The volume, 1944
Town Clerk, Winthrop · from the Internet Archive · 524 pages · 39.1 MB
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J. L. FAIRBANKS DlV.
Thomas Groom & Co.
Stationers
105 State St.. Boston
To duplicate this book order
No- V&Y-'o
O.U.7
rr ixi 1 ridrtim,!, nun UMi nuimj 11NIV 1 nlj 13 A r JC.KIVlANr.IN 1 KtCUKU. fc-very 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.
IM R-301 A
,2
/P
1 ■ t.
Suffolk
®l| flJmmttnmnrallli of fiIaflflarI|Hflrttja
» OFFICE OF THE SECRETARY
DIVISION OF VITAL STATISTICS
To be filed for bnrial permit
l§
(County)
witb Board of Health
<o
Winthrop
STANDARD
or it* Agent.
(City or Town)
CERTIFICATE OF DEATH
Registered No.
2 Maple Road. C. ( (If death occurred in a hospital or institution.
*** **' St. I give its NAME instead of street and number)
2 FULL NAME....
Re £ .e. .?. .?£. . . .?. 11.® 9. 9. :k® .®]?® Y® ( (ifu.s.
llf deceased is a married, widowed or divorced woman, give also maiden name.) j ^tcify WAR)
(a) Residence. No 5....^.P.^.?.....^.?3.^. St
(Usual place of abode) (If nonresident, give city or town and state)
Length of stay: In hospital or institution. years
(Specify whether)
months
days.
In this community ^ Qyrs.
days.
PERSONA!* AND STATISTICAL PARTICULARS
3 SEX
Female
4 COLOR OR RACE
White
5 SINGLE (write the word)
MARRIED
widowed WA dnw
or DIVORCED x u’ W
5a If married, widowed, or divorced
HUSEAND of
(Give maiden name of wife in full)
(Husband’s name in full)
(or) WIFE of..
6 Age of husband or wife if alive
7 IF STILLBORN, enter that fact here.
AGE.
88
.Years
Qr\ /~\ I If less than 1 day
Months... .£..U..Daysl Hours Minutes
Usual
9 Occupation:..,
Industry
10 or Business:.
House Wife
At Home
ii
Social Security No.
'None
12 BIRTHPLACE (Citv) ^
(State or country)
aev Brunswick
13 NAME OF
FATHER
Edmund Cole
0)
h
14 BIRTHPLACE OF
FATHER (Citv)
2
U
(State or country)
New Brunswick
K
<
cu
15 MAIDEN NAME
OF MOTHER _ , , . _
Catherine Buck
16 BIRTHPLACE OF
MOTHER (City)
(State or country)
New Brums wick
17
• Relation, if any
Informant AlVljM. PaUghftL
(Addr^) 2 Maple Rd . Winthroo
I HEREBY CERTIFY that a satisfactory standard certificate of death
was filed with rrys BEFORE the, burial or transit permit was issued:
nature of Agent of Board’ll Stealth or other)
4/ ..f
ion) / J (Date of Issu^/of Permit)/
MEDICAL CERTIFICATE OF DEATH
18 DATE OF
DEATH
>T
[j (Month) |
/. /9Y&.
(Day) (Year)
have occurred on the date stated above, at ? ft1 ,m.j
Immediate cause of death,,....i
Due to..
ihmuCht
Other conditions..
(Include pregnancy within 3 months of death)
Major findings:
Of operations..
Date of.
Of autopsy...^2(!c^7*^?sr*
WhaLtest confirmed diagnosisT ^r^ffPstf Tc'
Duration
WPMTJUn
PHYSICIAN
Underline
the cause to
which death
should be
charged sta-
tistically.
20 Was disease or injury in any way related ta occupation of deceased?. /OtQ.
(A Pat
j8i W.l.n.t.hr.Qp.
Place of Burial, Cremation or Removal. (City or Town)
date of burial Jfonixa'fryT 4.
22 NAME OF
FUNERAL DIRECTOL
ADDRESS.../'../? ' &
Received and filed..
(Registrar)
EXTRACTS FROM THE LAWS OF THE
COMMONWEALTH OF MASSACHUSETTS
GOVERNING THE
RETURN OF CERTIFICATES OF DEATH
A physician or registered hospital medical officer shall forthwith,
after the death of a person whom he has attended during his last illness,
at the request of an undertaker or other authorized person or of any
member of the family of the deceased, furnish for registration a standard
certificate of death, stating to the best of his knowledge and belief the
name of the deceased, his supposed age, the disease of which he died,
defined as required by section one, where same was contracted, the
duration of his last illness, when last seen alive by the physician or officer
and the date of his death . . . Gen. Laws, Chap. 46. Sec. 9.
No undertaker or other person shall bury or otherwise dispose of a
human body in a town, or remove therefrom a human body which has
not been buried, until he has received a permit from the board of health,
or its agent appointed to issue such permits, or if there is no such board,
from the clerk of the town where the person died; and no undertaker or
other person shall exhume a human body and remove it from a town, from
one cemetery to another, or from one grave or tomb other than the receiv-
ing tomb to another in the same cemetery, until he has received a permit
from the board of health or its agent aforesaid or from the clerk of the
town where the body is buried. No such permit shall be issued until
there shall have been delivered to such board, agent or clerk, as the case
may be, a satisfactory written statement containing the facts required by
law to be returned and recorded, which shall be accompanied, in case of an
original interment, by a satisfactory certificate of the attending physician,
if any, as required by law, or in lieu thereof a certificate as hereinafter
provided. If there is no attending physician, or if. for sufficient reasons,
his certificate cannot be obtained early enough for the purpose, or is in-
sufficient, a physician who is a member of the board of health, or em-
ployed by it or by the selectmen for the purpose, shall upon application
make the certificate required of the attending physician. If death is caused
by violence, the medical examiner shall make such certificate. If such a
permit for the removal of a human body, not previously interred, from
one town to another within the commonwealth cannot be obtained early
enough for the purpose, the certificate of death made as above provided
and in the possession of the undertaker desiring to make such removal
shall constitute a permit for such removal; provided, that such body shall
be returned to the town from which it was removed within thirty-six
hours after such removal, unless a permit in the usual form for the re-
moval of such body has been sooner obtained hereunder. If the death
certificate contains a recital, as required by section ten of chapter forty-
six. that the deceased served in the army, navy or marine corps of the
United States in any war in which it has been engaged, such recital shall
appear upon the permit. The board of health, or its agent, upon receipt of
such statement and certificate, shall forthwith countersign it and transmit
it to the clerk of the town for registration. The person to whom the permit
is so given and the physician certifying the cause of death shall thereafter
furnish for registration any other necessary information which can be
obtained as to the deceased, or as to the manner or cause of the death,
which the clerk or registrar may require.— Chap. 114, Sec. 45, G. L.,
(.Tercentenary Edition).
No undertaker or other person shall bury a human body or the ashes
thereof which have been brought into the commonwealth until he has
received a permit so to do from the board of health or its agent appointed
to issue such permits, or if there is no such board, from the clerk of the
town where the body is to be buried or the funeral is to be held, or from a
person appointed to have the care of the cemetery or burial ground in
which the interment is made. . . . Chap. 114, Sec. 46, G. L., (Tercentenary
Edition).
RULES OF PRACTICE
The fulfillment of the purpose of these laws calls for the observance of
the following rules of practice:
(1) Attending physicians will certify to such deaths only as those
of persons to whom they have given bedside care during a last illness from
disease unrelated to any form of injury.
(2) Board of Health physicians will certify to such deaths only as
those of persons who, though disabled by recognized disease unrelated to
any form of injury, have died without recent medical attendance or whose
physician is absent from home when the certificate of death is needed.
(3) Medical Examiners will investigate and certify to all deaths
supposably clue to injury. These include not only deaths caused
directly or indirectly by traumatism (including resulting septicemia),
and by the action of chemical (drugs or poisons), thermal, or electrical
agents, and deaths following abortion, but also deaths from disease
resulting from injury or infection related to occupation, the
sudden deaths of persons not disabled by recognized disease,
and those of persons found dead.
Statement of Cause of Death. — Cause of death means the disease,
or complication which causes death, not the mode of dying, e. g.. heart
failure, asphyxia, asthenia, etc. As principal cause name the disease
causing death As related causes, name earlier morbid conditions, if any,
related to the principal cause and any important complication of the
principal cause.
Statement of Occupation. — Precise statement of occupation is very
important, so that the relative healthfulness of various pursuits can be
known. Make some entry in this section for every person aged 10 years
or over. If the occupation had been given up or changed on account of
the disease causing death, report the usual occupation prior to illness.
If the deceased had retired from business, report the usual occupation
prior to retirement. Children not gainfully employed may be returned as
at school or at home. For a woman whose only occupation was that of
home housework, write housework. For a person engaged in domestic
service for wages, however, designate the occupation by the appropriate
terms, as housekeeper — private family, cook — hotel, etc. For a person who
had no occupation whatever write none.
SPACE FOR ADDITIONAL INFORMATION
7ITH UNFADING INK. Every item of information should be carefully supplied,
[y important. Physicians : please write the causes of death clearly and legibly.
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, Section 10, requires physicians to Insert • reoltal to that effeot.
JM R-301 A
ui
, /. /County)
O
< O
UJ
(City or Tqa
<
-J
^0.
No. .4^2 J
FULL
NAME
(Jf deceased Is
(a)
Residence/ No. ...tt.
(Usual place of anot
tChc (Hoittmoti&trallh of jiHassacIptsette
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.
o
Registered No .tj
h occurred in a hospital or Institution,
NAA1E Instead of street aud number)
/• rtl]
J (Was
' 1 U. S.
if so
PHYSICIAN - IMPORTANT
deoeased a
War Veteran,
apeoify WAR)
Length of stay: In nnsollal nr Institution
(Before death) < Specify
years
months
days.
rhether)
(If nonresident, give city or town and State)
In thia community yra. moa. days.
personal ano statistical particulars
3 SEX
4 COLOR OR RACE
Lvbift
5 SINGLE twrite the word)
MARRIED n,. ✓
WIDOWED W Qff/ &Q
or DIVORCED
5a If married, widq^Jl. or divorced Cv _ ^ / .
HUSBAND of a. ?7
/(Cive maiden name of wife In hill)
(or) WIFE of
fHusband's name In full)
6 Age of husband or wife if alive years
*1 IF STILLBORN, enter that fact here.
S
AGE
..Lr Years Months
Days
If less than 1 day
Hours Minutes
Usual
9 Occuoation:
GU
Industry
10 or Business:
X=.
11 Social Security No.
12 BIRTHPLACE f City)
( Siare or country) Ij'rcc C O
13 NAME OF --p /
FATHER £, L.14S
7^ ^/) «<4 Ur S
/
14 BIRTHPLACE OF
FATHER (Cily)
£
(State or country)
trnre dUU
15 MAIDEN NAME "T)
OF MOTHER <pL
y/fb ■%«Sdp<?<4/rcc
16 BIRTHPLACE OF
MOTHER (Citv)
(State or country)
17
7Z
( Address)
7*6.
ZrL/
Informant
I HEREBY CERTIFY that a satisfactory standard oertlfioata of death was
filed with me BEFORE the burial yen transit permit was issued:
„.UAjjLCt~C**k^
(Signature of Agent At Board of Health or other)
CU0jJ^A£..
(OfBclaJ^iosIgnation) // (Date of issue of Permit)
EDICAL CERTIFICATE OF DEATH
18 DATE OF
OEATH ....
Month)
(Bay)
(Year
19 I HER E^B Y CERTIFY, That I attended deoeased from
19 -to 19
I last saw h alive on 19 , death Is said to
have occurred on the date stated above, at
Immediate oause of death
Duration
IMPORTANT
Other conditions
(Include pregnancy within 3 months of death)
Major findings:
Of operations.
IMPORTANT
Physician
Date of..
Of autopsy
What test confirmed diagnosis?.
Underline
the cause to
which death
should b e
charged sta-
tistically.
20 Was disease or injury in any way related to oooupatlon of deceased?
If so, spooify yfO -"V
> . M.
ess) Oafa 19..^...
il, Crehiatioi) or Removal. (Cipfr or Town)
Reoeived and filed
EXTRACTS FROM THE LAWS OF THE
COMMONWEALTH OF MASSACHUSETTS
GOVERNING THE
RETURN OF CERTIFICATES OF DEATH
A phyjioian 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 dealh. stating to the best of his knowledge and belief the name of the
deceased, his supposed age, the disease of which hr died, defined as re-
quired by section one. where same was contracted, the duration of hia last
illness, when last seen alive by the physician or offleer and the dale of his
death ... Gen. Laws, Chap. 4 6, Sec. 9.
A phvsician or offleer 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, aerved
In the army, navy or marine corps of the fnited States in any war in which
it has been engaged, insert in the certificate a recital to that effect, signi-
fying the war. and shall also certify in such certificate both the primary
arid 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 offleer 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 purpose*, 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
gnd seventeen. G. L. Chap. 46, Sec. 10.
No undertaker or other person shall bury or otherwise dispose of a human
body in a town, or remove therefrom a human body which has not been
buried, until he has received a permit from the board of health, or its
agent appointed to issue such permits, or if there is no such board, from
the clerk of the town where the person died; and no undertaker or other
person shall exhume a human body and remove it from a town, from one
cemetery to another, or from one grave or tomb other 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 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 auch 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-alx, that the deceased aerved In the army,
navy or marine corps of the United State* 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 giveu 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&, 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 hoard of health or its agent ap|>oinlcd 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 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 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 body lies
and take charge of the same;... — General Laws, Chap. 3S, 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 phyaiolans 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 dealh is needed.
(8) Medloal Examiners will investigate and certify to all deaths iup-
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 diseasa resulting from injury or
Infeotion related to oooupation, the sudden deaths of persona not disabled
by reoognized disease, and those of persons found dead.
Statement of Cause of Death. — Cause of death meana the diaeaee, 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 ia 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 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 H)e appropriate terms, as housekeeper — privata
family, cook — hotel, etc. For a person who had no occupation whatever
write none.
SPACE FOR ADDITIONAL INFORMATION
tM R-301 A
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2!S
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.......
ui (County)
O
o Win thro p
(City or Town)
®br (Uotttmonforalllt of jiFa«arIpt«ett*
OFFICE OF THE SECRETARY
DIVISION OF VITAL STATISTICS
STANDARD
CERTIFICATE OF DEATH
To be tiled for burial permit
with Board of Health
or its Aqent.
rm.
Real stared Ho
no 2.1 Gr.Q.Y.e.rs....A.y.e. de,th occnrr*d ,0 * h0fp,u’ or "'•titut,on-
I give its NAME instead of street aurt number)
PHYSICIAN - IMPORTANT
2 FULL NAME J„a Cl&rk J (Was deceased a
(If deceased is a married, widowed or divorced woman, give also maiden name.) I 4- War Veteran,
I if so specify WAR)
(a) Residence. No. ...2.I.....GP.0.V.e.rS..-.&Ve SL
(Usual place of abode) (If nonresident, give city or town and State)
Length of stay: In hospital or Institution . I years months days. In this community 30;
( He fore death) (Specify whether)
yra.
days.
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
Male
4 COLOR OR RACE
Whl te.
5 SINGLE (write the word)
MARRIED
WIDOWED
or DIVORCEC
5a If married, widAMed. ar_diyorcedTT
husband of .....jOuClam Haywood..
(Give maiden name of wife in full)
(or) WIFE of
(Husband's name In full)
'faarrled
6 Age of husband or wile if alive
years
7 IF STILLBORN, enter that fact here.
AG^ 3 Years „...^Tr. Month* ”... Days
If less than 1 day
Hours Minutes
Usual
9 Occupation: ... Salas~-Sns-lne«-F»
Lumber
Industry
10 or Business:
11 Social Security No.
12 BIRTHPLACE (City)
( Slate or country)
Roxbury..
Mass
13 NAME OF
FATHER
John C. Clark
CO
h-
14 BIRTHPLACE OF
FATHER (Cily) ..
Liverpool
z
Id
oc
(State or country)
Ene
15 MAIDEN NAME
<
Q.
OF MOTHER
Anna Ward
16 BIRTHPLACE OF
MOTHER (Citv) ..
Needham
(State or country)
Mass
17
Informant ULlElStD -.C.lark. l(Wl*!CS
(Address) 2J Grr overs ave
elation, if any
I HEREBY CERTIFY that a satisfactory standard oertlfioat* of death was
fllebi vyRtume BEF0RE the burial or f/ansit permit was issued t
2m..E2>A...l
r Agent jif
(Official DcsignatiortY// // (Date of Issue
ature of Ageat pf Boar^* >( health or other)
or oiner) ^
MEDICAL CERTIFICATE OF DEATH
18 DATE OF
DEATH
19 I HEREBY CERTIFY,
Jb^. £ VEE5:.-
(Month) (Day) (YeaiO
HEREBY CERTIFY, That I attended deoeased from
TIC. -to /...r....J ,
I last taw h.../K?nrt:...allv* on ./...TT...?....0 19./f?Jl death Is said to
have occurred on the date stated above, at....l3
Immediate oause of death
Due to .
Due to..
Other conditions
(Include pregnancy within 3 months of death)
Major findings:
Of operations.
Date of..
Of autopsy
What test confirmed diagnosis? .
Duration
IMPORTANT
IMPORTANT
Physician
Underline
the cause to
which death
should b a
charged sta-
tistically.
20 Was disease or injury in any way related to oooupatlon of deoeased?
If so, specify.....^ ^
£..._ M. D.
Dale/r.4....::.-. 19.......
(Signed) ffi.'
(Address)
Date../!r..^..rr:.....19...b::'
21 ...uai.Ya.ry b.o.s..t,.Q.n ;
Place of Burial, Cremation or Kemerat. TQ(lEij]y or Town)
DATE OF BURIAL AA+AZA.. A. 19
22 NAME OF
FUNERAL DIRECTOR
2
—
ADDRESS
Wvlnthrop
Reoeived and Died /.
19.
.fit- -
( Registrar)
-I
EXTRACTS FROM THE LAWS OF THE
COMMONWEALTH OF MASSACHUSETTS
GOVERNING THE
RETURN OF CERTIFICATES OF DEATH
A phyjlolan or registered hospital medioal offioer shall forthwith, after
the death of a person whom he has attended during his Iasi Illness, at the
request of an undertaker or other stithorir.ed 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 as re-
quired by section one. where same was contracted, the duration of his last
illneaa, when last seen el ire by the physician or officer and the date of hia
death Ceu. Laws, Chap. 4 6, Sec. 0.
A' physician or officer furnishing a certificate of death as required by the
preceding section or by section fortv-flve 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
ft 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
physician or officer shall forfeit ten dollars. For the pun»oses of thia sec-
tion and of sections forty-five, forty-sii and forty-seven of said chapter one
hundred and fourteen, the word “war" shall include the China relief ex-
pedition and tile 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 undertaksr or other person shall bury or otherwise dispose of a human
bodv in a town, or remove therefrom a human body which has not been
buried, until he has received a permit from the board of health, or its
agent ap|K>inted to issue such permits, or if there is uo such board, from
the clerk of the town where the fieraon 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 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 aectlon 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, 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.
Thr |ierson to whom thr permit is so given and the physician certifying
thr causr of death shall thereafter furnish for registration any other necr*-
sary information which can be obtained as to thr deceased, or as to the
manner nr cause of thr 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 ashes
thereof which have been brought Into rhe 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 hosrd, front thr clerk of the town
where thr body is to be buried or the funeral is to he held, or from a person
api-oinled to have the care of the cemetery or burial ground in which lha
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 hy violence.
If a medical examiner has notice that there is within Ills county the body
of such a person, he shall forthwith go to the place where (lie 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 phyaiolans will certify to such deaths only as those
of leraon* who, though disabled by recognized disease unrelated to anv
form of injury, have died without recent medical attendance or whose physi-
cian is absent from home when the certificate of death ia needed.
(S) Medioal Examiners will investigate and certify to all death* tup-
posably due to injury. These inelude 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, and deaths
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.
Statsmant of Cauaa of Death. — Cause of death mean* the disease, or
complication which causes death, not the mode of dying, e. g., heart failure,
asphyxia, asthenia, etc. Aa principal cauae name the disease causing death.
As related causes, name earlier morbid conditions, if any, related to lha
principal cauae and any important complication of the principal cauae.
Statement of Oooupatlon. — Precise statement of occupation ia very im-
portant, so that the relative healthfulneaa 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 retiremenL
Children not gainfully employed may be returned aa at school or at home.
For a woman whose only occupatiou was that of home housework, writ*
housework. For a person engaged in domestic service for wages, however,
designate the occupation by tjje appropriate terms, aa housekeeper — private
family, cook — hotel, etc. For a person who had no occupation whatever
write none.
SPACE FOR ADDITIONAL INFORMATION
IM R-301 A
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rl Suffolk
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o
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J
^fl.
(County)
Winthrop
(City or Town)
tChr Coimttoti&tralili of (IHafisadfttsrttc
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 .a.
No Maple F{.es£ HO.EOS. Sl j (If death occurred in a hospital or Institution,
I give its NAAIK inatead o( street aud number)
imii i nvn t tt ( PHYSICIAN - IMPORTANT
2 FULL NAME * J (Was deceased ■
( If deceased Is a married, widowed or divorced woman, give also maiden name.) 1 S. War Veteran,
0/r „ , . I if so specify WAR)
(a) Residence. No .?.P.....S tUTglS S..t St
(Usual place of abode) (If nonresident, give city or town and State)
Length of stay: In nnsnltal nr Institution /
(Before death) (Specify whether)
year*
months
days.
In this community? 3 yrs.
daya.
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
Male
4 COLOR OR RACE
White
5 SINGLE
MARRIED
WIDOWED
or DIVORC
(write the word)
EMa rried.
5a If married, widowed
HUSBAND of
(or) WIFE of
fce%.. Howell.......
(Give" maiden name of wife in bill)
(Husband's name in full)
6 Age of husband or wife if alive 3&. yaarsl
^ IF STILLBORN, enter that fact here.
■66
8
AGEUy. .. Years Months Days
If less than X day
Hours Minutes
Usual
9 Occuoation:
Salesman
Industry
10 or Business:
Shoe
11 Social Security No.
12 BIRTHPLACE f City)
( Siale or ommtry)
■Boston
Mas s
13 NAME OF
FATHER
14 BIRTHPLACE OF
FATHER (Cily) .
(State or country)
John J. Henry
Ireland
15 MAIDEN NAME
OF mother Della O' Dowd
16 BIRTHPLACE OF
MOTHER (City) .
(State or country)
Ireland
i7 Mary A. Henry , iWiitdfe If any
PS atwir si '
I HEREBY CERTIFY that a srtl ifap^orv, standard oertlfioata of death was
filed, with -ma
OptE theyburlat pM^ftslM>ermlt was issued t
of Agent/hf .Board ^f/nei[firoT oth^r)
Designation) f / (Date of Issue
"or other)
of /erinit) / r /
MEDICAL CERTIFICATE OF DEATH
(Mont
(Day)
(Year)
19 I HEREBY CERTIFY
19.
4/^.
< 0
, /That t attended deoaased from
.O...V y' 19 4/Y..
I last saw h..l.*Mi alive on... M.«Jhi !)..* 19 (/*/ death is said to
have occurred on the date stated above, at m.
Immediate oajiea of death.., ....
Due to .
Due to .
Other conditions..
(Include pregnancy within 3 months of death)
Major findings:
Of operations.
Date of..
Of autopsy
What test
confirmed diagnosis? fUticaUy.
Duration
IMPORTANT
A-i.'Ojf'
/# fSftfl.
IMPORTANT
Physician
Underline
(he cause to
which death
should b a
charged sta-
20 Was disease or injury in any way
" “• Jhzz&zx&i
(Signed)
(Address)
lated to ae(Ju9atlon of deoeased
2i .....tSalxary...
-OyP
fie
DaleV^'f ' 19
Place of Burial, Crematior
DATE OF BURIAL .J
Hasten ::
or Removal. -» s-.j(WCT 0T Town)
B. 10 19' •
22 NAME OF
FUNERAL DIRECTOR
19..
ADpRgss /... w Inthrop
Reoelved and
fl'ed-V J. 19
(Registrar)
EXTRACTS FROM THE LAWS OF THE
COMMONWEALTH OF MASSACHUSETTS
GOVERNING THE
RETURN OF CERTIFICATES OF DEATH
A physician or reordered 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, bis supposed age, the disease of which he died, defined at* re-
quired by section one. where same was contracted, the duration of his last
illness, when last seen alive by the physician or officer and the date of his
death ... Gen. Laws, Chap. 46, Sec. 9.
A 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 1'nited States in any war in which
it has been engaged, insert in the certificate a recital to that effect, sjteci-
fying the war. and shall also certify in such certificate both the primary
and the secondarv 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, 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. C. L. Chap. 46, Sec. 10.
No undertaker or other person shall bury or otherwise dispose of a human
body in a town, or remove therefrom a human body which has not been
buried, until he has received a permit from the board of health, or its
agent appointed to issue such permits, or if there is no such board, from
the clerk of the town where the |ierson 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, ageot 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 uho 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
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 array,
navy or marine corps of the United 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 a* to the
manner or cause of the death, which the clerk or registrar may require.—
Chap. 114. Sec. 46, C. 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 hoard, front the clerk of the town
where the body is to be buried or the funeral is to he held, or from a per.-win
appointed to have the care of the cemetery or burial ground in which tbo
interment is made. ... Chap. 114. Sec. 46. C. 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 body 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 draths sup-
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, and deaths
following abortion, but also deaths from disease resulting from injury or
Infeotion related to oooupatlon, the sudden deaths of persons not disabled
by reoognlzed disease, and those of persons found dead.
Statement of Causa 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 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 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, as housekeeper — private
family, cook — hotel, etc. For a person who had no occupation whatever
write none.
SPACE FOR ADDITIONAL INFORMATION
N. B.— WRITE PLAINLY, WITH UNFADING BLACK INK— THIS IS A PERMANENT RECORD. Every item of
information should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state
CAUSE OF DEATH in plain terms, so that it may be properly classified. Exact statement of OCCUPATION
is very important. Sec instructions and extracts from the laws on back of certificate.
200m-10-’39. No. 8427-d
CRM R-301
^Suffolk.
(County)
u
O
o linthrop.
M (City or Town)
a.
®lje (Eommonfuealtlj of ,iitaBsac'jusett0
OFFICE OF THE SECRETARY
DIVISION OF VITAL STATISTICS
STANDARD
CERTIFICATE OF DEATH
(City or town making return)
a
Registered No...
. . _ f (If death occurred in a hospital or institution,
jyjQ iV Int hi Top C. .Q.Ifl njy.n.jL t^T. . . .H.O. S.p.i .t.3. J- St. I give its NAME instead of street and number)
2 FULL NAME Ia.o;....F.a.terlc.ia...Ghr.Ia.t.o.p±ier. ;
(If deceased is a married, widowed or divorced woman, give also maiden name.) ^ speciry wan;
152 Lincoln st st
_ (If nonresident, givJ^jty or town and state)
X months days. In this community yrs. mos. days.
(a) Residence. No
(Usual place of abode)
.ength of stay: In hospital or institution
(Specify whether)
years
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
'emale
4 COLOR OR RACE
White
(write the word)
5 SINGLE
MARRIED
WIDOWED _ .
or DIVORCEfilngle
5a If married, widowed, or divorced
HUSBAND of
(Give maiden name of wife in full)
(or) WIFE of
(Husband’s name in full)
G Age of husband or wife if alive Yaars
I H E kE BY CERTIFY, That I attended deceased from
19. to
I last saw h..«Cirt....a!ive on i».T7.. ..'.ji'm , 19 death is said
to have occurred on the date stated above,
Immediate cause of death..
7 IF STILLBORN, enter that lact here.
s 29
AGE Years Months Days
II less than 1 day
Hours Minutes
9 occ2paMill.....W.ar.k.e.r..
10 or Business: Mays.r.lck Mills..
11 Social Security No. .0.254.-12.-77.65..
12 BIRTHPLACE (City) ZES.S.t. ..b.QS t.Qn .
(State or country) M3-SS
13 NAME OF
FATHER John J.
Christonher
14 BIRTHPLACE OF
FATHER (City) ..
East
Boston
(State or country)
Mass
IS MAIDEN NAME
OF MOTHER
Catherine Johnson
1G BIRTHPLACE OF
MOTHER (City)
(State or country)
East
Boston
Mass
17
iniormanPathprine Johnson
(Address)- 152 Lincoln St
ion, ^jf any
I HEREBY CERTIFY that a satisfactory ntandard certificate of death was
filed lyith me BEFORE the burial or transit permit was issued:
f Health or other)
///2Ua.A.
(Date of Issue o \ Permity / /
MEDICAL CERTIFICATE OF DEATH
18 DATE OF
DEATH
(Month)
./Si
(Day)
( V>ar)
Immediate cause or death v..
;
Due to J.jtn..
Due to
Other conditions Jirxu
(Include pregnancy within 3 months of death)
Major findings:
Of operations ..
Dateof....^^£#L..
Of autopsy
What test confirmed diagnosis?
Duration
PHYSICIAN
20 Was disease or Injury In any say related to occniiatloa of decaasei
If so, specify .<rZ)
(Signed)
(Address)
M. D.
L...X)*\*./j//.SZ. 19
21 ..ff.in.thr.op linthrop
Place of Burial, Cremari^^^c Rem^Q J^^or Town)
Received and filed/
L
A TRUE COPY ATTEST:
fTEST: A O ■ (fefeistrar)
,.Q..1htz£c,
./..OMtsag.
EXTRACTS FROM THE LAWS OF THE
COMMONWEALTH OF MASSACHUSETTS
GOVERNING THE
RETURN OF CERTIFICATES OF DEATH
A physician or registered hospital medical officer shall forthwith,
after the death of a person whom he has attended during his last
illness, at the request of an undertaker or other authorized person
or of any member of the family of the deceased, furnish for regis-
tration a standard certificate of death, stating to the best of his
knowledge and belief the name of the deceased, his supposed age,
the disease of which he died, defined as required by section one,
where same was contracted, the duration of his last illness, when last
seen alive by the physician or officer and the date of his death . . .
Gen. Laws, Chap. 46, Sec. 9.
No undertaker or other person shall bury or otherwise dispose of a
human body in a town, or remove therefrom a human body which
has not been buried, until he has received a permit from the board
of health or its agent appointed to issue such permits, or if there
is no such board, from the clerk of the town where the person died ;
and no undertaker or other person shall exhume a human body and
remove it from a town, from one cemetery to another, or from one
grave or tomb other than the receiving tomb to another in the same
cemetery, until he has received a permit from the board of health or
its agent aforesaid or from the clerk of the town where the body is
buried. No such permit shall be issued until there shall have been de-
livered to such board, agent or clerk, as the case may be, a satisfac-
tory written statement containing the facts required by law to be
returned and recorded, which shall be accompanied, in case of an
original interment, by a satisfactory certificate of the attending
physician, if any, as required by law, or in lieu thereof a certificate
as hereinafter provided. If there is no attending physician, or if, for
sufficient reasons, his certificate cannot be obtained early enough for
the purpose, or is insufficient, a physician who is a member of the
board of health, or employed by it or by the selectmen for the pur-
pose, shall upon application make the certificate required of the at-
tending physician. If death is caused by violence, the medical exam-
iner shall make such certificate. If such a permit for the removal of
a human body, not previously interred, from one town to another
within the commonwealth cannot be obtained early enough for the
purpose, the certificate of death made as above provided and in the
possession of the undertaker desiring to make such 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, See. 46, G. L., ( Tercentenary Edition .)
RULES OF PRACTICE
The fulfillment of the purpose of these laws calls for the observ-
ance of the following rules of practice:
(1) Attending physician* will certify to such deaths only as those
of persons to whom they have given bedside care during a last ill-
ness from disease unrelated to any form of injury.
(2) Board of Health phyaieiana 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
aupposabiy 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
housekee]>er — private family, cook — hotel, etc. For a person who had
no occupation whatever write none.
SPACE FOR ADDITIONAL INFORMATION
fl
<
UJ
o
Suffolk...
(County)
UJ
o
<
-i
triii' tirnnimnufornllli ot jitfnssnrlntsctte
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.
o Winthrop . .
(City or Town yJ jjA
no. Station. Hospital, Fort Banks , Mas s .
Registered No.
((If death occurred in a hospital or institution,
*t. J give NAME instead of street and number)
r PHYSICIAN - IMPORTANT
2 FULL NAME .^.8X...T.„..^UINN; (W” °
(If deceased is a married, widowed or divorced woman, give also maiden name.)
(a) Residence, no 71 3e.a.c.p.D....S.treet jbc Arliag.t.Qn*...llass.«
(Usual place of abode) (If nonresident, give city or town and State)
U. S. War Veteran, Toy. XT
if so specify WAR) ..V.„i
Length of stay: In hospital or Institution
(Refore death) f Specify whether)
years
** months — days.
In this community
yrs.
- daya.
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
Female
4 COLOR OR RACE
"White
5 SINGLE (write the word)
MARRIED
WIDOWED s .
or DIVORCED Dingle
5a If married, widowed, or divorced
HUSBAND of TT ....
(Give maiden name of wife in full)
(or) WIFE of
(Husband’s name in full)
6 Age of husband or wife if alive ..." year
7 IF STILLBORN, enter that fact here.
S r*,rs n -i o I If less than 1 day
AGE .Cju.. Years (... Months ...JLD. Days | Hours
Mirtutes
Usual i-r s p
9 Occupation:
Industry TT 0
10 or Business: W.,
11 Social Security No. fJnknQYra..
( Siafe or country)
Massachusetts
13 NAME OF
FATHER
John J. Quinn
14 BIRTHPLACE OF
FATHER (City) .
(State or country)
Ireland
15 MAIDEN NAME
OF MOTHER
Mary Lahif’f
16 BIRTHPLACE OF
mother (City) .... Ireland..
(State or country)
17
Informant
(Address) station
. Relation, if any
Hospital, ... Ft. , Bank s . Ma s s .
MEDICAL CERTIFICATE OF DEATH
L8 DATE OF T p
death January. 15...
(Month) (Day)
...1.9.Ul..
( Year)
L9 I HEREBY CERTIFY, That I attended deceased from
..l.k...J.anuary, , i9..kk..., to.....l.5...J.amary. , 19. kk„
I last saw h.Sr. alive on. l5.....J.anmr:y. 19 iik death Is said to
nave occurred on the date stated above, at 9.;.k5. p„ m.
immediate cause of death. P.er.i.t.Qmt.l5.>-.a.c.ute.
..dl£i'.us.e.>....s.uppur.a.tlv.e.>....o^.tr.ome.,
caus.e....mde.t.erndn.e.d.t......
oue to..Eaptur.e....oi!....in£e.c.t.e.d...cys.t>...l.ei!.t
.ovary .. llo....o.per.a.tiona.
Oue to
Other conditions .TT.
(Include pregnancy within 3 months of death)
Major findings:
Of operations..
Date of
Of autopsy Findings... as... above. ,
Whal tesf confirmed diagnosis? .H.Q.H?
Duration
Important
Important
Physician
Underline
i he cause to
» hirli death
-lioilld b a
charged sta-
tist ica I ly.
DATE OF BURIAL
(CUy or Town)
I HEREBY CERTIFY that a
filed, wfth me BEFORE the.dii
■V
/ T (Signature of Age
(Official Designation)
y standard certificate of death was
it permit was issued:
Board ^or othgr) /
:.
(Date of Issue of Permit)' * '
address $0 7 ri
22 NAME OF
FUNERAL DIRECTOR
Reoeived and filed..
.19..
(Registrar)
EXTRACTS FROM THE LAWS OF THE
COMMONWEALTH OF MASSACHUSETTS
GOVERNING THE
RETURN OF CERTIFICATES OF DEATH
A physician or registered hospital medical officer shall forthwith, after
the death of a person whom he has attended during; his last illness, at the
request of an undertaker or other authorized person or id 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, l.is supposed atre, the disease of which he died, defined as re-
quired hv section one. where same was contracted. I he duration of his last
illness, when last seen alive by the physician or officer and the date of his
death ... Cen. 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 1'tiited 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 anil of sections forty-five, forty-six and forty-seven of said chapter one
hundred and fourteen, the word "war" shall include Ihe 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 ami 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. 4C, 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 lias received a permit from t lie 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 ihe 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 iomb other than the receiving
tomb to another in the same cemetery, until he has received a permit from
the board of lieallh 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 ami recorded, which shall lie 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, liis 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 afler 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 Ihe I'nited States in any war in which it has been
engaged, such recital shall appear U|hui 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 wlmin the permit is so given and the physician certifying
tile 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 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 lie has re-
ceived a permit so to do from the board of healih or its agent appointed to
issue sueli 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
appointed to have the care of the cemetery or burial ground in which the
interment is made. ... Chap. 114. Sec. 40. G. L., (Tercentenary Edition).
Medical examiners shall make examination upon the view of the dead
bodies of only such persons as are supposed to have died by violence.
If a medical examiner has notice that there is within liis county the body
of suelt a person, he shall forthwith go to the place where the body lies
and take charge of the same; . . . — General Laws, Cliap. 38, Sec. 6.
RULES OF PRACTICE
The fulfillment of the purpose of these laws calls for the observance of
the following rules of practice:
(1) Attending physicians will certify to such deaths only as those of
pprsons to whom they have given bedside care during a last illness from
disease unrelated to any form of injury.
(2) Board of Health physicians will certify to such deaths only as those
of persons who. though disabled by recognized disease unrelated to any
form of injury, have died without recenl 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, 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, ami 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 healthful ness of various pursuits can be known.
Slake 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
M R-301 A
■ £Z
19 O
"H
no <
•3S;
' o D
-go
o
to o
< o
2 ©
« 4-
3*
x r
’’O o
©
tc.*
Sj
. 4>
a; 5 ®
A v
'2h .
3 < *>
iw g
«Q t
eu, a
•20 £
(9 rj '
E« £
«4-i ^
.S U .2
Suffolk
(County)
i /'£ WInthrop
ju (City or Town)
Sllff (Sntmnnmuraltl) of fvi!tusarl)UHrllB
OFFICE OF THE SECRETARY
DIVISION OF VITAL STATISTICS
To be filed for burial permit
with Board of Health
or its Agent.
STANDARD
^ CERTIFICATE OF DEATH Registered No &
| N Wlnt,hrop Community Hospital ( (If death occurred in a hospital or institution.
* v’ l give its NAME instead of street and number)
2 full name Sl&rid. .. .( Arnp.l.^s.Q«.)....C.&.rlS.Q.o.
(If deceased is a married, widowed or divorced womam give also maiden name.)
(a) Residence. No..... .^5... Shore... D Tl Ve Sl '
(If nonresident, give city or town and state)
Of U. S.
War Veteran,
spocify WAR)..
(Usual place of abode)
Length of stay: In hospital or institution H.O.S..pi.t.ci 1
(Specify whether)
years
months
10da
In this community yrs.
days.
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
Female
4 COLOR OR RACE
White
S SINGLE (write the word)
MARRIED
WIDOWED
or DIVORCED ’ \ d OW
Sa If married, widowed, or divorced
HUSBAND of
(Give maiden name of wife in full)
(or) wife of E.rail.....Ca.r.ls.on
(Husband*s name in full)
6 Age of husband or wife if alive years
7 IF STILLBORN, enter that fact here.
m
8 ^ U I If less than 1 day
AGE Years Months Days! Hours Minutes
9 Occupation : B.P.US.PWlf .6..
Industry
10 or Business:.
At Home
11 Social Security No..
None
12 BIRTHPLACE (City)
(State or country) UfWCUC w • *
13 NAME OF
FATHER
Anderes Arnoldson
14 BIRTHPLACE OF
FATHER (City)
(State or country) SWftdft.fl
IS MAIDEN NAME
OF MOTHER
Unable to obtain
16 BIRTHPLACE OF
MOTHER (City)
(State or country) Sweden? n
17
Relation, if any
informant.....?..?.^™)£.....'^.??.?l®.™^.®.Q.?! (Brother )
(Address) 9 Marlon Rd. Belmont ase
I HEREBY CERTIFY that a satisfactory standard certificate of death
s fil^d with me BEF
;fo
(Official Designatioi
or transit permit was issued:
j (Signature of of Board^S Health or other)
(Date of Issue of
MEDICAL CERTIFICATE OF DEATH
18 DATE OF
DEATH
Ik. ..
(J (Month) f (Day) (Year)
^ ^ ^ ? f^,T I F,y , That I attended deceased from
/O y, 19
I last saw h.r&ir. .. alive on / SO, 19^
have occurred on the date sttted above, at ’
Immediate cause of death
death is said to
Other conditions..^
(Include pregnancy within 3 months f>l death)
Major findings:
Of operations..
..Date of..,
Of autopsy.. ^
What testconfirmed diagn«t»L.££f^^
Duration
IUP0XTANT
IMPORTANT
PHYSICIAN
Underline
the cause to
which death
should be
charged sta-
tistically.
20 Was disease or injury in any way Mated to occupation of deceased?.^
If so, specify..
(Signef»?3S- / D.
a t.crgesc Hills rn s ,
Place of Burial, Cremation or Removal. (City or Town)
DATE OF BURIAL J. A
Received and filed 19
(Registrar)
EXTRACTS FROM THE LAWS OF THE
COMMONWEALTH OF MASSACHUSETTS
GOVERNING THE
RETURN OF CERTIFICATES OF DEATH
A physician or registered hospital medical officer shall forthwith,
after the death of a person whom he has attended during his last illness,
at the request of an undertaker or other authorized person or of any
member of the family of the deceased, furnish for registration a standard
certificate of death, stating to the best of his knowledge and belief the
name of the deceased, his supposed age. the disease of which he died,
defined as required by section one, where same was contracted, the
duration of his last illness, when last seen alive by the physician or officer
and the date of his death . . . Gen. Laws, Chap. 46, Sec. 9.
No undertaker or other person shall bury or otherwise dispose of a
human body in a town, or remove therefrom a human body which has
not been buried, until he has received a permit from the board of health,
or its agent appointed to issue such permits, or if there is no such board,
from the clerk of the town where the person died; and no undertaker or
other person shall exhume a human body and remove it from a town, from
one cemetery to another, or from one grave or tomb other than the receiv-
ing tomb to another in the same cemetery, until he has received a permit
from the board of health or its agent aforesaid or from the clerk of the
town where the body is buried. No such permit shall be issued until
there shall have been delivered to such board, agent or clerk, as the case
may be, a satisfactory written statement containing the facts required by
law to be returned and recorded, which shall be accompanied, in case of an
original intennent, by a satisfactory certificate of the attending physician,
if any, as required by law, or in lieu thereof a certificate as hereinafter
provided. If there is no attending physician, or if, for sufficient reasons,
his certificate cannot be obtained early enough for the purpose, or is in-
sufficient, a physician who is a member of the board of health, or em-
ployed by it or by the selectmen for the purpose, shall upon application
make the certificate required of the attending physician. If death is caused
by violence, the medical examiner shall make such certificate. If such a
permit for the removal of a human body, not previously interred, from
one town to another within the commonwealth cannot be obtained early
enough for the purpose, the certificate of death made as above provided
and in the possession of the undertaker desiring to make such removal
shall constitute a permit for such removal; provided, that such body shall
be returned to the town from which it was removed within thirty-six
hours after such removal, unless a permit in the usual form for the re-
moval of such body has been sooner obtained hereunder. If the death
certificate contains a recital, as required by section ten of chapter forty-
six. that the deceased served in the army, navy or marine corps of the
United States in any war in which it has been engaged, such recital shall
appear upon the permit. The board of health, or its agent, upon receipt of
such statement and certificate, shall forthwith countersign it and transmit
it to the clerk of the town for registration. The person to whom the permit
is so given and the physician certifying the cause of death shall thereafter
furnish for registration any other necessary information which can be
obtained as to the deceased, or as to the manner or cause of the death,
which the clerk or registrar may require. — Chap. 114, Sec. 45, G. L„
( Tercentenary Edition).
No undertaker or other person shall bury a human body or the ashes
thereof which have been brought into the commonwealth until he has
received a permit so to do from the board of health or its agent appointed
to issue such permits, or if there is no such board, from the clerk of the
town where the body is to be buried or the funeral is to be held, or from a
person appointed to have the care of the cemetery or burial ground in
which the interment is made. . . . Chap. 114, Sec. 46, G. L„ (.Tercentenary
Edition).
RULES OF PRACTICE
The fulfillment of the purpose of these laws calls for the observance of
the following rules of practice;
(1) Attending physicians will certify to such deaths only as those
of persons to whom they have given bedside care during a last illness from
disease unrelated to any form of injury.
(2) Beard of Health physicians will certify to such deaths only as
those of persons who, though disabled by recognized disease unrelated to
any form of injury, have died without recent medical attendance or whose
physician is absent from home when the certificate of death is needed.
(3) Medical Examiners will investigate and certify to all deaths
supposably due to injury. These indude not only deaths caused
directly or indirectly by traumatism (including resulting septicemia),
and by the action of chemical (drugs or poisons), thermal, or electrical
agents, and deaths following abortion, but also deaths from disease
resulting from injury or infection related to occupation, the
sudden deaths of persons not disabled by recognized disease,
and those of persons found dead.
Statement of Cause of Death. — Cause of death means the disease,
or complication which causes death, not the mode of dying, e. g„ heart
failure, asphyxia, asthenia, etc. As principal cause name the disease
causing death. As related causes, name earlier morbid conditions, if any.
related to the principal cause and any important complication of the
principal cause.
Statement of Occupation. — Precise statement of occupation is very
important, so that the relative healthfulness of various pursuits can be
known. Make some entry in this section for every person aged 10 years
or over. If the occupation had been given up or changed on account of
the disease causing death, report the usual occupation prior to illness.
If the deceased had retired from business, report the usual occupation
prior to retirement. Children not gainfully employed may be returned as
at school or at home. For a woman whose only occupation was that of
home housework, write housework. For a person engaged in domestic
service for wages, however, designate the occupation by the appropriate
terms, as housekeeper — private family, cook — hotel, etc. For a person who
had no occupation whatever write none.
SPACE FOR ADDITIONAL INFORMATION
snouia dc careruuy suppnea. moc snouid De stated tAALlLT. rn TbltlANb should stare 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.
M R-301 A
5a If married, ywdowed, w
HUSBANO of
7^
1
(or) WIFE of
(Hive maiden name of wife in full /
(Husband** name in full)
6 Age of husband or wife i
f alive
(County)
(City or Town)
tEhr (Uttnmtoji&irallli of jfHnssarlntsrtta
OFFICE OF THE SECRETARY
DIVISION OF VITAL STATISTICS
STANDARD
CERTIFICATE OF DEATH
To be filed for burial permit
with Board of Health
or its Agent.
No.
Registered No.
2 FULL NAME .
is a married, widowed or divorced woman, give also maiden jy&me.)
/<jjf
iode) s'
644 st. ( (If death occurred in a hospital or Institution,
t>,‘l give its NAME instead of street and number)
PHYSICIAN - IMPORTANT
(Was deceased a
U. S. War Veteran,
if so specify WAR).
(a) Residence. No.
(Usual place of abode)
Length of stay: In nnsoital or Institution ...
(Refore death) (Specify whether)
years
"months S' days.
(If nonresident, give city or town and State)
In this community yrs. mos. days.
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
4 COLOR OR RACE
5 SINGLE (write the word) 1
MARRIED jA.Va.ri/
WIDOWED
or DIVORCED
7 IF STILLBORN, enter that fact here.
$0 Years /... Months
AGE
Days
If less than 1 day
Hours Minutes
Usual
9 Occuoatlon:
ir
10
11 Social Security No.
~o*7
12 BIRTHPLACE (City)
(State nr country)
oVT
13 NAME OF
FATHER
3.
14 BIRTHPLACE OF
FATHER (City) ....
(State or country)
^ / 1
15 MAIDEN NAME /? - / * fJ _ ,y j
OF MOTHER \J Cui^sCs. Sl<?X^Y>C
16 BIRTHPLACE OF
MOTHER (City) ....
(State or country)
17
In forma 1 if y
( Address
I HEREBY CERTIFY that a satisfactory standard certificate of death was
«..j the burial 0{. translt'permlt was issued:
Agept of Board of Health Vr^tl^er)
. , 4
(Official Designation) / (Date of Issue of/Permit)'
MEDICAL CERTIFICATE OF DEATH
IS OATE OF
DEATH
/ (p / 4 V 4
(Month) I (Day) (Year)
w That I attended deceased from
19^:....
I last saw alive AC. , 19 A/f"death Is said to
have occurred on the date stated above, at. ...d?r..
Immediate cause of death
Cj2s\J^
Due to Jtrr^.u ,/i
Due to..
Other conditions..
(Include pregnancy within 3 months of death)
Major findings:
Of operations..
..Date of..
Of autopsy^^U^^O^T^r. a ,
What test confirmed diagnosis ■{
Duration
IMPORTANT
IMPORTANT
Physician
way related to occupation of deceased?.
21
Date
Place of Buriat, Cre
DATE OF BURIAL
g or Removal. / (City or Town)
' /.F. * 19^
22 NAME OF
FUNERAL DIRECTOR .
ADDRESS
Reoeived and filed t
WIBS
.19
(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 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 he sect ion one. where same was contracted, the duration of his last
illness, when last seen alive by the physician or officer and the date of his
death ... Gen. Laws, Chap. 46, Sec. 9.
A physician or officer furnishing a certificate of death as required by the
preceding section or by section forty-five of chapter one hundred and four-
teen, shall, if the deceased, to the best of his knowledge and belief, served
in the army, navy or marine corps of the 1'nited States in any war in which
it has been engaged, insert in the certificate a recital to that effect, speci-
fying the war. and shall also certify in such certificate both the primary
and the secondary or immediate cause of death as nearly as he can state
the same. For neglect to comply with any provision of this section, such
phvsician or officer shall forfeit ten dollars. For the purposes of this sec-
tion and of sections forty-five, forty-six and forty-seven of said chapter one
hundred and fourteen, tile word “war" shall include the China relief ex-
pedition and the Philippine insurrection, which shall, for said purposes, be
deemed to have taken place between February fourteenth, eighteen hundred
and ninety-eight and July fourth, nineteen hundred and two, and the Mexi-
can border service of nineteen hundred and sixteen and nineteen hundred
and seventeen. G. L. Chap. 4 6, Sec. 10.
No undertaker or other person shall bury or otherwise dispose of a human
bodv in a town, or remove therefrom a human body which has not been
buried, until he has received a permit from the board of health, or its
agent appointed to issue such permits, or if there is no such board, from
the clerk of the town where the person died; and no undertaker or other
person shall exhume a human body and remove it from a town, from one
cemetery to another, or from one grave or tomb other than the receiving
tomb to another in the same cemetery, until he has received a permit from
the board of health or its agent aforesaid or from the clerk of the town
where the body is buried. No such permit shall be issued until there shall
have been delivered to such board, agent or clerk, as the case may be,
a satisfactory written statement containing the facts required by law to he
returned and recorded, which shall be accompanied, in case of an original
interment, bv a satisfactory certificate of the attending physician, if any,
as required by law. 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 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
6uch removal; provided, that such body shall be returned to the town from
which it was removed within thirty-six hours afier 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 ('tilted 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 ami certificate, shall forthwith
countersign it and transmit it to the clerk of the town for registration.
The person to whom the permit is so given ami the physician certifying
the cau~e of death shall thereafter furnish for registration any other neces-
sary information which can be obtained as to the deceased, or as to the
manner or cause of the death, which the clerk or registrar may require. —
Chap. 114. Sec. 45, G. L„ (Tercentenary Edition).
No undertaker or other person shall bury a human body or the ashee
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. 4 6. 0. L., (Tercentenary Edition).
Medical examiners shall make examination upon the view of the dead
bodies of only such persons as are supposed to have died by violence.
If a medical examiner has notice that there is within his county the body
of such a person, he shall forthwith go to the place where the body lie»
and take charge of the same; . . . — General Laws, Chap. 3S, 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 tup-
posably due to injury. Those include not only deaths caused directly oi in-
directly by traumatism (including resulting septicemia), and by the action
of chemical (drugs or poi»uns), thermal, or electrical agents, and deaths
following abortion, hut 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. nnt 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, teporl the usual occupation prior to illness, if the deceased
had retired from business, report the usual occupation prior to retirement.
Children not gainfully employed tnay 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
that it may be properly classmea. Lxact statement 02 OCCUPATION is very important, be© instructions and extracts
from the lav/s on back of certificate.
1-301 A
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OFFICE OF THE SECRETARY
DIVISION OF VITAL STATISTICS
STANDARD
CERTIFICATE OF DEATH
Registrar’s No.
To bo filed for burial permit
with Board of Health
or its Agent.,
„ f (If death occurred in a hospital or institution,
( give its NAME instead of street and number)
PHYSICIAN— IMPORTANT
deceased a
War Veteran,
Iso maiden name.) t* if so specify WAR)
stay: In hospital or 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
4 COLOR OR RACE
(or) WIFE of _
5 SINGLE (write the word)
MARRIED
WIDOWED
or DIVORCE!
(Husband’s name in full)
6 Age of husband or wife if alive_
xT-a
7 IF STILLBORN, enter that fact here.
Years Months Day
If less than 1 day
Hours . Minutes
11 Social Security Mo. 4/3
12 BIRTHPLACE (City)
(State or country)
13 NAME OF
fathe:
14 BIRTHPLACE OF
FATHER (City)
(State or country)
15 MAIDEN NAME
OF MOTHER
-V. r
16 BIRTHPLACE
MOTHER (City) f
(State or country)
BEFORE the burial or transit permit was issued:
>TTnr tkat^a satisfaptoryvstandard certificate of death
hjor other)
cial Designation)
of A^ejit of Board of He
&L- 44
(Date of Issue /6f
MEDICAL CERTIFICATE OF DEATH
-i2
(Day)
(Year)
That I attended deceased from
, 19 , death is said to
have occurred on the date stated above, at (&' V T P
CERTIFY,
19 , to
alive on .
""gr r:
Due to.
Due to-
other conditions
(Include pregnancy within 3 months of death)
Major findings:
Of operations-
Date of
Of autopsy.
What test confirmed diagnosis ?_
Duration
IPOfiTANT
IMPORTANT
Physician
Underline
the cause to
which death
should be
charged sta-
tistically.
20 Was disease or injury in any way related to occupation of deceased?.
If so, specify — _
(Signed) — L, — *
EXTRACTS FROM THE LAWS OF THE
COMMONWEALTH OF MASSACHUSETTS
GOVERNING THE
RETURN OF CERTIFICATES OF DEATH
A physician or registered hospital medical officer shall forthwith, after
the death of a person whom he has attended during his last illness, at the
request of an undertaker or other authorized person or of any member of
the family of the deceased, furnish for registration a standard certificate
of death, stating to the best of his knowledge and belief the name of the
deceased, his supposed age, the disease of which he died, denned as re-
quired by section one, where same was contracted, the duration of his last
illness, when last seen alive by the physician or officer and the date of
his death . . . Gen. Laws, Chap. 46, Sec. 9.
A physician or officer furnishing a certificate of death as required by the
preceding section or by section forty-five of chapter one hundred and four-
teen, shall, if the deceased, to the best of his knowledge and belief, served
in the army, navy or marine corps of the United States in any war in which
it has been engaged, insert in the certificate a recital to that effect, speci-
fying the war, and shall also certify in such certificate both the primary
and the secondary or immediate cause of death as nearly as he can state
the same. For neglect to comply with any provision of this section, such
physician or officer shall forfeit ten dollars. For the purposes of this sec-
tion and of sections forty-five, forty-six and forty-seven of said chapter
one hundred and fourteen, the word “war” shall include the China relief
expedition and the Philippine insurrection, which shall, for said purposes,
be deemed to have taken place between February fourteenth, eighteen
hundred and ninety-eight and July fourth, nineteen hundred and two, and
the Mexican border service of nineteen hundred and sixteen and nine-
teen hundred and seventeen. G. L. Chap. 46, Sec. 10.
No undertaker or other person shall bury or otherwise dispose of a human
body in a town, or remove therefrom a human body which has not been
buried, until he has received a permit from the board of health, or its
agent appointed to issue such permits, or if there is no such board, from
the clerk of the town where the person died; and no undertaker or other
person shall exhume a human body and remove it from a town, from one
cemetery to another, or from one grave or tomb other than the receiving
tomb to another in the same cemetery, until he has received a permit from
the board of health or its agent aforesaid or from the clerk of the town
where the body is buried. No such permit shall be issued until there shall
have been delivered to such board, agent or clerk, as the case may be,
a satisfactory written statement containing the facts required by law to be
returned and recorded, which shall be accompanied, in case of an original
interment, by a satisfactory certificate of the attending physician, if any,
as required by law. 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 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 iorty-six, that the deceased served in tne army,
navy or marine corps of the United States in any war in which it has been
engaged, such recital shall appear upon the permit. The board of health,
or its agent, upon receipt of such statement and certificate, shall forthwith
countersign it and transmit it to the clerk of the town for registration.
The person to whom the permit is so given and the physician certifying
the cause of death shall thereafter furnish for registration any other neces-
sary information which can be obtained as to the deceased, or as to the
manner or cause of the death, which the clerk or registrar may require. —
Chap. 114, Sec. 45, G. L., (Tercentenary Edition).
No undertaker or other person shall bury a human body or the ashes
thereof which have been brought into the commonwealth until he has re-
ceived a permit so to do from the board of health or its agent appointed to
issue such permits, or if there is no such board, from the clerk of the town
where the body is to be buried or the funeral is to be held, or from a person
appointed to have the care of the cemetery or burial ground in which the
interment is made. . . , Chap. 114, Sec. 46, G. L., (Tercentenary Edition).
Medical examiners shall make examination upon the view of the dead
bodies of only such persons as are supposed to have died by violence.
If a medical examiner has notice that there is within his county the body
of such a person, he shall forthwith go to the place where 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 any
form of injury, have died without recent medical attendance or whose phy-
sician 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
indirectly by traumatism (including resulting septicemia), and by the
action of chemical (drugs or poisons), thermal, or electrical agents, and
deaths following abortion, but also deaths from disease resulting from
injury or infection related to occupation, the sudden deaths of persons not
disabled by recognized disease, and those of persons found dead.
Statement of Cause of Death. — Cause of death means the disease, or
complication which causes death, not the mode of dying, e. g., heart failure,
asphyxia, asthenia, etc. As principal cause name the disease causing death.
As related causes, name earlier morbid conditions, if any, related to the
principal cause and any important complication of the principal cause.
Statement of Occupation. — Precise statement of occupation is very im-
portant, so that the relative healihfulness 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, how-
ever, 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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OFFICE OF THE SECRETARY
DIVISION OF VITAL STATISTICS
STANDARD
CERTIFICATE OF DEATH
( (If death occurred in a hospital or institution,
I give its NAME instead of street and number)
/ xrs
f deceased is a married, widowed or divorced woman, give also maiden nam^) jO | U. S. War
G X X> «* s- if so speoil
To be filed for burial permit
with Board of Health
or Its Agent.
" '
Registered No.
2 FULL NAME
(If
(a) Residence. No.
(Usual place of abode)
Length of stay: In hospital or Institution
(Refore death) (Specify whether)
PHYSICIAN - IMPORTANT
deceased a
Veteran,
specify WAR)
yean
months
□ays.
(If nonresident, give city or town and State)
In this community J <fyrs. mos. days.
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
4 COLOR OR RACE|
5 SINGLE (writ
_ MARRIED
WIDOWED
or DIVORCED
5a If married, widowed, or divorced
HUSBAND of ........
(Give maiden name of wife in full)
(or) WIFE of
(Husband’s name in full)
6 Age of husband or wife if alive years
7 IF STILLBORN, enter that fact here.
S
AGE
Years Months .
Days
If less than X day
Hours Minutes
Usual
9 Occupation:
Industry
10 or Business:
11 Social Security No.
12 BIRTHPLACE (City)
(State or country)
13 NAME OF
FATHER
14 BIRTHP
FATHE
(State or country)
*
15 MAIDEN NAM
OF MOTHER
MEDICAL CERTIFICATE OF DEATH
IS DATE OF
DEATH
/R / /
(Month) ( Day ) ' (Year)
H EREBY CERTIFY, That I attended deoeased from
19.^, to , 19^.5^
I last saw h .l..tr> alive on....*/#..* T J/ 19 J/tf death Is said to
have occurred on the date stated above, at
Immediate cause of death
C.
Due
Duration
Imr6htant
IyZ...
Due to..
Other conditions... rP.f.&AfZZ*....
(Include pregnancy within 3 months of death)
Major findings:
Of operations..
Of autopsy
What test confirmed
r
rmed diagnosis? ST, r
Date of..
zx.:
*
Important
Physician
Underline
the cause to
w hich death
should b e
charged sta-
... ti.stically.
20 Was disease or injury i
If so, specify
lated to occupation of deceased
Place of Burial, Crerdati;
DATE OF BURIAL
or Removal.
(City or Town)
I HEREBY CERTIFY that a
filed with me B£FQRE ti
Stisfa.ctory standard certificate of death was
it permit was issued:
22 NAME OF ^ s?
FUNERAL DIRECTOR
ADDRESS
nation c
M „
uv i OR
MH 2 6 1944 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 snj f member of
the family of the deceased, furnish for registration a standard certificate
of death, stating to the best of his knowledge and belief the name of the
deceased, his supposed age, the disease of which he died, defined as re-
quired bv section one, where same was contracted, the duration of his last
illness, when last seen alive by the physician or officer and the date of his
death.’. Cen. Laws, Chap. 46, Sec. 9.
\ 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.
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 boilv 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 phvsician. If death is caused by violence, the medi-
cal examiner shall make such certificate. If such a permit for the removal
of a human body, not previously interred, from one town to another within
the commonwealth cannot be obtained early enough for the purpose, the
certificate of death made as above provided and in the possession of the
undertaker desiring to make such removal shall constitute a permit for
such removal; provided, that such body shall be returned to the town from
which it was removed within thirty-six hours after such removal, unless
a permit in the usual form for the removal of such body has been sooner
obtained hereunder. If the death certificate contains a recital, as required
by section ten of chapter forty-six, that the deceased served in the army,
navy or marine corps of the United States in any war in which it has been
engaged, such recital shall appear upon the permit. The board of health,
or its agent, upon receipt of such statement and certificate, shall forthwith
countersign it and transmit it to the clerk of the town for registration.
The person to whom the permit is so given and the physician certifying
the cause of death shall thereafter furnish for registration any other neces-
sary information which can be obtained as to the deceased, or as to the
manner or cause of the death, which the clerk or registrar may require. —
Chap. 114, Sec. 45, G. L., (Tercentenary Edition).
No undertaker or other person shall bury a human body or the ashes
thereof which have been brought into the commonwealth until he has re-
ceived a permit so to do from the board of health or its agent appointed to
issue such permits, or if there is no such board, from the clerk of the town
where the body is to be buried or the funeral is to be held, or from a person
appointed to have the care of the cemetery or burial ground in which the
interment is made. ... Chap. 114. Sec. 46, G. L., (Tercentenary Edition).
Medical examiners shall make examination upon the view of the dead
bodies of only such persons as are supposed to have died by violence.
If a medical examiner has notice that there is within his county the body
of such a person, he shall forthwith go to the place where the body liei
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 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. 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 tile relative healthfulness of various pursuits can be known.
Make some entry in this section for every person aged 10 years or over.
If the occupation had been given up or changed on account of the disease
causing death, report the usual occupation prior to illness. If the deceased
had retired from business, report the usual occupation prior to retirement.
Children not gainfully employed may be returned as at school or at home.
For a woman whose only occupation was that of home housework, write
housework. For a person engaged in domestic service for wages, however,
designate the occupation by the appropriate terms, as housekeeper — private
family, cook — hotel, etc. For a person who had no occupation whatever
write none.
SPACE FOR ADDITIONAL INFORMATION
•as.wmsw vaiviuiij •wppiicw. hvl Jnuuu uc tldlCU bAMVIb I . rm JIV.IMI'U SnOUIO SfaTC bMUJC V/T UCM I H Id pi Jlfl
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 deceaied was a U. S. War Veteran, G. L. Chap. 46, Seotlon 10, requires phyaioians to Insert a reoltal to that effeot.
A R-301 A
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tCItc Conimotiforalllt of^Taosarlptsrtts
OFFICE OF THE SECRETARY
DIVISION OF VITAL STATISTICS
STANDARD
CERTIFICATE OF DEATH
2 FULL NAME
l2
Uj.
(City or TownjX y ' /7 7*^ /7Z7> " / ”
No. ,.<=>?.Q.
5>.
^eive also m
St.
To be filed for burial permit
with Board of Health
or its Agent.
{ 2
Reolsterad No
- I (If death occurred in a hospital or Institution,
St. ) gjve jta ^vaMK instead oi street aud number)
PHYSICIAN - IMPORTANT
(Was deceased a
(If deceased Is a married, widowed or divorced woman, cove alto maiden name.) . i *-*• S. War Veteran, O/
... %Lc<- s,
(Usual place of abode) /y^-% ^ (If nonresident, £ive city or town and State)
V
Length of stay: In nnepltal or Institution ..
(Before death) (Specify
years
months
days.
rhether)
In thla oommunltyvJ^J yra. — moa. — days.
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
4 COLOR OR RACE
'UcaA.
5 SINGLE (write the word)
MARRIED
WIDOWED
or DIVORCE
5a If married,
HUSBAND
oi' w,idttwed:..or diyorced^^^ ^
(Give maiden name of wife in full)
( Husband's name in full)
6 Age of husband or wife if alive
(or) WIFE of
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 ant 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 hia 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 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 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 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, 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 aud sixteen and nineteen hundred
•nd seventeen. C. L. Chap. 4 6, Sec. 10.
No undertaker or other person shall bury or otherwise dispose of a human
bodv in a town, or remove therefrom a human body which has not been
buried, until he has received a permit from the board of health, or its
agent appointed to issue such permits, or if there is no such board, from
the clerk of the town where the person died; aud 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 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. ot in lieu thereof a certificate as hereinafter provided.
If there is no attending physician, or if, for sufficient reasons, his certificate
cannot be obtained early enough for the purpose, or is insufficient, a physi-
cian who is a member of the board of health, or employed by it or by the
selectmen for the purpose, shall upon application make the certificate re-
quired of the attending physician. If death is caused by violence, the medi-
cal examiner shall make such certificate. If such a permit for the removal
of a human body, not previously interred, from one town to another within
the commonwealth cannot be obtained early enough for the purpose, the
certificate of death made as above provided and in the possession of the
undertaker desiring to make 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-etx. that the deceased served In the army,
navy or marine corps of the I’nited States io any war In which It has been
engaged, such recital shall appear upon the permit. The board of health,
or its agrnl. 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. 0. 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 lie has re-
ceived a |>ermit so to do from the board of health or its agent appmnlid 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 tba
interment is made. ... Chap. 114. Sec. 4 6. C. 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 lie*
aud take charge of the same;... — Ceneral Laws, Chap. 38, Sue. 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 phyaioiana 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 heme when the certificate of death is needed.
(S) Medical 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, anil deaths
following abortion, but also deaths from disease resulting from injury or
Infeotlon 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. Aa principal cauae name the disease causing death.
As related causes, name earlier morbid conditions, if any, related to the
principal cauae and any important complication of the principal cause.
Statement of Oooupatlon. — Precise statement of occupation ia 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
bad 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 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
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 Vetaran, Q. L. Chap. 46, Saotlon 10, requlrta physicians to Insert a reoltal to that affeot.
I R-301 A
1 Suffolk
r*-
*
ui
o
(County)
& Wlnthrop
(City or Town)
uJ
O
<
.1
V.Q.
tCbr QTmttmoti fora Hit of (iHawarfptsett*
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 Me.
< o
no. ...1 ...ElmwG>04-~ Court- - st{ <u dMth ocwred ,D ' or ,n't,tm,on’
2 FULL NAME .
(If deceased
(a) Residence. No.
(Usual place of abode)
Della....Wl... Curran Jla-r-r- i <w«
sed is a married, widowed or divorced woman, give also maiden name.) I 4*
. 1 if *o
..^.....Kinjw.Q.o.d..„.C..Q.ur.t st
give ita NAME instead of atreet aud Dumber)
PHYSICIAN - IMPORTANT
deoeased a
War Veteran,
•peoify WAR)
Length of stay: In hnsoltal nr Institution
(Before death) (Specify
yeara
months
days.
rhether)
(If nonresident, give ^ty or towa and State)
In this community yrs. mos. day*.
PERSONAL ANO STATISTICAL PARTICULARS
3 SEX
Female
4 COLOR OR RACE1 5 SINGLE (write the word)
MARRIED
WIDOWED
or Q'VQRCEqyidowed
White
3a If married, widowed, or divorced
HUSBAND of
wife
(Husband's name In full)
6 Age of husband or wife if alive years
*1 IF STILLBORN, enter that fact here.
S
AG
Years Months
Days
If less than 1 day
Hours Minutes
9 Occuoation: .. Ho.uaaw.lfe..
Industry
10 or Business:
..Qwn.Ho.me,
11 Social Security No.
12 BIRTHPLACE fCity)
(Slate or country)
Portland
JLe_
13 NAME OF
FATHER
Patrick Curran
14 BIRTHPLACE OF
FATHER (City) .
(State or country)
Ireland
15 MAIDEN NAME
OF
M.°™Eflylary. ..Curran
16 BIRTHPLACE OF
MOTHER (City) ^
(State or country) I re land
17
informant Upula... Ha raden V... )
,Address> .■4..E.lm«ooA^£fc
I HEREBY CERTIFY that a satisfactory standard oertlfioata of death was
filed with meJ)EfORE tfe Jlurlal/fr transit permit was Issued:
4t/Of BdaiyM^f f^Ctth or oth^r)
(Official Designation) [/ (J (Date of Tsmie of /*ertnTl
MEDICAL CERTIFICATE OF DEATH
18 DATE OF
DEATH
fed
(Month) (Day) (Year)
19 II HEREBY CERTIFY,
19...7
That I attended deoeased from
i9...y^
l^4st taw h .^Ed^rr. alive on.....JZZfrrrtyz:...2r....^.., 19 death Is said to
have occurred on the date stqf^ed above, at y?.»..^<5?.y~r....m.
Due to
Due to .
Other conditlona..
(Include pregnancy within 3 months of death)
Major findings:
Of operations.
Data of..
Of autopsy
What test oonfirmed diagnosis?.
IMPORTANT
Physician
Underline
ihe cause to
which death
should b a
charged sta-
tistically.
20 Was disease or injury in any way related to oooupatlon of deoeased?
If so, specify —rCl
(Signed) (X. M. D.
(Address) 'v'Iyi/... 19syC.
'.^xyai’y £.or^!an<l M.
Place of Burial, Cremation or Removal. (Citj or Town)
DATE OF BURIAL..
al. (City or Town)
Jan.. 2.6 19 44.
19.
22 NAME OF \L, Y
FUNERAL DIRECTOR ritlAAtJ.. . \J...L l.J.../XuCL
ADDRESS .. WintKrop..
Reoeived and filed
(Regiatrar)
X
EXTRACTS FROM THE LAWS OF THE
COMMONWEALTH OF MASSACHUSETTS
GOVERNING THE
RETURN OF CERTIFICATES OF DEATH
A physloian or registered hospital medioal offioer shall forthwith, after
the death of a person whom he has attended during hie last illness, at the
request of an undertaker or other authorized person or of ant member of
the family of the deceased, furnish for registration a standard certificate
of death, statin? 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 hia last
Illness, when last seen aliee by the physician or ofllcer and the date of hia
death ... Gen. Laws, Chap. 46, Sec. 9.
A phesician 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 lias been engaged, insert in the certificate a recital to that eflect, 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 purjKtses 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 purposea, be
deemed to have taken place between February fourteenth, eighteen hundred
and ninety- eight and July fourth, nineteen hundred and two, and the Meii-
can border service of nineteen hundred aud sixteen and nineteen hundred
and seventeen. G. L. Chap. 46, Sec. 10.
No undertaker or other person shall bury or otherwise dispose of a human
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 no such board, from
the clerk of the town where the person died; aud 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 aud recorded, which shall be accompanied, in case of an original
interment, by a satisfactory certificate of the attending physician, if any,
as required by law. ot in lieu thereof a certificate as hereinafter provided.
If there is no attending physician, or if, for sufficient reasons, his certificate
cannot be obtained early enough for the purpose, or is insufficient, a physi-
cian who is a member of the board of health, or employed by it or by the
selectmen for the purpose, shall upon application make the certificate re-
quired of the attending physician. If death is caused by violence, the medi-
cal examiner shall make such certificate. If such a permit for the removal
of a human body, not previously interred, from one town to another within
the commonwealth cannot be obtained early enough for the purpose, the
certificate of death made as above provided and in the possession of the
undertaker desiring to make such removal shall constitute a permit for
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 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 aud 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 nr 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-
ceited a |>ermit so to do front the board of health or its agent ap|Milnlcd to
issue such permits, or if there is no such hoard, from the clerk nf the town
where the hotly 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 6ha11 make examination upon the view of the dead
bodies of only such persons as are supposed to have died hy violence.
If s medical examiner has notice that there is within his county the I tody
of such a person, he shall forthwith go to the place where the body lie*
and take charge of the same;... — General Laws, Chap. 38, 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 phytlolans will certify to such deaths only as thosw
of (lersons 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) Medioal Examiners will investigate and certify to all deaths tup*
posably due to injury. These inrlurle 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, and death#
following abortion, but also deaths from dlaeasa resulting from injury or
Infeotion related to oooupatlon, the sudden deaths of persons not disabled
by reoognlzed disease, and those of persons found dead.
Statement of Cause of Death. — Cause of death mean* 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 th#
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 healthfulnesa 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 retiremenL
Children not gainfully employed may be returned aa 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)ye appropriate terma, 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 reoital to that effeot.
!M R-301 A
(EnmtmuifmaUlj of jiHaejarhusifte
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.
Jb&
Registered No.
14
s, ( (If death occurred in a hospital or Institution,
I Rive its NAME instead of street and number)
2 FULL NAME.
(a) Residence. No.
(Usual place of abode)
ArGL
[■ceased is a married, widowed or diwrced woman, give also maiden name.) | u. a. war veteran,
/A £t. A “ W<R)
(If deceased
PHYSICIAN - IMPORTANT
(Was deoeased a
U. S. War Veteran,
Length of stay: In hospital or Institution..
(Before death)
(Specify whether)
year*
months
days.
(If nonresident, give city or town and State)
In this community 3& yrs. mos. days.
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
4 COLOR OR RACE
5 SINGLE (write the word)
MARRIED
WIDOWED
or DIVORCED
5a If married, wi:
HUSBAND of
(or) WIFE of
ed, or divy
'Sxsa*CAs _ _
(Give mai
Cl l ,/p.uAx^^.. )
of wife in full) *
name of wife in full)
(Husband’s name in full)
6 Age of husband or wife if alive
£3-
years
7 IF STILLBORN, enter that fact here.
S
AGE
Usual
9 Occupation
(fi Sf Years )3. Months Days
If less than 1 day
Hours Minutes
10 or Business: ...
13 NAME OF
FATHER
14 BIRTHPLACE OF
FATHER (City)
(State or country)
15 MAIDEN NAME
OF MOTHER
16 BIRTHPLACE OF
MOTHER (City)
(State or country)
17
Informant/. A. rtrv...
(Address) //, t/t/i.
Relation, if any
MEDICAL CERTIFICATE OF DEATH
IS DATE OF
DEATH
19
7T
(Month) %S
(Day)
(Year)
REBY CERTIFY, ^That I attended deoeased from
^ 19 Vf . ^ , i9 mg*
I last saw alive , i9*r.5< death Is said to .
have occurred on the dat/'stated above, at ...
Immediqitf^ause of death
7
Due to.
,TT.
Due to.
Other conditions..
(Include pregnancy within 3 months of death)
Major findings:
Of operations..
Date of. '*..•*7
0f autopsy & <L .
What test confirmed diagnosis?
Duration
Important
Important
Physician
ation of deceased ?!**S0...
(Signed)
(Address)
21
I HEREBY CERTIFY that a satisfactory standard certificate of death was
IE thnb^rial «r transit permit was issued:
Place of Burial, Cremation or Reraov
DATE OF BURIAL
22 NAME OF
FUNERAL
(City or TowuO
is vy
ADDRESS
t of Board.<«f •fle^kh or other) .
(Date of Issu/ of Permi
DIRECTOR
( 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 dealh, stating to the best of his knowledge and belief the .name of lh«
deceased, his supposed age, the disease of which he died, defined as re-
quired bv section one, where same was contracted, the duration of Ins last
illness, when last seen alive by the physician or oflicer 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 tile 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 complv 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 [dace between February fourteenth, eighteen hundred
and ninetv-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 lo 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 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 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 (lie attending phvsician. If death is caused by violence, the medi-
cal examiner shall make such certificate. If such a permit for the removal
of a human body, not previously interred, from one town to another within
the commonwealth cannot be obtained early enough for the purpose, the
certificate of death made as above provided and in the possession of the
undertaker desiring to make such removal shall constitute a permit for
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 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 dealh shall thereafter furnish for registration any other neces-
sary information which can be obtained as to the deceased, or as to the
manner or cause of the death, which the clerk or registrar may require. —
Chap. 114, Sec. 45, G. L., (Tercentenary Edition).
No undertaker or other person shall bury a human body or the ashes
thereof which have been brought into the commonwealth until he has re-
ceived a permit so to do from the board of health or its agent appointed to
issue such permits, or if there is no such board, from the clerk of the town
where the body is to be buried or the funeral is to be held, or from a person
appointed to have the care of the cemetery or burial ground in which the
interment is made. ... Chap. 114. Sec. 46, G. L., (Tercentenary Edition).
Medical examiners shall make examination upon the view of the dead
bodies of only such persons as are supposed to have died by violence.
If a medical examiner has notice that there is within his county the body
of such a person, he shall forthwith go to the place where 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 call* 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 thoae
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 poisonsj, thermal, or electrical agents, and deaths
following abortion, but also deaths from disease resulting from injury or
infection related to occupation, the sudden deaths of persons not disabled
by recognized disease, and those of persons found dead.
Statement of Cause of Death. — Cause of death means the disease, or
complication which causes death, not the mode of dying, e. g., heart failure,
asphyxia, asthenia, etc. As principal cause name the disease causing death.
As related causes, name earlier morbid conditions, if any, related to the
principal cause and any important complication of the principal cause.
Statement of Occupation. — Precise statement of occupation is very im-
portant, so that the relative healthfulness of various pursuits can be known.
Make some entry in this section for every person aged 10 years or over.
If the occupation had been given up or changed on account of the disease
causing death, report the usual occupation prior to illness. If the deceased
had retired from business, report the usual occupation prior to retirement.
Children not gainfully employed may be returned as at school or at home.
For a woman whose only occupation was that of home housework, write
housework. For a person engaged in domestic service for wages, however,
designate the occupation by the appropriate terms, as housekeeper — private
family, cook — hotel, etc. For a person who had no occupation whatever
write none.
SPACE FOR ADDITIONAL INFORMATION
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. Section 10, requires physioians to Insert a reoltal to that effect.
H R-301 A
Ml (ui
tUttr Cmtimcm&trallli of fiHasaaeliusett*
OFFICE OF THE SECRETARY
DIVISION OF VITAL STATISTICS
STANDARD
ITIFICATE OF DEATH
— _. |
give its NAUR instead of street aud number)
To be filed for burial permit
with Board of Health
or its Agent.) >* r~
j> rt
Registered No ±
e f f If death occurred In a hospital or Inetitutlon,
5M|
2 FULL NAME ... m . . ..
( If deceased is a married, wtd
A ,1 ST I PHYSICIAN - IMPORTANT
t/ \ (Was deceased a
ased is a married, widowed or divorced woman, give alao maiden name.) I *
ko±L i £.d, s.
War Veteran,
WAR)
(a) Residence. No.
(Usual place of abode)
Length of stay: In nnspltal nr Institution
( Refore death) (Specify whether)
years
months
days.
(If nonresident, give city or town and State)
In this community yrs. moa. days.
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
4 COLOR OR RACE
SINGLE (write the word)
MARRIED
WIOOWED
or DIVORCED
lie me wi
5a If married, widowed, or divorced
HUSBAND of ....
(Give maiden name of wife in full)
(or) WIFE of
(Husband's name In full)
6 Age of husband or wife if alive years
*1 IF STILLBORN, enter that fact here.
S
AGE
Years Months
Days
If less than 1 day
Hours Minutes
Usual
9 OccuDatlon
*2 BIRTHPLACE fCily)
( Slate or country)
13 NAME OF
FATHER
7^'^^
/*( /i-4. •
14 BIRTHPLACE of
FATHER (City)
(State or country)
I HEREBY CERTIFY that a satisfactory standard oertlfioate of death was
lled.-tyfth.jwo BEFORE/the bgrJVl or trafwlt permit was Issued!
/ (Signature of Agent^o
(Official Designation) ^ (J [ j (Date of
enhit)
MEDICAL CERTIFICATE OF DEATH
IS DATE OF
DEATH
.u.A.v.v
(Sfonth)
1
3JSL.
(Day)
::....
\ oa 1
(Year)
19 I . HEREBY CERTIFY, _^That I attended deoeased from
...^..ft..n.vf.A\r..v,...l.ji, i9..V.f....L, 4o...^La^!rt..w.Qt.i r.yi...*UT., 19
I last saw h.,4.).^ .. alive on....^Db.n.U.<k.r^..2./. 19 death Is said to
have occurred on the date stated above, at X.™..Jj/.^...^\m.
Immediate oauea of death..
Due to...
Due to..
Other conditions b.l.M..L’.,£.G.i£
(Include pregnancy within 3 months of death)
Major findings:
Of operations
Date of..
Of autopsy..
What test confirmed diagnosis? .
Duration
IMPORTANT
*ir'
IMPORTANT
Physician
Underline
(he cause to
which death
should b e
charged sta-
tistically.
20 Was disease or injury in any way Related to oooupatlon of deceased ? £j
If so, speoify
(Signed) ^ M. D,
(Address) Xlfr-'Af.q
21
Place of Burial, Creniatioj^or Kemoval.
DATE OF BURIAk^2T..4?$?I'!l«^
^ (City or Town)
19
yy
22 NAME OF
FUNERAL Dl
ADDRESS
DIRecffefe
&3XJ
Reoeived and Died
Z i /344! (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 ant 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 hi*
death ... Gelt. 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, s|wci-
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 ol this section, such
physician or officer shall forfeit ten dollars. For the punmses 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 purpose*, 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
*nd seventeen. C. 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 ap|ioitited to issue such permits, or if there is no such board, from
the clerk of the town where the i»erson 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 game 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 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 ahall make *uch 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 6uch body has been sooner
obtained hereunder. If the death certificate contains a recital, as required
SPACE FOR ADDITIONAL INFORMATION
by section ten of chapter forty-six, that the deceased served in the army,
navy or marine corps of the I'nited State* in any war in which it has hren
engaged, such recital shall appear upon the permit. The board of hralth,
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 thr 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 a* to the
manner or cause of the death, which the clerk or registrar may require. —
Chap. 114. Sec. 45, C. 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 lie has re-
ceived a permit so to do from the board of health or its agent ap|H>inlcd 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 be held, or from a person
ap|K>inled to have the care of the cemetery or burial ground in which the
interment is made. ... Chap. 114. Sec. 46. C. 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 bis county the body
of such a person, he shall forthwith go to the place where the body lie*
and take charge of the same; . . . — General Laws, Chap. 38, Sec. 6.
RULES OF PRACTICE
The fulfillment of the purpose of these laws calls for the observance of
the following rules of practice:
(1) Attending physicians will certify to such deaths only at 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 physiolant will certify to such deaths only as thoa*
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) Medioal Examiners will investigate and certify to all deaths tup-
posably due to Injury. These include not only deaths caused directly or in-
directly by traumatism (including resulting septicemia), and by the action
of chemical (drugs or poisons), thermal, or electrical agents, ami 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 Causa 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 th»
principal cause and any important complication of the principal cause.
Statement of Oooupatlon. — Precise statement of occupation is 7ery im-
portant, so that the relative healthfulness of various pursuits can be known.
Make gome 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 retirernenL
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 tfoe appropriate terms, as housekeeper — private
family, cook — hotel, etc. For a person who had no occupation whatever
write none.
tM R-301 A
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J -
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J BU. g.
-•20 a
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s.Su.r
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C-»
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o
/£ Suf.fQ.lfc
I M (Coun
(County)
o Wi.nthrQp
M (City or Town)
2Hjr Ctommonmraltlj of fHaBoorljuBetla
OFFICE OF THE SECRETARY
DIVISION OF VITAL STATISTICS
To be filed for bnrial permit
with Board of Health
or its Agent.
f a
S.-C
STANDARD
^ CERTIFICATE OF DEATH Registered No HI
3 N Winthrop Community .HojSDltal c ( (If death occurred in a hospital or institution,
* p,° * bt. (give its NAME instead of street and number)
2 FULL NAME ( «£ uvs:
(If deceased is a married, widowed or divorced woman, give also maiden name.) j specify WAR)
(a) Residence. No St.
(Usual place of abode)
Length of stay: In hospital or insfitution...BO.Spi ta 1.
(Specify whether)
months
days.
(If nonresident, give city or town and state)
In this community 2^trs- mos. days.
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
Female
4 COLOR OR RACE
Whi te
5 SINGLE (write the word)
MARRIED
WIDOWED
or divorced. iarrlec
5a If married, widowed, or divorced
HUSBAND of
(Give maiden name of wife in full)
(or) WIFE of Hen^ry....S.Q.hl.ndhe.lni
(Husband's namejiijull)
6 Age of husband or wife if alive : z: years
7 IF STILLBORN, enter that fact here.
8
AGE.
28
Years..
I If less than 1 day
..Months Sr!.... Days I Hours Minutes
8
Usual
9 Occupation:..
Industry
10 or Business:.
Book keeper
Loan Co .
11 Social Security No ^,Q.l.|.-.Qb)-.5SS8
12 BIRTHPLACE
(City) .Boy Lori
13 NAME OF
FATHER
Bernhard Holgersen
14 BIRTHPLACE OF
FATKF.R fOitv)
(State or country)
Norway
IS MAIDEN NAME
OF MOTHER
Clara J Knud son
16 birthplace of East Rnqtnn
MOTHER (CitvV “.V.. DUS LOU
(State or country)
Mass .
17
Relation, if any
iiiiutu,„u Bernhard Ho lgersqfn Father'!
(Addles) "29 Ingle s ide Ave . V/lnt.hrnn
Informant..
I HEREBY CERTIFY that a satisfactory standard certificate of death
?ORE t\
/V" . CW &
REB
was i ilea with me BEFORE th<
L/.
transit permit was issued:
(Signature oLAgei
(Official Designate
DICAL CERTIFICATE OF DEATH
‘z*i.Hs.£Bz m
I last saw h..j6rHL.alive on
have occurred on the date state
Immediate cause ofdeath../tf.rf...^r.
That 1 attended deceased from
, 19.0?.
LI... , I9...W?death is said to
Of autopsy..
What test confirmed diagnosis?..
20 Was disease or injilt y in any way related to occupation ef deceased? 3H
If so, specify .... ..pj..
(Signed) T^r^frnj-J ■ — / M. D.
-Dateft/>*>..<?
21 .Winthro.p Qe. 1. w'i.nLnrp.p
Place of Burial, Cremation oi-Remcval. (City or Town)
DATE OF BURIAL ^.9. ig44
22 NAME OF
FUNERAL DII
ADDRESS ._
Received and filed..
ZEIIltlEl£$£
.19 .
(Registrar)
EXTRACTS FROM THE LAWS OF THE
COMMONWEALTH OF MASSACHUSETTS
GOVERNING THE
RETURN OF CERTIFICATES OF DEATH
A physician or registered hospital medical officer shall forthwith,
after the death of a person whom he has attended during his last illness,
at the request of an undertaker or other authorized person or of any
member of the family of the deceased, furnish for registration a standard
certificate of death, stating to the best of his knowledge and belief the
name of the deceased, his supposed age. the disease of which he died,
defined as required by section one, where same was contracted, the
duration of his last illness, when last seen alive by the physician or officer
and the date of his death . . . Gen. Laws, Chap. 46, Sec. 9.
No undertaker or other person shall bury or othenvise dispose of a
human body in a town, or remove therefrom a human body which has
not been buried, until he has received a permit from the board of health,
or its agent appointed to issue such permits, or if there is no such board,
from the clerk of the town where the person died; and no undertaker or
other person shall exhume a human body and remove it from a town, from
one cemetery to another, or from one grave or tomb other than the receiv-
ing tomb to another in the same cemetery, until he has received a permit
from the board of health or its agent aforesaid or from the clerk of the
town where the body is buried. No such permit shall be issued until
there shall have been delivered to such board, agent or clerk, as the case
may be, a satisfactory written statement containing the facts required by
law to be returned and recorded, which shall be accompanied, in case of an
original interment, by a satisfactory certificate of the attending physician,
if any, as required by law, or in lieu thereof a certificate as hereinafter
provided. If there is no attending physician, or if, for sufficient reasons,
his certificate cannot be obtained early enough for the purpose, or is in-
sufficient, a physician who is a member of the board of health, or em-
ployed by it or by the selectmen for the purpose, shall upon application
make the certificate required of the attending physician. If death is caused
by violence, the medical examiner shall make such certificate. If such a
permit for the removal of a human body, not previously interred, from
one town to another within the commonwealth cannot be obtained early
enough for the purpose, the certificate of death made as above provided
and in the possession of the undertaker desiring to make such removal
shall constitute a permit for such removal; provided, that such body shall
be returned to the town from which it was removed within thirty-six
hours after such removal, unless a permit in the usual form for the re-
moval of such body has been sooner obtained hereunder. If the death
certificate contains a recital, as required by section ten of chapter forty-
six, that the deceased served in the army, navy or marine corps of the
United States in any war in which it has been engaged, such recital shall
appear upon the permit. The board of health, or its agent, upon receipt of
such statement and certificate, shall forthwith countersign it and transmit
it to the clerk of the town for registration. The person to whom the permit
is so given and the physician certifying the cause of death shall thereafter
furnish for registration any other necessary information which can be
obtained as to the deceased, or as to the manner or cause of the death,
which the clerk or registrar may require.— Chap. 114, Sec. 45, G. L„
( Tercentenary Edition).
No undertaker or other person shall bury a human body or the ashes
thereof which have been brought into the commonwealth until he has
received a permit so to do from the board of health or its agent appointed
to issue such permits, or if there is no such board, from the clerk of the
town where the body is to be buried or the funeral is to be held, or from a
person appointed to have the care of the cemetery or burial ground in
which the interment is made. . . . Chap. 114, Sec. 46, G. L., (Tercentenary
Edition).
RULES OF PRACTICE
The fulfillment of the purpose of these laws calls for the observance of
the following rules of practice:
(1) Attending physicians will certify to such deaths only as those
of persons to whom they have given bedside care during a last illness from
disease unrelated to any form of injury.
(2) Board of Health physicians will certify to such deaths only as
those of persons who, though disabled by recognized disease unrelated to
any form of injury, have died without recent medical attendance or whose
physician is absent from home when the certificate of death is needed.
(3) Medical Examiners will investigate and certify to all deaths
supposably due to injury. These include not only deaths caused
directly or indirectly by traumatism (including resulting septicemia),
and by the action of chemical (drugs or poisons), thermal, or electrical
agents, and deaths following abortion, but also deaths from disease
resulting from injury or infection related to occupation, the
sudden deaths of persons not disabled by recognized disease,
and those of persons found dead.
Statement of Cause of Death. — Cause of death means the disease,
or complication which causes death, not the mode of dying, e. g., heart
failure, asphyxia, asthenia, etc. As principal cause name the disease
causing death. As related causes, name earlier morbid conditions, if any,
related to the principal cause and any important complication of the
principal cause.
Statement of Occupation. — Precise statement of occupation is very
important, so that the relative healthfulness of various pursuits can be
known. Make some entry in this section for every person aged 10 years
or over. If the occupation had been given up or changed on account of
the disease causing death, report the usual occupation prior to illness.
If the deceased had retired from business, report the usual occupation
prior to retirement. Children not gainfully employed may be returned as
at school or at home. For a woman whose only occupation was that of
home housework, write housework. For a person engaged in domestic
service for wages, however, designate the occupation by the appropriate
terms, as housekeeper - — private family, cook — hotel, etc. For a person who
had no occupation whatever write none.
SPACE FOR ADDITIONAL INFORMATION
RM R-301 A
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3 E n
<oEi - n
t-g « s r
®lje domiminforalili nf (iSTnsfarhusrtte
OFFICE OF THE SECRETARY
DIVISION OF VITAL STATISTICS
STANDARD
CERTIFICATE OF DEATH
To be filed for burial permit
with Board of Health
or Its Agent.
Registered No.
( (If death occurred In a hospital or institution,
dive its NAME instead of street and number)
2 FULL NAME
/V< /;
(If deceawjet7 is a married, widowed or divorced woman, give also maiden name.)
(a) Residence. No. rST.
PHYSICIAN -IMPORTANT
(Was deceased a
U. S. War Veteran,
if so speolfy WAR)
(Usual place of abode)
Length of stay: In hospital or institution ^ years ^ months JU days.
(Before death) (Specify whether)
(If nonresident, give city or town and State)
In this community yrs. ? mos. ? days.
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
4 COLOR OR RACE
*
5a If married, widcwe^fyO^gi vo^c^d
5 SINGLE (write the word)
MARRIED ,i * /
WIDOWED / H Ad-vU-H
or DIVORCED
-V
HUSBAND of
(Give maiden name of wif
(or) WIFE of
(Husband’s name.in full)
6 Age of husband or wife if alive rs- .TT. ’.T’ ‘years
7 IF STILLBORN, enter that fact here.
8 a? s 5 is I If less than 1 day
AGE r V . Years Vr. Months ./.La.. Days I Hours Minutes
~
Usual
9 Occupation:
Industry
10 or Business:
LI Social Security No. .
12 BIRTHPLACE (City)
(State or country)
2 ^ z &-<2s'0
13 NAME OF
FATHER
14 BIRTHPLACE OF
FATHER (City)
(State or country)
15 MAIDEN NAME
OF MOTHER
^
16 BIRTHPLACE OF
MOTHER (City) .
(State or country)
17
Informant &/*<! (__. W l{^a<
( AfMre<s)
I HER
file
MEDICAL CERTIFICATE OF DEATH
18 DATE OF
DEATH ^V..?*..h«..4.lr..^..
(Month)
(Day)
m$...
< Vnnr\'
(Year)
19 ^i*^H EREBY 9_ E R T. • F Y ■ /^That I attended deoeased from
1 9y.d.., ™JJh
I last saw h .J.*J alive on j death Is sal/to
have occurred on the date stated above, at f.f.jSfe
Immediate cause of death
^
Due to..
Other conditions
(Include pregnancy within 3 months of death)
Major findings:
Of operations.
n .p.r#®lkS.
Date of
is? jO.ia. sstesnz
Of autopsy
What test confirmed diagnosis?
Duration
Important
IJiiS
3.iL»j
IMPORTANT
Physician
Underline
the cause to
w hich death
should b e
charged sta*
tistieally.
20 Was disease orjgjury in any^wa
If so, specify
ot^ifljury ir. an^wa^rTpht«.d to occupation of deceased ?..-Wlft.
M'"n
(A^dd r e s s ) ..Pat 1 9^)*^
(Signed)^
21 '
Place of Burial, Cremation or
DATE OF BURIAL
2 FUNERAL. DIRECTOR ^ -
ADDRESS
if
( Registrar)
u
extracts from the laws of the
COMMONWEALTH OF MASSACHUSETTS
GOVERNING THE
RETURN OF CERTIFICATES OF DEATH
A physician or registered hospital medical officer shall forthwith. after
the death of a person whom he has attended during his last illness, at the
request of an undertaker or other authorized person or of any member of
the family of the deceased, furnish for registration a standard certificate
of death, stating to the best of his knowledge and belief the name of the
deceased, his supposed age, the disease of which he died, defined as re-
quired bv section one, where same was contracted, the duration of his last
illness, when last seen alive by the physician or officer and the date of hta
death ... Gen. Laws, Chap. 46, Sec. 9.
\ 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, navv or marine corps of the United Slates 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.
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 frqm 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 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,
s 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 early enough for the purpose, or is insufficient, a physi-
cian who is a member of the board of health, or employed by it or by the
selectmen for the purpose, shall upon application make the certificate re-
quired of the attending phvsician. If death is caused by violence, the medi-
cal examiner shall make such certificate. If such a permit for the removal
of a human body, not previously interred, from one town to another within
the commonwealth cannot be obtained early enough for the purpose, the
certificate of death made as above provided and in the possession of the
undertaker desiring to make such removal shall constitute a permit for
inch removal; provided, that such body shall be returned to the town from
which it was removed within thirty-six hours after such removal, unless
a permit in the usual form for the removal of such body has been sooner
obtained hereunder. If the death certificate contains a recital, as required
by section ten of chapter forty-six, that the deceased served in the army,
navy or marine corps of the United States in any war in which it has been
engaged, such recital shall appear upon the permit. The board of health,
or its agent, upon receipt of such statement and certificate, shall forthwith
countersign it and transmit it to the clerk of the town for registration.
The person to whom the permit is so given and the physician certifying
the cause of death shall thereafter furnish for registration any other neces-
sary information which can be obtained as to the deceased, or as to the
manner or cause of the death, which the clerk or registrar may require. —
Chap. 114, Sec. 45, G. L., (Tercentenary Edition).
No undertaker or other person shall bury a human body or the ashes
thereof which have been brought into the commonwealth until he has re-
ceived a permit so to do from the board of health or its agent appointed to
issue such permits, or if there is no such board, from the clerk of the town
where the body is to be buried or the funeral is to be held, or from a person
appointed to have the care of the cemetery or burial ground in which the
interment is made. ... Chap. 114. Sec. 46. G. L„ (Tercentenary Edition).
Medical examiners shall make examination upon the view of the dead
bodies of only such persons as are supposed to have died by violence.
If a medical examiner has notice that there is within his county the body
of such a person, he shall forthwith go to the place where 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 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. As principal cause name the disease causing death.
As related causes, name earlier morbid conditions, if any, related to the
principal cause and any important complication of the principal cause.
Statement of Occupation. — Precise statement of occupation is very im-
portant, so that the relative healthfulness of various pursuits can be known.
Make some entry in this section for every person aged 10 years or over.
If the occupation had been given up or changed on account of the disease
causing death, report the usual occupation prior to illness. If the deceased
had retired from business, report the usual occupation prior to retirement.
Children not gainfully employed may be returned as at school or at home.
For a woman whose only occupation was that of home housework, write
housework. For a person engaged in domestic service for wages, however,
designate the occupation by the appropriate terms, as housekeeper — private
family, cook — hotel, etc. For a person who had no occupation whatever
write none.
SPACE FOR ADDITIONAL INFORMATION
yy IX 1 1 u. ii.nuu-1, «nn unrHuimu iniv — mia IO A r£.RmA«tm KtLUKU. 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.
1M R-3Q1 A
Suffolk..
(County)
i Win thro p
(City or Town)
SHfr ffinntmmunraltlj of fflanflarljHHClta
OFFICE OF THE SECRETARY
DIVISION OF VITAL STATISTICS
STANDARD
CERTIFICATE OF DEATH
N 20 oart-lstt/ Pankt/ay ( (If death occurred in a hospital or institution.
(give its NAME instead of street and number)
To be filed for burial permit
with Board of Health
or its Agent. „ 0
■ 3
Registered No
2 FULL NAME .^.9.yi.?....^.P.ii.9.?.?.^....^.<?!P.^'. ( (ifU. S.
(If deceased is a married, widowed or divorced woman, give also maiden name.) ) specify5 WAR)
(a) Residence. No .?.P. . Bart le t t .. Parkway St
(Usual place of abode)
Length of stay: In hospital or institution..
(Specify whether)
months
days.
(If nonresident, give city or town and state)
In this community 4 0 yrs- mos. days.
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
Male
4 COLOR OR RACE
White
5 SINGLE
MARRIED
WIDOWED
or DIVORCED
(write the word)
Marrit
^US^B^Nd" o^,.Wi^OWO<^' 0r^iVOrCe^...M^..T1S®:^P^' ..yf.k.i tf pFl^
(Give maiden name of wife in full)
(or) WIFE of
(Husbajd's name in full)
6 Ago of husband or wife if alive. J6n::: years
7 IF STILLBORN, enter that fact here.
8
AGE
...7.3...:
Years. .5?. Months..
-i-i I If less than 1 day
..Tii.rir..Daysl Hours.. Minutes
Usual
Industry D LT
11
Social Security No.
None
15! BIRTHPLACE (CitvV.
Westfield
(State or country)
Mass .
13 NAME OF
FATHER
Watson Root
CO
14 BIRTHPLACE OF
FATHER (City)
Westfield
z
u
(State or country)
Mass .
K
<
0.
15 MAIDEN NAME
OF MOTHER
Emily Pettis
16 BIRTHPLACE OF
MOTHER (City)
Montgomery
(State or country)
Mass .
17
Relation, if any
informantEar6aret.....Root (..Wife )
(Addr^) go Bartlett Parkway Wlnthroi
3Y CERTIFY that a satisfactory
the burial oi ransit permit was issued:
andard certificate of death
IH1
was iiL6d with me BEFO]
/ V (Signature of ^^flt of Board of J^sltijgp-ath^r)
'Official DesignatioTf)^/ j/ (Date of Issue c* /
MEDICAL CERTIFICATE OF DEATH
18 DATE OF
, DEATH
d
1
(Mol
(Month)
(Day)
HEREBY CERTIFY
wM »
»st saw h.....V*<*... alive on.
have occurred on the date state^jlbave, at.
Immediate cause of death
That I attended deceased from
A..., 19.T2L
Ifl.Z^death is said to
...s..p...p.
tie to if.......
Other conditio
(Include pregnancy within 3 months of death)
Major findings:
Of operations .
..Date of..
Of autopsy
What test confirmed diagnosis?..
Duration
IUPOITANT
IMPORTANT
PHYSICIAN
Underline
the cause to
which death
should be
charged sta-
tistically.
20 Was disease or injury in any way related to occupadonfof deceased?..
If so, specify ...JL,
(Signed).. 4i*^r^xjL rr^rrrr^rrrr^rrT!^ M. D.
(Address) l/]^....LiU^irUU^irr^/.. Date U.A.ijj
2i .Middle ks rms ' 4esi,f lela
Place of Burial, Cremation or Removal.
DATE OF BURIAL.
3 J°s. nus' r1' 2§ity or Town) 44
Received and filed.
(Registrar)
1/U
EXTRACTS FROM THE LAWS OF THE
COMMONWEALTH OF MASSACHUSETTS
GOVERNING THE
RETURN OF CERTIFICATES OF DEATH
A physician or registered hospital medical officer shall forthwith,
after the death of a person whom he has attended during his last illness,
at the request of an undertaker or other authorized person or of any
member of the family of the deceased, furnish for registration a standard
certificate of death, stating to the best of his knowledge and belief the
name of the deceased, his supposed age. the disease of which he died,
defined as required by section one. where same was contracted, the
duration of his last illness, when last seen alive by the physician or officer
and the date of his death . . . Gen. Laws, CThe text goes on. The rest is in the file.