The volume, 1950

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

Stationers
105 State St., Boston

To duplicate this book order

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Qlljr (flmnmomnraUlj of flaBaarljafirtta
OFFICE OF THE SECRETARY
DIVISION if /!TAL STATISTICS

MEDICAL EXAMINER S
CERTIFICATE OF DEATH

To bo tUd for burial permit
with Board of Health
or Its Agent.

Registered No.

MA \ Ai/t , J 1/7 ( .n.. . j > . . , /. A^-tXV'K . IsJl i (If death occurred in a hospital or institution,

No. St. \ give its NAME instead of street and number)

/7\ V / ) 1/ / 1 , PUVfiiriiM lUDAITlUT

2 FULL NAME..

<£Z)*'VV'L

(If deceased is a married, widoired or divorced woman, give also maiden name.)
! of abode) r T—

1 PHYSICIAN — IMPORTANT

♦- I (Was deceased a

| U. S. War Veteran,
l if so specify WAR)

(a) Residence. No. " / ^rtT!V..V. St.

(Usual place of abode) r . TT

i Hour s t

Length of stay: In place of death years months days. In place of residence years JL-. months days.

(If nonresident, give city or town and State)

MEDICAL CERTIFICATE OF DEATH

\cu^...- .<£ - LG..£l.&.

' Month) fDavl « rv#ori

(Day)

(Year)

I HEREB V CERTIFY that I have investigated the death
of the person above-named and that the CAUSE AND MANNER thereof
s as follows: (If an Lniu/r was involved, sfrtdjfilty-r) p CP.4L, 't-aC

5 Accident, suifide, or homicide (specify)

Date and hour of injury 19.

AGE 36Years

Months

Days

(City or town and State)

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

Manner of
Injury

(Specify type of place)

iddus^L

/ (ifow did injury occur?) . , t .

b^JlJVy tWjJLr.y ''o kr, v?ijc.

Nature o!

Injury

While at work? P. Was autopsy performed?

leceased?

related to occupation of di

M. D.

VTr.. i9tfb

6 Was disease or injury i
If so, specif;

(Signed)

(A dress) ...

7 .flolx....Cjc.o.as balden..

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

DATE OF BURIAL - ,„ 19.j3.Cj

8 NAME OF Z

FUNERAL DIRECTOR ,(...

ADDRESS -

Received and filed..

JANE 1350

.19

(Registrar)

PERSONAL AND STATISTICAL PARTICULARS

9 SEX

Female

10 COLOR OR RACE

whj {~.e

11 SINGLE (write the word)
MARRIED
WIDOWED

or DivoRCEDmarri eri

1 la If married, widowed, or divorced

HUSBAND of

M <a (Give maiden name of wife in full)

(or) wife of Jame.s Gaehan

(Husband’s name in full)

12 IF STILLBORN, enter that fact here.

If under 24 hours

Hours Minutes

14 Usual

Occupation: A

O&nd^wSf^

done during most of working life)

15 o?dBus7ness: HoUSehO.l.d.

16 Social Security No.

17 BIRTHPLACE (City)
(State or country)

New Fnundl nd

18 NAME OF
FATHER

Eaunce -Abbot-t

19 BIRTHPLACE OF

FATHER (City)

(State or country) Wfiw FpUndlftnd

20 MAIDEN NAME

OF mother Emily Clancy

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

New Found land

•oae

I HEREBY CERTIFY that a satisfactory standard certificate of death was
filed^wjth me BEFORE the burial orWansit permit was issued:

vyai 7 7“ t

lU/&-

(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 authorised 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 tep 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, froip 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 aboriginal 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 nr
cause of the death, which the clerk or registrar may require. — Chap. 114, Sec.
45, G. L. as amended by Chap. 48, Acts of 1927 and Cnap. 414, Acts of 1931.

No undertaker or other person shall bury a human body or the ashes thereof
which have been brought into the commonwealth until he has received a permit
go 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., as amended.

disabled by recognisable disease, or when any person is found dead. — General

Laws, Chap. 38. Sec. 6.. as amended by Chap. 632, Sec. 4, Acts of 1945.

The medical examiner certifies the cause and manner of death to the best

of his knowledge and belief.

RULES OF PRACTICE

The fulfillment of the purpose of these laws calls for the observance of the 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 deatlis from disease resulting from injury or infection related to occupation,
the sudden deaths of persons not disabled by recognized disease, and those of
persons found dead.

STATEMENT OF CAUSE OF DEATH

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

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

SPACE FOR ADDITIONAL INFORMATION

DATE OF ENTERING MILITARY SERVICE

DATE OF DISCHARGE

RANK, RATING

ORGANIZATION AND OUTFIT

SERVICE NUMBER

)RM R-301A

Instructions
for

ICAL CERTIFICATE

In giving
ISE OF DEATH

do not enter
lore than one
i use for each
(a), (b) and (c)

Fhis does not mean
i ode of dying, such
i rt failure, asthenia, .
t means the disease,
mplicalions which
1 death.

lorbid conditions. ,
, giving rise to the "
cause (a) staling
underlying cause

'.onditions contrib- •
to the death but not
d to the disease or
ion causing death.

No.

2 FULL NAME

50 Court Rd

^ (fiommmtniralttf of fHaHaadjuartto

OFFICE OF THE SECRETARY

DIVISION OF VITAL STATISTICS

STANDARD

CERTIFICATE OF DEATH

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

Registered No. .

Harry

(If deceased is a married

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

, PHYSICIAN — IMPORTANT

Thomas Black * I (Was deceased a

1, widowcdor divorcea woman, give also maiden name.) I U. S. War Veteran.

(. if so specify WAR)

. St.

Court Rd

(If nonresident, give city or town and State)
Length of stay: In place of death years months days. In place of residence 37 years months days.

(a) Residence. No ^0

(Usual place of aEode)

MEDICAL CERTIFICATE OF DEATH

3 DATE OF
DEATH

\ 7

I J (Month) (Day) (Year)

F R*V r F R T T F V That T rWoacori

4 I H E R E BrY CERTIFY, That I attended deceased from

19 to 19

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

have occurred on the date stated above, at / A

8 SEX

Male

DISEASE OR CONDITION
DIRECTLY LEADING
TO DEATH (a)

ANTE Due To
CEDENT (b)
CAUSES

y Ls /\ u+e 10

Due To
(c)

OTHER

SIGNIFICANT

CONDITIONS

INTERVAL BE
TWEEN ONSET
ANO DEATH

Major findings:

Of operations..

Date of operation Was autopsy performed?..

What test confirmed diagnosis?

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

If so, specify

(Signed) j
(Address)

Dal(/^i^~ Y WS'fi

inthrop Wipthrop

ematioij (City_or To'

Place of Burial or Crematioq (Cjtyjor Town)

DATE OF BURIAL i Jan, 9/y, 1950 1

Informant .
(Address)

PERSONAL AND STATISTICAL PARTICULARS

9 COLOR OR RACE I 10 SINGLE (write the word)
MARRIED

White

WI qftWED.

i or

i^aluEted

ied. widowed, or.divorc£d -

ofGrertruae H. Welcome

10a If married, widowed, or^livorq
HUSBAND ofi

(Give maiden name of wife in full)

(or) WIFE of

(Husband's name in full)

11 IF STILLBORN, enter that fact here.

AGE

Years

Months .

Days

If under 24 hours

Hours Minutes

Occupati .Furniture Retired

(Kind of work done during most of working life)

14 Industry
or Business:

Furniture

15 Social Security No.

16 BIRTHPLACE (City) .
(State or country)

Woodstock
N. B.

17 NAME OF
FATHER

Harry — A,- Black

18 BIRTHPLACE OF

FATHER (City) St. Stephen

(State or country) N. B

19 MAIDEN NAME

OF MOTHER

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

Matftlda R, Wiliams

Canada

Gertrude H Black
50 Court Rd

I HER.EBY CERTIFY that a satisfactory standard certificate of death was
file# with me BEFORE the burial or transit permit was issued:

ture of Agent of BoafdAjf Health or other>

, . .

)fficial Designation) (Date of Issue of Bermit) /

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
cemeteiv 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

ORGANIZATION AND OUTFIT

SERVICE NUMBER

THIS IS A PERMANENT RECORD

ORM R-302

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X
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iSEssex

Q
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uiLynn

“• No Lynn Hospital

(County)
(City or Town)

QTlfr Cmmnonmraltt) of flSaBsari?usrtts

OFFICE OF THE SECRETARY

DIVISION OF VITAL STATISTICS

COPY OF

CERTIFICATE OF DEATH

Lynn

TWty or t

• town making return)
Registered No

I (If death occurred in a hospital or institution,
t- \ '

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

2 FULL NAME..

(If del

:8a9el)fl’^rriSHfeJ^o

or divorced woman, give also maiden name.)

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

fa> R1tep,Soi Temple A ve.

25 minutes

years months

St'

Length of stay: In place of death year

tit, give city or town and State)
days. In place of residence years months days.

MEDICAL CERTIFICATE OF DEATH

PERSONAL AND STATISTICAL PARTICULARS

3 DATE OF -

DEA™ 8* ■■"3

(Year)

8 SEX

male

9 COLOR OR RACE

white

10 SINGLE (write the word)

MARRIED

WIDOWED -

or DI VORCEDO lllg 1 6

to..

I last saw h alive ou 19 , dpatl^ is sajd tc

contusion of|

£7i3E,7TvTn, ~ AND Dl

DUWfTWWkPiBff face. Abrai'sior of

rW'^e.

Accident

ANTE Due To

CEDENT (b)

CAUSES

Due

(c)

Jan. 8 j

^Saugus, Mass.

50.

OTHER

SIGNIFICANT

CONDITIONS

If under 24 hours

ACjfiQ Years

Months

. Days

Hours Minutes

Major findings:
Of operations..

Date of operation Was autopsy performed?

What test confirmed diagnosis? Bo

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

(signed) Laurence F » Pusic

(Address) yahant^ fess. Date1

M. D

Want ter o $> Cremation
DATE OF BURIAL

7 NAME OF
FUNERAL DIRECTOR

Jan,

Mn>tfov>op

11, ’$0

ADDRESS

Wlntfir op , s sj^ x *7

Received and fifed......

j.. ^ J £Registrfcf}<ST pity or Town whi

We’deceJtSfd'rc

resided)

10a If married, widowed, or divorced

HUSBAND of

(Give maiden name of wife in full)

(or) WIFE of

(Husband's name in full)

1 1 IF STILLBORN, enter that fact here.

13 occupation, tudent

(Kind of work done during most of working life)

14 Industry
or Business:

15 Social Security No.

16 BIRTHPLACE (City)

(State or country)

Portland

Maine.

17 NAME OF
FATHER

W. Jason Nutter

18 BIRTHPLACE OF

father (city) Portland

(State or country)

19 MAIDEN NAME
OF MOTHER

tfcr-

Mary E. Foley

20 BIRTHPLACE OF

MOTHER (City).
(State or country)

..Portland
Maine

Informant...

(Addressj

W. Jason Nutter
72 Temple Ave^-Winthr-Qn

A TRUE COPY

ATTEST:

James Toflr.©£;e death occurTed)

DATEQffiswi.i.ss.lQ.ner...

..Jar..: .?.....i91...2.12

—

?*»

! 1

U-

RM R-301A

ISTRUCTIONS

FOR

:al certificate

In giving
>E OF DEATH

> not enter
►re than one
ise for each

), (b) and (c)

its dots not mean
dt of dying, such
\ failure, asthenia, .
means the disease,
i plications which
death.

yrbid conditions, ,
giving rise to them
ause (a) stating
xderlying cause

nditions conlrib - •
• the death but not
to the disease or
m causing death.

Suffolk

(County)

o Winthrop

(City or Town)

e (Cammomuraltfi of fHaBaarlfiiBPttB

OFFICE OF THE SECRETARY

DIVISION OF VITAL STATISTICS

STANDARD

CERTIFICATE OF DEATH

To ba filed for burial permit
with Board of Health
or it* Agent.

Registered No.

.4..

No. ...

2 FULL NAME

157 Grovers Ave •

James Clayton Ray

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

157 Grovers Ave*

I (If death occurred in a hospital or institution.
St. I 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 of abode)

St.

Length of stay: In place of death 20 years months days. In place of residence years months

20,

(If nonresident, give city or town and State)

days.

3 DATE OF
DEATH

1EDICAL CERTIFICATE OF DEATH

(Day)

/ 9 S~ 0

(Year)

41 HEREBY CERTIFY, That I attended deceased from
I last saw alive on 19 ? death is said tc

F 3 >A

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

DISEASE OR CONDITI
DIRECTLY LEADING
TQ» DEATH (a)

ANTE Due To
CEDENT (b)
CAUSES

Due To
(c)

OTHER

SIGNIFICANT .

CONDITIONS

Major findings:

Of operations.

Date of operation. ^ i T

What test confirmed diagnosis?

INTERVAL BE-
TWEEN ONSET

^yjutdL AGE 62

Years .5

performed?

5 Was disease of injury in any w'
If so, specify^

(Signed)

(Add:

M. D.
19 5 ~o

7" Winthrop Winthrop

Place of Burial or Cremation . (City or Town)

Jan. 11

DATE OF BURIAL

PERSONAL AND STATISTICAL PARTICULARS

8 SEX

Male

9 COLOR OR RACE

White

10 SINGLE (write the word)
MARRIED

WIDOWED TUIoyiyiA 01T

or divorced Marriea

10a If married, widowed, or divorced _ _ ,

husband of . Anna R Kelleher

(Give maiden name of wife in full)

(or) WIFE of

(Husband’s name in full)

1 1 IF STILLBORN, enter that fact here.

Months

Days

If under 24 hours

Hours Minutes

13 Usual

Occupation :

Retired

(Kind of work done during most of working life)

or Business: Draftsman

15 Social Security No.

16 BIRTHPLACE (City) .
(State or country)

oib-09-ooy2
White Haven

Penn*

17 NAME OF
FATHER

James W xcay

18 BIRTHPLACE OF _

father (city) White Haven

(State or country) Penn.

19 MAIDEN NAME
OF MOTHER

Koontz

20 BIRTHPLACE OF

mother (City) White Haven

(State or country) P ^

(Address) l^H^roveM Ave. Winthrop .

Informants

Received and filed

(Registrar)

I^HjpREBY CERTIFY that a satisfactory standard certificate of death was
BEFORE the.burial on transit permit was issued:

'Agent of Board of Hdalth or other)

^7 - / / //) / ^ O

(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 or 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).

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 orthe 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.

(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

ORM R-301 A

INSTRUCTIONS

FOR

IICAL CERTIFICATE

In giving
JSE OF DEATH

do not enter
lore than one
ause for each
(a), (b) and (c)

This does not mean
inode of dying, such
I art failure, asthenia, .
ft means the disease,
implications which
l| d death.

Morbid conditions. .
y, giving rise to the ’
cause (a ) staling
underlying cause

r ondilions conlrib- •
to the death but not
i to the disease or
lion causing death.

g (flommomnraltlj of fRaoaarliaBrttB

^^1., EDWARD J. CRONIN, SECRETARY

DIVISION OF VITAL STATISTICS

STANDARD

CERTIFICATE OF DEATH

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

Registered No

2 FULL NAME

(a) Resideno

I (If death occurred in a hospital or institution.

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

I PHYSICIAN — IMPORTANT

I (Was deceased a

I U. S. War Veteran.

I if so specify WAR)

(If nonresident, give city or town and State)

(Usual place of abode)/' . __

Length of stay: In place of death years months days. In place of residence^^^"years months days.

MEDICAL CERTIFICATE OF DEATH

PERSONAL AND STATISTICAL PARTICULARS

3 DATE OF
DEATH

/f<TD

(Year)

8 SEX

'Y CERTIFY.

, 19 AP. .. to

..alive on

have occurred on the date sta
DISEASE OR CONDITION
DIRECTLY LEADI
TO DEATH (a)

That I attended deceased from

u 19??

(( \9? . ^ . death is said to|

above, at

10a If married,
HUSBAND of

(or) WIFE of

10 SINGLE
MARRIED
WIDOWED
or DIVORCE

(write the word)

(Husband's name in full)

1 1 IF STILLBORN, enter that fact here.

ANTE Due To
CEDENT (b)
CAUSES

Due To
(c)

OTHER

SIGNIFICANT

CONDITIONS

/S'-t-f-

If under 24 hours

Minutes

15 Social Security No.

Major findings:

Of operations

Date of operation Was autopsy performed?

e r *

What test confirmed diagnosis? ?...SrZ

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

16 BIRTHPLACE (City) .
(State or country)

17 NAME OF
FATHER

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

-f

■vf-

I HER.EBY CERTIFY that a satisfactory standard certificate of death was
filedwith ja le BEFORE Uie burial or transit permit was issued:

Received and filed ...

filedwith ^ne BEFORE t)ie burial or transit permit was ij

(Signature of A^«nt of Board of HeSlth or other)

r/.JJ../A£.

(Official Designation) (Date of Issue of Pernyt) /

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 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 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 persons as are supposed to have died by violence, or by the action of
chemical, thermal or electrical agents or following abortion, or from diseases
resulting from injury or infection relating to occupation, or suddenly when not
disabled by recognizable disease, or when any person is found dead. ... — General
Laws, Chap 38. Sec. 6.. as amended by Chap. 632, Sec. 4. Acts of 1945.

No undertaker or other persons shall bury a human body or the ashes thereof
w'hich 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.

(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

IRM R-301A

Sugfolk

(County)

0 . Winthrop

(City or Town)

(Cmnmonoiraltl) of USaBBarifOBPttB

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.

Registered No.

n/n-.. , p/^ I (If death occurred in a hospital or institution.

.....V.y.UI..V St. \ give its NAME instead of street and number)

c PHYSICIAN — IMPORTANT

I (Was deceased a
| U. S. War Veteran.

[ if so specify WAR)

NSTRUCTIONS

FOR

CAL CERTIFICATE

In giving
SE OF DEATH

ilo not enter
ore than one
iuse for each
a), (b) and (c)

'his does not mean
ode of dying, such
rt failure, asthenia,
means the disease,
\nplicaiions which
death.

forbid conditions,
giving rise to the
cause (a) staling
Underlying cause

onditions conlrib -
o the death but not
to the disease or
I’on causing death.

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

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.

(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.

25m-(h)-10- 48-2 4658

JlSSOX

(County)

Lynn

No.

(City or Town)

Lynn Hospital

Qlffp (EnmmnmoraUlj of AasaadfttBrtta

OFFICE OF THE SECRETARY

DIVISION OF VITAL STATISTICS

COPY OF

MEDICAL EXAMINER’S
CERTIFICATE OF DEATH

Lynn

(City or town making return)

Registered No

St.

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

John L. Murphy • r

2 FULL NAME . . J (Was deceased a

(If deceased is a married, widowed or divorced woman, give also maiden name.) | U. S. War Veteran!

1 Coral A»e. Winter'*' WAR>

(a) Residence. No 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 years months days.

MEDICAL CERTIFICATE OF DEATH

3 date oJanuary id , I;pu

DEATH

(Month)

(Day)

(Year)

41 HEREBY CERTIFY that I have investigated the death
of the person above-named and that the CAUSE AND MANNER thereof

2 ofM ^m^an^JUT St? m 1 • face .

?rvaf s jra l l • wlthr ^•ags'oc';hraln"lnJ’ur-

FriOf-left-hume^ua; crush •of-

heat with a-ssoc-gint-e-rn&l

e.ra.o.t]ior.ax.a.

Accident

5 Accident, suicide, or homicide (specify)....
Date and hour of injury

Where did Walnut St. near Elm St.

Injury occur? ...

(City or town and State)

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

njury occur in or about home, oi

, , Saugus, lass.

place? Sr

_ _ _ . . (Specify type of place) .

Mannerof Collision of auto with tree

Injury

V- (Hpw did injury occur?)

Nature of 300 fibOX t)

Injury

no no

While at work? Was autopsy performed?

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

“".flmn'ceT; Cuaiclc M''n

^ ) KEuuf; Mass'; ;Jah;iZ' §)

: Malden

(Address)

^oly Cross

Place of Burial, or Cremation

DATE OF BURIAL

remauon. _ . (City or Town),,

anuar 7 111 pO

, ^ .'.19

8 NAME OF
FUNERAL DIRE

ADDRESS.

JoHrr IteTly

NT Y*T— YH I

e.rl.d.lan..S.t....,..E.^..Boston.
January..„l6 "

PERSONAL AND STATISTICAL PARTICULARS

9. SEX

10 COL,QR OR RACE

11 SINGLE
MARRIE
WIDOWE'
or DIVORCED

(wrije the word)

(write

gingl

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.

13 19

If under 24 hours

AGE Years

... Months

Days

Hours Minutes

14 Usual , Student

Occupation!

(Kind of work done during most of working life)

15 Industry Boston College

or Business: ^

16 Social Security No

029-22-011^

17 BIRTHPLACE (City) Ilf lQ£.hT9P

(State or country) laoiJ#

18 NAME OF
FATHER

John 0. Murphy

19 BIRTHPLACE OF
FATHER (City)

E. Boston

(State or country)

Mass.

20 MAIDEN NAME
OF MOTHER

Margaret M0 Downing

21 BIRTHPLACE OF
MOTHER (City) ...

E. Boston

(State or country)

Mass .

Margaret M. Johnson

(Address

A TRUE COPY.
ATTEST:

(Registrar of City or Town where death occurred)

DATE FILED

19..

n EC El v U

FEB-fel950 A"

)RM R-301A

INSTRUCTIONS

FOR

1CAL CERTIFICATE

In giving
USE OF DEATH

do not enter
tore than one
iuse for each

[a), (b) and (c)

Hits does not mean
i ode of dying, such
rt failure, asthenia, .

means the disease,
mplications which
i death.

forbid conditions,

, giving rise to the'
cause (a) staling
underlying cause

onditions conlrib- •
to the death but not
to the disease or
ion causing death.

Suffolk

(County)

Wlnthrop

(City or Town)

QJljr (Eommomnralilf of fltaoBadioBPttB

EDWARD J. CRONIN, SECRETARY

DIVISION OF VITAL STATISTICS

STANDARD

CERTIFICATE OF DEATH

To bo filed for burial parmit
with Board of Health
or it* Agent.

Registered No.

...3...

No.

W 1 nthrop Comrou n 1 ty Ho sp 1 ta 1

, St

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

2 full name Angelo Q- # Martini

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

(a) Residence. No. 45 Banks St

(Usual place of abode)

PHYSICIAN — IMPORTANT

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

St.

(If nonresident, give city or town and State)
Length of stay: In place of death years 1 months days. In place of residence 33 .years months days.

MEDICAL CERTIFICATE OF DEATH

3 DATE OF
DEATH

Jan. . 13

(Month)

(Day)

4 I,

to.

attended deceased from

I last saw h alive on f.3 19<3*P death is said to|

have occurred on the date stated above, at f VS'/?

l^E^E^Y CERTIFY

l al e

DISEASE OR CONDITION
DIRECTLY
TO DEATH (a)

DIRECTLY LEADING/7 j

ANTE Due To
CEDENT (b)
CAUSES

Due To
(c)

OTHER

SIGNIFICANT

CONDITIONS

INTERVAL BE-
TWEEN ONSET
AND OEATH

/ .

PERSONAL AND STATISTICAL PARTICULARS

8 SEX

3 v

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) fh * ...jS

(Address) 4L

St. Michatels

Place of Burial or Cremation
DATE OF BURIAL

7 NAME OF
FUNERAL DIRECTO

address x / WinthroD.

Received and filed./. /

PAN T6" )95q- 7/

(Registrar)

9 COLOR OR RACE I 10 SINGLE

White

MARRIED

(write the word)

I DO WED

or DIVORCEDg 6

10a If married, widowed, or divorced
HUSBAND of

(Give maiden name of wife in full)

(or) WIFE of

(Husband’s name in full)

1 1 IF STILLBORN, enter that fact here.

i2<§4

Years Months

Days

If under 24 hours

Hours Minutes

13 Usual pr»lr

Occupation: .V. X “ X

(Kind of work done during most of working life)

or Business: Proylsbna Imports

15 Social Security No,

613--03--559CT

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

Genoa

Italy

17 NAME OF
FATHER

August Ino Martini

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

Genoa Italy

19 MAIDEN NAME
OF MOTHER

Marla Ottornello

20 BIRTHPLACE OF

MOTHER (City) GenQ&

(State or country)

Maria Ciof fl
45 Banks St

Italy

I HEREBY CERTIFY that a satisfactory standard certificate of death was
: burialpr transit permit was issued:

(Official

y . VoigiitiLuic uiakciii oi JDoarci oi ineaiin or ornery

/./L/JL/Ju*

Designation) (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 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 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

Medical examiners shall make examination upon the view of the dead bodies
of persons as arc supposed to have died by violence, or by the action of
chemical, thermal or electrical agents or following abortion, or from diseases
resulting from injury or 'infection relating to occupation, or suddenly when not
disabled by recognizable disease, or when any person is found dead. .. — General
Laws, Chap. 38, Sec. 6., as amended by Chap. 632, Sec. 4. Acts of 1945.

. . . 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.

(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
sqme 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

*M R-301 A

STKUCTIONS

FOR

AL CERTIFICATE

n giving

E OF DEATH

not enter
ire than one
i se for each
|), (b) and (e)

is does not mean
ie of dying, such
ji failure, asthenia, .
neans the disease,

| plications which
\lealh.

rbid conditions , ,
giving rise to the "
luse (a) staling
derlying cause

iditions contrib- •
the death but not
o the disease or
n causing death.

■h

....Suffolk

(County)

2 FULL NAME

Winthrop

(City or Town)

N° 14-2 Pleasant Street

Richard 1. Howard

is a married, widowed or divorced woman,

STt|r (CmnmBrmiraltlj of ffRaBBartjnBPttB

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. .

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

PHYSICIAN — IMPORTANT

(If deceased

(a) Residence. No. P j
(Usual place of abode)

give also maiden name.)

Beal. ...Street st.

(Was deceased a

U. S. War Veteran.

if so specify WAR) 3”10

(If nonresident, give city or town and State)

Length of stay: In place of death 4p©~years ^umonths T" days. In place of residence ^)0ears months days.

MEDICAL CERTIFICATE OF DEATH

3 DATE OF
DEATH

4 L-HEREIBY CERTIFY,

Mvhi : >9^. '

Shat I attended deceased from

Lt. ipO.

I last saw hr*cTf. alive on .. jJfleCnlre death is said to

have occurred on the date stated above, at If ‘ ** P.

DISEASE OR CONDITJQN
DIRECTLY LEADING
TO DEATH (a)

U i UJXN

<2,

ANTE Due To
CEDENT (b)
CAUSES

Due To
(c)

OTHER

SIGNIFICANT

CONDITIONS

'Vt-V>

INTERVAL BE-
TWEEN ONSET
AND DEATH

/f^l

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)

date of burial ,t g> nua r y ^ 1 19^0 19

7 NAME OF -n • « -s i". rr » «

funeral director

Boston- ivlassaehns etts

PERSONAL AND STATISTICAL PARTICULARS

8 SEX

male

9 COLOR OR RACE

white

10a If married, widowed, or divorced

husband of Sarah M. Robich«£U

(Give maiden name of wife in

(or) WIFE of

10 SINGLE (write the word)
MARRIED
WIDOWED

or DIVORCEDwj^owe^_

full)

(Husband’s name in full)

1 1 IF STILLBORN, enter that fact here.

AGE y^3Yearsl-l- Months?*/^ Days

If under 24 hours

Hours Minutes

13 Usual

Occupation:..

(Kind of

Custodian

work done during mos

most of working life)

14 Industry

— Qr Business: U.Q.lOSt Qf f j C> ft Bftj Mi FI?

15 Social Security No. none

16 BIRTHPLACE (CitEaS t BOS tOH

(State or country) , r

ivia s s

17 NAME OF
FATHER

-Jamas Howard

18 BIRTHPLACE OF

FATHER (City) MaC.r.Q.QIll..

(State or country)

Irel and

19 MAIDEN NAME

OF mother Elizabeth Carl and

ADDRESS

Received and filed 19

JAN 2 3 wsn

(Registrar)

hrop

20 BIRTHPLACE OF

MOTHER (City) B.QS ton

(State or country) Ma s s .

informant ..^lchar.d ..P... Ho.awrd.. son

(Address) h? Beal Street Winthrop-

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

*(. ' -

_ -(Signature of Agent of Board of Hemth'or other) /■ /

L,.

(Official Designation) ^ (Date of Issue of Permi/) " /

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).

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 physician* 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 land 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

RM R-301A

4STRUCTI0NS

FOR

CAL CERTIFICATE

In giving
SE OF DEATH

o not enter
>re than one
Lise for each

»). (b) and (c)

i his does not mean
>de of dying, such
t failure, asthenia, .
means the disease,
iplications which
death.

orbid conditions, .
giving rise to the ~
ause (a) staling
sderlying cause

nditions conlrib- •
the death but not
to the disease or
>n causing death.

41 HEREBY CERTIFY, That I attended deceased from

...” , 19*^.^..., , 19.wTj??.

I last saw hsceysctr alive or., .«.. , 19.jf<?., death is said to|

have occurred on the date stated above, at i.O. A/.m.

< Suffolk

q (County)

° Winthrop

jjj (City or Town)

ft.

(Eommonmralttj of HJaBBadjuartta
OFFICE OF THE SECRETARY

DIVISION OF VITAL STATISTICS

STANDARD

CERTIFICATE OF DEATH

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

Registered No.

No Winthrop Nursing Home st. {«<„*?"' ffirUi 5TSSS. <£jn5SlSS:S'

Warren Wellington No^tes

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

77 Bowdoin Street

(If nonresident, give city or town and State)

Length of stay: In place of death years months lAdays. In place of residence Arrears months days.

2 FULL NAME

(a) Residence. No.

(Usual place of abode)

[ PHYSICIAN — IMPORTANT

I (Was deceased a

| U. S. War Veteran,

l if so specify WAR)

St.

MEDICAL CERTIFICATE OF DEATH

3 DATE OF
DEATH

UUr.

<7 (M«

(Month)

(Day)

(Year)

DISEASE OR CONDITION
DIRECTLY LEADING
TO DEATH (a)

cedInt o',) T° ‘ikm*. o&cyiJL 4

CAUSES *

Due To
(c)

INTERVAL BE-
TWEEN ONSET
AND DEATH

Major findings: A

Of operations

Date of operation [y^.. Was autopsy performed?

What test confirmed diagnosis?

3~c

5 Was disease or injury in any way related to occupation of deceased? " /•''VrO

M. D

(Address) WZuXxAMyL >3^^ Date^/tVCV- 4 ^ 19^0

6 Lincoln ’ Lincoln Me.

Place of Burial or Cremation (City or Town)

DATE OF BURIAL ^

7 NAME OF
FUNERAL DIRECT)

ADDRES:

L DIRECTOR-' «fW‘rlT w \JrfYj

,, MmXj.

Received and filed 19

JAN.2 5JS5Q

(Registrar)

PERSONAL AND STATISTICAL PARTICULARS

8 SEX

Male

9 COLOR OR RACE

White

10 SINGLE
MARRIED
WIDOWED
or DIVORCED

(write the word)

Wid/

10a If married, widowed, or divorced __

husband of ^ Mary A Norse

(Give maiden name of wife in full)

(or) WIFE of

(Husband's name in full)

11 IF STILLBORN, enter that fact here.

12 —. _

If under 24 hours

AGE ....(. -i-Years ....

. ..Months

Days

Hours Minutes

13 Usual

Occupation:

Barber

(Kind of work done during most of working life)

or Business: Ov/n shop

15 Social Security No.

None

16 BIRTHPLACE (City) .
(State or country)

Lincoln,, ...
Maine

17 NAME OF
FATHER

William E Noyes

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

Grey

Maine

19 MAIDEN NAME

of mother Margaret A Gerry

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

Patten

Maine

Informant Willi .Ml N Oye S

(Address) 36 North Ave . Winthrop , a

I HER.EBY CERTIFY that a satisfactory standard certificate of death was
filed with me BEFORE thei)>trial or transit 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 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 therelrom 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 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.

(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.

SPACE FOR ADDITIONAL INFORMATION

DATE OF ENTERING MILITARY SERVICE

DATE OF DISCHARGE

RANK. RATING

ORGANIZATION AND OUTFIT

SERVICE NUMBER

R-303 A

(Eammomnraltlj of iRaflaarliHflrttB

OFFICE OF THE SECRETARY

DIVISION OF VITAL STATISTICS

MEDICAL EXAMINER’S
CERTIFICATE OF DEATH

To bo filed for burial permit
with Board at Health
or it* Afent.

Registered No. .

J_L_

Lsf IrtytrOr^ShrUry

-ced woman, give also maiden name.)

(a) Residence. No.

(Usual place of

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

i PHYSICIAN — IMPORTANT

((Was deceased a

U. S. War Veteran. /./ j , ~7/
if so specify WAR)

(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.

MEDICAL CERTIFICATE OF DEATH

3 DATE OF
DEATH

5'|2‘5

>2q'o

Qs*\k..

(Month)

2J&.

(Day)

MAP....

CVear)

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

Q.. t~

~.Ca^.p

S Accident, suicide, or homicide (specify)

Date and hour of injury f. 19

Ux.

(City of town and State)

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

/ \ S'- h A . — l ^

place?

Where did
Injury occur?..

oocjjr in or about home, on

( S <C-r'C/7

Y" v (Specify typ^ of place)

!iggfe^.feiw«c. kte»f*u.<L A*

ps» CT5 JWSfc,

While at work? 'J^CtAA r..~k. ^ .^I^a^u^opsy performed?

6 Was disease or injury in ^ny way related to occupation of deceased? i..

If so, specify
(Signed)

(A dress) 12?.

$ 7 Dallas . Texas

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

DATE OF BURIAL ILl.b..r.H£.rX..£ 19 ...5.1

* FUNERAL DIRECTOR E.l.C.hS. rd C •i.X.by...

address

;BrOS"t on

Received and filed..

9 1950

.19 .

(Registrar)

PERSONAL AND STATISTICAL PARTICULARS

9 SEX

Male

10 COLOR OR RACE

WV.

7 hi t‘

11 SINGLE (write the word)
MARRIED

WIDOWED C/A/r / A~
or DIVORCED > "V G- t £

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.

AGE

y Years ^

Months ^...Days

If under 24 hours
Hours Minutes

Occupation: E Lecj7-*i c. rti /\t

(Kind of work done during most of working life)

IS Industry
or Business:

t/. s- syjrk' y

AS a

16 Social Security No..

17 BIRTHPLACE (City) . SP'4 J- S? 3

(State or country)

18 NAME OF
FATHER

C.3. L

19 BIRTHPLACE OF

FATHER (City)

C. D. L .

(State or country)

20 MAIDEN NAME

OF MOTHER 1/ / /s'/ /} A/ ^ A A/ /C

21 BIRTHPLACE OF

:„/l,

MOTHER (City)

(State or country)

is 22 Informant.. !-!.* S

h (Address) (J H C ' 5 ™ 3 Nrl VG ~ TlOSPl 7l

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

{JlUmfw r, SKfcnr r ^

.jQl.

' (Signature of Agent 6f Board of Health or other)

IH.DEf.Aa

(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.

N'o 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. as amended by Chap. 48, Acts of 1927 and Chap. 414, Acts of 1931.

No undertaker or other person shall bury a human body or the ashes thereof
which have been brought into the commonwealth until he has received a permit
so to do from the board of health or its agent appointed to issue such permits,
or if there is no such board, from the clerk of the town where the body is to be
huried 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„ as amended.

disabled by recognizable disease, or when any person is found dead — General

Laws, Chap. 38, Sec. 6., as amended by Chap. 632, Sec. 4, Acts of 1945.

The medical examiner certifies the cause and manner of death to the best

of his knowledge and belief.

RULES OF PRACTICE

The fulfillment of the purpose of these laws calls for the observance of the 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.

(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

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

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

SPACE FOR ADDITIONAL INFORMATION

DATE OF ENTERING MILITARY SERVICE

DATE OF DISCHARGE S4S A

RANK, RATING C_

ORGANIZATION AND OUTFIT <Z.:. A ZS X

SERVICE NUMBER . 2. J? 2 JL,2.. Z<£

*M R-301 A

STRUCTIONS
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
tealh.

rbid conditions,
living rise to the "
use (a) slating
derlying cause

ditions contrib- •
the death but not
o the disease or
» causing death.

Suffolk

(County)

Winthrop

(City or Town)

Qtyr (CommomDralttj of JRaaaartjUBrtta

OFFICE OF THE SECRETARY

DIVISION OF VITAL STATISTICS

STANDARD

CERTIFICATE OF DEATH

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

Registered No.

no Winthrop Community Hospital st.

2 FULL NAME

John Richard Elliott

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

(a) Residence. No. 89I Shirley Street

(Usual place of abode)

umber)

PHYSICIAN — IMPORTANT

(Was deceased a

U. S. War Veteran,

if so specify WAR)

Length of stay: In place of death years months

days. In place of residence

.. St.

(If nonresident, give city or town and State)
years months . days.

MEDICAL CERTIFICATE OF DEATH

, I H E R

Y CERTIFY, That I attended deceased from

JJJ wJTQ to 19

I last saw h alive on -^£^”19 vT~*-^death js said td

have occurred on the date stated above, at ffi-. Q.fia ./ 'rilTERVAL BE-
niccicr r»D r'ri\TTVT'rrr*\T 'TWEEN ONSET

DISEASE OR CONDITION
DIRECTLY LEADI
TO DEATIL (a)

ANTE Due To
CEDENT (b)
CAUSES

Due To

OTHER

SIGNIFICANT

CONDITIONS

AND OEATH

////2-A?u&&79 Years

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

(Signed) ^JLjC . feU. D

(Addres^Ayp gL ^J~f Date // j O /f~Zp9

6 . Woodlawn 7 Everett/

Place of Burial or Cremation (City or Town)

DATE OF BURIAL Jan . 31-

personal AND STATISTICAL PARTICULARS

8 SEX

Male

9 COLOR OR RACE

White

10 SINGLE (write the word)
MARRIED

WIDOWED , r . ,
or DIVORCED WldOWed

10a If married, widowed, or divorced , _ _

husband of Sarah L Bray

(Give maiden name of wife in full)

(or) WIFE of

(Husband's name in full)

11 IF STILLBORN, enter that fact here.

Months

Days

If under 24 hours

Hours Minutes

Occupation:.. Fish Dealer

(Kind of work done during most of working life)

14 Industry
or Business:

Retail Sterre

15 Social Security No. N one

16 BIRTHPLACE (City)
(State or country)

We Ilf leet
Mass

17 NAME OF

father John R Elliott

c n

18 BIRTHPLACE OF
FATHER (City)

Wellf leet

(State or country)

Mass

19 MAIDEN NAME

OF MOTHER

Jerusha Ryder

20 BIRTHPLACE OF

Wellf leet

MOTHER (City) ....

(State or country)

Mass

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 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 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.

(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.

SPACE FOR ADDITIONAL INFORMATION

DATE OF ENTERING MILITARY SERVICE

DATE OF DISCHARGE

RANK, RATING

ORGANIZATION AND OUTFIT

SERVICE NUMBER

ORM R-301 A

INSTRUCTIONS
FOR

|DICAL CERTIFICATE

In giving
(USE OF DEATH

r do not enter
I more than one
I cause for each
(a), (b) and (c)

This does not mean
I mode of dying, such
| 'art failure, asthenia, .

It means the disease,
complications which
| ed death.

Morbid conditions, ,
y, giving rise to the "
II? cause (a) stating
■ underlying cause

I Conditions conlrib- ■
If to the death but not
|?d to the disease or
mition causing death.

(CommnmtJTalrti of i®aBBarijUB?ttB
EDWARD J. CRONIN
Secretary of the Commonwealth

DIVISION OF VITAL STATISTICS

STANDARD

CERTIFICATE OF DEATH

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

Registered No.

2 FULL NAME

(If deceased is a married, widowe^for divorced woman, give also maiden name.)

(a) Residence. N

(Usual place of abode)

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^Ro specify WAR)

y or town and State)

9to

(If nonresident, give.

Length of stay: In place of death^ ^ years months days. In place of residence^’ 3 years months days.

MEDICAL CERTIFICATE OF DEATH

PERSONAL AND STATISTICAL PARTICULARS

3 DATE OF
DEATH ...

(Month)

A/.

(D/y)

o . .

8 SEX

4 I _H E R EmY CERTIFY, That I attended deceased from

., 19 , ^to OLLC .». 9- f ... 1 9&0

9 COLOgfOR RACE I 10 SJNGLE (write the word)
MARRIEDy i ‘

! WIDOW1

I or DIVOfi

I last si

lh,JLy- alive on death is said to||

have occurred on the date statecC4bove, at / : 3°‘Am

10a If married, widowed, or divorced
HUSBAND of

(Give

(or) WIFE of

in full)

(Husban^ s name in full)

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 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 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 persons as are supposed to have died by violence, or by the action of
chemical, thermal or electrical agents or following abortion, or from diseases
resulting from injury or infection relating to occupation, or suddenly when not
disabled by recognizable disease, or when any person is found dead. ... — General
Laws, Chap. 38, Sec. 6., as amended by Chap. 632, Sec. 4. Acts of 1945.

No undertaker or other persons shall bury a human body or the ashes thereot
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.

(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 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

DRM R-301A

I NSTIUCTIONS
FOR

ICAL CERTIFICATE

In giving
>SE OF DEATH

lo not enter
lore than one
I luse for each
l a), (b) and (c)

yhis does not mean
|i ode of dying, such
I rl failure, asthenia, ,

If means the disease,
mplications which
If death.

Ytorbid conditions,'
I , giving rise to the "
I cause (a) slating
underlying cause

Kondilions contrib- ■
I'o the death but not
K to the disease or
Ivor causing death.

2 FULL NAME

(Himtmommaltfy of j&aooarfyusPttB

EDWARD J. CRONIN, SECRETARY

DIVISION OF VITAL STATISTICS

STANDARD

CERTIFICATE OF DEATH

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

Registered No. .

(a) Residence. No

(Usual place of abode)

woman, give also maiden name.)

I (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)

(If nonresident, give city or town and State)

Length of stay: In place of death years months *?... days. In place of residence rv'

years months days.

MEDICAL CERTIFICATE OF DEATH

3 DATE OF

DEATH

(Month)

(Day)

(Year)

41 HEREBY CERTIFY. That I attended deceased fro

KMWf/UCj To I, £0 , t v?0 v&°.

I last saw h ... alive on. 'JnNUftW 3 o l(&b , death is said to|

have occurred on the date stated above, at

I..m.

INTERVAL BE-

DISEASE OR CONDITION T»m"oe!tHT

DIRECTLY LEADIN^^g^

TO DEATH (a)

cedInt go f\RT&KjOSO£.RO$/S

CAUSES

Due To

(c)

OTHER

SIGNIFICANT

CONDITIONS

5VKS

Major findings:

Of operations

Date of operation Was autopsy performed?

What test confirmed diagnosis? Ol/Al/cfih ObS£RVfnr0*

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

If so, specify.

(Signed) D

(Address) 0

7 NAME OF
FUNERAL DIRECTOR

ADDRESS

Received and filed 19

..F.EB....2 fggQ-

(Registrar)

PERSONAL AND STATISTICAL PARTICULARS

8 SEX

9 COLOR OR RACE

'^La/jL jnlu£c

10 SINGLE
MARRI
WIDOWED
or DIVORC

>. (write the word)

“ *%UuUi (ft. ft

10a If married, widowed, or divor?

HUSBAND of

(Give maiden name of wife in full)

(or) WIFE of

(Husband's name in full)

1 1 IF STILLBORN, enter that fact here.

AGE

'lo

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. ~ 7 7 Y

(£k

16 BIRTHPLACE (City)
(State or country)

17 NAME OF
FATHER

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

19 MAIDEN NAME
OF MOTHER

(&CUI&ZIAMS

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

Informant

(Address;

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

nt of Boaraof Health or other)

(Date of Issue of

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 desk, 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 persons as are supposed to have died by violence, or by the action of
chemical, thermal or electrical agents or following abortion, or from diseases
resulting from injury or infection relating to occupation, or suddenly when not
disabled by recognizable disease, or when any person is found dead. — General
Laws, Chap. 38, Sec. 6., as amended by Chap. 632, Sec. 4, Acts of 1945.

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
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.

(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.

SPACE FOR ADDITIONAL INFORMATION

DATE OF ENTERING MILITARY SERVICE

DATE OF DISCHARGE

RANK, RATING

ORGANIZATION AND OUTFIT

SERVICE NUMBER

ORM R-302

C O

«3’S{

u (S

*C'S3

s v-

J=-0

C (0

« s

•E-S

•a «

s.a->

a c

V- .
*

f V

2c8

Essex

(County)

Danvers

(City or Town)

®ljp CComnionmpaltl) of HassarlfUBrttB

OFFICE OF THE SECRETARY

DIVISION OF VITAL STATISTICS

COPY OF

CERTIFICATE OF DEATH

Danvers

(City or town making return)

Registered No sD...

.Danvers State Hospital^ Hathorne, k^ts^vde?th ,?«urred in a hospital or institution.

tve its NAME instead of street and number)

2 FULL

name Verna. ...Burns .. f (Was deceased a

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

l if so specify WAR)

(a) Residence. No

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

Length of stay: In place of death years months 13 ..days. In place of residence years months days.

MEDICAL CERTIFICATE OF DEATH

3 DATE OF
DEATH ...

January 1 19.5.Q...

(Month) (Day) (Year)

41 HEREBY CERTIFY, That I attended deceased from

Dec..* 1.9 19 49, to Jan • 1 i9..J?.P.

I last saw h ... er alive on Jan... 1... 19 5. death is said to|

have occurred on the date stated above, at 1.2 •45. pm.

DISEASE OR CONDITION

DIRECTLY LEADING
TO DEATH (a)

Bronchopneumonia

ANTE Due To

CEDENT (b)

CAUSES

Due To
(c)

OTHER

SIGNIFICANT

CONDITIONS

INTERVAL BE
TWEEN ONSET

AND DEATH

5 daty'giGE " r. . *Y ears Months Days

Major findings:
Of operations..

Date of operation Was^autopsy performed?..

What test confirmed diagnosis?

"No

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

If so, specify

(signed) F ra n c i s X » Sull i v an , m. d

(Address) . hflthprne , ^■iasE .Date I / 4 19

Place of Burial or Cremation
DATE OF BURIAL

(City or Town)

January ...4 19.5.C

David Fudge & Son
address Somerville.. Mass *

7 NAME OF
FUNERAL DIRECTOR

Received and filed

FEB 11 1350

(Registrar of City or Town where deceased resided)

.19 .

PERSONAL AND STATISTICAL PARTICULARS

8 SEX I 9 COLOR OR RACE

Female White

10 SINGLE
MARRIED
WIDOWED
or DIVORCED

(write the word)

Married

10a If married, widowed, or divorced

HUSBAND of

(Give maiden name of wife in full)

(or) wife of Fr ed $Js£ng>

s name in full)

11 IF STILLBORN, enter that fact here.

If under 24 hours
Hours Minutes

13 Usual

Occupation :

Housewife

(Kind of work done during most of working life)

14 Industry
or Business:

15 Social Security No. . None

16 BIRTHPLACE (City) LocklDOF trcr e *- '■■■

(State or country) n^QVa ScOtia

17 name of Cannot b e learned

Stevens )

FATHER

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

Nova Scotia

19 MAIDEN NAME

of mother Emily Wilson

20 BIRTHPLACE OF

MOTHER (City) ,
(State or country)

Nova Scotia

informantMary ~E.. Sheehan...

(AddressJ Hathorne- .—Mass*

A TRUE COPY
ATTEST:

/ s

(Registrar of City or Town where death occurred)

DATE FILED

Jan. £ i9..J5£.._

som-(e)-io-48-246S8 Waived by Medical

2Tt|r (Hommonuiraltl) of HaHaarliuaptlB

OFFICE OF THE SECRETARY

DIVISION OF VITAL STATISTICS

COPY OF

CERTIFICATE OF DEATH

BOSTON

(City or town making return)

CERTIFICATE OF DEATH Registered No .3.1.3 jL6l

(City or Town)

fTJV, ^ 1 n. „ „ • i. „ i I (If death occurred in a hospital or institution.

No. ..^n.S.....V..O.l.*.y-.T6n.S......xj10.S.pjL.t<.Q.i. St. \ give its NAME instead of street and number)

*-l

Lfh

•H

2 full name. Boyer., 1 eiris Charles I (Was deceased a

(If deceased is a married, widowed or divorced woman, give also maiden name.) | U. S. War Veteran, ,T

( if so specify WAR) I»Q

(a) Residence. No. 1.1 lave “ay., viint.hr.Q.p,.....Mas.s..* ... st.

(Usual place of abode)

Length of stay: In place of death years

(If nonresident, give city or town and State)

months days. Injplace of residence years months days.

f months days. In Diace ot residence

h hours and 20 minute

MEDICAL CERTIFICATE OF DEATH

PERSONAL AND STATISTICAL PARTICULARS

3 DATE OR- - 0. ,

death J.an . 12 th.....

(Month)

ay)

(Year)

41 HEREBY CERTIFY, That I attended deceased from

l-.i2-.3Cl 19 to 1-1.2 -3Q 19

I last saw h.. ...Ira alive on. 1-12-50 .... 19 death is said tej

have occurred on the date stated above, at 1 I 20 p m.

8 SEX

V7ale

9 COLOR OR RACE

•white

10 SINGLE (write the word)
MARRIED
WIDOWED

or DIVORCED S j n f~ 1 e

DISEASE OR CONDITION
DIRECTLY LEADING

to death (a) L&r.yn.g.o.t.r..a.c.he.a
bronchitis

cedInt °b)e To .Ini. luenzal , acute

CAUSES

Due To
(c)

OTHER

SIGNIFICANT

CONDITIONS

None

INTERVAL BE-
TWEEN ONSET
MO DEATH

10a If married, widowed, or divorced

HUSBAND of

(Give maiden name of wife in full)

(or) WIFE of

(Husband's name in full)

1 1 IF STILLBORN, enter that fact here.

12 .
AGE 2 Years Months 1/ |P,

ays

If under 24 hours
Hours Minutes

13 Usual

Occupation:.

none

(Kind of work done during most of working life)

Major findings: ,

of operations I r.a.che.ot~omy

Date of operatiorl/^12— 5'C Was autopsy performed?.. ...y.Q.g

What test confirmed diagnosis?

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

If so, specify

(signed) U.o.s..e ph Maher. M. D

(Address) IinngV-T>od Ayg Date 19

Mt..» I.eb.ann.on.-S.o.as ox Abr.aham.-W..]

Place of Burial or Cremation (City or Town)

DATE OF BURIAL JaHUary .15. -» 19 SO 19

7 funeral DiRECTORB.e.n.j.amin. .Birnbach-

address IQ Washington St... Porch-.

Received and filed Jan... 16.., I.9.5.Q 19..

HEB 171950-

(Registrar of City or Town where deceased resided)

14 Industry -.y

ot Business: tJOT) G ■

15 Social Security No. none

16 BIRTHPLACE (City).. • • ill t h-PO O •• MaS.S ..
(State or country)

17 NAME OF
FATHER

Max Boyer

18 BIRTHPLACE OF

FATHER (City) BoStOh, MaSS .

(State or country)

19 MAIDEN NAME
OF MOTHER

Betty OoTdb erg

20 BIRTHPLACE OF

mother (City) B.o.s.t.o.n.., Ma.s s

(State or country)

Informant M.aX BOje r .

f Address;

A TRUE CO
ATTEST: ..(

1 L W ^ "ay Avfii V/ i n --hdh

(Registrar of City or Town where death occurred)

DATE FILED 19..

n E C £ i V i

FEB 17 1950 AH

50m-(e)-l(V 48-24658

(County)

° Danvers

U (City or Town)

OHj? Qlommtmmralxi) or fuaBaacljUBrnB

OFFICE OF THE SECRETARY

DIVISION OF VITAL STATISTICS

COPY OF

CERTIFICATE OF DEATH

Danvers

(City or town making return)

Registered No 1 Z-

(If death occurred in a hospital or institution.

T-. o, , .1 . . it , i i.j I (If death occurred in a hospital or institution.

No. . iianvers o.tat e ..no.sprtal , iiathorne.,.. NAME instead of street and number)

2 full name Julia Einidquist

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

(a) Residence. . No. ,... :5.7rA.. Beac on .. St .^...Win thro. p., Mass.*

Length of stay: In place of death years months A. days. In place of residence years months days.

..♦ I (Was deceased a

U. S. War Veteran,

„ if so specify WAR) .

MEDICAL CERTIFICATE OF DEATH

PERSONAL AND STATISTICAL PARTICULARS

death°f anuary 13 19 5 Q

(Month) (Day) (Year)

41 HEREBY CERTIFY, That I attended deceased from

dan, 5 19.5Q, to dan.,. 13 I9 50

I last saw h B.ralive on... dart, 1-3 19 5- Q death is said tc|

have occurred on the date stated above, at 7:05 p

8 SEX 9 COLOR OR RACE

Female White

10 SINGLE
MARRIED
WIDOWED

(write the word)

or DIVORCED

Single

DISEASE OR CONDITION
DIRECTLY LEADING , ,

TO DEATH (a) 1.0. S C 1 £TQ. t. i C

heart disease — 12 yrs

ANTE Due To

CEDENT (b)

CAUSES

Due To
(c)

OTHER

SIGNIFICANT

CONDITIONS

INTERVAL BE
TWEEN ONSET
AND OEATH

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

.3.3.

Years ff. Months . 21

ays

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. None--

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

Stockholm

-Sweden

Major findings:

Of operations

Date of operation Was autopsy performed?.... AN. Q..

What test confirmed diagnosis? C.linlq.a.1

5 Was disease or injury in any way related to occupation of deceased? N Q

If so, specify

(s^ed) Francis —k, Sullivan - /---. m. d

(Address) hathorne t iiass Pate 1/20

6 Winthrop. Cemetery Winthrop

Place of Bunal or*Cremation (City or Town) r I

January 16 19 5.C

DATE OF BURIAL

7 NAME OF
FUNERAL DIRECTOR

ADDRESS

Reynolds Fun e ral H ome
Winthrop.., Mass •

Received and filed ,...~_...g......')....:,

(Registrar of City or Town where deceased resided)

.19 .

17 fatherf Forentine Lindquist

C/2

18 BIRTHPLACE OF
FATHER (City)

(State or country)

Sweden

19 MAIDEN NAME
OF MOTHER

Sophie Lundgren

20 BIRTHPLACE OF

MOTHER (City)

(State or country)

Sweden

informantiviary...E, Sheehan..

t Address j Fathome , iliaas-

A TRUE COPY
ATTEST:

(Registrar of City or Town where death occurred)

DATE FILED

occurred)

danuary-'2'5 19 5U

50m-(e)- 10-48-24658

d SUFFOLK!

BOSTON I

(City or Town)

(Umnnumuiraltt) of fUnBBarljuBrttB

OFFICE OF THE SECRETARY

DIVISION OF VITAL STATISTICS

COPY OF

CERTIFICATE OF DEATH

BOSTON

(City or town making return)

328 13,.

Registered No. .

ta-i-l-L. Tnnnol n_a_4 f.l I (If death occurred in a hospital or institution.

No. ..:Q.V.M.4l...l.S?..(s.X.4r .h.Q.Sp.l..T'.S-.4r. St. ( give its NAME instead of street and number)

2 FULL NAME ±.®: t'.®1’ I (Was deceased a

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

l if so specify WAR)

fa) Residence. No UZ ShOfC DrlVC * Viin i. hf OO

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

c .40

Length of stay: In place of death years months V. ..days. In place of residence years months days.

MEDICAL CERTIFICATE OF DEATH

PERSONAL AND STATISTICAL PARTICULARS

3 BeI?hf Jan... 13... .1.95.0..

(Month) (Day)

(Year)

8 SEX

male

41 HEREBY CERTIFY, That I attended deceased

Jan. 9... ip 50, to J.an.....l.3 w

I last saw h .l.m... alive on Jan 1.3, 19 5.Q death is said

have occurred on the date stated above, at ...8:1.5 a

from

9 COLOR OR RACE

white

10 SINGLE (write the word)
MARRIED wnnni A 3
WIDOWED Iflo-i. 1 iCU

or DIVORCED

5.(

DISEASE OR CONDITION
DIRECTLY LEADING

to death (a) 2A.c.u.t.e....my.o..c.ar.d.ial..
infarction

ANTE Due To

CEDENT (b)

CAUSES

Due To
(c)

Siiwifi. ANrh>?tHred . gall bladder]

conditions with abscess formati

INTERVAL BE
TWEEN ONSET
AND DEATH

sev

das

10a If married, widowed, or divorced

husband of 3.e 11 a Lappman

(Give maiden name of wife in full)

(or) WIFE of

(Husband's name in full)

11 IF STILLBORN, enter that fact here.

AGE

Years Months Days

If under 24 hours
Hours Minutes

13 Usual

Occupation:

Real estate dealer

(Kind of work done during most of working life)

14 Industry
or Business:

Real es tab e

15 Social Security No.

none

16 BIRTHPLACE (City) Qrvl Qrtri

(State or country) -T U -L HILLL

Major findings:
Of operations.

Date of operation

What test confirmed diagnosis?

, .....Was autopsy perforated? I..®.®

.^Autopsy confined gall

bladder' ''"pathology'

5 Was disease or injury in any way related to occupation of deceased? " n.Q

If so. specify...

(signed) E ..A...H.al.kxnao.n v m.

(Address) BIH Date 1/1.5 19

6 win t hr op.. T.lf e.r.e.th Israel Everett

Place of Burial or Cremation (City or Town)

Jan 15 1950

17 NAME OF
FATHER

Samuel Slater

18 BIRTHPLACE OF

FATHER (City)

(State or country)

Poland

19 MAIDEN NAME
OF MOTHER

Rebecca Rachwalska

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

Poland

DATE OF BURIAL “..f?1 1 YY. 19

H J Tor J
address u.h.e.l.s.e.a

7 NAME OF
FUNERAL DIRECTOR

2 1 informant.Ge.rt rude Slater

(Address)

A TRUE COP)

ATTEST:

Received and filed..

.19.

(Registrar of City or Town where deceased resided)

(Registrar of City or Town where death occurred)

DATE FILED 15 1.9 5.0 jp

B EC El Vi. :

(FEB1VI950 m

ORM R-302

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Essex

(County)

Danvers

(City or Town)

2ty* (Umnmmunraltl) of fBasaarljUBPttB
OFFICE OF THE SECRETARY
DIVISION OF VITAL STATISTICS

COPY OF

CERTIFICATE OF DEATH

Danvers

(City or town making return)

Registered No.

±a

No.

Danvers State Hospita^, Hathorne , i^^^eath-°-c-u--e<^ in a- h?spita’ or institution.

its NAME instead of street and number)

2 full name Arthur John Campbell • { (Was deceased a

(If deceased is a married, widowed or divorced woman, give also maiden name.) ] U. S. War Veteran,

129 River Rd., Winthrop, Mass^ if so specify war)

(a) Residence. No.

(Usual place of abode)

Length of stay: In place of death 7.... years 1.1... months'

(If nonresident, give city or town and State)
..days. In place of residence years months days.

MEDICAL CERTIFICATE OF DEATH

3 BeIthof. January 23 1.9.5 Q.

(Month) (Day) (Year)

41 HEREBY CERTIFY, That I attended deceased from

Sept... 11 19 /fD, to Jan.. 2.3 19.5.Q

I last saw h illlalive on. Jan * 23 ., 19 50 death is said td

have occurred on the date stated above, at 6:15 p

DISEASE OR CONDITION
DIRECTLY LEADING D

to death (a) Drone, hopneumon

ANTE Due To

CEDENT (b)

CAUSES

Due To
(c)

OTHER

SIGNIFICANT

CONDITIONS

INTERVAL BE-
TWEEN ONSET
AND DEATH

Major findings:
Of operations..

Date of operation Was autopsy performed?

What test confirmed diagnosis? Clinical

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

If so, specify r s

(signed) Julius .W.. fryer m. d

(Address) Hathorne , Mass. Date 1^/27 1^50

6 Walnut Drove Cemetery,.. Danvers

Place ofBunal or Cremation ■'(Ulty or Town)

DATE OF BURIAL January 27 19 59

7 NAME OF
FUNERAL DIRECTOR .

ADDRESS

William H. Crosby
Danvers, Mass.

Received and filed

r LD 1 -C looij

(Registrar of City or Town where deceased resided)

. 19-

PERSONAL AND STATISTICAL PARTICULARS

8 SEX

Male.

9 COLOR OR RACE | 10 SINGLE (write the word)

MARRIED

White

WIDOWED ,

or pivoRCEDUivorced

10a If married, widowed, or divorced

HUSBAND of Q/r

(Give m&i

SCO

(or) WIFE of

(Husband's name in full)

11 IF STILLBORN, enter that fact here.

63 5 1

AGE Years Months Days

If under 24 hours

Hours Minutes

13 Occupation : Carpenter ,

(Kind of work done during most of working life)

14 Industry
or Business:

15 Social Security No.

16 BIRTHPLACE (City).. "Boston.

(State or country)

Mass,

17 NAME OF
FATHER

John H, Campbell

18 BIRTHPLACE OF

FATHER (City)

(State or country)

Washington

B.e.

19 MAIDEN NAME
OF MOTHER

Rachel Woods

20 BIRTHPLACE OF

MOTHER (City)

(State or country)

England

E» Sheehan

(Address, Hathorne. ^ss.

A TRUE COPY
ATTEST:

DATE FILED

(Registrar of City or Town>wheee -death occurred)

E.e.b.*....l 19....5.Q...

“t.

, .

. ’

‘

. .

•

*M R-303 A

■*s

Ssj

tf'S.

• -< e-

0(/)-S u

h3° "

5"° s E

ill2

•§.

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Q.Sff |

^Ul ® 0 3

=111 ?
|i« 2

c .2

l3]4

I S 22

ptt

3 e a«

3|c .

CL. ^“.C
..el*!

* /VulKwjl

No.

(City or Town!

®4* (Cammonumiltlj of IRaBBarljaHrttfl

OFFICE OF THE SECRETARY

DIVISION OF VITAL STATISTICS

MEDICAL EXAMINER’S
CERTIFICATE OF DEATH

To bo filed for burial permit
with Board of Haalth
or It* Afant.

Registered No.

..2.0...

(a) Residence. No.

(Usual place of abode)

I .....

an, give a

(/t/^

abode)

^th occurred in a hospital or institution,
its NAME instead of street ar.d number)

1 „ , ( i PHYSICIAN — IMPORTANT

2 FULL NAME 1/\ LuVIJL.GIa^ .....O. W - I (Was deceased a

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

l if so specify WAR) .

St.

(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.

MEDICAL CERTIFICATE OF DEATH

3 DATE OF
DEATH ....

.shJL?....—..

(Month)

(Day)

/ £v£> c>

(Year)

♦ I HEREBY CERTIFY that I have investigated the deatl
of the person above-named and that the CAUSE AND MANNER thereo(|
are as hollows: (If an injury was involved, state fa tty>)

...Q^AA^AiX... C— LaJULj.

5 Accident, suicide, or homicide (specify)

Date and hour of injury 19..

Where d/d

Injury occur?

' (City or town and State)

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

place? .

Manner i
Injury

(Specify type of place) *

Nature of Cfe

Injury

While at work? Was autopsy performed? .Itdi?..

6 Was disease or injury in any way related to occupation of deceased? .
(A. ^ress) .A.

Place JfBurial. or

DATE OP BURIAL....^*
8 NAME OF
FUNERAL DI

ADDRESS.,
Received and filed..

ieeszjm:

.19..

(Registrar)

PERSONAL AND STATISTICAL PARTICULARS

10 COLOR OR RACE| 11 SJNGLE (write the word)
“ MARRIED

ILSEX

11a If married, wido
HUSBAND of

WIDOWED
or DIVORCE

(or) WIFE of

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

RN, enter that fact here.

« Usual
^'Occupation:

ft*

15 Industry - ,
or Business

16 Social Security No.

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

18 NAME OF
FATHER

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

20 MAIDEN NAME
OF MOTHER

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

If under 24 hours

Hours Minutes

(Kind of work done during most of working life)

I HEREBY CER
filed with me BEFO

tEFORE the tjJjirial or transit permit was issued:

riwutw / 3 37 2—

lature of .

Agent of Board of

fh or other)

(Official Resignation) ^ (Bate 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
that the deceased served in the army, navy or marine corps of
in any war in which it has been engaged, such recital shall appea
The board of health, or its agent, upon receipt of such statemi
shall fprthwith countersign it and transmit it to the clerk of the
tion. The person to whom the permit is so given and the pi
the cause of death shall thereafter furnish for registration an
information which can be obtained as to the deceased, or as
cause of the death, which the clerk or registrar may require.
45, G. L. as amended by Chap. 48, Acts of 1927 and Chap.

No undertaker or other person shall bury a human body or
which have been brought into the commonwealth until he has
so to do from the board of health or its agent appointed to ii
or if there is no such board, from the clerk of the town where
buried or the funeral is to be held, or from a person appoint**
of the cemetery or burial ground in which the interment is ma
Sec. 46, G. L., as amended.

Medical examiners shall make examination upon the view o
of persons as are supposed to have died by violence, or
chemical, thermal or electrical agents or following abortion,
resulting from injury or infection relating to occupation, or s
disabled by recognizable disease, or when any person is found d<
Laws, Chap. 38, Sec. 6.. as amended by Chap. 632, Sec. 4, Ac

The medical examiner certifies the cause and manner of

of his knowledge and belief.

RULES OF PRACTICE

The fulfillment of the purpose of these laws calls for the observi
ing rules of practice;

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

(2) Board of Health physicians will certify to such deat
persons who, though disabled by recognized disease unrelatec
injury, have died without recent medical attendance or whose p
from home when the certificate of death is needed.

(3) Medical Examiners will investigate and certify to all (i
due to injury. These include not only deaths caused directly
traumatism (including resulting septicemia) , and by the ac'
(drugs or poisons) thermal, or electrical agents, and deaths follow
also deaths from disease resulting from injury or infection relat
the sudden deaths of persons not disabled by recognized dise
persons found dead.

STATEMENT OF CAUSE OF DEATH

Medical Examiners in certifying to a death will state the ci
thereof, and will specify: (1) Under cause the nature of an i
consequences; and (2) under manner the mode of its producti
the circumstances when these are known. For example ; ‘ ‘ Comp
the femur with ensuing septicemia (gas bacillus) caused by
accident.” "Pistol shot wound of the chest with associated t
icidal.” "Asphyxiation by suspension, suicidal.” "Syncope
influence of ether administered as a surgical anaesthetic.” ‘
skull writh associated internal injury sustained under circumstai

If disease or injury was related to occupation, specify,
shows the death to have been due to disease, specify: (l)Undei
or presumable nature; and (2) under manner, indicate the circu
to medico- legal inquiry. For example: "Hemorrhage spontam
(basal ganglia) (found dead in bed).” "Heart disease, presi
sclerosis. (Sudden death.)”

SPACE FOR ADDITIONAL INFORMATION

DATE OF ENTERING MILITARY SERVICE

DATE OF DISCHARGE

RANK, RATING

ORGANIZATION AND OUTFIT

SERVICE NUMBER

fepLone dfylue hills 8-5700

Qlighl cJeleph one '^P)lu chills i

^3- o) chlosslerg and ofons

d'uneral (dLhreclors

& ha Pel: 12^2 cBlue Qhfill hh/lvenu,

Wi allapan 2 6, Q 7U.

3-1-50

Town Clerk
Town Hall
flinthrop Mass.

Dear Sir:

Cn #eb.3rd a death certificate
was recorded for the late Ha than Strauss
of 44 Underhill St W'inthrop Mass, in the
filling out of said paper an error was made
by our office in his age, the correct age
should be 65 years and we would be very
appreciative if you could correct the same.

-5701

Copies of returns of deaths which occurred in your city or town in case the deceased resided in another city or town at the time
of death should be transmitted on Form R-302 to the clerk of the city or town in which the deceased resided as soon as possible
after the close of the month in which the death occurred. (See Chap. 46, Sec. 12, G. L.)

R-302

SUFFOLK

BOSTON

No.

(City or Town)

Jewish Mem Hosp

(Unmmmtmraltb of fHaBBartjUBPtta

OFFICE OF THE SECRETARY

DIVISION OF VITAL STATISTICS

COPY OF

CERTIFICATE OF DEATH

(City or town making return)

Registered No. . 1103.2.1..

St.

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

2 FULL NAME Frieda Levine j (Was deceased a

(If deceased is a married, widowed or divorced woman, give also maiden name.) | U. S. War Veteran, HOI10

l if so specify WAR)

(a) Residence. No. 3 0 Cutler St Wi.Ot.hrQ.P

(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 years months days.

MEDICAL CERTIFICATE OF DEATH

PERSONAL AND STATISTICAL PARTICULARS

3 DATE OF
DEATH ...

Feb 6 1950

(Month) (Day) (Year)

8 SEX

female

41 HEREBY CERTIFY, That I attended deceased from

Jan 31 19 50, to Feb 6. 19 .<

I last saw h er ..alive on. .. Feb 6 i9 5Q death is said

have occurred on the date stated above, at 12: 10P

9 COLOR OR RACE

white

10 SINGLE (write the word)
MARRIED . ,

widowed married

or DIVORCED

DISEASE OR CONDITION
DIRECTLY LEADING

to death (a)Uremia

3das

cedInt ^)eToChr nephritis
causes Diabetes mellitus

D(c)e TtH.y.pert ens ion

siGxiFicANTHypertens ive & art er ib
conditions sclerotic heart dls 2yrs

10a If married, widowed, or divorced

HUSBAND of

(Give maiden name of wife in full)

Anchel Levine

INTERVAL BE-
TWEEN ONSET
AND OEATH

(or) WIFE of

(Husband's name in full)

11 IF STILLBORN, enter that fact here.

AGE

Years Months. Days

If under 24 hours
Hours Minutes

13 Usual

Occupation:..

-iyrs

Housewife

(Kind of work done during most of working life)

5yrs

14 Industry
or Business:

At home

15 Social Security No.

none

16 BIRTHPLACE (City)..

(State or country) It US S la

Major findings:

Of operations

Date of operation Was autopsy performed?. .. yes

What test confirmed diagnosis?.... clin & lab

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

If so, specify _ —

(Signed) C D Bonner M. d.

(Address) JMH Date 2 /6 19 50

6 Int Workers Order Everett

Place of Burial or Cremation (City or Town)

Feb 7 1950

17 NAME OF
FATHER

Nathan Lieb

18 BIRTHPLACE OF

FATHER (City)

(State or country) R USS ia

19 MAIDEN NAME
OF MOTHER

Mary Klayman

20 BIRTHPLACE OF

MOTHER (City)

(State or country) Rus sia

DATE OF BURIAL

7 NAME OF
FUNERAL DIRECTOR.

ADDRESS

L Schlossberg
Mattapen

Informant

(Addressj

Mark Levine

A TRUE
ATTEST:

(Registrar of City or Town where death occurred)

Received and filed <...,«

.19

(Registrar of City or Town where deceased resided)

DATE FILED F.G.b......9.... 19.5.0. 19..

>RM R-301A

NSTRUCTIONS
FOR

iCAL CERTIFICATE

In giving
SE OF DEATH

lo not enter
ore than one
use for each

a), (b) and (c)

'his does not mean
ode of dying, such
rt failure, asthenia, .

means the disease,
mplicalions which
( death.

forbid conditions, .

giving rise to the
cause (a) slating
underlying cause

dilions conlrib- ■
the death but not
| to the disease or
on causing death.

q (County)

o \A///yr//fiof

(City or Town)

(fiommontOFaltlj of fflaaBariiUBPtta

EDWARD J. CRONIN

Secretary of the Commonwealth

DIVISION OF VITAL STATISTICS

STANDARD

CERTIFICATE OF DEATH

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

Registered No.

No.

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

— IMPORTANT

2 FULL NAME

smei-Ey

frfA/VCESCA /r/irro c ^ Z (y Az-fv / as deceased

(If deceased is a married, widowed or divorced woman, give also maider/name.) 1 U. S. War Vete

I if so specify W,

& y# s///yjL e y

Veteran,
AR)

(a) Residence. No

(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 years months days.

MEDICAL CERTIFICATE OF DEATH

3 DATE OF
DEATH

JEsjbu 7~/?<ro

(Month) (Day) (Year)

M I HEREBY CERTIFY, That I attended deceased from

19.J.!?’ 19.J.y.

h..-?^. ...alive on..^b**^£...7. 19-/?.,

I last saw

have occurred on the date stated above, at

, death is said to

DISEASE OR CONDITION
DIRECTLY LEADING /
TO DEATH (a) A

3 /i.

tJZ V&Jm CuJjU ^l/lc

CEDENT 0?)

/hZAAyf' cU’/J&ZAsL.

CAUSES

Due To
(c)

OTHER

SIGNIFICANT

CONDITIONS

INTERVAL BE
TWEEN ONSET
AND DEATH

H a.;e 8%

Major findings:

Of operations

Date of operation ,.Was autopsy performed?

What test confirmed diagnosis? rv-.

—

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

(Address) . _ . Date /..ZcyTyf- 19

6 7

DATE OF BURIAL

7 NAME OF
FUNERAL DIRECTOR

ADDRESS

J/fitfOLP A, /to or

Received and filed 19..

FEB 9 1950

(Registrar)

PERSONAL AND STATISTICAL PARTICULARS

8 SEX

0 COI OR OR RATF I 10 SINGLE (write the word)
9 COLUK OK KALE 1 MARRIED

•- ivirtis.rc.inL/

WM/T£\

10a If married, widowed, or divorced
HUSBAND of

(Give maiden name of wife in full)

(or) WIFE of

1 1 idi ic 1 1 name ui mic in

11 IF STILLBORN, enter that fact here.

ears Months Days

If under 24 hours

Hours Minutes

13 Occupation: ftV'YUX

(Kind of work done during most of working life)

14 Industry
or Business:

15 Social Security No /WAV?

16 BIRTHPLACE (City) .
(State or country)

17 NAME OF
FATHER

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

ZZ/c/fA/~/is 6-£/t/r/£-/~

19 MAIDEN NAME
OF MOTHER

Y77KY

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

Li/C/ft /1/1/io C'/V/i

(Address) A*-* wsfiL/i Y "sir-

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

(Signature of) Agent of Board of Healtnor qther)

KrAZ/- ''

Official Designation) J / (Date of Issue 6f Perm:

nit)

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 cnapter 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 olace 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 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 persons as arc supposed to have died by violence, or by the action of
chemical, thermal or electrical agents or following abortion, or from diseases
resulting from injury or infection relating to occupation, or suddenly when not
disabled by recognizable disease, or when any person is found dead. — General
Laws, Chap. 38. Sec. 6., as amended bv Chap. 632, Sec. 4. Acts of 1945.

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.

(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 s

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