The volume, 1949
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J. L. FAIRBANKS DIV.
Thomas Groom & Co.
Stationers
105 State St., Boston
To duplicate this book order
No
O.U.7
#
#
M R-301A
TRUCTIONS
FOR
,L CERTIFICATE
1 giving
1 OF DEATH
not enter
e than one
te for each
, (b) and (c)
s does not mean
t of dying, such
ailure, asthenia, .
eons the disease ,
lications which
rath.
bid conditions,
iving rise to the "
use (a) stating
lerlying cause
dilions contrib - •
he death but not
) the disease or
causing death.
2 FULL NAME.
(Hommomoraltlj of Ifiaosactiuortte
FFICE OF THE SECRETARY
IVISION OF VITAL STATISTICS
STANDARD
CERTIFICATE OF DEATH
To be filed for burial permit
with Board of Health
or its Agent.
Registered No.
f (If death occurred in a hospital or institution,
St. \ give its NAME instead of street and number)
PHYSICIAN — IMPORTANT
(Was deceased a
U. S. War Veteran,
if so specify WAR)
(a) Residence. No.
(Usual place ofobo/e)
(If nonresident, give city or town and State)
Length of stay: In place of death years months days. In place of residence years^^ months days.
//Jj. A/
(Date of Issue of permit) Jf y /
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 o£ death, stating to the
best of his knowledge and belief the name of the deceased, his supposed age. the
disease of which he died, defined as required by section one, where same was
contracted, the duration of his last illness, when last seen alive by the physician
or officer and the date of his death. . .Gen. Laws. Chap. 46, Sec. 9.
A physician or officer furnishing a certificate of death as required by the
preceding section or by section forty-five of chapter one hundred and four-
teen. shall, if the deceased, to the best of his knowledge and belief, served in the
army, navy or marine corps of the United States in any war in which it has been
engaged, insert in the certificate a recital to that effect, specifying the war. and
shall also certify in such certificate both the primary and the secondary or imme-
diate 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 purpose^ 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 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 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 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 o'f health, or. (£s agent, upon receipt of such statement and certificate,
shall forthwith countersign it and transmit it to the clerk of the town for registra-
tion. The person to whom the permit is so given and the physician certifying
the cause of death shall thereafter furnish for registration any other necessary
information which can be obtained as to the deceased, or as to the manner or
cause of the death, which the clerk or registrar may require. — Chap. 114, Sec. 45.
G. L., (Tercentenary Edition).
Medical examiners shall. make examination upon the view of the dead bodies
of only such persons as are supposed to have died by violence. If a medical
examiner has notice that there is within his county the body of such a person, he
shall forthwith go to the place where the body lies and take charge of the same;
. . . -General Laws, Chap. 38. Sec. 6.
No undertaker or other persons 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 follow-
ing 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. — Physicians: see explanatory instructions
on face side of standard certificate of death.
Statement of Occupation. — Precise statement of occupation is very import-
ant. 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 occupa-
tion had been given up or changed, or if the deceased had retired from business,
report the kind of work done dunng most of working life even if retired. 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
6 V
ORGANIZATION AND OUTFIT
SERVICE NUMBER
25m-(h)-10- 48-24658
1-
Se Suf f olk
O (County)
Boston
(City or town)
QJljp (Emnmmtmraltlj of AaaBarlfttBrttB
OFFICE OF THE SECRETARY
DIVISION OF VITAL STATISTICS
COPY OF
MEDICAL EXAMINER’S
CERTIFICATE OF DEATH
Boston
(City or town making return)
161 2..
Registered No. .
No.
y 0 Harrison" Ave. / (If death occurred in a hospital or institution.
St. \
give its NAME instead of street and number)
2 FULL NAME Christ Flessas , (Was deceased a
(If deceased is a married, widowed or divorced woman, give also maiden name.)
236 Lincoln St
(a) Residence. No
(Usual place of abode)
St.
Length of stay: In place of death years months days. In place of residence.
28
U. S. War Veteran.
[ if so specify WAR)
f inthrop Mass .
(If nonresident, give city or town and State)
years months days.
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
DEATH
Jan.ii/U9
9 SEX
10 COLOR OR RACE
w
11
(Month)
(Day) (Y ear)
M
the death
of the person above-named and that the CAUSE AND MANNER thereof
are as follows: (If an injury was involved, state fully.)
Coronary occlusion
5 Accident, suicide, or homicide (specify)
Date and hour of injury 19..
Where did
Injury occur?..
(City or town and State)
Did injury occur in or about home, on farm, in industrial place, or in public
place?
Manner of
Injury
Nature of
Injury
(Specify type of place)
(How did injury occur?)
While at work? Was autopsy performed?
6 Was disease or injury in any way related to occupation of deceased?
If so, specify
(signed) R&chCTd . Ford m. d
(Address) Datel“5< 19. M
7 Mnthyop Cem-»Winthrop Mass
Place of Burial, or Cremation. (City or Town)
DATE OF BURIAL Jan..7/U9.
19
8 NAME OF
FUNERAL DIRECTOR
A C Hasiotis
ADDRESS Bps-tfin-Mflo
3*
Received and filed
r LLi
■•Trvvre
o iy4£
(Registrar of City or Town where deceased resided)
19.
PERSONAL AND STATISTICAL PARTICULARS
SINGLE (write the word)
MARRIED ,
widowed Single
or DIVORCED
11a If married, widowed, or divorced
HUSBAND of
(Give maiden name of wife in full)
(or) WIFE of.
(Husband's name in full)
12 IF STILLBORN, enter that fact here.
If under 24 hours
AGE Years
Months
Days
Hours Minutes
14 Usual .
Occupationi LOOK
(Kind of work done during most of working life)
15 Industry
or Business:
Restaurant
i6 Social Security NoCannQ.t...fes.. Qhtainaole-
17 BIRTHPLACE <qfe»eeCe
(State or country)
18 NAME OF
FATHER
Nicholas Flessas
19 BIRTHPLACE-PF
FATHER (City
(State or country)
;e-pi
itFreeCe
20 MAIDEN RodepOUlOS
OF MOTHER r
21 BIRTHPLACE, OF
MOTHER (Cityjr.e.e..C.e. .
(State or country)
Informant...
(Address)
James Flessas
■•ssr /
DATE FILED
should b# carefully supplied. AOt should be stated tA ALTLT. FWTSICIANS should stats CAUSE OF DEATH in plain
farms, so that it may bo proparly dassifisd. Exact statamant of OCCUPATION is vary important. Sae instructions and
ax tracts from tho laws on back of cbrtificata.
If deceased was a U. S. War Vataran, 0. L. Chap. 46, Section 10, requires physicians to Insert a reoltal to that effeot.
100m- (g)- 1-45- 155 10
M R-301
%
u I
o
5
v.0.
(a) Residence. No.
(Usual place of abode)
$hr Cffumnuntfnealtl) of jWaseac^iiBrttB
OFFICE OF THE SECRETARY
DIVISION OF VITAL STATISTICS
STANDARD
CERTIFICATE OF DEATH
To bo filed for burial permit
with Board of Health
or ita Agent.
Q
Regletared No Ajl«.
"intLrop
(City or Town) ?
n. Eos-p-i -La-l
PHYSICIAN - IMPORTANT
fl-SJL. ) /J - - Z~y\ ' UTi it .. n-7T- //'yy 1
2 FULL NAME
(If deceased Is a marrie^, widowed or divorced woman, giy
3k
Length of stay: In hnsnltsl nr Institution
(Before deeth) (Specify whether)
years
- {b
deceased a
War Veteran,
specify WAR) HQ...
months
(If nonresident, give city or town and State)
In this community yrs. mo*. 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 oivoRdEis rriea
18
S£Xh°:. J*MARY. SL LS>..fJ4
(Month)
(Day)
(Year)
5a If married, widowed, or divoroed
HUSBAND of
.(Qive maiden name of wife in full)
(or) WIFE of J.JLlll-.'im ... J....iLeXLy
f Husband’s name In full)
6 Age of husband or wife if aliva £y7 years
19 I HEREBY CERTIFY, That I attended deoeased from
Q.cn>te& 2 £., i M. . 19
I last law h iS’.!^ alive on .... j.mMRy.4. 19* f. death Is said to
have occurred on the date stated above, at .,.m.
Immediate oauee of death..
7 IF STILLBORN, enter that fact here.
AGE X7 ... Years Months
Dsys
If less than 1 day
Hourt Minutes
Usual
9 Occupation;
WACAHQ/fiL }N&uPFlCiBfitcy
Due to Jfdi U cM/EflC
Industry
10 or Business: Ht—iiOBl-©”
Due to .
11 Social Security No. nOil’©"’
(Stale or country)
Boston Hass.
13 NAME OF
FATHER Santo
Bonf iglio
14 BIRTHPLACE OF
FATHER (City)
(State or country)
Italy
15 MAIDEN NAME
OF MOTHER
c/b/1
16 BIRTHPLACE OF
MOTHER fPitv*
(State or country)
Italy
Other conditions.
1 Include pregnancy within 8 months of desth)
Major findings:
Of operations .
Date of
Of autopsy
What tett oonflrmed diagnosis?
Duration
IMPORTANT
■>
IMPORTANT
Physician
Underline
the cause to
which death
should be
charged sta-
tistically.
20 Was disease or injury in any way related to oooupatlon of deoeased
(Address^^^/^g^pj^^^^^^^^^ata 19
^nform.ni(ini^.J..^llZ ( Hfififi. )
uP\r»r0
I HEREBY CERTIFY that a satisfactory standard oertlfloate of death waa
filed with m* BEFORE tho burial or. transit nermtt was issued:
Place of Burial, Cremation or Removal. (City
DATE OF BURIAL.V an. 8,1949
(Signs tare of Agent o^ Board of Health or .other) ,
yC. a,.
(Official Designation) (Date of Ineoe/of Permit)
22 NAME OF
FUNERAL DIRECTOR
R^ialved and filed 19
(Registrar)
fell
EXTRACTS FROM THE LAWS OF THE
COMMONWEALTH OF MASSACHUSETTS
GOVERNING THE
RETURN OF CERTIFICATES OF DEATH
A physician or registered hospital medical officer shall forthwith, after
the death of a person whom he has attended during his last illness, at the
request of an undertaker or other authorized person or of any member of
the family of the deceased, furnish for registration a standard certificate
of death, stating to the best of his knowledge and belief the name of the
deceased, his supposed age, the disease of which he died, defined as re-
quired by section one, where same was contracted, the duration of his last
illness, when last seen alive by the physician or officer and the date of
his death . . . Gen. Laws, Chap. 46, Sec. 9.
A physician or officer furnishing a certificate of death as required by the
preceding section or by section forty-five of chapter one hundred and four-
teen, shall, if the deceased, to the best of his knowledge and belief, served
in the army, navy or marine corps of the United States in any war in which
it has been engaged, insert in the certificate a recital to that effect, speci-
fying the war, and shall also certify in such certificate both the primary
and the secondary or immediate cause of death as nearly as he can state
the same. For neglect to comply with any provision of this section, such
physician or officer shall forfeit ten dollars. For the purposes of this sec-
tion and of sections forty-five, forty-six and forty-seven of said chapter
one hundred and fourteen, the word “war” shall include the China relief
expedition and the Philippine insurrection, which shall, for said purposes,
be deemed to have taken place between February fourteenth, eighteen
hundred and ninety-eight and July fourth, nineteen hundred and two, and
the Mexican border service of nineteen hundred and sixteen and nine-
teen hundred and seventeen. G. L. Chap. 46, Sec. 10.
No undertaker or other person shall bury or otherwise dispose of a human
body in a town, or remove therefrom a human body which has not been
buried, until he has received a permit from the board of health, or its
agent appointed to issue such permits, or if there is no such board, from
the clerk of the town where the person died; and no undertaker or other
person shall exhume a human body and remove it from a town, from one
cemetery to another, or from one grave or tomb other than the receiving
tomb to another in the same cemetery, until he has received a permit from
the board of health or its agent aforesaid or from the clerk of the town
where the body is buried. No such permit shall be issued until there shall
have been delivered to such board, agent or clerk, as the case may be,
a satisfactory written statement containing the facts required by law to be
returned and recorded, which shall be accompanied, in case of an original
interment, by a satisfactory certificate of the attending physician, if any,
as required by law, or in lieu thereof a certificate as hereinafter provided.
If there is no attending physician, or if, for sufficient reasons, his certificate
cannot be obtained early enough for the purpose, or is insufficient, a physi-
cian who is a member of the board of health, or employed by it or by the
selectmen for the purpose, shall upon application make the certificate re-
quired of the attending physician. If death is caused by violence, the medi-
cal examiner shall make such certificate. If such a permit for the removal
of a human body, not previously interred, from one town to another within
the commonwealth cannot be obtained early enough for the purpose, the
certificate of death made a3 above provided and in the possession of the
undertaker desiring to make such removal shall constitute a permit for
such removal; provided, that such body shall be returned to the town from
which it was removed within thirty-six hours after such removal, unless
a permit in the usual form for the removal of such body has been sooner
obtained hereunder. If the death certificate contains a recital, as required
by section ten ot chapter torty-six, that the deceased served in the army,
navy or marine corps of the United States in any war in which it has been
engaged, such recital shall appear upon the permit. The board of health,
or its agent, upon receipt of such statement and certificate, shall forthwith
countersign it and transmit it to the clerk of the town for registration.
The person to whom the permit is so given and the physician certifying
the cause of death shall thereafter furnish for registration any other neces-
sary information which can be obtained as to the deceased, or as to the
manner or cause of the death, which the clerk or registrar may require. —
Chap. 114, Sec. 45, G. L., (Tercentenary Edition).
Medical examiners shall make examination upon the view of the dead
bodies of only such persons as are supposed to have died by violence.
If a medical examiner has notice that there is within his county the body
of such a person, he shall forthwith go to the place where the body lies
and take charge of the same; . , . — General Laws, Chap. 38, Sec. 6.
No undertaker or other person shall bury a human body or the ashes
thereof which have been brought into the commonwealth until he has re-
ceived a permit so to do from the- board of health or its agent appointed to
issue such permits, or if there is no such board, from the clerk of the town
where the body is to be buried or the funeral is to be held, or from a person
appointed to have the care of the cemetery or burial ground in which the
interment is made. . . . Chap. 114, Sec. 46, G. L., (Tercentenary Edition).
RULES OF PRACTICE
The fulfillment of the purpose of these laws calls for the observance of
the following rules of practice:
(1) Attending physicians will certify to such deaths only as those of
persons to whom they have given bedside care during a last illness from
disease unrelated to any form of injury.
(2) Board of Health physicians will certify to such deaths only as those
of persons who, though disabled by recognized disease unrelated to any
form of injury, have died without recent medical attendance or whose phy-
sician is absent from home when the certificate of death is needed.
(3) Medical Examiners will investigate and certify to all deaths sup-
posably due to injury. These include not only deaths caused directly or
indirectly by traumatism (including resulting septicemia), and by the
action of chemical (drugs or poisons), thermal, or electrical agents, and
deaths following abortion, but also deaths from disease resulting from
injury or infection related to occupation, the sudden deaths of persons not
disabled by recognized disease, and those of persons found dead.
Statement of Cause of Death. — -Cause ot 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
tM R-301A
t
5TRUCT10NS
FOR
AL CERTIFICATE
n giving
E OF DEATH
not enter
re than one
se for each
), (b) and (c)
is does not mean
\e of dying, such
failure, asthenia, .
neans the disease,
plications which
l eath.
rbid conditions, .
living rise to the "
luse (a) staling
derlying cause
iditions conlrib - «
the death but not
o the disease or
n causing death.
< Suffolk
(County)
Win t hr op
(City or Town)
QHjr (Commontdraltl) of fHaBBartiasrttB
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 55 Sargent Street
/? *
2 full name J ohn Israel Lent
(If deceased is a married, widowed or divorced woman, give also maiden name.)
(a) Residence. No. 55 Sargent Street
(Usual place of abode)
I (If death occurred in a hospital or institution,
St. \ give its NAME instead of street and number)
('PHYSICIAN — IMPORTANT
I (Was deceased a
I U. S. War Veteran, TJO *
l if so specify WAR) .. "Y *
St.
Length of stay:
(If nonresident, give city or town and State)
In place of death years months days. In place of residence years 50 months days.
MEDICAL CERTIFICATE OF DEATH
3 DATE OF « m -| rv i r*v
death January 7, 1949
(Month) (Day)
(Year)
EBY CERTIFY.
•SO, 19 ., to
I last saw alive on
have occurred on the date statea above, at •31- /sr
DISEASE OR CONDITION
DIRECTLY LEADING
TO DEATH (a)
That I attended deceased from
v 7
19
7 i4? , death is said to|
PERSONAL AND STATISTICAL PARTICULARS
Major findings:
Of operations.
Date of operation .Was autopsy ;
What test confirmed diagnosis?
rformed? ./73r?Q...
5 Was disease or injury in any way related to occupation of deceased? /HCLG
n
(Address) tytfaStCOfc/TTyfd \ Date 19
6 „S?S9t9ry . .
DATE OF BURIAL January 10.1949
7 NAME OF
FUNERAL DIRECTOP
_address_ 174 Wirithrop St . Winthrop.Mal
Received and filed JAN 11 4?-^
(Registrar)
8 SEX
male
9 COLOR OR RACE
white
10 SINGLE (write the word)
MARRIED
WIDOWED __ . ,
or divorced married
10a If married, widowed, or divorced
husband of Ella Peters
(Give maiden name of wife in full)
(or) WIFE of
(Husband's name in full)
11 IF STILLBORN, enter that fact here.
12
AGE Years
73,
lli
onths
25)
ays
If under 24 hours
Hours Minutes
Occupation: retired bank clerk
(Kind of work done during most of working life)
or Business: Boston Safe Deposit
15 Social Security No. [removed]
16 BIRTHPLACE (City) .
(State or country)
Pregort
(Co*
ova Scotia
17 NAME OF
FATHER
18 BIRTHPLACE OF
FATHER (City)
(State or country)
Manning Lent
Preport
[ova
Scotia
19 MAIDEN NAME
OF MOTHER
•unable** to apoortatn
20 BIRTHPLACE OF
MOTHER (City) ...
(State or country)
Preport
Nova Scotia
21
Informant
(Address)
* gargeni * stffeit hr op
I HEREB^ CERTIFY that a satisfactory standard certificate of death was
~ ~~~ RE the burial^r^ransiL-permit was issued:
ss.
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 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, specifying the war, and
shall also certify in such certificate both the primary and the secondary or imme-
diate 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 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 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 from which it was
removed within thirty-six hours after such removal, unless a permit in the usual
form for the removal of such body has been sooner obtained hereunder. If the
death certificate contains a recital, as required by section ten of chapter forty-six,
that the deceased served in the army, navy or marine corps of the United States
in any war in which it has been engaged, such recital shall appear upon the permit.
The board of health, or its agent, upon receipt of such statement and certificate,
shall forthwith countersign it and transmit it to the clerk of the town for registra-
tion. The person to whom the permit is so given and the physician certifying
the cause of death shall thereafter furnish for- registration any other necessary
information which can be obtained as to the deceased, or as to the manner or
cause of the death, which the clerk or registrar may require. — Chap. 114, Sec. 45,
G. L„ (Tercentenary Edition).
Medical examiners shall. make examination upon the view of the dead bodies
of only such persons as are supposed to have died by violence. If a medical
examiner has notice that there is within his county the body of such a person, he
shall forthwith go to the place where the body lies and take charge of the same;
. . . General Laws, Chap. 38, Sec. 6.
No undertaker or other persons 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
f
The fulfillment of the purpose of these laws calls for the observance of the follow-
ing 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. — Physicians: see explanatory instructions
on face side of standard certificate of death.
Statement of Occupation. — Precise statement of occupation is very import-
ant, 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 occupa-
tion had been given up or changed, or if the deceased had retired from business,
report the kind of work done dunng most of working life even if retired. 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
50m-(e)- 10-48-24658
< S.uffolk
q (County)
U.
° Bos. ton
j*j (City or Town)
2
a.
Q/ljp QJmnnumtoraltlj of UtaBBarljaBrttB
OFFICE OF THE SECRETARY
DIVISION OF VITAL STATISTICS
COPY OF
CERTIFICATE OF DEATH
Boston
(City or town making return)
Registered No.
219
No.
2 FULL NAME
Mass. General hospital
;orge Paterson
married, widowed or divorced woi
U7 Crystal Cove Ave,
( (If death occurred in a hospital or institution,
St. \ .give its NAME instead of street and number)
P.e.orge Paterson : { (was deceased a
(If deceased is a married, widowed or divorced woman, give also maiden name.) | U. S. War Veteran,
Winthro^‘arsiy.WAR>
(If nonresident, give city or town and State)
Length of stay: In place of death years months. 13 days. In place of residence 15 . .years months days.
(a) Residence. No fit... ... ; St.
(Usual place of abode)
MEDICAL CERTIFICATE OF DEATH
PERSONAL AND STATISTICAL PARTICULARS
3 DATE„0F Jan. ,1/19
DEATH
(Month)
(Day)
(Year)
41 HEREBY CERTIFY, That I attended deceased from
I>ee.'2-5 19 18 to Jan.*..7 19.. .1*9.
I last saw h lfflalive on 19.“?,, death is said tc
2; 30AM
8 SEX
M
9 COLOR OR RACE
W
10 SINGLE (write the word)
MARRIED w _ . ,
widowed Miarnea
or DIVORCED
voFldora L Leach
have occurred on the date stated above, at
DISEASE OR CONDITION
DIRECTLY LEADING
TO DEATH (a) .....
acute pyelonephritis bilateral
Uraemia from
ceSInt ^ .^ni^ Pr ostatic
causes hypertrophy
Due To
(c)
other Arteriolar nepnro scla^o si s
SIGNIFICANT
CONDITIONS
hyper ten sive--C'^rdio;-vascji^rY
INTERVAL BE-
TWEEN ONSET
AND DEATH
Few
10 Yrs
XS
m a jor findings : Suprapubi c pr o s ta t e c t omy
Of operations
Date of operation!"/ — - ^ Was autopsy performedSCSS..
What test confirmed diagnosis?
autopsy..
S Was disease or injury in any way related to occupation of deceased?
If so, specify
(Signed) M. D
(Address) Jlass.-^eneral...no.spi&ate 19.--.
Ifoodiaw^
Place of Burial or Cremation (City or Town)
DATE OF BURIAL Jan «...1Q./1a9
19..
7 FUNERAL DIRECTOR W....S...E.6ynpldS
Win thr op Ma ss ,
ADDRESS
Received and filed
EEte ms
(Registrar of City or Town where deceased resided)
.19
10a If married, widowed, or divo
HUSBAND of
(Give maiden name of wife in full)
(or) WIFE of
(Husband’s name in full)
11 IF STILLBORN, enter that fact here.
o12 72 U -j
*AGE Years Months r. ..Days
If under 24 hours
Hours Minutes
13 Usual
Occupation:
Engineer
(Kind of work d
done during most of working life)
14 Industry
or Business:
Stationery
IS Social Security No. . .0.3Q.-05-U653A
16 BIRTHPLACE (City)QuiUCy.."?a.S5..*..
(State or country)
17 NAME OF
FATHER
William H Paterson
18 BIRTHPLACE OF
FATHER (City) ...Scotland
(State or country)
19 MAIDEN NAME
OF MOTHER
Maria MacMillian
20 birthplace 0Fpr^nce Edward I sland
MOTHER (City) t
(State or country)
|'L..Paterson
.4....
strar of City or Town where death ofccurred)
11/U9 v-
19
.
■
.
'
:M R-301A
iTRUCTIONS
FOR
LL CERTIFICATE
n giving
i OF DEATH
not enter
•e than one
u for each
, (b) and (c)
ij does not mean
e of dying, such
failure, asthenia, .
leans the disease,
ilications which
eath.
'bid conditions. .
icing rise to the '
use (a) staling
ierlying cause
ditions conlrib- •
the death but not
0 the disease or
1 causing death.
Suffolk
(County)
Winthrop
(City or Town)
77 Triton Ave .
Qlommmuuralttj of JEaBBadjuBrlta
OFFICE OF THE SECRETARY
DIVISION OF VITAL STATISTICS
STANDARD
CERTIFICATE OF DEATH
Registered No
To be filed for burial permit
with Board of Health
or its Agent.
6
No.
2 full name Anna (Lef Strom) Hoey
(If deceased is a married, widowed or divorced woman, give also maiden name.)
(a) Residence. No. 77 Triton AV© St
(Usual place of abode)
Length of stay: In place of death years months days. In place of residence 34 ea
I (If death occurred in a hospital or institution.
St. \ give its NAME instead of street and number)
PHYSICIAN — IMPORTANT
(Was deceased a
U. S. War Veteran,
if so specify WAR)
(If nonresident, give city or town and State)
rs months days.
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
DEATH ...
pCc-vi
f (Month)
r
(Day)
££
(Year)
That I attended deceased from
**?■
41 HEREBY CERTIFY,
C 2 lb rtf $ . to
I fast saw h ...alive on. .. 7 .... i death is said td
have occurred on the date stated above, at r <*? m. I INTERVAL BE-
TWEEN ONSET
AND DEATH
DISEASE OR CONDITION
DIRECTLY LEADJ^C,
TO DEATH (a)^G Cuist C?
ANTE Due To
CEDENT (b)
CAUSES
Due To
(c)
OTHER
SIGNIFICANT
CONDITIONS
Major findings:
Of operations
Date of operation Was autopsy performed?
What test confirmed diagnosis?
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
9 COLOR OR RACE
Femalle White
10 SINGLE
MARRIED
WIDOWED
or DIVORCED
(write the word)
Widow
10a If married, widowed-or divorced-, TT
husband of Lloy d F Hoey
(Give maiden name of
i
(or) WIFE of
of wife in full)
usband’s name in full)
1 1 IF STILLBORN, enter that fact here.
12
AGE 72 Years .8 Months 14 Days
If under 24 hours
Hours Minutes
13 Usual
Occupation: HOUSeWlfe
(Kind of work done during most of working life)
14 Industry
or Business:
Own. home
15 Social Security No. None
16 BIRTHPLACE (City) .
(State or country)
Pittsburgh
Pa .
5 Was disease or injury in any way related to occupation of deceased?
If so. specify
(Signed) M. D
(Address) csTJ f*
Date
6 Winthrop
Place of Burial or Cremation
DATE OF BURIAL
y 19 pf
Winthrop
(City or Town)
Jan. 10
7 NAME OF
FUNERAL DIRECTO
ADDRESS
<hU
4g
Received and filed..
JAN 4 1 1949
(Registrar)
17 NAME OF ,
father John Henry Lef strom
18 BIRTHPLACE OF
FATHER (City)
(State or country)
Denmark
19 MAIDEN NAME
OF MOTHER Elisabeth Hirt
20 BIRTHPLACE OF
MOTHER (City)
(state or country) Switzerland
(Address) 'Melrose, Fiass
IH/REBY CERTIFY that a satisfactory standard certificate of death was
with ^ip^BEFORE the buoal or transit pei'biit was issued:
latu
(Official Designation)
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 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, specifying the war, and
shall also certify in such certificate both the primary and the secondary or imme-
diate 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 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 tne 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 from which it was
removed within thirty-six hours after such removal, unless a permit in the usual
form for the removal of such body has been sooner obtained hereunder. If the
death certificate contains a recital, as required by section ten of chapter forty-six,
that the deceased served in the army, navy or marine corps of the United States
in any war in which it has been engaged, such recital shall appear upon the permit.
The board of health, or its agent, upon receipt of such statement and certificate,
shall forthwith countersign it and transmit it to the clerk of the town for registra-
tion. The person to whom the permit is so given and the physician certifying
the cause of death shall thereafter furnish for- registration any other necessary
information which can be obtained as to the deceased, or as to the manner or
cause of the death, which the clerk or registrar may require. — Chap. 114, Sec. 45,
G. L., (Tercentenary Edition).
Medical examiners shall. make examination upon the view of the dead bodies
of only such persons as are supposed to have died by violence. If a medical
examiner has notice that there is within his county the body of such a person, he
shall forthwith go to the place where the body lies and take charge of the same;
. . . General Laws, Chap. 38, Sec.6.
No undertaker or other persons 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 follow-
ing 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. — Physicians: see explanatory instructions
on face side of standard certificate of death.
Statement of Occupation. — Precise statement of occupation is very import-
ant, 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 occupa-
tion had been given up or changed, or if the deceased had retired from business,
report the kind of work done during most of working life even if retired. 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
U R-301A
AUCTIONS
FOR
. CERTIFICATE
giving
OF DEATH
lot enter
: than one
j for each
(b) and (c)
does not mean
of dying, such
itlure, asthenia, .
ans the disease,
ications which
nth.
>id conditions, ,
ving rise to the
se (a) stating
•rlying cause
itions conlrib-
le death but not
the disease or
causing death.
Suffolk
(County)
'Vinthrop
(City or Town)
No. 35. Centre St.
Qtyp (Eommanroraltlj of ffflaBBarljUBfttB
OFFICE OF THE SECRETARY
DIVISION OF VITAL STATISTICS
STANDARD
CERTIFICATE OF DEATH
To b# filed for burial permit
with Board of Health
or ite Agent.
Registered No.
2 FULL NAME
John Peter Petersen
(If deceased is a married, widowed or divorced woman, give also maiden name.)
(a) Residence. No. 55 C en tr e S t
(Usual place of abode)
RO ■
Length of stay: In place of death.. nr.rr. years months days. In place of residence
I (If death occurred in a hospital or institution.
St. \ give its NAME instead of street and number)
PHYSICIAN — IMPORTANT
(Was deceased a
U. S. War Veteran,
if so specify WAR)
St.
(If nonresident, give city or town and State)
years months days.
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
DEATH
(Month)
//
(Day)
(Year
4 1 HEREBY
3ht
I last saw h tvi alive on
have occurred on the date stated
ERTIFY,
i9 yo. to
That I attended deceased from
f / ... 19
// . , 19 4/ $ death is said"to|
/ 2*-
DISEASE OR CONDITION
DIRECTLY LEAQTJG
TO DEATH (a)tT^t
ANTE Due To
CEDENT (b)
CAUSES
Due To
(c)
OTHER
SIGNIFICANT
CONDITIONS
NT
<0
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
Male
9 COLOR OR RACE
rVhi te
10 SINGLE
MARRIED
WIDOWED
or DIVORCED
(write the word)
71 do we d
Major findings:
Of operations 4^ °J
Date of operatio 2-^rWas autopsy performed? ..
What test confirmed diagnosis? errrr..
5 Was disease or injury in any way related to occupation of deceased?
cl rr
(Address) 2- f Date Cf"**** /X
M. D
19
6 . 7.QQdl.awn E-vere tt
Place of Burial or Cremation (City orJTown)
DATE OF BURIAL J
7 NAME OF
FUNERAL DIRECTOR
Received and filed..
m.
ADDRESS Vinthrop. Mass
-MO z. 1949I
.19 .
(Registrar)
10a If married, widowed, or divorced
husband of Nellie A . G-arvey
(Give maiden name or
(or) WIFE of
(Give maiden name of wife in full)
(Husband’s name in full)
11 IF STILLBORN, enter that fact here.
AGE 7.9
Years Months
Days
If under 24 hours
Hours Minutes
13 Usual
Occupation: Marine Engineer
(Kind of work done during most of working life)
14 Industry
or Business:
Steamship..
15 Social Security No.
16 BIRTHPLACE (City) .
(State or country)
Denmark
17
NAME OF
FATHER
Peter Petersen
18
BIRTHPLACE OF
FATHER (City)
(State or country)
Denmark
19
MAIDEN NAME
OF MOTHER
Cannot be learned
20
BIRTHPLACE OF
MOTHER (City)
(State or country)
Denmark
21
(Address) ■ throe"
I 1^ER.EBY CERTIFY that a satisfactory standard certificate of death was
pdjvitl^i^e BEFORE^ j>e buri^nbr transit permit was issued:
nt of Boardo/ Health or other)
/T/gM
(Date of Issue o^>ermit)
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 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, specifying the war. and
shall also certify in such certificate both the primary and the secondary or imme-
diate 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 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 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 from which it was
removed within thirty-six hours after such removal, unless a permit in the usual
form for the removal of such body has been sooner obtained hereunder. If the
death certificate contains a recital, as required by section ten of chapter forty-six,
that the deceased served in the army, navy or marine corps of the United States
in any war in which it has been engaged, such recital shall appear upon the permit.
The board of health, or its agent, upon receipt of such statement and certificate,
shall forthwith countersign it and transmit it to the clerk of the town for registra-
tion. The person to whom the permit is^ao given and the physician certifying
the cause of death shall thereafter furnish for- registration any other necessary
information which can be obtained as to the deceased, or as to the manner or
cause of the death, which the clerk or registrar may require. — Chap. 114, Sec. 45,
G. L., (Tercentenary Edition).
Medical examiners shall. make examination upon the view of the dead bodies
of only such persons as are supposed to have died by violence. If a medical
examiner has notice that there is within his county the body cf 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 persons 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 follow-
ing 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 its 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. — Physicians: see explanatory instructions
on face side of standard certificate of death.
Statement of Occupation. — Precise statement of occupation is very import-
ant, so that the relative healthfulness of various pursuits can be known. Make
spme entry in this section for every person aged 10 years or over. If the occupa-
tion had been given up or changed, or if the deceased had retired from business,
report the kind of work done during most of working life even if retired. 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
M R-301 A
TRUCTIOHS
FOR
kL CERTIFICATE
n giving
i OF DEATH
not enter
'e than one
>e for each
, (b) and (c)
s does nol mean
e of dying, such
failure, asthenia, .
i cans the disease,
dications which
eath.
■bid conditions, .
iving rise to the "
use (a) stating
ierlying cause
ditions contrib- •
'he death but not
r> the disease or
i causing death.
..Suffolk
(County)
o Winthrop
U (City or Town)
(Hmmnonmraltlj of JHaBBarijUBrtta
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.
.8...
C P ni !>’•+• RH f (If death occurred in a hospital or institution.
No r*1 ~c y.y.V~~ ~ f St. i give its NAME instead of street and nui
2 FULL name Margaret (Ramsay) Beach
(If deceased is a married, widowed or divorced woman, give also maiden name.)
number)
PHYSICIAN — IMPORTANT
(Was deceased a
U. S. War Veteran,
l if so specify W'AR)
(a) Residence. No. 5.5 COUrt Rd. St
(Usual place of abode) (If nonresident, give city or town and State)
Length of stay: In place of death years months days. In place of residence 39 years months days.
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
DEATH ..
(Month)
/3
(Day)/
(Year)
41 HEREBY CERTIFY,
. 19 7 , . to
^T last saw h .alive on
have occurred on the date stati
That I attended deceased from
****** f . 13 19 W
to
g
/i 19 ¥?■ death is said
above, at SiJoR m.
DISEASE OR CONDITION
DIRECTLY LEADI)
TO DEATH (a)
^ y.4./. h. *■ boSlS
[T o>)
rt-
ANTE Due T,
CEDENT
CAUSES
r.
Due To
(c)
OTHER
SIGNIFICANT
CONDITIONS
Major findings:
Of operations
Date of operation Was autopsy pejformed?
What test confirmed diagnosis?
INTERVAL BE-
TWEEN ONSET
AND DEATH
5 Was disease or injury in any way related to occupation of deceased?
(Signed^^CjCRXArf-^^^rt, t T "( , M. D
(Address J Y . Date 19
WlntTiro
6 Winthrop
Place of Burial or Cremation
iron
(City or Town)
Jan. 17
PERSONAL AND STATISTICAL PARTICULARS
8 SEX 9 COLOR OR RACE
Female White
10 SINGLE (write the word)
wrnowlo Married
or DIVORCED
10a If married, widowed, or divorced
HUSBAND of
(Give maiden name of wife in full)
(Husband’s name in full)
11 IF STILLBORN, enter that fact here.
i2 75
AGE ' -2 Years
1 22
Months Days
If under 24 hours
Hours Minutes
13 Usual
Occupation:....
Housewife
(Kind of work done during most of working life)
14 Industry
or Business:
Own Home
15 Social Security No.
16 BIRTHPLACE (City) .
(State or country)
Chicago
17 NAME OF
father Robert Ramsay
18 BIRTHPLACE OF
FATHER (City)
(State or country)
Hamilton
Scotland
19 MAIDEN NAME
OF MOTHER
Ap;nes Wellwood
20 BIRTHPLACE OF
MOTHER (City)
(State or country)
G-lasqow
Scotland
2i Robert Beach
(Address, gg Court Rd . Winthroo
I I^EREBY CERTIFY that a satisfactory standard certificate of death was
*’ DDDAnn burials transit permit was issued:
^(^gnature of/#Wht of Board of“EPealth or other)
C./7/Z///..
(Date of Issue of /Permit '
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 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, specifying the war. and
shall also certify in such certificate both the primary and the secondary or imme-
diate 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 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 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 from which it was
removed within thirty-six hours after such removal, unless a permit in the usual
form for the removal of such body has been sooner obtained hereunder. If the
death certificate contains a recital, as required by section ten of chapter forty-six.
that the deceased served in the army, navy or marine corps of the United States
in any war in which it has been engaged, such recital shall appear upon the permit.
The board of health, or its agent, upon receipt of such statement and certificate,
shall forthwith countersign it and transmit it to the clerk of the town for registra-
tion. The person to whom the permit is so given and the physician certifying
the cause of death shall thereafter furnish for registration any other necessary
information which can be obtained as to the deceased, or as to the manner or
cause of the death, which the clerk or registrar may require. — Chap. 114, Sec. 45,
G. L., (Tercentenary Edition).
Medical examiners shall. make examination uppn 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 persons 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 follow-
ing 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. — Physicians: see explanatory instructions
on face side of standard certificate of death.
Statement of Occupation. — Precise statement of occupation is very import-
ant, so that the relative healthfulness of various pursuits can be known. Make
spme entry in this section for every person aged 10 years or over. If the occupa-
tion had been given up or changed, or if the deceased had retired from business,
report the kind of work done during most of working life even if retired. 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
DEATH in plain terms, so that it may he properly classified. Exact statement ot UCL.UJHAI 1UW is very important.
See instructions and extracts from the laws on back of certificate.
If deceased was a U. S. War Veteran, G. 1. Chap. 46, Section 10, requires physicians to insert a recital to that effect.
R-301 A
V
(Cityor^ifwn) - 7
^Die (Eomnumfttealti] of
OFFICE OF THE SECRETARY
DIVISION OF VITAL STATISTICS
STANDARD
CERTIFICATE OF DEATH
To be filed for burial permit
with Board of Health
or its Agent.
Registered No.
9
st.
(If death occurred in a hospital or institution,
give its NAME instead of street and number)
2 FULL NAME
(If decease
idowed or divorced woman, give also maiden name.)
st.
PHYSICIAN- IMPORTANT
(Was deceased a
U. S. War Veteran,
if so specify WAR)
y>
(a) Residence. No
(Usual place of abode)
Length of stay: In hospital or institution ttOSP •
(Before death) (Specify whether)
. years _ monUis
hrs 10 rain
days.
(If nonresident, give city or town and State)
In this community
yrs.
days.
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
4 COLOR OR RACE
)y )Jtj
5 SINGLE (write the word)
MARRIED
WIDOWED
or DIVORCEC
write me woru;
E
5a If married, widowed or divorced
HUSBAND of . ■■ . . ■
(Give maiden name of wife in full)
(or) WIFE of
(Husband's name in full)
6 Age of husband or wife if alive
7 IF STILLBORN, enter that fact here.
8
AGE
Years
Months
Days
If tesTtl
f 1
than 1 day .
Hours / 0 Minutes
9 Occupation:
Industry
10 or Business:
11 Social Security No.
12 BIRTHPLACE (City)
(State or Country)
~Wjt /MAt/wp
13 NAME OF
FATHER j
14 BIRTHPLACE OF
FATHER (City)
(State or Country)
15 ffSSrXAc*
16 BIRTHPLACE OF
MOTHER (City)
(State or Country)
17
Informant
(Address) (
Relation, if any
3Y CERTIFY that a satisfactory standard, certificate of death was filed
3EFORE7the burial or Uansit/dfermit/was issued:
18 DATE OF
DEATH
MEDICAL CERTIFICATE OF DEATH
19
i
(Month)
/i 71.12...
( Day) (Year)
■) I HEREBY tfERTIFY, That I attended deceased from
jLst^rr f 7 . 19 ^ f , to
L 7 . 19 ~i i , to
alive on
47
I laif saw h *
have occurred on the date stated above, at
Immediate cause of death
. 19
< 7 .19 n death is said to
A.
£
Due to
Due to
fit
/1/lrrlVC- /t, -T'-
other conditions
(Include pregnancy within 3 months of death)
Major findings:
Of operations
Of autopsy
What test confirmed diagnosis?
Date of
Duration
IMPORTANT
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?
(Signed) D
(Address) 7
uJL 4-1 IrJZ ,/iir
, M. D.
19
91 1
Place of Burial, Cremation or Removal. (City or Town)
DATE OF BURIAL p * l
194.3
22 NAME OF
FUNERAL DIRECTO,
ADDRESS
Received and Filed
tji yte
'JAw as mg
19
(Registrar)
EXTRACTS FROM THE LAWS OF THE
COMMONWEALTH OF MASSACHUSETTS
GOVERNING THE
RETURN OF CERTIFICATES OF DEATH
A physician or registered hospital medical officer shall forthwith, after
the death of a person whom he has attended during his last illness, at the
request of an undertaker or other authorized person or of any member of
the family of the deceased, furnish for registration a standard certificate
of death, stating to the best of his knowledge and belief the name of the
deceased, his supposed age, the disease of which be died, defined as re-
quired by section one, where same was contracted, the duration of his last
illness, when last seen alive by the physician or officer and the date of
his death . . , Gen. Laws, Chap. 46, Sec. 9.
A physician or officer furnishing a certificate of death as required by the
preceding section or by section forty-five of chapter one hundred and four-
teen, shall, if the deceased, to the best of his knowledge and belief, served
in the army, navy or marine corps of the United States in any war in which
it has been engaged, insert in the certificate a recital to that effect, speci-
fying the war, and shall also certify in such certificate both the primary
and the secondary or immediate cause of death as nearly as he can state
the same. For neglect to comply with any provision of this section, such
physician or officer shall forfeit ten dollars. For the purposes of this sec-
tion and of sections forty-five, forty-six and forty-seven of said chapter
one hundred and fourteen, the word "war” shall include the China relief
expedition and the Philippine insurrection, which shall, for said purposes,
be deemed to have taken place between February fourteenth, eighteen
hundred and ninety-eight and July fourth, nineteen hundred and two, and
the Mexican border service of nineteen hundred and sixteen and nine-
teen hundred and seventeen. G. L. Chap. 46, Sec. 10.
No undertaker or other person shall bury or otherwise dispose of a human
body in a town, or remove therefrom a human body which has not been
buried, until he has received a permit from the board of health, or its
agent appointed to issue such permits, or if there is no such board, from
the clerk of the town where the person died; and no undertaker or other
person shall exhume a human body and remove it from a town, from one
cemetery to another, or from one grave or tomb other than the receiving
tomb to another in the same cemetery, until he has received a permit from
the board of health or its agent aforesaid or from the clerk of the town
where the body is buried. No such permit shall be issued until there shall
have been delivered to such board, agent or clerk, as the case may be,
a satisfactory written statement containing the facts required by law to be
returned and recorded, which shall be accompanied, in case of an original
interment, by a satisfactory certificate of the attending physician, if any,
as required by law, or in lieu thereof a certificate as hereinafter provided.
If there is no attending physician, or if, for sufficient reasons, his certificate
cannot be obtained early enough for the purpose, or is insufficient, a physi-
cian who is a member of the board of health, or employed by it or by the
selectmen for the purpose, shall upon application make the certificate re-
quired of the attending physician. If death is caused by violence, the medi-
cal 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 cliaptcr lorty-sut, tuat Uie 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, 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 suck board, from the clerk of the town
where the body is to be buried or the funeral is to be held, or from a person
appointed to have the care of the cemetery or burial ground in which the
interment is made. . . . Chap. 114, Sec. 46, G. L., (Tercentenary Edition).
RULES OF PRACTICE
The fulfillment of the purpose of these laws calls for the observance of
the following rules of practice:
(1) Attending physicians will certify to such deaths only as those of
persons to whom they have given bedside care during a last illness from
disease unrelated to any form of injury.
(2) Board of Health physicians will certify to such deaths only as those
of persons who, though disabled by recognized disease unrelated to any
form of injury, have died without recent medical attendance or whose phy-
sician is absent from home when the certificate of death is needed.
(3) Medical Examiners will investigate and certify to all deaths sup-
posably due to injury. These include not only deaths caused directly or
indirectly by traumatism (including resulting septicemia), and by the
action of chemical (drugs or poisons), thermal, or electrical agents, and
deaths following abortion, but also deaths from disease resulting from
injury or infection related to occupation, the sudden deaths of persons not
disabled by recognized disease, and those of persons found dead.
Statement of Cause of Death. — Cause of death means the disease, or
complication which causes death, not the mode of dying, e. g., heart failure,
asphyxia, asthenia, etc. As principal < ause 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 OE ENTERING MILITARY SERVICE
DATE OF DISCHARGE
RANK, RATING
ORGANIZATION AND OUTFIT
SERVICE NUMBER
M R-301A
RUCTIONS
FOR
CERTIFICATE
giving
OF DEATH
ot enter
than one
for each
(b) and (c)
does not mean
of dying, such
ilure, asthenia. .
ms the disease,
cations which
Ih.
id conditions,
ing rise to the "
\e (a) stating
dying cause
lions contrib- ■
t death but not
the disease or
causing death.
Suffolk
(County)
o Winthrop
(City or Town)
Qli)? (Hommonmraltlj of JHaBaarttuBrttB
OFFICE OF THE SECRETARY
DIVISION OF VITAL STATISTICS
To b« filed for burial permit
with Board of Health
STANDARD or it. Agent.
CERTIFICATE OF DEATH Registered No jJJ...
Nurseing home)
46* AVC CKi rkoatri ck ' i(If death °ccun-ed in a hospital or institutio
No “r. " ° s 11 T f 1 ‘ -L>rv- St. \ give its NAME instead of street and numbe
2 FULL NAME
Mary Ann (Bowen) Vessey
institution,
lumber)
r PHYSICIAN — IMPORTANT
J (Was deceased a
| U. S. War Veteran,
_ « , . I if so specify WAR)
No. 3 Almont Street st
(Usual place of abode) (If nonresident, give city or town and State)
Length of stay: In place of death years ! months days. In place of residence 5.0 years months days.
(If deceased is a married, wjdowed or divorced woman, give also maiden name.)
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
DEATH
CERT IF Y , That I attended deceased from
f , 19 19
list saw h ...alive on f , 19 X* death is said to|
[/ / / —p jA
have occurred on the date stated above, at S Of m.
DISEASE OR CONDITION
DIRECTLY LEADING
TO DEATH (a)
ANTE Due To
CEDENT (b) .
CAUSES
Due To
(c)
OTHER
SIGNIFICANT
CONDITIONS
INTERVAL BE-
TWEEN ONSET
AND OEATN
Major findings:
Of operations
Date of operation Was autopsy performed?
What test confirmed diagnosis?
5 Was disease or injury in any way related to occupation of deceased?
If so, specify. ...
(Signed) -
(Address) ...... K Date
M.
19
& ..Winthrop
Place of Burial or Cremation
DATE OF BURIAL
&
Winthrop
(City or Town)
Jan. 24 ,„49
*949-
(Registrar)
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
Femaal^
9 COLOR OR RACE
White
10 SINGLE (write the word)
MARRIED
WIDOWED , , . ,
or DIVORCED WidOW
10a If married, widowed, or divorced
HUSBAND of
(Give maiden name of wife in full)
(or) wife of Charles Ve s sey
(Husband’s name in full)
11 IF STILLBORN, enter that fact here.
12
AGE
80
Years
Months
Days
If under 24 hours
Hours Minutes*
13 Occupation: HOUSeWlfe
(Kind of work done during most of working life)
14 or ^Business: At home
IS Social Security No. -N One
16 BIRTHPLACE (City)
(State or country) (*
17 NAME OF
father James Bowen
18 BIRTHPLACE OF
FATHER (City)
(State or country) g flg J and
19 MAIDEN NAME
of mother Mary Jane Ashley
20 BIRTHPLACE OF
MOTHER (City)
(State or country) g ftg and
21 Informant He ster Kempt on
(Address; 56 Marshall st winthrop-
I HER.EBY CERTIFY that a satisfactory standard certificate of death was
filed with me BEFORE the burial or transit permit was issued:
(Signature of Age:
(Official Designation)
of Board of Health or />ther)
. ZL
(Date of Issue /f
* / 9
[ Pernrfit) ' Jr f I
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 knpwledge and belief the name of the deceased, his supposed age. the
disease of which he died, defined as required by section one. where same was
contracted, the duration of his last illness, when last seen alive by the physician
or officer and the date of his death. . .Gen. Laws. Chap. 46, Sec. 9.
A physician or officer furnishing a certificate of death as required by the
preceding section or by section forty-five of chapter one hundred and four-
teen. shall, if the deceased, to the best of his knowledge and belief, served in the
army, navy or marine corps of the United States in any war in which it has been
engaged, insert in the certificate a recital to that effect, specifying the war, and
shall also certify in such certificate both the primary and the secondary or imme-
diate cause of death as nearly as he can state the same. For neglect to comply
with any pro vision of this section, such physician or officer, shall forfeit ten dollars.
For the purposes of this section and of sections forty-five, forty-six and forty-seven
of said chapter one hundred and fourteen, the word “war" shall include the China
relief expedition and the Philippine insurrection, which shall, for said purposes, be
deemed to have taken place between February fourteenth, eighteen hundred and
ninety-eight and July fourth, nineteen hundred and two. and the Mexican border
service of nineteen hundred and sixteen and nineteen hundred and seventeen.
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 there! rom 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 su.h 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 from which it was
removed within thirty-six hours after such removal, unless a permit in the usual
form for the removal of such body has been sooner obtained hereunder. If the
death certificate contains a recital, as required by section ten of chapter forty-six.
that the deceased served in the army, navy or marine corps of the United States
in any war in which it has been engaged, such recital shall appear upon the permit.
The board of health, or its agent, upon receipt of such statement and certificate,
shall forthwith countersign it and transmit it to the clerk of the town for registra-
tion. 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. 1 14, Sec. 45,
G. L., (Tercentenary Edition).
Medical examiners shall make examination uppn 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 persons 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 otthe 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 follow-
ing 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. — Physicians: see explanatory instructions
on face side of standard certificate of death.
Statement of Occupation. — Precise statement of occupation is very import-
ant, 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 occupa-
tion had been given up or changed, or if the deceased had retired from business,
report the kind of work done during most of working life even if retired. 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
If deceased was a U. S. War Veteran, G. L. Chap. 46, Section 10, requires physicians to insert a recitaj to that effect.
301 A
(Eommonfocaltlj of jUftaBsacljuspttB
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.
2 FULL NAME
It
(If deceased is a'piarried
v?/>
ode) )
r institution 5
11
j (If death occurred in a hospital or institution. (
) give its NAME instead of street and number) '
f
(a) Residence. No.
(Usual place of abode)
widowed or divorced woman, give also maiden name.) — c? - , 1 o- "a.1
PHYSICIAN- IMPORTANT
(Was deceased a
} U. S. War Veteran,
( if >0 specify WAR) 'W/
Length of stay: In hospital 0
(Before death)
(Specify whether)
years
months
?
days.
specify WAR)
(If nonresident, give city or town and State)
In this community 33 yrs. mos.
days.
PERSONAL AND STATISTICAL PARTICULARS
EDICAL CERTIFICATE OF DEATH
3 SEX
4 COLOR OR RACE
5 SINGLE (write the word)
MARRIED
18 DATE OF
DEATH
(Month) '
J> 7
(Day)
/f'Yf
(Year)
5a If married, widowed or divorced
HUSBAND of
/(Gyre maiden
(or) WIFE of
(Husband
6 Age of husband or wife if alive
years
19 ^ I HEREBY CERTIFY. „ That I attended deceased from
ic. ...... „ . ,9 x/
I last saw h W alive on — Y . .... 19 9t death is said to
C? c, /f
have occurred on the dale stated above, at & r
7 IF STILLBORN, enter that fact here.
Immediate cause of death
8
AGE
¥■
Usual
9 Occupation:
Years
I
Months
Days
If less than 1 day
Hours
Minutes
Industry
10 or Business:
$ '&0-o-*Ca-+
11 Social Security No.
12 BIRTHPLACE (City)
(State or Country)
jjg?/ -**- S/*T
imcuiaic tauoc ui ucaui +
to i
Due to
Duration
IMPORTANT
Other conditions
(Include pregnancy within 3 months of death)
13 NAME OF
FATHER
14 BiRTHPLXeE DF / ^
FATHER (City)
(State or Country)
<Ut s.
15 MAIDEN NAME
!% OF MOTHER
16 BIRTHPLACE OF
MOTHER (City)
(State or Country)
Major findings:
Of operations
P.. Date of MX?
Of autopsy
What test confirmed diagnosis?
IMPORTANT
Physician
Underline
:he cause to
lich death
Should be
charged sta-
tistically.
£■€
20 Was disease or injury in any way related to occupatj
If so, specify
Informant
(Address)
„ OI wOUIl tl y I ^ ^
[eceased?
EXTRACTS FROM THE LAWS OF THE
COMMONWEALTH OF MASSACHUSETTS
GOVERNING THE
RETURN OF CERTIFICATES OF DEATH
A physician or registered hospital medical officer shall forthwith, after
the death of a person whom he has attended during his last illness, at the
request of an undertaker or other authorized person or of any member of
the family of the deceased, furnish for registration a standard certificate
of death, stating to the best of his knowledge and belief the name of the
deceased, his supposed age, the disease of which he died, defined as re-
quired by section one, where same was contracted, the duration of his last
illness, when last seen alive by the physician or officer and the date of
his death . . . Gen. Laws, Chap. 46, Sec. 9.
A physician or officer furnishing a certificate of death as required by the
preceding section or by section forty-five of chapter one hundred and four-
teen, shall, if the deceased, to the best of his knowledge and belief, served
in the army, navy or marine corps of the United States in any war in which
it has been engaged, insert in the certificate a recital to that effect, speci-
fying the war, and shall also certify in such certificate both the primary
and the secondary or immediate cause of death as nearly as he can state
the same. For neglect to comply with any provision of this section, such
physician or officer shall forfeit ten dollars. For the purposes of this sec-
tion and of sections forty-five, forty-six and forty-seven of said chapter
one hundred and fourteen, the word “war” shall include the China relief
expedition and the Philippine insurrection, which shall, for said purposes,
be deemed to have taken place between February fourteenth, eighteen
hundred and ninety-eight and July fourth, nineteen hundred and two, and
the Mexican border service of nineteen hundred and sixteen and nine-
teen hundred and seventeen. G. L. Chap. 46, Sec. 10.
No undertaker or other person shall bury or otherwise dispose of a human
body in a town, or remove therefrom a human body which has not been
buried, until he has received a permit from the board of health, or its
agent appointed to issue such permits, or if there is no such board, from
the clerk of the town where the person died; and no undertaker or other
person shall exhume a human body and remove it from a town, from one
cemetery to another, or from one grave or tomb other than the receiving
tomb to another in the same cemetery, until he has received a permit from
the board of health or its agent aforesaid or from the clerk of the town
where the body is buried. No such permit shall be issued until there shall
have been delivered to such board, agent or clerk, as the case may be,
a satisfactory written statement containing the facts required by law to be
returned and recorded, which shall be accompanied, in case of an original
interment, by a satisfactory certificate of the attending physician, if any,
as required by law, or in lieu thereof a certificate as hereinafter provided.
If there is no attending physician, or if, for sufficient reasons, his certificate
cannot be obtained early enough for the purpose, or is insufficient, a physi-
cian who is a member of the board of health, or employed by it or by the
selectmen for the purpose, shall upon application make the certificate re-
quired of the attending physician. If death is caused by violence, the medi-
cal examiner shall make such certificate. If such a permit for the removal
of a human body, not previously interred, from one town to another within
the commonwealth cannot be obtained early enough for the purpose, the
certificate of death made as above provided and in the possession of the
undertaker desiring to make such removal shall constitute a permit for
such removal; provided, that such body shall be returned to the town from
which it was removed within thirty-six hours after such removal, unless
a permit in the usual form for the removal of such body has been sooner
obtained hereunder. If the death certificate contains a recital, as required
by section ten ui chapter lortv-six, tuat the deceased served in the army,
navy or marine corps of the United States in any war in which it has been
engaged, such recital shall appear upon the permit. The board of health,
or its agent, upon receipt of such statement and certificate, shall forthwith
countersign it and transmit it to the clerk of the town for registration.
The person to whom the permit is so given and the physician certifying
the cause of death shall thereafter furnish for registration any other neces-
sary information which can be obtained as to the deceased, or as to the
manner or cause of the death, which the clerk or registrar may require. —
Chap. 114, Sec. 45, G. L., (Tercentenary Edition).
Medical examiners shall make examination upon the view of the dead
bodies of only such persons as are supposed to have died by violence.
If a medical examiner has notice that there is within bis county the body
of such a person, he shall forthwith go to the place where the body lies
and take charge of the same; . . . — General Laws, Chap. 38, Sec. 6.
No undertaker or other person shall bury a human body or the ashes
thereof which have been brought into the commonwealth until he has re-
ceived a permit so to do from the board of health or its agent appointed to
issue such permits, or if there is no such board, from the clerk of the town
where the body is to be buried or the funeral is to be held, or from a person
appointed to have the care of the cemetery or burial ground in which the
interment is made. . . . Chap. 114, Sec. 46, G. L., (Tercentenary Edition).
RULES OF PRACTICE
The fulfillment of the purpose of these laws calls for the observance of
the following rules of practice:
(1) Attending physicians will certify to such deaths only as those of
persons to whom they have given bedside care during a last illness from
disease unrelated to any form of injury.
(2) Board of Health physicians will certify to such deaths only as those
of persons who, though disabled by recognized disease unrelated to any
form of injury, have died without recent medical attendance or whose phy-
sician is absent from home when the certificate of death is needed.
(3) Medical Examiners will investigate and certify to all deaths sup-
posably due to injury. These include not only deaths caused directly or
indirectly by traumatism (including resulting septicemia), and by the
action of chemical (drugs or poisons), thermal, or electrical agents, and
deaths following abortion, but also deaths from disease resulting from
injury or infection related to occupation, the sudden deaths of persons not
disabled by recognized disease, and those of persons found dead.
Statement of Cause of Death. — Cause of death means the disease, or
complication which causes death, not the mode of dying, e. g., heart failure,
asphyxia, asthenia, etc. As principal cause name the disease causing death.
As related causes, name earlier morbid conditions, if any, related to the
principal cause and any important complication of the principal cause.
Statement of Occupation. — Precise statement of occupation is very im-
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 be carefully supplied. ACE should be stated EXACTLY. PHYSICIANS should state CAUSE OF DEATH in plain
terms, so that it may be properly classified. Exact statement of OCCUPATION is very important. See instructions and
extracts from the laws on back of certificate.
If deceased was a U. S. War Veteran, G. L. Chap. 46, Seotion 10, requires physicians to insert a reoital to that effeot.
®lte (Eommiiiifrualtlj of (ilTasfarhusi'tt©
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.
(County)
Registered No.
(If death occurred in a hospital or institution,
give its NAME instead of street and number)
PHYSICIAN -IMPORTANT
(Was deceased a _
U. S. War Veteran,
if so specify WAR) f**
2 FULL NAI
ive also maiden name.)
deceased is a mgrriedL widowecWpr divorced worm
(a) Residence. No. ...
(Usual place of abode) '
Length of stay: In hospital or Institution
(Before death) (Specify whether)
(If nonresident, give city or town and State)
In this community oi^yrs. mos.
months
years
DICAL CERTIFICATE OF DEATH
PERSONAL AND STATISTICAL PARTICULARS
18 DATE OF
DEATH ...
5 SINGLE (write Ihe word)
MARRIED /
WIDOWED
or DIVORCE!
IflX
4 COLOR OR RACE
(Month)
(Day)
(Year)
That I attended deceased from
5a If married, widowed, or divorced
HUSBAND of
(Give maiden name of wife in full)
(Husband’s name in full)
I last saw h alive on
have occurred on the date stated above, at.
Immediate cause of death
death Is said to
Duration
6 Age of husband or wife if alive
Important
7 IF STILLBORN, enter that fact here.
If less than 1 day
Hours Minutes
Years
Months
Usual
9 Occupation
Industry
or Business
II Social Security No.
Other conditions — .V r*.
(Include pregnancy within 3 months of death)
12 BIRTHPLACE (City)
(Slate or country )
Important
Physician
13 NAME OF
FATHER /
Major findings :
Of operations.
Underline
the cause to
which death
should b e
charged sta-
14 BIRTHPLACE OP
FATHER (City)
(State or country)
Of autopsy.
What test confirmed diagnosis?.
tistically.
15 MAIDEN NAME
OF MOTHER
any way related to occupation of deceased?.
If so, specify..^
(SignedV>rf(Y
(Address),
16 BIRTHPLACE OF
MOTHER (City)
(State or country)
Relation, if any
Place of Burial, 'Cremation^ Removal.
DATE OF BURIAL
City or Town)
Informant*
(Address U3L
22 NAME OF
IY CERTIFY that a satisfactory
Lire, BEFORE the bdHgf or.Jtfa
y standard certificate of death was
insit permit was issued:
FUNERAL DIRECTOI
ADDRESS J j/.'Zj
iigftature of Agent of ,Board of III
Received and filed.
(Official Designation)'
(Date of Issue of Permit)
(Registrar)
M R-301 A
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
net nf -in 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-
auired by section one, where same was contracted, the duration of his la.t
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 hu"dl.e^. V dJr “ d
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 wliicl
it Ins 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 office^ shall forfeit ten dollars. For the purposes of this sec-
tion and of sections forty-five, forty-six and forty-seven of said chapter one
hundred and fourteen, the word “war” shall include the China relief ex-
pedition and the Philippine insurrection, which shall, for said puiposes, be
deemed to have taken place between February fourteenth, eighteen 1 m '*?
and ninety-eight and July fourth, nineteen hundred and two, and the Mexi-
can border service of nineteen hundred and sixteen and nineteen hundied
and seventeen. G. L. Chap. 46, Sec. 10.
No undertaker or other person shall bury or otherwise dispose of *
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 oi 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 toyanother in the same cemetery, until he has received a permit from
the board of health or its agent aforesaid or from the clerk of the town
where the bodv is buried. No such permit shall be issued until there shall
have been delivered to such board, agent or clerk, as the case may be,
a satisfactory written statement containing the facts required by law to be
returned and* recorded, which shall be accompanied, in case of an original
interment, by a satisfactory certificate of the attending physician, if any,
as required by law, or in lieu thereof a certificate as hereinafter Provided.
If there is no attending physician, or if, for sufficient reasons, his certifies t
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 01 by the
selectmen for the purpose, shall upon application make the certificate re
quired of the attending physician. If death is caused by vioience, the medi-
cal examiner shall make such certificate. If such a permit for the removal
of a human body, not previously interred, from one town to another within
the commonwealth cannot be obtained early enough for the purpose, the
certificate of death made as above provided and in the possession of the
undertaker desiring to make such removal shall constitute a permit for
such removal; provided, that such body shall be returned to the town from
which it was removed within thirty-six hours after such removal, unless
a permit in the usual form for the removal of such body has been sooner
obtained hereunder. If the death certificate contains a recital, as required
by section ten of chapter forty-six, that the deceased served in the army,
navy or marine corps of the United States in any war in which it has been
engaged, such recital shall appear upon the permit. The board of health,
or its agent, upon receipt of such statement and certificate, shall forthwith
countersign it and transmit it to the clerk of the town for registration.
The person to whom the permit is so given and the physician certifying
the cause of death shall thereafter furnish for registration any other neces-
sary information which can be obtained as to the deceased, or as to the
manner or cause of the death, which the clerk or registrar may require. —
Chap. 114, Sec. 45, G. L., (Tercentenary Edition).
No undertaker or other person shall bury a human body or the ashes
thereof which have been brought into the commonwealth until he has re-
ceived a permit so to do from the board of health or its agent appointed to
issue such permits, or if there is no such board, from the clerk of the town
where the body is to be buried or the funeral is to be held, or from a person
appointed to have the care of the cemetery or burial ground in which the
interment is made. ... Chap. 114, Sec. 46. G. L., (Tercentenary Edition).
Medical examiners shall make examination upon the view of the dead
bodies of only such persons as are supposed to have died by violence.
If a medical examiner has notice that there is within his county the body
of such a person, he shall forthwith go to the place where the body lies
and take charge of the same;... — General Laws, Chap. 38, Sec. 6.
RULES OF PRACTICE
The fulfillment of the purpose of these laws calls for the observance of
the following rules of practice:
(1) Attending physicians will certify to such deaths only as those of
persons to whom they have given bedside care during a last illness from
disease unrelated to any form of injury.
(2) Board of Health physicians will certify to such deaths only as those
of persons who, though disabled by recognized disease unrelated to any
form of injury, have died without recent medical attendance or whose physi-
cian is absent from home when the certificate of death is needed.
(3) Medical Examiners will investigate and certify to all deaths sup-
posably due to injury. These include not only deaths caused directly or in-
directly by traumatism (including resulting septicemia), and by the action
of chemical (drugs or poisons), thermal, or electrical agents, and dealhs
following abortion, but also deaths from disease resulting from Injury or
infection related to occupation, the sudden deaths of persons not disabled
by recognized disease, and those of persons found dead.
Statement of Cause of Death. — Cause of death means the disease, or
complication which causes death, not the mode of dying, e. g., heart failure,
asphyxia, asthenia, etc. As principal cause name the disease causing death.
As related causes, name earlier morbid conditions, if any, related to the
principal cause and any important complication of the principal cause.
Statement of Occupation. — Precise statement of occupation is very im-
portant, so that the relative healthfulness of various pursuits can be known.
Make some entry in this section for every person aged 10 years or over.
If the occupation had been given up or changed on account of the disease
causing death, report the usual occupation prior to illness. If the deceased
had retired from business, report the usual occupation prior to retirement.
Children not gainfully employed may be returned as at school or at home.
For a woman whose only occupation was that of home housework, write
housework. For a person engaged in domestic service for wages, however,
designate the occupation by the appropriate terms, as housekeeper — private
family, cook — hotel, etc. For a person who had no occupation whatever
write none.
SPACE FOR ADDITIONAL INFORMATION
M R-301A
RUCTIONS
FOR
. CERTIFICATE
giving
OF DEATH
tot enter
than one
t for each
(b) and (c)
does not mean
of dying, such
ilure, asthenia, .
ans the disease,
ic at ions which
ilh.
id conditions,
ring rise to the
se (a) stating
rlying cause
ilions conlrib- ■
e death but not
the disease or
causing death.
5 Suffolk
q (County)
o Winthrop
(City or Town)
QIljp (Emnmatuuraltl) of JRaBBadjuBrttB
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.
13...
Registered No
No
19 Lewis Ave .
I (If death occurred in a hospital or institution.
St. \ give its NAME instead of street and number)
James Henrv Willis r physician — important
2 FULL NAME ° cUUC\®... ne IAi J. . I (Was deceased a
(If deceased is a married, widowed or divorced woman, give also maiden name.) I U. S. War Veteran.
I if so specify WAR)
(a) Residence. No ^?._LeWl S AV@ St
(Usual place of abode) (If nonresident, give city or town and State)
Length of stay: In place of death years 7 months days. In place of residence years .7 months days.
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
DEATH ...
{/
(Month)
(Day)
(Year)
That I attended deceased from
41 HEREBY CERTI
?~f . 19
1 last saw h ^/t*<~»alive on . LLf? ... 19
have occurred on the date stated above, at m.
19
death is said to
DISEASE OR CONDITION
DIRECTLY LEAD
TO DEATH (a) .
ANTE Due To
CEDENT (b)
CAUSES
Due To
(c)
OTHER
SIGNIFICANT
CONDITIONS
Major findings:
Of operations.
Date of operation ' W'as autopsy performed?
What test confirmed diagnosis?
INTERVAL BE-
TWEEN ONSET
AND DEATH
%
(a
S Was disease or injury in any way related to occupation of deceased?
If so. specify V-
(Signed) 0;lyy^.
(Address) vj# V- iV UrUjjJ. . ate
)v«C
M.
19
6 . Winthrop f ' ZZ.Wint.hr op
Place of Burial or Cremation (City or Town)
Jan. 31
DATE OF BURIAL
.,*9
7 FUNERAL DIR^C^bR
ADDRESS.
Received and filed
•FEB-1
(Registrar)
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
Male
9 COLOR OR RACE
White
10 SINGLE
MARRIED
WIDOWED
or DIVORCED
(write the word)
Single
10a If married, widowed, or divorced
HUSBAND of
(Give maiden name of wife in full)
(or) WIFE of
(Husband's name in full)
11 IF STILLBORN, enter that fact here.
12
AGE
81
Years Q Months
.8
Days
If under 24 hours
Hours Minutes1
13 Usual
Occupation:
Brass finisher
(Kind of work done during most of working life)
14 or ^Business: Bra s s foundry
15 Social Security No NOlfie
5L
16 BIRTHPLACE (City)
(State or country)
J ohn
Few Brumswlck
17 NAME OF
FATHER
William Willis
18 BIRTHPLACE OF
FATHER (City)
(State or country)
Ireland
19 MAIDEN NAME
OF mother Rebecca (Willis)
20 BIRTHPLACE OF
MOTHER (City) ....
(State or country)
Ireland
Charles Willis
(Address; 19 Lewis Ave . Winthrop, bias's
LEBY CERTIFY that a satisfactory standard certificate of death was
ith t»e„BEFORE the ljurial qj? transjt permit was issued:
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 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, specifying the war, and
shall also certify in such certificate both the primary and the secondary or imme-
diate 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 or nineteen hundred and sixteen and nineteen hundred and seventeen.
G. L. Chap. 46. Sec. 10.
No undertaker or other person shall bury or otherwise dispose of a human body
in a town, or remove therefrom a human body which has not been buried, until he
has received a permit from the board of health, or its agent appointed to issue
such permits, or if there is no such board, from the clerk of the town where the
person died; and no undertaker or other person shall exhume a human body and
remove it from a town, from one cemetery to another, or from one grave or tomb
other than the receiving tomb to another in the same cemetery, until he has
received a permit from the board of health or its agent aforesaid or from the clerk
of the town where the body is buried. No such permit shall be issued until there
shall have been delivered to such board, agent or clerk, as the case may be,
a satisfactory written statement containing the facts required by law to be
returned and recorded, which shall be accompanied, in case of an original 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 from which it was
removed within thirty-six hours after such removal, unless a permit in the usual
form for the removal of such body has been sooner obtained hereunder. If the
death certificate contains a recital, as required by section ten of chapter forty-six,
that the deceased served in the army, navy or marine corps of the United States
in any war in which it has been engaged, such recital shall appear upon the permit.
The board of health, or its agent, upon receipt of such statement and certificate,
shall forthwith countersign it and transmit it to the clerk of the town for registra-
tion. The person to whom the permit is so given and the physician certifying
the cause of death shall thereafter furnish for registration any other necessary
information which can be obtained as to the deceased, or as to the manner or
cause of the death, which the clerk or registrar may require.— Chap. 114, Sec. 45,
G. L., (Tercentenary Edition).
Medical examiners shall make examination uppn 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 persons 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 oithe 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 follow-
ing 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. — Physicians: see explanatory instructions
on face side of standard certificate of death.
Statement of Occupation. — Precise statement of occupation is very import-
ant, so that the relative healthfulness of various pursuits can be known. Make
spme entry in this section for every person aged 10 years or over. If the occupa-
tion had been given up or changed, or if the deceased had retired from business,
report the kind of work done during most of working life even if retired. 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
4 R-301 A
IUCTIONS
FOR
CERTIFICATE
giving
OF DEATH
ot enter
than one
for each
[b) and (c)
does not mean
of dying, such
lure, asthenia, .
ins the disease,
cations which
th.
d conditions, .
ing rise to the "
e (a) slating
•lying cause
tions contrib- •
• death but not
he disease or
ausing death.
2»ljf (Eamnummraltl) of jRaaaarljUBPtta
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.
14
Registered N’o
Suffolk
(County)
Winthrop
(City or Town)
. . 136 Herraon Street
No r. St.
2 full name C a rrie Eve lyn (Lake man )# . I ngersoll j 7 ,MPORTANT
(If deceased is a married, wjdowed or divorced woman, give also maiden name.)
136 Hermon St .
f (If death occurred in a hospital or institution,
t. \ give its NAME instead of street and number)
U. S. War Veteran,
if so specify WAR)
(a) Residence. No.
(Usual place of abode)
St.
Length of stay: In place of death ^"^ears months days. In place of residence rfr.V^e ars months days.
IQe
(If nonresident, give city or town and State)
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
DEATH
4 I
(Month)
(Day)
/ T
(Year)
HEREBYCERTIFY
/ 19
I last saw h alive on
have occurred on the date stated above, at
fThat I attended deceased from
19
19 .X^death is said to
DISEASE OR CONDITION f i
DIRECTLY LEADING ^ y
TO DEATH (a)
« n ■ ^ j ^ ^ g
ANTE Due To
CEDENT (b)
CAUSES
Due To
(c)
OTHER
SIGNIFICANT
CONDITIONS
INTERVAL BE-
TWEEN ONSET
AND DEATH
z
Major findings:
Of operations
Date of operation^? /’/Vi Was autopsy performed?
What test confirmed diagnosis?
L=>
5 Was disease or injury in any way related to occupation of deceased?
If so, specify ^ ^ ^
(Signed) y ff.
(Address) ^ Date // 3 y
Winthrop ' Winthrop
M.
19
Place of Burial or Cremation
DATE OF BURIAL
(City or Town)
Feb. 2 1949
7 NAME OF
FUNERAL DIRECTOF
ADDRESS
>yi /C**.
Received and filed
IebII
(Registrar)
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
Female
9 COLOR OR RACE
White
10 SINGLE (write the word)
MARRIED
or 'divorced Married
10a If married, widowed, or divorced
HUSBAND of
(Give maiden name of wife in full)
(or) wife of He r be rt Inge rap 11
(Husband’s name in full)
11 IF STILLBORN, enter that fact here.
12 71 1 11
AGE (. Years Months
Days
If under 24 hours
Hours Minutes*
13 Usual
Occupation:
Housewife
(Kind of work done during most of working life)
14 Industry
or Business:
Own Home
15 Social
Security No. iNlOne
16 BIRTHPLACE (City)
(State or country)
Grand Manan
N. B.
17 NAME OF
FATHER
George Lakeman
18 BIRTHPLACE OF
FATHER (City)
(State or country)
Lubec
Maine
19 MAIDEN NAME
OF mother Lucretia Griffin
20 BIRTHPLACE OF
mother (city) Manan
(State or country) N.B.
21
Informant
Herbert Ingersoll
(Address; 136 He rmbri St .Winthrop. Mas s
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 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, specifying the war. and
shall also certify in such certificate both the primary and the secondary or imme-
diate 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 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 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 from which it was
removed within thirty-six hours after such removal, unless a permit in the usual
form for the removal of such body has been sooner obtained hereunder. If the
death certificate contains a recital, as required by section ten of chapter forty-six,
that the deceased served in the army, navy or marine corps of the United States
in any war in which it has been engaged, such recital shall appear upon the permit.
The board of health, or its agent, upon receipt of such statement and certificate,
shall forthwith countersign it and transmit it to the clerk of the town for registra-
tion. The person to whom the permit is so given and the physician certifying
the cause of death shall thereafter furnish for registration any other necessary
information which can be obtained as to the deceased, or as to the manner or
cause of the death, which the clerk or registrar may require.— Chap. 114, Sec. 45,
G. L., (Tercentenary Edition).
Medical examiners shall make examination uppn 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 persons 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 ofthe 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
cemeteiy 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 follow-
ing 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. — Physicians: see explanatory instructions
on face side of standard certificate of death.
Statement of Occupation. — Precise statement of occupation is very import-
ant. 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 occupa-
tion had been given up or changed, or if the deceased had retired from business,
report the kind of work done during most of working life even if retired. 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
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
Q
u.
Ul
V
Suffolk
(County)
Winthrop
(City or Town)
(Contnumfiiraitlt of -fflasBctrlmsptts
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.
15
no. Winthrop Community Hospital
St.
2 FULL NAME
(If deceased is a
(a) Residence. No.
(Usual place of abode)
.rried, widowed or divorced wc/man, give also maiden name.)
bgV 144 Putnam
St.
(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)
East Boston
(If nonresident, give city or town and State)
Length of stay: In hospital or institution »
(Before death) (Specify whether)
months
days.
in this community
days.
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
Female
L
4 COLOR OR RACE
White
5 SINGLE (write the word)
MARRIED c-_
widowed oingei
or DIVORCED
5a If married, widowed or divorced
HUSBAND of
(Give maiden name of wife in full)
(or) WIFE of
(Husband’s name in full)
6 Age of husband or wife if alive
years
7 IF STILLBORN, enter that fact here. Stillborn
8
AGE
Years
Months
Days
If less than 1 day
Hours
Minutes
Usual
9 Occupation:
At-home
Industry
Jit hone
10 or Business:
11 Social Security No.
none
12 BIRTHPLACE (City) WlnthrOD
(State or Country) " *
13 NAME OF * ,
father Richard Medeiros
14 BIRTHPLACE OF
FATHER (City)
(State or Country)
Cambridge
Mass,
15 MAIDEN NAME
OF MOTHER
Patricia Reagan
16 BIRTHPLACE OF
MOTHER (City)
East Boston
(State or Country)
Mass.
17 informant , Richard Medei ros (Fktherfanv )
(Address) 6S3 Saratoga St, f East Boston
I HEREBY CERTIFY that a satisfactory standard-^ertificate of death was filed
witty rfteJJEEfliTE the burial dfefiansir permit .Was issued:
MEDICAL CERTIFICATE OF DEATH
18 DATE OF
DEATH
(Month)
(Day)
Ll.££
(Year)
19 I HEREBY CERTIFY,
19
I last saw h alive on
have occurred on the date stated above, at
Immediate cause of death
Due to
Due to
That I attended deceased from
, to , 19
, 19 ... death is said to
m.
Other conditions
(Include pregnancy within 3 months of death)
Major findings:
Of operations
Of autopsy
What test confirmed diagnosis?
Date of
Duration
IMPORTANT
IMPORTANT
Physician
Underline
the cause to
which death
should be
charged sta-
tistically.
20 Was disease or injury in any wayjelated tajjccupation of deceased?
If so, specify " “7') ^ /
(Signed) ^ > , M. D.
g?s) C~? ^ £-J Date //J?t 19
22 NAME OF
FUNERAL DIRECTOR
ADDRESS 257 PrO
St. , Cambridge
Received and/Filed
FEB 9 1949
(Registrar)
19
EXTRACTS FROM THE LAWS OF THE
COMMONWEALTH OF MASSACHUSETTS
GOVERNING THE
RETURN OF CERTIFICATES OF DEATH
A physician or registered hospital medical officer shall forthwith, after
the death of a person whom he has attended during his last illness, at the
request of an undertaker or other authorized person or of any member of
the family of the deceased, furnish for registration a standard certificate
of death, stating to the best of his knowledge and belief the name of the
deceased, his supposed age, the disease of which he died, defined as re-
quired by section one, where same was contracted, the duration of his last
illness, when last seen alive by the physician or officer and the date of
his death . . . Gen. Laws, Chap. 46, Sec. 9.
A physician or officer furnishing a certificate of death as required by the
preceding section or by section forty-five of chapter one hundred and four-
teen, shall, if the deceased, to the best of his knowledge and belief, served
in the army, navy or marine corps of the United States in any war in which
it has been engaged, insert in the certificate a recital to that effect, speci-
fying the war, and shall also certify in such certificate both the primary
and the secondary or immediate cause of death as nearly as he can state
the same. For neglect to comply with any provision of this section, such
physician or officer shall forfeit ten dollars. For the purposes of this sec-
tion and of sections forty-five, forty-six and forty-seven of said chapter
one hundred and fourteen, the word “war” shall include the China relief
expedition and the Philippine insurrection, which shall, for said purposes,
be deemed to have taken place between February fourteenth, eighteen
hundred and ninety-eight and July fourth, nineteen hundred and two, and
the Mexican border service of nineteen hundred and sixteen and nine-
teen hundred and seventeen. G. L. Chap. 46, Sec. 10.
No undertaker or other person shall bury or otherwise dispose of a human
body in a town, or remove therefrom a human body which has not been
buried, until he has received a permit from the board of health, or its
agent appointed to issue such permits, or if there is no such board, from
the clerk of the town where the person died; and no undertaker or other
person shall exhume a human body and remove it from a town, from one
cemetery to another, or from one grave or tomb other than the receiving
tomb to another in the same cemetery, until he has received a permit from
the board of health or its agent aforesaid or from the clerk of the town
where the body is buried. No such permit shall be issued until there shall
have been delivered to such board, agent or clerk, as the case may be,
a satisfactory written statement containing the facts required by law to be
returned and recorded, which shall be accompanied, in case of an original
interment, by a satisfactory certificate of the attending physician, if any,
as required by law, or in lieu thereof a certificate as hereinafter provided.
If there is no attending physician, or if, for sufficient reasons, his certificate
cannot be obtained early enough for the purpose, or is insufficient, a physi-
cian who is a member of the board of health, or employed by it or by the
selectmen for the purpose, shall upon application make the certificate re-
quired of the attending physician. If death is caused by violence, the medi-
cal examiner shall make such certificate. If such a permit for the removal
of a human body, not previously interred, from one town to another within
the commonwealth cannot be obtained early enough for the purpose, the
certificate of death made ap 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 witljn thirty-six hours after such removal, unless
a perniit in the usual formWor 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 aud 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 tnere 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-
posahly 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!
A3 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
Ictire<* “orT! 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
50m-(e)-10-48-24658
JTIjr (Cnmmomnraltl) of fSaBaar^uerttH
OFFICE OF THE SECRETARY
DIVISION OF VITAL STATISTICS
COPY OF
CERTIFICATE OF DEATH
Suffolk
(County)
Revere
(City or Town)
No Rest haven Conv. Home St. {‘give?^ N^ME Instead
REVERE
(City or town making return)
r»
Registered No jJUl.
2 full name Elizabeth B. Tewksbury (Nickerson)
(If deceased is a married, widowed or divorced woman, give also maiden name.)
(Was deceased a
U. S. War Veteran,
if so specify WAR)
(a) Residence. No. 7&.. Atlantic st Wint hrop
(Usual place of abode) (If nonresident, give city or town and State)
Length of stay: In place of death, — years 5 months — days. In place of residence 50 years .—...months •—.. .days.
MEDICAL CERTIFICATE OF DEATH
PERSONAL AND STATISTICAL PARTICULARS
3 DATE OF T
death J anuary
(Month)
10
(Day)
1.9.43
(Year)
That I attended deceased from
41 HEREBY CERTIFY,
June 13 .... 1&7 to.
I last saw h er alive on ... January 4, 19 49 death is saM
3:15
8 SEX
Female
9 COLOR OR RACE
White
10 SINGLE (write the word)
MARRIED
WIDOWED t»r< ^ o
or DIVORCED VflClOWea.
January. 10 19 49
i4(
10a If married, widowed, or divorced
HUSBAND of
(Give maiden name of wife in full)
have occurred on the date stated above, at
DISEASE OR CONDITION
DIRECTLY LEADING , , „ ,
to death (a) Cerebral Hemorrhage
with left hemiplegia
5mos .
cedInt °b> To Arteriosclerotic
causes Keart disease
o’-)' T Arte r i 0 s cl er os 1 s
OTHER hT^vs/-.
SIGNIFICANT KOuG
CONDITIONS
INTERVAL BE-
TWEEN ONSET
AND DEATH
(00 wife of Alfred Tewksbury
(Husband’s name in nil
ill)
Liyrs.
Lgyrs .
Major findings:
Of operations 4l v*lv
No
Date of operation Was autopsy performed?
What test confirmed diagnosis?Cl ini Cal & La t)0rat OTJ
5 Was disease or injury in any way related to occupation of deceased? m
If so, specify
(Signed)
(Address)
Maurice Traunsteln. ^ .... m. n
S62 Shirley . St. Datel/10 iM
Wihtfirop Wint.hr.QP..
6. V/inthrop
Place of Burial or Cremation
DATE OF BURIAL
Wint hr op
(City or Town)
January 13 , 19 4 j
funeral director J.Qhn....F« 0 '..Maley
address V/inthrop, Mass.
Received and filed
|FB~tTT9«
(Registrar of City or Town where deceased resided)
11 IF STILLBORN, enter that fact here.
12
AGE
7.2
Years
Months
Days
If under 24 hours
Hours Minutes
13 Occupation: H ousework
(Kind of work done during most of working life)
14 Industry
or Business:
Own Home
15 Social Security No.
16 BIRTHPLACE (City) .
(State or country)
Brewer
: Maine
17 NAME OF . „ _ ... ,
father Charles F. Nickerson
18 BIRTHPLACE OF
FATHER (City) ...
Brewer
(State or country)
Maine
19 MAIDEN NAME
OF MOTHER
Annette Chambers
20 BIRTHPLACE OF
MOTHER (City) .
(State or country)
Brewer
Maine
21 Informant A1 f T .©<1 ... T.g W.k Sby IT
(Address; 7& . Atlantic,-
A TRUE COPY
ATTEST:
(Registrar of City or Town where death occurred)
DATE FILED M..GU.4.*
Jan.* 2.1.,
19
25m-(h)-10-48-24658
Suffolk
(County)
Boston
(City or Town)
Qtyr CEommonroraltf) of maeaarljHBrtta
OFFICE OF THE SECRETARY
DIVISION OF VITAL STATISTICS
COPY OF
MEDICAL EXAMINER S
CERTIFICATE OF DEATH
Boston
(City or town making return)
Registered No
No.
Hass .General Hospital
I (If death occurred in a hospital or institution.
St. \ give its NAME instead of street and number)
2 full name Charles Holtnaus
(If deceased is a married, widowed or divorced woman, give also maiden name.)
(a) Residence. No
(Usual place of abode)
1U Highland Ave.
(Was deceased a
U. S. War Veteran,
if so specify WAR) .
St.
I it so speedy Wj
Winthrop Mass.
(If nonresident, give city or town and State)
Length of stay: In place of death years .1 months .2 . days. In place of residence. years months days.
MEDICAL CERTIFICATE OF DEATH
B£I?hop. J.an/l5.A9
(Month) (Day) (Year)
41 HEREBY CERTIFY that I have investigated the death
of the person above-named and that the CAUSE AND MANNER thereof
are as follows: (If an injury was involved, state fully.)
.Fr.a.Q.M.e...pf..hip..
Hhleboihrgmbpsis
Tnimonary embolism
5 Accident, suicide, or homicide (specify) Accident.....
Date and hour of injury I)e.Q.* ... IQ. 19. ...U.9.
Winthrop
(City or town and State)
Did injury occur in or about home, on farm, in industrial place, or in public
place?
Where did
Injury occur?..
Manner of
Injury
Nature of
Injury
Home
(Specify type of place)
Fell
(How did injury occur?)
See above
While at work? Was autopsy performed?
No
No
PERSONAL AND STATISTICAL PARTICULARS
9 SEX
10 COLOR OR RACE
11
M
W
MARRIED
WIDOWED
or DIVORCED
(write the word)
Widowed
1 la If married, widowed, or divorced _ _
husband of Mar y F Dunne
(Give maiden name of wife in full)
(or) WIFE of
(Husband’s name in full)
12 IF STILLBORN, enter that fact here.
13 Hi
If under 24 hours
AGE .0.1. Years
Months
Days
Hours Minutes
14 Usual
Occupation:..
Lithographer Retired
(Kind of work done during most of working life)
15 Industry
or Business:
16 Social Security No.
17 BIRTHPLACE (City).
(State or country)
Lithographic
[removed]
Boston Mass.
6 Was disease or injury in any way related to occupation of deceased?
If so, specify
(signed) A..R... Moritz M D
(Address) ... 25 Shat.tuck St Datel— 16. 19 ,il9
^ _ St Joseph’ s J^ston Mass
Place of Burial, or Cremation. (City or Town)
DATE OF BURIAL J.an* 18/U9 19
18 NAME OF
FATHER
Cannot be learned
19 BIRTHPLACE OF
FATHER (City) ....
(State or country)
Germany
20 MAIDEN NAME
OF MOTHER
Cannot be learned
21 BIRTHPLACE OF
MOTHER (City) ....
(State or country)
Germany
22
Informant .
(Address)
C Holthaus
4 yfv\ ““ST7
8 NAME OF
FUNERAL DIRECTOR
■jFQLjIaley
ADDRESS Winthrop Maas
A TRUE,
ATTEST: ....
Received and filed 19..
FEB j 1 1949
(Registrar of City or Town where deceased resided)
(Registrar of City or Town where death occupied)
Jan. 18/L9
DATE FILED 19
.
M R-301A
TRUCTIONS
FOR
1 CERTIFICATE
l giving
: OF DEATH
not enter
e than one
le for each
, (b) and (c)
s does not mean
t of dying, such
ailure. asthenia, .
eons the disease,
lications which
rath.
bid conditions. .
iving rise to the
use (a) stating
'crlying cause
i it ions contrib- •
he death but not
the disease or
causing death.
fflommonroraltlf of ^SaBaac^usrtts
OFFICE OF THE SECRETARY
DIVISION OF VITAL STATISTICS
STANDARD
CERTIFICATE OF DEATH
To be filed for burial permit
with Board of Health
or its Agent.
Registered No.
2 FULL NAM
(a) Residence. No
(Usual place of abode)
(If deceased is a married^ widowed or divorced woman, give also maiden name.)
I (If death occurred in a hospital or institution.
St. \ give its NAME instead of street and number)
PHYSICIAN — IMPORTANT
(Was deceased a , , /
U. S. War Veteran, i/ 1 1/ I
if so specify WAR) "...VY.... /
(If nonresident, give city or town and State)
Length of stay: In place of death years months /. days. In place of residence<4 years months days.
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
DEATH
(Month) f (Day) f (Year)
4 1 HEREBY CERTIFY, That I attended deceased from
J~£jrr^oty.i , iff. to <f... wtjf
I last saw h alive on f fcoMOfy T. 1 9 (Jrf , death is said to
y.'oo p
have occurred on the date stated above, at
DISEASE OR CONDITION
DIRECTLY LEAD
TO DEATH (a)
IN i 1C1.N
ANTE Due To
CEDENT (b)
CAUSES
Due To
(c)
OTHER JQ
SIGNIFICANT Aj F
CONDITIONS
Major findings:
Of operations f.
Date of operation Wras autopsy pejjormed?
What test confirmed diagnosis
INTERVAL BE
TWEEN ONSET
AND DEATH
ifJcxyt
3<ii
<*ys
5 Was disease or injury in any way related to occupation of deceased?
If so, soecify
(Signed)\M^ClJL^^. | \T<A^VVi , M
(^ddress)75-^>A 19
V/cofi chouu
Place of Burial or Cre,
YZeSwc*') \y (LajS
L. (City or Town) /
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
Wo
9 COLOR OR RACE
10 SINGLE (write the word)
MARRIED
WIDOWED
or DIVORCED
VW1IIC LUC won
10a If married, widowed, or gtivorced^?
HUSBAND of .
(Give maiden name of wife in full)
(or) WIFE of
(Husband’s name in full)
11 IF STILLBORN, enter that fact here.
12
AGE
Years Months
Days
If under 24 hours
Hours Minutes
13 Usual
Occupation:
(Kind of work done during most of working life)
14 Industry
or Business:
15 Social Security No.
16 BIRTHPLACE (City)
(State or country)
^ 7
17 NAME OF S S) . /)/!
FATHER
18 BIRTHPLACE OF
FATHER (Citv)
(State or country)
19 MAIDEN NAME .
'7) * -/^ / /)
OF MOTHER
JCho
20 BIRTHPLACE OF
MOTHER (City) ...J
(State or country)
' 1<
■w vji v.uuiu.1 y f
I HEREBY CERTiFY that a satisfactory standard certificate of death was
fi#d witfy pne BEFORE^ the burial or traireit permit was issued:
of Board of H^|pth"6r^other) / 7 ^ ^
'
j (Date of Issue of Per/nit)
EXTRACTS
FROM THE LAWS OF THE
COMMONWEALTH OF MASSACHUSETTS
GOVERNING THE
RETURN OF CERTIFICATES OF DEATH
A phvsician or registered hospital medical officer shall forthwith, after the
death of a person whom he has attended during his last illness, at the request
of an undertaker or other authorized person or of any member of the family of
the deceased, furnish for registration a standard certificate of death, stating to the
best of his knowledge and belief the name of the deceased, his supposed age, the
disease of which he died, defined as required by section one. where same was
contracted, the duration of his last illness, when last seen alive by the physician
or officer and the date of his death. . .Gen. Laws, Chap. 46, Sec. 9.
A physician or officer furnishing a certificate of death as required by the
preceding section or by section forty-five of chapter one hundred and four-
teen, shall, if the deceased, to the best of his knowledge and belief, served in the
army, navy or marine corps of the United States in any war in which it has been
engaged, insert in the certificate a recital to that effect, specifying the war, and
shall also certify in such certificate both the primary and the secondary or imme-
diate 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 theretrom 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 tp 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 from which it was
removed within thirty-six hours after such removal, unless a permit in the usual
form for the removal of such body has been sooner obtained hereunder. If the
death certificate contains a recital, as required by section ten of chapter forty-six,
that the deceased served in the army, navy or marine corps of the United States
in any war in which it has been engaged, such recital shall appear upon the permit.
The board of health, or its agent, upon receipt of such statement and certificate,
shall forthwith countersign it and transmit it to the clerk of the town for registra-
tion. The person to whom the permit is so given and the physician certifying
the cause of death shall thereafter furnish for- registration any other necessary
information which can be obtained as to the deceased, or as to the manner or
cause of the death, which the clerk or registrar may require. — Chap. 114, Sec. 45,
G. L., (Tercentenary Edition).
Medical examiners shall. make examination uppn 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 persons 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 oi 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 follow-
ing 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. — Physicians: see explanatory instructions
on face side of standard certificate of death.
Statement of Occupation. — Precise statement of occupation is very import-
ant, so that the relative healthfulness of various pursuits can be known. Make
spme entry in this section for every person aged 10 years or over. If the occupa-
tion had been given up or changed, or if the deceased had retired from business,
report the kind of work done during most of working life even if retired. 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 ..
50m-(e)-10-48-24658
Essex
(County)
Danvers
(City or Town)
QJif? (Eommonuiralll) of flllaHHartiUHrtta
OFFICE OF THE SECRETARY
DIVISION OF VITAL STATISTICS
COPY OF
CERTIFICATE OF DEATH
Danvers
(City or town making return)
Registered No.
JL9L
No.
2 FULL NAME
Danvers btate Hospital, Hathorne , lias® • death occurred in a hospital or institution.
t. St. \ .give its NAME instead of street and number)
{(Was deceased a
U. S. War Veteran,
if so specify WAR) .
Bridget Theresa Meagher
(If deceased is a married, widowed or divorced woman, give also maiden name.)
949 Dhirley St., Winthrop, Mass.
(a) Residence. No St
(Usual place of abode) (If nonresident, give city or town and State)
Length of stay: In place of death.. ...5.. ..years.. ..3. months^ days. In place of residence years months days.
MEDICAL CERTIFICATE OF DEATH
PERSONAL AND STATISTICAL PARTICULARS
3 BeI?h0F F.e binary. 5 1949. .
(Month) (Day) (Year)
8 SEX
Female
That I attended deceased from
Feb. 5 19. 49
>49
41 HEREBY CERTIFY,
...NOV. 4 19.4.3 to
I last saw h Of alive on 5 , 19 *+..<(, death is said tc
have occurred on the date stated above, at It 0.5 P «n. INTERVAL BE
TWEEN ONSET
ANO OEATH
6 yrs
9 COLOR OR RACE
’White
10 SINGLE
MARRIED
widowed oinfrle
or DIVORCED ■LUbJ-c
(write the word)
or DIVORCED
DISEASE OR CONDITION
DIRECTLY LEADING . ,. , . , .
thr.Qnic.....myQQarditis
TO DEATH (a)
cedInt ’(b) To Bronchopneumonia l\-2 day(
CAUSES
Due To
(c)
OTHER
significant
CONDITIONS
10a If married, widowed, or divorced
HUSBAND of
(Give maiden name of wife in full)
(or) WIFE of
(Husband's name in full)
11 IF STILLBORN, enter that fact here.
AGE 72 Y ears 7 .Months . . Days
If under 24 hours
Hours Minutes
13 Usual
Occupation: Unable to... work
(Kind of work done during most of working life)
14 Industry
or Business:
15 Social Security No
16 BIRTHPLACE (City) Ha.l.i i’.a.X v
(State or country)
Nova Scotia’, Canada
Major findings:
Of operations
Date of operation Was autopsy performed?....!! O..
What test confirmed diagnosis? Clinical
5 Was disease or injury in any way related to occupation of deceased?
If so, specify ;
(Signed) Fa S Qu ale Muonic oil t.o.«.../T._ m. d^
(Address) Ha t hOme ... lviass.. Date . 2/ 11 19. 4b
6 ..Oakdale ...Cemetery........ Mid. die ton
Place of Burial or Cremation (City or Town)
1 7 father.f John Keagher
18 BIRTHPLACE OF
FATHER (City)
(State or country)
Ireland
19 MAIDEN NAME
OF MOTHER
Ellen Condon
20 BIRTHPLACE OF
MOTHER (City) ...
(State or country)
Ireland
DATE OF BURIAL..
February 9 19 49
7 name of ij ij Trannan 60 Don
FUNERAL DIRECTOR T..* 9. ..
(AHHrps*; »
address Arlington , ...Mass.
21 informant..|yiary....h .... ahc Phillip s
hatnopne t lass.
*4
A TRUE COPY.
ATTEST:
(Registrar of City or town where death occurred)
Received and filed 19..
MAR....9. 1.9.49
(Registrar of City or Town where deceased resided)
DATE FILED “,r..„.„..r. .r. 19
February 12
49
25m-(h)-10-48-24658
Middlesex
25
(County)
Waltham
Murphy'' tie ne r al Ho spi ta 1
QHjp (Enmmomoraltlj of UtaBBarlftiBrttB
OFFICE OF THE SECRETARY Waltham
DIVISION OF VITAL STATISTICS
COPY OF (City or towpjjn
MEDICAL EXAMINER’S 63
CERTIFICATE OF DEATH Registered No.
aking return)
_.2.Q.
No,
Robert Spaulding
St.
/ (If death occurred in a hospital or institution,
. \ give its NAME instead of street and number)
2 FULL NAME I (Was deceased a
(If deceased is a married, widowed or divorced woman, give also maiden name.) | 0. S. War Veteran,
Port Banks Winthropy*
(a) Residence. No. St
(Usual place of abode) 1 1 ^ onresideijftjjy ve city or town and State)
Length of stay: In place of death years months days. In place of residence years months days.
3 DATE OF
DEATH ..
FoEruaryRTiFic^E 0F DEAj[^4o
(Month)
(Day)
(Year)
4 I HEREBY CERTIFY that I have investigated the death
of the person above-named and that the CAUSE AND MANNER thereof
SnW>VMollqfcflhSBll*i't4.li^fVWolve<3- state fully.)
Ldema of lungsand glottis
TerminaT Bronchopneumonia *
Aeeident* -
Accident
5 Accident, suicide, or ho^l<^^(ppg£jiy£».^....l£. ..
Date and hour of injury.,
^^rBa^s;"WiHthi-bp-
Where did
Injury occur?
(City or town and State)
Did injury o^u£in^£^^jg home, on farm, in industrial place, or in public
place?
Manner of S ' ldfce I*^ft0^¥©lH£>
Injury
Nature of
no
While at work? Was autopsy performed?
(How did injury occur?)y0 g
yes-
■mr
6 Was disease or injury in any way related to occupation of deceased?..
if so. spe^y.....Morton- -Gallagher-
(signed) ...Nowt-on-^ Masrr* 2-fr
w
...i?,...
* i
Plaice of Buriai, or ^feihu a r y ' 8
DATE OF BURIAL
William-' J. Cox
(City or Town) 49
19
8 NAME OF
FUNERAL DIRECTO^0.^^on.£-.....}£a.n«Vv.
ADDRESS
Received and filed [yj.^.jii..4...Q....!,r.^l.'T;.Q. „..19..
(Registrar of City or Town where deceased resided)
PERSONAL AND STATISTICAL PARTICULARS
1° O^L^OR RACE
11 SINGLE (write the word)
married Stride
WIDOWED
or DIVORCED
11a If married, widowed, or divorced
HUSBAND of
(Give maiden name of wife in full)
(or) WIFE of
(Husband's name in full)
12 IF STILLBORN, enter th:
13 J
AGE
t here.
Years Months
Days
If under 24 hours
Hours Minutes
14 Usual
Occupation:..
(Kind of work done during most of working life)
IS Industry
or Business:
16 Social Security No.
Waltham
17 BIRTHPLACE (City) M £l3fl.a
(State or country)
n
is NAMEobaniel Francis Spaulding
FATHER
19 BIRTHPLACE OF Fond <3U L&C
FATHER (City) fr iflC On S in
(btate or country)
20 maiden nam® lea nor Laura Newmann
OF MOTHER
21 BIRTHPLACE OF Llkhom
MOTHER (City) V*'T H P On HlTT
(State or country) ”180008111
22
La rile, 1 F. Spaulding
tfEr, For t Banks , Mas s *
A TRUE COPY.
ATTEST:
DATE
filed .February 8
.*
'I
lci.iis, so mat u may De properly classified, fi-xact statement of OCCUPATION is very important
See instructions and extracts from the laws on back of certificate.
If deceased was a U. S. War Veteran, G. L. Chap. 46, Section 10, requires physicians to insert a recital to that effect.
I R-301 A
Cnmmoufiicaltli of JHrissctrlmsetts
OFFICE OF THE SECRETARY
DIVISION OF VITAL. STATISTICS
STANDARD
CATE OF DEATH
To be filed for burial permit
with Board of Health
or its Agent.
Registered No.
(If death
1 give its 1
2 FULL NAME
(a) Residence. No.
(Usual place of a node)
Length of stay: In hospital or institution J.
(Before death) (Specify whether)
occurred in a hospital or institution,
NAME instead of street and number)
PHYSICIAN- IMPORTANT
(Was deceased a
U. S. War Veteran,
if so specify WAR)
(If nonresident, give city or town and State)
In this community yrs. mos.
days.
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
4 COLOR OR RACE
kJ
5 SINGLE (write the word)
MARRIED .
WIDOWED C
or DIVORCED
5a If married, widowed or divorced
HUSBAND of
(Give maiden name of wife in full)
(or) WIFE of
(Husband's name in full)
6 Age of husband or wife if alive
7 IF STILLBORN, enter that fact here.
years
-)
8
AGE
Years
Months
Days
If less than 1 day
Hours
Minutes
Usual
9 Occupation:
Industry
10 or Business:
14 BIRTHPLACE OF
FATHER (City)
(State or Country}
15 MAIDEN NAME
OF MOTHER
'(■<1
16 BIRTHPLACE OF
MOTHER (City)
(State or Country)
17
Informan
(Address)
7
ron.it/tny y
■J 'dAiJ.
HEREBY CERTIFY that a satisfactory standard certificate of death was filed
_with^/n4/ BEFORE^the burial or t/*r\sit petmft was issued:
MEDICAL CERTIFICATE OF DEATH
18 DATE OF
DEATH
M: ’
(Month)
7
(Day)
(Year)
19
I last saw h
JtEREBY CERTIFY, That I attended deceased from
19^.,. ?r
d7
alive on
have occurred on the date stated above, at
Immediate cause of death
Due to
Due to
Other conditions
(Include pregnancy within 3 months of death)
Major findings:
Of operations
Of autopsy
What test confirmed diagnosis?
20 Was disease or injury in any way related to occupation of deceased7
i«^. ■
(Address)
21 yttr. . : .
Place of Burial. Cremation or Removal.
DA1E OF BURIAL .1 tZ J
V — ^
22 NAME OF
FUNERAL DIRECTOR
ADDRESS
Received and Filed
FEB 14 7349
(Registrar)
EXTRACTS FROM THE LAWS OF THE
COMMONWEALTH OF MASSACHUSETTS
GOVERNING THE
RETURN OF CERTIFICATES OF DEATH
A physician or registered hospital medical officer shall forthwith, after
the death of a person whom he has attended during his last illness, at the
request of an undertaker or other authorized person or of any member of
the family of the deceased, furnish for registration a standard certificate
of death, stating to the best of his knowledge and belief the name of the
deceased, his supposed age, the disease of which he died, defined as re-
quired by section one, where same was contracted, the duration of his last
illness, when last seen alive by the physician or officer and the date of
his death . . . Gen. Laws, Chap. 46, Sec. 9.
A physician or officer furnishing a certificate of death as required by the
preceding section or by section forty-five of chapter one hundred and four-
teen, shall, if the deceased, to the best of his knowledge and belief, served
in the army, navy or marine corps of the United States in any war in which
it has been engaged, insert in the certificate a recital to that effect, speci-
fying the war, and shall also certify in such certificate both the primary
and the secondary or immediate cause of death as nearly as he can state
the same. For neglect to comply with any provision of this section, such
physician or officer shall forfeit ten dollars. For the purposes of this sec-
tion and of sections forty-five, forty-six and forty-seven of said chapter
one hundred and fourteen, the word "war” shall include the China relief
expedition and the Philippine insurrection, which shall, for said purposes,
be deemed to have taken place between February fourteenth, eighteen
hundred and ninety-eight and July fourth, nineteen hundred and two, and
the Mexican border service of nineteen hundred and sixteen and nine-
teen hundred and seventeen. G. L. Chap. 46, Sec. 10.
No undertaker or other person shall bury or otherwise dispose of a human
body in a town, or remove therefrom a human body which has not been
buried, until he has received a permit from the board of health, or its
agent appointed to issue such permits, or if there is no such board, from
the clerk of the town where the person died; and no undertaker or other
person shall exhume a human body and remove it from a town, from one
cemetery to another, or from one grave or tomb other than the receiving
tomb to another in the same cemetery, until he has received a permit from
the board of health or its agent aforesaid or from the clerk of the town
where the body is buried. No such permit shall be issued until there shall
have been delivered to such board, agent or clerk, as the case may be,
a satisfactory written statement containing the facts required by law to be
returned and recorded, which shaThe text goes on. The rest is in the file.