The volume, 1951

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f ■

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

Stationers

105 State St., Bolton
To duplicate this book order

No.

AC..:

\ (County)

fflommonfaraltl] of JHassachusettg
OFFICE OF THE SECRETARY

DIVISION OF VITAL STATISTICS

MEDICAL EXAMINER S
CERTIFICATE/OF DEATH

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

xi iricrti t/ur L-J c

Z h(. st.

-3E1-

Registered No.

2 FULL NAME.

(If deceased is a married, widowed or divorced woman, giyy-alsr^ maiden , name.)

(a) Resldenoe. No.

(Usual place of abode)

St.

( f If death occurred in a hospital or Institution,

I give its NAME instead of street and number)

('PHYSICIAN— IMPORTANT
J (Was deoeased a

I U. S. War Veteran, „ _

^ If so speolfy WAR) SS.*.

Length of stay: In hospital or Institution

(Before death) (Specify whether)

years

months

days.

(If nonresident, give city or town and State)

In this oommunlty . yrs. mos. days.

PERSONAL AND STATISTICAL PARTICULARS

MEDICAL CERTIFICATE OF DEATH

3 SEX

male

4 COLOR OR RACE

white

5 SINGLE (write the word)
MARRIED
WIDOWED

or DivoRCEQnarried

IS DATE OF
DEATH

(Month) )

J LSJSU

(Day) 1 (Year)

5a If married, widowed, or dlvoroed n _ ^ + _

HUSBAND of ye.OSL.AQ£! .0.1ft V.lt.Z..

(Give maiden name of wife in full)

(or) WIFE of

(Husband’s name in full)

6 Age of husband or wife If alive years

7 IF STILLBORN, enter that fact here.

AGE ..7.£. Years Months Days

If less than 1 day
Hours Minutes

19 I HEREBY CERTIFY that I have Investigated the death
of the person above-named and that the CAUSE AND MANNER thereof
Are ml follows: (M an. injury was involved,, State (oily.) /

» -

^ OulO_^6i,

Usual

9 Occupation : ^r.^.£.£ C.u.t..t.e.r (..r..©.t..;L.r..e.d.)

Industry

10 or Business:

20 Accident, sulolde, or./ftomlolde (specify)

Date of ooourrenoe 19 .J..

Where did 1 1J‘ fy/, . _

Injury ooour?

(City or jlo'

11 Soolal Seourity No...C..2-l-"^0"3'^-S-6"l-4-

12 BIRTHPLACE (City)
(State or country)

sSTa

13 NAME OF

father Abraham

Shepard Zimmermar

14 BIRTHPLACE OF

FATHER (Citvl

(State or country)

Russia

15 MAIDEN NAME

of mother Sarah

Ko p o 1 o v i t z

16 BIRTHPLACE OF

MOTHER ( Citvl

(State or country)

Russia

Did.

Dlaoe?

Manner

Injury

Nature

(City or town and State)
our In or about home, on farm. In Industrial plaoe, or I
tX\,

^pubUj)

17inform.nt.L.ena .J^sp&cOLfta ( .Rel!‘l0D:..“.!n7..

(vd.irvHM) ^0 ir, r

I HEREBY CERTIFY that
I filed /with m/f BEFORE the(

iafactp/y standard certificate of death was
al cry 'translbjfermit was Issued:

- «/ fyy _J_

it o|. Board of u/itU^r othep)

^ jlzL jz*/

(Date of Issue of Pdrirlty

~ (Specify type of place) ,

of (?>*-*■ (yL )^z..L~S9A l

. k .....L ' * X A f Ik... .. ..

While at work?

Was there an autopsy? .LCrvS..

21 Was disease or Injury In
If so, speolfy
(Signed)

(Address)

i or injury In My way related to oooupatlon of deoeasr

,rA'

M. D.

Wur~'*,..r:...\9A'z..

...H.a.nd.....i.a...H.an.de y.lejs..t....KQ.xb.iiry

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

DATE OF BURIAL .<J..a,Qiiar.y.....2.1. 1950.

23 FUNERAL DIRECTOR.B.§.aj.ara.m...Z.».0.Ql.Qni.On

address .4.20 ,-.£ix..Y.ar.u ,S..t.“Or.Q.ak.l.i.r*a..

Reoelved and filed 19

j . s A - -> - ■ i

l A.—J.1

(Registrar)

EXTRACTS FROM THE LAWS OF THE

COMMONWEALTH OF MASSACHUSETTS

GOVERNING THE

RETURN OF CERTIFICATES OF DEATH

A physician or registered hospital medical offioer shall forthwith, after
the death of a person whom he has attended during his last illness, at the
request of an undertaker or other authorized person or of any member of
the family of the deceased, furnish for registration a standard certificate of
death, stating to the best of his knowledge and belief the name of the
deceased, his supposed age, the disease of which he died, defined as required
by section one, where same was contracted, the duration of his last illness,
when last seen alive by the physician or officer and the date of his death . . .
Gen. l.aws. 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 tile deceased, to the best of his knowledge and belief, served
in the army, navy or marine corps of the United Slates in any war in which
it lias been engaged, insert in the certificate a recital to that effect, speci-
fying the war, and shall also certify in such certificate both the primary
and the secondary or immediate cause of death as nearly as he can state
the same. Kor neglect to comply with any provision of this section, such
physician or officer shall forfeit ten dollars. Kor the purposes of this sec-
tion and of sections forty-five, forty-si* and forty-seven of said chapter one
hundred and fourteen, the word ‘’war” shall include the China relief ex-
pedition and the Philippine insurrection, which shall, for said purposes, be
deemed to have taken place between February fourteenth, eighteen hundred
and ninety-eight and July fourth, nineteen hundred and two, and the Mexi-
can border service of nineteen hundred and sixteen and nineteen hundred
and seventeen. G. L. Chap. 46, Sec. 10.

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

DESCRIPTION (for unknown person)

it has been engaged, such recital shall appear upon the permit. The board
of health, or its agent, upon receipt of such statement and certificate, shall
forthwith countersign it and transmit it to the clerk of the town for regis-
tration. 'I'lie person to whom the permit is so given and the physician cer-
ti tying the cause of death -hall thereafter furnish for registration any other
necessary information which can be obtained as to the deceased, or as to
the manner or cause of the death, which the clerk or registrar may re-
quire.— Chap. 114, Sec. 45, G. L., (Tercentenary Edition).

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

Medical examiners shall make examination upon the view of the dead
bodies of only such persons as are supposed to have died by violence. If a
medical examiner has notice that there is withiu 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. 3S, Sec. 6.

... He shall in all cases certify to the town clerk or registrar in the
place where the deceased died his name and residence, if known; otherwise
a description as full as may be, with the cause and manner of death. —
General Laws, Chap. 33, Sec. 7.

. . . The medical examiner certifies the cause and manner of death to the
best of his knowledge and belief.

RULES OF PRACTICE

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

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

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

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

STATEMENT OK CAUSE OF DEATH
Medical Examiners in certifying to a death will state the cause and
marine r thereof, and will specify: (1) Under couje, the nature of an injury
and of its consequences; and (2) under manner, the mode of its production
together with the circumstances when these are known. For example: “Com-
pound fracture of the femur with ensuing septicemia (gas bacillus) caused
by a steam railway accident.’’ “Pistol shot wound of the chest with asso-
ciated hemorrhage, homicidal.” “Asphyxiation by suspension, suicidal.”
“Syncope while under the influence of ether administered as a surgical
anaesthetic.” “Fracture of the skull with associated internal injury sus-
tained under circumstances unknown.”

If disease or injury was related to occupation, specify. If investigation
shows the death to have been due to disease, specify: (1) Under came its
known or presumable nature; and (2) under manner, indicate the circum-
stances leading to medico-legal inquiry. Kor example: “Hemorrhage spon-
taneous of the brain (basal ganglia) (found dead in bed).” “Heart disease,
presumably coronary sclerosis. (Sudden death.)”

NOTICE TO UNDERTAKERS: No embalming fluid, or any substitute therefor, shall be injected into the body of
any person supposed to have met his death by violence, until a permit, signed by the Medical Examiner, has first been
obtained. — General Laws, Chap. 38, Sec. 14.

THIS CERTIFICATE CONSTITUTES SUCH PERMIT

FORM R-301A

INSTRUCTIONS

FOR

IEDICAL CERTIFICATE

in giving

AUSE OF DEATH

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

This does not mean
* mode of dying, such
heart failure, asthenia, .
, It means the disease,
complications which
used death.

Morbid conditions,
any, giving rise to the
jve cause (a) staling
: underlying cause

Conditions contrib- •
:ng to the death but not
ated to the disease or
edition causing death.

(Eommmuupalrtf of fUasaarijuartta

EDWARD J. CRONIN
Secretary of the Commonwealth

DIVISION OF VITAL STATISTICS

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

Registered No.

2 FULL NAME

& Cks&y

(If deceased is a ma^ied, widowed or divorced woman, give

STANDARD

CERTIFICATE OF DEATH

I (If death occurred in a hospital or institution

t- 1

St.

also maiden name.)

(a) Residence. No., x?
(Usual place of abode)

give its NAME instead of street and number)

PHYSICIAN — IMPORTANT

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

St. .

f — .

(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

t ~

(Month)

z_ -

(Day)

r /

(Year)

41 HEREBY CERTIFY,

- ft

f " X' -> I , 19

I last saw h -£/ 1 .. alive on
have occurred on the date stated above, at

That I attended deceased

to f “ V " j / 19

t - V'.r/

from

19 . . death is said to

— A

DISEASE OR CONDITION
DIRECTLY LEADING
TO DEATH (a)

ANTE Due To
CEDENT (b)
CAUSES

•i

' _ _

J@-dLjQuc/\. ,

OTHER <

SIGNIFICANT

CONDITIONS

INTERVAL BE
TWEEN ONSET
AND DEATH

Major findings:
Of operations.

Date of operation

What test confirmed diagnosis?

Was autopsy performed?

5 Was disease or injury in any way related to occupation of deceased?
(Address Date/ ^ 1 (>

M. D

-'of frugal or Cremation

Grtrs+Sf...

J\\y or Town)

DATE Ofr BURIAL / . fe T. ...£/ jfl.. 19

7 NAME OF
FUNERAL DIRECTORtLari

ADDRESS

Received and filed

t r

(Registrar)

PERSONAL AND STATISTICAL PARTICULARS

8 SEX

9 COLOR OR RACE

(write the yjprd)

10 SINGLE
MARRIED
WIDOWED

or DIVORCED Ay •

10a If married, widowed, or divorced

HUSBAND of

(Give maiden name of wife in full)

(or) WIFE of

11 IF STILLBORN, enter that fact here.

(Husband's name in full)

AGE o Years O Months C) Days

If under 24 hours
O Hours Minutes

13 Usual

Occupation:

(Kind of work done during most of working life)

14 Industry
or Business:

15 Social Security No.

16 BIRTHPLACE (City)
(State or country)

17 NAME OF
FATHER

18 BIRTHPLACE OF
FATHER (City) , -

/9 ^

(State or country)

5424/

19 MAIDEN NAME_

OF MOTHER

20 BIRTHPLACE OF
MOTHER (Citv)

(State or country)

Informant

< A.dd"”^ .r;

I HEREBY CERTIFY that a satisfactory standard certificate of death was
filed with me BEFORE the ^pr^al or >iymsit ji jrrmtt was issued:

7 cAT / t

gnature Board of Hc*1

/ (Date of Issue of Permip

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 won! “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 perniits, 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
r 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. 652, 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 unnl 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 ♦hr body is to be buried
or the funeral is to be held, or from a person appointed to have the care of the
cemetery or burial ground in which the interment is made.

Chap. 114, Sec. 46, G. L., (Tercentenary Edition).

RULES OF PRACTICE

The fulfillment of the purpose of these laws calls for the observance of the follow-
ing rules of practice:

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

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

(5) 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 i he 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 bee’-' given up or changed, or if the deceased had retired From business,
report the kind of work do^e 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

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

3 Middlesex..

g (County)

dommonoiFalttf of MaaBadjuBFtts

OFFICE OF THE SECRETARY

DIVISION OF VITAL STATISTICS

COPY OF

CERTIFICATE OF DEATH

Cambridge

(City or town making return)
Registered No i

Cambridge

(City or Town)

, a, + __ T : _ ! /(If death occurred in a hospital or institution.

No. ...d0.iy......wf-J-Q.S..C>.....d.Q.8.P.i..(?.S..-/r. St. \ .give its NAME instead of street and number)

2 full NAME....Ppank,...M.c.C.l.dS^.«J f (Was deceased a

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

(a) Residence. No.

(Usual place of abode)

l if so specify WAR)

306 Lincoln Strwt *

..'..../days. In nlace of residence

Length of stay: In place of death years months

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

MEDICAL CERTIFICATE OF DEATH

3 DATE OF

death Jan.,

(Month)

(Day)

1951

(Year)

PERSONAL AND STATISTICAL PARTICULARS

41 HEREBY CERTIFY, That I attended deceased from

Dec * 1& - 195>Q to Jatu. 4 19.5.1

I last saw h .ilU .alive on . xJs.n.e , 19 .. . J-death is said tc

have occurred on the date stated above, at 2. 2 .-3-Q

DISEASE OR CONDITION
DIRECTLY LEADING,

TO DEATH (a) .lh.rO.TR.b.,9. 3 i.S Ox leilj ^

nplitral artery

ANTE Due 10 . i -

cedent (b) Ar ter.i.o s.c.ler.Q.s.i.s.*

CAUSES

go n t ; ra 1

Due To

Due To
(c)

OTHER

SIGNIFICANT

CONDITIONS

Major findings:
Of operations

Ar terloscl.e.r.o..tl.c....iie.a r4?2 j r
disease .Myocardial — in4 2. no

INTERVAL BE-
TWEEN ONSET
UNO DEATH

15 yrir^

80 »

fare tlon"

Date of operation Was autopsy performed? ]QQ.

What test confirmed diagnosis?

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

(Signed) ^

(Address)

J>ate juft . 49 d

6 .... p, D..+. .1 a i_iO.W.C.ll

Place'dflB8nat' or'Crefnstiohz'" ‘ (City or Town)

date of burial Januar v- • 8 «■ 19-51

7 NAME OF , r . rf f -

FUNERAL DIRECTOR ..i?iaUL*iC.0

address W in t;hr»r»p -v l e w in t aro p-

Recei

JVl®t

.19

(Registrar of City or Town w

eceased resided)

8 SEX

Male

9 COLOR OR RACE

vv'hi te

10 SINGLE

(write the wo$d)

married Mamea

WIDOWED
or DIVORCED

10a If married, widowed, or divoxcadi. „ : ,.. «- ..

husband of Eri2^«TO .y . Dunigan

(Give maiden name of wife in full)

(or) WIFE of

(Husband's name in full)

11 IF STILLBORN, enter that fact here.

age.7.2

.Years Months..

Days

If under 24 hours
Hours Minutes

13 Usual

Occupation:

Unknown

(Kind of work done during most of working life)

Industry
or Business:.

Unknown

IS Social Security No. Un kxiown"

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

Ireland

17 NAME OF
FATHER

Patrick McCluskey

18 BIRTHPLACE OF

FATHER (City) ....
(State or country)

Ireland

19 MAIDEN NAME
OF MOTHER

Ann Dolan

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

Ireland

Informant!/.

(Address.)

Mrs... E.ll.z.ab.e ,th ..V McCluskey
2Q6 Lincoln Ti..* -lnt -rop

A TRUE COPY.
ATTEST:

t^gisfrar o/City or Towri wMere deatli ocrui+ed) '

DATE FILED !?^..U.§..0.....4.*. 4..9.e

R EC EiV H Y

>RM R-301A

NSTRUCTIONS

FOR

CAL 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
rl failure, asthenia, .
means the disease,
mplications which
' death.

forbid conditions.

, giving rise to the
cause (a) slating
mderlying cause

onditions conlrib- •

0 the death but not

1 to the disease or
ion causing death.

(City or

No.

2 FULL NAME

Tl)o£.A

(rtaeceased is i

(Eommomoraltfj of fflaBBarljaBPttB

OFFICE OF THE SECRETARY

-DIVISION OF VITAL STATISTICS

STANDARD

CERTIFICATE OF DEATH

Registered No

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

4,...

ECK

a married, widowed or divorced woman, give also maiden name.)

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

PHYSICIAN — IMPORTANT

( Was deceased a .

S. War Veteran. x| ^

(a) Residence. No. V ■

(Usual place of abode) v

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

(If nonresident, give
/ years months .. days.

if^o specify WAR)

own and State)

MEDICAL CERTIFICATE OF DEATH

3 DATE OF
DEATH

Month)

(Day)

\%£i

(Year)

41 HEREBY CERTIFY.

That I attended deceased from

'Vr^ . 19 to "S*"- * . 19.T.I..

I last saw htaf alive on ... 19 £ V. death is said to)

have occurred on the date stated above, at \ C> V (x- m.

DISEASE OR CONDITION
DIRECTLY LEADING
TO DEATH (a)

MG . I . , . '

\-\oQ ,®„ (gif'? ?.«»-«> 9 *

ANTE Due To

CEDENT (b)

CAUSES

Due To
(c)

OTHER

SIGNIFICANT

CONDITIONS

INTERVAL BE
TWEEN ONSET
AND OEATH

Major findings:
Of operations.

Date of operation Was autopsy performed?

What test confirmed diagnosis? ?.VO

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

(SigncdT , M. D

(Address) *Vt1 Ja" 'WW'cYtWf Date’Vs**. 19 Si

6 W£U -J>c.ofb-

Place of Burial or Cremation
DATE OF BURIAL

7 NAME OF
FUNERAL DIRECTO

ADDRESS \ C> bO
Received and filed

(City or Town)

'”3^ e:r'L> .

'-t

(Registrar)

PERSONAL AND STATISTICAL PARTICULARS

St SEX.

9 COLOR OR RACE

10 SINGLE
MA'feRIED
WlfDUWED
or DIVORCE

(write the word)

10a If married, widowed, or divorced
HUSBAND of

(or) WIFE of

(Give maiden j&me of wiflfelin full)

vo v) \jL

(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: .

(Kind of work done during most of working life)

14 Industry
or Business:

15 Social Security No,

16 BIRTHPLACE (City) .
(State or country)

17 NAME OF|
FATHER

18 BIRTHPLACE OF
FATHER (City)
(State or countr;

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

HQ.:. /

(Official Designation) / (Date of Issuer Permit)

EXTRACTS

FROM THE LAWS OF THE

COMMONWEALTH OF MASSACHUSETTS

GOVERNING THE

RETURN OF CERTIFICATES OF DEATH

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

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

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

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

Medical examiners shall .make examination 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 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.

(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 Examiner* 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

5RM R-301 A

INSTRUCTIONS

FOR

ICAL CERTIFICATE

In giving
JSE OF DEATH

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

This does not mean
node of dying, such
irl failure, asthenia, .
't means the disease,
implications which
d death.

Morbid conditions,

V, giving rise to the"
cause (a) staling
underlying cause

Conditions conlrib-
to the death but not
d to the disease or
lion causing death.

WIHIHBOP

(County)

..SUFjpQLK

No.

(City or Town)

winthrop Comm Hospital

$4* (£oimnamnpaltl| of fTOaHHartjuHftta

EDWARD J. CRONIN

Secretary of the Commonwealth

DIVISION OF VITAL STATISTICS

STANDARD

CERTIFICATE OF DEATH

Registered No

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

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

2 full name &«orge Bokelmen

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

(a) Residence. No.

(Usual place of abode)

Length of stay: In place of death years mont'

Wi&ljhrop

PHYSICIAN — IMPORTANT

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

St.

A?.

(If nonresident, give city or town and State)

days. In place of residence years

months

days.

MEDICAL CERTIFICATE OF DEATH

3 DATE OF
DEATH

4 1 H E R E B

/ffl

(Year)

CERTIFY, That I attended deceased from

wTR.... to -r : 19 jT./

alive on .., 19 death is said to|

ecT above, at s/sysA-

I last saw h
have occurred on the date stateT above, at

DISEASE OR CONDITION
DIRECTLY LEAD
TO DEATH (a)

INTERVAL BE-
TWEEN ONSET
AND DEATH

12 y ^

If under 24 hours

AGE ^J^Vears 1 Months

Days

Hours Minutes

OTHER

SIGNIFICANT

CONDITIONS

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? 1/LVT^

If so, speafv? f -LX? " 6

(Signed)L>^rf<S4;tO...^^«<.4U.* M. D

(Address) Ji/ Cmi /j “■ 1 » Date / f y _ iy/

•aTawn » KTereit

Place of Burial or Cremation _ (City or T<

Jan b Ifbi

own)

DATE OF BURIAL

7 NAME OF
FUNERAL DIRECTOR

ADDRESS

Received and filed

truest PCaggiano
147 Wlntkrop St.m *‘1 nthrop

PERSONAL AND STATISTICAL PARTICULARS

8 SEX

9 COLOR OR RACE

10 SINGLE
MARRIED
WIDOWED
or DIVORCED

(write the word)

■Divorce^

10a If married, widowed, or diverted ^

— a

HUSBAND of
(or) WIFE of

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

11 IF STILLBORN, enter that fact here.

13 Usual

Occupation:

Conductor

(Kind of work done during most of working life)

14 Industry Bailroad

or Business:

15 Social Security No.

Tione

16 BIRTHPLACE (City) .
(State or country)

Do relies ter,

Ma a s

17 NAME OF
FATHER

George Bokelmen

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

HoraS^cotia

19 MAIDEN NAME

of mother Lary Hpllingwortn

20 BIRTHPLACE OF,

MOTHER (City)

(State or country)

2\ Ha z el

(Address) 16b Seis St. ft .lYeymoutli M k

Greenfield
Hove Scotia
Holf.

3M 8 '!c31

(Registrar)

I HEREBY CERTIFY that a satisfactory standard certificate of death was
filed ^ith n^e BEFORE the^)yrial potrans^(^permit was issued:

ntJ^rBoard of tf^aCth 'or othgt)

'ft/IZ

(Date of Issue of/Permif

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 Uniter! 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, nr as to the manner nr
cause of the death, which the clerk or registrar may require. — Chap. 1 14, Sec. 4.S,
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 nr 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. 633, 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 unril 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 *hr body is to be buried
or the funeral is to be held, or from a person appointed to nave 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 do^e 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

INSTRUCTIONS

FOR

ICAL CERTIFICATE

In giving
ISE OF DEATH

Jo not enter
tore than one
mse for each

[a), (b) and (c)

Hits does not mean
lode of dying, such
\rt failure, asthenia, .
t means the disease,
mplications which
l death.

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

Conditions contrib- ~
to the death but not
i to the disease or
ion causing death.

Suffolk

(County)

o Winthrop

(City or Town)

(SommmtumtUlj of IflaBaarljUBTttH

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 b...

No.

o. Winthrop Community Hospital

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

2 full name William Sherman Hibbard

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

(a) Residence. No. 8 2 9 Sh XT 1 QJ S t V 0 0 t

(Usual place of abode)

Length of stay: In place of death years months 15 days. In place of residenc25

PHYSICIAN — IMPORTANT

(Was deceased a

U. S. War Veteran, \xr tttT

if so specify WAR)

St.

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

MEDICAL CERTIFICATE OF DEATH

3 DATE OF

death JamaF)y 7

(Day)

1951

(Year)

41 HEREBY CERTIFY

)fiwyj , i‘> Y ? , ^to

I last saw h alive on

have occurred on the date stated above, at

That I at

DISEASE OR CONDITION
DIRECTLY LEADI
TO DEATH (a)

ANTE Due
CEDENT (b)/rw
CAUSES Qf)

That I attended deceased from

s-i

, 1 9 J death is said to

Y Yr fr m. INTERVAL BE-

TWEEN ONSET

AND OEATH

Due To

rCVucAi. rkw s.

OTHER

SIGNIFICANT

CONDITIONS

16 BIRTHPLACE (City)!)
(State or country) JV

Ubi

Major findings: ^

Of operations ..J......J. ......

Date of operation . y 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)

)JLS~ SCtCAfl.

...., M. D

7 i^7

Winthrop Cemetery Winthrop

i of Buriaior CrCTnation v (Ciiy orTown)*

January 10 f 1951 "> *

Place

DATE OF BURIAL

7 NAME OF
FUNERAL DIRECTOF

ADDRESS

174 Winthrop St .Winthrop

Received and filed

JAN- 1 5

(Registrar)

PERSONAL AND STATISTICAL PARTICULARS

8 SEX

male

9 COLOR OR RACE

white

10 SINGLE (write the word)
MARRIED

o7SPv^i?ESiaowed

10a If married, ^id_°_'Yed, or (jivorced

HUSBAND of

(Give maiden name of wife in full)w

(or) WIFE of

, widowed, ordivorced

Anna Frances Stallary

(Husband's name in full)

1 1 IF STILLBORN, enter that fact here.

AGE QffYears 0 Months 18 Days

If under 24 hours

Hours Minutes

Occupation: . Architects inspector

(Kind of work done during most of working life)

or Business: Commercial Architects

15 Social Security NaQlQ«-l 8*~Q112

17 NAME OF
FATHER

John Lawton Hibbard

18 BIRTHPLACE OF ,

father (City) <7sst Brookfield

(State or country) MaS SE C hUS e 1 1 S

19 MAIDEN NAME

of mother Abigail

Ayers Poland

20 BIRTHPLACE OF

mother (city) north Brookfield

(State or c»untry)^aSgaQ fou SettS

Informant ^ Afcty.^R* Gaynor Wellings

I HEREBY CERTIFY that a satisfactory standard certificate of death was
filqfl with rpe BEFORE/^he burij^Lpr tra/f/it 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 ot
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 bv 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.

I 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 mter-
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. 58, Sec. 6., as amended by Chap. 642, 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 un'il 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 ‘he body is to be buried
or the funeral is to be held, or from a person appointed to have the care of the
cemetery or burial ground in which the interment is made.

Chap. 114, Sec. 46, G. L., (Tercentenary Edition).

RULES OF PRACTICE

The fulfillment of the purpose of these laws calls for the observance of the follow-
ing rules of practice:

(1) Attending physicians will certify to such deaths only as those of persons

to whom they have given bedside care during a last illness from disease unrelated
to any form of injury. ... , , , , ,, ,

(2) Board of Health physicians will certify to such deaths only as those ot
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.

(4) 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 oecupa-
tion had been given up or changed, or if the deceased had retired from
report the kind of work do^e 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, ror a
person engaged in domestic service for wages, however, designate the occupation
by the appropriate terms, as housekeeper— private family, cook— hotel, etc. t or
a person who had no occupation whatever write none.

SPACE FOR ADDITIONAL INFORMATION

DATE OF ENTERING MILITARY SERVICE Febuary 15,1918

date OF DISCHARGE February 13,1919

RANK, RATING Major

organization and outfit U . S. Army Quartermasters corp

SERVICE NUMBER

326-0. R. -0 • P •

R-302

(County

No.

2 FULL NAME

(EotmMmtnraltlf of jHaBsarliuartts

OFFICE OF THE SECRETARY

DIVISION OF VITAL STATISTICS

COPY OF

CERTIFICATE OF DEATH

(City or town making return)
Registered No

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

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

(a) Residence. No (t

(Usual place of abode)

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

(If nonresident, give city af'SjsVn 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 ...

tenth)

7 jlu/_

(Day) (Year)

8 SEX.

41 HEREBY CERTIFY, That I attended deceased from

19 to 19

I last saw h alive on 19 death is said tc

have occurred on the date stated above, at m

9 COLOR OR RACE

10 SINGLE (write the word)
MARRIED
WIDOWED^-,
or DIVORCED

DISEASE OR CONDITION
DIRECTLY LEADIN
TO DEATH (a)

Ul 1

ANTE Due To

CEDENT (b)

CAUSES

Due To
(c)

OTHER

SIGNIFICANT

CONDITIONS

INTERVAL BE-
TWEEN ONSET
UNO DEATH

10a If married, widowed, or divorced

HUSBAND of

(Give maiden name of wife in full)

(or) WIFE of

ywrue uie wuru;

11 IF STILLBORN, enter that fact here.

AGE

Years

Months

Days

(Husband’s name in full)

If under 24 hours
Hours Minutes

13 Usual

Occupation:..

(Kind of work done during most of working life)

14 Industry
or Business:

15 Social Security No.

16 BIRTHPLACE (City).
(State or country)

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 IS

17 NAME OF (Z*

FATHER

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

19 MAIDEN NAME,
OF MOTHER<<7^

20 BIRTHPLACE OF
MOTHER (City) ...

(State or country)

Received and filed

EES....S. I?5T

(Registrar of City or Town where deceased resided)

DATE FILED

opy. . y.

1 LX Y & * )

■'fRegistrar of City or ToWn^here death occurred)

25m-(b)- 11-49-900,475

Suffolk

(County)

Boston

(City or town)

CCommonmpalttj of fHasaarfyuBPttB

EDWARD J. CRONIN

Secretary of the Commonwealth

DIVISION OF VITAL STATISTICS

COPY OF

CERTIFICATE OF DEATH

.BOSTON

(City or town making return)

Registered No.

154

No.

, , , T . i TT I (If death occurred in a hospital or institution.

^..S.~.3.c*«I.....il.O.S .p^ St. \ give its NAME instead of street and number)

2 full name I.sr.&.e.l. .....C.ann.er j (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. .. 29...Perkins St. st lio.t.h.mp

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

Length of stay: In place of death years 1. ...months 5days. In place of residence h .Clears months days.

MEDICAL CERTIFICATE OF DEATH

PERSONAL AND STATISTICAL PARTICULARS

3 DATE OF
DEATH ...

Januc.r j 8 ; 1951

(Month) (Day)

(Year)

8 SEX

Mali

41 HEREBY CERTIFY, That I attended deceased from

.£.ec.,. 2..., i&.Q J.an.. 8 «51

I last saw him... .alive on ...J..&,G.. 3. 195.1 death is said to|

have occurred on the date stated above, at l.i.Q.OA

9 COLOR OR RACE

White

10 SINGLE (write the word)
MARRIED . ,

widowed''1'1 married

or DIVORCED

10a If married, widowed, or di vorccd
HUSBAND of A.Q.S.e. 1 1 n

U.O.,

(Give maiden name of wife in full)

DISEASE OR CONDITION
DIRECTLY LEADING

to death (a) R.e.^..lr,.a.tor.y.....f.ai.lu

cedent ^b) T°C. a r e i n Qm a .o. f

:AUSES ascending- colon

Due To

(c)

OTHER

siGNiFicANTar..t..e.r.i.Q.s.c.l.er..Q.t.ic h.t......

CONDITIONS , .

dis .

INTERVAL BE-
TWEEN ONSET
AND OEATH

’e few
— m-ln .

(or) WIFE of..

(Husband’s name in full)

11 IF STILLBORN, enter that fact here.

AGE

...3

ears Months Days

If under 24 hours
Hours Minutes

13 Usual

Occupation:

yrs

Furniture dealer

(Kind of work done during most of working life)

14 Industry
or Business:

ret ired

15 Social Security No.

IlUIltJ

16 BIRTHPLACE (City) -RU-S-S-i-R-

(State or country)

^^cho^uots c.ar..c±nomaQf.... .ascending col

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

What test confirmed diagnosis?

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

If so, specify ~y rr *

(Signed) ...BUP.r S.l.i....AX.*. jQS..e.pll.S M. D

Cl.

(Address]

. sr.a&.l. .. Jo g.^.^Date 1 W^i^.51l9

6 ..ilint^r.up Gem. Ev-er e-ht. Iviaea

Place of Bunal dr Cremation (City or Town;

17 NAME OF
FATHER

Abraham Canner

18 BIRTHPLACE OF

FATHER (City)

(State or country)

••Ru's-sra"

19 MAIDEN NAME
OF MOTHER

20 BIRTHPLACE OF

MOTHER (City) fi.USS.ia..

(State or country)

DATE OF BURIAL

January 8,

..SL

7 NAME OF
FUNERAL DIRECTOR

,3enjarnin Birnbach
ad dr ess .10 ashing t-on- -St-. *)(■> n c h ■ e ■, ? • ^

2 1 Informant MQE.jeJ.fl Gj&XUXSR.

( Address j

Received and filed

wirg-nggr ~

(Registrar of City or Town where deceased resided)

.19

A TRUE

jv^TTES'

JAN. 10, 1951

DATE FILED 19..

r _,a P

■

(M R-301A

5TRUCTI0NS

FOR

AL CERTIFICATE

n giving

E OF DEATH

not enter
re than one
se for each
), (b) and (c)

is does not mean
ie of dying, such
failure, asthenia, .
neons the disease,
plications which
leath.

irbid conditions,
giving rise to the
suse (a) stating
derlying cause

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

-h

uHjp (Cammonutpaltlj of fUasBarijuarttH

EDWARD J. CRONIN
Secretary of the Commonwealth

DIVISION OF VITAL STATISTICS

STANDARD

CERTIFICATE OF DEATH

Registered No.

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

2 FULL NAME

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

(a) Residence. No. ^ *■

(Usual place of abode)

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

Length of stay: In place of death years months

{PHYSICIAN — IMPORTANT

(Was deceased a
U. S. War Veteran. / v 0
^so specify WARX / f U.

(If nonresident, give city or town and State)

days. In place of residence

months

days.

1EDICAL CERTIFICATE OF DEATH

PERSONAL AND STATISTICAL PARTICULARS

3 DATE OF
DEATH

(Month)

(Day

1 .jlst. i

1 (Year)

8 SEX

41 HEREBY CERTIFY

• <3L.'T, 19 o to

I last saw h alive on

have occurred on the date stated \above, at

That I attended deceased from

, A .

S»..|„ death is said to

H '

10 SINGLE (write the., word)

MARRIED,^^^c

WIDOWED J
ir .DIVORCED

10a If married, .itfujjowed, or divorced J .

HUSBAND ol..Lf£9*e#L0L. $Zr./.. „L

• (Give maidEn name of w

DISEASE OR CONDITION
DIRECTLY LEA
TO DEATH (a)

Major findings:
Of operations.

Date of operation Was autopsy performed?

What test confirmed diagnosis?

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

S Was disease or injury in any w a v related to occupation of deceased? TW
If so. Specif V'. . ....... .'rZmk t v t vV »t

19 MAIDEN NAME
OF MOTHER

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

Informant

(Address)

I HfEREBY CERTIFY that a satis rf/tandard certificate of death was
filial with >fngr BEFORE tfy$ )*urial/<7 iw. permit was issued:

Received and filed

JAN 1 5 1351

(Registrar)

J (Date of Issue of Pijfi

thmr other# /

dkete-

ue of Permit) /

EXTRACTS

FROM THE LAWS OF THE

COMMONWEALTH OF MASSACHUSETTS

GOVERNING THE

RETURN OF CERTIFICATES OF DEATH

A physician or officer furnishing a certificate of death as required by the
preceding section or by section forty-five of chapter one hundred and four-
teen, shall, if the deceased, to the best of his knowledge and belief, served in the
army, navy or marine corps of the United States in any war in which it has been
engaged, insert in the certificate a recital to that effect, 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, nr as to the manner or
cause of the death, which the clerk or registrar may require. — Chap. 1 14, Sec. 45,
G. L., (Tercentenary Edition).

Medical examiners shall make examination 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 nr 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 undl 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 *hc 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.

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 do~e during most of working life even if retired. Children
not gainfully employed may be returned as at school or at home. For a woman
whose only occupation was that of home housework, write housework. For a
person engaged in domestic service for wages, however, designate the occupation
by the appropriate terms, as housekeeper — private family, cook — hotel, etc. For
a person who had no occupation whatever write none.

SPACE FOR ADDITIONAL INFORMATION

DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE

RANK, RATING

ORGANIZATION AND OUTFIT
SERVICE NUMBER

M R-301A

ITRUCTIONS

FOR

kL CERTIFICATE

n giving
E OF DEATH

not enter
-e than one
se for each

I, (b) and (c)

is does not mean
\e of dying, such
failure, asthenia, .
neons the disease,
plications which
leath.

rbid conditions,
living rise to the
i use (a) stating
derlying cause

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

t Suffolk

Q (County)

Gltjp (Eommamuraltlj of fUaHaarliUHFttH

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.

o Winthrop

jjj (City or Town)

5.8 Pleasant St . Winthrop , Mass .

Registered No.

No.

St.

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

2 full name Frederick Wagner Brush

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

(a) Residence. No. 58 Pie a san# Street

(Usual place of abode)

PHYSICIAN — IMPORTANT

(Was deceased a

U. S. War Veteran,

if so specify WAR)

St.

Length of stay: In place of death

years months .

(If nonresident, give city or town and State)
days. In place of residence 36 years months days.

MEDICAL CERTIFICATE OF DEATH

3 DATE OF
DEATH

(Month) /

(Day)

/?-dr/

(Year)

That I attended deceased from

4IHLREBY CERTIFY, . .

, 19 to \Z&J!fisajrp f i9<5V

I last saw h 9 alive on \/ 1/ & Jr ^ 19 5~/, death i
have occurred on the date stated above, at g 'em as

is said to

DISEASE OR CONDITION
DIRECTLY LEADING
TO DEATH (a)

Ul 1 1U.\

ANTE Due To
CEDENT (b)
CAUSES

Due To

(c)

OTHER
SIGNIFICANT
CONDITIONS

Q / r

INTERVAL BE
TWEEN ONSET
AND DEATH

Spsvy*,/

Major findings:
Of operations

Date of operation

Was autopsy per&rmed

What test confirmed diagnosis?

( Z^'C.

5 Was disease or injury in any way rj
If so, specify
(Signed) ...

(Address)

to occupation of deceased?

/ . M . D

Hat /Q 1‘LiY

V o o d 1 awn C re mat o rv Everett

Place of Burial or Cremation ° (City or Town)

DATE OF BURIAL

Jan. 12

>51

7 FUNERAL DIRECTOR.' .

ADDRESS

Received and filed

JAN IS 1251

(Registrar)

PERSONAL AND STATISTICAL PARTICULARS

8 SEX

Male

9 COLOR OR RACE

White

10 SINGLE
MARRIED
WIDOWED
or DIVORCED

(write the word)

Married

10a If marrie'
HUSBAN

^^‘LTlTia'^f^eed

(Give n^aiden name of wife in full)

(or) WIFE of

(Husband's name in full)

11 IF STILLBORN, enter that fact here.

AGE

6Shars 8

Months

If under 24 hours

Hours Minutes

Occupation : Salesman

(Kind of work done during most of working life)

or Business: Dental Supplies

Social Security No. 022-07l54g9

BIRTHPLACE (City) BOS t OU,,

(State or country) M<9.SS

17 FATHEERF Michael Brush

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

Unable to obtain
New York

19 MAIDEN NAME

of mother Ermina Snedecker

20 BIRTHPLACE OF

MOTHER (City)

(State or country) New York

Informant

(Address)

Winthran^. M

I HEREBY' CERTIFY' that a satisfactory standard certificate of death was
.fiHrn with 5TC BEFORE^ kfc luirpjl or tp^nsit permit was issued:

e BEFORMUp

Signature 01
icial Designation)

Alth or othpt) ^

(Date of Issue o^/Pcrmitf

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, nr as to the manner or
cause of the death, which the clerk or registrar may require. — Chap. 1 14, Sec. 45,
G. L., (Tercentenary Edition).

Medical examiners shall make examination 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.

No undertaker or other persons shall bury a human body or the ashes thereof
which have been brought into the commonwealth unbl 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 *hr body is to be buried
or the funeral is to be held, or from a person appointed to have the care of the
cemetery or burial ground in which the interment is made.

. Chap. 114, Sec. 46, G. L., (Tercentenary Edition).

RULES OF PRACTICE

The fulfillment of the purpose of these laws calls for the observance of the follow-
ing rules of practice:

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

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

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 do^e 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

Dr OBrien

I R-301A

IUCTIONS

FOR

CERTIFICATE

giving

OF DEATH .

ot enter
than one
for each
[b) and (c)

does not mean
of dying, such
'lure, asthenia, .
ins the disease,
cations which
th.

d conditions,
ing rise to the
e (a) slating
■lying cause

lions contrib- ■
: death but not
he disease or
ausing death.

IvJ

^ fflommomnraltli of HHaaHarljUBPttB

~ 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.

.11.

2 FULL NAME.

(a) Residence. No. <fh7
(Usual place of abode)

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

PHYSICIAN — IMPORTANT

(Was deceased a / -
U. S.^War Veteran,

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

Major findings:

Of operations

Date of operation
What test confirmed diagnosis?

15 Social Security No. a?- ^6 *//& //

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

S Was disease opinjury^na^y way related to occj^pSation of deceased?

I HEREBY CERTIFY that a satisfactory standard certificate of death^as
file<^\vith jpfy BEFORE »he burial^r trarf$it permit was issued:

, y

of Board ofiHeanh or other)/ /

w . „"U

(Official 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 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 thereirom 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. 1 14, Sec. 45,
G. L., (Tercentenary Edition).

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

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

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

IM R-301A

iTRUCTIONS

FOR

Kl CERTIFICATE

n giving

E OF DEATH

not enter
'e than one
se for each

I, (b) and (c)

is does not mean
le of dying, such
failure, asthenia, .
neons the disease,
plications which
leath.

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

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

Suffolk

(County)

Winthrop

(City or Town)

6 3 Rear Freemont St.

(Commonuipaltlj nf ifflasHarijUBrtta

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.

I (If death occurred in a hospital or institution,

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

2 full name Katherine (Pond) Rogers , phys.c.an - .mportant

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

(a) Residence. No. 1^39^%. St. St

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

Length of stay: In place of death 16 years months days. In place of residence 36 years months days.

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

MEDICAL CERTIFICATE OF DEATH

3 DATE OF
DEATH

(Month)

(Day)

(Year)

41 HEREBY CERTIFY,

• -1 ... 19 St to,

I last saw hJ&V” alive on
have occurred on the date stated above, at

That

I attended deceased from

t a ... 19 S /

9 . i9-r/. death is said to|

DISEASE OR CONDITION
DIRECTLY LEADIN
TO DEATH (a)

AND.0EAT

ANTE Due To,
CEDENT (b)
CAUSES

Due To
(c)

OTHER —r,

SIGNIFICANT .

CONDITIONS

INTERVAL BE
TWEEN ONSET
OEATH

12 81

If under 24 hours

AGE V M Years

. Months

Days

Hours Minutes

Major findings:
Of operations.

Date of operation
What test confirmed diagnosis?

Was autopsy performed?

5 Was disease or injury in any way related to occupation of deceased? .... 7-0

If so. specif’
(Signed )/0
(Address) A),

M. D

19 Of

Place of Burial or Cremation
DATE OF BURIAL

7 NAME OF

FUNERAL DIRECTOR^?*:

(City or Town)

J S?. \<S(

ADDRESS.

Received and filed

JAN

vrsg**

.l.«j w i

(Registrar)

PERSONAL AND STATISTICAL PARTICULARS

8 SEX

Female

9 COLOR OR RACE

White

10 SINGLE
MARRIED
WIDOWED

(write the word)

divorced Married

10a If married, widowed, or divorced

HUSBAND of

(Give maiden name of wife in full)

(or) WIFE of Charles Rogers

(Husband’s name in full)

11 IF STILLBORN, enter that fact here.

13 Occupation: HOUSewlfe

(Kind of work done during most of working life)

14 or Business: QWIl hOIHe

15 Social Security No.

None

16 BIRTHPLACE (City) .
(State or country)

Be]

tire

17 NAME OF . , , . _

father Addison Pond

18 BIRTHPLACE OF

FATHER (City)

(State or country) Vermont

19 MAIDEN NAME

of mother Fanny Janes

20 BIRTHPLACE OF

MOTHER (City)

(State or country) "\J Q 'fit

Informant ^ChBrle.s H Rogers

_ (Address) 63 Rear Fregfoont St. IVint.hvmj

I HEREBY CERTIFY that a satisfactory standard certificate of death was
fil yf withjng BEFORE th^ bjprial jg^transi thermit 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 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 whit h 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, nr as to the manner or
cause of the death, which the clerk or registrar may require. — Chap. 1 14. Sec. 45,
G. L.. (Tercentenary Edition).

Medical examiners shall make examination 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 of the town where *hr 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.

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 do^e during most of w'orking 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

Dr Dickinson

R-302

/ SUFFOLK

" "(iS^TO’N

(City or Town)

No peter Bent bri gh am h0sp i tal

OIIjp (Eommonuipaltlj of fflaBBarliuBFttB

EDWARD J. CRONIN
Secretary of the Commonwealth

DIVISION OF VITAL STATISTICS

COPY OF

CERTIFICATE OF DEATH

'T'iN

(City or town making return)

36313..

Registered No. .

St.

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

2 FULL NAME .f.t.f-k.f.M.. ENN E.Y . | (Was deceased a

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

I if so specify WAR)

(a) Residence. No .75....P**® 7...AY.P. St V I N T H RO P M AS3

(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 !.P . years months days.

MEDICAL CERTIFICATE OF DEATH

PERSONAL AND STATISTICAL PARTICULARS

3 DATE OF . .

DEATH J AN

(Month)

2/51

(Day) (Year)

tww EREBY CERTIFY. That ■WfT attended deceased from]

8 SEX

Male

9 COLOR OR RACE

IV H | T E

10 SINGLE (write the word)
MARRIED

WIDOWED HI | *\AU| rn
or DIVORCED 30 WEO

Jan 4

i9 5i tg Jan 1.2, 19 .5 1

I last saw h... l it .alive on JA N 12 19. . ..5 ,1 death is said t<j

have occurred on the date stated above, at ..7.1.35

...Am.

DISEASE OR CONDITION
DU
TO

DIRdeIt SLSD^c.mom* of stomach

ANTE^DueTo CORONARY OCCLUSION
CAUSES

Due To
(c)

OTHER

SIGNIFICANT

CONDITIONS

INTERVAL BE
TWEEN ONSET
AND OEATN

I YR

10a If married, widowed, or divorced

husband of Louise nolan

(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

TERM

13 Usual

Occupation:

ACTOR ■ ..

(Kind ot work done during most of working life)

14 Industry
or Business:

professional Stage

15 Social Security No.

16 BIRTHPLACE (City)

(State or country) NEW YORK NY

Major findings:

Of operations

Date of operation Was autopsy performed?. NO

What test confirmed diagnosis? CL-J N.J.CAL

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

(Signed) U K H 1 L H E L M

(Address) BOSTON MASS Date JAN. 1 2

M. D,
1951

6 llNTHROP CEM

Wl.NTH.ROP

Place of Burial or Cremation (City or Town)

DATE OF BURIAL

Jan 1 5

,.5'

7 NAME OF
FUNERAL DIRECTOR

A B Marsh

ADDRESS

Winthrop Mass

Received and filed

JM2TT9SI

17 NAME OF
FATHER

Patrick Kenney

18 BIRTHPLACE OF

FATHER (City)

(State or country) IRELAND

19 MAIDEN NAME
OF MOTHER

S /(RAH MCGURK

20 BIRTHPLACE OF

MOTHER (City)

(State or country) IRELAND

Informant LY.1 S0N

(Address;

CUlA

(Registrar of City or Town where death occurred)

(Registrar of City or Town where deceased resided)

DATE PILED 19...5..!.,

v* i i ■ >• • on f '

' i •

.'?■! * ! .1

’ 1

’ - • ' *

< •

v. ' *

f 4

? ?■» '• ' - JT ’ •

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

If deoeesed was a U. S. War Veteran, G. L. Chap. 46, Seotlon 10, requires physlolans to Insert a recital to that effeot

IM R-303-A

2 FULL NAME

till je Cdammonfarnltl] of JHassacbusetts
OFFICE OF THE SECRETARY
DIVISION OF VITAL STATISTICS

MEDICAL EXAMINER S
CERTIFICATE OF DEATH

To be filed for burial permit
with Board of Health
or Its Agent. ; j

Registered No

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

no. ztS/.

/ ?fcW6lflyAfefeedW3ORTANJ

ried, widowed or^djrorced woman, gfv^-a^so mat^gn. name.) | v/yap)' "vC

fak

(a) Resldenoe. No.

(Usual place of abode

Length of stay: In hospital or Institution

(Before death) < Specify whether)

years

months (3 days.

■

(If nonresident, give city or town and State)

In this oommunlty <&o yrg. mos. days.

personal and statistical particulars

3 SEX

4 COLOR OR RACE

5 SINGLE (write the word)
MARRIED
WIDOWED
or DIVORCEC

5a If married, widowed, or divoroed
HUSBAND of

(or) WIFE

(Husband’s name in full)

6 Age of husband or wife If alive

..Vyears

7 IF STILLBORN, enter that fact here.

AGE

Years Months..

Days

If less than 1 day
Hours Minutes

Usual

9 Occupation :

Industry

10 or Business:

11 Soolal Seourity No.

12 BIRTHPLACE (City) Z.U?.£t^

(State or country)

13 NAME OF ^ •

FATHER (. £) /<lJ

14 BIRTHPLACE OF
FATHER fCitvl

(SZo.

(State or country) *7 *V»

15 MAIDEN NAME ("
OF MOTHER ^

16 BIRTHPLAC^JJF^
MOTHER (City) ..

-&0. A Smhl,

(State or country)

if Health or other)/ . /

i 4M&.

of Iaaue of Permit) /

MEDICAL CERTIFICATE OF DEATH

18 DATE OF
DEATH

I (Month)

3..Z

(Day)

JJLS1

(Year)

19 I HEREBY CERTIFY that I have Investigated the death
of the person above-named and that the CAUSE A^tD MANNER thereof'

^-are as follows: (If an injury was involved, atate fully.)

...^T -

.....mm. ..... «

1 v/^t^AM^XA — : ~7) — '7?~ p —

20 Aocldent, sulolde, or homlolde («pecify)..(^ic....C^3i^r^Vau3^tS.

Date of ooourrenoe

Where did /? .T

Injury ooour7

ity or town and State)

Did Injury ooour In or about horp/, on farm, In Industrial place, or In publle

place?

\ (SpecMjxtype °* J>lAce) .

^"Tt&fdcc .Ln***.

ig?«

While at work? ZZ~.. Was there an autopsy?

21 Was disease oc-lniury In any way, related to oooupatlon of deoeased?..

If so, speolfy

:...rx.^. m. d.

(Signed).
(Addresa)

Place of Buria« Crem:
DATE OF BURIAL

a>»rKi or Removal.

Ji^..r/..^r;....i9^

(City or Town)

ADDRESS

Reoelved and filed 19 ...

• LAW 1 4ori

(Registrar)

EXTRACTS FROM THE LAWS OF THE

COMMONWEALTH OF MASSACHUSETTS

GOVERNING THE

RETURN OF CERTIFICATES OF DEATH

A physician or registered hospital medloal offioer shall forthwith, after
the death of a person whom he has attended during his last illness, at the
reqjest 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 hia 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 hia death . . .
Gen. Laws, Chap. 1 0, Sec. 0.

it has been engaged, insert in the certificate a recital to that effect, speci-

fying the war, and shall also certify in such certificate both the primary
and the secondary or immediate cause of death as nearly as he can stale
the same. For neglect to comply with any provision of this section, such
physician or officer shall forfeit ten dollars. For the purposes of this sec-
tion and of sections forty-five, forty-six and forty-seven of said chapter one
hundred and fourteen, the word “w,ar” shall include the China relief ex-
pedition and the Philippine insurrection, which shall, for said purposes, be
deemed to have taken place between February fourteenth, eighteen hundred
and ninety-eight and July fourth, nineteen hundred and two, and the Mexi-
can bonier service of nineteen hundred and sixteen and nineteen hundred
and seventeen. 0. L. Chap. 46, Sec. 10.

No undertaker or other oerscn shall bury or otherwise dispose of a human
body iu 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 ita
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 exiiume a human body and remove it from a town, from one
cemetery to another, or from one grave or tomb other than the receiving
tomb to another in the same cemetery, until he has received a permit from
the board of health or its agent aforesaid or from the clerk of the town
where the body is buried. No such permit shall be issued until there shall
have been delivered to such board, agent or clerk, as the case may be, a
satisfactory written statement containing the facts required by law to be
returned and recorded, which shall be accompanied, in case of an original
interment, by a satisfactory certificate of the attending physician, if any,
as required by law, or in lieu thereof a certificate as hereinafter provided.
If there is no attending physician, or if, for sufficient reasons, his certificate
cannot be obtained early enough for the purpose, or is insufficient, a physi-
cian who is a member of the board of health, or employed by it or by the
selectmen for the purpose, shall upon application make the certificate re-
quired of the attending physician. If death is caused by violence, the
medical examiner shall make such certificate. If such a permit for the
removal of a human body, not previously interred, from one town to an-
other within the commonwealth cannot be obtained early enough for the
purpose, the certificate of death made as above provided and in the pos-
session of the undertaker desiring to make such removal shall constitute a
permit for such removal; provided, that such body shall be returned to the
town from which it was removed within thirty-aix hours after such re-
moval, unless a permit in the usual form for the removal of such body ha*
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 iti 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 ami transmit it to the clerk of the town (or regia-
trarion. The person to whom I lie permit is so given and the physician cer-
tifying the cause of death shall thereafter furnish for registration any other
necessary information which can be obtained as to tile deceased, or as to
the manner or cause of (lie death, which the clerk or registrar may re-
quire.— Chap. 114, Sec. 45, 0. L., (Tercentenary Edition).

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

Medical examiners 6hall make examination upon the view of the dead
bodies of only surli 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.

... tie shall in all cases certify to the town clerk or registrar In the
place where the deceased died his name and residence, if known; otherwise
a description as full as may be, with the cause and manner of death. —
General Laws, Chap. 38, Sec. 7.

. . . The medical examiner certifies the cause and manner of death to the
best of his knowledge and belief.

RULES OF PRACTICE

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

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

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

(3) Medical Examiners will investigate and certify to all deaths sup-
posably due to Injury. .These include not only deaths caused directly or In-
direetiy by traumatism (including resulting septicemia), and by the action
of chemical (drugs or poisons), thermal, or electrical agents, aad death*
following abortion, but also deaths from disease resulting from injury or
infection related to occupation, the sudden deaths of persons not dlsablsd
by reoognized disease, and those of persons found dead.

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

If disease or injury was related to occupation, specify. If investigation
show* the death to have been due to di stair, specify: (1) Under cause it*
known or presumable nature; and (2) under manner, indicate the circum-
stances leading to medico-legal inquiry. Fur example: “Hemorrhage spon-
taneous 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

R-302

V 4>

i a

■ss

§s

.si

"O 0>

«.c

♦»

1*°*
ca c^r

4J-- ^

a> F .

§!*
uo S
•^S

oo^

U U

O 4> .

>>■311

. - 4> F
O X. 2

.£ ® a

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£ § c
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_ s «

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111
^ «J u

Or; V

■§^5

tSoll

MIDDLESEX

(County)

WATERTOWN

(City or Town)

JEANETTE CONVALESCENT HOME

©If* fflommamnralttf of HaoBarljuBPtta

EDWARD J. CRONIN

Secretary of the Commonwealth

DIVISION OF VITAL STATISTICS

COPY OF

WATERTOWN

cERiif9i<sajfe^rT.DEATH

(City or town making return)

1 ±5.

Registered No. .

No.

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

2 FULL NAME ******* V* ..RAWL, NG8 ( (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) NONE

497 A SHIRLEY 0, WINTHROP

(a) Residence. No St.

(Usual place of abode)

(If nonresident, give city or town and State)

3 4

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 deathof January 1 4p 1951

(Month) (Day) (Year)

8 SEX

MALE

9 COLOR OR RACE

WHITE

41 HEREBY CERTIFY

SEPT. 12 50

to..

That I attended deceased from

Jan, 14 51

10 SINGLE (write the word)
MARRIED

WIDOWED gj I n_

or DIVORCED * ' u*

WlW (Rawli nob)

III

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

a • Ort n

have occurred on the date stated above, at , CJJ U.*...m.

DISEASE OR CONDITION
DIRECTLY LEADING

TO DEATH (a) P ®T^0S * S

INSUFFICIENCY

ANTE Due To

CEDENT (b)

CAUSES

ARTERIOSCLEROSIS

Due To
(c)

OTHER

SIGNIFICANT .
CONDITIONS

Cerebral arteriosclerosis

INTERVAL BE-
TWEEN ONSET
AND DEATH

10a If married, widowed, qt diyprcefl
HUSBAND of..

(Give maiden name of wife in full)

(or) WIFE of

(Husband’s name in full)

11 IF STILLBORN, enter that fact here.

|0 VR8 . AGE

Y ears Months Days

If under 24 hours
Hours Minutes

13 Usual

Occupation:

SUPERINTENDENT

(Kind of work done during most of working life)

14 Industry
or Business:

Office building

15 Social Security No.

[removed]

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

GASPORT HANT8, ENGLAND

Major findings:

Of operations

Date of operation Was autopsy performed? TTY..

What test confirmed diagnosis?

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

"twt

“il'X^tHARLFS T. »*LC0TT

(Address)

1/14

IT. PLEASANT Q DIET E R V * A RL 1 NG TON (MASS.

Place of Burial or Cremation (City or Town)

DATE OF BURIAL JANUARY 1 7* 19

17 NAME OF
FATHER

John Rawlings

18 BIRTHPLACE OF

FATHER (City) GASPORT HANTS! ENQLANO

(State or country)

19 MAIDEN NAME
OF MOTHER

Caroline scott

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

England

7 FUNERAL DIRECTOR Q* N* <V*ANNAN & SON

Informant .»!«• WU FRASER (DAUGHTER)

( Address ) RINDQE AYE* » C.V.1BRI DC.E. MASS.

ADDRESS

378 mass. A ve* • Arlington* mass.

Received and filed ^ 19

_JA:i.i.a....3i

(Registrar of City or Town where deceased resided)

DATE FILED

M R-301A

TRUCTIONS

FOR

1 CERTIFICATE

i giving

: OF DEATH

not enter
e than one
e for each
, (b) and (c)

s does not mean
! of dying, such
ailure, asthenia, .
eans the disease,
lications which
?ath.

bid conditions .
iving rise to the "
use (a) staling
lerlymg cause

ditions conlrib- •
he death but not
) the disease or
causing death.

Suffolk

(County)

o Winthrop

W (City or Town)

®lje (EmnmmtumtUlj of Hasaartjuuptta

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 Winthrop Community Hospital st {(^sh N^1Jtneaad

d • (' K Q 5 t

2 FULL NAME c) A <T) £ ^ 1

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

IMPORTANT

PHYSICIAN

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

(a) Residence. No. 1024 Bennington. • St St East Boston

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

anf months -/.^^days. In place of residence 15y ears

Length of stay: In place of death

.months

days.

MEDICAL CERTIFICATE OF DEATH

3 DATE OF \
DEATH M

(Month)

l<S

(Day)

/fey

(Yeaf)

41 HEREBY CERTIFY,

19 t

That, I attended deceased horn

19 VJ

I last saw h.^rr^rTZ^alive on /////■ ip , , death is said toj

have occurred on the date stated above, at <£.!■> /.

DISEASE OR CONDITION
DIRECTLY LEADING

TO DEATH (a) yfcs

ANTE Due To
CEDENT (b)
CAUSES

4L.J4.

dcT.To4^.^

OTHE
SIGNIFICANT
CONDITIONS

INTERVAL BE
TWEEN ONSET
AND OEATH

- -V ;

Major findings:

Of operations

Date of operation £ JjVas autopsy performed?

What test confirmed diagnosis?

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

If so, specify... — ^ ..4^. p.,.....,

(Signed) _. / ..../. - . M. D

(Address) 0

1 ) yf

Pocasset Hi

Place of Burial or Cremation
DATE OF BURIAL

Date ///>.

19-V

( < v-/r Tivertor

(City or Town)

Jan. 18 ,o51

7 funeral director Willi am S Hathaway

ADDRESS 1813 Robeson St. Fall River

Received and filed

JAN 22 1351

(Registrar)

PERSONAL AND STATISTICAL PARTICULARS

8 SEX

9 COLOR OR RACE

10 SINGLE (write the word)
MARRIED

WIDOWED 0 „ -»

or DIVORCED Dingle

10a If married, widowed, or divorced

HUSBAND of

(Give maiden name of wife in full)

(or) WIFE of

(Husband's name in full)

II IF STILLBORN, enter that fact here.

3E 43

AGE ' ^ Years

Months

ays

If under 24 hours

Hours Minutes

13 Usual

Occupation:

Overseer

(Kind of work done during most of working life)

14 Industry
or Business:

Maverick Mills

15 Social Security No.

-07-2203.

16 BIRTHPLACE (City) .
(State or country)

Somerset

Mass.

17 NAME OF
FATHER

Harrison Frost

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

E-|

19 MAIDEN NAME
< OF MOTHER

20 BIRTHPLACE OF
MOTHER (City) ...

, I ^State or country)

Bowdoinham

Maine

Jennie Orvis

Somerset
Mass .

I HEREBY CERTIFY that a satisfactory standard certj^cate of death was
filed with me B/KrORElhe burial i

EXTRACTS

FROM THE LAWS OF THE

COMMONWEALTH OF MASSACHUSETTS

GOVERNING THE

RETURN OF CERTIFICATES OF DEATH

A physician or registered hospital medical officer shall forthwith, after the
death of a person whom he has attended during his last illness, at the request
of an undertaker or other authorized person or of any member of the family of
the deceased, furnish for registration a standard certificate of death, stating to the
best of his 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 un»il 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 f hr 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.

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 do^e during most of working life even if retired. Children
not gainfully employed may be returned as at school or at home. For a woman
wfiose 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-303-A

2 0
E -

e •

— ©

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5-s •>

= S£
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££3

S-S*

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2- S. «

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•

^tCIje dommnnfaraltl] of JHassachusetts
OFFICE OF THE SECRETARY
DIVISION OF VITAL STATISTICS

MEDICAL EXAMINER’S
CERTIFICATE OF DEATH

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

No. l..£Uj 8t{iwdtaV

,k TX\aj>(jL

(If deceased is a married. widowed or diiotced woman, gjve also maiden

(a) Resldenoe. No. x). UCl

(Usual place of abode)

Registered No.

17.

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

r PHYSICIAN-IMPORTANT

2 FULL NAME

t(Was deoeased a
U. S. War Veteran,
If so speoify WAR) .

Length of stay: In hospital or Institution

(Before death) < Specify whether)

years

onths

days.

(If nonresident, give city or town and State)

In this community yra. mos. days.

PERSONAL AND STATISTICAL PARTICULARS

3 SEX

^e^ale

4 COLOR OR RACE

T Ite

5 SINGLE (write the word)
MARRIED

WIDOWED, . ,

or DivoRctarri ed

5a If married, widowed, or dlvoroed

HUSBAND of

<«> WIFE .ToagiWhtgglfeti&tr*

(Husband’s name in full)

6 Age of husband or wife If alive .7.8 .... yearsll

7 IF STILLBORN, enter that faot here.

ag?Q

... Years Months

Days

If less than 1 day
Hours Minutes

Usual - ~

9 Occupation: HOUS.e.W.l.IS..

Industry

10 or Business: OW-Tl HO-TOS..

11 Soolal Seourity No.

(State or country) NeW f Ouhdlahfl

13 NAME OF
FATHER

Cannot he — learned

14 BIRTHPLACE OF

FATHER (City)

(State or country) TTff W f OUT) dland

15 MALDEN NAME

OF MOTHER Alice

Hanrahan

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

Newfoundland

o 17.nformant , Joseph MacDonald / x

- I ( \d«lr**iin) ! 15 Hermon vSt ;\

« — -

7 f /Sl^ature^bl of Health or other) /

i.////£7

(Official Designation') f (Date of Issue of Permit) <•

MEDICAL CERTIFICATE OF DEATH

lg DATE OF
DEATH

(Month)

12' L1A.L

(Day) ' (Year)

19 I HERE B4 CERTIFY that I have Investigated the death’'
of the person above-named and that the CAUSE AND MANNER thereof
are.as follows : (If' an injury was involved, state fully J

OS .... a.

20 Aooldent, aulolda, or homloide (specify).

Date of ooourrenoe.. 19SjUS>

Inju” ooour? ...J

^^(Cityror town and State)

Did Injury ooour In or about, horn*, on farm, In Industrial plaoo, or In publlo

place?

(2) n /) ' . *®peE?9k$Pe of place)

Manner i
Injury

Nature
Injury

While at work? (Z. Was there an autopsy?

<D f) b ' (Specify .type of place) /

J? ST *

21 Was disease or Injury In any way related to occupation of deoeased?
If so, speoify

(Signed)

(Address)

^ - M- o.

1*£7

22 ..Win.thr.qp. WlnthXQP..

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

2.Q .1.95.1.

DATE OF BURIAL

23 NAME OF

FUNERAL DIRECTOR

Reoelved and filed

ADDRESS .//W.lathr.Q.p.

M3i::sa:

(Registrar)

EXTRACTS FROM THE LAWS OF THE

COMMONWEALTH OF MASSACHUSETTS

GOVERNING THE

RETURN OF CERTIFICATES OF DEATH

A physician or registered hospital medloal officer shall forthwith, after
the death of u person whom he has attended during his last illness, at the
reqjcst of an undertaker or other authorized person or of any member of
the family of the deceased, furidsh 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 be.-t of his knowledge and belief, served
in the army, navy or marine corps of the United States in any war in which
it has been engaged, insert in the certificate a recital to that effect, speci-
fying the war, and shall also certify in such certificate both the primary
and the secondary or immediate cause of death as nearly as he can state
the same. For neglect to comply with any provision of this section, such
physician or officer shall forfeit ten dollars. For the purposes of this sec-
tion and of sections forty-five, forty-six and forty-seven of said chapter one
hundred and fourteen, the word “w.ar” shall include the China relief ex-
pedition and the 1’hilippine insurrection, which shall, for said purposes, be
deemed to have taken place between February fourteenth, eighteen hundred
and ninety-eight and July fourth, nineteen hundred and two, and the Mexi-
can bonier service of nineteen hundred and sixteen and nineteen hundred
and seventeen. O. L. Chap. 46, Sec. 10.

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

it has been engaged, such recital shall appear upon the permit. The board
of health, or. its agent, upon receipt of such statement and certificate, shall
forthwith countersign it and transmit it to the clerk of the town for regis-
tration. The person to whom I he permit is so given and the physician cer-
tifying the cause of death diall thereafter furnish for registration any other
necessary information which can be obtained as to tile deceased, or as to
the manner or cause of the death, which the clerk or registrar may re-
quire.— Chap. 114, Sec. 45, 0. L., (Tercentenary Edition).

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

Medical examiners shall make examination upon the view of the dead
bodies of only such persons as are supposed to have died by violence. If a
medical examiner has notice that there is within hig county the body of
such a person, he shall forthwith go to the place where the body liea and
take charge of the same;... — General Laws, Chap. 3S, Sec. 8.

... He shall in all cases certify to the town clerk or registrar in the
place where the decea.-ed died his name and residence, if known; otherwise
a description as full as may be, with the cauae and manner of death. —
General Laws, Chap. 88, Sec. 7.

. . . The medical examiner certifies the cause and manner of death to the
best of his knowledge and belief.

RULES OF PRACTICE

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

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

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

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

STATEMENT OF CAUSE OF DEATH
Medical Examiners in certifying to a death will state the cause and
manner thereof, aud will specify: (1) Under cause, the nature of an Injury
and of its consequences; and (2) under manner, the mode of its production
together with the circumstances when these are known. For example: “Com-
pound fracture of the femur with ensuing septicemia (gas bacillus) caused
by a steam railway accident.'’ “Pistol shot wound of the chest with asso-
ciated hemorrhage, homicidal.” “Asphyxiation by suspension, suicidal."
“Syncope while under the infiuence of ether administered as a surgical
anaesthetic.” “Fracture of the skull with associated internal injury sus-
tained under circumstances unknown.”

If diseuse or injury wa9 related to occupation, specify. If investigation
shows the death to have been due to disease, specify: (1) Under cause its
known or presumable nature; and (2) under manner, indicate the circum-
stances leading to medico- legs I inquiry. For example: “Hemorrhage spon-
taneous 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

R-301A

UCTIONS

■OR

CERTIFICATE

ultjp of fffltaaaarliUBTttB

EDWARD J. CRONIN
Secretary of the Commonwealth

DIVISION OF VITAL STATISTICS

STANDARD

CERTIFICATE OF DEATH

No.

2 FULL NAM

years months^*. Sr. days. In place of residence

Registered No.

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

(If death occurred

institution.

Q^StT*{ give its^NAME instead of street and number)

hospital

PHYSICIAN — IMPORTANT

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

(a) Residence. No.

(Usual place of abode)

Length of stay: In place of death

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

riving

>F DEATH

it enter
:han one
for each
b) and (c)

Iocs not mean
/ dying, such
ure. asthenia, .
ns the disease,
at ions which
h.

i conditions,
ng rise to the "
r (a) staling
lying cause

ions conlrib- •
death but not
he disease or
susing death.

3 DATE 01
DEATH

DICAL CERTIFICATE OF DEATH

(Day)

7737

(Year)

41 HER&'BY CERTIFY

TLA- «*7.

I last saw alive on

have occurred on the date sV^Ied above, at

Th^t I attended deceased from

. mV

19.$?, death is said to)

//•gfr.n

DISEASE OR CONDITION
DIRECTLY LEADIN
TO DEATH (a)

ANTE Due To
CEDENT (b)
CAUSES

DU-

OTHER

SIGNIFICANT

CONDITIONS

(T*-*r -

Major findings: Ktyn+Ui

Of operations * VY. . . .

tnnArJctytfW

Date of operation**^ _ W^autopsy performed?

What test confirmed diagnosis?

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

If so, specify

(Signed) „ , M

Received and filed

PERSONAL AND STATISTICAL PARTICULARS

9 COLOPLOR RACE

10 SINGLE
MARRIED
WIDOWED
or DIVORCI

10a If married, widowed, or divorced
HUSBAND of

(Give maiden na xiT. of wife in full) *
(Husband’s name in full)

(or) WIFE

14 Industry
or Business

15 Social Security No.

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

19 MAIDEN NAM
OF MOTHER

\ l ..

^ ^qk ,

AMEQ? / J7 ^

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, Secj9.

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)

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

Statement of Cause of Death. — 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

'M R-301A

►TRUCTIONS

FOR

Kl CERTIFICATE

n giving

E OF DEATH

not enter
re than one
se for each

I, (b) and (c)

is does not mean
\e of dying, such
failure, asthenia, .
neans the disease,
plications which
f ealh.

rbid conditions,
living rise to the '
luse (a) staling
derlying cause

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

SuffgJ,Sv»vr\'

Wint.hr op

(City or Town)

uiijr ^ummumui’uui] ui Maagaanjuama
EDWARD J. CRONIN
Secretary of the Commonwealth

DIVISION OF VITAL STATISTICS

STANDARD

CERTIFICATE OF DEATH

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

Registered No

no. 41 Washington Avenue. ...Winthr op St. { give its NAME instead of street and number)

2 FULL NAME

(If deceased is

Mary , E.f McDermott . (McKenzie)

s a married, widowed or divorced woman, give also maiden nameT)

PHYSICIAN — IMPORTANT

(Was deceased a
U. S. War Veteran,
x if so specify WAR) ... no

(a) Residence. No. 5 tr ee t St. E 3 S t B 0 S t OH * 5 S «

(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 i years months days.

3 DATE OF
DEATH

EDICAL CERTIFICATE OF DEATH

(Month)

I S- ~ Li f I

(Day) (Year)

4|[ HERE BM CERTIFY

iqS* 0 ,

I hm saw h-X2/l^alive on
have occurred on the date stated ;

attended deceased from

\ Jr i«T..(

1 19<\ |, death is said tc

DISEASE OR CONDITION
DIRECTLY LEADi;

TO DEATH (a)

ANTE Due To
CEDENT (b)
CAUSES

Due To
(c)

OTHER
SIGNIFICANT
CONDITIONS

Major findings:
Of operations

INTERVAL BE-
TWEEN ONSET
AND DEATH

PERSONAL AND STATISTICAL PARTICULARS

8 SEX

TejnaTe

9 COLOR OR RACE

white

10 SINGLE (write the woi
MARRIED
WIDOWED , ,
or DIVORCEEgyldOWe

Date of operation
What test confirmed diagnosis?

Was autopsy performed?

5 Was disease or i
If so. specify:

(Signed)

(Address) C ^

DATE OF BURIAL

Place .&L?,X?cr£SS,et*ry »

January 20th

FUNERAL DIRECTOR Richard C. Kirby
ADDRESS Boston, M fl?S.

Received and filed

m 2 2 1351

.19

(Registrar)

10a If married, widowed, or divorced
HUSBAND of

(Give maiden name of wife in full)

(00 wife of Vincent McBermott

(Husband’s name in Tull)

11 IF STILLBORN, enter that fact here.

/D rr//

If under 24 hours

Hours Minutes

Occupation: At HQIHft

(Kind of work done during most of working life)

Industry
or Business:

None

15 Social Security No. HOlift

16 BIRTHPLACE (City)

(State or country) 1

pe Breton
ftada

17 NAME OF
FATHER

18 BIRTHPLACE OF

FATHER (City)

(State or country) QaTiafla

John M . Me Ke n z 1 e

19 MAIDEN NAME

OF mother Many (CEL)

20 BIRTHPLACE OF

MOTHER (City)

(State or country) Canada

I HEREBY CERTIFY that a satisfactory af and ard certificate of death was
ijcd wy^ty me BEFORE Uie buri^or^tran yy 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 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 towrn
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 <ir
cause of the death, which the clerk or registrar may require. — Chap. 1 14. Sec. 45.
G. L.. (Tercentenary Edition).

Medical examiners shall make examination 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 unfil 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 th? 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.

Statement of Cause of Death. — Physicians: see explanatory instructions
on face side of standard certificate of death.

SPACE FOR ADDITIONAL INFORMATION none

DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE
RANK, RATING
ORGANIZATION AND OUTFIT
SERVICE NUMBER

M R-301A

TRUCTIONS

FOR

il CERTIFICATE

r» giving

L OF DEATH

not enter
e than one
»e for each
, (b) and (c)

s does not mean
e of dying, such
failure, asthenia, ,
leans the disease,
dications which
ealh.

rbid conditions,
living rise to the "
use (a) staling
ierlying cause

ditions conlrib- ■
the death but not

0 the disease or

1 causing death.

(Eommrmmroltlj of ffflaaHarljUHrttH

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.

Suffolk

(County)

Winthrop

(City or Town)

"] ZlZl y»ppf I (If death occurred in a hospital or institution

r r St. { give its NAME instead of street and number)

Registered No.

No.

2 full name Katherine T (Hold) Steinauer

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

(a) Residence. No. 144 He rmon St re e t

(Usual place of abode)

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

mber)

PHYSICIAN — IMPORTANT

(Was deceased a

U. S. War Veteran,

if so specify WAR)

St.

(If nonresident, give city or town and State)

In place of residence years months

days.

MEDICAL CERTIFICATE OF DEATH

3 DATE OF
DEATH

LIS

. i /(Month)

ll HEREBl/cERT IFY, UThat I attended deceased from

/ • iq , ,<47

j J last saw h alive •s ... 19 ^T^death is said to|

Viave occurred on the date stated above, at

J DISEASE OR CONDITION

DIRECTLY LEADING TV- D.,
TO DEATH (a) Hwi

ANTE Due To V**-

CEDENT (b) ’

CAUSES

?stT6

Aitu

siGNiFicANT^'^''*'^M-/*'MV,'‘tf

CONDITIONS

INTERVAL BE-
TWEEN ONSET
AND OEATH

Major findings:
Of operations.

Date of operation

What test confirmed diagnosis?

Was autopsy performed?

(Address) f

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

If so, speed

<s^Wvv- t ZTfiZSS '•/>* ,v

W inthro

Place of Burial orTremation

winthrop

(City or Town)

DATE OF BURIAL

7 NAME OF
FUNERAL DIRECTO

ADDRESS
Received and filed

RECTO W.t

^ t J an, 22

minm

(Registrar)

PERSONAL AND STATISTICAL PARTICULARS

8 SEX

Femal-

9 COLOR OR RACE

p White

10 SINGLE
MARRIED
WIDOWED
or DIVORCED

(write the word)

Widow

10a If married, widowed, or divorced
HUSBAND of

(Give maiden name of wife in full)

Charles J Steinauer

(Husband's name in full)

(or) WIFE of

11 IF STILLBORN, enter that fact here.

AGE W.T. Years

Months

Days

If under 24 hours

Hours Minutes

13 Usual

Occupation : .

Housewife

(Kind of work done during most of working life)

14 Industry
or Business:

15 Social Security No.

Own Home
None

16 BIRTHPLACE (City) .
(State or country)

Pennij£Lvania

17 NAME OF

FATHER -No Id

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

G-e rmany

19 MAIDEN NAME

OF mother Unable to obtain

20 BIRTHPLACE OF

MOTHER (City)

(State or country) Unable to obtain

Informant E- - ^

(Address) 144 Hermon^ot. Winthrop

I ELEREBY CERTIFY that a satisfactory standard certificate of death was
fildo with me BEFORE th^tjjmal ojhtransiV'permit was issued:

raMl&.

gnature o^/tojfnt 6f Board of other/ /

official 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, eightee

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