The volume, 1946

Town Clerk, Winthrop · from the Internet Archive · 524 pages · 37.4 MB
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J. L. FAIRBANKS DIV.
Thomas Groom & Co.

Stationers

105 State St., Boston

To duplicate this book order

No. ~7

O.U.7

(arms, so roar tr may d« proporiy classified, txact statement or UllUPATION i* vary important. See instructions ana
extracts from the laws on back of certificate.

If deceased war a U. S. War Vstaran, Q. L. Chap. 46, Seotlon 10, raqulraa phyilolam to Inaert a reoltal to that effeot.

R-301 A

VQ_

Suffolk

(Caunty)

Wlnthrop

(City or Town) _

No 57 Ocean View SPt'reet

(Ehf (Kumnumtocaltlj of ,JHnssacl|iisctt6

OFFICE OF THE SECRETARY

DIVISION OF VITAL STATISTICS

STANDARD

CERTIFICATE OF DEATH

To be filed for burial permit
with Board of Health
or its Agent. «
Registered No JL...

( (If death occurred in a hospital or institution,
oL j giv.e its NAME instead of street and number)

2 FULL NAME

Silas Arthur Cverturf

|r -

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

(a) Reildenca. No tr^cjL st

f PI

J (v

PHYSICIAN - IMPORTANT

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

(Usual place of abode)

Length of stay: In nosoltal or Institution

(Before death) (Specify whether)

yeara

months

dsys.

(If nonresident, give city or town and State)

In this oommunity ~^rJ yrs. mos. days.

PERSONAL AND STATISTICAL PARTICULARS

MEDICAL CERTIFICATE OF DEATH

3 SEX

Ma le

4 COLOR OR RACE

White

5 SINGLE (write the word)
MARRIED
WIDOWED

or divorced Marriec'

18 DATE OF
DEATH

(Month)

HusBAmN0,ie0df’ w:dowed:...or dl<0fC* Maud Ricard

(Give maiden name of wife in hill)

(or) WIFE of

(Husband’s name in full)

"6t.^

6 Age of husband or wife if alive

years

7 IF STILLBORN, enter that fact here.

AGE V..( ... Years

Months

2 3 Days

If less than 1 day
Hours Minutes

9 Occupation : luildi.9&... Inspector..

1 0 oT'bSLs, : . .. T O Wl. .. .0. £ ... M. XU % J&.E QP

020.-12- 01,3.0.

11 Social Security No.

12 BIRTHPLACE ICily)
( Slate or country)

'Benezetf

Penn.

13 NAME OF
FATHER

John Overturf

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

Penn.

15 MAIDEN NAME

OF MOTHER

Elizabeth Johnson

16 BIRTHPLACE OF

MOTHER (Citv) ...

(State or country)

Perm.

1T«sa WQSS&VlU-st . <&£!&£>

(Day)

(Year)

19 A HEREBY CERTIFY, ^?»«t I a

4 A

Uffst saw h..„T<w~. allv. «« *- *»#

st saw h ...Xnm . ally. on.,
hava occurred on tha data stated above, at..
Immediate oause of death

attended deoaased from

, 19

19 ^/Tdeath Is said to

& /Hr

Due to

IMPORTANT

Due

to i

* • ' O f

Other condltlona

I Include pregnancy within 3 months of death)

Major findings:
Of operations .

Data of..

Of autopsy

What test oonfirmed diagnosis? .

Duration

IMPORTANT

Physician

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

njury in any way related to oooupatlon of deoeased?

20 Was disease
If so, specify..

(Signed)

(Address/ Dale

21 Winthrop. ■.. ■.■7/111'

Place of Burial, Cremation nr Removal
DATE OF BURIAL J B nUf TY

. M. D.

irqp 1

or Town)

(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.

by section ten oi cuapier torty-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 tor 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 reauire.

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 g» to the place where the body lies
and take charge of the same; . . . —General Laws, Chap. 38, 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 United States in any war in which
it has been engaged, insert iu 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 toml/ 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

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 retmed 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

H R-301 A

B 9

! S

k o
If

3 i

t *

1 1

«E *

i " t

e _
5«c s 2

• u JB ^

is; “

S M ~ T

; 2 8 -

31 lip (Cunumiuforaltt] of 4%fiiseacl|uertts

OFFICE OF THE SECRETARY

DIVISION OF VITAL STATISTICS

STANDARD

CERTIFICATE OF DEATH

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

..... 2

Registered No.

2 FULL NAME

jencfl. No. ...jOrr..iU.

sual place of abode) '

. ( (If deach occurred in a hospital or institution,

.... SL|gjve jtJ NAME instead of street and number)

PHYSICIAN - IMPORTANT

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

(a) Residence

Length of stay: In hnsoltal nr Institution

(Before death) (Specify whether)

years

months

days.

(If nonresident, give city or town and State)

In this community c£/r 7r*- moa. days.

PERSONAL AND STATISTICAL PARTICULARS

5 SINGLE (write Jhj
MARRIED
WIDOWEO
or DIVORCED

ord)

18 DATE OF

EOICAL CERTIFICATE OF DEATH

(Month)

s?.

(Day)

(Year)

,£7 (Civo^alddfi/naDrfif at^rjte in hill)

(or) WIFE of

fHusband's name In full)

6 Age of husband or wife if alive yaars

19 I HEREBY CERTIFY, Tjjat * attended deoeased frorp

19..&/ST *3> 19 44*!..

I last taw h..£.Jr.. alive on. ..., 19 4(wTdeath It said to

have occurred on the dato stated above, at J. y Y y /?. m. \

Immediate oauee of death

I HEREBY CERTIFY that a satisfactory standard oertlfloate of dsath was
Bled with me BEFORE the burial or tunslt/pefnitt .was Issued i

(Siena
(O’lBclal Destination)

tare at Agent of Board n|f Health or otherju, /

$l5_.

ADDRESS

22 NAME OF

FUNERAL DIRECT/

of Tame of Permit)

Received and Died ,

- - mil.

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

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

RULES OF PRACTICE

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

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

(2) Board of Health physicians will certify to such deaths only as those
of persons who, though disabled by recognized disease unrelated to 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 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

DATE OF ENTERING MILITARY SERVICE

DATE OF DISCHARGE

RANK, RATING -

ORGANIZATION AND OUTFIT

SERVICE NUMBER

If deceased was a U. S. War Veteran, G. 1. Chap. 46, Section 10, requires physicians to insert a recital to that effect.

301 A

No.

Suffolk

(County)

'Vlnthrop

(City or Town)

125

(Tbr (EontmonWaitli of iHasejirljusctts
OFFICE OF THE SECRETARY
DIVISION OF VITAL STATISTICS

STANDARD

CERTIFICATE OF DEATH

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

Registered No.

Ave .

st.

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

full name Margaret Mac Donald Haraden ’ (^deceased a

(If deceased is a married, widowed or divorced woman, give also maiden name.) / ^ v> ar. v f.lrefan*

^ if so specify WAR)

(a) Residence, no. 194- Park Ave Arlington . * r

(Usual place of abode)

^ ;yy. < ✓

vears 8

PHYSICIAN- IMPORTANT

id :

Length of stay: In hospital or institution

(Before death) (Specify whether)

months

days.

(If nonresident, give city orjrown and State)

In this communi yg yrs. mos.

days.

PERSONAL AND STATISTICAL PARTICULARS

MEDICAL CERTIFICATE OF DEATH

/ /ffC

(Day) (Year)

3 SEX

Fein,

4 COLOR OR RACE

Ale White

5 SINGLE (write the word)

MARRIED

Wr DIVORCED WidOWed

( Month)

5a If married, widowed or divorced
HUSBAND of -

(Give^maiden ^am^oj^ wif^in ful^ ^

(or) WIFE of Mars hall

(Husband s name in full)

6 Age of husband or wife if alive

years

7 IF STILLBORN, enter that fact here.

CERTIFY

/ .1

I last saw h.Y^"r_ alive on
have occurred on the date : Ated above, at
Immediate cause of death

That I attended deceased from

. 19 £

19 death is said to

AGE

Years

Months

Days

If less than 1 day

Hours Minutes

9 Occupation: Housewife

Due to

Industry
10 or Business:

Own Horae

Due to

11 Social Security No.

12 BIRTHPLACE (City) ..............

(state or country) prjnce Edward Island

Other conditions

(Include pregnancy within 3 months of death)

13 NAME OF

father Angus

MacDonald

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

P.E.I.

15 MAIDEN NAME
OF M0THEgJarv

Me ‘ Intvre

16 BIRTHPLACE OF

MOTHER (Citv)

(State or Country)

P.E.I.

Major findings:
Of operations

Date of

Of autopsy

What test confirmed diagnosis?

Duration

MPORTANT

Physician

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

20 Was disease or
If so, specify

(Signed)
(Address)

in any way related to occupation of deceased?

^ informant Marshall Haraden (..£fcif“y.)
-(Address) j Elmwood Court ’.Vint hr op _

M. D.

*Vt Date 19 Y-

Me.

(City or Town)

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

(Signature of Agent of Board of Health or other)

CUa^-' b / Lf 1*

(Official E^ignation) f I (Date of Iss/e of Permit)

Oak Grove Gardner

Place of Burial. Cremation oyR CL

DATE OF BURIAL J^P ^ —

(/*

22 NAME OF

FUNERAL DIRECTOR

ADDRESS

Received and Filed

inthrop

JAN 7

1 9 46';;

(Registrar)

extracts from the laws of the
COMMONWEALTH OF MASSACHUSETTS
GOVERNING THE

RETURN OF CERTIFICATES OF DEATH

A ohvsician or registered hospital medical officer shall forthwith, after
the <£ath of a perlon 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 detth, stating to the best of his knowledge and belief the name of the

USE?,,' »bS tSiZiuM" Oy «H r bS*“,*“ " •»“' »“d ,h' d*“

his death • • • Gen. Laws, Chap. 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,
in the army navy or marine corps of the United States in any war in which
u has be“i engaged, insert in the certificate a recital to that effect, speci-
fying the war, and shall also certify in Cs“ch certificate both the pr iraa y
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 office/ shall forfeit ten dollars. For the purposes of .this sec-
tion and of sections forty-five, forty^six and forty-seven of 'hap‘'r

hundred and fourteen, the word war shall include the China reuci
expedition and the Philippine insurrection, which shall, for said purposes,
bePdeemed to have taken place between February fourteenth, eighteen
hundred and ninety-eight and July f o u r t h n i n e tee n h u nd red a n d t w o 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 n0 ,s“=h ,boar^
the clerk of the town where the person died; and no undertaker or oth er
person shall exhume a human body and remove 1‘^omha‘0*h"> rf™”v°n|
cemetery to another, or from one grave or tomb other than tne receiving
tomb toyanother in the same cemetery, until he has received ,a permit from
♦u- hoard 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 ^ .raa7 b'-

If there is no attending physician, or if, for sufficient reasons^ his certificate

°;hboei°,b^bearrloyf ST

2a 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 townfrom
which it was removed within thirty-six hours aft£r.su,ch removal,
a Dermit 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 oi chapter loriv-six, that the deceased served in the army,
navy or marine corps of the United States in any war in which it has been
engaged, such recital shall appear upon the permit. The board of health,
or its agent, upon receipt of such statement and certificate, shall forthwith
countersign it and transmit it to the clerk of the town for registration.
The person to whom the permit is so given and the physician certifying
the cause of death shall thereafter furnish for registration any other neces-
sary information which can be obtained as to the deceased, or as to the
manner or cause of the death, which the clerk or registrar may require.
Chap. 114, Sec. 45, G. L., (Tercentenary Edition).

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

should be carefully supplied. MEDICAL EXAMINERS should state CAUSE AND MANNER OF DEATH in plain terms,
so that it may be properly classified under the International Classification of Causes of Death. See reverse side for
extracts from the laws relative to the return of certificates of death.

If deoeased was a U. S. War Veteran, G. L. Chap. 46, Seotion 10, requires physioians to insert a recital to that effect.

M R-3Q3-A

v*o!

ll ^4

((County)

® Ije dontmcttifucalflf of JTI;is?arImsctt3
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 VaMs.

(If ^ceased is b married, widowed or_divorced woman

(a) Residence. No. dL...

(Usual place of abode) _ _

Length of stay: In hospital or institution •

(Rpfore death) (Specify whether)

maiden name.)

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

r PHYSICIAN - IMPORTANT
J (Was deceased a

' | U. S. War Veteran,

^if so specify WAR)

years

months

days.

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

days.

PERSONAL AND STATISTICAL PARTICULARS

3 SEX

4 COLOR OR RACE

SINGLE (write the word)

MARRIEO /, /,

WIDOWED LW.-
or DIVORCED

5a If married, widowed, or divorced ~0 \>4. . " . fj D

HUSBAND of i . .

(Give maiden name of wife in full) .

(Husband’s name in full)

(or) WIFE of

6 Age of husband or wife if alive years

7 IF STILLBORN, enter that fact here.

AGE^?...'?.. Years Months

Days

If less than 1 day
Hours Minutes

Occupation :

Industry

10 or Business:

|3-

II Social Security No.

12 BIRTHPLACE (City) 'ETC/UV'
(State or country)

13 NAME OF
FATHER

14 BIRTHPLACE OF

FATHER (City)

(State or country)

15 MAIDEN NAME
OF MOTHER

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

Informant

(

UcJXtPL L-

Address) •4^ Cel i iuilLl

Relation, if any

HERE

.filed

JY CERTIFY tha
BEFORE _)he

6^4....'.. .

.(Signature of

tidn)

stahdardM)ertificate of death was
nsit permit was issued:

Health or otheS,y 4

> ,iak

Issue of permit)

MEDICAL CERTIFICATE OF DEATH

IS DATE OF
DEATH

^,,,,^777, /<?£/(*>

J (Month) ^ (Day) (Yfear)

19 I HEREBY CERTIFY that I have Investigated the death
of the person above-name^i and that the CAUSE AND MANNER thereof
are as fallows: (If ary-iejury was involved, state fu)ly.)

)sJ*r.£:.L~.

20 Accident, suicide, or ^omicide (specify). _

Date of occurrence

Where did lA* -f ~i

Injury occur?

s TCity orltown and State)

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

place?

Manner
Inj

Nature
Injury

While at work?

(Specify type of place.)

°1 p..

..Was there an autopsy?

21 Was disease or injury in any way related to occupation of deceased? ^r..

If so, specify \A .(L^Z

(Signed) , M. D.

(Address)

Place of '■'Burial, Cremation or Removal.

DATE OF BURIAL:

emation or uemo1

-f4^v 7

(City or Town)

23 NAME OF

FUNERAL DIRECTOR

ADDRESS

ancc . u n . .

Reoeived and filed

3Mi im -

( 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. 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
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
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

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 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 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 per-
son appointed to have the care of the cemetery or burial ground in which
the interment is made. . . . Chap. 114, Sec. 46, Q. 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.

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

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

(3) Medical Examiners will investigate and ceitify 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, tt.he mode of its production
together with the circumstances when these are known. For example: “Com-
ound fracture of the femur with ensuing septicemia (gas bacillus) caused
y 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 s|>on-
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

Essex

(County)

& Danvers

(City or Town)
No,

®he (EommcmfneaHfj of iWassarlptsetts

OFFICE OF THE SECRETARY

COPY OF

MEDICAL EXAMINER’S
CERTIFICATE OF DEATH

jM.Y.e rs.

(City or town making return)

Registered No.

^Qirimnn qtn to tol I (If death occurred in a hospital or institution,

i, At. i .Y h? I?. . V. . .W.S .sA.S±A..4r..kfis«U St. | gjve jt3 NAME instead of street and number)

Gertrude Pike f <>/ u- s.

2 FULL NAME -s War Veteran,

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

184 W ood side Aye . st W i n t hr ojd

(If nonresident, give city or town and State)

Length of stay: In hospital or Institution 2 year£ moIntJis days.

(Before death) (Specify whether)

(a) Residence. No.

(Usual place of abode)

In this community

yrs.

days.

PERSONAL AND STATISTICAL PARTICULARS

3 SEX

f emalb

4 COLOR OR RACE

vvhi te

5 SINGLE (write the word)
MARRIED
WIDOWED

or DIVORCED Single

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

7 IF STILLBORN, enter that faot here.

8 7Q

AGE . ........... Years .

Months..

Days

If less than 1 day
Hours Minutes

9 Occupation : unable to work..

Industry

10 or Business:

11 Social Seourity No. .E1Q.IL©...

12 BIRTHPLACE (City) ... Pnleri

(State or country)

13 fatherF Francis

Henry P ike

14 BIRTHPLACE OF

FATHER (City)

*^t .^aul

(State or country)

Minn.

15 MAIDEN NAME

OF MOTHER MSTy

Lephe Htowell

16 BIRTHPLACE OF

MOTHER rcitvl

(State or country)

N.H.

informant.

(Address)

M.K.McPhillipS / Relation, if any ^

-j~7~)TISR ^ ;

A TRUE COP)

/r~ ~7"

ATTEST: L X*

(Registrar of city or town where death occurred)

DATE FILED lZ.28/46 19

MEDICAL CERTIFICATE OF DEATH

18 DEATH0.^ J.ajl.s IS.., 1.S46

(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.)

oenile Psychosis

..PX.Q.ba.bl.e....c.g^pnarx tliroiabo.sis

Found dead in bed, oinlden death.

20 Aooldent, suicide, or homiolde (specify)

Date of ocourrenoe 19

Where did

Injury occur?

(City or town and State)

Did Injury occur in or about the home, on farm, In Industrial place, or In

publlo plaoe?

(Specify type of place)

Manner of

Injury

Nature of

Injury

While at work? Was there an autopsy?

-ftd-

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

If so, specify..,

(Signed) ^.£ll.P.b.t..4.*.....?.'..Q..3.S. . M- D-

(Address) DateiZ.4.Q...l£J?

22 .^.l.enw.Q.a.d. li.v.ar.u.t.t

Place of Burial, Cremation or Removal. /^Cjtw or^.Town)

DATE OF BURIAL .4 19

23 NAME OF J OllTl ''•'a I'd

FUNERAL DIRECTOR

address Iwerett..

Received and filed

FEB 8 j 94.fi

(Registrar of City or Town where deceased resided)

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

-301 A

No.

Suffolk

(County)

’Vinthrop

(City or Town)

72 Centre

?D|c (Eommonhicaltlj of

OFFICE OF THE SECRETARY
DIVISION OF VITAL STATISTICS

STANDARD

CERTIFICATE OF DEATH

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

2 FULL NAME

rojair w

Registered No. ...^ Si,.

St. ) (If 'iL'ath occurred in a hospital or institution, t
I Rive its NAME instead of street and number) )

Agnes L. McGilva*»y » (MacDonald )

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

(a) Residence. No. 72 Centre St

(Usual place of abode) \ '

.... PHYSICIAN- IMPORTANT

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

ength 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 4l yrs. mos.

days.

PERSONAL AND STATISTICAL PARTICULARS

4 COLOR OR RACE

JZhi te

5 SINGLE (write the word)

MARRIED

WIDOWED

- orD'vQRCRftarrled

5a If married, widowed or divorced
HUSBAND of

(Give maiden name o£_wifa in full)

(or) wife of Joseph G-. llcGllv-

(Husband's name in full)

6 Age of husband or wife if alive

v44

• “ years

7 IF STILLBORN, enter that fact

here.

8 AT

AGE- Years Months

Days

If less than 1 day

Hours Minutes

Usual

9 Occupation:

Housewife

Industry
10 or Business:

Own Home

11 Social Security No.

—

12 BIRTHPLACE (City)
(State or Country)

vinthrop
-Ma s s a chuse tts_

13 NAME OF
FATHER

James J. Ma c D o nal d

14 BIRTHPLACE of
FATHER (City)
(State or Country)

Nova SfiOtla

15 MAIDEN NAME
OF MOTHER

.Hell le Clear

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

Ireland

Informant Joseph G. MCGilVS^ ( ftfrSb&fld)

(Address) 7 2 Centre St 'Vinthrop

I HEREBY CERTIFY that a satisfactory standard certificate of death was filed
,with jnq/BEFORE the-t*mal or trSM perphf was issued:

jCSignrftnre of Agent .of ijfoard ot Healtb-dfTithef) ,

(Official Designate

MEDICAL CERTIFICATE OF DEATH

2- b

I last saw alive on

have occurred on the date stl
Immediate r • - , '

from t/. »

^^death is said to
above, at ' / .'/ 0 m

yfidtvii-il . . V: t- . . e ,• ‘ ,v

Duration

IMPORTANT

DueJo

Due to

Other conditions

(Include pregnancy within 3 months of death)

Major findings: '~f.
Of operations

Of autopsy
What test confirmed diagnosis?

20 Was disease or injuif in any way related
It so, specify

(SignedlJ

!Adfe(sL^

21 -Vinthrop

Place of Burial, Cremation or Removal.

DATE OF BURIAL J^fflUarL

of Oc&sfxf

((.Occupation of dec

IMPORTANT

Physician

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

eased?a

Date

nthr oi

. M. 0,

22 NAME OF

FUNERAL DIRECTOR

Received and Filed

Vinthrop

(City or Town)

„ i9T*5

address Vintbfop, Massachusetts

S'S . j-»u

(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 durmg 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.

by section ten oi ciiapter tortv-SLx, tnat 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).

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

No undertaker or other person shall bury or otherwise dispose of a human
body in a town, or remove therefrom a human body which has not been
buried, until he has received a permit from the board of health, or its
agent appointed to issue such permits, or if there is no such board, from
the clerk of the town where the person died; and no undertaker or other
person shall exhume a human body and remove it from a town, from one
cemetery to another, or from one grave or tomb other than the receiving
tomb to another in the same cemetery, until he has received a permit from
the board of health or its agent aforesaid or from the clerk of the town
where the body is buried. No such permit shall be issued until there shall
have been delivered to such board, agent or clerk, as the case may be,
a satisfactory written statement containing the facts required by law to be
returned and recorded, which shall be accompanied, in case of an original
interment, by a satisfactory certificate of the attending physician, if any,
as required by law, or in lieu thereof a certificate as hereinafter provided.
If there is no attending physician, or if, for sufficient reasons, his certificate
cannot be obtained early enough for the purpose, or is insufficient, a physi-
cian who is a member of the board of health, or employed by it or by the
selectmen for the purpose, shall upon application make the certificate re-
quired of the attending physician. If death is caused by violence, the medi-
cal examiner shall make such certificate. If such a permit for the removal
of a human body, not previously interred, from one town to another within
the commonwealth cannot be obtained early enough for the purpose, the
certificate of death made as above provided and in the possession of the
undertaker desiring to make such removal shall constitute a permit for
such removal; provided, that such body shall be returned to the town from
which it was removed within thirty-six hours after such removal, unless
a permit in the usual form for the removal of such body has been sooner
obtained hereunder. If the death certificate contains a recital, as required

RULES OF PRACTICE

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

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

(3) Medical Examiners will investigate and certify to zll deaths sup-
posably due to injury. These include not only deaths auoed 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
“.?<?, Jetired 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 ior 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

miormauon snoum dc careiuuy suppnea. aok. snouia De statea r-AAt- 1 l, x . rnioiuiaiNS snouia state CAUSE OK
DEATH in plain terms, so that it may be properly classified. Exact statement of OCCUPATION is very important.
See instructions and extracts from the laws on back of certificate.

M R-301 A

Suffolk

(County)

Wln.th.ro. j>

(City or Town)

(E!|c (Eontmonfoealtlt of JiHassarliusdts
OFFICE OF THE SECRETARY
DIVISION OF VITAL STATISTICS

STANDARD

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

No.

33 Hutchinson

CERTIFICATE OF DEATH

St.

Registered No.

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

2 full name Ruth B . Regan

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

(a) Residence. No. 33 HUtchlnSOn St

(Usual place of abode)

( bright )

PHYSICIAN- IMPORTANT

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

Length of stay: In hospital or institution __

(Before death) (Specify whether)

years

months

days.

(If nonresident, give city or town and State)

In this community if yrs- mos.

days.

PERSONAL AND STATISTICAL PARTICULARS

3 SEX

Female

4 COLOR OR RACE

White

5 SINGLE (write the word)

MARRIED

WIDOWED

or divorced Married

If married, widowed or divorced
HUSBAND of

(Cue maiden name of

(or) wife of James A.

(Husband's name in full)

Age of husband or wife if alive

30 years

IF STILLBORN, enter that fact here.

AGe29 Years —

Months Days

If less than 1 day

Hours Minutes

Usual

9 Occupation:

Housewife

Industry
or Business:

Own Home

Social Security No.

. . .

BIRTHPLACE (City)
(State or Country)

Lynn

Massachusetts

13 NAME OF
FATHER

Herbert '/right

(/)

14 BIRTHPLACE OF
FATHER (City)

(State or Country)

Nova Scotia

15 MAIDEN NAME
OF MOTHER

Florence

Schlahuber

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

Nova Scotia

Informant

(Address)

James Re&an (H^iS'b&frer )

Hutchinson St Wlnthrop

I HEREBY CERTIFY that a
wi(£ me 8EF0R£4h

(Signature

(Official Designation

or nthe&f ,

'/S' //&■-■

(Date of Issue/of Permitfr '

MEDICAL CERTIFICATE OF DEATH

18 DATE OF
DEATH

(Day)

T/yT

(Year)

ft ° ■ 19

b , 19 Y£ death is said to

19 j i I HEREBY CERTIFY, <fThat I attended deceased f/om
PWt . wYV . to

I last saw h alive on

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

Caa Qj Lvtnvy^

Due to

Major findings
Of operations

far/jvtQ Date of

? CJU'im'ulL *

Of autopsy
What test confirmed diagnosis?

T {/^i

IMPORTANT

Physician

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

20 Was disease or inirfry irp#ny way
If so, specify '

(Signed) , . ^ .

(Address)

21 Holy Cross ^

Place of Burial, Cremation or Removal.

DATE OF BURIAL J ^nUaiy

22 NAME OF

FUNERAL DIRECTOR

ADDRESS

Received and Filed

alden Mass

(City or Town)

hrop, Mass.

JAiiS

(Registrar)

EXTRACTS FROM THE LAWS OF THE
COMMONWEALTH OF MASSACHUSETTS
GOVERNING THE

RETURN OF CERTIFICATES OF DEATH

A^hysician 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 iu 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 cuapter ioriy-tLx, tnat tne 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.

(3) Medical Examiners will investigate and certify to all deaths sup-
posably due to injury. These include not only deaths .^ed 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

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

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

DRM R-301

ailjr (Commomoraltlf of fHossariinorlto
OFFiCE OF THE SECRETARY

DIVISION OF VITAL STATISTICS

STANDARD

CERTIFICATE OF DEATH

(City or town making return)

Registered No..

.8...

No.

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

(PHYSICIAN— IMPORTANT
(Was deceased a
U. S. War Veteran?

If BO,

specify WAR)

(a) Residence. No,.Ji.,

(Usual place of abode)

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

(Before death) "fSpecif ^whether)

.St.

(If nonresident, give city or town and State)

In this community yrs. mos. days.

PERSONAL AND STATISTICAL PARTICULARS

3 SEX

4 COLOR OR RACE

S SINGLE (write the word)

MARRIED
WIDOWED
or DIVORCED

Sa If married, widowed, or divorced

HUSBAND of

(Give maiden name of wife in full)

(or) WIFE of

(Husband’s name In full)

6 Age of husband or wife if alive years

7 IF STILLBORN, enter that fact here.

8 it I If less than 1 day

AGE Years Months.... ././... Days | Hours Minutes

Usual

B Occupation:..

Industry
10 or Busit.esa:..

18 MAIDEN NA
OF MOTHEF

18 EIRTHPLACE OF- ~
MOTHER

(State or country) (/ v

MEDICAL CERTIFICATE OF DEATH

18 DATE OF
DEATH

(Month)

(Bay)

/ Z.Y.A

(Year)

19 I HEREBY CERTIFY, That 1 attended deceased from

, I9..fg7>> yV- 19

last saw h,.4?<V??.aliTe on Cj&Crttrtr... 7?. 19. death is said to

have occurred on the date statedabove, at

Immediate cause of death

Due to

Other conditions

(Include pregnancy within 3 months of death)

Major findings:
Of operations .

Of autopsy

What test confirmed diagnosis?..

Date of.„

Duration

Important

PHYSICIAN

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

20 ® «i distue or injury in any ny related te eceuyation el deceeied?..

If ao, specify..

(Signed) M. D.

idresa)/.^

Received and filed

A TRUE COPY ATTEST:

(Registrar)

EXTRACTS FROM THE LAWS OF THE
COMMONWEALTH OF MASSACHUSETTS
GOVERNING THE

RETURN OF CERTIFICATES OF DEATH

A physician or registered hospital medical officer shall forthwith,
after the death of a person whom he has attended during his last Illness,
at the request of an undertaker or other authorized person or of any
member of the family of the deceased, furnish for registration a standard
certificate of death, stating to the best of hie 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
fourteen, 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, specifying 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 pro-
vision of this section, such physician or officer shall forfeit ten dollars.
For the purposes of this section 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 nineteen hundred and seventeen. — General Laws,
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 receiv-
ing tomb to another in the same cemetery, until he has received a permit
from the board of health or its agent aforesaid or from the clerk of the
town where the body is buried. No such permit shall be issued until
there shall have been delivered to such board, agent or clerk, as the case
may be, a satisfactory written statement containing the facts required by
law to be returned and recorded, which shall be accompanied, in case of an
original interment, by a satisfactory certificate of the attending physician,
if any, as required by law, or in lieu thereof a certificate as hereinafter
provided. If there is no attending physician, or if, for sufficient reasons,
his certificate cannot be obtained early enough for the purpose, or is in-
sufficient, a physician who is a member of the board of health, or em-
ployed by it or by the selectmen for the purpose, shall upon application
make the certificate required of the attending physician. If death is caused
by violence, the medical examiner shall make such certificate. If such a
permit for the removal of a human body, not previously interred, from
one town to another within the commonwealth cannot be obtained early
enough for the purpose, the certificate of death made as above provided
and in the possession of the undertaker desiring to make such removal
shall constitute a permit for such removal; provided, that such body shall
be returned to the town from which it was removed within thirty-six
hours after such removal, unless a permit in the usual form for the re-
moval of such body has been sooner obtained hereunder. If the death
certificate contains a recital, as required by section ten of chapter forty-

six, that the 1 eceased served In the army, navy or marine corps of the
United States In any war In which It has been engaged, such recital shall
appear upon the permit. The board of health, or its agent, upon receipt of
such statement and certificate, shall forthwith countersign it and transmit
it to the clerk of the town for registration. The person to whom the permit
is so given and the physician certifying the cause of death shall thereafter
furnish for registration any other necessary information which can be
obtained as to the deceased, or as to the manner or cause of the death,
which the clerk or registrar may require. — Chap. 114, Sec. 45, G. L.,
( Tercentenary Edition).

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; . . . — Generol 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
received a permit so to do from the board of health or its agent appointed
to issue such permits, or if there is no such board, from the clerk of the
town where the body is to be buried or the funeral is to be held, or from a
person appointed to have the care of the cemetery or burial ground In
which the Interment Is made. . . . Chap. 114, Sec. 46, G. L„ (Tercentenary
Edition).

RULES OF PRACTICE

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

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

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

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

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

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

SPACE FOR ADDITIONAL INFORMATION

ft"

1 4

Suffolk

(County)

IJFinthrop

■<

LCU

(City or Town)

No. 7 Beacon

®Ije (Enimitonfitealilj of (JlitassacIiuscitB

OFFICE OF THE SECRETARY

DIVISION OF VITAL STATISTICS

STANDARD

CERTIFICATE OF DEATH

To be filed for bnrUl permit
with Board of Health
or Its Agent.

Registrar’s No.

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

give its NAME instead of street and number)

PHYSICIAN-IMPORTANT

2 FULL NAME-

Anthony MacArthur

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

{tra i

(Was
U. S.
if so

deceased a
War Veteran, r\
specify WAR) "YL

(a) Residence. No.

7 Beacon

(Usual place of abode)

St.

Length of stay: In hospital or Institution...

(Before death)

(Specify whether)

years

months

days.

(If nonresident, give city or town and State)

In this community ^ yrs. nos. days.

PERSONAL AND STATISTICAL PARTICULARS

MEDICAL CERTIFICATE OF DEATH

3 SEX

4 COLOR OR RACE

5 SINGLE (write the word)

MARRIED

Male

White

widowed Divorced

or DIVORCED

5a If married, widowed, or divorced

HUSBAND of a

'Vr:,'

13 DATE OF
DEATH _

January 7* 12^6

(Month) (Day)

(Year)

(or) WIFE of

(Give maiden name of wife in full)

Beatrice A.MacNabb,

19 I HEREBY CERTIFY, That I attended deceased from

hejr , 19 V «/, to xZzV.^-2 , IS..

alive on a. , 19 death is said to

I last saw k_Un_

6 Age of husband or wife if alive.

(Husband’s name in full)

have occurred on the date stated above, atlf ^ ..

9 « Duratl

Immediate cause of death

7 IF STILLBORN, enter that fact here.

AGE._.

Years-

Months_

Days

If less than 1 day
Hours Minute:

9 Occupation: Druggist

Industry
10 or Business:

11 Social Security No.

015- ig- 7'3o6"

12 BIRTHPLACE (City)
(State or country)

13 NAME OF
FATHER

cannot be learned

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

cannot be learned

15 MAIDEN NAME
OF MOTHER

cannot be learned

7 ^ / ^ c- v a r

( rJ r? A-f y~ •-/ )

/ -

(Include pregnancy within 3 months of death)

IMPORTANT

Physician

Major findings:

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

Duration

IMPORTANT

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

cannot be learned

If so, specify.
(Signed)

Igucu; --f

(Address)

, M. D.

Informant-

(Address)

jss Doreen MacArthur,

i: xaoe ui jounar, uicmauuu ui ivcmuv ai. .(City or Town)

DATE OF B, U R I AL ^anLt .^Tyl2 ^1^4.0 19,

or^transit permit was issued:
standard certificate of death

22 funeral director Ja£.»H endersoiiQo,

ADDRESS _

-5l7-BroadgaytEveT.ett.Ua3S«.

Received and filed-

_19

(Registrar)

EXTRACTS FROM THE LAWS OF THE
COMMONWEALTH OF MASSACHUSETTS
GOVERNING THE

RETURN OF CERTIFICATES OF DEATH

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

No undertaker or other person shall bury or otherwise dispose of a human
body in a town, or remove therefrom a human body which has not been
buried, until he has received a permit from the board of health, or its
agent appointed to issue such permits, or if there is no such board, from
the clerk of the town where the person died; and no undertaker or other
person shall exhume a human body and remove it from a town, from one
cemetery to another, or from one grave or tomb other than the receiving
tomb to another in the same cemetery, until he has received a permit from
the board of health or its agent aforesaid or from the clerk of the town
where the body is buried. No such permit shall be issued until there shall
have been delivered to such board, agent or clerk, as the case may be,
a satisfactory written statement containing the facts required by law to be
returned and recorded, which shall be accompanied, in case of an original
interment, by a satisfactory certificate of the attending physician, if any,
as required by law, or in lieu thereof a certificate as hereinafter provided.
If there is no attending physician, or if, for sufficient reasons, his certificate
cannot be obtained early enough for the purpose, or is insufficient, a physi-
cian who is a member of the board of health, or employed by it or by the
selectmen for the purpose, shall upon application make the certificate re-
quired of the attending physician. If death is caused by violence, the medi-
cal examiner shall make such certificate. If such a permit for the removal
of a human body, not previously interred, from one town to another within
the commonwealth cannot be obtained early enough for the purpose, the
certificate of death made as above provided and in the possession of the
undertaker desiring to make such removal shall constitute a permit for
such removal; provided, that such body shall be returned to the town from
which it was removed within thirty-six hours after such removal, unless
a permit in the usual form for the removal of such body has been sooner
obtained hereunder. If the death certificate contains a recital, as required

by section ten of chapter torty-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.

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

—

6 & + zrT' / X) cy /) & 1/ S C

^ " ✓

,4,

777

r - -

vl R-303-A

S-F £

< ”■£

(A t; rr

; o

CO C - rH

<y I. b

a 2 g I

X . 3 W

“St;

•A 9 a

? >.

| S,vs<J/»/tk.-

2 / (County)

^0.

No.

(City or Town)

v .&C, ^

®lje (ttonnnonfitraltlf of ifl;is?nrlmsctts
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.

..WV_UH/L£ZI.(

Elizabeth . [

2 FULL NAME I -

(If deceased is u married, widowed or divorced wo ( — , .

,.) Residence. Nc l.l.fc ffe .ilM.lIWi "fl' «.

(Usual place of abode) 1

Length of stay: In hospital or Instltutlon^r^^. year* months -

( rtefnrp death) (Spoony whether)

KL ,./-\ /->- t^TZst' c» f Of death occurred in a hospital or institution,

njrdrt-lQ A ot.| gjve ;ts instead of street and number)

r PHYSI

J (Was

1 U. S.

t>f so s

• PHYSICIAN - IMPORTANT

ive also maiden name.)

deoeased a
War Veteran,
speoify WAR)..

days.

(If nonresident, give city or town and State)

In this oommunlty

yrs.

days.

PERSONAL AND STATISTICAL PARTICULARS

3 SEX

Female

4 COLOR OR RACq

White

5 SINGLE (write the word)
MARRIED

WIDOWED . ,

or DIVORCED -idOW~ J

5a If married, widowed, or divoroed

HUSBAND of

<CivR,Ef8gF>e>e

(Husband's name in full)

(or) WIFE of

6 Age of husband or wife if alive years

7 IF STILLBORN, enter that faot here.

AGE

.7.6.

Years .+..4: Months ,i..-ioaya

If less than 1 day
Hours Minutes

MEDICAL CERTIFICATE OF DEATH

9 Occupation: At HftfflS.

Industry

10 or Business:

11 Social Seourity No H.O.Ii.S..

12 BIRTHPLACE (City)
(State or country)

England

13 NAME OF
FATHER

Samuel Bainbridge

IS DATE OF
DEATH

(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
afa, as follows: (If an injury was involved, state fully.)

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

England

15 MAIDEN NAME

of mother Elizabeth Hea tj)loQ%e

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

20 Accident, suicide, or
Date of occurrence

Where did
Injury occur?

r'vhomicide (

( specify )

19...tf...&>.

(City or town ami State)

Did injury ooour In or about home, on farm, in industrial plaoe, or in public
place?

Manner of
Injury

, (Specify type of place)

Ct— c/v'v-

'as there an autopsy?

Nature of .

Injury

While at work? Wl

England

i7informantLeslie M Walker / Belati03 #Any \

m.mX)“T75 Heriiion'-ST".' WlnbhTbb >

21 Was disease or Injury in any way related to oooupation of deceased? ~

If so, speoify V/j \z

(Signed) ' ^ ***

(Address)

22 V o od la wn ...G.re ma t, o / £ ye re 1 1

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

DATE OF BURIAL A.Q..

I HEREBY CERTIFY that a
filed With me BEFORE the

: ^nature of '

°t.

(Official Designation)

actory standard certificate of death was
transit permit was Issued:

Board of Uea|Scf| d£other) /

late of Issue

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

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.

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
intercept, 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

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

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

(3) Medical Examiners will investigate and certify to all deaths sup-
posably due to Injury. These include not only deaths caused directly or in-
directly by traumatism (including resulting septicemia), and by the action
of chemical (drugs or poisons), thermal, or electrical agents, 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 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 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 iiilernul 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)

THIS CERTIFICATE CONSTITUTES SUCH PERMIT

3RM R-301

(Fljjf (EnmtnnmDeallb nf fHanBarfinartl*
OFFICE OF THE SECRETARY

DIVISION OF VITAL STATISTICS

STANDARD

CERTIFICATE OF DEATH

(City or town making return)

Registered No

(If death occurred in a hospital or institution,
give its NAME instead of street and number)
/ PHYSICIAN— IMPORTANT
t(Was deceased a
<U. S. War Veteran?

FULL NAM

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

(a) Residence.

(Usual place of abode)

Length of stay: In hospital or institutioi

(Before death)

(If nonresident, give city or town and State)

In this community yrs. mos.

months

(Specify whether)

MEDICAL CERTIFICATE OF DEATH

PERSONAL AND STATISTICAL PARTICULARS

8 SINGLE
MARRIED
WIDOWED
or DIVORC

(Year)

(Month)

That X attended deceased from

19 I H E RE BY C E
* 19

I last taw h .;..jr_^^*!ive on
have occurred on the date stall
Immediate cause of death

dm If married, widowed, or divorced
HUSBAND of

(Give maiden name of wife In full)

Duration

Important

(Husband's name in full)

8 Age of husband or wife if alive.

7 IF 8TILLBORN, enter that fact hei

If leas than 1 day

.Minutes

.Months.

Usual

9 Occupation:.

Industry
10 or Business:.

Important

Other conditions

(Include pregnancy within 3 months of death)

II Social Security No.

12 BIRTHPLACE (Ci!
(State or country) /

Major findings:
Of operations

13 NAME OF
FATHER

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

14 BIRTHPLACE OF
FATHER (City)-

(State or country)

Of autopsy

What test confirmed diagnosis?.

18 MAIDEN NAME
OF MOTHER ^

20 Wti diser-e tr injery hi eny n; re'ited tc ortupsiisn cl Jereased?
If so, specify ... ■rv (A rv

10 BIRTHPLACE OF

MOTHER (City)

(Stgtp/dr country)

: any

lace of Burial, ^Temationior Removal.

!y of Town)

(Addri

DATE OF BURIAL

22 NAME OF

FUNERAL DIREj

ADDRES&^&L

I HEREBY CERTIFY that a sat 1 s fa c Co
wu i fil^d with me BEFORE the burial

>ry, standard certificate of death
t or transit permit was issued:

[nature ol

[Official Designation)’

(Date of Issue o/ Pi

A TRUE COPY ATTEST:

(Registrar)

EXTRACTS FROM THE LAWS OF THE

COMMONWEALTH OF MASSACHUSETTS

GOVERNING THE

RETURN OF CERTIFICATES OF DEATH

A physician or registered hospital medical officer shall forthwith,
after the death of a person whom he has attended during his last Illness,
at the request of an undertaker or other authorized person or of any
member of the family of the deceased, furnish for 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. Lavs, Chap. 46, Stc. 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
fourteen, 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, specifying 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 pro-
vision of this section, such physician or officer shall forfeit ten dollars.
For the purposes of this section 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 nineteen hundred and seventeen. — General Laws,
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 receiv-
ing tomb to another in the same cemetery, until he has received a permit
from the board of health or its agent aforesaid or from the clerk of the
town where the body is buried. No such permit shall be issued until
there shall have been delivered to such board, agent or clerk, as the case
may be, a satisfactory written statement containing the facts required by
law to be returned and recorded, which shall be accompanied, in case of an
original interment, by a satisfactory certificate of the attending physician,
if any, as required by law, or in lieu thereof a certificate as hereinafter
provided. If there is no attending physician, or if, for sufficient reasons,
his certificate cannot be obtained early enough for the purpose, or is in-
sufficient, a physician who is a member of the board of health, or em-
ployed by It or by the selectmen for the purpose, shall upon application
make the certificate required of the attending physician. If death is caused
by violence, the medical examiner shall make such certificate. If such a
permit for the removal of a human body, not previously interred, from
one town to another within the commonwealth cannot be obtained early
enough for the purpose, the certificate of death made as above provided
and in the possession of the undertaker desiring to make such removal
shall constitute a permit for such removal; provided, that such body shall
be returned to the town from which it was removed within thirty-six
hours after such removal, unless a permit in the usual form for the re-
moval of such body has been sooner obtained hereunder. If the death
certificate contains a recital, as required by section ten of chapter forty-

six, that the 1 eceased served In the army, navy or marine corps of the
United States in any war in which It hat been engaged, such recital shall
appear upon the permit. The board of health, or its agent, upon receipt of
such statement and certificate, shall forthwith countersign it and transmit
it to the clerk of the town for registration. The person to whom the permit
Is so given and the physician certifying the cause of death shall thereafter
furnish for registration any other necessary information which can be
obtained as to the deceased, or as to the manner or cause of the death,
which the clerk or registrar may require. — Chap. 114, Stc. 45, G. L„
(Tercentenary Edition ).

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

RULES OF PRACTICE

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

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

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

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

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

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

SPACE FOR ADDITIONAL INFORMATION

extracts from tho laws on back of cftrtiflcoto.

If deoeased was a U. S. War Vataran, G. L. Chap. 46, Saotton 10, raqulraa phyalolans to Insert a reoltal to that affaot.

100m- (g)- 1-45- 155 10

-301 A

Clir ffiurunumtncaltfi of 4Df{a9eacf|iiertts

OFFICE OF THE SECRETARY

DIVISION OF VITAL STATISTICS

STANDARD

CERTIFICATE OF DEATH

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

Registered No.

(a) ResIdeW No.

(Usulil place of abode ^

( (If death occurred in a hospital or institution.

* 3t"(give its NAME instead of street and number)

r PHYSICIAN - IMPORTANT

I (Was deceased a

J U. S. War Veteran,

I if so specify WAR)

Length of itay: In nnsoitsl nr Institution

(Before death) (Specify whethe

years

months

(If nonresident, give city or town and State)
days. In this oommunlty^J^^yra. mos. daya.

PERSONAL AND STATISTICAL PARTICULARS

AL CERTIFICATE OF DEATH

5 SINGLE (write the
MARRIED

ord )

18 DATE OF
OEATH ...

(Year)

5a If married, wl
HUSBAND of ...

(or) WIFE of

Fed, gr

(Give maiden name of wife in hill)
(Husband's name In full)

H E lUr-i T C E R T I F Y , TKlt I attended deoeased from

6 Age of husband or wife if alive

years

7 IF STILLBORN enter that fact here.

If less than 1 day

Hours Minutes

I lest taw alive on....™^^»n«igt../<itf? , W/fp death is said to

have occurred on the dato stated above, at

Immediate oeuaecjl death

Due to

Other cendltlona

( Include pregnancy within 3 months of death)

Major findings:
Of operations .

14 BIRTHPLACE OF
FATHER (City)

(State or country)

15 MAIDEN NAME }

OF MOTHER

Data of..

Of autopsy

What test confirmed diagnosis? ..

Duration

IMPORTANT

Physician

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 bis 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 bis 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 leu ot cliapter loriy-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.

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

DATE OF ENTERING MILITARY SERVICE

DATE OF DISCHARGE

RANK, RATING

ORGANIZATION AND OUTFIT

SERVICE NUMBER

DEATH in plain terms, so that it may be properly classified. Exact statement ot UU-UfAliUN is very important.
See instructions and extracts from the laws on back of certificate.

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

R-301 A

Suffolk

(County)

No.

Wlnt.hrop

(City or Town)

387 Shirley

^Ehc (Commtmfoealtb of 4'WassacijUBP^s
OFFICE OF THE SECRETARY
DIVISION OF VITAL STATISTICS

STANDARD

CERTIFICATE OF DEATH

Registered No

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

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

2 FULL NAME

Elizabeth l, Saunders

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

(a) Residence. No. 387 Shirley

(Usual place of abode)

Length of stay: In hospital or institution years

(Before death) (Specify whether)

PHYSIC

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

IAN- IMPORTANT

months

St.

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^

or DIVORtytjdOWed

18 DATE OF
DEATH

( Month)

ffY6

(Year)

5a If married, widowed or divorced
HUSBAND of

(Giye maiden giame oLwife in full)

Joseph Saunders

(Husband's name in full)

(or) WIFE of

6 Age of husband or wife if alive

years

7 IF STILLBORN, enter that fact here.

I BCREBY CERTiFf,

I last saw h alive on

have occurred oh\the dale stated above.
Immediate cause oHdeath

That I attended deceased ft
to

death is Said to
m

8 about

AGE fif) Years

Months

_ Days

If less than 1 day

Hours Minutes

Usual

9 Occupation:

Waitress

Industry
10 or Business:

Restaurant

Duration

IMPORTANT

Due to

11 Social Security No.

030--01— 5901

12 BIRTHPLACE (City)
(State or Country)

Lowell

Maaa_.

Other conditions

(Include pregnancy within 3 months of death)

13 NAME OF
FATHER

Cannot be learned

14 BIRTHPLACE OF
FATHER (City)

(State or Country) Cannot be learned

15 MAIDEN NAME

of mother Cannot

Major findings:
Ot operations

Of autopsy

What test confirmed diagnosis?

Date of

MPORTANT

Ph ysician

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

e learned

16 BIRTHPLACE OF
MOTHER (City)

(state or country) Cannot be lftamPrl

20 Was disease or^kljuix in any way related to occupation ot deceased?
If so, specify

(Signed)

(Add

informant Helen Brisco

(Address)

(

Relation, if any

-Oro-carcl

Rever.e.

I HEI$BY CERTIFY that a satiyttctory/JtaOdard certificate of death was filed
e BEF0Fl€-~y<e bur<j^y^F/t«nsrt, 'pwmjt was issued:

)ard^t£-'j^alln"T>r other)

y/x

(Date of I ssue /( Peri

.(Sigryiture of Age,
(Official Designation)

(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 be 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.

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

Medical examiners shall make examination upon the view of the dead
bodies of only such persons as are supposed to have died by violence.
If a medical examiner has notice that there is within bis 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.

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 iu 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

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.

(3) Medical Examiners will investigate and certify to all deaths sup-
posably due to injury. These include not only deaths .■ *u»ed 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 retn-ed 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

DEATH in plain terms, so that it may be properly classified. Exact statement of OCCUPATION is very important.
See instructions and extracts from the laws on back of certificate.

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

R-301 A

gale

1 Suffolk

q (County)

o Winthrop

(City or Town)

(The (Eontmonfiiealtlj of jHHaasacIjusctta
OFFICE OF THE SECRETARY
DIVISION OF VITAL. STATISTICS

STANDARD

CERTIFICATE OF DEATH

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

Registered No.

No.

34 Read ?£

st.

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

2 FULL NAiIatrlck W. Barry

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

(a) Residence. No.

(Usual place of abode)

34 Read

PHYSICIAN- IMPORTANT

(Was deceased a

U. S. War Veteran,

if so specify WAR)

St.

Length of stay: In hospital or institution

(Before death) (Specify whether)

years

months

days.

(If nonresident, give city or town and State)

In this communily44 yrs. mos.

days.

PERSONAL AND STATISTICAL PARTICULARS

3 SEX

4 COLOR OR RACE

White

5 SINGLE (write the word)

MARRIED

WIDOWED ,

or DIVORCED ff Id OWed

HusBANDio1:.RM,4divoU Norton

(or) WIFE of

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

6 Age of husband or wife if alive

years

7 IF STILLBORN, enter that fact here.

AGE

Years

Months

Days

If less than 1 day
Hours

Minutes

9 occupation: Retired Postal Clerk

Industry
10 or Business:

U. S. Goverment

11 Social Security No.

BIRTHPLACE (City)
(State or Country)

Boston

Mass

13 NAME OF

fatheI llllam

Barry

( t )
H
Z

lii

o :
<

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

Ireland

15 MAIDEN NAME

OF mother Ellen Hvde

16 BIRTHPLACE OF

MOTHER (Citv)

(State or Country)

Ireland

Informant ThOUlS. S
(Address) ~2)Q

Barry
Head St .

Relation, if any ^

I HEREBY CERTIFY that a satisfarfbry standard certificate of death was filed
with, W JI£F0Rf-4f»^ burial ^fl>f»r^it/Dierow was issued:

nature

(Official Designation)

MEDICAL CERTIFICATE OF DEATH

18 DATE OF
DEATH

(j (M«(tjifh)

/ 5

(Day)

7JW

(Year)

lu , I HEREBY CERTIFY, That I attended deceased from

0 d , 19 /-f , to /j 19 y &

19 ^Kdeath is said to

f - ** A,n

• . to

I last saw h alive on ld.A-1

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

Cx\ m

t0 [ahK.

Due

((Include pre

OtAAtAM>~

Other conditions

.Include pregnancy withilff 3 months of death)

Major findings:
Of operations

Date of

Of autopsy

What test confirmed diagnosis?

Duration

IMPORTANT

(XuA ciWot-C .£. y.

IMPOR^AN;

Physician

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

20 Was disease ofinjur) in any way stated to occupation of deceased? Av-c?

It so, specify A /J / (A TJT~~

(Signed) U U 1/ 1 /.rr? ^ / , M. D.

(Address) 57 O iJZTit Date ' /I $ 19

2, Winthrop /

Place of Burial, Cremation or Removal.-

DATE OF BURIAtJ S-H,.. 1 6

(City or Town)

22 NAME OF

FUNERAL DIRECTOR

ADDRESS

Winthrop

Received and Filed

miTM::

(Registrar)

EXTRACTS FROM THE LAWS OF THE

COMMONWEALTH OF MASSACHUSETTS

GOVERNING THE

RETURN OF CERTIFICATES OF DEATH

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

No undertaker or other person shall bury or otherwise dispose of a human
body in a town, or remove therefrom a human body which has not been
buried, until he has received a permit from the board of health, or its
agent appointed to issue such permits, or if there is no such board, from
the clerk of the town where the person died; and no undertaker or other
person shall exhume a human body and remove it from a town, from one
cemetery to another, or from one grave or tomb other than the receiving
tomb to another in the same cemetery, until he has received a permit from
the board of health or its agent aforesaid or from the clerk of the town
where the body is buried. No such permit shall be issued until there shall
have been delivered to such board, agent or clerk, as the case may be,
a satisfactory written statement containing the facts required by law to be
returned and recorded, which shall be accompanied, in case of an original
interment, by a satisfactory certificate of the attending physician, if any,
as required by law, or in lieu thereof a certificate as hereinafter provided.
If there is no attending physician, or if, for sufficient reasons, his certificate
cannot be obtained early enough for the purpose, or is insufficient, a physi-
cian who is a member of the board of health, or employed by it or by the
selectmen for the purpose, shall upon application make the certificate re-
quired of the attending physician. If death is caused by violence, the medi-
cal examiner shall make such certificate. If such a permit for the removal
of a human body, not previously interred, from one town to another within
the commonwealth cannot be obtained early enough for the purpose, the
certificate of death made as above provided and in the possession of the
undertaker desiring to make such removal shall constitute a permit for
such removal; provided, that such body shall be returned to the town from
which it was removed within thirty-six hours after such removal, unless
a permit in the usual form for the removal of such body has been sooner
obtained hereunder. If the death certificate contains a recital, as required

by section leu oi chapter loriy-six, tuat 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 tor registration.
The person to whom the permit is so given aud 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
intermtnt 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.

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

information should be carefully supplied. Aub should be stated LAAbiLi. rnioitiAnD should state
CAUSE OF DEATH in plain terms, so that it may be properly classified. Exact statement of OCCUPATION
is very important. See instructions and extracts from the laws on back of certificate.

R-301 A

3, SEX

®fj t fflnmmnmnraltlj of JHafiaarlfUflrlta
OFFICE OF THE SECRETARY

DIVISION OF VITAL STATISTICS

STANDARD

CERTIFICATE OF DEATH

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

2 FULL NAME

(If deceased

(a) Residence. No

(Usual place of abode)

Length of stay: In hospital or institution

1 is a marriecLJvidowed or divorcejtvwoman, give also maiden name.) / / . '

(If nom

Registered No.

.15...

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

(If U. S.

ar Veteran
specify WAR)

(Specify whether)

year3 ' months

days.

(If nonresident, fake, city or town and state)

In this community ^yrs. mos. days.

PERSONAL AND STATISTICAL PARTICULARS

ICAL CERTIFICATE OF DEATH

4 COLOR OR RACE

S SINGLE (write the word)
MARRIED /! • //

18 DATE OF
DEATH

or DIVORCE

5a If married, widowed, or divorced
HUSBAND of

(Month)

jkSL

(Day)

>1%L

(Year)

(or) WIFE of..

full)

6 Age of husband-dr wife if alive years

I HEREBY CERTIFY, That I attended deceased bom

, 19 , to , 19

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

have occurred on the date stated above, at m.

Immedial

7 IF STILLBORN, enter that fact here.

8 J /j I If less than 1 day

AGE.../..*f. Years Months Days! Hours Minutes

Usual

9 Occupation: . 1

Industry
10 or Business:

Due

mediate cause oWeatb...^..^

*!*•*^^

to'

Duration

IMPORTANT

Due to..

11 Social Security No.

Other conditions

(Include pregnancy within 3 months of death)

12 BIRTHPLACE (City).....'!t^.

(State or country) jTjyfyfi

(Registrar)

EXTRACTS FROM THE LAWS OF THE
COMMONWEALTH OF MASSACHUSETTS
GOVERNING THE

RETURN OF CERTIFICATES OF DEATH

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

No undertaker or other person shall bury or otherwise dispose of a
human body in a town, or remove therefrom a human body which has
not been buried, until he has received a permit from the board of health,
or its agent appointed to issue such permits, or if there Is no such board,
from the clerk of the town where the person died; and no undertaker or
other person shall exhume a human body and remove it from a town, from
one cemetery to another, or from one grave or tomb other than the receiv-
ing tomb to another in the same cemetery, until he has received a permit
from the board of health or its agent aforesaid or from the clerk of the
town where the body is buried. No such permit shall be issued until
there shall have been delivered to such board, agent or clerk, as the case
may be, a satisfactory written statement containing the facts required by
law to be returned and recorded, which shall be accompanied. In case of an
original interment, by a satisfactory certificate of the attending physician,
if any, as required by law, or in lieu thereof a certificate as hereinafter
provided. If there is no attending physician, or if. for sufficient reasons,
his certificate cannot be obtained early enough for the purpose, or Is in-
sufficient. a physician who is a member of the board of health, or em-
ployed by it or by the selectmen for the purpose, shall upon application
make the certificate required of the attending physician. If death is caused
by violence, the medical examiner shall make such certificate. If such a
permit for the removal of a human body, not previously interred, from
one town to another within the commonwealth cannot be obtained early
enough for the purpose, the certificate of death made as above provided
and In the possession of the undertaker desiring to make such removal
shall constitute a permit for such removal; provided, that such body shall
be returned to the town from which it was removed within thirty-six
hours after such removal, unless a permit in the usual form for the re-
moval of such body has been sooner obtained hereunder. If the death
certificate contains a recital, as required by section ten of chapter forty-
six. that the deceased served in the army, navy or marine corps of the
United States In any war in which it has been engaged, such recital shall
appear upon the permit. The board of health, or its agent, upon receipt of
such statement and certificate, shall forthwith countersign it and transmit
It to the clerk of the town for registration. The person to whom the permit
is so given and the physician certifying the cause of death shall thereafter
furnish for registration any other necessary information which can be
obtained as to the deceased, or as to the manner or cause of the death,
which the clerk or registrar may require.— Chap. 114, Sec. 45. G. L„
( Tercentenary Edition).

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

RULES OF PRACTICE

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

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

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

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

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

SPACE FOR ADDITIONAL INFORMATION

extract* from the laws on back of certificate.

If deceased war a U. S. War Vataran, Q. L. Chap. 46, Saetlon 10, raqulraa physlolans to Insert a reoltal to that aftaot.

100m- (g)- 1-45- 155 10

-301

Suffolk

(Coanty)

-I

^0.

Wintbirop. ....

(City or Town)

no 22...WilXc.w.._'S! MXnthto® ...

(Dip (Cuninuintucaltli of iHassadiusctis

OFFICE OF THE SECRETARY

DIVISION OF VITAL STATISTICS

STANDARD

CERTIFICATE OF DEATH

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

Registered No.

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

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

PHYSICIAN - IMPORTANT

2 FULL NAME William... J....Montgomery.

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

(a) Residence. No 22 Willow at WtTll.1lT*Op SL

(Usual place ot abode)

{PHI

(Was
U. S.
if so

deceased a
War Veteran,
specify WAR) .UO.

Length of stay: In hospital nr Institution

(Before death) ( Specify whether)

years

months

days.

(If nonresident, give city or town and State)

In thla oommunity £Qjn. moe. days.

personal ano statistical particulars

MEDICAL CERTIFICATE OF DEATH

3 SEX

male

4 COLOR OR RACE

white

5 SINGLE (write the word)
MARRIED
WIOOWEO

of divorced married:

5a If married, widowed, or divorced m -t ■* , ~ -

husband of Ellen. .M. •Cleary

(Give maiden name of wife in hill)

(or) WIFE of

(Husband's name In full)

6 Age of husband or wife if alive

1&.

years

18 dDeAaTtEh0F ; JbRSte 2-2 LfXA...

■ '(Month) (Day) (Year)

19 I, HEREBY CERTI F,Y , ^ That I attended deceased from

J.... , 19..!tAL 4.0 WzzjQ

I last saw h uamnoXUo on . 19 .^^death Is said to

have occurred on the date stated above, at

Immediate cause of death

7 IF STILLBORN, enter that fact here.

AGE y.y.. Yeer,

Ntonths

...2.7ba

If less than 1 day
Hours Minutes

s cause of death J.

Usual

9 Occupation :

Block-maker

Due to

10 or Business: .Bos^

11 Social Security No. Qc£l.— 1 U3-— 9824-

Due to .

12 BIRTHPLACE (Cily)
( Stale or country)

..LTlTohh:

Other conditions

(Include pregnancy within 3 months of death)

13 NAME OF
FATHER

James Montgomery

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

St John
New Bruns wl ck

15 MAIDEN NAME
OF MOTHER

Emma Clark

Major findings:
Of operation* .

Oita of..

Of autopsy

What test confirmed diagnosis} .

IMPORTANT

Phyartetao

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

16 BIRTHPLACE OF

MOTHER (City) fe.t.....J.Ohn

(State or country) NeW BrUTtSWlck

informant Ellen ^ M..MontgQmery

(Address) _ 22 Willow Ave (Hnthrnn

any

I HEREBY CERTIFY that a satisfactory standard oertlfioate of death w„s

filed with me BEFORE the burial or transit permit was Issued i

(Signs tare of Agent of Board of Health or other)

CLcjiAJr-' Gu^a~. X x. J u (,

(Offirial designation) 7 (Date of l*aue oy Ptlrmlt)

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

If ao, speoify

(Signed)

M. 0.,

(Address) .yrT" . Oats 19 ^

2i tf/iitthrop cemetery .(inthrop _

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

date of burial January. 23 .194.6

19..

22 NAME OF yi j J r, tv- . s

FUNERAL DIRECTOR . nlCIiar.Q C • K1 T hy

ADDREss Boston

Reoeived and filed ,.x.

19.

Registrar)

EXTRACTS FROM THE LAWS OF THE
COMMONWEALTH OF MASSACHUSETTS
GOVERNING THE

RETURN OF CERTIFICATES OF DEATH

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 frem 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 oi chapter toriy-stx, tnat the deceased served in the army,
navy or m~.rine 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 oaly such persons as are supposed to have died by violence.
If a medical examiner has notice that there is within his county the body
of such a person, he shall forthwith go to the place where the body lies
and take charge of the same; . . . —General Laws, Chap. 38, Sec. 6.

RULES OF PRACTICE

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

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

Statement of Cause of Heath. — 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

DATE OF ENTERING MILITARY SERVICE

DATE OF DISCHARGE

RANK, RATING

ORGANIZATION AND OUTFIT

SERVICE NUMBER

Suffolk

(County)

Wlnthrop

(City or Town)

3.1

Centre

(Die (Commonwealth of ^ilHassiecIiusctts

OFFICE OF THE SECRETARY

DIVISION OF VITAL STATISTICS

STANDARD

CERTIFICATE OF DEATH

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

Registered No.

2 full name August J. Petzke

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

(a) Residence. No. 31 Centre -&C

(Usual place of abode)

St.

Length of stay: In hospital or institution

(Before death) (Specify whether)

years

months

days.

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

PHYSICIAN- IMPORTANT

(Was deceased a

U. S. War Veteran,

if so specify WAR)

(If nonresident, give city or town and State)

In this community2

yrs.

mos.

days.

PERSONAL AND STATISTICAL PARTICULARS

MEDICAL CERTIFICATE OF DEATH

3 SEX

-Male-

4 COLOR OR RACE

White..

5 SINGLE (write the word)

MARRIED

WIDOWED -

oroivoRCEMarrled

18 DATE OF
DEATH

(Month)

2. 3

(Day)

a**

5a If married, widowed.ar diyorcad t

husband of Hattie Mar tell

(Give maiden name of wife in full)

(or) WIFE of

(Husband's name in full)

6 Age of husband or wife if alive

13 fj I HEREBY CERTIFY,

I last saw li^«-vC<C|alive on
have occurred on the date stated above.

That I attended deceased from

'/A** 2. Z-

years

7 IF STILLBORN, enter that fact here.

c . 19 death is said to

a7e1

Years

Months

Days

If less than 1 day
Hours

Minutes

9 occupati&hlpper

Industry
10 or Business:

Hood Milk Co,

II Social

Security mg 2 ~ 10 - -7 53T JTTJ

12 BIRTHPLACE (City)
(State or Country)

13 NAME OF
FATHER

Germany-

Cannot be learned

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

Germany

15 MAIDEN NAME

of mother nannot. be learned

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

Ge rmany

Hattie Petzke (•§**

(Address) ~51 Centre St.

, if any

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

(Signedl^xX

(Address) £rf Date

2, iVlnthrop^ 7 in thro p

Place of Burial, CrematiQp or Remora,

DATE OF BURIAL

or Kemo^a

own)

I HEREBY CERTIFY that a satisfactory standard certificate of death was filed
with me BEFORL^ the Q^rajjfsit permit was issued:

\ ^ignatifreoi Agent

UA£~/f^ ^

(QmcialH)esi^hatfon)

^alth of or)
(Date of of Permit)

22 NAME OF

FUNERAL DIRECTOR

ADDRESS

vrqR John F. O'
.Yinthrop

Received and Filed

JA?5 29 MB.

(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 ot
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 ot
his death ... Gen. Laws, Chap. 16, 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 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” shal include the China relict
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.

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 Prov'deffi
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 deaih is caused by v!°'*ncf/
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 chapter torty-tut, tuat the deceased served m 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.

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.

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