The volume, 1948

Town Clerk, Winthrop · from the Internet Archive · 522 pages · 38.2 MB
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/■

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

Stationers

10S State St., Boston

To duplicate this book order

No. /6 2<f-A3

* j

O.U.7

T '

If deceased was a U. S. War Veteran, G. L. Chap. 46, Section 10, requlree physiolans to Insert a reoltal to that affaoL

301 A

(Ehr (Uonumiiiluc;iltl| of .iWassacljusctts

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.

..: i

Regl stared No.

2 FULL NAME

iseJFIs a married, widowed or divorced woman.

CrJcj | (If death occurred in a hospital or institution.

| \at Uiaui v/vv UIIVU i • I a uuj|'iiai oi III Jtll UISWII.

I give its NAME instead of street and number)

r PHYSICIAN - IMPORTANT

(If deceasocris a married, widowed or divorced woman, give aleo maiden name.)

(a) Residence. No

(Usual place of abode)

Length of stay: In no.oltal nr lnstltutlon^J2Sfcs^rat^6.-:...

(Before death) (Specify wither)

J (Was deceased a

1 y-

S. War Veteran,
I if so specify WAR)

yeara months days.

(If nonresident, give city or town and State)

In thla community yrs. mos. days.

personal and statistical PARTICULARS

MEDICAL CERTIFICATE OF DEATH

3 SEX

-Ff F

4 COLOR OR RACE

14/

5 SINGLE (write the word)
MARRIED . . u /}

WIOOWED M/j
or DIVORCED

18 DATE OF
DEATH

(_/ (Month)

7 fv/

(Year)

3a If married, widowed, or divorced
HUSBAND of

(or) WIFE

( Husband's name In full)

6 Age of husband or wife if aliva years

19 ri HEREBY CERTIFY, A"hat * attended deoeased from

.s....«h2r....„ 1 9...yJ, ,

I last saw h...d.T". alive 19 death Is said to

have occurred on the date stated above, at

Immediate pa

Duration

7 IF STILLBORN, enter that fact here.

AGE /V Years

Months

Days

If less than 1 day
Hours Minutes

Usual

9 Occupation:

Due to

Irt.axry./.C'..

IMPORTANT

o' j 1

Industry
or Business:

Oue to .

1 1 Social Security No.

12 BIRTHPLACE (City)
(Siale or country)

Other condition!

(Include pregnancy within 3 months of death)

13 NAME OF
FATHER

Major findings:
Of operations .

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

Data of..

Of autopsy.

15 MAIDEN NAME
OF MOTHER

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

What test confirmed dlagnosl

20 Was disease or injury in any way ralatad to
If ao, tptoify ,A

nation of deoeased

M. 0.

\9 >/5r

Relation. If any t

22 NAME OF

FUNERAL DIRECTOR. ...\)

tsue of Agent Board of Health or other) /

u..& r*-.

Received and Iliad

j / (Date of Isaue ot/Pe

-.ffiN?

(Regietrar)

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 tber»of a certificate as hereinafter provided.
If there is no attending physician, or if, for sufficient reasons, his certificate
cannot be obtained early enough for the purpose, or is insufficient, a physi-
cian who is a member of the board of health, or employed by it or by the
selectmen for the purpose, shall upon application make the certificate re-
quired of the attending physician. If death is caused by violence, the medi-
cal examiner shall make such certificate. If such a permit for the removal
of a human body, not previously interred, from one town to another within
the commonwealth cannot be obtained early enough for the purpose, the
certificate of death made as above provided and in the possession of the
undertaker desiring to make such removal shall constitute a permit for
such removal; provided, that such body shall be returned to the town from
which it was removed within thirty-six hours after such removal, unless
a permit in the usual form for the removal of such body has been sooner
obtained hereunder. If the death certificate contains a recital, as required

by section ten oi chapter lorty-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 aud the physician certifying
the cause of death shall thereafter furnish for registration any other neces-
sary information which can be obtained as to the deceased, or as to the
manner or cause of the death, which the clerk or registrar may require. —
Chap. 114, Sec. 45, G. L., (Tercentenary Edition).

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

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

RULES OF PRACTICE

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

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

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

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

DATE OF ENTERING MILITARY SERVICE

DATE OF DISCHARGE

RANK, RATING

ORGANIZATION AND OUTFIT

SERVICE NUMBER

r £ ,MU. Y <

u A' 4-,y v;_

j ^

3Hic Camntnnfiicalti) of 4®tasaacfjnsrtts5

OFFICE OF THE SECRETARY

DIVISION OF VITAL STATISTICS

STANDARD

CERTIFICATE OF DEATH

c/fc

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

Registered No. 1W._.

2 FULL NAME

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

(a) Residence,

(Usual

(If deceased Is a married, widowed or divorced woman, gi

nca. No CM.JC.

Lai place of abode)

sZZL

give alao maiden name.)

Length of stay: In hospital nr Institution

(Before death) (Specify whether)

months

days.

r PHYSICIAN - IMPORTANT

J (Was deceased a f''7,

" 1 U. S. War Veteran, / / / /.

^if so specify WAR) {..//Cl.

J/k. <-.

(if nonresident, give city or town and State)

In this community - Z,

yrs.

days.

PERSONAL AND STATISTICAL PARTICULARS

MEDICAL CERTIFICATE OF DEATH

3 SEX

4 COLOR OR RACE

/ML

5 SltlpLEr^ (write the word)
MARRIED

18 DATE OF
OEATH ...

"(f ifii

(Month)

(Day)

(Year)

' ~ ^

5a if married, widowed, or divorced y f J . ?

HUSBAND of
(or) WIFE of

ce°.

(Give maiden name of wife in hill)

(Husband's name In full)

6 Age of husband or wife if alivo years

19 I HEREBY CERTIFY,

I9.!t.k.. , -to ^?r^rrr... .4/. .......

I last taw hwt^dto alivo on ’Lit. <r. , 19 Y&> 1

tad above, at

have occurred on the data state

That I attended deoeased from

i9 yjL.

death la said to

7 IF STILLBORN, enter that fact here.

S
AGE

Immediate osuee of death

Years Months

Days

If lees than 1 day
Hours

Minutes

Usual

9 Occuoatlon:

Oue to

C&UlJ&r.

Industry

10 or Business:

11 Social Security No.

Due to .

12 BIRTHPLACE (City)
(State or country)

?fezzzar

Other conditions

(Include pregnancy within 3 months of deith)

13 NAME OF
FATHER

14 BIRTHPLACE OF
FATHER (City)

(State or country)

15 MAIDEN NAME
OF MOTHER

Major findings:
Of operations .

Data of..

Of autopsy

What test oonfirmed diagnosis?

Duration

( C/

IMPORTANT

:::zf

importaWV

Physician

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

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

td&fr&r.

Informanf. J

( Address) / U/ If.

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

If ao, apaoify

, m. o.

( Address )/^f!T Dat»/.~..j£ 19

"tl

21 'La/L^.l rf/teAd -

Place of Sunat, Cremation or Removal. , (City or Towrt)

■I >. . 7, wfcff'

DATE OF BURIAt

:BY CERTIFY that a satisfactory stai

Ith

^prlat^/ transit

~7z /*. - - -.taw-t m— —

(Date of Issue of (Permlyf *

(Official Designation)

22 NAME OF / • /I x /' /

FUNERAL DIRECTOR ■

,D[”,ESS /A

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

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

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 tbe 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

>RM R-302

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®I|e QJcrmmnnfnraltlf of JHaseactyueetta
OFFICE OF THE SECRETARY
DIVISION OF VITAL STATISTICS

COPY OF

CERTIFICATE OF DEATH

Registered No.

h Middlesex

2 (County)

Cambridge

(City or Town)

no. Holy Ghost Hospital st j

name Miss... Mary A ... W:mston «[

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

Cambridge

(City or town making return)

-65-

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

2 FULL NAME J wi^vfter.n,

1 speolfy WAR)

(a) Residence. No 1.Q5... Sa^ampr.e ...Avenue. sl .....Wintlxrap?....Mass„*

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

Length of stay: In hospital or Institution. ...H?..?P.44.?:.l... i years i monthsU days.

(Before death) (Specify whether)

In this oommunlty 73 Frs- — mos. — days.

PERSONAL AND STATISTICAL PARTICULARS

3 SEX

Female

4 COLOR OR RACE]

White

5 SINGLE (write the word)

MARRIED
WIDOWED

or DIVORCED

Single

5a If married, widowed, or divoroed _

HUSBAND of

(Give maiden name of wife in full)

(or) WIFE of

(Husband’s name in full)

6 Age of husband or wife If alive

years

7 IF STILLBORN, enter that fact here.

AGE? 3..

..Years....” Months Days

If less than 1 day
Hours Minutes

9 Occupation: ...At....h.ome..

Industry
or Busin

11 Soolal Security No. N.QPP

10 or Business: .*At .home

12 BIRTHPLACE (City) ...4a.$t Boston,

(State or country) MclSS .

13 NAME OF
FATHER

Michael Winston

14 BIRTHPLACE OF
FATHER (City)

Ireland

(State or country)

15 MAIDEN NAME
OF MOTHER

Mary Mitchell

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

Ireland

)

(Address) 10$ Sagamore Ave.Winthrop '

ATTEST

IsU/WOZS

(Registrar of city or town where death occurred)
DATE FILED January 33.* 19.48..

MEDICAL CERTIFICATE OF DEATH

18 death0!! January. .7 1948

(Month) (Day) (Year)

Duration

13r I H ER EBY CERTJFY, Thpt I attended deoeated from

.Novs....2.7 , 19..4P..., to ‘.ran,....?:. , 19 .4.8

I last saw h.6? alive on January 7 s , 19.4.8 death Is said to

have ooourred on the date stated above, at..9..*3.Q...A.«

Immediate oause of death

Generalized Arteriosclerosis

Cerebral Thrombosis

Due to Hemplegia..-..ri^ht

Due to .

Other conditions

(Include pregnancy within 3 months of death)

Major findings:
Of operations..

..Date of.

14 ...mos ,
14... mos ,

Of autopsy

What test oonfirmed diagnosis?

20 Was disease or injury in any way related to occupation of deceased?
If so, s
(Signed)

(Address)

Physician

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

Date. .1— ?. 19 48

21 cremation8 or ^removal Holy C ro s s ...C erne ter y ,Ma Id ,

(Cemetery) (City or Town)

date of burial January. 10. 19.48...

22 NAME OF

FUNERAL DIRECTOR

address 210....Win.th.rQp....S.t...^....Winthr.Qp.^...Ma.ss,

Received and filed I.

■1/ 1

(Registrar of City or Town where deceased resided)

• » '

—

carefully supplied. ACL should be stated tAAULT. rri Y jiciAi’ia snouio state Lsuat wr L»c.ftin in piam terms, so umi
it may be properly classified. Exact statement of OCCUPATION is very important. See instructions and extracts from the laws
on back of certificate.

If deceased was a U. S. War Veteran, G. L.t Chap. 48, Sec. 10, requires physicians to insert a recital to that effect.

h
<
I U

< U.

1°

Suffolk

(County)

Winthrop

(City or Town)

®fje Commontoealtb of 4tla*0acbu*etfg

OFFICE OF THE SECRETARY

DIVISION OF VITAL STATISTICS

STANDARD

CERTIFICATE OF DEATH

aking return)

Registrar's Number

No.

9 4 S oners e t Avenue st.

2 FULL NAME

(a) Residence. No.

Lulu Emma Newhall

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

94 Somerset Avenue st

(Usual place of abode)

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

PHYSICIAN— IMPORTANT
deceased a
War Veteran, **

specify WAR) 0 *

Length of stay: In hospital or institution

(Before death)

months

(Specify whether)

days.

(If nonresident, give city or town and State)

In this community y| years months days-

PERSONAL AND STATISTICAL PARTICULARS

3 SEX

4 COLOR OR RACE

female

white

5 SINGLE (write the word)
MARRIED
WIDOWED

or DIVORCED wl DWftfl

5a If married, widowed, or divorced
HUSBAND OF

(Give maiden name of wife in full)

(or)

WIFE OF Rufus Newhall

(Husband s name in full)

6 Age of husband or wife if alive

7 IF STILLBORN, enter that fact here.

AGE 85 Year»5

o o If leas than 1 day

Months Ct Cd Days Hours Minutes

Usual

*9 Occupation:

housewife

Industry
10 or Business:

at home

11 Social Security No.

none

12 BIRTHPLACE (City)
(State or country)

uniToya . -4 —

Maine

13 NAME OF
FATHER

James Lee

14 Birthplace of

FATHER (City)
(State or country)

Pitts ton

Maine

15 MAIDEN NAME 0 4-

of mother Nancy Stewart

16 BIRTHPLACE OF - ,

mother (City) Charles t on

(State or country)

Maine

Informant Sarah Lee Whorf

(Address) S.Qmarafit A V8-,

I HEREBY CERTIFY that a
ed, with mr BEFORE theduitial

natii

(Official Designatioi

actory standard certificate of death was
ansit permit, was issued:

“ ,
(Date of Issu^ of

MEDICAL CERTIFICATE OF DEATH

18 DATE OF

death January

(Month)

(Day)

1948

(Year)

19 I HEREBY CERTIFY, That I attended deceased from

^•C/VvgC 1 7 . i9.4f 7. to ..? /..«>. , 19

I last saw h alive on % /

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

... Tyyty r-c-avjL(*«

Due to

, 19 ^Tdeath is said to
M.

* ■*>

Other conditions

(Include pregnancy within 3 months of death)

Major findings:
Of operations

Date of

Of autopsy

What test confirmed diagnosis?

Duration

Important

i ft**,
(ft A

jlAJNL

Important

Physician

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

20 Was disease or injury in any way related to occupation of deceased? ^4$

If so. specify 1J.. ^ a

(Signed ) ^ M.D.

(Address) / T .«* ' yj Pat >) 19 <-•<

21 Winthrop Cemetery, Winthrop "

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

_SftT.E. ?F BURIAL January 19,«lg48 - 19

A TRUE COPY ATTEST

EXTRACTS FROM THE LAWS OF THE
COMMONWEALTH OF MASSACHUSETTS
GOVERNING THE

RETURN OF CERTIFICATES OF DEATH

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

A physician or officer furnishing a certificate of death as required by the
preceding section or by section forty-five of chapter one hundred and fourteen,
shall, if the deceased, to *he best of his knowledge and belief, served in the army,
navy or marine corps of the United States in any war in which it has been engaged,
insert in the certificate a recital to that effect, specifying the war. and shall also
certify in such certificate both the primary and the secondary or immediate cause
of death as nearly as he can state the same. For neglect to comply with any
provision of this section, such physician or officer shall forfeit ten dollars. For
the purposes of this section and of sections forty-five, forty-six and forty-seven
of said chapter one hundred and fourteen, the word “.war” shall include the China
relief expedition and the Philippine insurrection, which shall, for said purposes,
be deemed to have taken place between February fourteenth, eighteen hundred
and ninety-eight and July fourth, nineteen hundred and two, and the Mexican
border service of nineteen hundred and sixteen and nineteen hundred and
seventeen. 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 boaid 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 inter-
ment, by a satisfactory certificate of the attending physician, if any. as required
by law. or in lieu thereof a certificate as hereinafter provided. If there is no
attending physician, or if, for sufficient reasons, his certificate cannot be obtained
early enough for the purpose, or is insufficient, a physician who is a member
of the board of health, or employed by it or by the selectmen for the 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
front which it was removed within thirty-six hours after such removal, unless
a permit in the usual form for the removal of such body has been sooner obtained
hereunder. If the death certificate contains a recital, as required by section ten

of chapter forty-six, that the deceased served in the army, navy or marine corps
of the United States in any war in which it has been engaged, such recital shall
appear upon the permit. The board of health, or its agent, upon receipt of such
statement and certificate, shall forthwith countersign it and transmit it to (he
clerk of the town for registration. The person to whom the permit is snJ 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. 4">. G. L.. (Tercentenary Edition).

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

No undertaker or other person shall bury a human body or the ashes thereof
which have been brought into the commonwealth until he has 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 tojmch 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 indirect I v by
traumatism (including resulting septicemia), and by the action of chemical (drugs
or poisons), thermal, or electrical agents, and deaths following abortion, but also
deaths from disease resulting from injury or infection related to occupation, the
sudden deaths of persons not disabled by recognized disease, and those of persons
found dead.

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

Statement of Occupation. — Precise statement of occupation is very im-
portant, so that the relative healthfulness of various pursuits can be known.
Make some entry in this section for every person aged 10 years or over. If the
occupation had been given up or changed on account of the disease causing
death, report the usual occupation prior to illness. If the deceased had retired
from business, report the usual occupation prior to retirement. Children not
gainfully employed may be returned as at school or at home. For a woman
whose only occupation was that of home housework, write housework. For :i
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

DATE OF ENTERING MILITARY SERVICE

DATE OF DISCHARGE ,.

RANK. RATING !

ORGANIZATION AND OUTFIT

SERVICE NUMBER

Suffolk

(County)

.Xin.th.ro p

(City or Town)

Commoitfoealtl] nf ,JNa8sacl{U0ett8
OFFICE OF THE SECRETARY
DIVISION OF VITAL STATISTICS

STANDARD

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

No.

88 Brookfield

CERTIFICATE OF DEATH

Rd st.

Registered No.

2 full name G-race C, Nickerson (9heehan<)

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

(a) Residence. No 88 BrOOkfleld Rd

(Usual place of abode)

Length of stay: In hospital or institution years

(Before death) (Specify whether)

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

PHYSICIAN- IMPORTANT

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

months

St.

days.

(If nonresident, give city or town and State)

In this community^O yrs. mos.

days.

PERSONAL AND STATISTICAL PARTICULARS

3 SEX

Female

4 COLOR OR RACE

White

5 SINGLE (write the word)

MARRIED

WIDOWED

or DIVORCED .IldOWed

MEDICAL CERTIFICATE OF DEATH

:ar) &

18 DATE OF
DEATH

( Month)

- 1

(Day)

(Year)

5a If married, widowed or divorced
HUSBAND ot

(or) WIFE of

CharT^T 'r.e '’Wd'^Vson

(Husband's name in full)

6 Age of husband or wife if alive

years

7 IF STILLBORN, enter that fact here.

AGE ^Years

Months Days

If less than 1 day

Hours Minutes

Usual

J 9 Occupation:

Clerk

Industry r
10 or Business^ U U.I

ti/ouse

| 11 Social Security No.

19 I HEREBY CERTIFY

, 19

I last saw h alive on

have occurred on the date stated above, at

Immediate cause of death

That I attended deceased from

, to , 19

, 19 , death is said to

% 3"© A n

Due to

Duration

IMPORTANT

Due

BIRTHPLACE (City)
(State or Country)

Bast Boston

M a ,q q

13Ther0F Daniel J. Sheehan

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

Boston

Mass

15 MAIDEN NAME
OF MOTHER

1 7ahf>t.b Cnrly

16 BIRTHPLACE OF

S'1'. Johns

MOTHER (City)

(State or Country)

1LJL.

Other conditions

(Include pregnancy within 3 months of death)

Major findings:
Of operations

Of autopsy

What test confirmed diagnosis?

Date of

IMPORTANT

Physician

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

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

(Address) Date l "*j

17 informant Mary Sheehan

(Address)

£3 i* any )
88 Brookfield Rd .

Tinthron * Vinthrop

Place of Burial, Cremati

DATE OF BURIAL J 9-1

or Removal.

JCity or Town)

I HEREBY CERTIFY that a satisfactory standard Certificate of death was filed
with.m* BEFOBEjthe burial on transit ^Te*mit wfls issued:

(Official Designation

22 NAME OF

FUNERAL DIRECTOR

ADDRESS

inthron

Received and Filed

JAN 1 9. tq48

(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 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 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 a3 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 oi chapter torty-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 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).

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

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

If deoeaaed was a U. S. War Veteran, Q. L. Chap. 46, Section IQ, requires pliyslolans to Insert • recital to that effect.

IM R-301 A

tUlic QToimttcmfbraltlt of ^Tassnclptsette
OFFICE OF THE SECRETARY
DIVISION OF VITAL STATISTIC*

STANDARD

CERTIFICATE OF DEATH

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

Registered No

occurred in a hospital or Institution,
NAME instead of street and number)

IMPORTANT ’

2 FULL L.A.M J ?^«SJe^ease^ a 1

(If deceased Is a married, widowed or divorced woman, give also maiden name.) | *-*• S. War Veteran, tj/f y y

^ ^ if so speoify WAR) jHf.ilK /..

(a) Residence. No. SL

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

Length of stay: In no.oltal nr Institution

( Before death) (Specify whether)

years

months

days.

In this oommunity

yrs.

days.

PERSONAL AND STATISTICAL PARTICULARS

MEOICAL CERTIFICATE OF DEATH

l is.. llTt.

A (Month) Q (Day) (Year)

3 SEX

4 COLOR OR RACE 5 SINGLE (write the word)

MARRIED • 0

IS DATE OF
OEATH

WIDOWED
or DIVORCED

5a If married, widowed, or divorced / / • .

husband of .jg.im.AS (..A..H-

(or) WIFE of

(Give maiden name of wife in full)

fHusband's name In full)

6 Age of husband or wife if alive

years

*1 IF STILLBORN, enter that fact here.

19 I HEREBY CERTIFY, That I attended daoaased from

1S.HL, 4o 19 i£...

I laet saw hj.fs/y alive 19 !.Ql, death Is said to

have occurred on tho date stated above, at j?...

Immediate oauee of death

Duration

AGE

Years Months

Days

If Ies9 than 1 day
Hours Minutes

Usual

9 OccuDatlon

Due

Industry
10 or Business

: J

Due to

(fflE

mAL. <£L j tuiMiiA

11 Social Security No.

12 EIRTHPLACE (City)
(State or country)

13 NAME OF ~ ^ j • ^

FATHER G-f^r A b*d Chvd

14 BIRTHPLACE OF n

FATHER (City) .£I.A.£. .fi.fJ.A...,. ti A..

(State or country)

Date of..

15 MAIDEN NAME

Of autopsy

What test confirmed diagnosis?

OF MOTHER p^/aN PcLn ^er ; Ar M

16 BIRTHPLACE OF i.

MOTHER (City) E, .... .A.r..

(State or country)

20 Was disease or inWy ip any way related to oooupatlen of deoeased

If so, speoify...ij...>^C. .k

17 (°
Informant
( Address)

, Relation, If any

( |

Place of Burial,/Creni»ti<

Cremation or Removal.
DATE OF BURIAL ...QtfLAM JL./.

177. r rftiTf iianjf

(City^or Town)

19.^

I HEREBY CERTIFY that a satisfactory standard oertlfioate of death was
file)! wllh^ °t* BEFORE the Burial or transit permit was Issued:

filed; with ms BEFORE the Buflal or transit permit was 1

/ (Signature pf Agent of Board of Hejuth of^ther)
{o(mtA Designation) / (Date of Tseue Perfkiit^ ’

: NAME OF v \ & I r. :

FUNERAL DIRECTOR./? ~

ADDRESS /..U...7..7....Q2U*

Reoeived and filed

233333

19..

(Regisirer)

EXTRACTS FROM THE LAWS OF THE
COMMONWEALTH OF MASSACHUSETTS
GOVERNING THE

RETURN OF CERTIFICATES OF DEATH

A physioian or registered hospital madical 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 deaih, stating to the best of his knowledge and belief the name of the
deceased, his supposed age, the disease of which he died, defined ae re-
quired by section one. where same was contracted, the duration of hi« last
Illness, when last seen alive by the physician or officer and the date of his
death ... Ceu. Laws. Chap. 46, Sec. 9.

A phvsician or officer furnishing a certificate of death as required by the
preceding section or by section fortv-flve of chapter one hundred and four-
teen, shall, if the deceased, to the best of his knowledge and belief, served
In the army, navy or marine corps of the I'nited Slates in any war in which
It has been engaged, insert in the certificate a recital to that effect, sjieci-
tying the war. and shall also certify in such certificate both the primary
and the secondarv or immediate cause of death as nearly as he can state
the same. For neglect to comply with any provision of this section, such
physician or officer shall forfeit ten dollars. For the purposes of this sec-
tion and of sections forty-five, forty-six and forty-seven of said chapter one
hundred and fourteen, the word "war" shall inelude the China relief ex-
pedition and the Philippine insurrection, which shall, for said purposes, he
deemed to have taken place between February fourteenth, eighteen hundred
and ninety eight and July fourth, nineteen hundred and two, and the Mexi-
can border service of nineteen hundred and sixteen and nineteen hundred
and seventeen. G. L. Chap. 4 6, Sec. 10.

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

by section ten of chapter forty-six, that the deceased served In the army,
navy or marine corps of the linked 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 nrers-
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 ashea
thereof which have been brought Into the commonwealth until he has re-
ceived a permit so to do from the board of health or its agent appointed to
issue such permits, or if there is no such hoard, from the clerk of the town
where the body is to be buried or the funeral is to he held, or from a person
appointed to have the care of the cemetery or burial ground in which tho
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 physiolans will certify to such deaths only as those
of persons who, (hough disabled by recognized disease unrelated to any
form of injury, have died without recent medical attendance or whose physi-
cian is absent from home when the certificate of death is needed.

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

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

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

SPACE FOR ADDITIONAL INFORMATION

H
<
I U
I Q

Suffolk

(County)

] 0 Wint hrop

I (City or Town)

je Commontoealtf) of 4$ta0*ac{)U*ett0

OFFICE OF THE SECRETARY
DIVISION OF VITAL STATISTICS

STANDARD

CERTIFICATE OF DEATH

ing return)

Registrar's Number

No.

44 cliff Avenue

2 full name *»**£ Austin Torrey

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

(a) Residence. No. 44 Cliff Avenue st

(Usual place of abode)

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

PHYSICIAN— IMPORTANT
/Was deceased a
iU. S. War Veteran, p, *»

.if so specify WAR) IN U *

Length of stay: In hospital or institution

(Before death)

months

(Specify whether)

days.

(If nonresident, give city or town and State)

In this community40 years months days'

PERSONAL AND STATISTICAL PARTICULARS

3 SEX

4 COLOR OR RACE

5 SINGLE (write the word)
MARRIED

-male —

— whl te

WIDOWED « ,

or DIVORCED IHSrri 00.

5a If married, widowed, or divorced

husband of Mao ex Byrne

(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.

8 _ If less than 1 day

AGE YY Years 9 Months 10 Days Hours Minutes

Usual

*9 Occupation:

Pensioned

Industry

10 or Business: Merchants National Bank

Social Security No.

N0A/£~

12 BIRTHPLACE (City)
(State or country)

“Bhmbridge,,,.

Mass.

13 NAME OF
FATHER

riobert Torrey

C/1

14 Birthplace of

FATHER (City)
(State or country)

Cambrldg9jjaS s—

15 MAIDEN NAME
OF MOTHER

Bar ah Arkerson

16 BIRTHPLACE OF
MOTHER (City)

Cambridge

(State or country)

Mass •

\Armant Mrs. HjA^Torres, j JWiiTovfny ..)

(Address) 45 Gllrf Ive.Winthron mass

I HEREBY CERTIFY that a satisfactory standard certificate of death was
I ed with ^theburialpi/transit permit was issued:

Signature of
(Official Designation

ard of Health or other) /

jJxL

(Date of Hsue of Pernryft) ‘

MEDICAL CERTIFICATE OF DEATH

deatfP^ January 1$,1948

(Month) (Day)

(Year)

19 I HEREBY CERTIFY, That I attended deceased from

to stttr&rrXn

. /<&. , 19^ApT..

I last saw hy**-z<*-v . alive on . ( 19 .^^Tdeath is said

have occurred on the date stated aliove, at . . . .^rrr/^ M .

Immediate cause of death

Due t

Due to

Other conditions

(Include pregnancy within 3 months of death)

Major findings:
Of operations

Date of

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

M.D.

Of autopsy

What test confirmed diagnosis?

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

f' N

If so, specify A... ..^<0

(Signed)

(Address) J2.3 ^ ^QDate / 'J''* I94*yp~

21 entombed Wint hrop Com, Wint hup

Place of Burial, Cremation or RemoVfcl. _ (City or TdWn)

DATE OF BURIAL _ Jan

22 NAME OF
FUNERAL DIRECTO:

ADDRESS ..174 Wi

—Received and filed

J A N 2 3 !fl 4J

(Rc

egistrar)

A TRUE COPY ATTEST:

EXTRACTS FROM THE LAWS OF THE
COMMONWEALTH OF MASSACHUSETTS
GOVERNING THE

RETURN OF CERTIFICATES OF DEATH

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

A physician or officer furnishing a certificate of death as required by the
preceding section or by section forty-five of chapter one hundred and fourteen,
shall, if the deceased, to 'he best of his knowledge and belief, served in the army,
navy or marine corps of the United States in any war in which it has been engaged,
insert in the certificate a recital to that effect, specifying the war, and shall also
certify in such certificate both the primary and the secondary or immediate cause
of death as nearly as he can state the same. For neglect to comply with any
provision of this section, such physician or officer shall forfeit ten dollars. For
the purposes of this section and of sections forty-five, forty-six and forty-seven
of said chapter one hundred and fourteen, the word “.war” shall include t he China
relief expedition and the Philippine insurrection, which shall, for said purposes,
be deemed to have taken place between February fourteenth, eighteen hundred
and ninety-eight and July fourth, nineteen hundred and two, and the Mexican
border service of nineteen hundred and sixteen and nineteen hundred and
seventeen. 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 boaid of health, or its agent appointed
to issue such permits, or if there is no such board, from t he 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 inter-
ment, by a satisfactory certificate of the attending physician, if any, as required
by law', or in lieu thereof a certificate as hereinafter provided. If there is no
attending physician, or if, for sufficient reasons, his certificate cannot be obtained
early enough for the purpose, or is insufficient, a physician who is a member
of the board of health, or employed by it or by the selectmen for the 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 tow'n
from which it was removed within thirty-six hours after such removal, unless
a permit in the usual form for the removal of such body has been sooner obtained
hereunder. If the death certificate contains a recital, as required by section ten

of chapter forty-six, that the deceased served in the army, navy or marine corps
of the United States in any war in which it has been engaged, such recital shall
appear upon the permit. The board of health, or its agent, upon receipt of such
statement and certificate, shall forthwith countersign it and transmit it to {he
clerk of the town for registration. The person to whom the permit is soJgiven
and the physician certifying the cause of death shall thereafter furnish for
registration any other necessary information which can Ik* 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 4d. 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 i>ermit
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 tojsuch 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 alldeaths supposably
due to injury. These include not only deaths caused directly or indirect I v 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, eg., 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 itn-
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
occupJ&tion 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.

DATE OF ENTERING MILITARY SERVICE

DATE OF DISCHARGE

RANK. RATING

ORGANIZATION AND OUTFIT

SERVICE NUMBER

301 A

Suffolk

(County)

Winthrop

(City or Town)

*/7/+f

Cl|c (ftommonfaealtli of riHaBearljusrtte
OFFICE OF THE SECRETARY
DIVISION OF VITAL STATISTICS

STANDARD

CERTIFICATE OF DEATH

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

Registered No.

no. Winthrop Community Hosp,

s».

2 FULL name Baby (boy) Alongi

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

(a) Residence. No.

(Usual place of abode)

19 Frankfort St.

Length of stay: In hospital or institution

(Before death) (Specify whether)

months

St.

days.

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

PHYSICIAN- IMPORTANT

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

Eas t Bo ston

(If nonresident, give city or town and State)

In this community

yrs.

days.

PERSONAL AND STATISTICAL PARTICULARS

MEDICAL CERTIFICATE OF DEATH

1 I

£ <

3 SEX

male

4 COLOR OR RACE

white

5 SINGLE (write the word)

MARRIED

WIDOWED Qincrl o

DIVORCED Single

18 DATE OF
DEATH

Jan .

(Month)

(Day)

1948

(Year)

or I

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

19 f) I HEREBY CERTIFY.

/? ... .

I last (saw hy<^v. alive on

have occurred on the date stated above, at

7 IF STILLBORN, enter that fact here.

fftri-itborrr-

AGE

Years

Months

Days

If loss than 1 day.

y Hours 1J. Minutes

Immediate^caose^f death

That I attended deceased from
. to /%. . 19

/..? ,19 Vt. death is said to

^ J Duration

IMPORTANT

Usual

9 Occupation:

Industry
10 or Business:

Due to

11 Social Security No.

12 BIRTHPLACE (City)
(State or Country)

Winthrop Mass.

Other conditions

(Include pregnancy within 3 months of death)

13 NAME OF

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

...Italy.

LlJ

15 MAIDEN NAME

sephine Peretti

OF MOTHER J0

16 BIRTHPLACE OF
MOTHER (City)

Ite ly

(State or Country)

Major findings:

Of operations

Of autopsy

What test cenfirmed diagnosis?

Date of

IMPORTANT

Physician

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

dormant Alf ODZO Alongi ( )

(Address. 19 Frankfort St. Eas t Boston

I HEREBY CERTIFY that a satisfactory standari
with; pie BEFORE the burialerZransit perrnjt;

'^nature <>f'^Z*Zt of ^J3oard ofi

(Official Designation

20 Was disease or injury i)i any -way related to occupation of deceased?

If so, specify ^

(Signed) S# , . M. D.

(Address) 3S f / r Vote //* 19^

21 St. Michael

(Registrar)

EXTRACTS FROM THE LAWS OF THE

COMMONWEALTH OF MASSACHUSETTS

GOVERNING THE

RETURN OF CERTIFICATES OF DEATH

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

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

by section ten oi chapter lorty-six, tuat the deceased served in the army,
navy or marine corps of the United States in any war in which it hat been
engaged, such recital shall appear upon the permit. The board of health,
or its agent, upon receipt of such statement and certificate, shall forthwith
countersign it and transmit it to the clerk of the town tor registration.
The person to whom the permit is so given and the physician certifying
the cause of death shall thereafter furnish for registration any other neces-
sary information which can be obtained as to the deceased, or as to the
manner or cause of the death, which the clerk or registrar may 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 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 . a deaths only as those
of persons who, though disabled by recognized disease unrelated to any
form of injury, have died without recent medical attendance or whose phy-
sician is absent from home when the certificate of death is needed.

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

SPACE FOR ADDITIONAL INFORMATION

Suffolk

(County)

Winthrop

(City or Town)

(Eommonfoealtlj of .JHassacliuBeitB

OFFICE OF THE SECRETARY
DIVISION OF VITAL STATISTICS

STANDARD

CERTIFICATE OF DEATH

Registered No

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

mo Winthrop Community Hosp,

2 full name Baby $ girl) Alongi

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

(a) Residence. No. 19 Frankfort St.

(Usual place of abode)

St.

Length of stay: In hospital or institution

(Before death) (Specify whether)

months

days.

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

C PHYSICIAN- IMPORTANT

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

( if so specify WAR)

Eaa t Bos xon

(If nonresident, give city or town and State)

In this community yrs. mos.

days.

PERSONAL AND STATISTICAL PARTICULARS

MEDICAL CERTIFICATE OF DEATH

3 SEX

female

4 COLOR OR RACE

white

5 SINGLE (write the word)

MARRIED

WIDOWED , ,

or DIVORCED Single

5a If married, widowed or divorced
HUSBAND of

(Give maiden name of wife in full)

(or) WIFE of

(Husband's name in full)

6 Age of husband or wife if alive

years

7 IF STILLBORN, enter that fact here.

-sti-H-barir

AGE

Years

Months Days

If less than 1 day.

y Hours 4-cWinutes

Usual

9 Occupation:

Industry
10 or Business:

11 Social Security No.

12 BIRTHPLACE (City)
(State or Country)

Winthrop

Informant Alfonzo Alongi (..fafer .any )

(Address' 19 Frankfort St . EnS t Boston

I HEREBY CERTIFY that a satisfactory star^ard
with m« B£FQ8E?the burial or transit

tOfficial Designation)

r tificate of death was filed
issued:

oi Board of Heakn'or^ther)

cli. //%. £ , ,

(Date of Issue of Permit)

18 DATE OF
DEATH

Jan. ,

(Month)

(Day)

1948

(Year)

I HEREBY CERTIFY, That I attended deceased from

/ ....... Vi!/'*' . to /**-. . / f ,

st saw h>b alive on / 9 , 19^"', death is said to

have occurred on the date stated above, at

Immediate cause of death

Duration

IMPORTANT

Due to

Other conditions

(Include pregnancy within 3 months of death)

13 NAME OF
FATHER

Alfonzo Alongi

(/)

14 BIRTHPLACE OF

Italy

FATHER (City)

(State or Country;

LlI

15 MAIDEN NAME

Josephine fehti Peretti

OF MOTHER

16 BIRTHPLACE OF
MOTHER (City)

Italy

(State or Country)

Major findings:
Of operations

Of autopsy

What test confirmed diagnosis?

Date of

IMPORTANT

Physician

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

20 Was disease or fnju
If so, specify /

any way related to occupation of deceased?

(Signed) S ' . . . , M. D.

(Address) 2.

21 St. Michael

Place of Burial, Cremation or RemovaJ,.

DATE OF BURIAL

Jafl.^25 / 48

22 NAME OF

FUNERAL DIRECTOR

ADDRESS

Received and Filed

9 Chelsea St.

I.2.. u-4g.A.q

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

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

should bo carefully supplied, mob should do stated tAAtiu. rn TiitiANi should state LAUbt up dla i m in plain
forms, so that it may bo properly classified. Exact statement of OCCUPATION is very important. See instructions and
extracts from the laws on back of certificate.

If deceased was a U. S. War Veteran, Q. L. Chap. 46, Seotlon 10, requires physlolans to Insert a recital to that effect.

1 00m- (g)- 1-45- 155 10

* R-301

<£Iif ConumnitocaltF| of 49fassacf|tisrtts

OFFICE OF THE SECRETARY
DIVISION OF VITAL STATISTICS

STANDARD

CERTIFICATE OF DEATH

To bo filed for burial permit
with Board of Health

or its Agent.

2 FULL NAME

(a) Residence. No.

(Usual place ot ab

Registered No.

also maiden name.)

St ...

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

' ' PHYSICIAN - IMPORTANT

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

Length of stay: In nosoltal or Institution s&. ..

(Before death 1 (Specify whether)

yeare months / days.

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

daya.

PERSONAL AND STATISTICAL PARTICULARS

MEDICAL CERTIFICATE OF DEATH

18 DATE OF
DEATH ...

/?. , LtASL

(Day) / (Year)

19 I HEREBY CERTIFY, A That I attended deoeased from

T last saw h.JLrr alive 19 death Is said to

have occurred on the date staled above, at .../(S ,. m.

Immediate cauae of death

7 IF STILLBORN, enter that fact here.

AGE

7. Years Months

Days

If less than 1 day
Hours Minutes

Usual
9 OccuDat

Due

Industry

10 or Business:

Due to .

11 Social Security No.

12 BIRTHPLACE (City)
(Si ale or country)

13 NAME OF
FATHER

Other conditions.

(Include pregnancy within 3 months of death)

Major flndinga:
Of operations .

..Vr

14 BIRTHPLACE of (J J/

FATHER (City)

(State or country) '

15 MAIDEN NAME

OF MOTHER ^

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

Q. a.

Date of..

Duration

IMPORTANT

JL,

2,.«

IMPORTANT

Physician

Of autopsy 7J—X

What test confirmed diagnosis?

20 Was disease or injury in any way related to oooupation of deoeased 7S
If so, speoify „

:..‘.iM»A-... m.

<L*&. DatgJ^ILsAn.l?. 19 ^0

I HEREBY

ef death was
It

Bled with ns* BEFORE tl

_.v.. -L C—r.....

(Signature of Agent of Board of Health or other)/ / ,

/ Al/Ai

(Official Designation) f (Date of Inaue of Perynlt)

(Regfatrar)

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

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

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

If deceased was a U. S. War Veteran, Q. L. Chap. 46, Section 10, requires phyelolans to Insert a reoltal to that effaot

1 00m- (g)- 1-45- 155 10

I R-301

2 f / /(Ceaqty)

“J (City or Town) /

(^ity or Town)

3 No. '../..L.C..

va.

®hc ffiomnuntfajcaltfj of .JWassacljtisf tta

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. . ,

Reolstered No.

' — ft — *-£-/ I <If death occurred in a hospital or institution.

.k....... yt A/y - ®**|give its NAME instead of street and number)

2 FULL NAME ,/L.t....f LjJ. 4„ Z7.!v...

(If deceased fa a married, widowed or divorced

(a) Residence. No.

(Usual place of abode)

a — i + p

UiUs r ,/> f «

woman, give Slao maiden name.) J | r^'

PHYSICIAN - IMPORTANT

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

Length of stay: In hospital nr Institution

(Before desth) (Specify

rhether)

years

months

/ days.

(If nonresident, give city or town and State)

In this oommuni V# yra. moa. days.

personal ano statistical PARTICULARS

MEDICAL CERTIFICATE OF DEATH

D E A T Dr1/ /■ S^.C P"...

Q (Months-/ / (Day) (5

3 SEX

4 COLOR OR RACE

y L

5 SINGLE (write the word)
MARRIED
WIDOWED

or DIVORCED ' iCt* [

(Year)

5a If married, widowed, or divorced
HUSBAND of

(or) WIFE

(Give maiden name of wife in full)

of ....... . .. , .. .. . . .. . .... . ...... .jjt.... ........

t if . . .i i • aan

(Husband's nsme In rull)

19 il HEREBY CERTIFY,
^^£^....^3...., -to

I last saw h_8£r. alive on.

That I attended deoeased from

6 Age of husbsnd or wife if alive

//■

years

have occurred on the date staled above, nf m.
Immediate oauee of death

•If/., 19 f/tfi

f"19Xc7^" death Is said to

7 IF STILLBORN, enter that fact here.

AGE Year* Monthe

Days

If less then 1 day
Hours Minutes

Usual ~v'r / -/ , , , /

9 Occuoetlon :

Due to

Industry

10 or Business:

y/z

Due to .

11 Social Security No.

12 BIRTHPLACE (City) ,...

(Slate or country) '/v J j- .

13 NAME OF

FATHER ;

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

15 MAIDEN NAMt
OF MOTHER

/LcUtaZ.

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

( S/ls. '/t Sis J / Relation, (f any /l

Informant ( )

(Addreset ■ ^

Relation, If any

HEREBY CERTIFY that a satisfactory standard oertlfioata of death was
filed with me. BEFORE the j^urlat^o r transit permit was Issued >

of Agent o( Board of Ife^lth or other)

(Date of Issue oL Permit)

Other conditions..

t Include pregnancy within 3 months of death)

Major findings: s’} 1

Of operations

oJk^or

Of autopsy
What test oonflrmed diagnosis

Duration

IMPORTANT

ZpAua.

20 Was disease or injury in ony way related to oooupatlon of deoeased ? ,^0....
If so, speoify

Place of Burial, Cremation or Removal.

DATE OF BURIAL

22 NAME OF ■ 1 , , ,, (// X

FUNERAL DIRECTOR. . /£/ Hr. //

ADDRESS 4-rC7r.../. u/. ,/.;

Reoaivad and hied t.G.^_......^.....1..Q.A.il £....13.

(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 or ciiapicr torty-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).

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.

SPACE FOR ADDITIONAL INFORMATION

DATE OF ENTERING MILITARY SERVICE

DATE OF DISCHARGE

RANK, RATING

ORGANIZATION AND OUTFIT

SERVICE NUMBER

li deceased was a U. 8. War Veteran, G. L, Chap. 48, Sec. 10, requires physicians to insert a recital to that effect

100m-(f)-l-4vmi()

■<

V.O.

Suffolk

(County)

Winthrop

No.

(City or Town)

5 Ocean View St

®Ije (Cotratumfeealtlj of <ilSa»*acIpiBrtt*

OFFICE OF THE SECRETARY

DIVISION OF VITAL STATISTICS

STANDARD

CERTIFICATE OF DEATH

(City or town making return)

Registrar’s No.

1 FULL NAME

Frederick G-ould Knell

(a) Residence. Ho.

(Usual place o( abode)

Length of stay: In hospital or Institution

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

5 Ocean View St .

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

° ' 1 give its NAME instead of street and number)

PHYSICIAN — IMPORT AHT

deceased a

Veteran,

specify WAR)

{PHYSK

(Was decea
U. S. War

if so specif:

(Before death)

(Specify whether)

years

months

-St.

days.

(If nonresident, give city or town and State)

In this communlt/^Y yrs. mos. days.

PERSONAL AND STATISTICAL PARTICULARS

MEDICAL CERTIFICATE OF DEATH

3 SEX

Male

4 COLOR OR RACE

White

5 SINGLE (write the word)
MARRIED
WIDOWED
or

idiI'orceeJ^ & Tried

18 DATE OF
DEATH _

(Month)

H z TjHL

Zr_

(Day)

(Year)

5a If married, widowed, or divmratL- ,,, rj T T

husband of i1 ipra j?.. oe. jli

(Give maiden name of wife in full)

19 I HEREBY CERTIFY

^ . 1 9±LjL

to.

(or) WIFE of

I last saw h

_alive on.

(Husband’s name in full)

That I attended deceased from

L , X Udl X dl

yzZ. $ S'

<3 7 , 19J^ death is iaid to

4 Age of husband or wife if alive-

-m

_years

7 IF STILLBORN, enter that fact here.

* rjrj Q orv I* !«» than 1 day

AGE-L-L. Year._Z__ Months^ I Days Hours Minutes

have occurred on the date stated above, at ,-r M

Immediate cause of death

/■ ‘ -Jo JJ

g_, — ■ —

Usual

9 Occupation:

Retired

Due to_

Duration

IMPORTANT

Industry Wholesale Picture Frames

10 or Business:

Due to-

ll Social Security No.

None

12 BIRTHPLACE (City)
(State or country)

Cambridge

Other conditions

Mass .

(Include pregnancy within 3 months of death)

13 NAME OF
FATHE

Frederick G Knell

Major findings:
Of operations-

IMPORTANT

Physician

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

Boston

-Date of-

Mass

Of autopsy-

15 MAIDEN NAME

of mother Cecelia Blaisdell

What test confirmed diagnosis?.

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

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

Boston

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

If so, specify JZ.

(Signed) -

Mass .

— / —

(Address)/ > S' (f - V3- --9^

Mt Auogrn

, , M. D.

-Dapt^Zna^aLcS-19^H-^

Informant ,-FlOr
(Address) 3 Bel

a- Kne^

?hgr-

I Hl^lEBY CERTIFY that a satisfactory standard certificate of death
ilfid ^rytH’-me-BEFQRE thc/^urial/or transit permit was issued:

Place of Burial, Cremation or Removal.
DATE OF BURIAL

22 NAME OF

FUNERAL DIRE]

Uampridge"

(v^ltT O

Jan. 31

(City or Town)

Received and filed

A TRUE COPY ATTEST:

eglstrar)

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, hit 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.

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 cleric 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, 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 hoard of health,
or its agent, upon receipt of such statement and certificate, shalllortbwith
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 regist: lr 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, cr 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 at those
of persons who, though disabled by recognized disease unrelated to any
form of injury, have died without recent medical attendance or whose phy-
sician is absent from home when the certificate of death is needed.

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

Statement of Occupation. — Precise statement of occupation is very im-
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 ___________________________

i n in piam icmis, so mat it may De properly ciassmea. r.xact srarement oi uoourrtiiuiN is very important.
See instructions and extracts from the laws on back of certificate.

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

R-301 A

Suffolk

(County)

Winthrop

(City or Town)

82 Brookfield

C ommcmfriealtlr of jUtasaacfyusetts
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.

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

2 FULL NAME Margaret j, Malone Le Cour

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

82 Brookfield Rd

her)

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

St.

days.

(If nonresident, give city or town and State)

In this community 40y

rs. mos.

days.

PERSONAL AND STATISTICAL PARTICULARS

3 SEX

Female

4 COLOR OR RACE

White

5 SINGLE (write the word)

MARRIED

WIDOWED

or DIVORCED’^ Id 0 We d

5a If married,
HUSBAND of .

(or) WIFE of

widowed or divorced

jBKrf: nate£f iSStP

(Husband’s name in full)

6 Age of husband or wife if alive

years

7 IF STILLBORN, enter that fact here.

AGE ^5 years Months

Days

If less than 1 day

Hours Minutes

Usual

9 Occupation:

Housewife

Industry
10 or Business:

Own

Home

11 Social Security No.

12 BIRTHPLACE (City)
(State or Country)

Nova Scotia

13 NAME OF

FATHER Jamoa

Ma 1 nnp

14 BIRTHPLACE OF
FATHFR (Citv)

(State or Country)

T nel and

15 MAIDEN NAME

OF MOTHER ?

Rogers

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

Ireland

,, , Frank LeCour ( >f any \

Informant _ . A._ )

(Address) 8? Brookfield Rd

I HEREBY CERTIFY that a satisfactory standard certificate of death was filed
with jnje BJLFOR& the burial or itfansit/permit/was issued:

MEDICAL CERTIFICATE OF DEATH

18 DATE OF
DEATH

f J (Mo^i) ’ (Day) (Ycari

I UP Of D V PrDTirV That I AtonrlnH dnnnornd (rr\ m

10V I HEREBY CERTIFY,

UfuuJL f rfto

I last saw UO-L alive on

That I attended deceased from _

Xf.tS

19^C^death is said to

_ _ 0 W A _

have occurred on the date*ftated above, at

Immediate cause of deattL jr *

UUaAajC

Duration

Due to

Other condition^^/ dajtu£

^fncluBe preg^jCy within 3 months of death)

/vbefl-

Major findings:
Of operations

Date of

Of autopsy
What test confirmed

SLfrZecc*

x-dLoujo

IMPORTANT

Physician

20 Was disea.

If so, specif;

(Signej

(/VffdoJss

(Registrar)

■>

EXTRACTS FROM THE LAWS OF THE
COMMONWEALTH OF MASSACHUSETTS
GOVERNING THE

RETURN OF CERTIFICATES OF DEATH

A physician or officer furnishing a certificate of death as required by the
preceding section or by section forty-five of chapter one hundred and four-
teen, shall, if the deceased, to the best of his knowledge and belief, served
in the army, navy or marine corps of the United States in any war in which
it has been engaged, insert in the certificate a recital to that effect, speci-
fying the war, and shall also certify in such certificate both the primary
and the secondary or immediate cause of death as nearly a3 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 lteu 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 cnapier lorty-aix, luat 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 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).

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, be shall forthwith go to the place where the body lies
and take charge of the same; . . . — General Laws, Chap. 38, Sec. 6.

RULES OF PRACTICE

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

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

Statement of Occupation. — Precise statement of occupation is very im-

Kortant, 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 OE ENTERING MILITARY SERVICE

DATE OF DISCHARGE

RANK, RATING

ORGANIZATION AND OUTFIT

SERVICE NUMBER

L fs

H
<
I U

!Q
1 < fc.

1°

Suffolk

(County)

Winthrop

(City or Town)

jt Commontoealtt) of iflatfaacbuaetts

OFFICE OF THE SECRETARY Winfc.hXO.p

(City or town making return)

DIVISION OF VITAL STATISTICS

STANDARD

CERTIFICATE OF DEATH

Registrar's Number

XT 1 Rorf 1 flf t Rnofl e, I (If death occurred in a hospital or institution

No J- * D Baxiiei c Itoaa St- { give its NAME instead of street and number)

2 FULL NAME

(a) Residence. No.

George Jason Godfrey

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

PHYSICIAN— IMPORTANT
/Was deceased a
|U. S. War Veteran, -- _
if so specify WAR) . Jj|.Q

175 Bartlett, Road

/Usual place of ab

St.

Length of stay: In hospital or institution

(Before death) (Specify whether)

abode)

years

months

days.

(If nonresident, give city or town and State)

In this community ^ Q years months days*

PERSONAL AND STATISTICAL PARTICULARS

3 SEX

4 COLOR OR RACE

5 SINGLE (write the word)
MARRIED

18 DATE OF
DEATH

January

30, 1948

male

white

WIDOWED . ,

or divorced married

(Month)

(Day)

(Year)

19 I HEREBY CERTIFY. That I attended deceased from

5a If married, widowed, or divorced m • _ j ^ j T _ A A

husband of Winifred. Ladd

. (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.

If less than 1 day

AGE 00 Years

Q Months Q Days

Hours Minutes

Usual

*9 Occupation:

salesman

or Business: Lawrence&klein Lumber Oo

11 Social Security No. ' 61 S'- 01- 2 96 8

Northwood, Otr.
New Hampshire

12 BIRTHPLACE (City)
(State or country)

FATHE°F Albert M. Godfrey

14 Birthplace of

FATHER (City)
(State or country)

Candia

flew Hampshire

15 MAIDEN NAME 4- U

OF MOTHER J Ul la Omittl

16 BIRTHPLACE OF .T 4-1

MOTHER (City) NOr txlWOOd_ Ut T. «

(State or country)

Hew. Hampshire

Informant

(Address)

I HEREBY CERTIFY that a satisfactory standard certificate of death was
ed-wvth me>Bj£FQRE thebb^al or/tc&nsit petmit was issued:

jgnatur^Aof/Agdnt of Board of H<felth or other) .

<7 kMczz

(Official Designation)^ j J (Date of Issue of Permit)

MEDICAL CERTIFICATE OF DEATH

CX$J\jSL 7 . 19 tJQ. to^t^VM . ... 19

, 19^<p, death is said
tecl above, at . 1 (P. M.

1 last saw h uua. . alive on
have occurred on the date stai

Immediate cause of death
Due to

Due to

Other conditions CW/Vvs*.

(Include pregnancy within 3 months of death)

Major findings:
Of operations

Date of

Of autopsy

What test confirmed diagnosis?

Duration

Important

cslelfryi

portent

Physician

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

20 Was disease or j^njury in any way related to occupation of deceased?
If so, specify
(Signed)

(Address) / 2 S~

~rj- nS

Date /

M.D.

21 imtombed Winthrop T omb tfint hr op

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

pate

22 NAME OF

FUNERAL DIRECTOR

address 174 Wintlirop

Wint hr op

Received and filed

A TRUE COPY ATTEST:

FEB-3 tW

(Registrar)

EXTRACTS FROM THE LAWS OF THE
COMMONWEALTH OF MASSACHUSETTS
GOVERNING THE

RETURN OF CERTIFICATES OF DEATH

A physician or officer furnishing a certificate of death as required by the
preceding section or by section forty-five of chapter one hundred and fourteen,
shall, if the deceased, to the best of his knowledge and belief, served in the army,
navy or marine corps of the United States in any war in which it has been engaged,
insert in the certificate a recital to that effect, specifying the war, and shall also
certify in such certificate both the primary and tne 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 section and of sections forty-five, forty-six and forty-seven
of said chapter one hundred and fourteen, the word “.war” shall include the China
relief expedition and the Philippine insurrection, which shall, for said purposes,
be deemed to have taken place between February fourteenth, eighteen hundred
and ninety-eight and July fourth, nineteen hundred and two, and the Mexican
border service of nineteen hundred and sixteen and nineteen hundred and
seventeen. 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 boaid 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 inter-
ment, by a satisfactory certificate of the attending physician, if any, as required
by law, or in lieu thereof a certificate as hereinafter provided. If there is no
attending physician, or if, for sufficient reasons, his certificate cannot be obtained
early enough for the purpose, or is insufficient, a physician who is a member
of the board of health, or employed by it or by the selectmen for the 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 w'ithin 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 sucK removal; provided, that such body shall be returned to the town
from which it was removed within thirty-six hours after such removal, unless
a permit in the usual form for the removal of such body has been sooner obtained
hereunder. If the death certificate contains a recital, as required by section ten

of chapter forty-six, that the deceased served in the army, navy or marine corps
of the United States in any war in which it has been engaged, such recital shall
appear upon the permit. The board of health, or its agent, upon receipt of such
statement and certificate, shall forthwith countersign it and transmit it to (he
clerk of the town for registration. The person to whom the permit is soJgiven
and the physician certifying the cause of death shall thereafter furnish for
registration any other necessary information which can !>e obtained as to the
deceased, or as to the manner or cause of the death, which the clerk or registrar
may require. — Chap. 114, Sec. 4“>. G. 1... (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 |»ermit
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 tojsuch 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 alldeaths supposably
due to injury. These include not only deaths caused directly or indirect I v 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 iin-

Kortant, so that the relative healthfulness of various pursuits can be known.

lake some entry in this section for every person aged 10 years or over. If the
occujfSition 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, conk — 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

(County)

tHl|c <Komntmtfoea!tl| of JHaseachuaftts
OFFICE OF THE SECRETARY
DIVISION OF VITAL STATISTICS

COPY OF

CERTIFICATE OF DEATH

Medford

(City or town making return)
Reglatered No

fe Medford

til (City or Town)

< „ /', 'Z. TT Qr>vQ r>ri A VP ( (If death occurred in a hospital or institution,

-J No SL < gjve it8 NAME instead ol street and number)

- OL I

2 FULL NAME / Wa^vfteran,

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

(a) Resldenoe. No X51...£le..&s.ant sl Minthrop.

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

Length of stay: In hospital or I nstltutlon-.I.H.? ^ 0r:1£ars 6 months days.

(Before death) (Specify whether)

In this oommunlty4;5 yrs- mos. days.

PERSONAL AND STATISTICAL PARTICULARS

MEDICAL CERTIFICATE OF DEATH

3 SEX

F emal e

4 COLOR OR RACE

white

5 SINGLE
MARRIED
WIDOWED
or DIVORCED

(write the word)

s ingl e

IS DATE OF
DEATH

.J.^.ua*X

(Month)

9 1948

(Day) (Year)

5a If married, widowed, or dlvoroed

HUSBAND of

(Give maiden name of wife in full)

(or) WIFE of

(Husband’s name in full)

6 Age of husband or wife If alive years

7 IF STILLBORN, enter that faot here.

19 I HEREBY CERTIFY, That I attended deoeaaed from

J.an* 1.0...... 19 4.s> to Jan.,. 9. , 19 4.8

I last saw h. ...alive oJ.an • 8 .... , 19.4.8, death Is said to

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

Immediate oause of death

.Chr.Q.nl.c ¥.a.a.c.al.ah....My.Q..c.ar..di..ti.a

AGE ...®.5. Years .3. Months...?.?.. .Days

If less than 1 day
Hours Minutes

Due to..

9 Occupation : Retired

Industry BOOkke
10 or Business:

.^Island Creek

Due to .

11 Soolal Seourity No.

12 BIRTHPLACE (City)
(State or country)

Bast-on.

Other conditions. P analysis..... Agi t ans

(Include pregnancy within 3 months of death) phTR"

Mas 3.

13FNAATMHEEr Daniel

Rand

14 BIRTHPLACE OF

FATHER fCitvl

(State or country)

Mai no

15 MAIDEN NAME

OF MOTHER SaTail

G-ailey

16 BIRTHPLACE OF

MOTHER fCitvl

(State or country)

Mai ne

Major findings:
Of operations..

Date of..

Duration

...?.y.rs...

Physician

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

Of autopsy

What test confirmed diagnosis? .

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

If so, speoify..

(Signed) .

(Address)

>11 J -,.y

§.a.Erx,.L*.Q.afflP.be.l.l M. x>.

-» D... l/lS-ig..

informantMrs. Russell W. Bird )

(Address) -[7 Brooks Park, ifcaforci '

cremaitonbor,aremoval jlnthrop^ intnrop^

(Cemetery) (City or Town)

DATE OF BURIAL J.aH.e 1 1.94.8 19

A TRUE COPY.
ATTEST:

?/„

(Registrar of city or town where death occurred)

DATE FILED .J.an.,.. ..X..3./1..X..94.8 .1.... 19..

22 FUNERAL DIFJECTOR ...Alfred... B.g.M^Sh,

address 1.7.4 .7in.thr.Qp.. Sl -l..&throp..

Reoeived and filed rr.rr..f7V...14 19

. I... :... 1.94a

(Registrar of City or Town where deceased resided)

i
1

,M.&cLl.e.s.ex.

(County)

1 1 °
8

I 3

®I|c Cdmrtmon&ealtlj of ilffassaclfusetts
OFFICE OF THE SECRETARY
DIVISION OF VITAL STATISTICS

COPY OF

CERTIFICATE OF DEATH

EVERETT

(City or town nuking return)

Registered No.

o Ev.exe.t..t.

(City or Town)

WVl TTnqnit.al ( (If desth occurred in a hospital or institution,

No SL | give it8 NAME Instead of rtreet and number)

2 full name Nevill e

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

(a) Residence. No ? SL ....

(Usual place of abode) .

Length of stay: In hospital or Institution years months 26 <

(Before death) (Specify whether)

f (If U. S.

-< War Veteran,

1 days.

I speolfy WAR)

Wlnthrop m

(If nonresident, give city or town and State)

In this oommunlty yrs. mos. days.

PERSONAL AND STATISTICAL PARTICULARS

3 SEX

4 COLOR OR RACE

5 SINGLE (write the word)

white

MARRIED qinO’Tp
WIDOWED c,-LU&-Le
or DIVORCED

MEDICAL CERTIFICATE OF DEATH

18 DATE OF
DEATH

Jan.

(Month)

22,

(Day)

1948

(Year)

5a If married, widowed, or divoroed

HUSBAND of ...

(Give maiden name of wife in full)

(or) WIFE of

(Husband’s name in full)

19 I

\’o

• last saw h .6.r alive on 1 -.22 i^_15 ...4&leath Is said to

have ooourred on the date stated above, at.. .2. a *

6 Age of husband or wife If alive years

7 IF STILLBORN, enter that faot here.

Immediate oause of death

Carcinoma of Liver

AGE

.45...

Years....7T. Months..

..Days

If less than 1 day
Hours Minutes

Usual

9 Occupation:

Cost Clerk

Due to.Ge.n.. .C.a.roi.npmatosls

Care i noma.... of. ...Ri

Beacon Oil Co.

11 Soolal Seou rl ty No Qi Q.^.T. 2.Q.25. .

Industry
10 or Business:

Due to .

12 BIRTHPLACE (City)
(State or country)

..Bo.s.tgn.

Other conditions

(Include pregnancy within 3 months of death)

ass.

13 NAME OF
FATHER

Patrick

Major findings: Advanced Carcinoma

Of operations

Rt. Breast D.te 9-194o

14 BIRTHPLACE OF
FATHER (City) .

Mass'.'

Duration

11-^7

11-47

IE56

Physician

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

PARE

15 MAIDEN NAME n . T ,

of mother Catherine Lynch

16 BIRTHPLACE OF

MOTHER (City)

(State or country)

Mass.

informant Mother

. Relation, if any

(Address) —

\ /

irir.:,;:.;,,;....,;, gmnrrnainp

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

J.F. Williams

Everett Data 1-2.S i ..AS

If so, speolfy..

(Signed)

(Address) £5?.Y.55.i..5?.Af..¥. Date .

Winthrpp., Winthrop

21 PLACE OF BURIAL,

CREMATION OR REMOVAL

(Cemetery) -i p /j^City or Townl q

DATE OF BURIAL .9. 19 Z.9

22 funeral director . ..Frank M .., Doniyiue..
address Chari e s town

DATE FILED

1 FEB 1 3 •'943 ** 48

Received and filed..

(Registrar of City or Town where deceased resided)

—

- ■

■ R. -

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-302 to the clerk
of the city or town in which the deceased resided. (See Chap. 46, Sec. 12, G. L.)

RM R-302

®lje (Jontmonfopaltlj of JHassadjusetfs
OFFICE OF THE SECRETARY
DIVISION OF VITAL. STATISTICS

COPY OF

CERTIFICATE OF DEATH

£e4er ^ent ^righam B-ospital

Suffolk

(County)

Boston

(City or Town)

Peter "enn “rijrntun

No 17. ot.

Agata Jeveli

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

(a) Resldenoe. No ?.15 ..Pleasant st

Boston

(City or town making return)

916

Registered No.

.17.

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

2 FULL NAME .

(If U. S.

War Veteran,
speolfy WAR)

Winthro 5 Mass*

(Usual place of abode)

Length of stay: In hospital or Institution

(Before death) (Specify whether)

years 1 months 22 days.

(If nonresident, give city or town and State)

In this oommunlty yrs. mos. days.

PERSONAL AND STATISTICAL PARTICULARS

3 SEX

4 COLOR OR RACE

5 SINGLE (write the word)

MARRIED Mi j

widowed Widowed

or DIVORCED

5a If married, widowed, or dlvoroed
HUSBAND of

6 Age of husband or wife If alive

7 IF STILLBORN, enter that faot here.

(Give maiden name.of wife in full)

(or) wife of „..£at.sy..sIe.Y.ela.

(Husband’s name in full)

full)

MEDICAL CERTIFICATE OF DEATH

dde4atte„of Jan .27/48

(Month) (Day)

(Tear)

19 I HEREBY CERTIFY,

I HERE

..P.®c*....5

I last saw h....6.r alive on , 19../^.?, death la said to

That J atteg

ed deoeased

Ian,:

48'

it’

have ooourred on the date stated above, at .'..a.+.Sf.f. m.

7-ipp;

Immediate oause of death

Chronic duodenal ulcer with

AGE.

Years Months..

Days

If less than 1 day
Hours Minute*

bleeding

Due to

Usual

9 Occupation:

Housewif e

Industry

10 or Business:

11 Soolal Seourity No.

12 BIRTHPLACE (City)
(State or country)

■itBtjr

13 NAME OF
FATHER

PeNasi

14 BIRTHPLACE OF

Italy

FATHER fCitvl

(State or country)

15 MAIDEN NAME

OF MOTHER

-----

16 BIRTHPLACE OF

MOTHER fCitvl

Italy

(State or country)

informant

(Address)

E Jevel^ Kelati'S^ftany ^

DATE

Due to..

Other conditions

(Include pregnancy within 3 months of death)

Major findings:
Of operations .

..Date of..

Duroram

-2 •Yr s

Physician

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

Of autopsy

What test oonfirmed diagnosis?. ...C.lini.c.ftl

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

If so, speoify

(Signed) .®..A. Wi lhclm M. n

(Address) .if8

21 place of burial, Winthrop Cem-Winthrop Mass,

CREMATION OR REMOVAL

JeSu

(City or Town)

DATE OF BURIAL " 19

E P Caggiano

22 NAME OF

FUNERAL DIRECTOR ...

address Winthrop... Mass#

Reoelved and filed fVJ A Fv 9^ 1348

(Registrar of City or Town where deceased resided)

’

ftlje (Eommcmfoealtli of ,j3fta08arl|UBptt6
OFFICE OF THE SECRETARY
DIVISION OF VITAL STATISTICS

STANDARD

CERTIFICATE OF DEATH

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

Registered No.

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

St.

days.

PHYSICIAN- IMPORTANT

(Was deceased a

ar Veteran,
ecify WAR)

MruK i an

(If nonresident, give city or town and State)

In this community

yrs.

days.

MEDICAL CERTIFICATE OF DEATH

( Month)

/9 ^ ^

(Day)

(Year)

19 ^

19 HEREBY CERTIFY, That I attended deceased from

^.v4/^Ca~V' , 19V ¥ , to ..

I last saw h-'*-'''*’' alive on ^ f. Q , lg^T^death is said to

have occurred on the dale stated above, at /' ^ ^

'K&m. \JzJJu

Other conditions

(Include pregnancy within 3 months of death)

Major findings:

Of operations

Date of

Of autopsy —

What test confirmed diagnosis?

N AJ

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

20 Was disease or injury m any ^ay relate*} to occupation of deceased?

If so, specify .1 D JV. (0 . g

(Signed) \ , , M. 0..

1 19 tb&'

22 NAME OF

FUNERAL DIRECTO

ADDRESS

ived and Filed

FEB

T9-4-3

(Registrar)

EXTRACTS FROM THE LAWS OF THE
COMMONWEALTH OF MASSACHUSETTS
GOVERNING THE

RETURN OF CERTIFICATES OF DEATH

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

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

by section ten oi chapter loriv-wx, tuat the deceased served in the army,
navy or marine corps of the Upilpd 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 rjhich 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

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.

VI R-301 A

VSs

DIVISION OF VITAL STATISTICS

STANDARD

CERTIFICATE OF DEATH

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

2 FULL N

(a) Residence

(Usual place of abode)

Registered No... 19.

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

ddowed jffr divorced womaivgive also maiden name.)

v^ouai piaLt yji auuuc; » y y (If nonresident, give city or town and state)

Length of stay: In hospital or years months days. In this community ' U-^yrs. mog days.

(Specify whether) '

PERSONAL AND STATISTICAL PARTICULARS

4 COLOR OR RACE

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

live maiden nar

fejn full) •

(Husband's h£me in full;

(or) WIFE , of ..,

6 Age of husband or wife if alive . years

7 IF STILLBORN, enter that fact here.

8 ^ / I ^ loss than 1 day

AG&/...K?. Years Months Days| Hours Minutes

Usual

9 Occupation

Industry

10 or Business

11 Social Security No.

I HEREBY CERTIFY that a satisfactory standard certificate of death
was filed with me BEFOR^t^eJiuri«l-or^fransit j>ermit wa6 issued:

. (Signature oLAgejM/^f Bo^rof Ifealth-or other)/ / . ^

htJULi W4zK...:

(Official Designation) (Dateof Issue of Permit) ,

MEDICAL CERTIFICATE OF DEATH

18 DATE OF
DEATH

(Month) (Day)

(Year)

19 l HEREBY CERTIFY,,

//j *7 to *7 /j

That 1 attended deceased from

I last saw Ij alive on .? , J9 , dea

have occurred on the date stated above, at m.

Immediate cause of death.

h is said to

Duration

IMPORTANT

Due ......I ./....I.:/...

Due to^rf3f. ’*

Other conditions

^TT

^(Include pregnancy within 3 months of death)

IMPORTANT

PHYSICIAN

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

Major findings:

Of operations.-.

Date of

Of autopsy ?7.

What test confirmed diagnosis?...^..!'.''.;...*?!..:.....".

20 Was disease or injury in any way related lo occupation of deceased? .
If so, specify /£, J ..

Received and filed.

EEE3=ot:

(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,
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 certificate. If such a
permit for the removal of a human body, not previously interred, from
one town to another within the commonwealth cannot be obtained early
enough for the purpose, the certificate of death made as above provided
and in the possession of the undertaker desiring to make such removal
shall constitute a permit for such removal; provided, that such body shall
be returned to the town from which it was removed within thirty-six
hours after such removal, unless a permit in the usual form for the re-
moval of such body has been sooner obtained hereunder. If the death
certificate contains a recital, as required by section ten of chapter forty-
six, that the deceased served in the army, navy or marine corps of the
United States in any war in which it has been engaged, such recital shall
appear upon the permit. The board of health, or its agent, upon receipt of
such statement and certificate, shall forthwith countersign it and transmit
it to the clerk of the town for registration. The person to whom the permit
is so given and the physician certifying the cause of death shall thereafter
furnish for registration any other necessary information which can be
obtained as to the deceased, or as to the manner or cause of the death,
which the clerk or registrar may require. — Chap. 114, Sec. 45, G. L.,
(.Tercentenary Edition).

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

RULES OF PRACTICE

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

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

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

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

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

Statement of Occupation. — Precise statement of occupation is very
important, so that the relative healthfulness of various pursuits can be
known. Make some entry in this section for every person aged 10 years
or over. If the occupation had been given up

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