The volume, 1945

Town Clerk, Winthrop · from the Internet Archive · 520 pages · 39.4 MB
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J- L. FAIRBANKS DIV.

Tbomai Groom & Co.

Stationers

105 State St., Boston

To dnplicate this book order

No- ^69 VO

°*U-7

Copies of returns of dentils recorded during the previous month which occurred in your city or town in case the deceased
resided in another city or town at the time of death should be made forthwith and transmitted on Form R-302 to the clerk
of the city or town in which the deceased resided. (See Chap. 40, Sec. 12, G. L.)

?M R-302

Suffolk
Cli^T^oa

Choi sea

tjti'

(City or town making return)

No.

2 FULL NAME

tHIje (Eommanfacalil} of ,JHassacf{us£tts

OFFICE OF THE SECRETARY

DIVISION OF VITAL STATISTICS

COPY OF

CERTIFICATE OF DEATH

(%°»s« IIor.oTiospital

f Toothy “ Jo's 0pE"" i^lllvah 5t‘ 1 give its NAME instead of street and number)

f at u. s. Spanish

Registered No.

| (If death occurred in a hospital or institution.

(If deceased is a mai0g£, 4* dfvjoQgl(Avoman, give also maiden name.) Winthro tyStfiSSs

(a) Residence. No St

(Usual place of abode) hOf? itc-. 1 *7 (If nonresident, give <§y or town and State)

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

(Before death) (Specify whether)

PERSONAL AND STATISTICAL PARTICULARS

TUflBA,Tfc OF DEATH

3 SEX

4 COLOR OR RACE!

5 SINGLE (write the wordL

married Marrisa

WIDOWED
or DIVORCED

18 DATE OF
DEATH

(Month)

(Day)

(Year)

5a If married, widowed, orKilvdr^ed^ • lltJ. i‘ o

19 I H S#5c E R 44-F Y , attended deoea45 from

im...., 19 45 , 19

HUSBAND of
(or) WIFE of

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

6 Age of husband or wife if alive

~69~

years

I last saw h alive on 9.2.3jQ9.p.« death is said to

have occurred on the date stated above, at m.

7 IF STILLBORN, enter that fact h

-74

AGE Years

If less than 1 day

Usual

9 Occupation :

:>t.lr TT'^otjdI--a^!^

inutes

xj . S » Government

.Hyportenslon.&...hyp.er.t.ena.lv.e

Due to hear? t di.sease .. .... ...

Generalized art.erio sclerosl

2-iyp.s..

Industry

10 or Business:

none

Due to.

T1 Social Security No..

oaten »Kass ,

12 BIRTHPLACE (City)

(State or country) q*}

Other conditions

(Include pregnancy within 3 months of death)

13 NAME OF
FATHER

Major findings:
Of operations

OT 14 BIRTHPLACE OF
H ; FATHER (City)

z ; (State or country)

Ireland

Ddl^nical

CC j 15 MAIDEN NAME

< I OF MOTHER
Q-

-it

el-ett Birch ell

Of autopsy

What test confirmed diagnosis?
20 Was disease or
If so, specify

Physician

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

deceased?..

16 BIRTHPLACE OF
MOTHER

“Ireland-

(State or

r&cgflorn* Kane Heap.

ir injury in any w$y related to occupation of

Samuel S.Groonsteln

(Signed) S.O.ldi.Qr.a.’ lORM*. ffS. M. 8 5

(Addre^t y Josephs v Qlrt w- lyW<M 111 19

Informant

(Address)

^ Relation, if any ^

21 PLACE OF BURIAL, JowA 1945

CREMATION OR REMOVAC .*“*.•

(Cemetery). (City or Town)

DATE OF BURIAL JoUtl 1 ...0 ■ L& lQy 19

22 name of 79 AtlfiHEltf" St .’“irithrop

FUNERAL DIRECTOR

A TRUE COPY.
ATTEST:

fRegi/trar fU C£ty or town \yfere death occurn

ADDRESS

ed)

DATE FILED ' 19

Reoeived and filed f. -....L 19

/Rnflricfror rtf Gifu np Tnurn u/hprA rlpppnQpH rpsidpH^

■

5 .^..^ILoCk

3 1 /(County)

l .

“j (City or Town) f

5 no. MCf. st.

r(ffbc QIomiiuin(ui-;tItIj of JHnssnrlyttsctts

OFFICE OF THE SECRETARY

DIVISION OF VITAL STATISTICS

MEDICAL EXAMINER’S
CERTIFICATE OF DEATH

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

Registered No.

(If death occurred iii a hospital or Institution,
(five its NAME instead of street and number)

2 FULL NAME

(If deceased is a ma

(a) Residence. No.

(Usual place of abode)

■x I r> \ / ^PHYSICIAN— IMPORTANT

Q...(/3AJLa^.lAJ^.^LS. J (Was deceased a OTXi

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

| U. S. War Veteran, Ur^yit
^ if so specify WAR)

- J

Length of stay: In hospital or Institution years months

(Before death) (Sppcify whether)

days.

(If nonresident, give city or town and State)
In this community yrs. mos.

days.

PERSONAL AND STATISTICAL PARTICULARS

3 SEX

Female

4 COLOR OR RACE

White

5 SINGLE (write the word)
MARRIED

WIDOWED w .

or divorced Married

5a If married, widowed, or divorced

HUSBAND of

<*) wife * ->.

(Husband’s name in full)

6 Age of husband or wife if alive years

7 IF STILLBORN, enter that fact here.

AGE J§A.. Years Months Days

If less than 1 day
Hours Minutes

Usual

9 Occupation :

Houaewif e

Industry

10 or Business:

At Home

11 Social Security No

12 birthplace (City) Worcester.

(Slate or country)

Maaa

13 NAME OF
FATHER

Albert Dorman

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

.IS.r.cester.

Nias a.

is maiden name Qertrude Robinson

OF MOTHER

16 BIRTHPLACE OF

MOTHER (City) AUgUSta

(State or country)

Maine

Informant Albert ...I «... .flouthirtek /

r A.i.ir.-~> 45 SLrenfr at., Wlnthrop

l_ HEREBY CERTIFY _thal a satisfactory standard certificate of death was
thp^buyla[ oy transit permit was issued:

filed With me BEFORE

^nature of Jneavof Board o

±-J..

Hcial Designation) (J /j (Date of Issue of Permit)

otli

MEDICAL CERTIFICATE OF DEATH

IS DATE OF
DEATH

(Month)

.3. - l.£9.£.

(Day) (Year)

19 I HEREBY CERTIFY that I have Investigated the death
of the person above-named and that the CAUSE AND MANNER thereof
was involved, state fully.)

f..£rfLv*_£l_ 7.

arenas fotlowji_(I^p injury

20 Accident, suioide, or homlolde (specify)

Date of ooourrenoa 19..

Where did
Injury occu/?

place?

Manner of
Injury

(Specify type of j>lace)

Nature of

Injury

While at work? Was there an autopsy?

21 Was disease or injury in an/\vay rotated tc
If so, specify

(Signed)

(Address)

to occupation of deceased?

(City or town and State)

Did Injury ocour In or about home, on farm, In Industrial plaoe, or In publlo

f.int.nr.^p.

22 Wiut.hr.op. W.iut.ur _

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

DATE OF BURIAL. .. Jun..... .8,.. JL9..i5 19

23 NAME OF

FUNERAL DIRECTOR

ADDRESS

Reoelved 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 offioer shall forthwith, after
the death of a person whom he has attended during his last illness, at the
request of an undertaker or other authorized person or of any member of
the family of the deceased, furnish for registration a standard certificate of
death, stating to the best of his knowledge and belief the name of the
deceased, his supposed age, the disease of which he died, defined as 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. 4 0, 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 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 purposes of this sec-
tion and of sections forty-five, forty-six and forty-seven of said chapter one
hundred and fourteen, tiie word ‘‘war” shall include the China relief ex-
pedition and the Philippine insurrection, which shall, for said purposes, be
deemed to have taken place between February fourteenth, eighteen hundred
and ninety-eight and July fourth, nineteen hundred and two, and the Mexi-
can border service of nineteen hundred and sixteen and nineteen hundred
and seventeen. G. L. Chap. 46, Sec. 10.

No undertaker or other person shall bury or otherwise dispose of a human
body in a town, or remove therefrom a human body which has not been
buried, until he has received a permit from the board of health, or its
agent appointed to issue such permits, or if there is no such board, from
the clerk of the town where the person died; and no undertaker or other
person shall exhume a human body and remove it from a town, from one
cemetery to another, or from one grave or tomb other than the receiving
tomb to another in the same cemetery, until he has received a permit from
the board of health or its agent aforesaid or from the clerk of the town
where the body is buried. No such permit shall be issued until there shall
have been delivered to such board, agent or clerk, as the case may be, a
satisfactory written statement containing the facts required by law to be
returned and recorded, which shall be accompanied, in case of an original
interment, by a satisfactory certificate of the attending physician, if any,
as required by law, 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
medical examiner shall make such certificate. If such a permit for the
removal of a human body, not previously interred, from one town to an-
other within the commonwealth cannot be obtained early enough for the
puipose, the certificate of death made as above provided and in the pos-
session 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 re-
moval, 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 it- agent, upon receipt of such statement and certificate, shall
forthwith countersign it and transmit it to the clerk of the town for regis-
tration. The person to whom the permit is so given and the physician cer-
tifying 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 re-
quire.— Chap. 114, Sec. 45, G. L., (Tercentenary Edition).

No undertaker or other person shall bury a human body or the ashei
thereof which have been brought into the commonwealth until he hat 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 per-
son appointed to have the care of the cemetery or burial ground in which
the interment is made. ... Chap. 114, Sec. 46, G. L., (Tercentenary Edi-
tion).

Medical examiners shall make examination upon the view of the dead
bodies of only such persons a» 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.

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

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

RULES OF PRACTICE

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

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

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

(RI Medical Examine” 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
Medical Examiners in certifying to a death will state the cause and
manner thereof, and will specify: (1) Under cause, the nature of an injury
and of its consequences; and (2) under manner, the mode of its production
together with the circumstances when these are known. For example: “Com-
pound fracture of the femur with ensuing septicemia (gas bacillus) caused
by a steam railway accident.” “Pistol shot wound of the chest with asso-
ciated hemorrhage, homicidal.” “Asphyxiation by suspension, suicidal.”
“Syncope while under the influence of ether administered as a surgical
anaesthetic." “Fracture of the skull with associated internal injury sus-
tained under circumstances unknown.”

If disease or injury was related to occupation, specify. If investigation
shows the death to have been due to disease, specify: (1) Under cause its
known or presumable nature; and (2) under manner, indicate the circum-
stances leading to medico-legal inquiry. For example: “Hemorrhage spon-
taneous of the brain (basal ganglia) (found dead in bed).” “Heart disease,
presumably coronary sclerosis. (Sudden death.)”

DESCRIPTION (for unknown person)

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

THIS CERTIFICATE CONSTITUTES SUCH PERMIT

_ - -- -

60m (e)-l-41-4667

-302

Bris tol

(County)

Pall River

(City or Town)

No.

Pall Hlver

(City or town making return)

leglstered No *3..

Roc e E&v/thom© La t hr op Hospital C If death occurred in a hospital or institution,

St. | gjve ;ts NAME instead of street and number)

®he (Ecimmmt&ii'altlf of Massachusetts

OFFICE OF THE SECRETARY

DIVISION OF VITAL STATISTICS

COPY OF

CERTIFICATE OF DEATH

Margaret A* beagle foru. s.

2 FULL NAME .. ^ War Veteran.

(If deceased is a married, widowed or divorced woman, give also maiden name.) 1 specify WAR)

(., Residence. Re £3 FsiTVieW s, | Wh %«.

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

Length of stay: In hospital or Institution year*

(Before death) (Specify whether)

‘ months

2Q,

ays.

In this oommunity

yrs.

day*.

PERSONAL AND STATISTICAL PARTICULARS

3 SEX 4 COLOR OR RACE

Female White

5 SINGLE
MARRIED
WIDOWED
or DIVORCED

(write the word)

Single

5a If married, widowed,
HUSBAND of

or divorced

(or) WIFE of

(Give maiden name of wife in full)

(Husband’s name

in full)

6 Age of husband or wife if alive

7 IF STILLBORN, enter

that fact here.

s 85

AGE LL... Years

Months Days

If less than 1 day
Hours Minutes

Usual

housework

Industry

uwn iiuL'it

Ti Social Seourity No.

12 BIRTHPLACE (City)
(State or country)

xiurniw

13 NAME OF
FATHER

Could

not

learned

14 BIRTHPLACE OF

FATHER fCitvl .

(State or country)

15 MAIDEN NAME

OF MOTHER

16 BIRTHPLACE OF
MOTHER (City)

(State or country)

a. l,-,.

i»

gce-

Y intbrop* Katas,

^ Relation, if any ^

DATE FILED

MEDICAL CERTIFICATE OF DEATH

18 nrA/TEM0F January 4 , 1945

(Month) (Day)

(Tear)

19 I Hrfr/^E SlYj. £ E R TA,f. Y
9 19..

Jjhat .l^att&ided deoeased f/t>i*Tv
19

, ... h. mii',. r —

have occurred on the date stated above, at m

Immediate cause of death

Cancer of left breast

Oue to..

Due to..

Duration

5..yr.!

Other conditions

(Include pregnancy within 3 months of death)

Physician

Underline

Major findings:

Of operations the cause to

which death

Date of -hould be

charged *ta-

: -Ic 1 X) ncoplc listically.

What test confirmed diagnosis? r I

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

„ „ no

If 80, speolfy..

Of autopsy..

(Signed) •>••••. /*• O.

■■16fe..oCw....jSai ns** l/£/ 45

(Address)

21 yC..; ... Sale i, ■

iflEnSabei;. 6. I’SfcT**

Hov;a r d ^ • R & yno Id S

DATE OF BURIAL

22 NAME OF

FUNERAL DIRECTOR
AOORESS ’.T"

tWpop 0 Mas s.

Received and filed 19

|H||

(Registrar of City or "Tbwn where deceased resided)

R £ C E 1 V ‘

•strict* from the laws on back ot certificate.

It deceased wn a U. S. War Vstsran, Q. L. Chap. 46. Saotlon 10, requires phytlolans to Insert a reoital to that effeot.
IDO M- C -2-4 2 -BBSS

•301

Suf folic

(County)

o Ilut.ar.aa

“J (City or Town)

j No.

'•a.

®ttr (Utmuttcmforalilt of

OFFICE OF THE SECRETARY

DIVISION OF VITAL STATISTIC*

STANDARD

CERTIFICATE OF DEATH

To be tiled for burial permit
with Board of Health

or its Agent.

151 Lincoln JJfc . t | (If death occurred in a hospital or Institution,

Registered No.

red in a hospital
give its NAME instead ot street and number)

.Sl

2 full i»auc Bent £ay F. Healey I - important

(If deceased 19 a married, widowed or divorced woman, give also maiden name.) | *-*. S. War Veteran,

^ if so specify WAR)..M.V.n.S:

(a) Residence. No 15X...LtaC0lja....Sf.».y SL

(Usual place of abode)

Length of stay: In nnsoltal nr Institution

(Refnre death) (Specify whether)

years

months

days.

(If nonresident, give city or town and State)

In this community ^.J^yrs, mos, days.

PERSONAL AND STATISTICAL PARTICULARS

MEDICAL CERTIFICATE OF DEATH

3 SEX

Male

4 COLOR OR RACE

Wni te

SINOLE (write the word)

MARRIED

WIDOWED

or oivorced Married

18 d°eaTtEh0F Jan... s ,. 1945

(Month)

(Day)

(Year)

5a If married,

19 I HEREBY CERTIFY,

That I attended deoeased from

HUSBAND
(or) WIFE of

(Cive maiden name of wife in full)
(Husband's name in full)

I las1

, 1 9.U.£...., -to ..^T.LrtriA 6. 19&£...

ir law h...Lrv^. alive on ^.C2Ua..«...6. 19.HL, death is said to

6 Age of husband or wife if alive pT yearsl

have occurred on tho date stated above, at S m.

Immediate oauae of death..

*1 IF STILLBORN, enter that fact here.

SoeM. Years

Months

200a

If less than 1 day
Hours Minutes

Usual

9 Occuoaticn:

R= 1 1. r.etl .

Oue to .

Industry _ . , . .

10 or Business: .CliA'.ldr.0i4a...lli$).l0y.eP..

Oue to..

11 Social Security No UOT1 A .

12 BIRTHPLACE (City) ItQCiUL&UCL

( Slate or country)

Maine

Other conditions..

( Include pregnancy

k*T..

in 3 months of death)

13 NAME OF

father Oscar Healey

Major findings:
Of operations .

14 BIRTHPLACE OF

FATHER (City) .
(State or country)

Rocicland

Date of..

Maine

15 MAIOEN NAME

of mother Elvira Hosier

Of autopsy

What test confirmed diagnosis? ..

Duration

••iM+'QfPfANT

IMPORTANT ,
Physician

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

16 BIRTHPLACE OF

MOTHER (City) .
(State or country)

Roctciand

20 Was disease pr injury in any way related to oooupatlon of deoeased ? LLttT'
If so, $peoify.....7. .. A

(Slgned)..7X-af^i_<_*a Xfc:. M. D.

Maine

q *a .0...9 M.

( Address) t.XS...p.:^,4^C<i<rfnf....S%.i Oate...ftSU»e..jp. 19 #ji~

Informant Etnal W. Healey. ( W’ M ‘ny

(Address) iji Lincoln St.'. a/..

21 .Wi.nt.ur.Qi>. QSMm

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

DATE OF BURIAL... J.&tt. ...... IQ. ».. .19.45 W

I HEREBY CERTIFY that a satisfactory standard oertlfloata of death was
(lied ^Ith BEFORE the burial or transit permit wat Issued!

(Sifiiaiiire of of Board oil nr othft) /

/.Lb./.

(Official Deslgnationf// / (Date of I«eue of /Permit

22 NAME OF

FUNERAL DIRECTOR

address ..1.47....Iiia.t!ur.o.jri....S.t..* , ...Wimorap. _..

Reoeived and Nled..

V u\piei tees /

extracts from the laws OF the
COMMONWEALTH OF MASSACHUSETTS
GOVERNING THE

return of certificates of death

r-rtitUrid hosDital medical officer shall forthwith, after
f £r"n whom he his .ttUd during hie Let illness. at the
the death of a person wnom «.r person or of anv member of

requeel of an u'idert.ker or othe_^ ( <Unrt,rd certificate

^riie best of his knowledge and belief the name of the
death ... Gen. Laws, Chap. 46, Sec. 9.

humlred and fourteen, the word war ►h»l.,1"cl', e ‘ e , he

can border service of nineteen hundred and sixteen and nineteen bund
•nd aeventeen. G. L. Chap. 46, Sec. 10. .... . .

No undertaker or other peraon shall bury or otherwise dispose of a human

KfS M3U1TS1? aWW &vS

£SS Ss. ~h= rvsi rsu-JST.wa lag

tomb to^ another in the same cemetery, until he has received,, perrmt from

where” the bod^U* burfed!* No^ch permit shall be issued until there shall
Sve been delivered to such board, agent or clerk, as the case may be.
a satisfactory written statement containing the facts required by l*w
returned and recorded, which shall be accompanied, in case of an original
interment by a satisfactory certificate of the attending .physician, if any,

I* there'^^no^tUmding 'phvsfieianf mr* if^ for^uthcient 8reasm!^*h\Vcenrfl^a?e

c?an°»hoe ia^j^membm^of *theU boari/1 o'ffi emp* & 'the

quired'^n? ihe" a t^endhlg^phy stcfan. **1? death' f^ca^ed'^^vUitenw^'tl^^Mlj
cal examiner shall make such certificate. If such a permit for the removal
ot a human body, not previously interred, from one town to another within
the* commonwealth cannot be obtained early enough for the purpose, the
^rtiflcate of death made as above provided and in the possession of the
undertaker desiring to make such removal shall constitute a permit for
mch removal! prodded, that such body shall be returned to the town from
which it was removed within thirty-six hours after such removal mdes.
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

hv section ten of chapter forty-six, that the deceased served In tne aray,
na»y*or Marine rorpsof the United State, in any war in which it ha, been
engaged, such recital shall appear upon the permit. The board I of '
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 oiher necea-
gary information which can be obtained as to the deceased, or as to the
manner or cause of the death, which the clerk or registrar uiay require. —
Chap. 114. Sec. 4 5. G. L„ (Tercentenary Edition).

No undertaker or other person shall bury a human body or the ashea
thereof which have been brought Into the comnionwealih until he has re-
ceived a ireriitit so to do from the board of health or its agem appointed to
issue such permits, or if there is no such board, from the clerk of the town
where the bodv 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. 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 Ins county the Imdy
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 phyaiolana will certify to such deaths only as those
of persons 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 is needed.

(*) Medloal Examiners will investigate and certify to all death* tup-
posably due to injury. These include not only deaths caused directly oi in-
directly by traumatism (including resulting septicemia), and by the action
of chemical (drugs or poisons), thermal, or electrical agents, and death*
following abortion, but also deaths from diseasa resulting from injury or
Infeotion related to oooupatlon, the sudden deaths of persons not disabled
by reoognized disease, and those of persons found dead.

Statement of Cause of Death. — Cause of death means the disease, or
complication which cauaea 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 ia very im-
portant, so that the relative healthfulnesa of various pursuits can be known.
Make some entry in this section for every persou aged 10 years or over.
If the occupation had been given up or changed on account of the disease
causing death, report the usual occupation prior to illness. If the deceased
had retired from business, report the usual occupation prior to retiremenL
Children not gainfully employed may be returned as at school or at home.
For a woman whose only occupation was that of home housework, write
housework. For a person engaged in domestic service for wages, however,
designate the occupation by the appropriate terms, at housekeeper — -private
family, cook — hotel, etc. For a person who had no occupation whatever
write none.

SPACE FOR ADDITIONAL INFORMATION

200ra-I0-’39. No. 8427-d

\£

42 .

^ Tac

tHIfe Commonfnealtfj af ,jSfcr9BaeIfKMii*
OFFICE OF THE SECRETARY

DIVISION OF VITAL STATISTICS

STANDARD

CERTIFICATE OF DEATH

(City or town making return)

Registered No

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

(II V. S.

Woi Veto'rm. jyy _
specify WAR) 'LG......

2 FULL

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

(a) Residence. No. dze.: .^St.

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

ength of stay: In hospital or institution --years - months e) days. In this community 7*. yrs. mos.-^ days.

(Specify whether) octy

PERSONAL AND STATISTICAL PARTICULARS

3 SEX

4 COLOR OR RACE

S SINGLE
MARRIED
WIDOWED
or DIVORCED

(write the word)

5a If married, widowed, or divorced
HUSBAND of

(or) WIFE of...

(Husband’s ffode in full)

G Age of husband or wife if alive /£>■ . years

7 IF STILLBORN, eater that fact here.

AGE

..Years Months..

Usual

9 Occupation:

..Days

Ii less than 1 day
Hours Minutes

1G SrtKS— rs

11 Social Security No

12 BIRTHPLACE (City)

(State or country)

13 NAME OF '—7-'#

FATHER / £c<T14*.<Z<L.

14 BIRTHPLACE OF

FATHER (Citvl

— //

(State or country)

15 MAIDEN NAME<^3> *
OF MOTHER

16 BIRTHPLACE OF

MOTHER (City)

V^,^T .

(State or country)

Informant ^
(Address)

6 / to A>£Z

HER

CERTIFY that a satisfactory standard certificate of death was
"'"'ORE the J»urlal or transit permit was issued:

Board of H<^thi\S£bther

Ljlfc/M-

(Date of Issue of Permit), ' '

DEATH

(Year)

ME 6 Y CERTIFY, ThaO I attended deceased from

L.fZ i9...7^to 7.....^ wk.X'

1 last sat eatb is said

to have

22 NAME

FUNERAL DIRECTOR L. ..

ADDRESS

City/oc'Town) . _

'koJL

Received and filed

A TRUE COPY ATTEST: '

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. 46,
G. L., (Tercentenary Edition.)

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

RULES OF PRACTICE

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

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

(2) Hoard of Health physicians will certify to such deaths only

as those of persons who, though disabled by recognized disease un-
related to any form of injury, have died without recent medical
attendance or whose physician is absent from home when the
certificate of death is needed. ,

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

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

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

SPACE FOR ADDITIONAL INFORMATION

cuj wr iu»u iu

R-302

U-

'-0.

x-ssex

(County)

Danvers

(City or Town)

no. ...Danvers £.t.a..t.e HQ.s.p.i.t.al . si. j

tUlje (Emttmtmfbraltlf of JWasBacljttsetis

OFFICE OF THE SECRETARY

DIVISION OF VITAL STATISTICS

COPY OF

CERTIFICATE OF DEATH

Danver s

(City or town making return)

Registered No.

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

2 FULL NAME.

?.avis f rto™.

(If deceased is a married, widowed or divorced woman, give also maiden name.) 1 speoify WAR)

, . _ „ 249 Lahore Drive .. Winthrop^

(a) Residence. No SL .-ft.

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

Length of stay: In hospital or Institution years months 7 days.

(Before death) (Specify whether)

In this oommunlty

days.

PERSONAL AND STATISTICAL PARTICULARS

MEDICAL CERTIFICATE OF DEATH

3 SEX

male white

4 COLOR OR RACE

5 SINGLE (write the word)

MARRIED

WIDAWfiB-rj ed

18 ddeaaTth0F . Jan .... 8 , 1945

(Month) (Day) (Year)

&*Maxy. B.<j

(Give maiden name of wife in full)

(or) WIFE of

(Husband's name in full)

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

19 I HEREBY CERTIFY, That I attended deoeased from

e J.&xu I 19 45, toJj&Jl* feU v, 19....4.5

I last saw h iffi.. alive on Jan . _ 8 5(|eaih Is said to

have occurred on the date stated above, at..<ff..T...^.^ m.

7 IF STILLBORN, enter that faot here.

'Tr£e r io sfcdlae 'vo'tid he art di'sea^e"

i r-IBG-,

AGE ^..+Years

ei>

Months..

..Days

If less than 1 day
Hours Minutes

Due to..

usual Manufact urer

9 Oooupatlon:

Industry

10 or Business:

Fire works

Due to..

11 sooiai security no cannot b.e le.ajxie.5I

12 BIRTHPLACE (City) l h})..B Q.St.Q.h

Other conditions

(Include pregnancy within 3 months of death)

(State or country)

13 NAME OF
FATHER

Warren Davis

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

Bolton

Canada

15 MAIDEN NAME
OF MOTHER

Ellen Cragg

16 BIRTHPLACE OF
MOTHER (City)

Milton

(State or country)

Major findings:
Of operations..

Date of .

Physician

Underline
the cause to
which death
should b e

, charged sta-

Of autopsy .. ,,

Clinl Cfii tiatically.

What test oonfirmed diagnosis? .Y±.±.....±..r’.“±..

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

If so, speoify.pa.s.„.a.a.^.e.....g.u.0.n.i..c.on.t.0

(Sioned > -• "Dali 1/12* M*4Ife

Duration

Relation, if any

jar;-

(Address) Date..

21 place of BURiA’uinthrc p in throp

CREMATION OR REMOVAL 5.

(Cemetery) n / T 1 / ^yCity or Town)

DATE OF BURIAL ... 19

DATE FILED

1^7^‘ty

22 NAME OF

FUNERAL DIRECTOR

ADDRESS

JotUl'F. c; •Malay

or town where death occurred)

19 .

Reoeived and filed 19

(Registrar of City or Town where deceased resided)

101

-J

•3

u v

1 I

° 3

o jfc

3 «

a b

a a

; i

1 a

K (City or Town) r w

®lje <Eotmtu>nbcaItl{ of ^laesaclftwfti*

OFFICE OF THE SECRETARY

DIVISION OF VITAL STATISTICS

STANDARD

CERTIFICATE OF DEATH

(City or town making return)

Registrar’* No.

3 FULL NA

(a) Residence. No,

(Usual place of abode)

gt ( (If death^occurred in a> hospital or institution,

l i

give its NAME instead of street and number)

(If deceased is a m^Fied, widowed or <Jj,vorced woman, give

PHYSICIAN— IMPORTANT

(Was deceased a

U. S. War /eteran,

if so specify WAR)

Length of stay: In hospital or Institution

(Before death)

(Specify whether)

years

months

days.

:, give city or town and State)

In this community vj* yrs. mos. days.

PERSONAL AND STATISTICAL PARTICULARS

3 SEX

4 COLOR OR RACE

5 SINGLE (write the word)
MARRIED v. »

WIDOWED <<i t,

18 DATE OF
DEATH _

MEDICAL CERTIFICATE OF DEATH

A; CtflUtll-l.

or DIVORCED

(Month)

(Day)

1 -

(Year)

5a If married, widowed, or divorced
HUSBAND of

EREBY CERTIFY

That I attended deceased from

i9.

t Age of husband or wife if alive

<2?-^rL

7, 19^ , to ft* ,

I last’ saw h t\' alive on — j — Ijr, 19 , death is said to

have occurred on the date stated above, at U-3& pc M

7 IF STILLBORN, enter that fact here.

Years-O^ Months^f^^

AGftrf.

Days

If less than 1 day
_Hours Minutes

Immediate cause of death

-SLc>.y ?* t a YnD

OtilQ

Usual
9 Occupation :

Due to_

Industry
10 or Business:

Due to-

ll Social Security No

her conditions-

(Include pregnancy within 3 months of death)

Major findings:

’ ~f operations-

-Date of-

Of autopsy-

What test confirmed diagnosis 7-

Duration

IMPORTANT

fit

IMPO

T-

IMPORTANT

Physician

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

Informant -
(Address) J

Relation, if any

I HEREBY CERTIFY that a satisfactory standard certificate of death
wa*,fila4^ with jjrt BI^FTDRIJ the buYial or transit permit was issued:

Sl '

Boar

lesignatlom)

20 Was disease or injury in any way related to occupation of deceased
If so. aoecifv . * ^ 1

fSigneHl TO-Vtl j

uhrajUlA><U*J

+ , M T)

(Address) ll A.

P Tl

r- V wftcX-

si q ./ 1

Date. iU an : 19 --

21 13&UUL iULAta*

m.7 ‘i"?j

Place of Burial, CrematiiM or
- DATE OF BURIAL____J|i

Removair

(City or Tows) Vg,.^

o iTj^F

22 NAME OF Z<&

FUNERAL DIRECTOR OL7

rj$ QJLl .

ADDRESS

g^--^sgtrfz.

Received and filed

A TRUE COPY ATTEST:

(Registrar)

EXTRACTS FROM THE LAWS OF THE
COMMONWEALTH OF MASSACHUSETTS
GOVERNING THE

RETURN OF CERTIFICATES OF DEATH

A physician or registered hospital medical officer shall forthwith, after
the death of a person whom he has attended during his last illness, at the
-equest of an undertaker or other authorized person or of any member of
he family of the deceased, furnish for registration a standard certificate
>f 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-
luired by section one, where same was contracted, the duration of his last
llness, when last seen alive by the physician or officer and the date of
lis death . . . Gen. Laws, Chap. 46, Sec. 9.

A physician or officer furnishing a certificate of death as required by the
receding section or by section forty-five of chapter one hundred and four-
;een, shall, if the deceased, to the best of his knowledge and belief, served
n the army, navy or marine corps of the United States in any war in which
t has been engaged, insert in the certificate a recital to that effect, speci-
ying the war, and shall also certify in such certificate both the primary
ind the secondary or immediate cause of death as nearly as he can state
he same. For neglect to comply with any provision of this section, such
ihysician or officer shall forfeit ten dollars. For the purposes of this sec-
ion and of sections forty-five, forty-six and forty-seven of said chapter
ine hundred and fourteen, the word “war” shall include the China relief
ixpedition and the Philippine insurrection, which shall, for said purposes,
>e deemed to have taken place between February fourteenth, eighteen
mndred and ninety-eight and July fourth, nineteen hundred and two, and
he Mexican border service of nineteen hundred and sixteen and nine-
een hundred and seventeen. G. L. Chap. 46, Sec. 10.

No undertaker or other person shall bury or otherwise dispose of a human
lody in a town, or remove therefrom a human body which has not been
turied, until he has received a permit from the board of health, or its
gent appointed to issue such permits, or if there is no such board, from
he clerk of the town where the person died; and no undertaker or other
lerson shall exhume a human body and remove it from a town, from one
emetery to another, or from one grave or tomb other than the receiving
orab to another in the same cemetery, until he has received a permit from
he board of health or its agent aforesaid or from the clerk of the town
rhere the body is buried. No such permit shall be issued until there shall
lave been delivered to such board, agent or clerk, as the case may be,

. satisfactory written statement containing the facts required by law to be
eturned and recorded, which shall be accompanied, in case of an original
nterment, by a satisfactory certificate of the attending physician, if any,
s required by law, or in lieu thereof a certificate as hereinafter provided,
f there is no attending physician, or if, for sufficient reasons, his certificate
annot be obtained early enough for the purpose, or is insufficient, a physi-
ian who is a member of the board of health, or employed by it or by the
electmen for the purpose, shall upon application make the certificate re-
uired of the attending physician. If death is caused by violence, the medi-
al examiner shall make such certificate. If such a permit for the removal
■f a human body, not previously interred, from one town to another within
he commonwealth cannot be obtained early enough for the purpose, the
ertificate of death made as above provided and in the possession of the
indertaker desiring to make such removal shall constitute a permit for
uch removal; provided, that such body shall be returned to the town from
vhich it was removed within thirty-six hours after such removal, unless
: permit in the usual form for the removal of such body has been sooner
ibtained hereunder. If the death certificate contains a recital, as required

by section ten oi chapter torty-six, mat the deceased served in the army,
navy or marine corps of the United States in any war in which it has been
engaged, such recital shall appear upon the permit. The board of health,
or its agent, upon receipt of such statement and certificate, shall forthwith
countersign it and transmit it to the clerk of the town for registration.
The person to whom the permit is so given and the physician certifying
the cause of death shall thereafter furnish for registration any other neces-
sary information which can be obtained as to the deceased, or as to the
manner or cause of the death, which the clerk or registrar may require. —
Chap. 114, Sec. 45, G. L., (Tercentenary Edition).

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

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

RULES OF PRACTICE

The fulfillment of the purpose of these laws 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 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, 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

If deceased was a U. S. War Vetsran, Q. L. Chap. 46, Section 10, requires physloians to Insert a reoital to that effeot.

101 A

No.

2 FULL NAME

(City or '

3 ±

®hc (JTonimoti&traHIt of ^fa^sarlptartt*
OFFICE OF THE SECRETARY
DIVISION OF VITAL STATISTIC*

STANDARD

CERTIFICATE OF DEATH

To bo filed for burial permit
with Board of Health

Registered No,

or its Agent, .

ill

iXL-

( (If death occurred in a hospital or institution,
”*• | jive its N All K instead of street and number)

ased is a married, widowed pr divorced woman, jive also J mait

. 3.U.. UlL&a use. w...Qdj.. ,.y>2e....:

(a) Residence. No.

(Usual place of abode)

Length of stay: In nnsoltal nr Institution

(Before death) (Specify whether)

PHYSICIAN - IMPORT^

(Was deoeased a /,') s*-,

U. S. War Veteran, if

so specify WARpO..C^^..jrj

(If nonresident, gTee-eity of town and State)

year* months days. In this community , - 0 yrs. mos. day*.

PERSONAL AND STATISTICAL PARTICULARS

MEDICAL CERTIFICATE OF DEATH

3 SEX - <* Lui-urt un

4 COLOR OR RACE

5 SINGLE
MA,
WIDOWED

18 DATE OF '71 _ / X » / ^

death J /.qtJTLX.

/ / (Month) (Thy) (Tear)

I HERLfir C E,.R T I F

.^19

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

V, /that

I attended deceased from
, 19.

*1 IF STILLBORN, enter that fact here.

I last saw h •^/'T.allve on......^:C zz. , death is said to

have occurred on tha data stated above, at .../&. m.

Immediate oause of death..

" PORTANT

zJA

Years Months Days

Usual

9 Occuoation:

If less than 1 day
Hours Minutes

Industry

10 or Business:

Due to

to7^..^^.Iv..T.....v **7^

ll Social Security No. ...

'2 BIRTHPLACE (Cily)
( Siste or country)

Due

Other condltlofis..

(Include pregnancy within 3 months of death)

13 NAME OF /

father^ AbfJ /VLAJJ Ae

0/(1 Q 0

14 BIRTHPLACE OF Y ‘
FATHER ( Cilv)

(State or country)

15 MAIDEN NAM SyAA

of mother

Major findings:
Of operations .

Of autopsy

What test confirmed diagnosis?.

IMPORTANT

Physician

Data of..

MOTHER (City)
(Staleor country)

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

If so, speoify

m. d.

fate i9...^J-

Place of Burial, Creniat,
DATE OF BURIAL.

or-Hemoval. (City or Town) v

19.^6

22 NAME OF

FUNERAL DIRKTOI

I HEREBY CERTIFY that a satisfactory standard oertifioate of death was
filed with me BEFORE the 6uri»T or transit permit was Issued:

/ / t® ^nature of Agent of Board of JfpaWf or other) ,

(Official Designation)!/ 7/ (hate of faeue of Pernili)

ADDRESS

Reoelved and died..

19..

( Registrar)

EXTRACTS FROM THE LAWS OF THE
COMMONWEALTH OF MASSACHUSETTS
GOVERNING THE

RETURN OF CERTIFICATES OF DEATH

A physioian or registered hospital medical offioer shall forthwith, after
the dealt) of a person whom he has attended during his last illness, at the
request of an undertaker or other authorized person or of any member of
the family of the deceased, furnish for registration a standard certificate
of deaih. slating 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 hia
death ... Gen. Laws, Chap. 4 6, Sec. 6.

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, sjieci-
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, fortv-si* and forty-seven of said chapter one
hundred and fourteen, the word “war” shall include the China relief ex-
pedition and the Philippine insurrection, which shall, for said purposes, be
deemed to have taken place between February fourteenth, eighteen hundred
and ninety-eight and July fourth, nineteen hundred and two, and the Mexi-
can border service of nineteen hundred and sixteen and nineteen hundred
and seventeen. G. L. Chap. 4 6, Sec. 10.

No undertaker or other person shall bury or otherwise dispose of a human
bodv in a town, or remove therefrom a human body which 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, 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 who is a member of the board of health, or employed by it or by the
selectmen for the purpose, shall upon application make the certificate re-
quired of Ihe attending physician. If death is caused by violence, the medi-
cal examiner shall make such certificate. If such a permit for the removal
of a human body, not previously interred, from one town to another within
the commonwealth cannot be obtained early enough for the purpose, the
certificate of death made as above provided and in the possession ot the
undertaker desiring to make 6uch removal shall constitute a permit for
such removal; provided, that such body shall be returned to the town from
which it was removed within thirty-six hours after such removal, unless
a permit in the usual form for the removal of such body has been sooner
obtained hereunder. If the death certificate contains a recital, as required

by section ten of chapter forty-six, that the deceased aerred in the army,
navy or marine corps of the I'nited States in any war In which It has been
engaged, such recital shall appear upon the permit. The board of health,
or its agent, upon receipt of such statement and certificate, shall forthwith
countersign it and transmit it to the clerk of the town for registration.
The person to whom the permit is so given and the physician certifying
the cause of death shall thereafter furnish for registration any other neces-
sary information which can be obtained as to the deceased, or a* to the
manner or cause of the death, which the clerk or registrar may require. —
Chap. 114. Sec. 46, G. L., (Tercentenary Edition).

No undertaker or other person shall bury a human body or the ashes
thereof which have been brought into the commonwealth until he has re-
ceived a permit so to do 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 Editiou).

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

RULES OF PRACTICE

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

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

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

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

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

Statement of Oooupation. — Precise statement of occupation is very im-
portant, so that the relative healthfulness of various pursuits can be known.
Make some entry in this section for every persou aged 10 years or over.
If the occupation had been given up or changed on account of the disease
causing death, report the usual occupation prior to illness. If the deceased
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 occupatiou was that of home housework, write
housework. For a person engaged in domestic service for wages, however,
designate the occupation by t J>e appropriate terms, as housekeeper — private
family, cook — hotel, etc. For a person who had no occupation whatever
write none.

SPACE FOR ADDITIONAL INFORMATION

I R-

§ S.u££qUk

W (County)

tElfe (Ecnruttunfitcalflj of ^Inssaaciptsett*
OFFICE OF THE SECRETARY
DIVISION OF VITAL STATISTICS

STANDARD

CERTIFICATE OF DEATH

(City or town making return)

-f H?

Registered No

o Winthrop

(City or Town)

< ■.)„+. tt_. _ 4 + oT I (W death occurred in a hospital or institution,

£ No /. .i.Q.If h 3C.Q.B Q.?....lID.WD..i.s'.X hQ. .§. P. j. .XtS X St. I sive its NAME instead of street and number)

Eft

2 full name. Elizabeth .H,....F^llram Hl.land j wle?y*\»ran.

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

(a) Residence. No £12

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

.Linc.Qln...S.i....

St. ...

(Specify whether)

years 1 months ^ days.

(If nonresident, givcdjty or town and state)

In this community 2 J yrs. m0s. days.

PERSONAL AND STATISTICAL PARTICULARS

3 SEX j 4 COLOR OR RACE

female I White

S SINGLE
MARRIED
WIDOWED
or DIVORCED

(write the word)

Marrlett-

5a If married, widowed, or divorced

HUSBAND of

JOhll Civejfcide^njeafrd6 in full)
(or) WIFE of ^>yti

(HusBana's* name in full)

6 Age of husband or wife if alive .

.6.9..

..years

7 IF STILLBORN, enter that fact here.

If less than 1 day
Hours Minutes

Usual

9 Occupation: Housewife--

10 or

In<&83: Own Home.,

11 Social Security No.

12 BIRTHPLACE (City)

Bob ton

13 NAME OF

FATHER John

Fulham

14 BIRTHPLACE OF

FATHER (City)

(State or country)

Ireland

15 MAIDEN NAME

OF MOTHER Ellen

Leonard

16 BIRTHPLACE OF

MOTHER (Citv)

(State or country)

Ireland

Informant... John Hi.la.nd.

(Add^) LlnccOBu^

I HEREBY CERTIFY that a satisfactory standard certfficate of death was
Hied /rith me BEFORE the burial or transit permiLiwas Issued:

ADDRESS ....

MEDICAL CERTIFICATE OF DEATH

18 DATE OF
DEATH

7SZZZM?

(Day) (Year)

BY CERT UFX • lTbat I attended deceased from

., 19...^

I last saw h...cC&LaIive on 19.H/^fc death is said

to have occurred on the dat^itated above, at..^.*../JD$in.

Immediate cause

Due to S

Other conditions

(Include pregnancy within 3 months of death)

Major findings
Of operations

ate

oU±/±uy..^

Of autopsy

What test confirmed diagnosis ? .

PHYSICIAN

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

20 Was disease or Injury lo any way related lo occopatlon ol deceased T ....

If to, specify..

(Signed) I y. M. D.

19 S/.C

— Wlnthrop — fflnthitfep

•/•

Place of Burial, Cremation or Removal^

DATE OF BURIAL JaD* ../Jkjg.,,

22 NAME OF

FUNERAL DIRECTOR

Received and filed

a" TRUE ' CO W ATTEST:

-•»

(Registrar)

EXTRACTS FROM THE LAWS OF THE

COMMONWEALTH OF MASSACHUSETTS

GOVERNING THE

RETURN OF CERTIFICATES OF DEATH

No undertaker or other person shall bury or otherwise dispose of a
human body in a town, or remove therefrom a human body which
has not been buried, until he has received a permit from the board
of health or its agent appointed to issue such permits, or if there
is no such board, from the clerk of the town where the person died ;
and no undertaker or other person shall exhume a human body and
remove it from a town, from one cemetery to another, or from one
grave or tomb other than the receiving tomb to another in the same
cemetery, until he has received a permit from the board of health or
its agent aforesaid or from the clerk of the town where the body is
buried. No such permit shall be issued until there shall have been de-
livered to such board, agent or clerk, as the case may be, a satisfac-
tory written statement containing the facts required by law to be
returned and recorded, which shall be accompanied, in case of an
original interment, by a satisfactory certificate of the attending
physician, if any, as required by law, or in lieu thereof a certificate
as hereinafter provided. If there is no attending physician, or if, for
sufficient reasons, his certificate cannot be obtained early enough for
the purpose, or is insufficient, a physician who is a member of the
board of health, or employed by it or by the selectmen for the pur-
pose, shall upon application make the certificate required of the at-
tending physician. If death is caused by violence, the medical exam-
iner shall make such certificate. If such a permit for the removal of
a human body, not previously interred, from one town to another
within the commonwealth cannot be obtained early enough for the
purpose, the certificate of death made as above provided and in the
possession of the undertaker desiring to make such 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 ns to the deceased, or as to the manner or cause of the
death, which the clerk or registrar may require.— Chap. 114, Sec. 46,
G. L., (Tercentenary Edition.)

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

RULES OF PRACTICE

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

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

(2) Board of Health physicians will certify to such deaths only

as those of persons who, though disabled by recognized disease un-
related to ar.y 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
sapposably 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 Causo of Death. — Cause of death means the disease,
or complication which causes death, not the mode of dying, e. p.,
heart failure, asphyxia, asthenia, etc. As principal cause name the
disease causing death. As related causes, name earlier morbid con-
ditions, if any, related to the principal cause and any important
complication of the principal cause.

SPACE FOR ADDITIONAL INFORMATION

•strict* 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.

•301 A

V.Q.

Suffolk

(County)

.Wi.jft6Jur.oj?

(City or Town)

tUbr CToitimoti&traHIt of (iftasssrlfttsrtfa
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.

4 o

JL.-W-

Registered No

u. fih WonHai oa ir® ( (It death occurred In ■ hospital or Inatltution,

No. - 51. j ?(ve jti NAME instead of street and number)

2 FULL NAME.

J JEWS'* ^portant

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

(a) Residence. No JS.Ci....WQfi.filS.i.a.fe...AY..e..a., St

(Usual place of abode)

/(£?.
1 U. S.
^ if ao

War Veteran,
apeoify WAR) HOZ1S •

Length of stay: In hospital nr Institution

( Before death) (Specify

rhether)

yeara

months

days.

(If nonresident, give city or town and State)
in this oommunity rs. mos. days.

personal ano statistical particulars

MEDICAL CERTIFICATE OF DEATH

3 SEX

Male

4 COLOR OR RACE

Whi u e

5 SINGLE (write the word)
MARRIED
WIDOWED

or divorced Married

IS DATE OF T 1Cl 1C ,,-

DEATH Jan* .4?.j....l.S.'io..

(Month)

(Day)

(Year)

5a If married, widowed, or diaorced _ . . ,

husband of FlftfeAi.e. Thoeup.aQn...^^

(Give maiden name of wife in hill)

(or) WIFE of

(Husband’s name In full)

....59.

19 l,H ER EB Y CERTIFY, That I attended deoeased from

6 Age of husband or wife if alive

years

».w.£.£..A#?.., 19..^.., /..f...., 19

I last saw h....Uri.r).. alive on 19 ;Jj"death Is said to

have occurred on the date stated above, at !p.r&.40fi..m.

*1 IF STILLBORN, enter that fact here.

Immediate oause of death..

8 rj A o , r, I If less than 1 day

AGE (.7m. Years ..£.... Months ltd Days I Hours Minutes

Usual _

9 Occuoation: Iie.t IX.e.d..

S.Jc.r..«.!»..i.s

Due to

Industry

10 or Business:

Brito.....C.oai9k

Due to .

11 Social Security No. p Q 1 i (? -

Other conditions..

(Slate or country)

Nova. Scotia.

13 NAME OF

father James

Henry

£L:ith

14 birthplace of

FATHER ( Citv)

(State or country)

No/a

Scotia

15 MAIDEN NAME
OF MOTHER

Mary Orchard.

16 BIRTHPLACE OF

MOTHER fCitv)

(Slate or country)

No/a

Scotia

(Include pregnancy within 3 months of death)

Major findings:
Of operations.

Date of..

Of autopsy

What test confirmed diagnosis?.

Duration

lALHOaXAMT

#«•'

IMPORTANT i
Physician

L’nderline
the cause to
which death
>houl<l h e
charged sta-
tistically.

20 Was disease or injury in ony
If so, speoify

(Signed)
(A

eoity.....^« j

ned ) ..... ^.A.M7%ArfsL.
ddfess)

' , . _ . . Relation, If any

Informant I.lQj^la...I..,....Sua tA ( WlX© )

(Address) COKOOgSiasli/e ■ , nuw\f66

M. D,

21 ..£urLfc.i&.»....Lam..~^ .31

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

DATE OF BURIAL J.*a.e....22.,...l&.*& 19.

to oooupation of deoeased ? fll.i.?.

iff

22 NAME OF

FUNERAL DIRECTOR^. , . „ , „

address 1*7 W-nturop St . , Wintnrop

Reoeived and filed

(Registrar)

EXTRACTS FROM THE LAWS OF THE
COMMONWEALTH OF MASSACHUSETTS
GOVERNING THE

RETURN OF CERTIFICATES OF DEATH

A physioian or registered hospital medical offioer shall forthwith. after
ie death of a person whom he has attended during his last illness, at the
*i|uesl of an undertaker or other authorized person or ol any member of
he family of the deceased, furnish for registration a standard certificate
f death, stating to the best of his knowledge and belief the name of the
eceascd, his supposed age, the disease of which he died, defined ae re-
uired by section one. where same was contracted, the duration of hia last
1 1 ness, when last seen alive by the physician or officer and the date of hia
eath . . . Gen. Laws, Chap. <6, Sec. 9.

Al physician or officer furnishing a certificate of death as required by the
receding section or by section forty-five of chapter one hundred and four-
een, shall, if the deceased, to the best of his knowledge and belief, served
a the army, navy or marine corps of the I'nited States in any war in which
t has been engaged, insert in the certificate a recital to that effect, speci-
ying the war. and shall also certify in such certificate both the primary
nd the secondary or immediate cause of death as nearly as he can state
he same. For neglect to comply with any provision of this section, such
.hysician or officer shall forfeit ten dollars. For the purjioses of this sec-
ion and of sections forty-five, forty-six and forty-seven of said chapter one
lUinlred and fourteen, the word "war” shall include the China relief ex-
edition and the Philippine insurrection, which shall, for said purposes, he
leetucd to have taken place between February fourteenth, eighteen hundred
nd ninety-eight and July fourth, nineteen hundred and two, and the Mexi-
in border service of nineteen hundred and sixteen and nineteen hundred
>nd seventeen. G. L. Chap. 46, Sec. 10.

No undertaker or other person shall bury or otherwise dispose of a human
Kxjv in a town, or remove therefrom a human body which has not been
turied, until he has received a permit from the board of health, or its
igent appointed to issue such permits, or if there is no such board, from
he clerk of the town where the |>erson died; and no undertaker or other
terson shall exhume a human body and remove it from a town, from one
temetery to another, or from one grave or tomb other thau the receiving
;omb to another in the same cemetery, until he has received a permit from
;he board of health or its agent aforesaid or from the clerk of the town
vhere the body is buried. No such permit shall be issued until there shall
tave been delivered to such board, ageot or clerk, as the case may be,
l satisfactory written statement containing the facts required by law to be
etumed and recorded, which shall be accompanied, in case of an original
nterment, by a satisfactory certificate of the attending .physician, if any,
is required by law. oi in lieu thereof a certificate as hereinafter provided,
f there is no attending physician, or if, for sufficient reasons, his certificate
tannot be obtained early enough for the purpose, or is insufficient, a physi-
:ian who is a member of the board of health, or employed by it or by the
lelectmen 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
jf a human body, not previously interred, from one town to another within
ie commonwealth cannot be obtained early enough for the purpose, the
certificate of death made as above provided and in the possession of the
indertaker desiring to make such removal shall constitute a permit for
luch removal; provided, that such body shall be returned to the town from
which it was removed within thirty-six hours after such removal, unless
i 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 nr cause of the death, which the clerk or registrar may require. —
Chap. 114. Sec. 4 5, G. L., (Tercentenary Edition).

No undertaker or other person shall bury a human body or the ashee
thereof which have been brought into the commonwealth until he has re-
ceived a iiermit so to do front the board of health or its agent appointed to
issue such permits, or if there is no such hoard, from the clerk of the town
where the body is to be buried or the funeral is to he held, or from a |>erson
appointed to have the care of the cemetery or burial ground in which the
interment is made. ... Chap. 114. Sec. 46. G. L, (Tercentenary Editiou).

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 physioians will certify to such deaths only aa those
of persons who, though disabled by recognised disease unrelated to any
form of injury, have died without recent medical attendance or whose physi-
cian is absent from home when the certificate of death is needed.

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

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

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

Statement of Oooupation. — Precise statement of occupation is very im-
portant, so that the relative healthfulness of various pursuits can be known.
Make some entry in this section for every person aged 10 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 retiremeoL
Children not gainfully employed may be returned as at school or at home.
For a woman whose only occupation was that of home housework, write
housework. For a person engaged in domestic service for wages, however,
designate the occupation by tj)e appropriate terms, aa housekeeper — private
family, cook — hotel, etc. For a person who had no occupation whatever
write none.

SPACE FOR ADDITIONAL INFORMATION

If deceased was a U. S. War Veteran, G. L.. Chap. 4B, Sec. 10, requires physicians to insert a recital to that effect.

/■W

i A

Suffolk

(County)

No.

(City or Town)

51 A tlantlc St.

(Eummojtfoeaitlj of $&assatl]usztt%

OFFICE OF THE SECRETARY

DIVISION OF VITAL STATISTICS

STANDARD

CERTIFICATE OF DEATH

To be filed tor burial permit
with Board of Health
or It* Agent.

A O

Registrar’s No. A .3

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

Charles J. Tiews

2 FULL NAME

(a)

Length of stay: In hospital or Institution

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

{PHI

(Was
U. S.
if so

PHYSICIAN— IMPORTANT

deceased a
War Veteran,
specify WAR)

Residence. No. _

(Usual place“of~abode

(Before death)

(Specify whether)

years

months

days.

(If nonresident,

In this commun^P

yrs.

town and 5-tgte)

rass. days.

PERSONAL AND STATISTICAL PARTICULARS

MEDICAL CERTIFICATE OF DEATH

3 SEX

Male

4 COLOR OR RACE

White

5 SINGLE (write the word)
MARRIED
WIDOWED MPY’Tifil
or DIVORCED 1Vldl 1 -1 ™

18 DATE OF
DEATH _

(Year)

5a If married, widowed, or divorced _ _ ,

husband of Mary V . Sullivan xirew-s--

(Give maiden name of wife in full)

(or) WIFE of

(Husband’s name in full)

F last saw h

HERE VY C E R T I F Y i That I attended deceased from

19 I HERE yy C E R T I F
, to —

6 Age of husband or wife if alive_

~EJ..

19.

19.V.iSr death is said

7 IF STILLBORN, enter that fact here.

have occurred on the date(«tated above, a t.f.~0.» ^LM .

Immediate cause oi death

Years Months Days

If less than 1 day
Hours Minutes

Usual
9 Occuoa

Jtth

Industry
or Business:

U, s. Army

Social Security No.

—

12 BIRTHPLACE (Citv)

New York„

(State or country)

N.Y .

13 NAME OF
FATHER

Charles Tiews

14 BIRTHPLACE OF
FATHER (City)

New York

(State or country)

n. t;

15 MAIDEN NAME
OF MOTHER

Anna Miller

16 BIRTHPLACE OF
MOTHER (City)

New York

(State or country)

N. Y.

Due to-

Other conditions-

(Include pregnancy within 3 months of death)

Major findings:

Of operations

Date of

Of autopsy

What test confirmed diagnosis?-

IMPORTART

Physician

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

I nformant M& ry V

(Address)

Tantl

,ation, if any

20 Was disease or injury in any way related to occupation of deceased?-
If so, specify-

(Signed)— -4 — s > M. D.

(Address)

21 Wlnthrop

Place of Burial, Cremation
DATE OF BURIAL

Lr*$.. ~...i9 y£r

was filed with me BEFORE the burial or transit permit was issued:

I HEREBY CERTIFY that a^satis^actory standard certificate of death

t a .satisfactory standan

..QUldUm

t of Bi -----

(Signature of Agent of Board of Health or other)

(Lcua^T Qmax^M/

(Official l^signation) f~j (Date of Issfie 6f Permit)

22 NAME OF

FUNERAL DIRECTOR /..J

ADDRESS
Received and filed-

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 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 bh 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 forty-six, that the deceased served in the army,
navy or marine corps of the United States in any war in which it has been
engaged, such recital shall appear upon the permit. The board of health,
or its agent, upon receipt of such statement and certificate, shall forthwith
countersign it and transmit it to the clerk of the town for registration.
The person to whom the permit is so given and the physician certifying
the cause of death shall thereafter furnish for registration any other neces-
sary information which can be obtained as to the deceased, or as to the
manner or cause of the death, which the clerk or registrar may require. —
Chap. 114, Sec. 45, G. L., (Tercentenary Edition).

RULES OF PRACTICE

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

(1) Attending 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 fo occupation, the sudden deaths of persons not
disabled by recognized disease, and those of persons found dead.

Statement of Occupation. — Precise statement of occupation is very im-
portant, so that the relative heaLhfulness of various pursuits can he known.
Make some entry in this section for every person aged 10 years or over.
If the occupation had been given up or changed on account of the disease
causing death, report the usual occupation prior to illness. If the deceased
had retired from 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

•strict* from the laws on back of certificate.

If deceased was a U. S. War Veteran, G. L. Chap. 46, Seotlon 10, requires physlolans to Insert a reoltal to that effeot.

1-301

3 SEX

Female

jE Suffolk

ui (County)

Vfl-

...WintJaxap

(City or Town)

tUtir CHotmttotiforaHIt of (iHassarfptsetts
OFFICE OF THE SECRETARY
DIVISION OF VITAL STATISTICS

STANDARD

CERTIFICATE OF DEATH

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

Registered No

No. 41 S( | (If death iocewred In a hospital or Institution,

I five its NAME instead of street and number)

2 FULL NAME j (^Y«§5S>SF« ' IMP OR TAN 1

1 U. S.

^ if so i

(If deceased i9 a married, widowed or divorced woman, give also maiden name.)

(a) Residence. No .9 .*?. ... A SL

(Usual place of abode)

. War Veteran,
specify WAR).

Length of stay: In nosoltal or Institution

(Itefore death) (Specify whether)

yeara

months

days.

(If nonresident, give city or town and State)

In this oommunlty.^-^ yrs. mos. days.

personal and statistical particulars

4 COLOR OR RACE

White

5 SINGLE (write the word)
MARRIED
WIOOWED

or DIVORCED yj_a0 ^

5a If married, widowed, or divorced

- , JCive. maiden name of. wife in full)

(or) wife of . J. ohn...Le wi a . . whi.t.fcai£;e.r

(Husband's name In full)

6 Age of husband or wife if alive

y IF STILLBORN, enter that fact here.

AGE 7.P.... Years C. Months l.loays

If less than 1 day
Hours Minutes

9 Oecuoation:

Industry

10 or Business:

..JU-Howa-

11 Social Security No.

..UQH6..

12 BIRTHPLACE (City)

(S.sle or country) Ls.nCL

13 NAME OF
FATHER

Thomas Barrow

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

England

15 MAIDEN NAME

of MOTHEREli^abeth Robineon

16 BIRTHPLACE OF

MOTHER (City)

(State or country) England

informant. T..om...Wiiithr.Qp...Walfar.eBe(aarcti»

( Address!

Relation, it any

I HEREBY CERTIFY that a satisfactory, standard oertlfloata of death was
fllt^Wth me BEFOR^ the permit was Issued:

(Official Resignation)^ "III / (Rate of Issue of permit! /

MEDICAL CERTIFICATE OF DEATH

18 DATE OF

death Jan*....21, 194 &

(Month) * (Day)

(Year)

19 I HEREBY CERTIFY, /frhat I attended deceased from

, »>..//. ,

I last saw h..<=...Vr....allve on
have oocurred on the data sta<

Immediate oaus^ of death

.y.A.j, , 19 y.<L.

...yd:.c. 19 ^(0, death is said t«
fated above, at — T

Due to

SzajtZk.

Due to .

Other conditions..

(Include pregnancy within 3 months of death)

Major findings:
Of operations .

n: Date of .-...

Of autopsy ,

What lest oonfirmed diagnosis?

Duration

•liiBLMU AN T

IMPORTANT

Physician

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

20 Was disease or injury in ojiy way related t^ oooupatlon of deoeased

If so, specify .^.U. _

< Signed) M. D.

(Address)

21 ....W.iiiii.hr.Qit Winhl&Qp...

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

DATE OF BURIAL J/^n.a....£4>....lS.45.....

22 NAME OF

FUNERAL DIRECTO

_ ?L..ZZ.

ADDRESS St . • Winnrnr

Reoeived and Hied..

IIOIEii

19..

oia..

(Registrar)

JtM

EXTRACTS FROM THE LAWS OF THE

COMMONWEALTH OF MASSACHUSETTS

GOVERNING THE

RETURN OF CERTIFICATES OF DEATH

A physloian or registered hospital medical offioer shall forthwith, after
the dealh of a person whom he has attended during his last illness, at the
requesl of an undertaker or other authorised person or of ant member of
the family of the deceased, furnish for registration a standard certificate
of deaih, stating to the best of his knowledge and belief the name of the
deceased, his supposed age, the disease of which he died, defined a» re-
quired by section one. where same was contracted, the duration of hia last
Illness, when last seen alive by the physician or officer and the date of his
death ... Gen. 1-aws, Chap. 4 6, Sec. #.

A physician or officer furnishing a certificate of death as required by the
preceding section or by section forty-five of chapter one hundred and four-
teen, shall, if the deceased, to the best of his knowledge and belief, served
In the army, navy or marine corps of the I'nited States in any war in which
it has been engaged, insert in the certificate a recital to that effect, speci-
fying the war. and shall also certify in such certificate both the primary
and the secondary or immediate cause of death as nearly as he can state
the same. For neglect to comply with any provision of this section, such
physician or officer shall forfeit ten dollars. For the purposes of this sec-
tion and of sections forty-five, forty-six and forty-seven of said chapter one
hundred and fourteen, the word “war" shall include the 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 lleii-
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
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 |>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 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 aucb board, agent or clerk, as the case may be,
a satisfactory written statement containing the facts required by law to be
returned and recorded, which shall be accompanied, in case of an original
interment, by a satisfactory certificate of the attending physician, if any,
as required by law. oi in lieu thereof a certificate as hereinafter provided.
If there is no attending physician, or if, for sufficient reasons, his certificate
cannot be obtained early enough for the purpose, or is insufficient, a physi-
cian who is a member of the board of health, or employed by it or by the
selectmen for the purpose, shall upon application make the certificate re-
quired of Ihe attending physician. If death is esused by violence, the medi-
cal examiner shall make such certificate. If such a permit for the removal
oi a human body, not previously interred, from one town to another within
the commonwealth cannot be obtained early enough for the purpose, the
certificate of death made as above provided and in the possession of the
undertaker desiring to make such removal shall constitute a permit for
such removal; provided, that such body shall be returned to the town from
which it was removed within thirty-six hours after such removal, unless
a permit in the usual form for the removal of such body has been sooner
obtained hereunder. If the death certificate contains a recital, as required

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 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 transmil 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 deaih 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-
ceiled a permit so to do from the hoard of health or its agent ap|>ointed to
issue such permits, or if there is no such hoard, from the clerk of the town
where the body is to be buried or the funeral is to be held, or from a person
appointed to have the care of the cemetery or burial ground in which tha
interment is made. ... Chap. 114. Sec. 46. C. L., (Tercentenary Edition).

Medical examiners shsll 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 Ilea
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 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 physiolani 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 deaih is needed.

(8) Medloal Examiners will investigate and certify to all deaths sup-
poaably due to Injury. These include not only deaths caused directly ot in-
directly by traumatism (Including resulting septicemia), and by the action
of chemical (drugs or poisons), thermal, or electrical agents, and deaths
following abortion, but also deaths from dlseast 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 Causa of Death. — Cause of death meana the disease, or
complication which causes death, not the mode of dying, e. g., heart failure,
asphyxia, asthenia, etc. As 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 cauae.

Statement of Oooupation. — Precise statement of occupation la 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 discaee
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 wages, however,
designate the occupation by tj)e appropriate terms, aa houaekeeper — private
family, cook — hotel, etc. For a person who had no occupation whatever
write none.

of the citj or town in which the deceased resided. (See Chap. 40, Sec. 12, Q. L.)

R-302

1 ^ssex

2 (County)

Danvers

tHIje (Sotttmcmfnraltlj of JWassactfusdts

OFFICE OF THE SECRETARY

DIVISION OF VITAL STATISTICS

COPY OF

CERTIFICATE OF DEATH

Danvers

(City or town making return)

Registered No.

§ iSa^vere* otate Hospital Qf \ (If death occurred in a hospital or institution,

_i No ~ St. < gjve j£g NAME instead of street and number)

“■ bdith Habethge

;(lf u. s.

War V

2 FULL NAME •( War Veteran,

(If deceased is a married, widowed or divorced woman, give also maiden name.) . 1 speoify WAR)

228 Bowdoin Wmthiop

(a) Resldenoe. No SL

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

Length of atay: In hospital or Institution yean months 6 days.

(Before death) (Specify whether)

In this oommunlty

yrs.

days.

PERSONAL AND STATISTICAL PARTICULARS

3 SEX

female

4 COLOR OR RACE

white

5 SINGLE (write the word)

MARRIED

WIDOWED

or divorced niarr led

5a If married, widowed, or divorced
HUSBAND of

t } WIFp nfl .Chai<li^Siai<lfc,tW5®freif^“ MUdolph 4J m Ee...allve on tJ„an...™.22.^ 19...45 death Is said to

(Husband’s name in fuil ) 110.be' t TTge ' have occurred on the date stated above, at.tLe.A.Sc.™?. m. Duration

6 Age of husband or wife if alive Q .4 years

7 IF STILLBORN, enter that faot here.

AGE :...*?.Years Months..

.Days

If less than 1 day
Hours Minutes

Usual i • n

9 Occupation: .JlQ..US.e.Y\l.l.X.S..

Industry

10 or Business:

11 Sooial

Security No. -_.Jl.Qi}.®.

i'es'tbri"

12 BIRTHPLACE (City)

(State or country)

bibridge i. Gilman

13 NAME OF
FATHER

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

cannot be

learned

15 MAIDEN NAME^nnj_e M. White
OF MOTHER

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

Cannot be

learned

i-i-ir _ , Relation, if any

Informant Li»b.»l>-.d..llil.l.i.D.S ( )

( ArMrese)

copy y J

A TRUE
ATTEST

city or town where death occurred)

DATE FILED 19

MEDICAL CERTIFICATE OF DEATH

18 DATE OF
DEATH

Jan. 22, 1945

(Month) (Day)

(Year)

19 I HEREBY CERTIFY, That I attended deoeased from

Jan.. X6-. 19-45.., to....J‘.a&x 22 19....45

Immediate cause of death

Cardiorenal disease

2 mor

Due to.

Other conditions

(Include pregnancy within 3 months of death)

Major findings:
Of operations.

Date of

clinical

Duration

ths

Physician

Of autopsy ....

What test oonfirmed diagnosis?

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

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

(Signed) £.0^^ M." D.

(Address) D,8li DataL^..2.Q./.,49&

21 PLACE OF BURIAL,

N OR RE

luemeierys / /(V/ijyor 10

DATE OF BURIAL X/,2.4/,4.5 19

rLMbt Ur DUnlML, • x. 1- _ _ _ _ • . . i

CREMATION OR REMOVMl ln.LilT.Q.p Jlimt Jir.O.P

(Cemetery) _ / _ /(City or Town)

j. Reynolds

noward

22 NAME OF

FUNERAL DIRECTOR

address .(•In.tJir.o.p

Reoeived and filed 19

(Registrar of City or Town where deceased resided)

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

i A

f\A

◄

1 <

Suffolk

(County)

Wi nth rap,

(City or Town)

©Ije (EammottfrieaUfy of (JWassarfyusette

OFFICE OF THE SECRETARY
DIVISION OF VITAL STATISTICS

STANDARD

CERTIFICATE OF DEATH

To he filed lor barlal permit

with Board of Health
or Its Agent.

Registrar’s No. ..L

No.

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

bt- 1 giv ’ ■' ‘ ' ’ ’ -

FULL NAME

(a)

Pleasant Pk. Rd. „ , . „. . .. ,

ol- 1 give its NAME instead of street and number)

PHYSICIAN— IMPORTANT

deceased a
War Veteran,

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

William H. Westlake

{PHY!

(Was
U. S.
if so s

Residence. *22-- _

(Usual place of abode)

Length of stay: In hospital or Institution

(Before death)

(Specify whether)

years

months

St.

days.

(If nonresident, give city or town and State)

In this communitJO yrs. mos. days.

PERSONAL AND STATISTICAL PARTICULARS

3 SEX

Male

4 COLOR OR RACE

White life.

5 SINGLE (write the word)
MARRIED
WIDOWED

,rqr$3@RCEP

husband6 d ’{ w ldo "Tfei &nrc?$cCart hy

HUSBAND of
(or) WIFE of

(Give maiden name of wife in full)

(Husband’s name in full)

6 Age of husband or wife if alive

isb|p

7 IF STILLBORN, enter that fact here.

Years_ Months Days

If less than 1 day
Hours Minutes

Usual

Boilermaker

Industry
or Business: _

Boiled

Social Security No.

03I-o5— 5296 ...

12 BIRTHPLACE (Citv)

(State or country)

“England:

13 NAME OF

FATHER

William H. Westlake

14 BIRTHPLACE OF
FATHER fCitv)

(State or country)

England

IS MAIDEN NAME
OF MOTHER

Isabell Kelly

16 BIRTHPLACE OF
MOTHER (City) . ..

(State or country)

Englana

InformanHSlej
(Address)

“Pk,

was filed with me BEFORE the
I HEREBY CERTIEY that

ligature o

r transit permit was issued:
'orj^standard certificate of death

Board oi Iforljth^r ^hcr) ,

ate of Issuc/of Peraj<) ‘

18 DATE OF
DEATH .

MEDICAL CERTIFICATE OF DEATH

"L-K

inn

(Year)

19 L HEREBY CERTIFY

have occurred on the date
Immediate, cause of death.

ated (above, at.

-:'^A

.iv_tiicvLo, taube oi ueaiu — ^

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

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)//^ i > M. D.

q^atew(-.^-itU..~.19..f^.J"

Place of Burial, Cremation
DATE OF BURIAL

22 NAME OF

FUNERAL DIRECTOR

(Registrar)

.. . ........ ....... . ,. That I attended deceased from

, 19 , 19—

I last saw h ^^•-alive oii -^l — , 19±£> death is said to

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 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 be 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 unoriginal
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. Tf 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 lorty-six, that the deceased serveu 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 i$ no such board, 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 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 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), thermt^l, or electrical agents, and
deaths following abortion, but also yearns iroih disease resulting from
injury or infection related to occupation, the sudden deaths of persons not
disabled by recognized disease, and those of persons found dead.

Statement of Occupation. — Precise statement of occupation is very im-
portant, so that the relative heallhfulness 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

sagfo^k

(City

;£/h (jLI: -H L0H

ity or Town)

®lje (Eammonfoealtlj of <ililas*acIjusettB
OFFICE OF THE SECRETARY
COPY OF

MEDICAL EXAMINER’S
CERTIFICATE OF DEATH

(Citi' or Iowa making return)

Chelsea

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

3 No «npaatc...to.-C.h©X«-ea- *ive it3 NAME instead of stre*t snd Dumbsr)

Registered No. 51

2 FULL

NAME < Wa^ Veteran, V *)

(If deceased is a married, widowed or divorced woman, give also maiden name.) j ap0cify WAR).........!

356 Winthrop

(a) Residence. No

(Usual place of abode)

Length of stay: In hospital or institution ............

6 (Specify whether)

years

months

St.

days.

V; In thr op , Ma as*

(If nonresident, give city or town and«tate)

In this community yrs. mos. ^ days.

PERSONAL AND STATISTICAL PARTICULARS

3 SEX

4 COLOR OR RACE 5 SINGLE

MARRIED
WIDOWED

__ i or DIVORCED

5a If married, widowed, of divorced
HUSBAND of

(or) WIFE of

(Give maiden name of wife in full)

( Husband’s naitSjTn full)

6 Ago of husband or wife ii alive yeaTB

7 IF STILLBORN, enter that fact here.

AGE

-54-

Usual

9 Occupation:

Years ... Months Days

— Brio o '"usifror

If le3s than 1 day

Hours Minutes

Industry
10 or Business:

C ity of Bo a t o rt

029^9-3070 -

11 Social Security No.

12 BIRTHPLACE (City)
(State or country)

13 NAME OF
FATHER

Janes R.

M 14 BIRTHPLACE OF
£ FATHER (City)

* ! (State or country)

Yr.rmora th,TJ .3",

« 15 MAIDEN NAME

< OF MOTHER

f-cthlldo fnl-rre

16 BIRTHPLACE OF
MOTHER (City) .

(State or country)

Yarmouth,!^ *S,

Informant

(Address)

Ma>j hite , R«ta|HLf*y

60G Qe©an AverRetrere )

A TRUE COPY.
ATTEST:

DATE FILED

(Registrar of city or town w)t/re death occurred)
i / z'. ra / ** n

1/25/45

MEDICAL CERTIFICATE OF DEATH

18 DATE OF
DLAl'H

Jan. 23 f 19 4 5

(Month) (Day)

(Year)

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

Acute c ardicc dilatation

Right QQrouary sclorpsla

Old cardiac infarct

20 Accident, suicide, or homicide (specify).

Date of occurrence

Where did

Injury occur?

.19..

(City or town and State)

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

public place?

Manner of C ©1 lEpS ©<Mfy ^ieOP'^Uloklj

Injury

Nature of

Injury

yes

While at work? Was there an autopsy?.,

2 1 Was disease or Injury la any way related to occupation ol deceased ?
If so, specify W®

Boston

1/23 4# D

~ ‘ 19

specify
(Signed)

(Address) Date

— Holy dr os r, ,Mg-ld en , Ma r, a #

Place of Burial, Cremation or 6 "*'own^

DATE OF BURIAL V. " * * 19 .

23 NAME OF F. CGlinChOY

FUNERAL DIRECTOR .

583 Broadv/ay#CliQlsea

ADDRESS

V •u;...

■iiTTlt-

Received and filed

(Registrar of City or Town where deceased resided)

iry important. Seo instructions and extracts from the laws on back of certifacati

301 A

) •

c >

3.2

/ /j J / ^

/S-! , <<Y A A, ®be (Eammottfuealth of i^tnssnclrasetts

•», OFFICE OF THE SECRETAJRY

DIVISION OF VITAL STATISTICS

STANDARD
CERTIFICATE OF

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

4 Q

Registered No rttbr.Vut...

T. j ( (If death occurred in a hospital or institution,

.. ft. ....... y. si#. ( give its NAME instead of street and number)

\ (If U. S.

War Veteran,
specify WAR).

(a) Residence. No. /£L

(Usual place of abode)

Length of stay: In hospital or institution.

(Specify whether)

(If nonresident, give city or town and state)

In this community yrs.

mos. days.

PERSONAL AND STATfSTICAL PARTICULARS

MEDICAL CERTIFICATE OF DEATH

OR OR RACE I 5 SINGLE
MARRIE
WIDOWE'

1 or DIVOR'

5a If married, widowed, or divorced —

HUSBAND of .rT v v

(Give maiden najne of wife in full)

(or) WIFE of

(Husband's name in full)

18 DATE OF
DEATH

(Day) (Year)

19 1 HEREBY CERTIFY. That 1 attended deceased from

, 19 to 19

, I last saw li clive on 19 , death is said

to have occurred on the date stated above, a\..7:.f..X.Ak....m. r),irnt;nn'\

8 Age of husband or wife if alire._L...y<v

7 IF STILLBORN, enter that fact hcr^

AGE . .

jlf less than 1 day

Years Months Days I Hours Minutes

Immediate cause of death..

Due to

Usual

3 Occupation

Industry
10 or Business

11 Social Security No

12 BIRTHPLACE (City)

(State or country) j

Due to ..y

y,/.. /.

Other conditions

(Include pregnancy within .? menths of death)

PHYSICIAN

Underline

Major findings :

Of operations | the cause to

Date of !wh!ch death

ishould be

Of autopsy charged «ta-

What test confirmed diagnosis? tistically.

23 Yias disease cr Injury In any way related to occupation ot deceased? .

If 30, specify

(Signed) *1 M. D

(Address) ^^^.Date,.

I HEREBY CERTIFY that a satisfactory standard certificate of de
Clod v/ith mo BEFOBE tho hurihl oy^ra^tiit portnif was issued:

r. ' ‘ r

v (Signature o of~t!oard of HedU'nYCr ^th^r)

death was

22 NAME OF
FUNERAL

ADDRESS

Place of Burial, Cremation jfcr Removal, si *~~(City or Town) / / /*r'

13/D

DATE OF BURIAL

(Registrar)

EXTRACTS FROM THE LAWS OF THE
COMMONWEALTH OF MASSACHUSETT
governing the

return of certificates of death

A physician °r registered hu?P1“,(1"'e^fl3°attSdad8durinK his
after the death of a peIs°” Undertaker or other authorized person
illness, at the requestof « d°ceased. furnish for regis-

or of any member of -**™11*.' death stating to the best of his
tration a standard °fQf thg deceased, his supposed age.

knowledge and belief the aame ot tn required by section one
the disease of which hedied dchnea^ ^ ^ last illness. when last
officer and the date of h.s death . . .

%n;

human body in a town, o received a permit from the board

has not been buried, JJ ^onolnted to issue such permits, or if there
of health, or its agent P' P ibe town where the person died .

is no such board, from .he i cleric of Lhe \°” hume a human body and
and no undertaker or othei ' cemetery to another, or from one

remove it from a town, from one cemece j another in the same
grave or tomb other than the Ieae™n?it fro m the board of health or
cemetery, until he lias rec^vedaperm.t romt^ whe th e body is
its agent aforesaid F““d t51 there shall have been de-

buried. No such permit shall be issuea u may he, a satisfac-

livered to such board, agent <mc ^ facts required by law to be
tory written statement co i 11 he accompanied, in case of an

returned and recorded "h^isfaf0*e ^Tificate of the attending
original interment, by a r in i;eu thereof a certificate

physician, if any. i-ni attending physician, or if for

as hereinafter ^ r 0 ‘ r t i ft catif ca n not be obtained early enough for
sufficient reasons, his c%t'.“qate.. ,,hvsician who is a member of the
the purpose, or is insufficient, P the selectmen for the pur-

board of health, or employ F , certificate required of the at-
pose, shall upon thi medical exam-

tending pnysician. If death is cau xaoy ^ permit for the removal _ of
iner shall make such v ‘ interred, from one town to another
a human body, not previo . bg obtained early enough for the
within the commonwea L death made as above provided and in the
purpose, the certificate of deatn maae make such renloval sha
possession of the undertaker des ^ g “v^ed_ that such body shall
constitute a permit for which' it was removed within thirty-

be returned to the town from nprmit in the usual form for

six hours after bTen* oon^/Xained hereunder If the

the removal of such body has been r6quired by section ten of

death certificate containsa deceas'd served in the army, navy or
chapter forty-six, that the deceas ^ ^ wal. in which it has been
marine corps of the Uni ‘ upon the permit. The board of

engaged, such recital shal « ...l statement and certificate,

health, or its agent, the clerk of. the

shall forthwith countersign it and t the permit is so given

town for registration. The person to shaU therea{ter fur-

and the physician cel Anther necessary information which can be

nish for registration any other jieMssaiY rnannfir or oi the

3S'4h“h »*• s“- «•

G. L.t ( Tercentenary Edition.)

SPACE FOR ADDITIONAL INFORMATION

No undertaker or other person ^o^on^lTth until

ashes thereof which have ^rto do from the board of health or it.
he has received a permit so i , -t or ;f there is no such board,
agent appointed to issue such pmm t . t0 be buried or the

from the clerk of eXm a ^appointed to have the care
funeral is to be held, or “om P ° h interment is made

as stk *wms»ss «*»>

rules of practice

The fulfillment of the purpose of these laws calls for the observ-
ance of the following rules of practM* • deaths only as those

(1) A«.~diXPmytheynhave g£en bedside care during a last Ul-

SLS ' ^ed - any deaths only

attendance &or whTse°physician is absent from home when the
certificate of death is neede . , certify to all deaths

(3) Medical E™'rn'r" WThe"V indude not only deaths caused
suppo.ably due to , , "JKvy traumatism (including resulting septice-
dlrectly or indirectly by _vemjcal (drugs or poisons), thermal,
mia), and by the actio h following abortion, but also deaths

or electrical agents, and deaths louow related to oeeupa-

UoT thra»dd“n dMths “f persons not di.abled by rceooni.ee,

disease, and those of persons found dead.

„ _ , n .. Cause of death means the disease,

Statement of Cause “f,,®* death *not the mode of dying, e. 9-.
or complication which cause th pr;ncipal cause name the

heart failure, asphyxia, asthenia, etc n as eaJ.Uer m?rbld con-

ditions Tany, related^ ^ principal cause and any important
complication of the principal cause.

Statement of Occupation.— ^h^nMS ^'various pursuits
important, so ^at the relative h^altM^ne^ ^ person

can be known. Make some ent y had been given up or

aged 10 years or over. If the ' °“cupau report rthe usual

changed on account of the disease caus^g had retired from busi-
occupation prior to illness. ■ _ to retirement. Children not

ness^ report the ^l occupatmn prior to retire^ ^
gainfully employed may he returnea as home housework, write

woman whose only occupation was «adomestic service for wages.
housework. For a p*rs0" paflpn by the appropriate termA. as
I'ZTeJ Z^^a^eoo^-hot*. etc. For a person who had
no^ccup at ion whatever write none.

R-305

*S5

oj ca

co £

S£

h 5

a o

C 0)

25 £

•o a

08*0
,5 «
•a 3:

>Jt3

z*>

*» «*-■

5 2d

*"0 .

£ a 2

Siico

o * ®

! >»c .

la?

t|6

~~ a>

: C u '-

: s ow

III?

» u o O

ysTO©i7

J BOSTON

(City or Town)

®lp (Eontmonfoealil] of jJHassacltusetts

OFFICE OF THE SECRETARY

COPY OF

MEDICAL EXAMINER’S
CERTIFICATE OF DEATH

e°sr/

O /y ’

(City or town making return)''

Registered No.

770

No.

Boston City Hospital st. { ((-f death_°scurred in ? or institution.

give its NAME instead of street and number)

2 FULL NAME

Jos«Ph....Mciiityre f

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

(a) Residence. No l?5 CirCUit Rd# St

(Usual place of abode)

Length of stay: In hospital or Institution

(Before death) (Specify whether)

years

months

days.

(If nonresident, give city or town and State)

mos. days.

In this community yrs.

PERSONAL AND STATISTICAL PARTICULARS

3 SEX

4 COLOR OR RACEI

5 SINGLE (write the word)

MARRIED

WIDOWED .

or DivoRCEDMarriea

5a If married, widowed, or divorced — . , • (1 1tI_ a

husband of Catherine.

(Give maiden name of wife in full)

(or) WIFE of

(Husband’s name in full)

6 Age of husband or wife If alive .. 7S year:

7 IF STILLBORN, enter that faot here.

S _Q If less than 1 day

AGE 1.0 Years Months Days Hours Minutes

Usual

9 Occupation:

Retired

Industry

10 or Business: GrOOer

11 Social Seourity No..

12 BIRTHPLACE (City)
(State or country)

Boston; Mass.

13 NAME OF
FATHER

John McIntyre

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

Ireland

15 MAIDEN NAME
OF MOTHER

Ann Harkins

16 BIRTHPLACE OF
MOTHER rCitvl

Ireland

(State or country)

Informant

dilation, if any

(Address)

" * ", )

A true o
ATTEST:

(Registrar of city oif tpwn where deatli

DATE filed Jan. 29, 1945

MEDICAL CERTIFICATE OF DEATH

18 death°F Jan ...M* 19.45

(Month) (Day)

(Year)

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

Cerebral . . hmer r.hage

Mxw.r...ia.fle.ration

20 Acoldent, suicide, or homlolde (specify)

Date of occurrence 19

Where did
Injury occur?

(Specify type of place)

Manner of
Injury

Nature of
Injury

While at work? Was there an autopsy? QO

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

If so, speoify

(Signed) T*. Leary M. d.

(Address) Date .... 1/25/46

22 Holy Cross, Malden

Place of Burial, Cremation or Removal.

DATE OF BURIAL

(City or Town)

Jan* 27 f 1945 19

23 NAME OF r f O

FUNERAL DIRECTOR .. • Y

address Winthrop

Received and filed 19

rtj 3 1345

(City or town and State)

Did injury occur In or about the home, on farm, In Industrial place, or In
publlo plaoe?

(Registrar of City or Town where deceased resided)

Jlu

■

• ■ ■ ' ■ ,1

extracts from the laws relative to the return of certificates of death.

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

303-A

ll.

^0-

7 (County)

lity or TWrai

(City

No.

(£ammrmfai'nlttj af JHassnrfjnsetts
OFFICE OF THE SECRETARY

DIVISION OF VITAL STATISTICS

MEDICAL EXAMINER'S
CERTIFICATE OF DEATH

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

Registered No.

2 FULL NAME.

St. ( (If death occurred in a hospital or institution,

’ I give its NAME instead of street and number)

f PHYSICIAN-IMPORTANT

V_. O ; J (Was deceased a

(a) Residence. No.

(Usual place of abode)

Length of stay: In hospital or Institution.. 3*0=....

(Before death) < Specify whether)

"l U. S. War Veteran,

If so speoify WAR)....N.Q

years

months

days.

(If nonresident, give city or town and State)

In this community*? yrs. mos. days.

PERSONAL AND STATISTICAL PARTICULARS

MEDICAL CERTIFICATE OF DEATH

3 SEX

Female

4 COLOR OR RACE

White

5 SINGLE (write the word)
MARRIED

widowed Single

or DIVORCED 0

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.

AGE 41 Years Months

Days

If less than 1 day
Hours Minutes

Usual

9 Occupation : ■•Ra.ta.ll-.S.t-ar.a.-Pr.gpple-t-<a?-

10 or Business: K.S..fc.&i.l....V.£lP.i.9.t.y....S.t-GI?.e..

11 Social Security No UOH3.

12 BIRTHPLACE (City)
(State or country)

St. iPhtt'A

Kew Brunswick

13 NAME OF
FATHER

William Cohen

</)

»-

Q. !

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

..Russia.

15 MAIDEN NAME
OF MOTHER

Flora Wolgemuth

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

"Russia"

Informant

( Ait'lrec*

t Lewis Cohan (

1 bo za It an i.. & 1 1 a. p an

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

_ (Signature of Agent of Board pf Health a>r other)

... //^ t/9S~r

| (bfflcia^Besigiiation) (Ijfte of Is^jm or Permit)

SeaTh°f L. &*== >...? -.1.1 l..±

J (Month) (Day) (Year)

19 I HEREBY CERTIFY that I have investigated the death
of the person above-named and that the CAUSE AND MANNER thereof
are as follows: (If an injury was involved/

are as follows: (If an injury was UvoIved^'S&fte fully.)

20 Acoident. suioide, or homloide (specify).

Date of ooourrenoe J.Auu,—.. 2r...^..XZ. i9..u:.0..

Where did v\r-r T/Lvs.yf1?

Injury ocour7

or town a

Did Injury ocour In or aoou^hon
plaoe? .7.™

and State)

on farm, In Industrial plaoe, or In publlo

(Specify type of place)

Ql&Z.

_wr^TTT....Was there an autopsy?

Manner
Injury

Nature of
Injury ....

While at work?

21 Was disease or Injury in any.watM^ftded to oooupation of deoeased?

" ”;z: ’’

J&svd i9 )/i

(Address)

22 Tiferath Israel of....^i^nthPOG-3v^p.9.t \

Place of Burial, Cremation or Removal. (City or “own)

DATE OF BURIAL January..... 2.8.th, i9.V.i

ADDRESS

/S'

Ct.v/.d...

23 NAME OF

FUNERAL DIRECTOR yS

Reoeived and filed T9

(Registrar)

EXTRACTS FROM THE LAWS OF THE

COMMONWEALTH OF MASSACHUSETTS

GOVERNING THE

RETURN OF CERTIFICATES OF DEATH

A physician or registered hospital medioal offioer shall forthwith, after
the death of a person whom he has attended during his last illness, at the
request of an undertaker or other authorized person or of any member of
the family of the deceased, furnish for registration a standard certificate of
death, stating to the best of his knowledge and belief the name of the
deceased, his supposed age, the disease of which he died, defined as 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.

A physician or officer furnishing a certificate of death as required by the
preceding section or by section forty-five of chapter one hundred and four-
teen, shall, if the deceased, to the best of his knowledge and belief, served
in the army, navy or marine corps of the United States in any war in which
it has been engaged, insert in the certificate a recital to that effect, speci-
fying the war, and shall also certify in such certificate both the primary
and the secondary or immediate cause of death as nearly as he can state
the same. For neglect to comply with any provision of this section, such
physician or officer shall forfeit ten dollars. For the purposes of this sec-
tion and of sections forty-five, forty-six and forty-seven of said chapter one
hundred and fourteen, the word “war” shall include the China relief ex-
pedition 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
til.- clerk of thp 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
medical examiner shall make such certificate. If such a permit for the
removal of a human body, not previously interred, from one town to an-
other within the commonwealth cannot be obtained early enough for the
purpose, the certificate of death made as above provided and in the pos-
session 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 re-
moval, 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

DESCRIPTION (for unknown person)

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 regis-
tration. The person to whom the permit is so given and the physician cer-
tifying the cause of death -ball thereafter furnish for registration any other
necessary information which can be obtained as to the deceaoe.i, or as to
the manner or cause of ihe death, which the clerk or registrar may re-
quire.— Chap. 114, Sec. 4 5, G. L., (Tercentenary Edition).

No undertaker or other person shall bury a human body or the ashes
thereof which have been brought into the commonwealth until he has re-
ceived a permit so to do from the board of health or its agent appointed to
issue sucli 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 per-
son appointed to have the care of the cemetery or burial ground in which
the interment is made. ... Chap. 114, Sec. 46, G. L., (Tercentenary Edi-
tion).

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.

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

RULES OF PRACTICE

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

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

(vl) 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 front disease resulting from Injury or
Infection related to occupation, the sudden deaths of persons not disabled
by reoognized disease, and those of persons found dead.

STATEMENT OF CAUSE OF DEATH
Medical Examiners in certifying to a death will state the cause and
manner thereof, and will specify: (1) Under cause, the nature of an injury
and of its consequences; and (2) under manneT, the mode of its production
together with the circumstances when these are known. For example: “Com-
pound fracture of the femur with ensuing septicemia (gas bacillus) caused
by a steam railway accident.” “Pistol shot wound of the chest with asso-
ciated hemorrhage, homicidal.” “Asphyxiation by suspension, suicidal.”
“Syncope while under the influence of ether administered as a surgical
anaesthetic." “Fracture of the skull with associated internal injury sus-
tained under circumstances unknown.”

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

THIS CERTIFICATE CONSTITUTES SUCH PERMIT

Veteran, Q. L. Chap. 46. Seotlon 10, require* phyelolans to Ineert • reoiUI to that effeot.

101 A

S.UflQ.Ifc.

(Ehr ConmumfacaItJ| of JHassacljusctts

OFFICE OF THE SECRETARY

DIVISION OF VITAL STATISTICS

STANDARD

CERTIFICATE OF DEATH

(Ceunty)^>

o Winthrop

“j (City or Town)*'

2 «• flnthrap Community Hoapltnl "U’tsa

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

Registered No .L^kSr...

( PHYSICIAN - IMPORTANT

2 FULL NAME B.Q.R.0Xt.€L...G.Q.V.e.i.& J (Was deceased a

(If deceased Is a married, widowed or divorced woman, give also maiden name.) I ?;■ Wa.( vf*eran, _

I if so specify WAR) ffy

(a) Residence. No £.3.3. S.&r.ft.t.Qg.&..^l££.» BaS±:.:.BO.SCtDH SL EaSt-BOSt-OIl

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

Length of stay: In hospital nr Institution .SOSpirt&X »year* _ months ^^dayg.
(Before death) (Specify whether)

In this community — yrs. _ moa. ^ ^ . dara.

PERSONAL AND STATISTICAL PARTICULARS

MEDICAL CERTIFICATE OF DEATH

3 SEX

female

4 COLOR OR RACE

white

5 SINGLE (write the word)
MARRIED
WIDOWED
or DIVORCED

18 DATE OF /
DEATH L

(Month)

(Day)

/*yC.

(Year)

5a If married, widowed, or divoroed

HUSBAND of

(Give maiden name of wife in full)

(or) WIFE of

(Husband's name in full)

6 Age of husband or wife if alive „ years

19. I HEREBY CERTIFY, That I attended deoeased from

-to ..j£*rrerr....?Uy.. , 19 ifl-

last saw h^i!/L alive on....AJg^^..Z)Sr.'^. 19 ."death Is said to ..

ive occurred on tha data stAJed above, at..., m. 7 — ^ K

have

Immediate oauee of death

7 IF STILLBORN, enter that fact here.

,z_

AGE

Years

If less than 1 day

Mnnthe J»40ays I Hours Minutes

Usual

9 Occuoalion :

at home

Due to

Industry

10 or Business:

none

Oue to .

1 1 Social Security No.

12 BIRTHPLACE (Cily)

(Siafe or country) MclSS

irons

Mnthrop.

Other conditions

(include pregnancy within 3 months of death)

13 NAME OF
FATHER

Augustino Goveia

Major findings:
Of operations .

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

Lowell
Mas s •

Data of .

13 MAIDEN NAME
OF MOTHER

Sarah Petralia

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

East Boston
Mass.

Informant
( Addrtst)

B§a§£&e0gg^. €iir

OIL

I HEREBY CERTIFY that a satisfactory standard oartlfloate of death was
Hitjf ywltb sm BEFORE the Jkttrial or tranelt/permlt wee Issued t

(S%n'.t4re of
*1 Dcslfmatlon)

ard of

(Date of feaue

TCmI 7

Of autopsy

What test oonflrmed diagnosis? .

Duration

IMP.QUIAN

■s

IMPORTANT

Physician

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

20 Was disease or injury in any way related to oooupatlon of deoeased 7
If so, specify j

(Signed) . M. 0.,

(Address)

Place of (Mfial, Cremation or Removal. (City 01

date of burial. J.&nuary 31,1945

(City or Town)

19.

22 NAME OF r> p m-phtT

funeral director uy

Boston...

ADDRESS

-Received and illad 19.

( Regietrer

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 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
bis death . . . Gen. Laws, Chap. 46, Sec. 9.

A physician or officer furnishing a certificate of death a9 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 ui cliapter lorty-six, tnat tile 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).

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.

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, 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

lrom me laws on dock o»

If deceased was a U. S. War Veteran, G. L., Chap. 4G, Sec. 10, requires physicians to insert a recital to that effect.

1 A

1 <

3 Suffolk

(County)

° Winthrop

No.

(City or Town)

86 Ingleside Ave.

OFFICE OF THE SECRETARY

DIVISION OF VITAL. STATISTICS

STANDARD

CERTSFICATE OF DEATH

To be filed for barlftl permit
with Board of Health
or ft* Agent.

Registrar’s No.

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

2 FULL NAME_

Minnie F Richardson (Williams)

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

{FUt

(Was
U. S.
if so

PHYSICIAN— IMPORTANT

deceased a
War Veteran,
specify WAR)..

(a) Residence. No. 52 Washington Ave.

(Usual place of abode)

Length of stay: In hospital or Institution....

(Before death)

(Specify whether)

years

months

..St.

days.

(If nonresident, give city or town and State)

In this community 25)rs. mcs. days.

PERSONAL AND STATISTICAL PARTICULARS

3 SEX

Female

4 COLOR OR RACE

White

5 SINGLE (write the word)
MARRIED
WIDOWED

IDUWED IaMR 0.1.7

DIVORCED « 1 CLOW

5a If married, widowed, or divorced
HUSBAND of

(or) WIFE of

(Give maiden name of wife in full)

.Edward G Richardson

(Husband’s name in full)

6 Age of husband or wife if alive_

7 IF STILLBORN, enter that fact here.

AGE_.

.73

Years_ Months Days

If less than 1 day
Hours-___— .Minutes

Usual

9 Occupation:

At Home

Industry
10 or Business:

11 Social Security No.

Hone.

12 BIRTHPLACE (City)
(State or country)

Charlestown
Mass .

13 NAME OF

FATHER jamejJ

Williams

14 BIRTHPLACE OF
FATHER (City)

Gloucester

(State or country)

England

15 MAIDEN NAME

Marglla F Seabe r

16 BIRTHPLACE OF

MOTHER (City)

Boston

(State or country)

Mass .

Informan

(Address)

WlnlMF

--)

with me BEFORE the burial or transit permit was issued:
1EBY CERTIFY tlurtul satisfactory standard certificate of death

ICAL CERTIFICATE OF DEATH

7Ty^

(•Year!/ ^

FII E R

Y C E RT I F Y

^ i9 Ur

saw on.

occurred on the date
Immediate cause of death

That I attended deceased from

19^d^Tdeath is said to

Due to

Other conditions

(Include pregnancy within 3 months of death)

Major findings:
Of operations-

Of autopsy—

What test confirmed diagnosis?-

-Date of-

Duration

IMPORTANT

Physician

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

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

If so, specify

(Signed). _.C.—. ^2 — , M. D.

(Address)

21 Wood lawn ~

Place of Burial, Cremation or Removal.

DATE OF BURIAL.. January 29

ate.irA->..--19

ye ret _

(City or Town)

22 NAME OF

FUNERAL DIRECjTO.

ADDRESS
Received and filed-

-19

(Registrar)

EXTRACTS FROM THE LAWS OF THE

COMMONWEALTH OF MASSACHUSETTS

GOVERNING THE

RETURN OF CERTIFICATES OF DEATH

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

A physician or officer furnishing a certificate of death as required by the
preceding section or by section forty-five of chapter one hundred and four-
teen, shall, if the deceased, to the best of his knowledge and belief, served
in the army, navy or marine corps of the United States in any war in which
it has been engaged, insert in the certificate a recital to that effect, speci-
fying the war, and shall also certify in such certificate both the primary
and the secondary or immediate cause of death as nearly as he can state
the same. For neglect to comply with any provision of this section, such
physician or officer shall forfeit ten dollars. For the purposes of this sec-
tion and of sections forty-five, forty-six and forty-seven of said chapter
one hundred and fourteen, the word “war” shall include the China relief
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. Tf death is caused by violence, the medi-
cal examiner shall make such certificate. Tf 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 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).

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.

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 v.-as 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

VI R-SOl

! JSO

# n

‘."V <t

•30-

? 03
»-5u
u

50 O

Zu.

j < 0

*0-

! A

u *

5 .Suff olk ^..v?.

M (County)

/!#>

O Wlnthjog TTO,

®Ije Conurtnnfnealtli of ,JR>tBsaclpx9tHa
OFFICE OF THE SECRETARY

DIVISION OF VITAL STATISTICS

STANDARD

CERTIFICATE OF DEATH

(City or town making return)

•n>*>

Registered No .fyj:!.

..St.

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

J (If u. s.

2 full NAME Luo.inda..M.etI3a^Q.t..±eQ...Sw.ini.|

(If deceased is a married, widowed or divorced woman, give also maiden name.) f 8Pocl™ VYrtn>

2.44...Ba.y.s*a.t«p. St Ea.S.t....B.o.afeQ».^?.?...

(If nonresident, give city or town and state)

— months / • days. In this community /^0---yrs. mos. days.

‘ (a) Residence. No...

(Usual place of abode)

1 ength of stay : In hospital or institution

(Specify whether)

’ years

. «J X

<HW
U „
5<f . «

4) ft

,-V 2 "

c JiJjo

i J2 u c
* J? 0

; «> u •>

a 5

:-o2;

•3

'2 s'*'
5'S-Q E

s* o

<C **

E *“

• O
\<
j . «
1- g

l’ a o-53
: a « c

) 2 “ *

C>.

-3 o

: 2^ =

- I.

£ c
*.2

PERSONAL AND STATISTICAL PARTICULARS

3 SEX

4 COLOR OR RACE

Female White

5 SINGLE (write the word)

MARRIED

WIDOWED ,, .

or DIVORCED Ma T» T» 1 A fj

5a If married, widowed, or divorced

HUSBAND of

(Give maiden name of wife in full)

(or) WIFE of

S Ago of husband or wife if alive .6. 5 years

7 IF STILLBORN, enter that fact here.

AGE..

.6.2

.Years ...5 Month*. 22 Days

If loss than 1 day
Hours Minutes

10 or^Busmess: M . MM.

12 BIRTHPLACE (City) . Glar.ks .Earbir..

(State or country) 11 (W&

13 NAME OF
FATHER

Michael Swim

14 BIRTHPLACE OF
FATHER (City) ..

Clarks Harbor

(State ot country)

Nnva Sr.rs-hia

15 MAIDEN NAME
OF MOTHER

Sarah Smith

16 BIRTHPLACE OF
MOTHER (City)

UiihBiown

(State or country)

Nova Scotia

17 Relation, if any

informant George... A...lnih.ynot /husband \

^Address) i44_Bay swa t er St« j5eBos4^Q£U-—

I HEREBY CERTIFY that a satisfactory standard certificate of death was
filod with me BEFpRE the, burial 0/ I trapoit pormit was Issued:

Signature oKMent of Board oflfIeal[tG^or oth/f) ,

.. . ' ' _ x

(Official Designation)/) // (Date of Issue oyPermi*

MEDICAL CERTIFICATE OF DEATH

18 DATE OF
DEATH ....

(. £r7 *

y (Month) \ (Da t) (Year)

19 if HEREBY CERTI B<Y

That I attended deceased from

r , ^..22^ 19*f

last saw h-.f^T..... alive 19.^ death is said

4 9 A:.,.

‘ ................................

to have occurred on the d,
Immediate cause of death,

Du, 10

Other conditions

(Include pregnancy within 3 months of death)

Major findings:
Of operations

..Dale of.,

Of autopsy

What test confirmed diagnosis).

Duration

tje:

TfZ*-

PHYSICIAN

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

20 Was disease or Injury In any way related to occupation ol deceased 7 .

If 10, specify .)

(Signed).,

(Addreoa)..

21 W oodlattn Ev.e.r.s.tt...

Place of Buriai, Cremation or Removal. (City or Town)

DATE OF BURIAL ...B.Q.y^ / H A4r

22 NAME OF

FUNERAL DIRECTOR

■r*

address ...BOO-Xeridian St^-yE-Bos-top.

Received and filed

ly* c£’"'

..19

A TRUE COPY ATTEST:

(Registrar)

EXTRACTS FROM THE LAWS OF THE

COMMONWEALTH OF MASSACHUSETTS

GOVERNING THE

RETURN OF CERTIFICATES OF DEATH

No undertaker or other person shall bury or otherwise dispose of a
human body in a town, or remove therefrom a human body which
has not been buried, until he has received a permit from the board
of health or its agent appointed to issue such permits, or if there
is no such board, from the clerk of the town where the person died ;
and no undertaker or other person shall exhume a human body and
remove it from a town, from one cemetery to another, or from one
grave or tomb other than the receiving tomb to another in the same
cemetery, until he has received a permit from the board of health or
its agent aforesaid or from the clerk of the town where the body is
buried. No such permit shall be issued until there shall have been de-
livered to such board, agent or clerk, as the case may be. a satisfac-
tory written statement containing the facts required by law to be
returned and recorded, which shall be accompanied, in case of an
original interment, by a satisfactory certificate of the attending
physician, if any, as required by law, or in lieu thereof a certificate
as hereinafter provided. If there is no attending physician, or if, for
sufficient reasons, his certificate cannot be obtained early enough for
the purpose, or is insufficient, a physician who is a member of the
board of health, or employed by it or by the selectmen for the pur-
pose, shall upon application make the certificate required of the at-
tending physician. If death is caused by violence, the medical exam-
iner shall make such certificate. If such a permit for the removal of
a human body, not previously interred, from one town to another
within the commonwealth cannot be obtained early enough for the
purpose, the certificate of death made as above provided and in the
possession of the undertaker desiring to make such 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 3hall bury a human body or the
ashes thereof which have been brought into the commonwealth until
he has received a permit so to do from the board of health or its
agent appointed to issue such permits, or if there is no such board,
from the clerk of the town where the body is to be buried or the
funeral is to be held, or from a person appointed to have the care
of the cemetery or burial ground in which the interment is made. . . .
Chap. 114, Sec. 46, G. L., ( Tercentenary Edition.)

RULES OF PRACTICE

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

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

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

(3) Medical Examiners will investigate and certify to all deaths
supposably due to injury. These include not only deaths caused
directly or indirectly by traumatism (including resulting septice-
mia), and by the action of chemical (drugs or poisons), thermal,
or electrical agents, and deaths following abortion, but also deaths
from disease resulting from injury or infection related to occupa-
tion, the sudden deaths of persons not disabled by 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
houseivork. For a person engaged in domestic service for wages,
however, designate t

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