The volume, 1947

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T ■;*>*?•

; fit&

J. L. FAIRBANKS DIV.
Thomas Groom & Co.

Stationers

105 State St., Boston

To duplicate this book order

No.

)

RM R-301 A

to *j

i o

1 £
E

\Eiie Cammottfoealtfy of iMassarl|ueptts

OFFICE OF THE SECRETARY

DIVISION OF VITAL STATISTICS

STANDARD

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

Registered No.

h occurred in a hospital or institution,

gTve its NAME instead of street and number)

2 full name Annie Slanch (Cropley ) Moody

(If deceased is a married, jjjjduwed or divorced woman, give also^ajiden name.)

(a) Residence. No.

(Usual place of abode)

Length of stay: In hospital or institution v - yean? » mo

(Before death) (Specify wheth/r) ys f-TTl P —

months

days.

(If nonresident

In this community dV yrs.

PHYSICIAN- IMPORTANT

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

SK~4 14S>

or town and State)

days.

PERSONAL AND STATISTICAL PARTICa

4 COLOR OR RACE

5 SINGLE (write the word)

MARRIED Vl *

WIDOWED
or DIVORCED

5a If married, widowed or divorced
HUSBAND of

(Give maiden najne qf wife

FreaericK moo

(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

7 s*

Years

Months

Days

If less than 1 day
Hours

Minutes

Usual

9 Occupation:

Industry
10 or Business:

11 Social Security No.

12 BIRTHPLACE (City)
(State or Country)

Tl<r

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

(Address

/ illation. if any

MEDICAL CERTIFICATE OF DEATH

18 DATE OF
DEATH

th)

(Day) /

/*V7

(Year)

I HEREBY CERTIFY,

«fiB -

Pk 30 .

I Hast saw h -ft/- alive on
have occurred on the date stated above, at

That I attended deceased from

TIFY, That I attende
. 19 , to

death is said to

Immediate cause qf_ deaths

Duration

IMPORTANT

Due to CLccdt
Duo -to

cA.r-i* w i

Other condition

(Include pregnancyoviUiin 3 gionths of d<Afh) .

-IMPORTANT

Of operations

’ - tx/77 /SYS

Of autopsy YUVvU

diagnos.srC^^f^Wi^

What test confirmed i

impo:

(t> dc

*y>

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

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

(Signed)'^sC>v~v-<-«5-tr ( ^c~~ — — yj — t
(Address) l^fi^Wate W- I

1 4* Vi m ^

21 Winthrop ....

Place of Burial. Cremation or Removal

UntHrop

(City or Town)

DATE OF BURIAL

ADDRESS
Received and Filed

JAN 3 1347

(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 t/eatb of a person whom he has attended during his last illness, at the
reauest of an undertaker or other authorized person or of any member of

illness, when last seen alive by the physician or officer and the date ot
hia death , . . Gen. Laws, Chap. 46, bee. 9.

A physician or officer furnishing a certificate of death as required by the
preceding section orby 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 wh ch
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 .tbcP"™|ty
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
?ion and of section, forty-five, forty;.ix and the Chfna reUe

one hundred and fourteen, the word war shall *nc>u.def th* 1 ??'“* "*'**
expedition and the Philippine insurrection, which shall, for said purposes
bePdeemed to have taken place between February fourte 'nth>

hundred and ninety-eight and luly fourth “a^.lxte en^ nd nine^
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
burfed 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 i boar rd, from
the clerk of the town where the person died; and no undertaker or other
person shall exhume a human body and remove lt ™m a r,*n' «£“ving
eemeterv to another, or from one grave or tomb other than tne receiving
tomb to another in the same cemetery, until ^he has rece ived ^a permit f
ihr hoard of health or its agent aforesaid or from the cleric oi tne 10 i
where the body is buried, ffo such permit shall be issued until there shall
have been delivered to such board, agent or clerk, as th« case may be,
a satisfactory written statement containing the facts required by law to be
returned^nd^ recorded, which shall be accompanied in case of an original
interment, by a satisfactory certificate of the attending physician,

L. required by law or in lieu thereof a certificate as hereinafter provided.
If there is no attending physician, or if, for sufficient reason^ his certificate
cannot be obtained early enough for the purpose, or is a

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 c*rtlfi.c®*5
nuired of the attending physician. If death is caused by violence, the medi-
« examiner , Si 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 af*" such 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 lorty-aix, tuat the deceased served in the army,
n£vy or marine corps of tbe United States in any war in which it has been
engaged, such recital shall appear upon the permit. The bo?rd °f
or its agent, upon receipt of such statement and certificate, shall forthwith
countersign it and transmit it to the clerk of the town for rcgMstrat.om
The person to whom the permit is so given and the physician certifying
the cause of death shall thereafter furnish for rrg.stranon 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, oec. 6.

No undertaker or other person shall bury a human body or the ashes
thereof which have been brought into the commonwealth until he has re-
ceived a permit so to do from the board of health or its agent appointed to
issue such permits, or if there is no such board, from the clerk of the town
where the body is to be buried or the funeral 13 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 physician* 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.

(S) Medical Examiners will investigate and certify to all deaths sup-
posahly due to injury. These include not only deaths caused P1

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 trom
injury or infection related to occupation, the sudden deaths of persons not
j- i- '.-.-A .tiennon onH n^rsnns 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

Suffolk

(County)

W inthrop

(City or Town)

3r©4 Hil&and Avenue-Fisher Rest Home

(Comnumfoealtlj of JMaBBacIjusetts
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.

st.

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

2 full name Jacob Mendoza

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

(a) Residence. No. 1510 North Shore Road, .

(Usual place of abode)

Rest Home 7

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

(Before death) (Specify whether)

C PHYSICIAN- IMPORTANT

J (Was deceased a
J U. S. War Veteran, y.

( if so specify WAR)

Revere , Mass.

(If nonresident, give city or town and State)

In this community

days.

PERSONAL AND STATISTICAL PARTICULARS

MEDICAL CERTIFICATE OF DEATH

3 SEX

male

4 COLOR OR RACE

white

5 SINGLE (write the word)

MARRIED

WIDOWED

or divorced Divorced

18 DATE OF
DEATH

(Mont|J»f

O’,

(Day)

5a If married, widowed or divorced
HUSBAND of ./r&.

( (Give maidennsme of_wjfe in full)

\ Olive. El well

(Husband's name in full)

19 r • HERpBY CERTIFY, That I attended deceased from

J- 4; ....... 19 V <P, to ^ dtl ' 19 ^ y

(or) WIFE of

6 Age of husband or wife if alive

years

7 IF STILLBORN, enter that fact here.

I HEREBY CERTIFY,

I last saw h 1 alive on ./•l*-'*-? "

have occurred on the date sfated above, at ^7 df "
Immediate cause^qf death

AGE

Years

Months

Days

use_o
' <

If less than 1 day
Hou rs

Minutes

9 Occupation: Cigar-Packer (retired)

Industry
10 or Business:

Due to

death is said to

m ’ Duration

IMPORTANT

11 Social Security No.

none

12 BIRTHPLACE (City)
(State or Country)

London ,

fcnpland

Other conditions

(Include pregnancy within 3 months of death)

13 NAME OF
FATHER

Abraham Mendoza

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

London,

England

15 MAIDEN NAME

of mother Abagail Lyons

Ma^or findings:

operations

Date of

Of autopsy 1 ^

What test confirmed diagnosis?

IMPORTANT

Physician

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

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

London ,

England

17 informant .«Iudah Mendoza ,
(Address) 151Q N. Shore Road

CRc,i#tfrifany )

Revere.

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

It so, specify

(Signed)

(Address' Z-dS- — ■V’ Data

21 TA15rsrmsen; W« _ io*. kYxxxsk

Place of Burial, Cremation oi Removal. VCity or Town)

date of^ burial January 5j

22 NAME OF SI » ‘ -t"

FUNERAL DIRECTOR /d^^TtL / ft „

aooress 420 Harvard Street

Received and Filed

Ml 134?

Brookline.

(Registrar)

Dr. Daniel O'Brien-73 Washington Ave-Winthrop

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 bis 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 bis 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, bis 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 cnaptcr lorty-sut, tuat 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 registiation any other neces-
sary information which can be obtained as to the deceased, or as to the
manner or cause of the death, which the clerk or registrar may require. —
Chap. 114, Sec. 45, G. L., (Tercentenary Edition).

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

RULES OF PRACTICE

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

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

(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 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

FORM R-301 A

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(Elje QJommmtfosaltfj of ,i®ta86acl]usetts
OFFICE OF THE SECRETARY
DIVISION OF VITAL. STATISTICS

STANDARD

CERTIFICATE OF DEATH

\ A . .

Registered No.

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

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

2 FULL NAME

(If deceased is'a married, wi

PHYSICIAN- IMPORTANT

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

(a) Residence. No.

(Usual place of abode)

Length of stay: In hospital or institution

(Before death) (Specify whether)

years

months

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

days.

PERSONAL AND STATISTICAL PARTICULARS

3 SEX

4 COLOR OR RACE

5 SINGLE tiyrite the word)

MARRIED ) • >

W,D0WErDc

or DIVORC

5a If married, widowed or divorc
HUSBAND of . _

(Give maiJ?n nam§

(or) WIFE of

(Husband’sldame i

6 Age of husband or wife if alive

years

7 IF STILLBORN, enter that fact here.

AGE

Years ^

Months

jJL

Days

Usual

9 Occupation:

If less than 1 day
Hours

Minutes

11 Social Security No.

Industry
10 or Business:

12 BIRTHPLACE (City)
(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)

( R2&ZZf..

(Address i

I HEREBY CERTIFY that a satisfactory standard /certificate of death w^S filed
,nre BEFORE/ the burial or transit permit was issued:

A AgTr)t /f^Hoard ofHed^ffP o^hUier)

(Date of Issuer of P

MEDICAL CERTIFICATE OF DEATH

18 DATE OF
DEATH

(Mo/th)

</ / ?47.

(Day) / (Year)

19~^ I HEREBY CERTIFY
I las/ saw h-t-v~*^ alive on

have occurred on the date st;
Immediate cause of death
CftrE.

Due to

That I attended deceased from

S4V-V- , 19 ^7
3 , 19 y 7, death is said to

/4f /*r

■) eject

£f/«_

<^AaS^>*^L r

Due to

Other conditions i

(Include prsamlncy within^) months of death)

Ma^or findings:

operations

Date of

Of autopsy ^

What test confirmed diagnosis^^XA*vJt<t^T.<^TAtVr^^>,i^f

Duration

IMPORTANT

■$/> ,
3

IMPORTANT

Physician

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

'y©

20 Was disease or injury in any way related to occupation of deceased? 1
It so, specif . . - n . 1

— - . v-5- , M. D.

Received and Filed

JSS f 1^4?

(Registrar)

EXTRACTS FROM THE LAWS OF THE
COMMONWEALTH OF MASSACHUSETTS
GOVERNING THE

RETURN OF CERTIFICATES OF DEATH

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

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

No undertaker or other person shall bury or otherwise dispose of a human
body in a town, or remove therefrom a human body which has not been
buried, until he has received a permit from the board of health, or its
agent appointed to issue such permits, or if there is no such board, from
the clerk of the town where the person died; and no undertaker or other
person shall exhume a human body and remove it from a town, from one
cemetery to another, or from one grave or tomb other than the receiving
tomb to another in the same cemetery, until he has received a permit from
the board of health or its agent aforesaid or from the clerk of the town
where the body is buried. No such permit shall be issued until there shall
have been delivered to such board, agent or clerk, as the case may be,
a satisfactory written statement containing the facts required by law to be
returned and recorded, which shall be accompanied, in case of an original
interment, by a satisfactory certificate of the attending physician, if any,
as required by law, or in lieu thereof a certificate as hereinafter provided.
If there is no attending physician, or if, for sufficient reasons, his certificate
cannot be obtained early enough for the purpose, or is insufficient, a physi-
cian who is a member of the board of health, or employed by it or by the
selectmen for the purpose, shall upon application make the certificate re-
quired of the attending physician. 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 ot chapter lony-iix, 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.
'I he person to whom the permit is so given and the physician certifying
the cause of death shall thereafter furnish for registration any other neces-
sary information which can be obtained as to the deceased, or as to the
manner or cause of the death, which the clerk or registrar may require.—
Chap. 114, Sec. 45, G. L., (Tercentenary Edition).

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

RULES OF PRACTICE

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

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

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 c^use 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

)RM R-301 A

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l1"

| -So

^ T

1*3
*< £
°o.S
E u. o

i’OJi

*3?

. < n

‘°v i

is J

/»Z

»< «

; a- o

5 1

=8 =
■s

5 c

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ill

is j

!* d

JO >
5 1

l R

«ns: ;

**18 3

r£

-I

^0.

Suffolk

(C«anty)

Winthrop

(City or Town)

®hp (Uuninumtucnltlj of jWassacljusr tts

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 .TC

No.

..§.4...c.pttas§....Aye.A, sl { 'Ld'rrNAME‘mS^cf snsz 7ndT«*ra

2 FULL NAME -

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

death occujrred in a hospital or institution,
stead of street and number)

PHYSICIAN - IMPORTANT

(a) Residence. No. .

(Usual place of abode)

84 Cottage Ave.

Length of stay: In nnsoltal Institution

(Defore death) (Specify

years

months

days.

{rni

(Was
U. S.
if so :

deceased a
War Veteran,

specify war) ....none

rhetherl

(If nonresident, give city or town and State)

In thla community 1 yra. 3 m0®- days.

PERSONAL AND STATISTICAL PARTICULARS

3 SEX

male

4 COLOR OR RACE

white

5 SINGLE (write the word)
MARRIED

WIDOWED .. . ,

or divorced Mamed

5a If married, widowed, or divorced _ .

husband of Helen. .Lee....Bri.der. ■••■....

(Give maiden name of wife in full)

(or) WIFE of

(Husband's name In full)

6 Age of husband or wife if alive

35"

7 IF STILLBORN, enter that fact here.

8 Qn p Ilf less than 1 day

AGE Yeara 9 Months .A.W.. Days l Hours Minutes

Usual

9 Occupation:

Salesman

Rubber

ll Social Security No. ...0.I5=l6.rJ.675:

Industry

10 or Business:

12 BIRTHPLACE (City) M.j.d.He.tOn,.LlaS.Sw.7

(State or country)

13 NAME OF
FATHER

Alpheus Noyes,

14 BIRTHPLACE OF
FATHER (Cltvl

... Bow.NHT.

(State or country)

IS MAIDEN NAME
OF MOTHER

Harriett Coolidge Walke

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

Lowe 11, Mass.

informant ( ..Sftjtta. If

fAddr.v.1 04 .Qttace AVft- Eli n + hyryp o 00

any

I HEREBY CERTIFY that a satisfactory standard o.rtlfloat. of daath wa*
tiled with naa BEFORE the bqrtal or transit oarmlt was Issuads

MEDICAL CERTIFICATE OF DEATH

18ddeaatteh0F Jmmw.A'im

(Month) (Day) (Year)

19 I HEREBY CERTIF/,

19.^6 Ao

I last saw h...fefc*v... allva on

have occurred on tha data stated above, at
Immediate oauae of death

That I attended deooased fro
• 19

19. death Is said to
f m.

* Duration

IMPORTANT

Due

Due to..

.4- 4.&.,

Other condition.

Othi

Include pregnane

icy^Uh^p ^8^i^ootl

t&s of

Major findings:
Of operations .

Data of

Of autopsy

What test confirmed diagnosis?

IMPORTANT

Phyufctan

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

If to, spsoify

(Signed)

(Address)

kd Q .

21 yakdal«....CBmc.ier.y_ .ll.iddletonjMassw *

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

a ui uunai, viciua tiuu ur rcuiutri,

DATE OF BURIAL «.*

.47.

22 NAME of

FUNERAL DIRECTOR

J .E .Henderson Co..

gHal or transit oarmlt. was Issued 1 r,.»wl, vinu'wi... • , , ’

| address J.1.7 Broadway, bve re ttjjasft,,.

of Board of Hssfla ofoth.r)

IJJ2...

(Data of Inane of Qannlt)

Raoalvod and Died.

JS4t

i»..

(Rsfidrtr)

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 tnc 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 temb 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
s pepnit 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 or cnapter loriy-six, luat 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).

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.

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.

Statement of Occupation. — Precise statement of occupation is very im-
rtant, so that the relative healthfulness of various pursuits can be known,
ake 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

skeuM k« carefully supplied. ACI should b« 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 an*
extracts from the laws on back of certificate.

If deemed was a U. S. War Veteran, Q. L. Chap. 46, Section 10, requlree pliyelolans to Insert a reoltal to that effeot.

RM R-301 A

la.

Suffolk

(Ceunty)

®hp (Euninuut&Jealtlf of .JHitsBacIjuscttB

OFFICE OF THE SECRETARY

DIVISION OF VITAL. STATISTICS

STANDARD

CERTIFICATE OF DEATH

o Wintnrop

“J (City or Town)

3 no st

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

Registered No

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

m [ PHYSICIAN • IMPORTANT

2 FULL NAME TllO.iPs-?: J . VlcC^be J <Was deceased a

(If deceased Is a married, widowed or divorced woman, give alto maiden name ) I “• War Veteran,

I if so specify WAR)

(a) Reeldenca. No. ...2Q....lMLUIL..Bjk.C....A./.l2.*..,. St

(Usual place of abode)

Length of stay: In Hospital "r Institution

(If nonresident, give city or town and State)

(Before death)

(Specify whether)

yeara

months

dsys.

In this oommunlty

■yrs.

days.

PERSONAL and STATISTICAL PARTICULARS

3 SEX

iA^ie

4 COLOR OR RACE

Wnite

5 SINGLE (write the word)
MARRIED
WIDOWED

or DIVORCED Miirri SCL

5, If married, li JJ

HUSBAND
(or) WIFE of

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

6 Age of husband or wife if alive ,yU years

7 IF STILLBORN, enter that fact here.

AGE

Yeere Months

Days

If less than 1 day
Hours Minutes

Usual n

9 Occupation : v.U^.JTiX..

10 or* Business: U.f S .... JIJ U.§.t .QjJttJjl .

1 1 Social Security No.

12 BIRTHPLACE (City) £.0. SbOft

(Slate or country) M&fi3 .

13 NAME OF
FATHER

f GGuiiis Me Cube

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

Ireland.

15 MAIDEN NAME

of mother Briquet Wall

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

Ireland

Informant ...<

( Add rets)

b*9SA±T*f9!i^-r!,j£

Relation, If any

v • Wile

ft liMiru^

MEDICAL CERTIFICATE OF DEATH

18 DATE OF T _ c

oeath Jan. 6 194?

(Month)

(Day)

(Year)

19 I HEREBY CERTIFY, That I attended daoeased from
19.. Sfe-ra •to U . . &. , 19 ftt.

I last saw alive on (fa 19 y/f death Is said to

/ ■j c '

have occurred on the data stated above, at J..Q..ZZ m.

Immediate oauaa of death

Due to .

IMPORTANT

Oue to .

Other conditions. ..

(Include pregnancy within 3 months of death)

Major findings:
Of operations .

J&btJLa...

Oats of .

Of autopsy ... U&xtiL*

test oonflrmed dlagnoslaT

What

Duration

IMPORTANT

Phy*ic4ao

Underline
(he cause ro
which death
should be
charged sta-
tistically.

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

If so, spool fy. 4..... ^ \

(Signed)

(Address)

21 yv i n t nrpi; ' Wi n .*■> £*r

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

DATE OF BURIAL JtjJ2 m S

1^.7...

FUNERAL DIRECTOR Ri-CJXird H. Will 1 6

aooress ...1:»? WinUix-v^. St-, iifl.ttiiir.Qp..

Rooaivad and Iliad. ....

•J-Ari-l-Q-t-94'f-

( Registrar)

EXTRACTS FROM THE LAWS OF THE
COMMONWEALTH OF MASSACHUSETTS
GOVERNING THE

RETURN OF CERTIFICATES OF DEATH

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

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.

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-
??rfant’ 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

H i.S

2 <

la.

O
UJ
O

3 No.

(CltTgOr^wi^ s rae ^ Hospital

®lje Cttotnntoitfapaltff of JHaseacIjuaetls
OFFICE OF THE SECRETARY
DIVISION OF VITAL STATISTICS

COPY OF

CERTIFICATE OF DEATH

BOSTON

(City or town making return)

Registered No.

130 A

, O.

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

Genevieve Minsky f (if u. s.

2 FULL NAME ... War Veteran,

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

Hn-hr'hin^on Winthrop Mass.

(a) Resldenoe. No St

(Usual place of abode)

Length of stay: In hospital or Institution

(Before death) (Specify whether)

years

months

days.

(If nonresident, give city or town and State)

In this oommunlty yrs. mos.'' days.

PERSONAL AND STATISTICAL PARTICULARS

MEDICAL CERTIFICATE OF DEATH

3 SEX

4 COLOR OR RACE

5 SINGLE (write the word)

MARRIED . .

widowed Married

or DIVORCED

DEAT H°F .

(Month)

(Day)

(Year)

5a If married, widowed, or dlvoroed
HUSBAND of

(Give maiden ni

(or) WIFE of —

(Husband’s name in full)

19 I HEREBY CERTIFY, That I attended deoeased f/otn

., 19... 46..., to ... , 19.3.Z..

..D.ec-w....5..

in full)

I last saw h ^.T.. alive on

19 ... death is said to

have ooourred on the date stated above, at .6.i.l.QA^.

6 Age of husband or wife If alive

1ST

years

7 IF STILLBORN, enter that fact here.

Immediate oause of death

...failure..

AGE....*..' Years.

Months..

I If less than 1 day
..Days I Hours Minutes

Usual

9 Ocoupation:

Housewife

Industry

10 or Business:

11 Sooial Seourity No.

None

12 BIRTHPLACE (City)
(State or country)

Boston Mass.

13 NAME OF
FATHER

David Plotnick

14 BIRTHPLACE OF

Russia

FATHER fCitvl

(State or country)

15 MAIDEN NAME
OF MOTHER

Mary Rosenberg

16 BIRTHPLACE OF
MOTHER fCitvl

Russ ia

(State or country)

Informant...

(Address)

„ , , , Relation, if any

Husband ... ( .)

«r

A TRUE COPY.
ATTEST:

DATE FILED ^..

erWhijwhere death occurred)

Jan*8...„ 19 4.7.

Due to..

Rheumatic heart disease

Due to..

Other conditions

(Include pregnancy within 3 months of death)

Major findings:
Of operations .

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

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

If so, speolfy

(Signed) L WQ.l5.ky ... m n

l“b io 1 1

Date of

Of autopsy

What test oonfirmed diagnosis?..

Duration

T-2 "Mo S e

"6" Yrs

Physician

(Address) 3.30... B.I?Q&lcl All.©.... Date

21 place of burial, Qnichtv Cem-Mel rose Mass

CREMATION OR REMOVAC ?.

Jags M.

(City or Town)

DATE OF BURIAL 19

H J Torf

22 NAME OF

FUNERAL DIRECTOR ^

address Chelsea Ma.ss (

Reoelved and filed

JAN2"2"t^-4"7- — —

(Registrar of City or Town where deceased resided)

i •-

5RM R-301 A

* O

a Z

•or "own jn

(Elir GT u ni mint lu calif] of .JNassadinsrtts

OFFICE OF THE SECRETARY

DIVISION OF VITAL STATISTICS

STANDARD

CERTIFICATE OF DEATH

2 FULL NAME

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

•--/

Registered No A. ...

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

L s,. ..

place of abode) /? / ' * )l—0 (If nonresident, ifive city or

or divorced woman, pive alao maiden name.)

r PHYSICIAN - IMPORTANT

J (Was deceased a

"S u. s.

War Veteran,
pecify WAR)

..lUr

(a) Residence,

(Usual

Length of stay: In nnsoltal or Institution

(Before death) f Specify

town and State)

years

months

days.

In this community

ether)

yrs.

days.

PERSONAL ANO STATISTICAL PARTICULARS

3 SEX

■i^r t ;

4 COLOR OR RACE

ioMxfc.

5 SINGLE (write the word],
MARRIED
WIDOWED
or DIVORCED '

5a If married, widowed, or divorced

HUSBAND of

(Cive maiden name of wife in full)

(or) WIFE of

(Husband's name In hill)

6 Age of husband or wife if alive

7 IF STILLBORN, enter that fact here.

Years

Months Days

If less than 1 day
Hours Minutes

Usual

9 Occupation;

Industry

10 or Business:

K “jj . $

U • .

<i,i5 S

j-oli f-

■ L)

OJ 3 s j

z-SjS 6

Q- U~- .

<o».° 5

«.< ‘A i

oa >

11 Social Security No.

fib**#

12 BIRTHPLACE
(Slate or count

13 NAME OF
FATHER

14 BIRTHPLACE of
FATHER (Cily) .

(State or country)

15 MAIDEN NAME
OF MOTHER

16 BIRTHPLACE OF f

MOTHER (Cily)

(State or country)

I HEREBY CERTIFY that a satisfactory standard oertlfloata of death was
Hied with me BEFORE tha burial or transit oermlt was Issued i

, (alRwatare of Agaat »< Board of Health nr other)

/*/yZ

MEDICAL CERTIFICATE OF DEATH

DEATH0!! ff'. /.S'Y..

( (Month) (Day y (Year)

(Official Designation)

( Date of IsaVe of permit)

19 I HEREBY CERTIFY, That I attended deoeased from

19 , 4o , 19

I last taw h alive on , 19 , death Is said to

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

Duration

mmedlata cause of death

' IMPORTANT

Due to

Due to .

Other conditions

t Include pregnancy within 3 months of death)

Major findings:
Of operations

Of autoDsy

What test oonflrmed diagnosis?

Data of

IMPORTANT

Physician

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

20 Was disease or injury in or,y way related to oooupatlon of deerrsnd? ..

If so, tpaoify.../3. — 0,

(Signed) ^ M. 0.

( Address) Oita 19

^B^Crem

22 NAME OF

FUNERAL DIRECTOR

ADDRESS

Reoelved and died

/] (Citf or 1 own )

(X <K*W ■ ■■/■/.

( Registrar)

EXTRACT8 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 bis 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 cnapter toriy-six, tuat 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).

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.

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

WRITE PLAINLY, WITH UNFADING BLACK INK - THIS IS A PERMANENT RECORD

Coplea of returns of deaths recorded during the previous month which occurred in your city or town in caae the deceased
resided in another city or town at the time of death ahouid be made forthwith and transmitted on Form R-302 to the clerk
of the city or town in which the deceased resided. (See Chap. 46, Sec. 12, 0. L.)

ORM R-302

(County)

(City or Town)

(EtmtmpitfnpaHfy of iWTaseacfpisetts

OFFICE OF THE SECRETARY

(City or town making return)

2 FULL NAME.

(If deceased is a m

(a) Resldenoe. No. JL.L-
(Usual place of abode)

Length of stay: In hospital or Institution

(Before death) (Specify whether)

OFFICE OF THE SECRETARY

DIVISION OF VITAL STATISTICS

COPY OF

CERTIFICATE OF DEATH

— - - -- - .... Registered No

y) Jjtj sfS . Ad-iVo Un J Vy _. S (If death occurred in a hospital or institution,

St. ( give it8 name instead of street and number)

widowed or- divorced

woman, give also maiden name.) f v ' ,

5, sk

(If u. s.

War Veteran,
Jfy WAR)

years months / days.

(If nonresident, give city or town and State)

In this community yrs. mos. days.

PERSONAL AND STATISTICAL PARTICULARS

3 SEX I 4 COLOR OR RACE

5 SINGLE, (write the word)

MARRIED^ .

Wl DOWE/7^LrTXt<^^

or DIVORCED

IS DATE OF
DEATH

5a If married, widowed, or divoroed
HUSBAND of

(or) wife of

(Husband's name in futy)

6 Age of husband or wife If allv

7 IF STILLBORN, enter that faot here.

Years Months .

Days

If less than X day
Hours Minutes

Usual

9 Occupation:

Industry

10 or Business:

11 Sooial Seourity No.

12 BIRTHPLACE (City)
(State or country)

13 NAME Of

FATHE^U-Q^

14 birthplace or

FATHER (City) ..

(State or country)

15 MAIDEN NAME . n

OF “0

16 BIRTHPLACE OF
MOTHER (City) ..

(State or country)

A TRUE COPY.
ATTEST:

DATE FILED ..

(Registrar of city or tbwn where death occurred)

MEDICAL CERTIFICATE OF DEATH

* (Year)

1 9/Ji HEREBY 1C E R T.I.F Y , That I attended deoeased from

19^4. to .\j IS^Z

I last saw h^ri^?/...alive on 19 ,.^/death Is said to

have ooourred on the date stated above, at ...

Immediate

, of death ....

Due to .

Other conditions

(Include pregnancy within 3 months of death)

Major findings:
Of operations..

Date of .

Duration

Physician

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

,'Xo.

Of autopsy

What test oonflrmed diagnosis 3^.

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

T Cemetery) (City or Towp)^/^.

DATE OF BURIAL !9 ^

21 PLACE OF
CREMATION

22 NAME OF

FUNERAL DIRECp

ADDRESS

Reoelved and filed 19

EE.a.2., j.Q.4.7

(Registrar of City or Town where Tleceased resided)

WRITE PLAINLY, WITH UNFADING BLACK INK - THIS IS A PERMANENT RECORD

Coplea of returns of deatha recorded during the previous month which occurred in your city or town in case the deceased
resided in another city or town at the time of death should be made forthwith and transmitted on Form R-802 to the clerk
of the city or town in which the deceased resided. (See Ohap. 46, Sec. 12, 0. L.)

ORM R-302

x } SUFFOLK

(City or Town)

dtmtmtmfnealtlj of JRaseacfyuaetis
OFFICE OF THE SECRETARY
DIVISION OF VITAL STATISTICS

COPY OF

CERTIFICATE OF DEATH

BOSTON

(City or town making return)

Registered No.

....2.62.... 9

No.

P,eth Israel ^OSTDital c. J (H death occurred in a hospital or institution,

»•■«*■* SL < give itg NAme instead of street and number)

Mrs Rae Elf man fotu. s

2 FULL NAME 4 War Veteran,

(If deceased is a married, widowed or divorced woman, give also maiden name.) I speolfy WAR) f.ASr.

20 Beach st Winthroff

(If nonresident, give city or town and State)

(a) Resldenoe. No.

(Usual place of abode)

Length of stay: In hospital or Institution. ll.Q.S.pi.ti.S.1
(Before death) (Specify whether)

years

months

177

days.

In this oommunlty

yrs.

,177

days.

PERSONAL AND STATISTICAL PARTICULARS

3 SEX

Female

4 COLOR OR RACE

White

5 SINGLE (write the word)

MARRIED . •,

widowed I. armed

or DIVORCED

5a If married, widowed, or divoroed
HUSBAND of

<«> wife louffil' °?l*f’SVf1 ’*11' ** '“u>

(Husband’s name in full)

6 Age of husband or wife if alive XL/. years

MEDICAL CERTIFICATE OF DEATH

ddeattehof Ja.nu.ar.x....9.....19.ta..'...,

(Month) (Day) * (Year)

19 I HEREBY CERTIFY, That I attended deoeased from

.Q.p.t 1.5 - , 19.4-6.., to ,J.a.n....9. , i9.i4-7-

I last saw h....er alive on J.ELn....^. , 19...-..., death It said to

have ooourred on the date stated above, at... l.Q.z.JQP. ...m. 1

Immediate oause of death

7 IF STILLBORN, enter that faot here.

AGE.I4.6.... Years Months

Days

If less than 1 day
Hours Minutes

Usual

9 Occupation:

Rous ewife

Industry

10 or Business:

11 Soolal Seourity No. dOOG

12 BIRTHPLACE (City) ...t'Q.nt.E.ej&l...

(State or country) Canada

13 NAME OF
FATHER

Louis Greenfield

14 BIRTHPLACE OF
FATHER ( Citvl ...

(State or country)

Russia

15 MAIDEN NAME
OF MOTHER

Anna Markowitz

16 BIRTHPLACE OF

MOTHER (Citvl

(State or country)

Russia

Informant . ...Louis Elfma.n , ( .MMM

(Address) 20 Beach Rq Winfchrop

A TRUE COPY^*W . C^Oi^ _ . ' _

ATTEST:

*-)

_ city or town where death occurred)

DATE FILED L..J&n....X.3.~..19U-7 19..

Pemphigus

Due to

Due to-

other conditions

(Include pregnancy within 3 months of death)

Major findings:
Of operations..

Date of .

Physician

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

What test oonflrmed diaflnosisfAll.i.O.pSU.

20 Was disease or Injury in any way related to oooupatlon of deoeased? L.Q..
If so, speolfy

(Signed) .1: 'e.ur.i.c.a....Ka.ufmn m. d.

(Address) ...B.....X...H Data. 1/9 19 ...lljL

Of autopsy ,...A?....$.fe.Q.Y.@..

Duration

"7lli?s

21 PLACE OF BURIAL, -r T

CREMATION OR REMOVAL Tif ai\0.t.h I-S-Tael

DATE OF BURIAL

(Cemetery) £ g re &^wn)

Jan....lL I.94.7 19

22 NAME OF r. ^ ,

FUNERAL DIRECTOR ...0.11 J F -Solf

address Brookline...

Reoeived and filed

2:21311.

(Registrar of City or Town where deceased resided)

■

WRITE PLAINLY, WITH UNFADING BLACK INK - THIS IS A PERMANENT RECORD

Copies of returns of deaths recorded during the previous month which occurred in your city or town in case the deceased
resided In another city or town at the time of death should be made forthwith and transmitted on Form R-802 to the clerk
of the city or town iD which the deceased resided. (See Chap. 40, Sec. 12, Q. L.)

ORM R-302

* WORCESTER

2 (County)

| RUTLAND

w
o

No.

(City orTpwn)tland state Sanatorium

®I|e CttmtirannfneaHIj of JHasearfp»etis
OFFICE OF THE SECRETARY
DIVISION OF VITAL STATISTICS

COPY OF

CERTIFICATE OF DEATH

RUTLAND

(City or town making return)

Registered No.

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

2 FULL

NAME J.Qfe?L... Jo S .©pL... en / War^Veteran,

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

90 Sagamore Ave . .. v; in t hr op. Mass .

(■) Residence. No S SL

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

Length of stay: In hospital or Instltu^iftiQ.^.tf.Q.iP.A.VI??- 4 years 9 months 13 days. In this community 4 yrs. 9 mos. 13 days.

(Before death) (Specify whether)

PERSONAL AND STATISTICAL PARTICULARS

3 SEX

. i.al e

4 COLOR OR RACE

Nhite

5 SINGLE (write the word)
MARRIED Mo-p-p-? far)
WIDOWED 1'ta.X i. -L«U
or DIVORCED

5a If married, widowed, or dlvoroed MaDiarOfc GreaVeS

HUSBAND of h?.

(Give maiden name of wife in full)

(or) WIFE of

(Husband’s name in full)

6 Age of husband or wife If alive 9.5 years

MEDICAL CERTIFICATE OF DEATH

7 IF STILLBORN, enter that faot here.

AGC..R.9. Years A. Months

Days

If less than 1 day
Hours Minutes

18 DATE OF
DEATH

January 9, 1947

( Month) (Day) (Tear)”

j'an .9

have ooourred on the date stated above, at .3..:..1.5.....A,..M. *n

last saw h lil alive on 4.an„* ^ , 19... ^7 death Is said to

Immediate cause of death

Pulmonary tMbeilGulo s is

9 Oooupatlon : Shipper

Industry

10 or Business:

Standard Oil Co.

11 Soolal Security No. R.Q.h-.®

12 BIRTHPLACE (City) ....h.OAUUl'y

(State or country)

Mass.

13 NAME OF
FATHER

Thomas Patten

14 BIRTHPLACE OF

FATHER (City)

(State or country) Ireland

15 MAIDEN NAME
OF MOTHER

Nor ah McCarthy

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

Ireland

Informant? San. Re COrdS / Relation, If any

(Address) . \ut 1 and , Mass", ^ *

I A TRUE COPY. '-T /), ^

| ATTEST:

(Registrar of city^ or town, wjbcrc^

I DATE FILED Z. !] 19

rred)

Due to..

Due to .

Other conditions

(Include pregnancy within 3 months of death)

Major findings:
Of operations .

Date of

Of autopsy

What test oonfirmed diagnosis?

in any wa

Unkn

Duration

13 year;

Physician

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

20 Was disease or injury in any way related to oooupatlon of deoeased?
if so. specify unknown.

(Signed)..,. ^a^I^o cHe —

( Address) U..V.l..s(H.d.....R.t..a.t..e T.fcih.* Datel/7.9 19.4Z...

Mthenedict , Boston, Mass

21 PLACE OF BURIAL,

CREMATION OR REMOVAL

or Town)

DATE OF BURIAL 19

22 NAME OF

FUNERAL DIRECTOR

ADDRESS

Frank H. Miles Co.
Jeff ers on. Miiss.

.1 19

F t&l

Reoelved and filed

(Registrar of City or Town where deceased resided)

FORM R-30S

•g-S3

cd 0) at

JjU

O) o

3 **-o

3JCJ3

3« Et
°“a

•£S~

CS5

|fco

2§E

o-o ?!

►>+5

oSo

■

*- c
3 efl ®

(ft O - o

z52 ^ o

O
Z
D (/)

CD H

K I

u.y

2*
kO
u <

5 Q

.5 c <u

"“S
*;5 k.
1 1®
3 5*-

c — cl

o r
O © «

f«o
^ S ft

2*^3 a

C11

■ j2 ■

I"s

> .fl

•5- -J

■e w
g**3~

£ |j= 2
© OCG
-C -.*<= -

1b*5

•S^d

*r O c «

° ^

» a. o O

2gS£

l " 17-' «

— c“ , £
o~ o-o ^

||| I |

o'** o T
f°5wO NO
O u o o

,L<kM4^.

(County)

ul (City or Town) fl-/- ' < — .

N *Cj2bL^^ St. { g

®he (Gtnutmmfbraltlf of JHassaclpjsetts

OFFICE OF THE SECRETARY

COPY OF

MEDICAL EXAMINER’S
CERTIFICATE OF DEATH

(City or town making return)

jt n

Registered No .'3....1.—

^0.

2 FULL NAME

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

(If deceased is a married,

Ksr.

../s?..:....!???

widowed or divorced woman, give also maiden name.)

St.

(a) Resldenoe. No.

(Usual place of abode)

Length of stay: In hospital or Institution years / months -3 days.

(Before death) (Specify whether)

(If nonresident, give city or town and State)

In this community yrs. mos. days.

PERSONAL AND STATISTICAL PARTICULARS

3 SEX

4 COLOR OR RACE

5 SINGLE (write the word)

5a If married, widowed, or divorced
HUSBAND of

(or) WIFE

(Husband’s name in full)

6 Age of husband or wife If alive years

7 IF STILLBORN, enter that fact here.

AGE

XL-

Years Months..

Days

If less than 1 day
Hours Minutes

Usual

9 Oocupatlon:

Industry

10 or Business:

11 Sooial Security No.

12 BIRTHPLACE (City)

13 NAME OF „
FATHER Qi

14 BIRTHPLACE
FATHER (Ci
(State or cour

ty) ^ .7“.. _

try) f

15 MAIDEN NAM
OF MOTHER

16 8IRTHPLACE
MOTHER (Ci

(State or cour

I n f o r m a n . . .

(Address)

Relation, if any

^yy -

A TRUE COPY.
ATTEST:

DATE FILED

lown where death occurred)

.4.1

MEDICAL CERTIFICATE OF DEATH

IS DATE OF
DEATH

// /9 4 2

(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.)

20 Aooldent, sulolde, orOhomlolde (specify).

Date of ooourrenoe !(?. 19 ....tfrlj.

Where did / /TJ/

Injury ocour?

(City or town and State)

Did Injury ooour In or about the home? qn_farai, In Industrial plaog. or In
publio plao

(Specify type of place)

SgT iJltM. ..d?^

” * °* Ouo CL*btr~u-c—

Nature

Injury

While at work? Was there an autopsy?.

21 Was disease or Injury In any way related to oooupatlon of deoeased?

If so, speolfy

(Signed) r..Y?:. M. D.

( Address) 'v*-wo«7Ar;.«..frA<^*. i..|r.b«MS»7..y .........

Place of Burial, Cremation or RemovaL (City or Town)

DATE OF BURIAL IS 19'

23 NAME OF \J C7 If) ' kV! fit

FUNERAL DIRECTOR

ADDRESS "St. (/....

RoCOl V0d find fl lod . .......... ■R,m..r^...ia.iM rn"'f"T * ••••••••••••••

FEBT [947

(Registrar of City or Town where deceased resided)

19.

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

RM R-3Q1 A

3 8EJC ^ 4 COLOR OR RACE

®fje ©ammonmealtlj nf HHammrljuHf Its
OFFICE OF THE SECRETARY
DIVISION OF VITAL STATISTICS

STANDARD
CERTIFICATE

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

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

*...St. I give its NAME instead of street and number)

2 FULL N

(a) Residence

(Usual place of abode'

(If U. S.

War Veteran,
specify WAR)..

Length of stay: In hospital or institution ..r^U

(Specify whether)

PERSONAL AND STATISTICAL PARTICULARS

(If nonresident, give city or town and state)

In this community yrg. mos. days.

S SINGLE (write the word)
MARRIED P - y>
WIDOWED— .^3-^" c
or divoRoed y

5a If married, widowed, or divorced

HUSBAND of

(Give maiden name of wife in full)

(or) WIFE of

(Husband's name in full)

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

IF STILLBORN, enter that fact here.

8 I If less than 1 day

AGE Years Months Days| Hours Minutes

Usual
^ 9 Occupation:.

Industry

I HEREBY CERTIFY that a satisfactory standard certificate of death
was^ijCd witbijffe BEFORE ^tp^urij^pV tr^rfyiit permit was issued:

of Board of Health or other)

JjjJ&L

of Issue el Permit/ '

(Date <

MEDICAL CERTIFICATE OF DEATH

18 DATE OF
DEATH

(Month) (Day) (Year)

19 I/HEREBY CERTIFY, That I attended deceased from

M.. , to 19..£.%

1 fast saw h^t.L. alive on 19 .^/ death is said to

have occurred on the date stated above, at m. '

Immediate cause of death.

Due to

Due to..

Other conditions

(Include pregnancy within 3 months of death)

Major findings:

Of operations

Of autopsy

What test confirmed diagnosis?.

..Date of...

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

If so, specify yCZ/. n^^T.r. —/

(Signed)..

IMPOITANT

PHYSICIAN

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

Racaivad and filed

JMZZiS'fJ (Registrar)

SA/st*/, rro/

EXTRACTS FROM THE LAWS OF THE
COMMONWEALTH OF MASSACHUSETTS
GOVERNING THE

RETURN OF CERTIFICATES OF DEATH

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

No undertaker or other person 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 cer ificate. If such a
permit for the removal of a human body, not previously interred, from
one town to another within the commonwealth cannot be obtained early
enough for the purpose, the certificate of death made as above provided
and in the possession of the undertaker desiring to make such removal
shall constitute a permit for such removal; provided, that such body shall
be returned to the town from which it was removed within thirty-six
hours after such removal, unless a permit in the usual form for the re-
moval of such body has been sooner obtained hereunder. If the death
certificate contains a recital, as required by section ten of chapter forty-
six, that the deceased served in the army, navy or marine corps of the
United States in any war in which it has been engaged, such recital shall
appear upon the permit. The board of health, or its agent, upon receipt of
such statement and certificate, shall forthwith countersign it and transmit
it to the clerk of the town for registration. The person to whom the permit
is so given and the physician certifying the cause of death shall thereafter
furnish for registration any other necessary information which can be
obtained as to the deceased, or as to the manner or cause of the death,
which the clerk or registrar may require. — Chap. 114, Sec. 45, G. L„
(Tercentenary Edition).

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

RULES OF PRACTICE

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

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

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

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

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

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

SPACE FOR ADDITIONAL INFORMATION

should bo carefully supplied. ACK should bo stated EXACTLY. PHYSICIANS should state CAUSE OF DEATH in plain
terms, so that it may bo properly classified. Exact statement of OCCUPATION is very important. See instructions end
extracts from the laws on back of certificate.

If deceased was a U. S. War Vataran, Q. L. Chap. 46. Seotlon 10, requires phyelolans to Insert a reoltal to that affaot.

100 m- (g)- 1 -4V 1 55 10

M R-301

®hr (ffuruntmtincaltlj of ,J{ta9Bacl)usrttB

OFFICE OF THE SECRETARY
DIVISION OF VITAL STATISTICS

STANOARD

CERTIFICATE OF DEATH

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

1 **

Registered No ii t i

,, I (If death occurred in a hospital or institution,
al*Vgr9e its NAME instead of street and number)

PHYSICIAN - IMPORTANT

2 FULL NAME

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

(a) Residence. No.

(Usual place of''abode)

Length of stay: In hospital nr Institution

(Before death) (Specify whether)

(If nonresident, give dry or town and State)

In this community ^^^yrs. mon. days.

PERSONAL AND statistical PARTICULARS

5a If married, widowed, or divorced

HUSBAND of .rf. ^ ........

// . (Oiye maiden name of wife In full )

(or) WIFE of

f HiTsDand's'naine (n full)

6 Age of husbend

/ «

(pr wife if alivt

1 IF STILLBORN, enter that fact here.

AGE °.Y Year*

Mentha

Usual

9 Occupation

77SZ

Days

If lass than 1 day
Hours Mlnutas

Industry

10 or Business:

11 Social Seourity No.

12 BIRTHPLACE ICity)
( Slate or country)

I HEREBY CERTIFY that a satisfactory standard oartlfloate of death was
£F9RE the burial *r transit permit was Issued i

Agent •( B< Mrd of HealtKinr other)

(OAetat Designation)

MEDICAL CERTIFICATE OF DEATH

19 I HEREBY CERTIFY, That I attended deosased from
Ahu/. 1.$ 19..%...., 4b...j£8d*t , 19^....

I last saw hj&r. allva on , 19 death Is said to

have occurred on the dato stated above, at ^..L. ‘is-.fr. m.

Immedlato cause of death

Due to

Other condltlona

( Include pregnancy within 3 months of death)

Major findings:
Of operations .

Data of.

Of autopjy

What test oonflrmed diagnosis? .

Duration

IMPORTANT

•/*—*•*-
A..<H 4!tUV&,

IMPORTANT

PhysfvHan

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

20 Was disease or injury in ony way related to occupation of deosased? (7T-0.
If so, spaolfy .^ry.

M. 0.

C.. . Date ... 19 j.J..

(Bate of la

City or Town)

ADDRESS

IZ..SSI.

22 NAME OF

FUNERAL DIRECTOR

Rapaived and bled

(Registrar)

- A

EXTRACTS FROM THE LAWS OF THE
COMMONWEALTH OF MASSACHUSETTS
GOVERNING THE

RETURN OF CERTIFICATES OF DEATH

No undertaker or other person shall bury or otherwise dispose of a human
body in a town, or remove therefrom a human body which has not been
buried, until he has received a permit from the board of health, or its
agent appointed to issue such permits, or if there is no such board, from
the clerk of the town where the person died; and no undertaker or other
person shall exhume a human body and remove it from a town, from one
cemetery to another, or from one grave or tomb other than the receiving
tomb to another in the same cemetery, until he has received a permit from
the board of health or its agent aforesaid or from the clerk of the town
where the body is buried. No such permit shall be issued until there shall
have been 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 secti >a ten oi 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).

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 orbits agent appointed to
issue such permits, or if there is no such board, front 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.

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

100m-(g)-l"tvmi0

-5 ouffolk.

ft- ouxa VAn.« _

uJ (County)

M o ...lin.tJa.r_op..* ....

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

Registered No ..C...tA

2 FULL NAME

(Elif (Eumnumfncaltlf of 4Wassacl|HsrttB

OFFICE OF THE SECRETARY

DIVISION OF VITAL STATISTICS

STANDARD

CERTIFICATE OF DEATH

(City or Town)

u 125 01 iff Avenue •> f<If death occurred in a hospital or institution,

No /*>•«.« "‘•(give jtJ NAME instead of street and number?

. „ , „ ^ . . PHYSICIAN - IMPORTANT

Adel la M0ntaiT9 J (Was deceased a

War Veteran, vs
specify WAR).....i^.r

(If deceased Is a married, widowed or divorced woman, give also maiden name.)
(a) Residence. No. . 12..5 G_l. Jt.f f .. SL ...

r PHY

J (Was

i U. S.

I if so s

(Usual place of abode)

Length of stay: In hnsolta* or Institution ,R..e.S..fc Jl.0.flie4 years

months

day9.

(Before death)

(Specify whether)

(tf nonresident, give city or town and State)

In this oommunlty ^5 T™* mos. days.

PERSONAL AND STATISTICAL PARTICULARS

MEDICAL CERTIFICATE OF DEATH

3 SEX

femald

4 COLOR OR RACE

white

5 SINGLE (write the word)
MARRIED
WIDOWED

18 DATE OF _ n r-

oeath J.anuary 15

(Montn) (Day)

□OWED c« 4 A

DIVORCED OJ.Ilg.LW

.1.94.7

(Year)

5a If married, widowed, or divorced

HUSBAND of ........

(Give meiden name of wife In hill)

(or) WIFE of

(Husband's name In full)

That I attended deoeased from

■4*4 19^

6 Age of husband or wife if alive years

19 I HEREBY CERTIFY

X 19.. 4o .

I last saw h .'AA' alive on.^*raa-S!Sflt /..*/ , 19.5^ death Is said to

have occurred on the date stned above, at ° ...Q-

7 IF STILLBORN, enter that fact here.

AGE 93

Yeart

Mentha

.14

Days

If less than 1 day
Hours Minutes

Immediate cause of death..

9 Occuoatlon: X.S.t.lT. S.dL..

Due to

Industry

10 or Business:

Due to .

11 Social Seourity No.

12 BIRTHPLACE (City)
( Slate or country)

nO.n.e.

Other condltlona..

(Include pregnancy within 3 mouths of death)

13 NAME OF

father Alexander Montaire

Major findings:
Of operations

14 BIRTHPLACE of

FATHER (City)

(State or country)

....'.Valdoboro

Maine.

15 MAIDEN NAME
OF MOTHER

unable to obtain

Of autopsy..

What test confirmed diagnosis? C^vvy'*.

Duration

IMPCffiTANT '

IMPORTANT

Physician

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

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

Maine

Informan
( Addre*«>

e....Boy.al.,

mao ave

any

20 Was disease or injury in any way related to oooupetlon of deoeased ? lh^O

If eo, epeoify__ *.f. a..

t Signed . M. D.

(Address) TO Date ‘Jj 6t 19 kf.-'J .

21 Woodlawn o4me.t ery. .. j;var e t ti.a ss../

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

date of burial. January 17,1.947

in/hrop St 7/ i nth r op'

19...

I HEREBY CERTIFY that a satisfactory 'standard oerllflo/te of death
Hied a*l)h ms BEFORE the burial aer transit permit was Issued:

/ 7 WSIgnatare of Af«ht e( Boaril of HealUrvir Other)

JjLl

(OfBctal Designation) J J (Date of Jnoue of Pi

22 NAME OF

FUNERAL DIRECTOR

.174... Wl

AOORESS

Reoelved and Iliad

-f-Wi^fj'ff

(Registrar)

. J

EXTRACTS FROM THE LAWS OF THE
COMMONWEALTH OF MASSACHUSETTS
SOVERNING THE

RETURN OF CERTIFICATES OF DEATH

by section ten or chapter tony-six, 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).

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.

Statement of Occupation. — Precise statement of occupation is very im-
ortant, so that the relative healthfulness of various pursuits can be known,
fake 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

i- (b) -6-44- 14607

2 FULL NAME.

2 (Coui

ounty)

®I je Crmtmmtfoealtlj of JfHaseadfusetts
OFFICE OF THE SECRETARY
DIVISION OF VITAL STATISTICS

COPY OF

CERTIFICATE OF DEATH

(City or town making return)

Registered No.

St.

!(If death occurred in a hospital or institution,
1

give its NAME instead of street and number)

(If deceased is a married, widowed or divorced woman, give also maiden name.)
(a) Resldenoe. No. ... 1JMA...A. u SL

(Usual place of abode)

Length of stay: In hospital or Institution

(Before death) (Specify whether)

days.

(If nonresident, give city dr town and State)

In this oommunlty yrs. mos. days.

PERSONAL AND STATISTICAL PARTICULARS

MEDICAL CERTIFICATE OF DEATH

3 SEX

4 COLOR OR RACE| 5 SINGLE (write the word)
MARRIED

r°?V;0ERDCED ' ^ -

IS DATE OF
DEATH

6 Age of husband or wife If alive

7 IF STILLBORN, enter that faot here.

5a If married, widowed, or dlvoroed
HUSBAND of

(or) WIFE of

(Husband's name in full)

R E B

A'... . — d

' (Month) fj (Day)

IS.

(Year)

nanie^bf wife in full)

m CERTIFY, That I attended deoeased from

, 19^..^, to ..SjgZko*.,. A 51.. , 19::..:%..

I last saw h._^t^<allve on....)i^Cl rZiSKt.i).. \9S..t death Is said to

have ooourred on the date stated above, at ..//:..?rr.!i...j!?.:.....

Remediate oause of di

AGE..I

'....Years Months..

Days

Usual

9 Occupation:

If less than 1 day

..Hours Minutes

Industry

10 or Business:

11 Sooial Security No.

12 BIRTHPLACE (City) ./Q.../Z //..

(State or country)

13 NAME OF
FATHER

14 BIRTHPLACE
FATHER (C
(State or country)

15 MAIDEN NAME .

°FM° ZU-

16 BIRTHPLACE ^ s s?

MOTHER

(State or country)

.'Relation, if any

(Address) SZA ■>_ — CZ

A TRUE COPY
ATTEST:

(Registrar of city or town where death occurred)
DATE FILED ..

Due to .

Other conditions

(Include pregnancy within 3 months of death)

Major findings:
Of operations .

Date of .

Of autopsy

Duration

...^...vfotjSTD •

Physician

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

What test oonflrmed diagnosis?

20 Was disease or Injury In any wi y related to oooupatlon of deoeased? dJ.j

21 PLACE OF BURIAL,

CREMATION OR REMOV,

(Cemetery)

DATE OF BURIAL

s.c.

(City or Town)

19..^$

22 NAME OF , .

FUNERAL DIRECT(lB-'w^Y~Art2<?Tfc<5fcr..,

ADDRESS

Received and filed 7 J.^.

(Iiegiatrar of City or Town where deceased resided)

WRITE PLAINLY, WITH UNFADING BLACK INK - THIS IS A PERMANENT RECORD

Copies of returns of deaths recorded during the previous month which occurred in your city or town in case the deceased
resided in another city or town at the time of death should be made forthwith and transmitted on Form R-802 to the clerk
of the city or town in which the deceased resided. (See Chap. 48, Sec. 12, Q. L.)

3RM R-302

.Suffolk

(County)

tCffe fflotttmnnfnraltfy of JtTaseadjuaetls
OFFICE OF THE SECRETARY
DIVISION OF VITAL STATISTICS

COPY OF

CERTIFICATE OF DEATH

Boston

(City or town making return)

570 $

Registered No _....., JJjtJ....

o B.Q.s.t.Q.n.

u (City or Town) ,

< no Mass. General Hospital ?1 J (If death occurred in a hospital or institution,

-i N0 “• ) give its NAME Instead of street and number)

- Q. i

Nellie Belcher f (if u. s.

2 FULL NAME , ■< War Veteran,

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

No. 77 Cottage Ave» st Winthrcfr Mass«

(If nonresident, give city or town and State)

Length of stay: In hospital or Institution years months 2 days. In this oommunlty yrs. mos. 2

(Before death) (Specify whether)

(a) Residence,

(Usual place of abode)

days.

PERSONAL AND STATISTICAL PARTICULARS

3 SEX

4 COLOR OR RACEl

w I

5 SINGLE (write the word)

widowed Widowed

or DIVORCED

MEDICAL CERTIFICATE OF DEATH

SS tEh0F Jan/l7/47

(Month) (Day)

(Tear)

5a If married, widowed, or divoroed

HUSBAND of

(or) WIFE of

(Husband’s name in full)

6 Age of husband or wife If alive years

7 IF STILLBORN, enter that faot here.

IM.

19 I HEREBY CERTIFY, . ,

vlan/lS/47. , 19 , to . Jan/17/47.., ~

I last saw h....®.T alive on .„.&d/17/' 4? , death is said to

have ooourred on the date stated above, at ll.j2.0AMm.

Thai

attended deoeased from
19..

Immediate oause of death

.Carcinoma ..of.. ..gall... blft.d.dg.r..

Years. Months Days I Hours .Minutes | Due to Rupture Olf gal 1 bladder

9 Occupation:

Industry

10 or Business:

Housework

11 Sooial Security No. Non®

12 BIRTHPLACE (City) Nova.. S-COtla

(State or country)

13 NAME OF
FATHER

John

Refuse

14 BIRTHPLACE OF

FATHER (Citv)

Nova

Scotia

(State or country)

15 MAIDEN NAME
OF MOTHER

Cannot be learned

16 BIRTHPLACE OF
MOTHER ( Citv)

Nova

Scotia

(State or country)

17(Addn*") Mrs ^ ..Rcl6!rtLn5dHJai^ it^Te

Duo to..

PeHton^

other condition. Hypertensive ...heart diseas^

(Include pregnancy within 3 months of death)

Major findings: Kfrtn*
Of operations .”?.'.1."

Date of .

Duration

5 Weeks
24 Hrs

24 Hrs

Physician

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

Of autopsy

What test oonflrmed diagnosis? &?..Y.PP?y.

20 Was disease or Injury in any way related to oooupation of deoeased?

If so, speolfy

(Signed) J. ,. M.

(Address)

..V.....S....M.O!>Sy ... . ... M. D

Mass^^eneral Ho apt Date l.ri.7 19 .*7

21 cremation8 oRIAREMolWjn.thr.Q.p >..... Q oni”Winthrop Mass

(Cemetery) (City or Town)

OF BURIAL Jan/21/4.7 19

(Cemetery)

Jan/21/47

22 NAME OF

FUNERAL DIRECTOR

ADDRESS

A A Duncan

Somerville ^ass.

Reoelved and filed . zzzz::JAIt3±:MI

(Registrar of City or Town where deceased resided)

RM R-301 A

It?

2Tlj c Cunutuuiiuraltl] of jWassjirlinsrtts

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.

1.3

Registered No.

( (If death occurred in a hospital or institution.
3*. \ gj

2 FULL NAME

(If deceased la/ a married, widowed or divorced woman. Rive/ alao maiden name.)

(a) Residence. No : St.

(Usual place of abode)

Length of stay: In no.Dltal or Institution y

(Before death) f Specify/whether)

yeara

months

days.

give its NAMK instead of street and number)

r PHYSICIAN - IMPORTANT

J (Was deceased a
| U. S. War Veteran,

^ ^ if so specify WAR) r

(If nonresident, give city or town and State)

In this community

yrs.

days.

PERSONAL ANO STATISTICAL PARTICULARS

3 SEX

4 COLOR OR RACE

5 SINGLE (wri^e the word)
MARRIED
WIOOWED
or DIVORCI

5a If married, widowed, or divorced

HUSBAND of ......

(Give maiden name of wife in full)

(or) WIFE of

(Husband's name In full)

( Year)

6 Age of husbsod or wife if alive

7 IF STILLBORN, enter that fact here.

AGE

Years

Months

Days

If less than 1 day

Hours Mlnutas

Usual

9 Occupation:

Industry

10 or Business:

II Social Security No.

^ r*U

12 BIRTHPLACE f City )
( Slate or romriry )

| 13 NAME OF
FATHER

14 BIRTHPLACE 0
FATHER (City)
(Stale or country)

15 MAIDEN NAME
OF MOTHER

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

I HEREBY CERTIFY that a satisfactory atandard oertlfloata uf death was
rORE the OufU) or transit permit was Issued :

•f Agent *

1 Designation)

loard of Hesrtuf oryither) ,

( Date of fsauybf Permit)/ / /

p Y »— C E FLTfL fit , Sf Isa t 1 attended— deoeased from

’/S.

olive on death Is said to

the date stated above,
jauaayjf death

st saw hr)6*rr.. „ _

have occurred on the date stated above, at m. —

Immediate ca

Due to

Oue to 7

Other conditions..

(Include pregnancy withii 1 months of death)

Major findings:

Of operations

Duration

IMPORTANT

Of autopsy

What test oonflrmed diagnosis?

Date of .

IMPORTANT

Phyniciao

Underline
the cause to
which death
should he
charged st.i-
tisticallv.

20 Was disease or injury in any way related to oooupatlon of deemed?
If 80, tpooify....^ .//. fa-y,.

( Signed) IT.... k

(Address)

my.

M. D.

Pete f f „ I9^y?

CCiky or 7 own)

i9 y.,7

Reoeived and Rlad 1J

- — - Mi-H-mi

(Rvyrietrur)

EXTRACT8 FROM THE LAWS OF THE
COMMONWEALTH OF MASSACHUSETTS
GOVERNING THE

RETURN OF CERTIFICATES OF DEATH

by section ten oi chapter iorty-six, 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).

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 prac;ice:

(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

Suffolk

(County)

Vint hr op

(City or Town)

?£Ije (£ mtt mmtfo ea It h 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.

no. finthrop Community Hospital

Registered No

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

2 full name Fraher

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

(a) Residence. No. 69 Fremont St

(Usual place of abode)

PHYSICIAN* IMPORTANT

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

St.

Length of stay: In hospital or institution r h P

(Before death) (Specify whether)

years

* J 2

months 3T*days.

/ r, __

' - --

(If nonresident, give city or town and State)

In this community yrs. mos.

days.

PERSONAL AND STATISTICAL PARTICULARS

3 SEX

ta_ .

4 COLOR OR RACE

'UCjlc

5 SINGLE (wr4e.the word)

married Bungle

WIDOWED u

or DIVORCED

5a If married, widowed or divorced
HUSBAND of

(Give maiden name of wife in full)

(or) WIFE of

(Husband's name in full)

6 Age of husband or wife if alive

7 IF STILLBORN, enter that fact here.

AGE

Years

Months

Days

Usual

9 Occupation:

Industry
10 or Business:

11 Social Security No.

(State or Country)

Fa a sar; hfi a a t t.a

13 NAME OF
FATHER

Thomas Fraher

14 BIRTHPLACE OF
FATHER (City)

Roxbury

(State or Country;

Massachusetts

LlI

15 MAIDEN NAME
OF MOTHER

AT 1 no F» Sea.rs

16 BIRTHPLACE OF
MOTHER (City)

Boston

(State or Country)

Massachusetts

Thomas Fraher ( ¥&'t>h£ry )
Fremont St. , Vinthrop

I HER£|3Y CERTIFY that a satisfactory standaul certificate of death was filed
re BEFjORf the burial of Jtansir berm tf/Was issued:

(Date of Issui

oftfer)

uerof PErnm)

MtCICAL CERTIFICATE OF DEATH

18 DATE OF
DEATH

I HER

(Day)

(Year)

years

p „ CERTIFY

/fl .19

I lastr slw alive on

havt i6ccurred on the date sta^S/above
Immediate cause

That

Ided deceased from

'/CM 13 .19 Y7

tr . 19 u ^^eath is said to

n/.

:f-^s than 1 dav j-

Hours -LD Minutes

Due to

Duration

(wyt '7fS

/ if*

Other conditions

(Include pregnancy within 3 months of death)

Major findings: J J a

Of operations rM.

Of autopsy

What test confirmed diagnosis?

20 Was disease or ii)fu}y in^fiy
If so, specify

EXTRACTS FROM THE LAWS OF THE
COMMONWEALTH OF MASSACHUSETTS
GOVERNING THE

RETURN OF CERTIFICATES OF DEATH

by secuon ten ot chapter tony -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 for registration.
The person to whom the permit is so given and the physician certifying
the cause of death shall thereafter furnish for registration any other neces-
sary information which can be obtained as to the deceased, or as to the
manner or cause of the death, which the clerk or registrar may require. —
Chap. 114, Sec. 45, G. L., (Tercentenary Edition).

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

RULES OF PRACTICE

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

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

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

1-9-44-1 4955

d]c (HomnumfaeaStSj of JUftassacljusefis
OFFICE OF THE SECRETARY
DIVISION OF VITAL. STATISTICS

STANDARD

CERTIFICATE OF DEATH

(If deceased is a mailed, widowrt^r divorced worn^ir, give also maidc

Residence. No. / ^ 'w 4 & C- '

(Usual place of abode; '

upf

laiderrname.)

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

Registered No.

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

jmber)

PHYSICIAN- IMPORTANT

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

Length of stay: In hospital or institution

(Before death) (Specify whet,

years - months ..

St.

days.

(If nonresident, give city or town and State)

In this community yrs. mas.

days.

PERSONAL AND STATISTICAL PARTICULARS

MEDICAL CERTIFICATE OF DEATH

4 COLOR OR'RACE

5 SINGLE (write the*svord) .

MARRIED
WIDOWED
or DIVORCED

5a If married, widowed or divorced
HUSBAND of

(Give maiden name of wife in full)

(or) WIFE of

(Husband's name in full)

s the*.word) -

6 Age of husband or wife if alive

7 IF STILLBORN, enter that fact here.

AGE Years

Months

Days

If less than 1 day
Hours

Minutes

Usual

9 Occupation:

Industry
10 or Business:

11 Social Security No

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

s5?

y..

15 MAIDEN NAME w
OF MOTHER

(State or Country)

Informant '•••/

■y ,

. / / / ( Relation„if any \

4 _ M.Jj. "/ •* (v . )

-Address,

I HEREBYtCERTIFY that a satisfactory standard certificate 'of death was filed
with me BEFORE the burial or traiftii nermilOwas issued:

UJc _ .

(Signature of AgejjQrU^f iGAwlP Health or other)

H-tO ■ 9^/.

(Official Designation) // (Date of Issuevif Pejmit)

18 DATE OF
DEATH

(Mi>

onth)

(Day)

/9J^ 7

(Year)

19 I HEREBY CERTIFY, That I attended deceased from

/?. ° , 19^ 1. , to JcfVry. ..!•*$? , 19

/ S T' // h o r v 1 / ^ XXr\ ✓_/

. - ,19 , death is said to

£ . o s- (p

I -tast-sew- h *h*e on

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

ZXt

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.

. -V-

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

Received and Filed

JAN 29 1941

(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.

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

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

RULES OF PRACTICE

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

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

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

3RM R-302

r fE Suffolk....

2 (County)

& .... Boston

(City or Town)

Cimtmtmfoealtlj of JHassadfuaetis
OFFICE OF THE SECRETARY
DIVISION OF VITAL STATISTICS

COPY OF

CERTIFICATE OF DEATH

Boston

(City or town making return)

7KCp» •?

Registered No. .... -AwtJL.

No,

II -S M Ho «!TVfc Cl $ (If death occurred in a hospital or institution,

1 .W.t?..y.y. St. < give jts NAME instead of street and number)

2 FULL NAME..

Frank Leonard Cot u. s. Spanish

■=■ : : -• {^tyWAR)^«.^.«.^?..

Winthrop Mass

(If nonresident, give city or town and State)

(If deceased is a married, widowed or divorced woman, give also maiden name.)
(a) Resldenoe. No. .....1.11....S .ynny .side.Ave sl

(Usual place of abode)

Length of stay: In hospital or Institution

(Before death) (Specify whether)

years months days. In this oommunity 44 yrs. mos. days.

1 hr and 50 mins*

PERSONAL AND STATISTICAL PARTICULARS

3 SEX

4 COLOR OR RACE

5 SINGLE
MARRIED
WIDOWED
or DIVORCED

(write the word)

Marriec

5a If married, widowed, or divoroed ua,,Ja (1 yrrm
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 ...: 57 yearn

7 IF STILLBORN, enter that faot here.

8 ca n c If less than 1 day

AGE. ...94... Years. ...7. Months..? Days Hours I

..Minutes

9 Occupation : Vet eran ...Foreman..

Boston Army Base

11 Sooial Seourity No 0i.2-zy-6.6bQ

Industry

10 or Business:

12 BIRTHPLACE (City)
(State or country)

..Jo.hns.on....ci.ty..I«m.*..

13 NAME OF
FATHER

Burke Leonard

14 BIRTHPLACE OF

FATHER f City I

New Jersey

(State or country)

15 MAIDEN NAME
OF MOTHER

Catherine Short

16 BIRTHPLACE OF

MOTHER fCitvl

Unable to learn

(State or country)

Informant

(Address)

|linl.|aX^e‘ar'&*."' )

A TRUlS^.^ * ^ J*

■y ( Registrar of < Ip

DATE FILBb L.

.'jni.2.7./47 X/i 9

f ^

MEDICAL CERTIFICATE OF DEATH

18 DATE OF
DEATH

Jan. 21/47

(Month)

(Day)

(Tear)

That

attended . deoeggpi

Jan

19 I HEREBY CERTIFY,

J.an».....2.I , 19.....47, t«

I last saw h....irn alive on . „ . ?9 , death is said to

have ooourred on the date stated above, at IX. EM m.

Immediate oause of death

Myocardial... Infarction

Due to ArteriQ.....S.cl^

Due to..

Other conditions

(Include pregnancy within 3 months of death)

Major findings:
Of operations..

Date of..

Duration

Unknown

Physician

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

Of autopsy

What test oonfirmed diagnosis?

20 Was disease or injury in any way related to oooupation of deoeased? No

If so, speolfy

(Signed) T... H ..Flynn m. d.

(Address) U .SJAarine So sp.t .. Datel-22 19.47...

21 cPreSat%nB oRRIARLEMOVAPin.throp.. .C«n-Winthrop Maes,

(Cemetery) (City or Town)

date of burial Jftn.2.4/47 19

22 NAME OF it O J „

FUNERAL DIRECTOR .J} .f.....^®yh5JrH..6

address Winthrop “as 8..

Reoeived and filed

::: jam. 3:l:: i:a $7 j

(Registrar of City or Town where deceased resided)

Entered Service Sept, 6,1901
Discharged Sept, 9,1910
Musician

7th Co, Coast Art, Corps

WRITE PLAINLY, WITH UNKAUlNli tSLALiK. INK. 1H13 IS A rLiuviAi'iti'i i ivc-v-uru. tvery item or

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

M R-301 A

10 / tfCc&nty)

(City or Town)

±±L

ffiljr (ttotmnnmuralllj of MaBaarijuflrlt*
OFFICE OF THE SECRETARY
DIVISION OF VITAL STATISTICS

Registered No.

•***•*<**•

To be filed for burial permit
with Board of Health

or its Agent.

STANDARD

CERTIFICATE OF DEATH

No 7/...TT. L.

2 FULL NAM . .V;

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

(a) Residence. No...^..^.....^^^W.^..^..'. St

(Usual place of abode) (H nonresident, gtfe city or town and state)

Length of stay: In hospital or institution 7 years months days. In this community yrs. mos. days.

(Specify whether)

/ / ) j A j o ! death occurred in a hospital or institution,

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

(If U. S.

War Veteran,

specify WAR)...,...

PERSONAL AND STATISTICAL PARTICULARS

3 SEX

4 COLOR OR RACE

5 SINGLE Xwrite the word)

MARRIED {,

WIDOWED
or DIVORCED

5a If married, widowed, or divorced

HUSBAND of ./

(Give maiden name of wife in full)

(or) WIFE of

"usband's name in full)

6 Age of husband op wife if alive..

years

7 IF STILLBORN, enter that fact here.

8 ecT/

AGE

I If lees than 1 day

..Years Months..., Days| Hours Minutes

Usual
9 Occupation

Industry
10 or Business:.

11 Social Security No..

■-e-— * — ■

12 BIRTHPLACE (City)..
(State or country)

13 NAME OF //
FATHE^^

14 BIRTHPLACE &

FATHER (Citvl

(State or country)

IS MAIDEN NAME ,
OF MOTHER r.

^ ✓ 7/ y' /

16 BIRTHPLACE OF "

MOTHER fCitvl

(State or country)

/J / 4 Relation, if any

(Address)^/ ^ OLCU -

I HEREBY CERTIFY that a satisfactory standard certificate of death
was filed. with me BEFOREDv# bur^st or transit permit was issued:

MEDICAL CERTIFICATE OF DEATH

18 DATE OF

on 1 £. Ul ( I /V SJ A J J

DEATH

(Month) l

2- 2-
(Day)

>»}

That I attended deceased from

h is

., 'death is said to

have occurred on the date stated above, at jJ. m.

Immediate cause of de^th.

Duration

IMPORTANT

.■«"8e^^

Due

Due to . . . . ,

Other conditions. /C.

(Include pregnancy within 3 months of death)

IMPORTANT

PHYSICIAN

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

Major findings:

Of operations.'7^^£^3L.

7 a, Date of

„ Of aufnpsy

What test confirmed dia^osjs^r^.^rT?^^r^7^£^^^£ . . . .

20 Wat disease or injury in any way related te occupation of deceased?

^ If so, specify.. J /....

\ (Signed) ... -kz.k;. ....

\ ( A d dress ) v ^7^, ■ ■ -P ate. 7^,. 1

•Jf&v

.....,..........^.....7v...zS

date of Burial

22 NAME OF

FUNERAL DIREC

t ur itexvnu u uusV/iv^y. — „ >w. tt: . . t ,k ^

ADDRESa^^ ..j/.. .

Received and filed rw..

im 2. mil.

(Registrar)

: ij

EXTRACTS FROM THE LAV/S OF THE

COMMONWEALTH OP 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).

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

should bo 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 anu
extracts from the laws on back of certificate.

If deotased was ■ U. S. War Vetaran, Q. L. Chap. 46, Seotlon 10, requires pliysioians to Insert a reoltal to that affaot.

IOOm-(g)-l-45-155lO

M R-301 A

Suffolk

(County)

ll.nb.hr.m

(City or Town)

<EI;e (jdumnuuitucaitlf of JfMasBacljnsrtts

OFFICE OF THE SECRETARY

DIVISION OF VITAL STATISTICS

STANDARD

CERTIFICATE OF DEATH

r* rp

Registered No

^ o.

«• I-...ElmKQ.Q.d -HfiLUXi XtSL °nd" number f

rPI

I if s

n + v, a a TT In \ I PHYSICLAN • IMPORTANT

2 full name Catherine A. Haley ( Coyne ) I (Wa, deceased a

(If deceased Is a married, widowed or divorced woman, give also maiden name.) 1 V' ar. X £t,e.rin’

I if so specify WAR)

(a) Resldenca. No. .Z....S.lmw.D..Q.d.....C.o.ur.t. sl

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

Length of stay: In nosDltai nr Institution T

(Before death) (Specify

rhether)

years

months

days.

In this oommunity30 yra.

days.

PERSONAL AND STATISTICAL PARTICULARS

3 SEX

Female

4 COLOR OR RACE

’Vhite

5 SINGLE (write the word)
MARRIED

WIDOWED n* flowed
or DIVORCED JCU

3a If married, widowed, or divorced

HUSBAND of

w,fE „

f Husband’* name fn full)

6 Age of husband or wife if alive years

7 IF STILLBORN, enter that fact here.

8 71

AGE J...± Years

Months

Days

If less than 1 day
Hours Minutes

Usual

9 Occupation:

Housewife

Industry

10 or Business:

Own Home

1 1 Social Security No.

12 BIRTHPLACE ( City) S.Q.u.t.h a.Q.a.t.Qja

<s,,,e °r rn,l,,,ry) Massachusetts

13 NAME OF
FATHER

Michael Coyne

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

Ireland

13 MAIDEN NAME
OF MOTHER

211en 7elch

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

Ireland

informant Henry Haley / Sttti0"- ,f ‘ny *

( Addresat 7 Elmwood court ,V3 n throe

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

18 DATE OF
OEATH

[CAL CERTIFICATE OF DEATH

(Day) (Year) » j*

19 I HEREBY /CERTIFY I That I attended deoeased from

V£., 19.Sf A. . to *f<KAAj.lr?z 19.H.XS

I last saw h.JLAvf alive on , 19 death Is said to

nave oocurred on the date stfeled above, at.....h^-...l.OCi m.

Immediate cause of death.Clj3LOdrX.(LkVi.C3~v.

Duration

IMPORTANT

Due

to ■ .<£..v\.aiV

Due to..

Other conditions

(Include pregnancy within 3 months of death)

Major findings:
Of operations .

Data of

Of autopsy

What test oonflrmed diagnosis?.

IMPORTANT

Phyfnc4an

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

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

If so, spsoify A.

. M. D.

19»j-I

2D t*.... nary. s.

Place of Burial, Crcmatif(n\or
DATE OF BURIAL

pn\or Removal. (Cits-air Town)

22 NAME OF

FUNERAL DIRECTOR j.

ADDRESS

A in t hr op Mass

Received and • led'S_<rX.

JA,CI9:S47

19..

( Regie* rar)

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

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

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

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 th^
principal cause and any important complication of the principal cause.

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