there is no attending physician, or if, for
sufficient reasons, his certificate cannot be obtained early enough for
the purpose, or is insufficient, a physician who is a member of the
board of health, or employed by it or by the selectmen for the pur-
pose, shall upon application make the certificate required of the at-
tending physician. If death is caused by violence, the medical exam-
iner shall make such certificate. If such a permit for the removal of
a human body, not previously interred, from one town to another
within the commonwealth cannot be obtained early enough for the
purpose, the certificate of death made as above provided and in the
possession of the undertaker desiring to make such removal shall
constitute a permit for such removal ; provided, that such body shall
be returned to the town from which it was removed within thirty-
six hours after such removal, unless a permit in the usual form for
the removal of such body has been sooner obtained hereunder. If the
death certificate contains a recital, as required by section ten of
chapter forty-six, that the deceased served in the army, navy or
marine corps of the United States in any war in which it has been
engaged, such recital shall appear upon the permit. The board of
health, or its agent, upon receipt of such statement and certificate,
shall forthwith countersign it and transmit it to the clerk of the
town for registration. The person to whom the permit is so given
and the physician certifying the cause of death shall thereafter fur-
nish for registration any other necessary information which can be
obtained as to the deceased, or as to the manner or cause of the
death, which the clerk or registrar may require.— Chap. 114, Sec. 45,
G.L., (.Tercentenary Edition.)
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 i3 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 bealthfulness 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
>RM R-301 A
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5 3 Is
tEfir (Conmtoitliirnfllt ot ^{Tnssarlfusrtts
OFFICE OF THE SECRETARY
DIVISION OF VITAL STATISTICS
STANDARD
CERTIFICATE OF DEATH
unty) - y
(City or Town)^ /> / ^ ,
$£5‘ , Yj< Y// r II Tl, . , c, ((If death occurred in a_ hospital
•— •— | give its N A M K instead of slret
To be filed fop burial permit
with Board of Health
or its Agent.
Registered No.
10
2 FULL NAME.
(If
(a) Residence. No.
(Usual place of abode)
(..0'£uJ£^^h. ,(.w"s
dfe^ased is a married, widowed or divorced wornan, give also maiden name.) x I s®' speoj
or institution,
street and number)
PHYSICIAN -IMPORTANT
deceased a
Veteran
specify WAR)
st.
Length of stay: In hospital or Institution
f Before death) (Specify whether)
years
months
days.
(If nonresident, give city or town and State)
In this community /d yrs. " mos. — day*.
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
V'
4 COLOR OR R
ACE
5 SINGLE (write the word)
MARRIED s~^r • s
WIOOWED
or DIVORCED
5a If married, widowed, or divorced
HUSBANO of
_ (Give maiden pamemf wifeln full)
(or) WIFE of j&uitA^a^uCC
(TRishawra name in full)
;fe.
6 Age of husband or wife if alive year
7 IF STILLBORN, enter that fact here.
S
AGE TA Years Months ...ZTT.. Days
If less than X day
Hours Minutes
Usual
9 Occupation:
Industry
10 or Business:
ll Social Security No.
12 BIRTHPLACE (City)
(Slate or cnuntry)
13 NAME OF
FATHER
14 BIRTHPLACE/
FATHER ((
(State or country)
■4.1.
15 MAIDEN NAME
OF MOTHER
16 BIRTHPLAC
MOTHER ((
(State or country)
V:
CS)
17
. Relation, if any
( ***» )
r tA-
I HEREBY CERTIFY that a satisfactory standard Certificate of death was
filed vyitl/me BEFORE.the burial or trarfsitjrermit was issued:
gem of Board
eiltbopr.other)
(Official Designation)
/.//If../.?. K,
' (Date of Issue/of Permit) '
MEDICAL CERTIFICATE OF DEATH
IS DATE OF
DEATH
ZZ
(Month)
7"
(Day)
1.9m...
(Year)
19 I HEREBY CERTIFY, That I attended deceased from
, i9.+/..j£-, t o....'s/*..!3..\ , i95^...2w^
I last saw h...(S..br:..allve on 19..y.-4-death Is said to
nave occurred on the date stated above, at 7..: m.
Immediate cause of death
/Wj4...a... G..../^..r.^/..72^
Due
Due to..
Other conditions
(Include pregnancy within 3 months of death)
Major findings:
Of operations..
Date of..
Of autopsy..
What test confirmed diagnosis? 9/..*?*. £...£.
Duration
Important
Important
Physicim
I'nderline
the cause to
v»hich death
-Imuld b e
charged sta-
tistically.
21 J$t ^Joseph Ce.m*
Place of Burial, Cremati<)q or Removal.
yj.
(City or Town)
DATE OF BURIAL..
194'...?
22 NAME OF
FUNERAL DIRECTOR . _
ADDRESS SlOf 23cr ■HVadaiA*
Received and filed..
(Registrar)
20 Was disease or injury in any way related to occupation of deceased TZ&ScX
If so, specify a. x I —
(Sig.-ed) M. D.
( Address) Dat^r?f*fw.. 19 y.tb'
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 ttie best of his knowledge and belief the name of the
deceased, bis supposed age, the disease of which he died, defined as re-
quired by section one. wlu-re 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. 40, Sec. 9.
A physician or officer furnishing a certificate of death as required by the
preceding section or by section forty-five of chapter one hundred and four-
teen, shall, if the deceased, to the best of his knowledge and belief, served
in the army, navy or marine corps of the f'nited States in any war in which
it has been engaged, insert in the certificate a recital to that effect, speci-
fying the war. and shall also certify in such certificate both the primary
and the secondary or immediate cause of death as nearly as he can state
the same. For neglect to comply with any provision of this section, such
physician or officer shall forfeit ten dollars. For t lie purposes of this sec-
tion and of sections forty-five, forty-six and forty-seven of said chapter one
hundred and fourteen, the word “war" shall include the China relief ex-
pedition and the Philippine insurrection, which shall, for said purposes, be
deemed to have taken place between February fourteenth, eighteen hundred
and ninety-eight and July fourth, nineteen hundred and two, and the Mexi-
can border service of nineteen hundred and sixteen and nineteen hundred
and seventeen. G. L. Chap. 4G, Sec. 10.
No undertaker or other person shall bury or otherwise dispose of a human
body in a town, or remove therefrom a human body which has not been
buried, until he has received a permit from the board of health, or its
agent appointed to issue such permits, or if there is no such board, from
the clerk of the town where the person died; and no undertaker or other
person shall exhume a human body and remove it from a town, from one
cemetery to another, or from one graie or tomb other than the receiving
tomb to another in the same cemetery, until he has received a permit from
the board of health or its agent aforesaid or from the clerk of the town
where the body is buried. No such permit shall be issued until there shall
have been delivered to such board, ageut 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, oi 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 physi-
cian who is a member of the board of health, or employed by it or by the
selectmen for the purpose, shall upon application make the certificate re-
quired of the attending physician. If death is caused by violence, the medi-
cal examiner shall make such certificate. If such a permit for the removal
of a human body, not previously interred, from one town to another within
the commonwealth cannot be obtained early enough for the purpose, the
certificate of death made as above provided and in the possession of the
undertaker desiring to make such removal shall constitute a permit for
such removal; provided, that such body shall be returned to the town from
which it was removed within thirty-six hours after such removal, unless
a permit in the usual form for the removal of such body has been sooner
obtained hereunder. If the death certificate contains a recital, as required
by section ten of chapter forty-six, that the deceased served in the army,
navy or marine corps of the Fnited 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 neces-
sary 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 ashea
thereof which have been brought into the commonwealth until he has re-
ceived 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 he 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. Spc. 40. G. L., (Tercentenary Edition).
Medical examiners shall make examination upon the view of the dead
bodies of only such persons as are supposed to have died by violence.
If a medical examiner lias notice that there is within his county the body
of such a person, he shall forthwith go to the place where the body lies
and take charge of the same;... — General Laws, Chap. 38, Sec. 6.
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
pprsons 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 physi-
cian is alwent from home when the certificate of death is needed.
(3) Medical Examiners will investigate and certify to all deaths «up-
posably due to injury. These include not only deaths caused directly or in-
directly t -Tj 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 Deatn. — 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. — -l’recise statement of occupation is very im-
portant, 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, leport 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 occupatiou whatever
write none.
SPACE FOR ADDITIONAL INFORMATION
WRITE PLAINLY, WITH UNFADING BLACK INK - THIS IS A PERMANENT RECORD
Copies of returns of deaths recorded during the previous month which occurred in your city or town in case the deceased
resided in another city or town at the time of death should be made forthwith and transmitted on Form R-302 to the clerk
of the city or town in which the deceased resided. (See Chap. 46, Sec. 12, G. L.)
FORM R-302
WORCESTER..
(County)
fe RUTLAND.
Ui (City or Town) , .
Rutland State Sanatorium
tUhe (Eommonfornttlj of (JfliTassacIfusetis
OFFICE OF THE SECRETARY
DIVISION OF VITAL STATISTICS
COPY OF
CERTIFICATE OF DEATH
RUTLAND
(City or town making return)
11..
1
No.
St.
Registered No.
urred in a hospil
give its NAME instead of street and number)
!( If death occurred in a hospital or institution,
gi
2 FULL
NAME J War Veteran,
(If deceased is a married, widowed or divorced woman, give also maiden name.) I specify WAR)
(a) Residence. No §.3...^PW0.11.. Joad st I. Op.,.^a S S...
(Usual place of abode) (If nonresident, give city or town and State)
Sanatorium
Length of stay: In hospital or institution
(Before death) (Specify whether)
years Jj months 29r,ays>
In this oommunity yrs. 5 mos- 29 days.
PERSONAL AND STATISTICAL PARTICULARS
4 COLOR OR RACEl 5 SINGLE (write the word)
MARRIED y. .s j _ j
— I .. widowed V. idoued
eiaala white I or divorced
3 SEX
£
5a If married, widowed, or divorced
HUSBAND of
(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
47
AGE . Years Months .“.... Days
If less than 1 day
Hours Minutes
9 Occupation: .Jiouse.wif a
Industry
10 or Business:
II Social Security No.
12 BIRTHPLACE (City)
(State or country)
Ireland
13 NAME OF
FATHER
John Slattern
14 BIRTHPLACE OF
FATHER (City)
(State or country)
Ireland
15 MAIDEN NAME
OF MOTHER
Cannot fee learned
16 BIRTHPLACE OF
MOTHER (City)
(State or country)
Ireland
17
JMX. F , Mul<? afey / .“SSS&Sbe)
(Aaj.,.,1 j3 x.Q'7911 itd.V.lnthrop
A TRUE COPY.
ATTEST:
(/?
ed)
(Registrar of city or town where death
DATE FILED 19
MEDICAL CERTIFICATE OF DEATH
1sdDeAaTtEhOF January. 16
(Month) (Day)
19AZ.
(Year)
19 I
That I attended deoeased from
HEREBY CERTIFY,
July .18 19...41., to...^anuary....lS...... 19.4. 2
I last saw h. a.r alive on.. JaH.Uar.y.....lfi., 1942. death is said to
have occurred on the date stated above, at... 3;..aQ Am
f)uraiion
Immediate cause of death
P.ulm.Qn.ary......t.uiJ.ar.c.ul.Qii.is A yrs..
Due to..
Due to..
Other conditions
(include pregnancy within 3 months of death)
Major findings:
Of operations..
..Date of..
Physician
Underline
the cause to
which death
should b e
charged sta-
tistically.
Of autopsy
What test confirmed diagnosis?:}. jL.Cr.O.S..GQp.I.C.£Ll
20 Was disease or injury in any way related to occupation of deceased?
If so, specify
(Signed) P.a.ul...X!uC.aul.t m. d.
(Address) ... Ru.tl.and.....S.l.ata....S.aDfatA....l/l6i9 42
21 CREMATION8 OR^REMOVAL
DATE OF BURIAL
22 FUNERAL DIRECTOR ,.J.9.L^.,.S1..»..Q.!..M.3:l.Sy.
address Atlantic S.tj..«..,.W.int'lir..Qp..
Received and filed
imiih::::::
(Registrar of City or Town where deceased resided)
19
RM R-301 A
c c-o
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SSI
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<-5
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<a°
v # **i
O
X
r>-
<
af folk.
(County)
®hr Conmtoji&tralMi of ,iilfassac[|usctts
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.
j!Li£v.....
Registered No.
....d.n.tbx.Q.p.
(City or Town)
«• ••■inthrop ,0,«mmi.tz jiggpltal »(&WBI?aiaJfaaL!r»
f PHYSICIAN - IMPORTANT
2 FULL NAME §.§. ra.h.(..L!C.Q inn.iS.)..Se.0.rge J (Was deceased a
(If deceased is a married, widowed or divorced woman, give also maiden name.)
(a) Residence. No 8.5 -Cliff. .t.Y.SILU.S St.
U. S. War Veteran,
if so speoify WAR).
(Usual place of abode)
Length of stay: In hospital or Institution
(Reforo death) (Specify whether)
years
months D days.
(If nonresident, give city or town and State)
In this community 60 yrs. mos. days.
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
Female
4 COLOR OR RACE
Vhite
5 SINGLE (write the word)
MARRIED
widowed i flowed
or DIVORCED ^ Wv-'u-
3a If married, widowed, or divorced
HUSBAND of
« TalrfBytftMWtd* -ShMIgfl
(Husband's name in full)
(or) WIFE
6 Age of husband or wife if alive years
7 IF STILLBORN, enter that fact here.
AGE .8.8.... Years "... Months .7...
Days
If less than 1 day
Hours Minutes
9 Occupation: .*.£ fcfiffle.
Industry
10 or Business:
11 Social Security No.
12 BIRTHPLACE (City)
(State or country) U OVa ,COti&
13 NAME OF
FATHER
Angus McGinnis
14 BIRTHPLACE OF
FATHER (City) .
(State or country)
"S'co'tTana."
15 MAIDEN NAME r_ , _ , . .
of mother enable to obtain
16 BIRTHPLACE OF
mother (City) IIn&i).l.e .t.o. o.b.t.a.f H-
(State or country)
17
informant..::rsA ] aud^,...i<eonayd (cLMgfj^d^.....)
( Address) So J1 in vo. m v .ron ,.ags/
I HEREBY CERTIFY that a satisf^ptory standard certificate of death was
filed with me BEFOF
FOgE^he bur^^f transit permit was issued:
gdature of Agent of Board of Health 2r^^erJ /
SL
iation) J I (Date of issue of Bermit/ / '
MEDICAL CERTIFICATE OF DEATH
(Month) (Day) (Year)
18 ddeaatteh /..I <££3L.
19«i I HE R"E BY CERTIFY,
^ !9. y ~
/ last saw IvnfflLr alive on
-That I attended deceased from
/? isYA
have occurred on the date s
Immediatsocause of deal
Duration
Due
Due
to,
Other conditions..
(Include pregnancy within 3 months of death)
Important
Physician
<il .7.
Place of Burial, Cremation or Removal.
Place of Burial, Cremation or Removal. (City or.'
DATE OF BURIAL ry 20 f IS
22 NAME OF
funeral director .Gxl^X.l.SS Benmson
ADDRESS -WintbXQI
Reoeived and filed 19
JUULXjO^^
(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
renuesi of an undertaker or other authorized person or ol 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 re-
aiiired bv section one. where same was contracted, ihe duration of his last
illness. When last seen alive by the physician or officer and the date of hi*
death ... Ceu. Laws. Cliup. 46, Sec. 9.
A phvsician or officer furnishing a certificate of death as required by the
preceding section or by section forty-five of chapter one hundred and four-
teen shall, if the deceased, to the best of his knowledge and belief, served
in the army uavv or marine corps of the 1'tiited States in any war in winch
it has been engaged, insert in the certificate a recital to that effect, speci-
fying the war. and shall also certify in such certificate both the primary
and [lie secondare or immediate cause of death as nearly as he can state
the same For neglect to comply with any provision of this section, such
phvsician' or officer shall forfeit ten dollars. For the purposes of this sec-
tion and of sections forty-five, forty-six and forty-seven of said chapter one
hundred and fourteen, the word “war" shall include the China relief ex-
pedition and the Philippine insurrection, which shall, for said purposes be
deemed to have taken place between February fourteenth, eighteen hundred
and ninety eight and July fourth, nineteen hundred and two, and the Mexi-
can border service of nineteen hundred and sixteen and nineteen hundred
and seventeen. G. L. Chap. 46. Sec. 10.
No undertaker or other person shall bury or otherwise dispose of a human
body in a town, or remove therefrom a human body which has not been
buried, until he has received a permit from the board of health, or its
agent appointed to issue such permits, or if there is no such board, from
the clerk of the town where the person died; and no undertaker or other
person shall exhume a human body and remove it from a town, from one
cemetery to another, or from one grave or tomb other than the receiving
tomb to another in the same cemetery, until he has received a permit from
the board of health or its agent aforesaid or from the clerk of the town
where the body is buried. No such permit shall be issued until there shall
have been delivered to such board, agent or clerk, as the case may be,
a satisfactory written statement containing the facts required by law to be
returned and recorded, which shall be accompanied, in case of an original
interment, by a satisfactory certificate of the attending physician, if any,
as required by law, oi 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 physi-
cian who is a member of the hoard of health, or employed by it or by the
selectmen for the purpose, shall upon application make the certificate re-
quired of Ihe attending physician. If death is caused by violence, the medi-
cal examiner shall make such certificate. If such a permit for the removal
of a human bodv, not previously interred, from one town to another within
the commonwealth cannot he obtained early enough for the purpose, the
certificate of death made as above provided and in the possession of the
undertaker desiring to make siich removal shall constitute a permit for
such removal; provided, that such body shall be returned to the town from
which it was removed within thirty-six hours after such removal, unless
a permit in the usual form for the removal of such body has been sooner
obtained hereunder. If the death certificate contains a recital, as required
by section ten of chapter forty-six, that the deceased served In the army,
navy or marine corps of the United States in any war in which it has been
engaged, such recital shall appear upon the permit. The board of health,
or its agent, upon receipt of such statement and certificate, shall forthwith
countersign it and transmit it to the clerk of the town for registration.
The person to whom the permit is so given and the physician certifying
the cause of death shall thereafter furnish for registration any other neces-
sary 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 re-
ceived 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).
Medical examiners shall make examination upon the view of the dead
bodies of only such persons as are supposed to have died by violence.
If a medical examiner has notice that there is within his county the body
of such a person, he shall forthwith go to the place where Ihe body liea
and take charge of the same; . . . — General Laws, Chap. 88, Sec. 6.
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.
(8) 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 physi-
cian is absent from home when the certificate of death is needed.
(3) Medical Examiners will investigate and certify to all deaths sup*
posably due to injury. These include not only deaths caused directly or in-
directly 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 riving, 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 im-
portant, 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, teport 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
(County)
te . Suf f lo&.
to
1 inthrgp .
(City or Town)
31jr Clnmmnnuiraltlf nf MaoHarljuHrttjB
OFFICE OF THE SECRETARY
DIVISION OF VITAL STATISTICS
STANDARD
CERTIFICATE OF DEATH
To be filed for burial permit
with Board of Health
or its Agent.
No.
193 Main fcifde
-V” - at. (give i
Registered No.
13.
death occurred in a hospital or institution,
its NAME instead of street and number)
2 FULL NAME.
Mary Ellen Illingworth ( (hu.s.
] War Veteran,
(If deceased is a married, widowed or divorced woman, give also maiden name.) ) specify WAR)..
(a) Residence. No rl.... 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 $ 0 yrs. — mos. — days.
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
Female
4 COLOR OR RACE
7/hite
S SINGLE (write the word)
MARRIED
WIDOWED r, .
or DIVORCED jlHglg
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 J± ^ | If less than 1 day
AGE Years Months .rr.....Days| Hours Minutes
9 Occupation : B.Q.US W. Q £& .
Industry At Home
10 or Business:
11 Social Security No.
12 BIRTHPLACE (City)
(State or country) England
13 NAME OF
FATHER
Alfred Illingworth
14 BIRTHPLACE OF
FATHER (City)
(State or country)
Cngland.
15 MAIDEN NAME
OF MOTHER
Martha Ann Hinds
16 BIRTHPLACE OF
MOTHER (City)
(State or country)
England
17
Relation, if any
iniormanx ~ —
(Address) 1 y ^
2BY CERTIFY that a satisfactory standard certificate of death
1 BEFGjE^2> thaKurial or transit permit was issued:
rithvit^e I
.a-.. —
feu J
(Official Designation) i l / (Date of Issue ofA’ermit )/ 1
MEDICAL CERTIFICATE OF DEATH
18 DATE OF
DEATH
/J (Monthly
?zA
(Day) (Year)
:REB Y_C ERTI F- Y . That 1 attended decease
^ i9^..
'last saw h-#r3r... alive is said to
have occurred on the date stareu above, at...
Immediate cause ofedeat
,'^7T -i/j?
Due to ...\
Due to..
Other conditions
(Include pregnancy within 3 months of death)
Major findings:
Of operations..
Of autopsy..
What test con
Date of
lied diagno
Duration
IMMRTANI
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? <L.4rT.(?
If so, specify ..2
{Signed). M. D.
ai
Place of Burial, Cremation or Removal. (City or Town)
DATE OF BURIAL ,J.&.3[lW.SXy.....25..
lS&.X-'
Received and filed
(Registrar)
-
EXTRACTS FROM TME 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 hi3 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 needed.
(3) Medical Examiners will investigate and certify to all deaths
supposably due to injury. These include not only deaths caused
directly or indirectly by traumatism (including resulting septicemia),
and by the action of chemical (drugs or poisons), thermal, or electrical
agents, and deaths following abortion, but also deaths from disease
resulting from Injury or infection related to occupation, the
sudden deaths of persons not disabled by recognized disease,
and those of persons found dead.
Statement of Cause of Death. — 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
T
Sufflqk
(County)
£ Winthrqp
(City or Town)
Wife (flmmmtnmealtfj of ffiaflflarfjnarttii
OFFICE OF THE SECRETARY
DIVISION OF VITAL STATISTICS
STANDARD
CERTIFICATE OF DEATH
To be filed forburial permit
with Board of Health
or its Agent.
Registered No.... ItL
13 n 1,0 m _ ( (If death occurred in a hospital or institution,
No rt-.Ti.4s Jf..4s«.§'.^.5t.tr.^....!sCV.Jb St. (give its NAME instead of street and number)
2 FULL NAME.
(a) Residence. No
(Usual place of abode)
Length of stay: In hospital or institution..
....4.^®.^^.^....®^®™
(If deceased is a married, widowed or divorced woman, give also maiden name.)
142 Pleasant St....
(If u. s.
War Veteran,
specify WAR)..
(Specify whether)
years
months
days.
(If nonresident, give city or town and state)
In this community^: yrs. mos. - days.
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
Male
4 COLOR OR RACE
White
S SINGLE (write the word)
MARRIED
WIDOWED . .
or DIVORCED lfem6
5a If married, widowed, or divorced - _ ,
husband of J.e.annat.t.e
(or) WIFE of..
(Give maiden name of wife in full)
(Husband’s name in fjuH)
6 Age of husband or wife if alive years
7 IF STILLBORN, enter that fact here.
8 Q 1 *7 I If lees them 1 day
AGE. ....V.Q... Years.....1- Months 77:... .Days] Hours Minutes
9 Occupation: B..o..oM.ee.pe r
10 orB^staeas: EnmiMse Store.
11 Social Security No .0.2.2.” Q.7..T. 9.6.6.$?.
12 BIRTHPLACE (City) nfe..SjL...5® nni S .
(State or country)
■ :
13 NAME OF
FATHER
Bro
/TV
vAns K Baker
14 BIRTHPLACE OF
FATHER (City)
West Dennis
(State or country)
Ma s s .
IS MAIDEN NAME
OF MOTHER
Ahbie T Baxter
16 BIRTHPLACE OF
MOTHER (City)
Wes# Dennis
(State or country)
Mass .
17
Reljit^im if any
inforrnant...J.panne.tte....3aker ( jlJ1..® .)
(Address) 142 Pleasant St . Wlnthrop y
I HEREBY CERTIFY that a satisfactory standard certificate of death
was UJfed with me PEFOR£ the burial'or transit permit was issued :
iture
(Official Designation)
MEDICAL CERTIFICATE OF DEATH
18 DATE OF
DEATH
(Month)
*4
(Day)
(Year)
IQ
I H E,
f'
EBY CERTIFY, That I attended deceased from
f 19 ^.^, , I9.t£...?r.
ast saw h.<f*^r... alive on ... ^h<0 , 19^-.£r-death is said to
have occurred on the date statq&sbove, qt wr Sf m.|
b H- *!&*■&*■ 1
Immediate cause of death...
Due to ^Tcirr.Grvsr®.. .r
Due to.
IMPORTANT
Other conditions Z.
(Include pregnancy within 3 months of death)
Major findings:
Of operations
Of autopsy
What test confirmed diagnosis?..
Date of..
Duration
IMPORTANT
PHYSICIAN
Underline
the cause to
which death
should be
charged sta-
tistically.
20 Was duease or injury in any way related te occupation of deceased?..
If so, specify i«i 1 lm'T.1' '/ ft jl £••
]. (Signed) irJtLrRl/., M. D.
(Address)..' fJ..
2i Sou t h...Ue nni s
Place of Burial, Cremation or Removal.
South Demi,
(City or Town)
date of BURiAL..„.«I.a.n.u.ary 2.8. 19.^.?
<5Lc.?.«
22 NAME OF
FUNERAL DIRECTO,
ADDRESS.
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. 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 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 needed.
(3) Medical Examiners will investigate and certify to all deaths
supposably due to Injury. These include not only deaths caused
directly or indirectly by traumatism (including resulting septicemia),
and by the action of chemical (drugs or poisons), thermal, or electrical
agents, and deaths following abortion, but also deaths from disease
resulting from injury or infection related to occupation, the
sudden deaths of persons not disabled by recognized disease,
and those of persons found dead.
Statement of Cause of Death. — 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
RM R-301 A
c e-o
2 m £
™ a M
E c £
six
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5> O <u
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II •» ¥»
w -a
■» ai
No.
(Citjc-or Town, . - /
>s < -
®be dmiimmiforallli of (fUnssncIfuscits
OFFICE OF THE SECRETARY
DIVISION OF VITAL STATISTICS
STANDARD
CERTIFICATE OF DEATH
r 5—
To be filed for burial permit
with Board of Health
or Its Agent.
15...
Registered No.
< If death occurred In a hospital or Institution,
give its NAME instead of street and number)
2 FULL NAM£^/^srm*dC*<^..C
t'Cir deceased is a marriei
Widowed or divorced woman, ^give also maiden nan
(a) Residence. No.
(Usual place of abode)
Length of stay: In hospital or Institution rTHTTi * years months days.
(Refnre death) ( Specify whether)
PHYSICIAN - IMPORTANT
J (Was deceased a
1 u.
S. War Veteran,
(if so specify WAR)..
(If nonresident, give city or town and State)
In this community yrs. mos. days.
PERSONAL AND STATISTICAL PARTICULARS
4 COLOR OR RACE
SINGLE (write the word)
MARRIED
WIDOWED
or DIVORCED
- -
5a If married, widowed, or divorced
HUSBAND of . ’
„ LQire maidca nami
(or) WIFE of '
wife JjLAill
(Husband’s name in full)
6 Age of husband or wife if alive “ years
7 IF STILLBORN, enter that fact here.
S
JY,
AGE V /Years
Months
Days
If less than 1 day
Hours Minutes
/..< |...^.V
Usual
9 Occupation :
Industry
10 or Business:
11 Social Seourity No.
12 BIRTHPLACE (City)
(State or country)
13 NAME OF
FATHER
14 BIRTHPLACE OF y yy jX
FATHER (City) ^
(State or country)
15 MAIDEN NAME X? y, X'
OF MOTHER FvJ i
16 BIRTHPLACE OF
MOTHER (City)
(State or country)
Informant
(Address) ~ St/ ^ V
tory standard certificate of death 'was
or transit permit was Issued:
lth or other
if-'fMalth or other) .
(Z.x.bA<4.
of Issu/ of Pernt/t) ' ’
MEDICAL CERTIFICATE OF DEATH
IS DATE OF
DEATH
jJ.G, rw-*
(/ (Month) (Day) (Yeary
19 I HEREBY CERTIFY, That I attended deceased from
Qt- rC-* 3...... 19 j/.l.., to.£^«*Ss ^r..«r , 19..^...V
I last saw hyfrSLt*... alive on... 19 *jf ?fleath Is said to
have occurred on the date stated above, at m.
Immediate cause of death .
Due
Ch,#
to
*
Other conditions c Tl
(Include pregnancy within 3 months of death)
Major findings:
Of operations..
Date of
Of autopsy. ?.
What test confirmed diagnosis? . £^&r*Osl.
Duration
Important
20 Was disease or injury in any way related to jmoupation of deceased ? .O •
If so, specify.
lSigned)/2L
FUNERAL DIRECTOR
ADDRESS JkZt?....
Reoeived and filed.
■trr
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 re-
quired hv section one. where same was contracted, the duration of his last
illness, when last seen alive by the physician or officer and the dale of hta
death ... Gen. I.aws, Chap. 46, Sec. 9.
A phvsician or officer furnishing a certificate of death as required by the
preceding section or by section forty-five of chapter one hundred and four-
teen. shall, if the deceased, to the best of his knowledge and belief, served
in ttie army, navy or marine corps of the I'nited States in any war in which
it has been engaged, insert in the certificate a recital to that effect, speci-
fying the war. and shall also certify in such certificate both the primary
and '’the secondary or immediate cause of death as nearly as he can state
the same For neglect to comply with any provision of this section, such
physician or officer shall forfeit ten dollars. For the purposes of this sec-
tion and of sections forty-five, forty-six and forty-seven of said chapter one
hundred and fourteen, the word “war” shall include the China relief ex-
pedition and the Philippine insurrection, which shall, for said purposes, be
deemed to have taken place between February fourteenth, eighteen hundred
and ninety- eight and July fourth, nineteen hundred and two, and the Mexi-
can border service of nineteen hundred and sixteen and nineteen hundred
and seventeen. G. L. Chap. 4 6, Sec. 10.
No undertaker or other person shall bury or otherwise dispose of a human
bodv in a town, or remove therefrom a human body which has not been
buried, until he has received a permit from the board of health, or its
agent appointed to issue such permits, or if there is no such board, from
the clerk of the town where the person died; and no undertaker or other
person shall exhume a human body and remove it from a town, from one
cemetery to another, or from one grave or tomb other than the receiving
tomb to another in the same cemetery, until he has received a permit from
the board of health or its agent aforesaid or from the clerk of the town
where the body is buried. No such permit shall be issued until there shall
have been delivered to such board, agent or clerk, as the case may be,
a satisfactory written statement containing the facts required by law to be
returned and recorded, which shall be accompanied, in case of an original
interment, bv a satisfactory certificate of the attending physician, if any,
as required by law. oi iii lieu thereof a certificate as hereinafter provided.
If there is no attending phvsician, or if, for sufficient reasons, his certificate
cannot be obtained early enough for the purpose, or is insufficient, a physi-
cian who is a member of the board of health, or employed by it or by the
selectmen for the purpose, shall upon application make the certificate re-
quired of the attending phvsician. If death is caused by violence, the medi-
cal examiner shall make such certificate. If such a permit for the removal
of a human bodv, 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 Tinted 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 neces-
sary 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 re-
ceived 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).
Medical examiners shall make examination upon the view of the dead
bodies of only such persons as are supposed to have died by violence.
If a medical examiner has notice that there is within his county the body
of such a person, lie shall forthwith go to the place where the body lie*
and take charge of the same;... — General Laws, Chap. 38, Sec. 6.
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) 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 physi-
cian is absent from home when the certificate of death is needed.
(3) Medical Examiners will investigate and certify to all deaths tup-
posably due to injury. These include not only deaths caused directly or in-
directly 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 im-
portant, 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, teport 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
•VTMib rkMiiib i | »»un unrHumu ULMk.iv imv— i mj ij m ruiiviMnbM i hkwiw, tvery nem ui miurmjuun
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.
If deoeased was a U. S. War Veteran, G. L. Chap. 46, Seotlon 10, requires physicians to insert a reoital to that effect.
*M R-301 A
? '
jy / /
tEJto Conttnojiforallli of jiHassacIjitsctts
OFFICE OF THE SECRETARY
DIVISION OF VITAL STATISTICS
STANDARD
CERTIFICATE OF DEATH
No.
If deceased is a married, widowed or divorced woman, give also mai
Registered No
( (If death occurred in a hospital or Institution,
St. {give jts KAllli instead of street and number)
PHYSICIAN • IMPORTANT
2 FULL NAME 1 <w»* *«•«**<* *
(If deceased is a married, widowed or divorced woman, give also maiden name.) I r; wa?. .rflllV
„ RasidenM. », AC ^ ^ S, L" "
(Usual place of abode)
Length of stay: In hospital or Institution
( Refnre death) (Specify whether)
years
months
days.
(If nonresident, give city or town and State)
In this community (p 3 yrs. mos.
days.
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
4 COLOR OR RACE
5 SINGLE (write the word)
MARRIED . . . , , A
WIDOWED
or DIVORCED
5a If married, widowed, or divorced
HUSBAND of
(Give maiden name of wife in full)
(or) WIFE of a *...
(Husband’s name in full)
?/
6 Age of husband or wife if alive
years
7 IF STILLBORN, enter that fact here.
AGE
lA Years . Months
Days
If less than 1 day
Hours Minutes
Usual
9 Occupation:
&
Industry
10 or Business:
11 Social Security No,
12 BIRTHPLACE (City)
(Slate or country ) n ^
13 NAME OF
FATHER
14 BIRTHPLACE OF
FATHER (City)
(State or country)
15 MAIDEN NAME^A
OF MOTHER
±£2l
16 BIRTHPLACE OF
MOTHER (City)
(State or country)^^ <?i, A i fttZ
I
standard certificate of death was
nsiy permit was issued:
rignature
(Official Designatio
MEDICAL CERTIFICATE OF DEATH
18 DATE OF
DEATH
(Month)
IS
(Day)
th..
(Year)
That I attended deoeased from
19 I HEREBY CERTIFY,
, 19 , to ,
I last saw h L. alive on 19<^.i*f death Is said to
have occurred on the date stated above, at .m.
Immediate oause of death
Due to
Due to .
Other oonditlons
(Include pregnancy within 3 months of death)
Major findings:
Of operations..
Date of..
Of autopsy
What test confirmed diagnosis?..
Duration
Important
Jttyd...
.(.I.
Important
Physician
Underline
the cause to
which death
should b e
charged sta-
tistically.
z.0 Was disease or injury in any way related to oooupation of deceased? jSfrrff
If so, speoify
(Signed^^rjr,
. (Adflres
. / M. D.
Dalai J tfr 19 .’fr "*
T
To be filed for burial permit
■with Board of Health
or its Agent.
1£L
l'lace of Burial, Cremation or KenRyah' ^ I (City or Town)
DATE OF BURIAL^^.r?<l^..’fc*-
19<^.<
SC
ADDRESS CAl?*...
22 NAME OF
FUNERAL DIRECTOR
Reoeived and filed ^.*.**....r...^,.....‘(942...
..19..
( Registrar 1
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 re-
quired bv 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 hta
death ... Cen. Laws, Chap. 46, Sec. 9.
A physician or officer furnishing a certificate of death as required by the
preceding section or by section forty-five of chapter one hundred and four-
teen shall if the deceased, to the best of his knowledge and belief, served
in the army, navy or marine corps of the t'nited States in any war in which
it has been engaged, insert in the certificate a recital to that effect, speci-
fying the war. and shall also certify in surh certificate both the primary
and llie secondary or immediate cause of death as nearly as he can state
the same For neglect to comply with any provision of this section, such
physician or officer shall forfeit ten dollars. For the purposes of this sec-
tion and of sections forty-five, forty-six and forty-seven of said chapter one
hundred and fourteen, the word “war" shall include the China relief ex-
pedition and the Philippine insurrection, which shall, for said purposes be
deemed to have taken place between February fourteenth, eighteen hundred
and ninety- eight and July fourth, nineteen hundred and two, and the Mexi-
can border service of nineteen hundred and sixteen and nineteen hundred
and seventeen. G. L. Chap. 4 6, Sec. 10.
No undertaker or other person shall bury or otherwise dispose of a human
body in a town, or remove therefrom a human body which has not been
buried, until he has received a permit from the board of health, or its
agent appointed to issue such permits, or if there is no such board, from
the clerk of the town where the person died; and no undertaker or other
person shall exhume a human body and remove it from a town, from one
cemetery to another, or from one grave or tomb other than the receiving
tomb to another in the same cemetery, until he has received a permit from
the board of health or its agent aforesaid or from the clerk of the town
where the body is buried. No such permit shall be issued until there shall
have been delivered to such board, agent or clerk, as the case may be,
a satisfactory written statement containing the facts required by law to he
returned ami recorded, which shall be accompanied, ill case of an original
interment, bv a satisfactory certificate of the attending physician, if any,
as required bv law, oi 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 physi-
cian who is a member of the board of health, or employed by it or by the
selectmen for the purpose, shall upon application make the certificate re-
quired of the attending phvsician. If death is caused by violence, the medi-
cal 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 tow-n 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 array,
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 neces-
sary information which can be obtained as to the deceased, or as to the
manner or cause of the death, which the £lcrk 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 ashe9
thereof which have been brought into the commonwealth until he has re-
ceived a permit so to do from the hoard of health or its agent appointed to
issue such permits, or it tlu-re is no such hoard, 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).
Medical examiners shall make examination upon the view of the dead
bodies of only such persons as are supposed to have died by violence.
If a medical examiner has notice that there is within his county the body
of such a person, he shall forthwith go to the place where the body lie*
and take charge of the same;... — General Laws, Chap. 38, Sec. 6.
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) 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 physi-
cian is absent from home when the certificate of death is needed.
(3) Medical Examiners will investigate and certify to all death* *up-
posably due to injury. These include not only deaths caused directly or in-
directly 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 im-
portant, 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
boston notified
FORM R-301
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3 SEX
Fera le
4 COLOR OR RACE
Wh 5 1 e
5 SINGLE (write the word)
MARRIED
widowed Farr i ed
or DIVORCED
Z ^.-e S Jj
5a If married, widowed, or divorced
WTTSRflNn M
Z 2 ° c
.(Give, maide
n name of wife in full)
[,o TaronQ
— vo 0
(or) WIFE oi
Ra Inh Del.
m 22 >
K X* g-j
0 H tj 2 .
(Husband’s name in full)
6 Age of husband or wile ii alive
£•2 0 |
m Eu'“
£ Sen £>
- g3 $
£.£U.2
z
ea
z
9 1942
u? f oik
(County)
o p
M (City or Town)
tEljc (EontmonCDealtl} of ,i®ta00acl]n«tt®
OFFICE OF THE SECRETARY
DIVISION OF VITAL STATISTICS
STANDARD
CERTIFICATE OF DEATH
(City or town making return)
Registered No..
HU 7
No lJ..r..thr..0.p....C.QL'r...u:a.i.t^r....-.S.S.3.--^^-^ StJ
(If death occurred in a hospital or institution,
give its NAME instead of street and number)
2 FULL NAME...£2.^.9..®.t.t;..^.....Uti.l.l.Q....X.S.C.&P.O....(.yAluuniA ]
(If deceased is a married, widowed or divorced woman, give also maiden name.) ( opeciiy wm;.
3os t on
(a) Residence. No H.Q.Y.S.l?. St.
(Usual place of abode)
.ength of stay: In hospital or institution I
(Specify whether)
years
months
1
days.
(If nonresident, give city or town and state)
In this community- yrs. mos. days.
PERSONAL AND STATISTICAL PARTICULARS
7 IF STILLBORN, enter that fact here.
9 Occupation: .K.QUSJfiLltti£fi.
10 or^Bumness: At ZSffiLR
11 Social Security No .Q2. .8 - 05 - .1 .9.6 9..
12 BIRTHPLACE (City)
13 NAME OF
father Edward
A]unni
14 BIRTHPLACE OF
FATHER ICitvl
(State or country)
Italy
15 MAIDEN NAME
OF MOTHER ^opR
Paolucci
19 BIRTHPLACE OF
MOTHER (Citvl
(State or country)
Italy
17
Informant MlSh BtUfi iMOllCb
" t . f loYori
(Address) g ^ q P a n o v e r
or transtf permit was issued:
I HEREBY CERTIFY that a satisfactory standard certificate oi death was
.trail 1
MEDICAL CERTIFICATE OF DEATH
IS DATE OF
DEATH ....
(Month)
4..^:.
(Day) (Year)
',3 h.r(Sr^*...aliv
19 . 1 HEREBY CERTIFY, d Hat I attended dcceaicd from
, 19.^.£ 19.Y..V
alive on™Ji.&&ta..i...hifc...£ 19..T\.^rdeath it said
to have occurred on the datettated above, at..<fl.V:£($n
Immediate cau^-of death.™.........
Duration
Other conditions
(Include pregnancy within 3 months of death)
PHYSICIAN
Major findings :
Of operations
..Date of..
Of autopsy
What test confirmed diagnosis?.
Underline
the cause to
which death
should be
charged sta-
tistically.
20 Was disease or injury In any way related to occupation ol deceased I ...
If so, specify . ,|y
(Signed).
(Address).^.
M. D.
2i s.t... lJi.cha.s.1 ilQs££hn..
Place of Burial, Cremation or Removal. (City or Town)
DATE OF BURIAL u.£L.Zl., £8 19 4.2-
1
22 NAME OF
FUNERAL DIRECTO!
address ■j.9......0.r,l.e.a.ns t.an„
Received and filed
"A TRUE ' COPY "ATTEST: '
•o"T‘194r
.19..
(Registrar)
X
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 dnration 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.
IVo undertaker or other person shall bury or otherwise dispose of a
human body in a town, or remove therefrom a human body which
has not been buried, until he has received a permit from the board
of health or its agent appointed to issue such permits, or if there
is no such board, from the clerk of the town where the person died ;
and no undertaker or other person shall exhume a human body and
remove it from a town, from one cemetery to another, or from one
grave or tomb other than the receiving tomb to another in the same
cemetery, until he has received a permit from the board of health or
its agent aforesaid or from the clerk of the town where the body is
buried. No such permit shall be issued until there shall have been de-
livered to such board, agent or clerk, as the case may be, a satisfac-
tory written statement containing the facts required by law to be
returned and recorded, which shall be accompanied, in case of an
original interment, by a satisfactory certificate of the attending
physician, if any, as required by law, or in lieu thereof a certificate
as hereinafter provided. If there is no attending physician, or if, for
sufficient reasons, his certificate cannot be obtained early enough for
the purpose, or is insufficient, a physician who is a member of the
board of health, or employed by it or by the selectmen for the pur-
pose, shall upon application make the certificate required of the at-
tending physician. If death is caused by violence, the medical exam-
iner shall make such certificate. If such a permit for the removal of
a human body, not previously interred, from one town to another
within the commonwealth cannot be obtained early enough for the
purpose, the certificate of death made as above provided and in the
possession of the undertaker desiring to make such a removal shall
constitute a permit for such removal ; provided, that such body shall
be returned to the town from which it was removed within thirty-
six hours after such removal, unless a permit in the usual form for
the removal of such body has been sooner obtained hereunder. If the
death certificate contains a recital, as required by section ten of
chapter forty-six, that the deceased served in the army, navy or
marine corps of the United States in any war in which it has been
engaged, such recital shall appear upon the permit. The board of
health, or its agent, upon receipt of such statement and certificate,
shall forthwith countersign it and transmit it to the clerk of the
town for registration. The person to whom the permit is so given
and the physician certifying the cause of death shall thereafter fur-
nish for registration any other necessary information which can be
obtained as to the deceased, or as to the manner or cause of the
death, which the clerk or registrar may require. — Chap. 114, See. 46,
(?. L., (Tercentenary Edition.)
No undertaker or other person shall bury a human body or the
ashes thereof which have been brought into the commonwealth until
he has received a permit so to do from the board of health or its
agent appointed to issue such permits, or if there is no such board,
from the clerk of the town where the body is to be buried or the
funeral is to be held, or from a person appointed to have the care
of the cemetery or burial ground in which the interment is made. . . .
Chap. 114, See. 46, G. L., (Tercentenary Edition.)
RULES OF PRACTICE
The fulfillment of the purpose of these laws calls for the observ-
ance of the following rules of practice :
(1) Attending physician* will certify to such deaths only as those
of persons to whom they have given bedside care during a last ill-
ness from disease unrelated to any form of injury.
(2) Board of Health 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
supposahly duo 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, «. 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 Ihat 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
Suffolk
(County)
1 \o Winthrop.
(City or Town)
OJornmnnutralUj of fSaBaarfiituflla
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.
1ft
No.
. .9.^.. .4T « . St. {gvett^Ehistead of street and number)
Registered No
in a hospital or institution,
2 FULL NAME.. X&.V. 1. . . .8 .9. 0 8 S War Veteran.
(If deceased is a married, widowed or divorced woman, give also maiden name.)
(a) Residence. No...a32..Sftir.lSX.:Sk*^ St
(Usual place of abode)
Length of stay: In hospital or institution
specify WAR)...
(Specify whether)
years
months
days.
(If nonresident, give city or town and state)
In this community 26yrs. mos. — days.
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
Male
4 COLOR OR RACE
Whi t e
(write the word)
S SINGLE
MARRIED
^divorced Wi doe wed
oa xt married, widowed, or divorced
HUSBAND J.roywi
(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
AGE
6«3
Years Months. ...26 _ Days| Hours Minutes
If less than 1 day
9 Occupation: .?_§« OMfct |T,
Industry
10 or Business:
11 Social Security No...
12 BIRTHPLACE (City) JUT.llXli.t.QIL......
(State or country)
''TSfifcslT
13 NAME OF
FATHER
James Seddeoa
14 BIRTHPLACE OF
FATHER (City)
(State or country)
not known
IS MAIDEN NAME
OF MOTHER
not known
16 BIRTHPLACE OF
MOTHER (City).
(State or country)
not Known
17
Relation, if any
Informant., )
(Address) Snlfley St., IffintMirop '
ry standard certificate of death
ansit permit was issued:
MEDICAL CERTIFICATE OF DEATH
18 DEATHS... J^m... 1.9.42.
(Month)
(Day)
(Year)
19
I HEREBY CERTIFY,
That I attended deceased from £
I last saw h alive on ... 19 . death is said to
have occurred on the date stated above, at m.
Duration
Immediate cause of death.
IIIPOKTAMT^
ctfCxky
\ M
Due to •
C Or "TV J , SC. .
4 Awv O
Due to
y
Other conditions l
(Include pregnancy within 3 months of death)
IMPORTANT
Major findings:
Of operations..
Date of
Of autopsy
What test confirmed diagnosis?..
Underline
the cause to
which death
should be
charged sta-
tistically.
i
20 Was disease or injury in any way related te occupation of deceased?
If so, specify yer.*. i— -</..
(Signed)..
(Address).
...JucLmx M. D.
Dat
2i Wint.hr op. Wi n t hr op
Place of Burial, Cremation or Removal. _ _. _(City or Town)
. 1, 1942
DATE OF BURIAL
22 NAME OF
FUNERAL DIRECTO:
.19..
ADDRESS .1.4.7..
Received and filed..
3 - 1942
..19..
(Registrar)
sM
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 lias
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, j 14, See. 46, G. L., ( Tercentenary
Edition ) .
RULES OF PRACTICE
The fulfillment of the purpose of these laws calls for the observance of
the following rides of practice :
(1) Attending physicians will certify to such deaths only as those
of persons to whom they have given bedside care during a last illness from
disease unrelated to any form of injury.
(2) Board of Health physicians will certify to such deaths only as
those of persons who, though disabled by recognized disease unrelated to
any form of injury, have died without recent medical attendance or whose
physician is absent from home when the certificate of death is needed.
(3) Medical Examiners will investigate and certify to all deaths
supposably due to injury. These include not only deaths caused
directly or indirectly by traumatism (including resulting septicemia),
and by the action of chemical (drugs or poisons), thermal, or electrical
agents, and deaths following abortion, but also deaths from disease
resulting from injury or Infection related to occupation, the
sudden deaths of persons not disabled by recognized disease,
and those of persons found dead.
Statement of Cause of Death. — 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
knowm. 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
)RM R-303A
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The text goes on. The rest is in the file.