The volume, 1943

Town Clerk, Winthrop · from the Internet Archive · 592 pages · 45.6 MB
open the file ↗ · original at the source ↗

margin RESERVED for binding

WRITE PLAINLY. WITH UNFADING BLACK INK — THIS IS A PERMANENT RECORD

CoDics of returns of deaths which occurred in your city or town in case the deceased resided in another city or town at the time
of death should be transmitted on Form R-305 to the clerk of the city or town m which the deceased resided as soon as possible
after the close of the month in which the death occurred. (See Chap. 46, Sec. 12, G. L.)

FORM

?-305

(County)

©l|e Commcntfbcaltlj of ^dSftassacljusetts .

OFFICE OF THE SECRETARY REVERE

Si (City or town making return)

COPY OF

MEDICAL EXAMINER’S

Revere certificate of death

„ (^^brth Shore Road f (If death occurred in a hospital or institution.

.... St. t give its NAME instead of street and number)

►t

,BUl«h....t:li.X.d?.S.d....A.XX.6.0.....(.RU.SS.e.XX.).... | WoF Vote

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

240 V'lnthroo Shore Drive Wlnthfrop

* St

(a) R(U*ut*ptaS of abode) HOIie I nontesident.' give city or town “d stle)

Length of stay: In hospital or institution... years months days. In this commun.ty yrs. mos. days.

6 (Specify whether)

2 FULL NAME

Registered No.

Veteran,
specify WAR)

PERSONAL AND STATISTICAL PARTICULARS

(write the word)

3 SEX _ 4 CO^OR OR F

Feraalel white

iR RACE; S SINGLE
MARRIED
WIDOWED
or DIVORCED

[write the word)

Widowed

5a If married, widowod, or divorced

k„sba..d oi Leg-feggpive^i^i tjAEfeifeifc in(f>eSfe ceased)

(or) WIFE of

(Husband’s name in full)

6 Age of husband or wife if alive years

7 IF STILLBORN, enter that fact here.

AGE

Years

Months

Jays

Ii less than 1 day

Hours ... Minutes

Usual

9 Occupation:

At Home

or Business: ... Keeping. House .

11 Social Security No. None

South Boston*

12 BIRTHPLACE (City)
(State or country)

Maas.

13 NAME OF „ _ _

father Herbert Russell

13 DATE OF
DEATH

MEDICAL CERTIFICATE OF DEATH

January

DEATH „ ,

Srp2 — 194-3-

(Month)

(Day)

(Year)

14 BIRTHPLACE OF

father (City) Unable to obtain

IS MAIDEN NAME
OF MOTHER

Unabl f to obtain

16 BIRTHPLACE OF
MOTHER (City) ..

(State or country)

Uri&ulc mO ouvSin

Relation, if any

Informant

(Address)

irs. Ruth Carlton ( Daughter)

’h?) Fihn-re url yp ,Wlnthrop ’lias

A TRUE COPY.

ATTEST*" / t-S L

/ j city or/fo^n where jjjatb occurred)

DATE FILfD^_ mmx. Ax * AT

19 ! HEREBY CERTIFY that I have investigated the death

of the person above-named and that the CAUSE AND MANNER thereof

Probably Coronary Sclerosis
Hypertensive Heart Disease

20 Accident, suicide, or homicide (specify)

Date of occurrence 19..

Where did

Injury occur?

(City or town and State)

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

public place?

Manner oi
Injury

Nature of

Injury

COllaps^

While at work? Was there an autopsy?.,

21 Was disease or Injury In any way related to occupation o( deceased?
If so, specify Wta. J. Brichley

(Signed). Boston, Mass*

(Address)

Wlnthrop , —

Date„

Place of Burial, Cremation

DATE OF BURIAL

Jan. - b, D/13
Wlftt3ak>p
January 4^,yorTown) wj£

name of p r> Rprinl non

FUNERAL DIRECTOR V» DeimXfJUJl

address vinthrop, Mass.

Rocoived and filed

(Registrar of City or Town where deceased resided)

FORM R-301

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(County)

(City or town making return)

t£fye Cttommonbealtl} of JRa9zncipt*att»

OFFICE OF THE SECRETARY

DIVISION OF VITAL STATISTICS

STANDARD

CERTIFICATE OF DEATH

(City or Town)

• . ... — - . n , - tv f (If death occurred in a hospital or institution.

No »„...' St. ( give its NAME instead of street and number)

Registered No.

b>3)

2 FULL NAME

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

590

(a) Residence. No...

(Usual place of abode)
ength of stay : In hospital or institution

maiden name.)

J (If U. S.

V Wot Veteran,
/specify WAR)..

(Specify whether)

years

7 (If nonresident, give city or town and state)

days. In this community

yrs.

days.

PERSONAL AND STATISTICAL PARTICULARS

3 SEX

nip

4 COLOR OR RACE

5 SINGLE
MARRIED
WIDOWED
or DIVORCED

(write the word)

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

(or) WIFE of.-..

(Give maiden name of wife in full)

(Husband’s name in full)

6 Ago of husband or wife if alive years

7 IF STILLBORN, enter that fact here.

AGE.

__ If less than I da7

Years Months Days Hours Minutes

Usual t; p , a

9 Occupation: .ir..- .A..

Industry-

10 or Business:

0’7>

11 Social Security No.

12 BIRTHPLACE (City) _

(State or country)

13 NAME OF
FATHER

Informant ...t.

(Address) OH T’- - -.o'1

Relation, if any

I HEREBY CERTIFY, that a satisfactory standard certfHcate ol death was
filed .with, me BEF0RE thp-burial or transit permit was issued:

18 DATE OF

DEATH

t . ..

/?/-3

’Month)

(Day)

(Year)

14 BIRTHPLACE OF

FATHER (Citv) ^

(State or country)

15 MAIDEN NAME
OF MOTHER

■;rrorJ

16 BIRTHPLACE OF

MOTHER (Citv)

(State or country)

: be 1- am

1EDICAL CERTIFICATE OF DEATH

19 J HE

R Y Cl

I Iasi saw h.rwr.... .alive on

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

Immediate cause of death

Duration

Due to

e cause ot death ,

..W£3£c^.JsA!!£f!^

TtSjfcXZ S=P

Other conditions
(Include pregnancy within 3 months of death)

Major findings:
Of operations

•Date of..

Of autopsy .tth..

What test confirmed diagnosis?.

PHYSICIAN

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

20 Was disease or Injury In any way related to sccnpatlon ol deceased T ..
If so, specify^

(Signed)

(Address)

Place of Burial, Cremation (or Removal, -(City or Town)

DATE OF BURIAL

22 NAME OF i 'll !

FUNERAL DIRECTOR

•/> 19>(3

attended deceased from

Ite. 19.^

M. D.

ADDRESS

Received and filed

A TRUE ’ COPY ATTEST:

(Registrar)

,-..19

EXTRACTS FROM THE LAWS OF THE

COMMONWEALTH OF MASSACHUSETTS

GOVERNING THE

RETURN OF CERTIFICATES OF DEATH

A physician or registered liospit.il 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. Lazvs, 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, Sec. 45,
G. L., (Tercentenary Edition.)

No undertaker or other person shall bury a human body or the
ashe3 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 physirizns 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 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
houselcecper — private family, cook — hotel, etc. For a person who had
no occupation whatever write none.

SPACE FOR ADDITIONAL INFORMATION

FORM R-301 A

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(County)

'-a.

No.

(City or Town)

102 Court Rd

(ConintotiforaHIt of jfiTassarlptsette
OFFICE OF THE SECRETARY
DIVISION OF VITAL STATISTIC*

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,

**• I give its NAME instead of street and number)

r PHYSICIAN - IMPORTANT

2 FULL NAME.

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

(a) Residence. No.

(Usual place of abode)

™.C...»......i.

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

Length of stay: In hospital nr Institution

( Before death) (Specify whether)

years

months

days.

(If nonresident, give city or town and State)

In this community yrs. mos. day*.

PERSONAL AND STATISTICAL PARTICULARS

3 SEX

4 COLOR OR RACE

5 SINGLE (write the word)
MARRIED
WIDOWED

or DIVORCED

r> -

•1 c

5a If married, widowed, or divorced

HUSBAND of

(Give maiden name of wife in hill)

(Husband's name in full)

6 Age of husband or wife if alive

years

^ IF STILLBORN, enter that fact here.

AGE ^5). Years Months Days

If less than 1 day
Hours Minutes

Usual 'I • v + voo

cj a

Industry „ •

10 or Business:

11 Social Security No.

12 BIRTHPLACE (City)
( Slate or country)

13 NAME OF
FATHER

14 BIRTHPLACE OF

FATHER (City)

—

(Stale or country)

V--> -'j - P

15 MAIDEN NAME
OF MOTHER

r, 4- V. p *1 ^

16 BIRTHPLACE OF
MOTHER (City) ..

(Slate or country)

Informant

(

Relation, if any ^

( Address)

CERTIFY that a satisfactory standard osrtlfioate of death was
IE IhaAmrifL or/)fan»lt permit was issued:

^ hit pf Board Other)

/ /4L/<£*J

(Official Designation)^/ J (Date of feaue of ^Permlin

MEDICAL CERTIFICATE OF DEATH

18 DATE
DEATH

A /fv&

(Month) (Day) (Year)

HEUEBY CERTIFY, That I attended daoeased from

, i9.y..L, *•. i 19..SL4

I last saw h.. alive on • is death Is said to

have occurred on the date stated above, at lyLff.i?. si . . ^ m.

Immediate oause of death

Oue to .Sfefc.iir

— %

Due

Other conditions

(Include pregnancy within 3 months of death)

Major findings:
Of operations.

Date of..

Of autopsy

What test confirmed diagnosis?

'77'"

Duration

IMPORTANT?

/j.d~yo

...y

IMPORTANT

Physician

Underline
the cause to
«hich death
should b e
charged sta-
tistically.

20 Was disease or injury in any way related to oooupatlon of deoeased?.

If so, speoify.„^srt^...;.T.35

(Signed).. t , , . ............

(Address) D 19.#4

Place of Burial, Cremation or Removal
DATE OF BURIAL $1. w

(City or Town)

22 NAME OF

FUNERAL DIRECTOR

Reoalved 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
rei|uesl 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-
quired by section one. where same was contracted, the duration of hie last
illness, when last seen alive by the physician or officer and the date of hia
death ... Ceti. 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 ellect, sj>eci-
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. Por 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, fortv-sii 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 undertakar 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 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
oi a human body, not previously interred, from one town to another within
the commonwealth cannot be obtained early enough for the purpose, the
certificate of death made as above provided and in the possession of the
undertaker desiring to make such removal shall constitute a permit for
such removal; 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 heen
engaged, sucb 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. 4 6, 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 front the board of health or its agent appointed to
issue such permits, or if there is no such hoard, from the clerk of the town
where the 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 Cdiliou).

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 liea
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 frotn
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 phyai-
cian is absent from home when the certificate of death is needed.

(3) Medioal Examiners will investigate and certify to all deaths sup-
posably due to Injury. These include not only deaths caused directly ot in-
directly by traumatism (including resulting septicemia), and by the action
of chemical (drugs or poisons), thermal, or electrical agents, ami deaths
following abortion, but also deaths from disease resulting from injury or
Infeotion related to oooupation, the sudden deaths of persons not disabled
by reoognized disease, and those of persons found dead.

Statement of Causa of Death.— —Cause of deatli means the disease, or
complication which causes death, not the mode of dying, e. g., heart failure,
asphyxia, asthenia, etc. At 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 Oooupation. — 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 yeara 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 retiremenL
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 tj)e appropriate terms, aa housekeeper — private
family, cook — hotel, etc. For a person who had no occupation whatever
write none.

SPACE FOR ADDITIONAL INFORMATION

—

M R-301 A

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Suffolk jl

(County)

( City or Town)

tSTIrc CcitmtotiforaHlt of ^Tassaflptsett#

OFFICE OF THE SECRETARY

DIVISION OF VITAL STATISTIC*

STANDARD

CERTIFICATE OF DEATH Registered No.

\\jnj or i"»ni -p ,-u ( (If death occurred In a hospital or Institution,

J. CO O; S..1 St- \ jive its NAME Instead of street aud number)

r PHYSICIAN - IMPORTANT

Nellie Corbett J (Wat deceased a

(If deceased is a married, widowed or divorced woman, give also maiden name.) I if ,0 ,peoify WAR)

J5&T& St.

No.

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

(a) Residence. No. .l.C

(Usual place of abode)

■ Mti

Length of stay: In hosoltal nr Institution

(Before death) (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

’e^ale

4 COLOR OR RACE

7hi te

5 SINGLE (write the word)
MARRIED

WIDOWED .T. ,
or DIVORCED

5a If married, widowed.

or divorced

• n (Give maiden name of wife in lull)

(Husband's name in full)

Age of husband or wife if alive years

IF STILLBORN, enter

thal fact here.

s 75

AGE Years

I If less than 1 day

Months “ Days I Hours Minutes

Usual

Occupation:

’?r -1 f“p

Industry

or Business: -s*..

Tr*^ T- q p

Social Security No.

( Sialo or country)

f.t.s

13 NAME OF
FATHER

'•••onas ‘:crbett

14 BIRTHPLACE OF

—

(State or country)

T ^ q 3. Ei c!.

15 MAIDEN NAME
OF MOTHER

-ciny ’ •hP'P

16 BIRTHPLACE OF

London

(State or country)

England

Relation,,.!! any ^

( Address!

MEDICAL CERTIFICATE OF DEATH

IS DATE OF jT ^ .«| . 1, u. u

DEATH A.)2.£AY

(Month)

(Day)

(Year)

EREBY CERTIFY, That I attended deoeased from

19MJU *0 £a,M#+L.: JL 1

death Is said to

19 I

». / -

, / ^

1 last saw h m...... alive on 19

have occurred on the date stated above, at .Vfc..J..flA.^.t(m.

Immediate oause of death

Oue to .

Due to.

I HEREBY CERTIFY that a
flledWth me BEFORE the

(Signature of

ndard oertlfioate of death was
permit was Issued »

Board nK^tfealth *«r other!

&*t,-

(Bate of T«eue of Perinlt)

Other conditions

( Include pregnancy within 3 months of death)

Of operations ..

. Data of....jwlPXfc,4^_

Of autopsy

What test confirmed diagnosis?

' ■

Du ration

IMPORTANT

::::::

IMPORTANT

Physician

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

20 Was disease or injury in any way related to oooupatlon of deoeased ......

If so, specify .. - * -

(Signed) i J..! *?. - M. D.

(Address) ' -) ,_Dater *4- 19 *-)

Place of Burial, Cremation
DATE OF BURIAL.

22 NAME OF

FUNERAL DIRECTOR

ADDRESS

Reoelved and filed..

(City or Town)

..J;.//.:.:.::: - : £

(Regietrar)

EXTRACTS FROM THE LAWS O^THE

COMMONWEALTH OF MASSACHUSETTS

GOVERNING THE

RETURN OF CERTIFICATES OF DEATH

A physloian or registered hospital medical offioer 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 deaih, stating to the best of his knowledge and belief the name of the
deceased, his supposed age, the disease of which he died, defined a* re-
quired by section one. where same was contracted, the duration of hi* last
illness, when last aeen alive by the physician or officer and the date of hia
death ... Gen. Laws, Chap. 4 6, 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 I'nited Slates in any war in which
it has been engaged, insert in the certificate a recital to that efiect. sj>eci-
fying the war. and shall also certify in such certificate both the primary
and the 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
physician or officer shall forfeit ten dollars. For the purposes of thia sec-
tion and of sections forty-five, forty-si* 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 purposea, he
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 undortaker 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 ita
agent appointed to issue such permits, or if there is uo 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 thau the receiving
tomb to another in the same cemetery, until he has received a permit from
the board of health or ita 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 u|>on 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 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 ot the
undertaker desiring to make such removal shall constitute a permit for
auch 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 receipl of such statement and certificate, $hall 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. 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 re-
ceived a permit so to do front the hoard of health or its agent appointed to
issue such permits, or if there is no such board, from Ihe 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 tho
interment is made. ... Chap. 114. Sec. 46. G. L., (Tercentenary Ediliou).

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 hotly lies
and take charge of the same;... — General Laws, Chap. 38, See. 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.

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

(8) Medloal Examiners will investigate and certify to all deaths sup-
posably due to Injury. These include not only deaths caused directly ot in-
directly by traumatism (including resulting septicemia), and by the action
of chemical (drugs or poisons), thermal, or electrical agents, ami deaths
following abortion, but also deaths from dlseast resulting from injury or
Infeotion related to oooupation, the sudden deaths of persons not disabled
by reoognlzed disease, and those of persons found dead.

Statement of Cause of Death Cause of death meana the disease, or

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

Statement of Oooupation. — Precise statement of occupation is very im-
portant, so that the relative heaithfulness of various pursuits can be known.
Make some entry in this section for every persou 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 retiremeoL
Children not gainfully employed may be returned as at school or at home.
For a woman whose only occupation was that of home housework, writ*
housework. For a person engaged in domestic service for wsges, however,
designate the occupation by t t»e appropriate terms, aa housekeeper — private
family, cook — hotel, etc. For a person who had no occupation whatever
write none.

SPACE FOR ADDITIONAL INFORMATION

301 A

tUhr Common fora My of ^iffassaclptsette
OFFICE OF THE SECRETARY
DIVISION OF VITAL STATISTICS

STANOARD

CERTIFICATE OF DEATH

To be filed for burial permit
with Board of Health
or its Age?t<<

Registered No

gj | (If death occurred In a hospital or Institution,

give its NAME instead of street and number)

PHYSICIAN - IMPORTANT

2 FULL NAME.

(if deceased is a m^fnedLyHdo^erJ, or divorced woman, give also maiden name.)

(a) Residence. No

(Usual place of abode)

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

St.

Length of stay: in hnsoltal nr Institution

(Before desth) (Specify

years

months

days.

vhether)

(If nonresident, give city or town and State)

In this community 7 yrs. mos. days.

PERSONAL AND STATISTICAL PARTICULARS

MEDICAL CERTIFICATE OF DEATH

3 SEX

Ykt&

4 COLOR, OR RACE

tS.

5a If married,
HUSBAND of

(or) WIFE of

5 SIMPLE (write the word)
MARRIED
WIDOWED
or -DIVORCED

(write the word)-

o“£teh°! Js3~=*. k L.ZJZI.

(Month) (Day) (Year)

(Give maiden name of wife in full)
(Hnsband'9 name In full)

6 Age ol husband or wiie if alive

*1 IF STILLBORN, enter that fact here.

years

19 I HER Y CERTIFY, That I attended deoeased from

» 15 40

I last saw h alive on 19 death Is said to

have occurred on the date stated above, at.. sj a -

r Duration

Imr^edlate oause of dOath„vf. /F

IMPORTANT

AGE

t*, Years Months

Usual

9 Occuoation

Industry / - ‘

10 or Business: ...ui,

I If less than X day
Days 1 Hours Minutes

11 Social Security No.

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

15 MAIDEN NAME
OF MOTHER

IMPORTANT

Of autopsy
What test confirmed diagnosis?

20 Was disease or injury in any way related to oooupatlon of deceased ?..
If so, speoify...

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

HEREBY CERTIFY that a satlsfutorv standard oertlfioata of death was
flle4r*y<ttLme BE^IJRE the^o/la )_m tjplnslt permit was Issued i

’/ 7 (Signature of Agent of Board oTtHeafth or other)/ ,

./ZfZf-3

'(Official Designation) // / / TDate of f«eue/of Pennlt)

22 NAME OF fJ

FUNERAL DIRECTOR

ADDRE9&-

Received and filed 19

(Regietrar)

EXTRACTS FROM THE LAWS OF THE
COMMONWEALTH OF MASSACHUSETTS
GOVERNING THE

RETURN OF CERTIFICATES OF DEATH

A physloian or reg iatered hospital madioal offioer 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 hi* last
illness, when last seen alive by the physician or officer and the date of hia
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 I'nited States in any war in which
it has been engaged, insert in the certificate a recital to that effect, s|>eci-
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-si* 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 ha6 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 ae 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 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 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 6uch 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 array,
navy or marine corps of the I'nited States in any war In which it has been
engaged, sucb 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 Ihe 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 front the hoard of health or its agent appointed to
issue such permits, or if there is no such hoard, front the clerk of the town
where the body is to be buried or the funeral is to he 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 6hall 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 liea
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.

(2) Board of Health physloians 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.

(S) Medioat 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, anil death*
following abortion, but also deaths from disease resulting from injury or
Infeotion related to oooupatlon, the sudden deaths of person* not disabled
by reoognlzsd 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 Oooupatlon.— 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 persou 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 retiremenL
Children not gainfully employed may be returned as at school or at home.
For a woman whose only occupation was that of home housework, writ*
housework. For a person engaged in domestic service for wages, however,
designate the occupation by tfye appropriate terms, as housekeeper — private
family, cook — hotel, etc. For a person who had no occupation whatever
write none.

Jr'S

SPACE FOR ADDITIONAL INFORMATION

•• a /

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

200tn-10-'39. No. 8427-d

FORM R-301

£.1

^(County) l\'

(City or Tara)

t£f;e Ctmtnton&tealtlj of jSlatssacljttBefi*

OFFICE OF THE SECRETARY

DIVISION OF VITAL STATISTICS

STANDARD

CERTIFICATE OF DEATH

(City or town making return)

Registered No.

2 FULL NAM

(a) Residence. No
(Usual place of abode)

! ength of stay: In hospital or institution

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

!(If U. S.

Wot Veteran.

specify WAR)

also maiden name.)

(Specify whether)

years

(If nonresident, give city or town and state)
months ? days. In this community yrs. mos. days.

PERSONAL AND STATISTICAL PARTICULARS

3^SEX_

OR RACE

5 SINGLE
MARRIED
WIDOW,
or DIV

,E 'yi^y(write the word)
[ED /// '

5a If married, widowed, or divorced

HUSBAND oi

■"'/ X (Give maidel
(or) WIFE of 5

(Husband’s name i*brf

B Age of husband or wife if alive years

7 IF STILLBORN, enter that iact here

If loss than 1 day
Hours Minutes

Y ears Months Days

■My..

9 Occupation:...

0 or Business: ...

11 Social Security No.

12 BIRTHPLACE (City)
(State or country)

13 NAME OF
FATHER

14 BIRTHPLACE OF
FATHER (City)

(State or country)

Informant^;

(Address)

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

(Official Designation)

MEDICAL CERTIFICATE OF DEATH .

') 1 7 93

\ /[Month ) (Day) (Year)

13 DATE OF
DEATH ....

19 I HEREBY CERTIFY. That I attended deceased from

SLi

said

to have occurred on the dateTtated above, at H5~r

Immediaje cause of death

19 I HEREBY CERTIFY. r I hat i attended deceased trom

3* 19#.&, to..lj^fc<**w...!Z 19.51

I lasWaw alive on... , 19 death is said

Duration

Due to

J2ZJJUL* i

Other conditions

(Include pregnancy within 3 months of death)

Major findings : /O -y *

Of operations

L»« Date ol.../.J...&f.*

Of autopsy

What test confirmed diagnosis?.

20 Was disease or Injury In any way related to occupation jij deceased ? .
If so, specil

PHYSICIAN

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

Received and filed

A TRUE COPY ATTEST:

(Registrar)

EXTRACTS FROM THE LAWS OF THE

COMMONWEALTH OF MASSACHUSETTS

GOVERNING THE

RETURN OF CERTIFICATES OF DEATH

A physician 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, See. 9.

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 such permits, or if there is no such board,
from the clerk of the town where the body is t.o 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) Hoard of Health physicians will certify to such deaths only
as those of persons who, though disabled by recognized disease un-
related to any form of injury, have died without recent medical
attendance or whose physician is absent from home when the
certificate of death is needed.

(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 rccoguized
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.

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

SPACE FOR ADDITIONAL INFORMATION

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®ljr ffitintmonfiji'nllFf of jilHitssarhitei'tts

OFFICE OF THE SECRETARY

DIVISION OF VITAL STATISTICS

STANDARD

CERTIFICATE OF DEATH

To be filed for burial permit
with Board of Health
or Its AflentSW

Registered No

«. f (If death occurred in a hospital or institution,
— - 1 give its NA31E instead of street and number)

2 FULL NAM «?Sr.

(If de^fised is a married

(a) Residence. No. ...ft.. .?>. St.

(Usual place of abode)

divorced woman, give'>glso maiden name.)

PHYSICIAN - IMPORTANT
(Was deceased a
U. S. War Veteran,
if so speoify WAR)

Length of stay: In hospital or Institution

(Itefore death) (Specify whether)

years

months

days.

(If nonresident, give city or town and State)

In this community <? yrs. mos.y^ daye.

PERSONAL AND STATISTICAL PARTICULARS

3 SEX

4 COLOR OR RACEl

5 SINGLE (write the word)
MARRIED
WIDOWED
or DIVORCEE

^JiX(€^iAXJtcX .

5a If married, widowed, or divorced
HUSBAND of

(or) WIFE

n fSSiSS

'V (Husband"

6 Age of husband or wife if alive years|

7 IF STILLBORN, enter that fact here.

AGE ^ ^Years Months

Days

If less than 1 day
Hours Minutes

Usual

9 Occupation:
Industry

10 or Business:

C2~A

11 Social Security No.

12 BIRTHPLACE (City)
(Slate or country)

13 NAME Of
FATHEI

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

15 MAIDEN NAME
OF MOTHER

16 BIRTH PL^(6jE// OF
MOTHER (City)

(State or country)

tv ^ *

^ it

MEDICAL CERTIFICATE OF DEATH

IS DATE OF
DEATH ...

JJL.

(Day)

Li ££.

(Year)

That I attended deoeased from

/JL..

Y CERTIFY,

I last saw h_«^?rrr... alive on. >v ^ _ (

have occurred on the date stkfed above, at. /O' * 0$+

19.

death Is said to

Immei

Due

Due to

ilwte cauy of death, j. A

to..(Xrt-<^

ES3zr:::::z:

Other conditions^

(include pregnancy within 3 months of death)

Major findings: _ _ . q

Of operations

Date of

Of autopsy.

What test confirmed diagnosl^2r^^-dt^ ^

Duration

Important

Physician

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

^^n^.::.!"j!rL;"..any ",ated »«

(Signed Ctl - ~

(Ad<&£x3.%A ^

2i isr-^lx£/T4r'/ "

Place of Rurial, Carnation or Removal. < (City or

DATE OF BURIAL *

22 NAME OF

FUNERAL DIRECTOR

ADDRESS

Received and filed

19.

( Registrar)

EXTRACTS FROM THE LAWS OF THE
COMMONWEALTH OF MASSACHUSETTS
GOVERNING THE

RETURN OF CERTIFICATES OF DEATH

A physician or registered hospital 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 . . . 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 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
anti the secondary or immediate cau»e of death as nearly as he can state
the same For neglect to complv 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 jjr 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 bodv 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 by violence, the medi-
cal examiner 6hall 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
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 ueces-
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).

RULES OF PRACTICE

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

(1) Attending physicians will certify to such deaths only as (hose 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 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 dying, e. g., heart failure,
asphyxia, asthenia, etc. Aa 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.

ySPACE FOR ADDITIONAL INFORMATION

©fye (Etrnmuirtfm’aliff of ^assacbuscitB
OFFICE OF THE SECRETARY
DIVISION OF VITAL STATISTICS

STANDARD

OF DEATH

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

Registered No

2 FULL NAME

(If deceas'd is

(a) Residence. No. l£1
(Usual place of abode)

Length of stay: In hospital or Institution

(Refore dealh) (Specify whether)

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

PHYSICIAN - IMPORTANT

deceased a
War Veteran,
specify WAR)

months

days.

(If nonresident, give city or town and State)

In this community Jyrs. mos. days.

PERSONAL AND STATISTICAL PARTICULARS

MEDICAL CERTIFICATE OF DEATH

3 SEX

4 COLOR OR RACE

5 SINGLE (write the word)
MARRIED
WIDOWED
or DIVORCED,

M. /£ jM

ay) (Year)

5a If married, widowed, or divorced
HUSBAND of

(or) WIFE of

(Husband’s name in full)

6 Age of husband or wife if alive years

CERTIFY, ^ That I attended deceased from

■■■£/

alive , 19*1:? death Is said to

have occurred on the date Staled above, at

Immediate cause of death*:

of -nfealth or other) ,

r. :

of Issue of Permit) £ t

M 19.

(Registrar)

EXTRACTS FROM THE LAWS OF THE
COMMONWEALTH OF MASSACHUSETTS
GOVERNING THE

RETURN OF CERTIFICATES OF DEATH

A physlolan or registered hospital medical offioer shall forthwith, after
the death of a person whom he has attended during his last illness, at the
reouest 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-
auired 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 bv section forty-five of chapter one hundred and four-
teen shall, if the deceased, to the best of his knowledge and belief, served
in the army, navy or marine corps of the United States in any war in which
it has been engaged, insert in the certificate a recital to that effect, 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. 46, Sec. 10.

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 bv 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 earlv 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 tile
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 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),

RULES OF PRACTICE

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

(1) Attending physioians 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 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, ami deaths
following abortion, but also deaths from disease resulting from injury or
infection related to occupation, the sudden deaths of persons not disabled
by recognized disease, and those of persons found dead.

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

SPACE FOR ADDITIONAL INFORMATION

WRITE PLAINLY, WITH UNFADINC BLACK INK— THIS IS A PERMANENT RECORD, Every item of information
should be carefully supplied. ACE 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 deceased was a U. S. War Veteran, G. L. Chap. 46, Seotion 10. requires physloians to insert a recital to that effect.

DRM R-3Q1 A

BOSTON MOTI* '^

Suffolk.

(County)

& Winthrop

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

Registered No

tElje dotttmuti&iralllj of (JUfassarhitsitts
OFFICE OF THE SECRETARY
DIVISION OF VITAL STATISTICS

STANDARD

CERTIFICATE OF DEATH

(City or Town)

Mrt Winthrop Coummnitv Hospital f (If death occurred in a hospital or institution,

N0 r v '’Igive its NAJUE instead of street and number)

r PHYSICIAN - IMPORTANT

2 FULL NAME J (Was deoeased a

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

" I if so speoify WAR)

(a) Residence. No St. ...B&.S.t. .BOStOfl

(Usual place of abode)

Length of stay: In hospital or institution

(Before death) (Specify whether)

years

months

davs.

(If nonresident, give city or town and State)

In this community 44

’ yrs.

days.

PERSONAL AND STATISTICAL PARTICULARS

3 SEX

Femal9

4 COLOR OR RACE

White

5 SINGLE (write the word)
MARRIED
WIDOWED

or DIV0RCEDMarried

5a If married, widowed, or divorced

HUSBAND of

(or) WIFE of ln

(Husband’s name in full)

6 Age of husband rymiifa-if alive

62- years

7 IF STILLBORN, enter that fact here.

AGE

Years Months

Days

If less than 1 day
Hours Minutes

Usual

9 Occupation :

..H.ous.a....m>.rk..

Industry

10 or Business:

11 Social Security No.

none

12 BIRTHPLACE (City)
(State or country)

13 NAME OF
FATHER

Alfonso Di Mattia

14 BIRTHPLACE OF

FATHER (City) .

(State or country)

Italy

15 MAIDEN NAME

OF MOTHER

Giulia Galas si

16 BIRTHPLACE OF

MOTHER (City) .PT7T:

fState or country) Italy

MEDICAL CERTIFICATE OF DEATH

IS DATE OF '

DEATH

( (Month)

(Daf)

jlsol

(Year)

19 I HEREBY CERTIFY, That I attended deoeased from

19 -.yj... to /# 19

I last saw h^L. alive on.^CSS*-:. 19. fa death ,s sa,d lo

have occurred on the date stifled above, at . L;

' Duration

mmediate cause of death

. Important

Due to

Other conditions

(Include pregnan^within 3 months of di

■

Major findings:

Of operations

Date of

Of autopsy “5^

What test confirmed diagnosis?.

Important

Physician

Underline
the cause to
w hich death
should b e
charged sta-
tistically.

?,0^aSJiSe,aSe °r injury ^any ^ reiated to occupation of deoeased?
ir so, specify /Tlss. /

( Signed ) .. 1

<A»d n... ~rr/T“ "v-i

21^

Place of Burial, Cremj '

DATE OF BUJ

22 NAME OF
FUNERAL DI

ADDRESS 9....C.

Received and filed ...

JAN I S "1943

( 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 the name of the
deceased, his supposed age, the disease of which he died, de6ned as re-
quired by section one, where same was contracted, the duration of Ins 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
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
snd 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 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 bod}' 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).

Medical examiners shall make examination upon the view of the dead
bodies of only such persons as are supposed to have died by violence.
If a medical examiner has notice that there is within his county the body
of such a person, he shall forthwith go to the place where the body lies
and take charge of the same;... — General Laws, Chap. 38, Sec. 6.

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 auy
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 chemica' (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 auy important complication of the principal cause.

SPACE FOR ADDITIONAL INFORMATION

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

RM R-301 5

I Suffolk

I W (County)

i <o Vi'inthrop

(City or Town)

94* flffnratnonmraltlj of Maeaatifastna
OFFICE OF THE SECRETARY
DIVISION OF VITAL STATISTICS

STANDARD

CERTIFICATE OF DEATH

No .^..9.....^.?.h'.ik...S?<..»....„ St.

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

Registered No.

10.

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

FULL NAME ,?.fi?.^^....9.....L9..9.S??:9.?. j W^'v^ran. H©"

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

(a) Residence. No... st.

(Usual place of abode)

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

(Specify whether)

(If nonresident, give city or town and state)

In this community yrs. mos. T 4 days.

PERSONAL AND STATISTICAL PARTICULARS

3 SEX

Female

4 COLOR OR RACE

■.fiiite

S SINGLE (write the word)

MARRIED r. A .-

WIDOWED J 1 Cl O W >
or DIVORCED

5a If married, widowed, or divorced

HUSBAND of

Pat2^Tai?n.nar

(or) WIFE of

(Husband's name in full)

6 Age of husband or wife if alive jO e CeaQeCi years

7 IF STILLBORN, tntw that fact hw.

AGE

/• p I If l*ss than 1 day

. . Y ears Months. Days| Hours Minutes

9 Occupation:

Variety Store
ITorie

Industry
10 or Business

11 Social Security No. ..

12 BIRTHPLACE (City)

13fatherf Philip Cleary

14 BIRTHPLACE OF

FATHER (City)

(State or country)

St# iTohns

Lew I’oundland

13 MAIDEN NAME
OF MOTHER

>1 1 i p TJill-j fiT.i.cfn-p

16 BIRTHPLACE OF
MOTHER (City)

S...V...4. . r.oh.ns.

(State or country)

Lew Found land

Mrs. Ruth Bensoi> Re%nuif.any x
56 Beal Sir; TInfcrop ;

Informant

(Address)

i he:

BY CERTIFY that a i
with zb«/BEFOJS

rith me/B

C-

""'gnature of AgfiWof Board of.
cial Designation)

tisfactory standard certificate of death
^ rial -or transit permit was issued:

other)

%r^.

(Date of Issue of FY

MEDICAL CERTIFICATE OF DEATH

18 death°F.

(Month)

(Day)

(Year)

I HEREBY CERTIFY, That I attended deceased from

H , 19.S1A to ls:....., 19...4.3

I last saty h .^fs alive on 19(1.3.,

have occuned on the date stated above, at

death is said to

. m.

Immediate cause of death..

Duration

IMPSKTANT

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 Wat diaeasa ar injury in any way ratal ad ta occupation sf docoaaod?

„ »

(Addru«b3..fd^...C^Psft^Sfcr?hfltr!.^^:.Sl:S®oto..^)vi.aj»er..L'3.19..‘g3

21 Hol.Y

Place of Burial, Cremation or Removal.

«Tan. 18

tjT

(City or Town)

DATE OF BURIAL

Recsivsd end filed.

(Registrar)

WRITE PLAINLY. WITH UNFADINC BLACK INK — THIS IS A PERMANENT RECORD. Every item of information
should be carefully supplied. ACE 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 deceased was a U. S. War Veteran, G. L. Chap. 46, Seotlon 10, requires physicians to Insert a recital to that effect.

ORM R-301 A

'wfl.

tutu* (Ccnmtuuifuraltli of fJlTnssnrl{usctts
OFFICE OF THE SECRETARY

DIVISION OF VITAL STATISTICS

STANDARD

CERTIFICATE OF DEATH

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

Registered No.

A -'S

..JLJL.

Suffolk

(County)

Winthrop

(City or Town)

„ "PI po Pn vil r ( < If death ocrnrred in a hospital or institution

No 5l )jjive its NAME instead of street and number/

r PHYSICIAN - IMPORTANT

2 PULL NAME .. (Was deceased a

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

3.8 Peasant.... Park... Rq

U. S. War Veteran,

if so specify WAR) ...CTT??..

(a) Residence. No .tf.Tz. St.

(Usual place of abode)

Length of stay: In hospital or Institution

Mtidnrn ib-arhl rRpccifv whether)

(If nonresident, give city or town and Sta!:e)

years

months

days.

In this community

yrs.

days.

PERSONAL ANO STATISTICAL PARTICULARS

3 SEX

Female

4 COLOR OR RACE

White

5 SINGLE (write the word)
MARRIED
WIDOWED

or O'VORCEISlngle

3a If married, widowed, or divoroed

HUSBAND of

(Cive 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.

S Cr\ •« If less than 1 day

AGE V V Years .XU Months XI... Days Hours

Minutes

Usual

9 Occupation:

At Home

Industry

10 or Business:

Home

11 Social Security No.

None

12 BIRTHPLACE (City)
( Siale <>r country)

.last fe.Q.a.t.Qn..

.Maas. *

13 NAME OF
FATHER

Charles Wilson

14 BIRTHPLACE OF
FATHER (Cily)

—

(Scute or country)

Norway

15 MAIDEN NAME

OF MOTHER

Emma C Anderson

16 BIRTHPLACE OF

MOTHER (Cily)

(State or country)

Swe^den

. unaries Wilson ( v

r 38 Pleasant park Ro^d Wint.hrr

informant. -G^rleS WllSOn

( Aildress

I HEREBY CERTIFY that a satisfactory standard certificate of death was
fjledjwjrtfwne B&F0RE t>« Ujiriai/orAransi t permit was issued:

Signature

(Official Designation)

1th or other)

U/J./,

(Date of Issue of Pyrmit)

MEDICAL CERTIFICATE OF DEATH

id OATE OF
DEATH

/. /.fid.

/ (Month) J (Day) Year)

19 I HEREBY CERTIFY, That I attended leoeased from

, 19.5r..?...., to 19*..^....

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

have occurred on the date stated above, at

Immediate cause of death

Due to..

Other conditions

(Include pregnancy within 3 months of death)

Major findings:
Of operations..

Of autopsy

What test confirmed diagnosis?

Dale of..

Duration

Important
S9** /

Important

Physician

t mlerline
1 lie cause to
w hirli death
should b e
ilia rgeil sta-
tistically.

40 Was disease or injury in any way_(elated to occupsion of deceased?.
If so, specify ...rxtt..../.

(Signed)
(Address)

41 ' winthrop wi.rPi^PP

Jate '.htx.t.y. 19.f.

Place of Uurial, CrematioiLor Kemoval
OATE OF BURIAL

nor Kemoval. Lity or Town)

January Jo 19 43

42 NAME OF

FUNERAL DIRECTO

Reoeived 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 dean of a person whom he has attended during his last illness, at the
request if an undertaker or other authorized person or of am member of
the famly 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, bis 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, wlen last 6een alive by the physician or officer and the date of his
death . . . («n. Laws, Chap. 4 6, 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, shal’, if the deceased, to the best of his knowledge and belief, served
in the arny, navy or marine corps of the United States in any war in which
it has beei engaged, insert in the certificate a recital to that effect, speci-
fying the var. and shall also certify in such certificate both the primary
and the secondary or immediate cause of death a> nearly as he can state
the same. Km neglect to comply with any provision of this section, such
physician or oticer 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 foirteen. the word “war” shall include the China relief ex-
pedition ami th* Philippine insurrection, which shall, for said purposes, be
deemed to have taken place between February fourteenth, eighteen hundred
and niiietv eigln and July fourth, nineteen hundred and two, and the Mexi-
can border service of nineteen hundred and sixteen and nineteen hundred
and seventeen. 4. L. Chap. 4 6, Sec. 10.

No undertaker >r other person shall bury or otherwise dispose of a human
body in a town, >r remove therefrom a human body which has not been
buried, until he las received a permit from the board of health, or its
agent appointed to issue such permits, or if there is no such hoard, from
the clerk of the to*n where the person died; and no undertaker or other
person shall exluiny a human body and remove it from a town, from one
cemetery to anolinr, 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 hiried. No such permit shall be issued until there shall
have been deliverer to such board, agent or clerk, as the case may be,
a satisfactory writtn statement containing the facts required by law to be
returned and reconed, which shall he accompanied, in ca<e of an original
interment, by a saisfactory certificate of the attending physician, if any,
as required bj law.oi in lieu thereof a certificate as hereinafter provided.
If there is no attendng physician, or if, for sufficient reasons, his certificate
cannot be obtained tarly enough for the purpose, or is insufficient, a physi-
cian who is a rnenibr of the hoard of health, or employed by it or by the
selectmen for the pupose, shall upon application make the certificate re-
quired of the attendii* physician. If death is caused hv violence, the medi-
cal examiner shall mke such certificate. If such a permit for the removal
of a human body, not previously interred, from one town to another within
the commonwealth camot be obtained early enough for the purpose, the
certificate of death nnle as above provided and in the possession of the
undertaker desiring U make such removal shall constitute a permit for
such removal; provider 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 onn for the removal of such body has been sooner
obtained hereunder. If he 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 >.hall 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. 4 5, G. L.f (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 hoard of health or its agent appointed to
issue such permits, or if there is no such hoard, from the clerk of the town
where the body is to he buried or the funeral is to he held, or from a person
appoint »*d 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 lias notice that there is within his county the body
of such a person, he shall forthwith go to the place where the hotly lies
and take charge of the same;... — General Laws, Chap. 38, See. 6.

RULES OF PRACTICE

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

(I) 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.

(J) 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 oi in-
directly by traumatism (including resulting septicemia), and by the action
of chemical (drugs or poisons.), thermal, or electrical agents, ami 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, 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 occupation whatever
write none.

SPACE FOR ADDITIONAL INFORMATION

bdstom

Suffolk

(County)

tUhr Coiimtotifuralllt ct -iflnssnrltitsctts
OFFICE OF THE SECRETARY

DIVISION OF VITAL STATISTICS

STANDARD

CERTIFICATE OF DEATH

o Winthrop

J|j (City or Town)

2 no StatiQn...HQS.pital»...ZQr.k..B^nks*...Mag.§.,

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

Registered No -

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

r PHYSICIAN -IMPORTANT

2 fu ll n AME..EOEERT...BEMINGTOH...K)EDSN.#.....J.r».. *... Captain J (Was deceased a

(If deceased is a married, widowed or divorced woman, give also maiden name.) j jj* So speoify ' WAR) WQXXcL

(a) Residence. No. J&b . .Q.O.> . . .. .17.9X....2

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

Length of stay: In hospital or Institution — years— monthsi|3 days- In • this community yrs. 0 mos. 0 days.

(Refore death) (Specify whether)

PERSONAL AND STATISTICAL PARTICULARS

3 SEX

Male

4 COLOR OR RACE

"White

5 SINGLE (write the word)
MARRIED
WIDOWED

or divorced Married

5a If married, widowed, or divorced 7T*sU-n

husband of y.nmpym.

(Give maiden name of wife in full)

(or) WIFE of

(Husband's name in full)

6 Age of husband or wife if alive

Unknown..

7 IF STILLBORN, enter that fact here.

AGE

-jrs s q If less than 1 da

Years .0 ... Months Days Hours .....TT.

Minutes

Usual

9 OccuDation:

Officer

10 or" Business: .R*....S.'....kXW-.

11 Social Security No. . ...iJnknovm

12 BIRTHPLACE (City) Fali...ki.Yer>

(Slate or country)

13 NAME OF

father Robert Remington Borden

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

Fall River,
Massachusetts

15 MAIDEN NAME
OF MOTHER

Helen Shove

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

Fall .River.

Massachusetts

17 it c . . Relation, if any

Informant ArPQT. ( .TTT. )

(Address)

MEDICAL CERTIFICATE OF DEATH

18 DEAATTH0F..J.anua.ry 16., 1.9.k3..

(Month) ’(Day) (Year)

19 I HEREBY CERTIFY, That I attended deceased from

D.e.c.ember....i4> , i9..k.2..., to...January...l.6> , i9.k3...

I last saw h.lffl alive on...J&.D.Ui&ry...l.6.,... , 19li3 •. death Is said to

have occurred on the date stated above, at 8.;.£.6....a.... ,m. j

Immediate cause of deathl.«...PnS.UniQni.a.,.hr.0.nCh0.,.

..acnte,.p.yo.genic,sev.er.e.,.bilateral*

Due to ... EtiQlQgy....uDk.mymi

Due to..

2t--T^

other oonditionsrig&t....npp.er...XQDe»aec.anaary-

(Include pregnancy within 3 months of death) tO 1.

3* Pleurisy with effusion, secondary

Major findings*:

Of operations

..jMone

Date of “

of autoPsy ..I^agnos6s l^ 2 a;nd. 3.f...

What test confirmed diagnosis?.. XtR&YS..

Duration

iMPOjt^ANT

Important

Physician

Place of'Duriai, Cremation >>r Removal. (City or Town)

DATE OF BURIAL 4/3?..

I HEREBY CERTIFY that a satisfactory standard certificate of death was
filed AWith me BEFORE the Wriaf or tramlt/permit was issued:

Signature of Age
^Official Designation)

22 NAME OF

FUNERAL DIRECT^

ADDRESS 33 f

Reoeived and filed 19..

1 1 r>f

LIU)-.

(Registrar)

EXTRACTS FROM THE LAWS OF THE

COMMONWEALTH OF MASSACHUSETTS

GOVERNING THE

RETURN OF CERTIFICATES OF DEATH

A physician or registered hospital medical offioer 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 ... Cien. 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 Cnited 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. 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 hotly 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 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 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 Flitted States in any war in which it ha* been
engaged, such recital shall appear upon the permit. The board of health,
or its agent. upon receipt of such statement ami certificate, shall forthwith
countersign it ami 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 he 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 Kdition).

No undertaker or other person shall bury a human body or the ashes
thereof which have been brought into the commonwealth until lie 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 hoard, from the clerk of the town
where the body is to be buried or the 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. 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 lias notice that there is within his county the body
of such a person, he shall forthwith go to the place where the body liea
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.

(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 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, icport 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

®tr doitmtotiforaUlt of jifTassaclptseti*
OFFICE OF THE SECRETARY
DIVISION OF VITAL STATISTIC*

STANDARD

CERTIFICATE OF DEATH

To be filed for burial permit
with Board of Health
or its Ag^nt-s

Registered No

2 FULL NAME

(If deceased 19 a married, widowed o tj divorced vyoman, give also maiden name.)

(a) Residence. No

(Usual place of abode)

_ ( (If death occurred in a hospital or Institution,
stM give its NAME instead of street aud number)

PHYSICIAN - IMPORTANT

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

Length of stay: In hosoltal or Institution

(Ref ore death) (Specify whether)

years

months

days.

(If nonresident, /five city or town and State)

In this community C ^ yrs. mos. day*.

PERSONAL AND STATISTICAL PARTICULARS

/IEDICAL CERTIFICATE OF DEATH

3 SEX

4 COLOR OR RACE

5 SINGLE (write the wgrd)
MARRIED
WIDOWEO
or DIVORCEf

l. write me wuru;

IS OATE OF
DEATH

(Month)

l A

(Day)

5a If married, widowed, or divorced
HUSBAND of

(OivA>maic

(or) WIFE of '.a* Ki

(Husband's name in full)

Hll)

Y CERTIFY, / That I attended deosased from

19.3.2.., 19 Jfc.3

l^t saw alive 19 death Is said to

have orourreH on thn Halo cfnforf ohnua at / /f * /tA »

I HEREBY CERTIFY that a satisfactory standard oertlfioats of death was
filed with ms BEFORE the buKal or transit permit was Issued!

(Signature of Agent of Board of .Health or other)

O^^r.. jTiiJM J

(Official Resignation)

rof fsaue of Permit)

EXTRACTS FROM THE LAWS OF THE

COMMONWEALTH OF MASSACHUSETTS

GOVERNING THE

RETURN OF CERTIFICATES OF DEATH

A physioian or registered hospital medical offioer 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 per<on 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, ihe duration of his last
illness, when last Been alive by the physician or officer and the date of hia
death .’. . Celt. Laws, 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 the army, navy or marine corps of the I'ntted 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, he
deemed to have taken place between February fourteenth, eighteen hundred
and uinetv- 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 ill 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 ap|M>inted 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 board of health, or employed by it or by the
selectmen for the purpose, shall upon application make the certificate re-
quired of Ihe 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 ot 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 (Inited 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. 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 physi-
cian is absent from home when the certificate of death is needed.

(3) Medloal 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 death*
following abortion, but also deaths from disease resulting from injury or
Infeotion related to oooupatlon, the sudden deaths of persons not disabled
by reoognized 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 Oooupatlon. — Precise statement of occupation is very im-
portant, so that the relative healthfulneas 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, writ*
housework. For a person engaged in domestic service for wages, however,
designate the occupation by tt)e appropriate terms, as housekeeper — private
family, cook — hotel, etc. For a person who had no occupation whatever
write none.

SPACE FOR ADDITIONAL INFORMATION

®ommonm»aItlf of 4taiusarlfn»tt«
OFFICE OF THE SECRETARY
DIVISION OF VITAL STATISTICS

STANDARD

CERTIFICATE OF DEATH

r.St.

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

Registered No

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

(If U. S.

War Vataran,
•pacify WAR)..

2 FULL NAME....^^?

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

(a) Residence. No.../.#. h. .d<2r St

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

Length of stay: In hospital or institution .

(Specify whether)

months

days.

In this community yrs.

days.

PERSONAL AND STATISTICAL PARTICULARS

3 SEX

4 COLOR OR RACE

5 SINGLE
MARRIED
WIDOWED
or DIVORCED

(write the word)

ED ff

5a If married, widowad, or divorcad

HUSBAND of 1. .rrH....l.

(Give maiden name of wife in full)

(or) WIFE of -....-Trrr

(Husband's name in full)

6 Aga of husband or wifa if alive ...rrr^TT^Z^T. years

7 IF STILLBORN, enter that fact hare.

8 I If 1ms than 1 day

AGE. ..rrrr: Y aara. Month®. .rn^T. D®y»| mTT.TBoura. . . i.TT^T.Minutes

Usual

9 Occupation:

Industry

10 or Bus in ass

11 Social Bacurity No

12 BIRTHPLACE (City)

(State or country) ^ ^ • •

13 NAME OF // /

FATHER

14 BIRTHPLACE OF
FATHER (City)

(State or country)

13 MAIDEN NAME
OF MOTHER

16 BIRTHPLACE OF
MOTHER (City)

(State or country)

Informant.."^

(Address) /0 £ _ -J, ...

Relation, if ai)y

/sCfA-P. -

itand*rd certificate of death
transit permit waa iaauad :

18 DATE OF
DEATH

CAL CERTIFICATE OF DEATH

/*S^T

(Day) (Year)

Th^I^aj|anded dece^g^d jrorn

/ i/ast saw h.^Or alive on /. J. , 19 , death is said to

ve occurred on tta date stated above, at...# m

Immediate cause y L../

Duration

iupbitant

Due I

Due to

. .

Other conditions irrnr.T..

(Include pregnancy within 3 months of death)

Major findings:

Of operations..

Of autopsy ...

What test confirmed diagnosis?....

Date of. "

IMPORTANT

PHYSICIAN

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

20 Wat disease er injorjje any way related te ecctjaation ef deceased!..

If eo, specify;... d

(Signed) «...„> M. D.

19^?

ai ^;L%.

Place of Burial, Cremation or Removal.

DATE OF BURIAL
22 NAME OF

FUNERAL DIRECTOR ...

ADDRESS

(City or Town)

.... > 1 9jr...3

Recsltsd and filed..

..19..

(Registrar)

U %

> rj

“«o

d?~

gas

“SS

H « »
Z. - 3
w>- « «

Z J xh:

|uWt

“ S -3

T> « a

o
y

S> *0 Um

^ 4> 0

tf) *

** «

li^J

U 2 » E
>
a:

\ ' - -r

e
0

.. !• «
„-S.?

Hu 2*“
i — a si

►> 0

(t *"

. ~ u

„ " £
CO-oi x

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2 ‘

O "TJ

* a
«

“ e S

U. _* £ .2

7"s*J U
^ C 3
« •- £
** <3 **
« -r «
a c

s «.£ o
> JQ tl

Ie/7

C2H

j3<J

5- 2w c

« « Q
< u
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£.20 t

u *u'r

H £“
— o2 «•
C£d:< >

£.5o.s

- '*/*?/*3

ffe (Eommoiifcealtl] of <4Ra*sarIjvsslis
OFFICE OF THE SECRETARY
DIVISION OF VITAL STATISTICS

STANDARD

CERTIFICATE OF DEATH

(City or town making return)

Registered No.

i N 1. 1

2 FULL NAME t .

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

(a) Residence. St ^...,

(Usual place of abode;
ength of stay : In hospital or institution

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

(Specify whether)

years

months

days.

(If U. S.

Wat Vel «»(ts.
specify WAR)..

f nonresident, give city or town and state)

In1 this community yrs. mos. days.

PERSONAL AND STATISTICAL PARTICULARS

4 COLOR OR RACE

3. SEX

5 SINGLE
MARRIED
WIDOWED
or DIVORCED

(write the word)

5a If married, widowed, or divorced

HUSBAND of

(Give maiden name of wife in full)

(or) WIFE of..

(Husband’s name in full)

6 Age of husband or wife if alive x-yv-yi years

7 IF STILLBORN, enter that fact here.

AGE Years Months Days

If less, than 1 day
{.. C^Hours....

Usual

9 Occupation:

Industry

10 or Business:

JT& Min

utes

11 Social Security No.

12 BIRTHPLACE (City) f (2d.

(State or country)

:&*-r tf,rpc}A.„... ......

13 NAME OF
FATHER

tf /

14 BIRTHPLACE OF
FATHER (City) .

(State or country)

15 MAIDEN NAME
OF MOTHER

/ -tf TZ.

16 BIRTHPLACE OF
MOTHER (City)

(State or country)

/frstf,

Inlormant..ic^r7i.^r^...

Kelation, if &ny

r 'a \

(Address) / ,y * —

<3 \

CERTIFY that a satisfa
me BEFORE the

ih me BEFORE

jandard certificate of death was
permit was Issued:

Signature of

✓Jerri?!

(Official Designation)

DICAL CERTIFICATE OF DEATH

18 DATE OF 77 s, / C < ...

DEATH i

A T ... ,1. \ ' cr\„,.\

(Month)

(Day)

(Year)

19 THEREBY CERTIFY. Tfyt I attended deceased from

-J— n- 19.^2., to.....ZhTrt_. I?.?. 19

I last saw h..r£3_...alive on 19...^, death is said

C/ ' _y 3

to have occurred on the date stated above,

Immediate cause of death

Due to ^...^....?2&£?.

Due to

Other conditions

(Include pregnancy within 3 months of death)

Major Endings:
Of operations

.Date of..

Of autopsy r..

What test confirmed diagnosis ? .

Duration

PHYSICIAN

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

20 Was disease or injury la eny way related te occupation el deceased ?
If ao, specify

(Signed)..

(Address) JLLL

U (7

y. , M. D.

Dot 19/Si

"z:

21 . .w^ii . . .

Place of Burial, Cremation or Removal. (City or Town)
DATE OF BURIAL

22 NAME OF
FUNERAL DIRECTOR

ADDRESS ^..,1

Received and filed

A TRUE COPY ATTEST

(Registrar)

EXTRACTS FROM THE LAWS OF THE

COMMONWEALTH OF MASSACHUSETTS

GOVERNING THE

RETURN OF CERTIFSCATES OF DEATH

No undertaker or other person shall bury or otherwise dispose of a
human body in a town, or remove therefrom a human body which
has not been buried, until he has received a permit from the board
of health or its agent appointed to issue such permits, or if there
is no such hoard, from the clerk of the town where the person died :
and no undertaker or other person shall exhume a human body and
remove it from a town, from one cemetery to another, or from one
grave or tomb other than the receiving tomb to another in the same
cemetery, until he has received a permit from the board of health or
its agent aforesaid or from the clerk of the town where the body is
buried. No such permit shall be issued until there shall have been de-
livered to such board, agent or clerk, as the case may be, a satisfac-
tory written statement containing the facts required by law to be
returned and recorded, which shall be accompanied, in case of an
original interment, by a satisfactory certificate of the attending
physician, if any, as required by law, or in lieu thereof a certificate
as hereinafter provided. If there is no attending physician, or if, for
sufficient reasons, his certificate cannot be obtained early enough for
the purpose, or is insufficient, a physician who is a member of the
board of health, or employed by it or by the selectmen for the pur-
pose, shall upon application make the certificate required of the at-
tending physician. If death is caused by violence, the medical exam-
iner shall make such certificate. If such a permit for the removal of
a human body, not previously interred, from one town to another
within the commonwealth cannot be obtained early enough for the
purpose, the certificate of death made as above provided and in the
possession of the undertaker desiring to make such a removal shall
constitute a permit for such removal ; provided, that such body shall
be returned to the town from which it was removed within thirty-
six hours after such removal, unless a permit in the usual form for
the removal of such body has been sooner obtained hereunder. If the
death certificate contains a recital, as required by section ten of
chapter forty-six, that the deceased served in the army, navy or
marine corps of the United States in any war in which it has been
engaged, such recital shall appear upon the permit. The board of
health, or its agent, upon receipt of such statement and certificate,
shall forthwith countersign it and transmit it to the clerk of the
town for registration. The person to whom the permit is so given
and the physician certifying the cause of death shall thereafter fur-
nish for registration any other necessary information which can be

obtained as to the deceased, or as to the manner or cause of the
death, which the clerk or registrar may require. — Chap. 114, Sec. 45,
G.L., (Tercentenary Edition.)

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.

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

SPACE FOR ADDITIONAL INFORMATION

extracts from the laws on back of certificate.

If deceased was a U. S. War Veteran, G. L. Chap. 46, Section 10, requires physicians to Insert a recital to that effect.

-301 A

^Suffolk

(County)

k Winthrop

-J

VQ.

No.

(City or Town)

Winthrop Community Hospital

DIVISION OF VITAL STATISTICS

STANDARD

CERTIFICATE OF DEATH

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

Registered No

- ((If death occurred in a hospital or institution,
( give its XA1112 instead of street and number)

{PHYSICIAN - IMPORTANT

(Was deceased a
U. S. War Veteran,

„ .. WAR,....

(a) Residence. No.

(Usual place of abode)

Hospital

(If nonresident, give city or town and State)

Length of stay: In hospital or institution..

( Itofnrn death) ( Spnrifv wllrllirrl

years

months

2 days.

In this community

yrs.

days.

PERSONAL AND STATISTICAL PARTICULARS

3 SEX

Female^

4 COLOR OR RACE

White

5 SINTLE (write ibe wurd)
MARRIED

WIOOWEO , ,

or oivorced Married

3a If married, widowed, or divorced

HUSBAND of

niiishnnrl’* name in full)

6 Age of husband or wife if alive

■#9"

years

7 IF STILLBORN, enter that fact here.

AGE

Years

5...

Months ...T\ Days

If less than 1 day
Hours Minutes

Usual

9 Occupation:

Housewife

Own Home

11 Social Security No. Hone

Industry
10 or Business

12 BIRTHPLACE (City)
( Suite <*r country)

Revere

Maas

13 NAME OF
FATHER

J Neils Miller

14 BIRTHPLACE OF
FATHER (City) ..

(Stale or country)

Denmark

15 MAIDEN NAME
OF MOTHER

Anna Nelson

16 BIRTHPLACE OF
MOTHER (Citv) „

— j

(State or country)

Denmark

Informant ./

( A«Mros*)

rt ie?f Q9arkwa ^ winthrop)

I HEREBY CERTIFY that a satisfactory standard certificate of death was
filed /iyUh me BEFORE the buf)^yof Jtfint 1/ permit waa issued:

. r. . . . -

.(Signature of Afe»nt of Board of IlealtWorothm:)

of Issue of Jrerm It) *

(Official Designatio

(Date

MEDICAL CERTIFICATE OF DEATH

IS DATE OF
DEATH

19^ I HERE, BY CERTI r\wn , uiai i aitenueu ueceaseu irom
alive on. hfc death Is said to

A.#. /J..V.3.

(Day)1 (Year)

That 1 attended deceased from

I last saw

have occurred on the date stated above, at....Ss?

Immediate causa at death

Oue to .

Oue to..

Other conditi
(Include

itions

pregnancy within ^months of de^jm)

Of autopsy

What test oonfirmed diagnosis ?

4b b

Duration

Important

IMPORTANT

Physician

CO was disease or injury in any way related to occupation of deoeasei
If so, specify

Vflnthrop

Place of Burial, Creiuatiou or lteiuoval. (City or Towu) .

date of burial February 1 1943

ft NAME OF

FUNERAL DIRECJOF

ADDRESS

UAL

Reoeived and filed 19

1QA0

(Registrar)

EXTRACTS FROM THE LAWS OF THE

COMMONWEALTH OF MASSACHUSETTS

GOVERNING THE

RETURN OF CERTIFICATES OF DEATH

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

No undertaker or other person shall bury or otherwise dispose of a
human body in a town, or remove therefrom a human body which
has not been buried, until he has received a permit from the board
of health or its agent appointed to issue such permits, or if there
is no such board, from the clerk of the town where the person died :
and no undertaker or other person shall exhume a human body and
remove it from a town, from one cemetery to another, or from one
grave or tomb other than the receiving tomb to another in the same
cemetery, until he has received a permit from the board of health or
its agent aforesaid or from the clerk of the town where the body is
buried. No such permit shall be issued until there shall have been de-
livered to such board, agent or clerk, as the case may be, a satisfac-
tory written statement containing the facts required by law to be
returned and recorded, which shall be accompanied, in case of an
original interment, by a satisfactory certificate of the attending
physician, if any, as required by law, or in lieu thereof a certificate
as hereinafter provided. If there is no attending physician, or if, for
sufficient reasons, his certificate cannot be obtained early enough for
the purpose, or is insufficient, a physician who is a member of the
board of health, or employed by it or by the selectmen for the pur-
pose, shall upon application make the certificate required of the at-
tending physician. If death is caused by violence, the medical exam-
iner shall make such certificate. If such a permit for the removal of
a human body, not previously interred, from one town to another
within the commonwealth cannot be obtained early enough for the
purpose, the certificate of death made as above provided and in the
possession of the undertaker desiring to make such a removal shall
constitute a permit for such removal ; provided, that such body shall
be returned to the town from which it was removed within thirty-
six hours after such removal, unless a permit in the usual form for
the removal of such body has been sooner obtained hereunder. If the
death certificate contains a recital, as required by section ten of
chapter forty-six, that the deceased served in the army, navy or
marine corps of the United States in any war in which it has been
engaged, such recital shall appear upon the permit. The board of
health, or its agent, upon receipt of such statement and certificate,
shall forthwith countersign it and transmit it to the clerk of the
town for registration. The person to whom the permit is so given
and the physician certifying the cause of death shall thereafter fur-
nish for registration any other necessary information which can be

obtained as to the deceased, or as to the manner or cause of the
death, which the clerk or registrar may require.— Chap. 114, Sec. 45,
G. L„ (Tercentenary Edition.)

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.

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

SPACE FOR ADDITIONAL INFORMATION

- W Kilt rLAlNLT , Willi u in rAUl inu dlaciv INK — l n lb lb A rtKMANcN l KtLUKU. tvery item or information
should be carefully supplied. ACE 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 deceased was a U. S. War Veteran, G. L. Chap. 46, Seotlon 10, requires pliyslolans to Insert a recital to that effect.

RM R-301 A

r£Suffolk

5 (County)

£ Winthrop

ul (City or Town)

< No Winthrop Community Hospital

tEbr QTmmtuuifurallFi of jiJTnssarljusctts
OFFICE OF THE SECRETARY

DIVISION OF VITAL STATISTICS

STANDARD

CERTIFICATE OF DEATH

To be filed for burial permit
with Board of Health
or its A^ent.

St.

Registered No

(If death occurred in a hospital or Institution,

five its .NAME instead of street and number)

PHYSICIAN - IMPORTANT

2 full name Chris tlna Marie Dodson , (Was deceased a

(If deceased is a married, widowed or divorced woman, give also maiden name.) | u- ®' War Veteran,

(a) Residence. No. .. #

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

Length of stay: In hospital or institution years months 2 days. In this community yrs. mos. days.

( It, .fore dearhl < S|»pcify whether)

PERSONAL AND STATISTICAL PARTICULARS

3 SEX

Female

4 COLOR OR RACE

White

5 SINGLE (write the word)
MARRIED

WIDOWED ,, . .

or divorced Married

3a If married, widowed, or divorced

HUSBAND of

( llu^hand** name in full)

6 Age of husband or wife if alive

■te

years

7 IF STILLBORN, enter that fact here.

AGE“J V f Years

.5..

Month. ...” Day.

If less than 1 day
Hours Minutes

Usual

9 Occupation:

Housewife

Industry

10 or Business:

11 Social Security No.

Own Home

— iTdne —

12 BIRTHPLACE (City)
( Si ale «»r country)

Revere

Mass.

13 NAME OF
FATHER

J Neils Miller

14 BIRTHPLACE OF
FATHER (City) ..

—

(Stale or country)

Denmark

15 MAIDEN NAME
OF MOTHER

Anna Nelson

16 BIRTHPLACE OF
MOTHER (Citv) _

. —

(Stale or country)

Denmark

Informant...1
( Address

Wl^hrgp)

I HEREBY CERTIFY that a satisfactory standard certificate of death was
filed,nyfth me BEFORE lha bf'ffayof Permit wa» issued:

HEREBY CERTIFY t
led swlth me BEFORE

t of Board of Iteal

(Date of Issue of permit) *

MEDICAL CERTIFICATE OF DEATH

US DATE OF
DEATH

Af. lSJ/3

(Day)1 Oear)

1 HERE. BY CERTI rv^/i , . mai i auenueu ueuuaseu irom

I last saw alive on. death is said to

have occurred on the date stated above, at. :..s €J/t£25:. m. f
Immediate cause jfl death.

That I attended deoeased from

Due to .

Due to..

Other conditions
{.include

pregnancy within Q/months of de^/m)

o, -J

What test confirmed diagnosis ? )£-

IMPORTANT

Physician

Underline
lie cause to
« hit'll death
sliuuld b e
eliarged sta-
listically.

Z0 Was disease or injury in any way related to occupation of deoeased
If so, specify /^. /T.

tSigned M. D.

( AodnSss) C5 . .«?. DalJ&H..?/ 1 &J.

^jr^BInLiu

„ '•■lnthTOl) -yiiii-i.rup

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

, w.vW.».VM V. Itbuivot, U1 lUHli; J

** FUNERAL DIRECJO

ADDRESS £L....

Reoeived and filed 19

1 124?. Zl!‘~

(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 lias 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 host 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 ... (leu. 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 I'nited Slates in any war in which
it lias 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-sis and forty-seven of said chapter one
hundred and fourteen, tile word "war" shall include the China relief ex-
pedition and the Philippine insurrection, which shall, for said purposes, he
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 he 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 dealh 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 I'nited 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 dealh, 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 lie has re-
ceived a permit so to do front the board of health or its agent appointed to
issue such permits, or if there is no such board, from Ihe clerk of the town
where the body is io be buried or the funeral is to he 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 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:

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

(3) Medical Examiners will investigate and certify to all deaths «up-
posably due to injury. These include not Vmly deaths caused directly oi 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, 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 occupation whatever
write none.

SPACE FOR ADDITIONAL INFORMATION

should ba carefully supplied. ACE 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 deceased was a U. S. War Veteran, 0. L. Chap. 46, Seotlon 10, requires physicians to Insert > recital to that effaot.

»M R-301 A

5a If married, widowed, or divorced
HUSBAND of

tChp GTaitmtotifnralllt of ^TaMacIptsett*
OFFICE OF THE SECRETARY
DIVISION Or VITAL STATISTIC*

STANDARD

CERTIFICATE OF DEATH

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

Registered No.

, --.'fa.- ( fit death occurred In a hospital or Inatitution,

«5t. j gj

give its NAME instead of street and number)

HYSICIAN - IMPORTANT

2 FULL NAME ....

( If deceased Is a

(a) Residence. No.

(Usual place of abode)

Length of stay: In hoscltal or Institution^

(Before death) (Specif

(Was deceased a
J. S. War Veteran
cify WAR)

years

months days.

whether)

(If nonresident, give city or town and State)

In this community yrs. moa. days.

PERSONAL AND STATISTICAL PARTICULARS

MEDICAL CERTIFICATE OF DEATH

3 SEX

4 COLOR OR RACE

SINGLE
MARRIE
WIDOW
or DIV

tv (write the word)
I ED.

/VED

IS DATE OF
DEATH

( Hiisban^#^)amp in full)

6 Age of husband or wife if alive ~mr years|

^ IF STILLBORN, enter that fact here.

19) I HERE BpY C E R T I F Y ,

, i9.!

last saw h .Iky:... alive on death is said to

have occurred on the date s(at4d above, at

Immediate cause of-^death .

Years

Months ...rrrr... Days

If less than 1 day
Hours Minutes

Usual

9 Occupation:

Industry

10 or Business:

11 Social Security No.

12 BIRTHPLACE fCily)
( Si ale or country)

Due

...

iadlate cause gKdeath A

Duration

Other conditions..

(Include pregnancy wMiin 3 months of death)

13 NAME OF •

14 BIRTHPLACE OF

FATHER (City) 7TT

(State or country)

15 MAIDEN NAME ^ / ,

of mother

Maior findings:
Of operations .

Date of..

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

.Relation, Jt any y

tS%r~rr ~

I HEREBY CERTIFY that a satljfaciory standard oerllfloata of death was
filed with me BEFORE the burial or transit permit was Issued:

filed with rna BEFORE the burial or Oanelt permit was Issuer

fu»* ,i

— ‘ — " * — * of Board of Health or

Of autopsy

What test confirmed diagnosis?.

20 Was disease or injury in any way related to oooupatlon of deoeased?

If so, specify ...r <pr: ./

<siQn«6) . m. d.

(Addrey) 19^3

Place of Burial, C^ejbation or Removal.

DATE OF BURI

22 NAME OF

FUNERAL DIRECT

Removal. (City or Town)

/ i9 M3

(Official

(Signature of Agent of Board of Health or other)

wXr~ hz/Jms

Iguatlon) rDate </ f*ue of Permit)

(Regiatrar)

EXTRACTS FROM THE LAWS OF THE

COMMONWEALTH OF MASSACHUSETTS

GOVERNING THE

RETURN OF CERTIFICATES OF DEATH

A physioian 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 atandard 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 dale of his
death ... Gen. Laws, Chap. 4 6, 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 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 purj»oses 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 ita
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 thau 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 ahall
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 ami 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 tor 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 phvsiciau 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. 4&, 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 front the board of health or its agent appointed to
issue such permits, or if there is no such hoard, front the clerk of the town
where the body is to be buried or the funeral is to he held, or front 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 hotly liea
and take charge of the same;... — General Laws, Chap. 38, See. 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.

(2) Board of Health physlolans 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.

(8) Medioal Examiners will investigate and certify to all deaths sup-
posably due to Injury. These include not only deaths caused directly ot 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
Infeotion related to oooupation, the sudden deaths of persons not disabled
by reoognized 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 Oooupation. — 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 persou 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
bad retired from business, report the usual occupation prior to retirement.
Children not gainfully employed may be returned as at school or at borne.
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 tfye appropriate terms, as housekeeper — private
family, cook — hotel, etc. For a person who had no occupation whatever
write none.

SPACE FOR ADDITIONAL INFORMATION

should be carefully supplied. ACE 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 deceased was a U. S. War Veteran, G. L. Chap. 46, Seotlon 10, requires physicians to Insert a recital to that effect.

R-301 A

r*~

Suffolk..

(County)

tEhf Coimttmtfnralllt ct jJInssarlmsctts

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

o Winthrop

^ (City or Town)

< No Station Hospital* Fort Banks, Mass, u if death occurred in a hospital or institution

qJ fH0 *?• 3 - give iU NAME instead of street and number)

r physician - UQS&WULtJ

2 FULL NAME, HERBERT AL0MZ0 mDSBORTH J (was deceased a TT I

(If deceased is a married, widowed or divorced woman, give also maiden name.) | fj- VVARy^”

(a) Residence. No 9..83..M.eiaQrial...DrlYe sk ...Cambridge,...Mass,

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

*• years 0 months 21d

Length of stay: In hospital or Institution

(Before death) (Specify whether)

-days.

In this community 0 yrs. 0 mos. 0 days.

PERSONAL AND STATISTICAL PARTICULARS

3 SEX

Male

4 COLOR OR RACE

White

5 SINGLE (write the word)
MARRIED
WIDOWED

or divorced Married.

5a If married, wido
HUSBAND of ...

(or) WIFE of

(Give maiden name of wife in full)

6 Age of husband or wife if alive

(ITiishand*s name in full)

....Urum.QM&

year

7 IF STILLBORN, enter that fact here.

AGE . Years ...1 Months .. 22 Days

If less than 1 day

Hours rr. Minutes

9 Occupation: ....Qf fiG£X..

industry tt q ,

10 or Business:

11 Social Security No. ... Hone...

12 BIRTHPLACE (City) . Idaho.

(Slate or country)

13 NAME OF

father John Ribble Wadsworth

14 BIRTHPLACE OF

FATHER (City) ...

..ffinMom)

(State or country)

Indiana

15 MAIOEN NAME

0F M0THER Mary Herbert

16 BIRTHPLACE OF
MOTHER (City) ...

(J^tauown) —

(State or country)

Indiana

17 TT « „ z Relation, if any

Informant II S*... JLERlir. ( )

(Address)

I HERE/5Y CERTIFY that a
filed wi(lv_me BE

ryy standard certificate of death was
sit permit was issued:

Health or other)

Boari

(Date of Isaue of Permit

MEDICAL CERTIFICATE OF DEATH

iSoD£>TrEHOF January. 2% laid..

(Month)

(Day)

(Year)

19 I HEREBY CERTIFY, That I attended deceased from

..J.amaary....8., i9...1i3., to..i.a®.ix..29.,. wU3

I last saw hi.m alive on Janua ry . ..29.,..., i9.li3., death Is said to

have occurred on the date stated above, at.. 6;3Q .m.

immediate cause of death...1 C.Q.n£].6..S.iiV6...h6.3!r't.

failure..,

Due Mitral insufficiency and
arteriosclerosis.

Due to...

other condi ti0ns...Br.Qnchp....p.ne'UMonia(Fri6d“
(.Include pregnancy within 3 months of death) landsrJ .

Cardiac hypertrophy. Anemia, simple

Major findings: m _

Of operations il.V.Lt®

Date of ,TTT.

Of autopsy 1.011*3.

What test confirmed diagnosis? .TTT.

Duration

IMPORTANT

10 days

Important

Physician

Underline
i he cause to
which death
should b •
charged sta-
tistically.

20 Was disease

If so, speoif

M. D.

ry in any ocouPation of deoeased?..

lsigned).T>jfJ^^^.p^..^^.^^....^.orp3 . ... I

(Aodress) Station •H-OSpit^i Date ..1/2.9/ 19u3-

Fort Banks. Mass. '

latfa JiL dpinutKa BuGal'C^Xa-ifi ^ M

DATE <JF BURIAL

dJZ-

22 NAME OF

FUNERAL DIRECTOR

AODRESS 2-S S'

Reoeived and filed .

-igzir

( Registrar)

EXTRACTS FROM THE LAWS OF THE >\f.H

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 host of his knowledge and belief the name of the
deceased, bis supposed a ire, the disease of which lie died, defined as re-
quired by <ection one, where same was contracted, the duration of bis la<t
illness, when last seen alive by the physician or officer and the date of his
death ... Gen. 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 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 ('hina 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 0, 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 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
6iich 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 l 'fitted 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 cau>e of death shall thereafter furnish for registration any other neces-
sary informal ion 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 Kdition).

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 healih or its agent appointed to
issue such permits, or if there is no such hoard, from the clerk of the town
where the body is to lie buried or the funeral is to he held, or from a per>uti
appointed to have the care of t lie cemeter

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