The volume, 1953
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EXTRACTS
FROM THE LAWS OF THE
COMMONWEALTH OF MASSACHUSETTS
GOVERNING THE
RETURN OF CERTIFICATES OF DEATH
A phracian or reRistered 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 decea^d, his supposed age. the
disease of which he died, defined as required by section one. where same xyas
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 deceas«l, to the best of his knowledge and belief, served in the
army, navy or marine corps of the United States in any war in whiifh it has been
eng.aged. 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.
ser\'ice 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 txjdy
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 satisfactor>" 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, unle^ 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 nopear 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 reifistra-
tion. The person to whom the permit is so given and the physician certifying
the cause of death shall thereafter furnish for registration any other necessary
information which can be obtained as to the deceased, or as to the manner or
cause of the death, which the clerk or registrar may require. — Chap. 114, Sec.
45, G. L. as amended by Chap. 48, Acts of 1927 and Chap. 414, Acts of 1931.
No undertaker or other person shall bury a human body or the ashes thereof
which have been brought into the commonwealth until he has received a permit
so to do from the board of health or its agent appointed to issue such permits,
or if there is no such board, from- the clerk of the town where the body is to be
buried or the funeral is to be held, or from a person appointed to have the care
of the cemetery or burial ground in which the interment is made Chap. 114,
Sec. 46, G. L.. as amended.
Medical examiners shall make examination upon the view of the dead ^dies
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
tlis^Ued by rec^mizable disease, or when any person is found dead — General
• ■Ld’wS' Chap. 38^ec. 6.. as amended by Chap. 632, Sec. 4. Acts of 1945.
The medical examiner certifies the cause and manner of death to the best
of iiis knowledge and belief.
' RULES OF PRACTICE
; fvtlfiHment of the purpose of these laws calls for the observance of the follow-
. ijigTules bfjjractice:
1 '(I) , Attending physicians will certify to such deaths only as those of persons
■'■to whom they hqve given bedside care during a last illness from disease unrelated
’ ,4o any form of injury. .
' 't (.i) Board of Health physicians will certify to such deaths only as those of
f.'^rsons whp, though disabled by recognized disease unrelated to any form of
< - ininrj'. hayO.died without recent medical attendance or whose physician is absent
faorrt'W^fe when the certificate of death is needed.
( Medical Examiners will investigate and certify to all deaths supposably
due''to irfjury. These include not only deaths caused directly or indirectly by
trapmatisip (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 jol persons not disabled by recognized disease, and those of
JJpAteifts Jdund dead)
,-.ls_.. I.* 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 tnese are known. For example: ' ‘Compound fracture of
the femur with ensuing septicemia (gas bacillus) caused by a steam railway
accident.” "Pistol shot wound of the chest with associated hemorrhage, hom-
icidal.” “Asphyxiation by suspension, suicidal.” “Syncope while under the
influence of ether administered as a surgical anaesthetic.” “Fracture of the
skull with associated internal injury sustained under circumstances unknown.”
If disease or injury was related to occupation, specify. If investigation
shows the death to have been due to disease, specify: (l)Under cause its known
or presumable nature; and (2) under manner, indicate the circumstances leading
to medico-legal inquiry. For example: “Hemorrhage spontaneous of the brain
(basal 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..
VI R-301A
AUCTIONS
FOR
. CERTIFICATE
giving
OF DEATH
)ot enter
than one
i for each
(b) and (c)
does not mean
of dying, such
lilure. asthenia, •
ans the disease,
ications which
jth.
tid conditions,
inng rise to the
se (a) slating
rrlying cause
)ns contrib- *
’eath but not
r disease or
*sing death.
Suffolk
(County)
T 1 n throp
(City or Town)
0Ii|F (SammamoFalti? of ilaB0arl|UBrttB
EDWARD J. CRONIN
Secretary OF THE Commonwealth
DIVISION OF VITAL STATISTICS
Registered No.
To be filed for burial permit
with Board of Health
or its Agent.
2
STANDARD
CERTIFICATE OF DEATH
ftp' I (If death occurred in a hospital or institution.
No St. \ give its NAME instead of street and number)
39 Jlrovers A
2 FULL NAME Annie. ..MacK.e.nna Mills..
(If deceased is a married, widowed or divorced woman, give also maiden name.)
(a) Residence. No 2^9. Ta s.b .ing.t ,o.n Ave,. St.
(Usual place of abode)
PHYSICIAN — IMPORTANT
(Was deceased a
U. S. War Veteran.
if so specify W'AR)
Length of stay; In place of death years months days. In place of residence .1.7. years months days.
(If nonresident, give city or town and State)
MEDICAL CERTIFICATE OF DEATH
^ DEATH J.A.nua rjT 6 195.3
(Month) (Day) (Year)
41 HEREBY CERTIFY, ^That I attended deceased from
i9..y;r to^^Ur^r^rrr. k 19
I last saw h .jS^rTrrr... alive on l^S^.2., death is said tc
have occurred on the date stOsA above, at
DISEASE OR CON
DIRECTLY LEA
TO DEATH (a)
Major findings;
Of operations..
Date of operation Was autopsy performed?..
What test confirmed diagnosis?....^:!
■7^
5 Was diseas^r injury in any way related to occupation of deceased?
If so, specily)
(Signed). M. D
(Addres^^?^n?.."M^^-'^-*^r*-*-;a;>>'*-^ 19).7T.V..
6 .I.ln.t.'i.rpp l.iD..tl.ro.p.
Place of Burial or Cremation (City or Town)
1^.3
DATE OF BURIAL
7 NAME OF
FUNERAL DIRECTOR...
T"
ADDRESS '
5^...
/hrop Mass
imrsz
Received and filed .™...-“.0.'.h 19
TOTT"
J'-'
(Registrar)
11 IF STILLBORN, enter that fact here.
12 93
AGE Years
Months Days
If under 24 hours
Hours .. -Minutes
13 Usual
HoiJ ae w1 f p
V
(Kind of work done during most of working life)
14 Industry
or Business: ..
.O.Vv'n Ho.me
■
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
Female
9 COLOR OR RACE
'.Vhi te
10 SINGLE
MARRIED
WIDOW
(write the word)
DOWEJ) .
DivoRCExrr ler^
10a If married, widowed, or divorced
HUSBAND of
(Give maiden name of wife in full)
(or) WIFE of .G-.e.o..rg.e. . .,M a.c K .e .n.n.a
(Husband's name in full)
15 Social Security No.
16 BIRTHPLACE (City) , ^ _
(State or country) PTlnije EuwaTl TslarK^f^
FA-nfER--a’=^n^^-5s '-l-ekrnbd-
18 BIRTHPLACE OF
FATHER (City) ^
(State or country) F(^ward TslancS -
19 MAIDEN NAME !~fGJ>o>u O. lu VO 1 li
OF MOTHEganno t be- leaT’ned—
20 BIRTHPLACE OF
MOTHER (City)
(State or country) prlnce Fdv/ard Island
Informan
(Address)
ve
I HEREBY CERTIFY that a satisfactory standard certificate of death was
filed with me BEFC^E the burial oiv<f3hsit n^mit was issued:
(O
/ (Signatur^f JfaSu-of Btard of Health orothftjr^'^
MO.
fncial Designation) . (Date of Issue (^Permit)
^ /
EXTRACTS
FROM THE LAWS OF THE
COMMONWEALTH OF MASSACHUSETTS
GOVERNING THE
RETURN OF CERTIFICATES OF DEATH
A physician or rci?istercd 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
l)est of his knowledge and belief the name of the decea^d. 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.
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 he obtained as to the deceased, or as to the manner or
cause of the death, which the clerk or registrar may require. — Chap. 114, ^c. 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, therrnal or electrical agents or follo\Wng 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.
A physician or officer fumi.ffiing a certificate of death as required by the
preceding section or by sectioi: forty-five of chapter one hundred and four-
teen. shall, if the decea^d. to ihe best of his knowledge and belief. ser\'cd 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 secondar>' 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,' £ C* E
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 ‘nken 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 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.
. . . (ihap. 114, Sec. 46, G. L.. (Tercentenary Edition).
RULES OF PRACTICE
No undertaker or other person shall bur>’ or otherwise dispose of a human body
in a town, or remove therefrom a human body which has not been buried, until
has received a permit from the board of health. or*its agent appointed to issuer;
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 arui,'v,
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
ltb.^^0mi^bey have given bedside care during a last illness from disease unrelated
\tb*ahy‘fqrm,of injury.
(2) ^ Bb>t^ 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'. hav5e died without recent medical attendance or whose physician is absent
from home-when the certificate of death is needed.
(3) ^IS^dical Examiners will investigate and certify to all deaths supposably
remove it from a town, from one cemetery to another, or from one grave or torr^‘ include not only deaths caused directly or indirectly byj
other than the receiving tomb to another in the same cemetery, until he has\ (inclu(h resulting septicemia), ami by the action of chemical
•* - ... . 9fP?**^ns) thermal, or electrical agents, and deaths following abortion, but
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 ^
law. 9r in lieu thereof a certificate as hereinafter provided. If there is no atteneyfc r|
physician, or if. for sufficient reasons, his certificate cannot be obtained early '
gefeo-jd^aihs from disease resulting from injury or infection related to occupation,
>the ^dden deaths of persons not disabled by recognized disease, and those of
persons -found dead.
Staternent oCi Uause of Death. — Physicians: see explanatory instructions
face side of standard certificate of death.
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
Statement of Occupation. — Precise statement of occupation is very import-
ant. so that the relative healthfulness of various pursuits can be knowm. 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, w'rite 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
LM R-301
nucTioiis
rot
L CElTinCATE
I f irinc
OF DEATH
not enter
I than one
• for each
(b) and (c)
' does not mean
of dying, such
lilure, asthenia, .
usns the disease,
'ications which
ath.
Hd conditions, .
ving rise to the *
iw (a) slating
erlying cause
Utions contrib- •
He death but not
the disease or
causing death.
0
Suffolk..
(County)
...V/irLt.h.r.0.0
(City or Town)
dlammnmoraltt; of fflaBaartiuartta
EDWARD J. CRONIN
Secretary OF THE Commonwealth
DIVISION OF VITAL STATISTICS
STANDARD
CERTIFICATE OF DEATH
Registered No.
No. “ •-
give its NAME instead of street and number)
2 FULL NAME.. ....Me..l.i.a....Jf,ne. (a..Qbl5,.) Be.lQ.i10r _.../ (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 .1.5 Blmw.o..Q(i....vd.v.e.a st
(Usual place of abode) (If nonresident, give city or town and State)
Length of stay: In place of death years months days. In place of residence.70 years months days.
MEDICAL CERTIFICATE OF DEATH
" DEATH ! January 9^.
(Month) (Day)
(Year,
41 HEREBY CERTIFY, ^ attended deceased from
19.y^..., 19.4!3
I last saw h.i/..^...aUve ..2C. 19. death is said to|
have occurred on the date above, at..y(.«^ ,m. IlNTERfAL BE
TWEER ONSn
AMD DEATR
DISEASE OR CONDITION
DIRECTLY LEADING
TO DEATH (a).
ANTE Due To
CEDENT (b)
CAUSES
%Se
Due To
(c)
OTHER
SIGNIFICANT
CONDITIONS
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
'emale
9 COLOR OR RACE
White
10 SINGLE (write the word)
MARRIED j ^ j
WIDOWED wi Q owe a
or DIVORCED
10a If married, widowed, or divorced
HUSBAND of -
(Give maiden name of wife in full)
(or) WIFE of He.iiry ...Mo o re Be lo he r.
(Husband's name in full)
1 1 IF STILLBORN, enter that fact here.
12
agB9. . ..Years. 3 Months. 18. ..Days
If under 24 hours
Hours Minutes
5 Was disease or injury ir^njLS^ay related to occupatipp ot d
_ of deceased?....^!
If so, specify.'):
(Signed)...ju><..Xt.V:^--?^--<T(:..F:.)X ^..... m. p.
Wint.hrop.„..Q^ .Winthrop...”
Place of Burial or Cremation
DATE OF BURIAL .M Qry[ny.
(City or Town)
12.,.., ...lB.3.,
A TRUE COPY ATTEST:
Kation: ^9 iisework
(Kind of work done during most of working life)
era home.
IS Social Security No n On0
16 BIRTHPLACE (City) Q j
(State or coimtry) pToiy|(**. P
'^own
17 NAME OP
FATHER
Samuel Oobb
18 BIRTHPLACE OF
FATHER (City)
(State or country)
England
19 MAIDEN NAME
OF MOTHER
Mary Brakey
20 BIRTHPLACE OP
MOTHER (City) ...
(State or country)
Ireland
Informant .Karrison C. B0.1c.her..
(Address) 15 H^lmwood Ava.^
CERTIFY that a satisfactory standard ^rtificate of death was
BJ^^)ORE the buii^^^r transi^^fjbrmit ^/is issued:
Board of Health or -otfier) /
(Date of Issue of Permip ^
EXTRACTS
FROM THE LAWS OF THE
COMMONWEALTH OF MASSACHUSETTS
GOVERNING THE
RETURN OF CERTIFICATES OF DEATH
A phvsician or registered hospital medical officer shall forthwith, after the
death o? 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 decca^d. 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 aliv'e by the physician
or officer and the date of his death. . .Gen. Laws. Chap. 46, Sec. 0.
A physician or officer furnishing a oeriifie&te off 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 Stat^ ip any war in which it has been
engaged, insert in the certificate a recital to tjjat eff<jct, specifying the war, and
shall also certify in such certificate both and the secondary or imme-
diate cause of death as nearly as he can staW.tf^.Jsairie. 'For neglect to comply
with any provision of this section, such phy;^iQi^rt‘or offi6^r/;9hall forfeit ten dollars.
For the pun>oses of this section and of sections /oiit^-fivei'^pty-six and forty-seven
of said chapter one hundred and fourteeii, t^ ^dro^/war’V.simll'include the China
relief exj>ealtion and the Philippine insurneciion, which shkUjfor said purposes, be
deemed to have taken place between PebrtJi^ry fourteenth-1 eighteen hundred and
ninety-eight and July fourth, nineteen hirfid^^d and two;'»a6dThe Mexican border
service of nineteen hundred and sixteen’ Hundred and seventeen.
G. L. Chap. 46, ^c. 10. \*^/ **^*' ^
No undertaker or other person shall bury 'dispose of a human body
in a towTi, or remove therefrom a human bod/ ^/iich tjasyiot been buried, until he
has received a permit from the board of healt^r^s-Us^gent 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 ^ . human body and
remove it from a town, from one cemetery or from’ofie grave or tomb
other than the receiving tomb to anottt3rthwt£e »fea?me 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 w'ritten statement containing the facts required by law to be
returned and recorded, which shall be accompanied, in case oi 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 reaspns. 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 chaoter 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 api>ear upon the permit.
Tbe 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 bydy 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 b^n 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 w'hich the interment is made.
. . . Chap. 114, Sec. 46, G. L.. (Tercentenary Edition).
RULES OF PRACTICE
The fulfillment of the purpose of these laws calls for the observance of the follow-
ing rules of practice:
(1) Attending physicians will certify to such deaths only as those of persons
to whom they have given bedside care during a last illness from disease unrelated
to any form of injury.
(2) Board of Health physicians will certify to such deaths only as those of
persons who. though disabled by recognized disease unrelated to any form of
injury, have died without recent medical attendance or whose physician is absent
from home when the certificate of death is needed.
(3) Medical Exanniners 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
M R-301A
raUCTIONS
FOR
L CERTIFICATE
I giving
; OF DEATH
not enter
b than one
e for each
, (b) and (c)
; does not mean
of dying, such
dilure, asthenia, •
cans the disease,
lications which
:ath.
bid conditions,
iving rise to the '
use (a) stating
'erlying cause
iilions contrib- ■
he death but not
> the disease or
causing death.
\ y
(flammonoiraltl) of ffflasBarliuBPttB
L V t' ^ crr-4\A/Am-\ i
EDWARD J. CRONIN
Secretary OF the Commonwealth
DIVISION OF VITAL STATISTICS
STANDARD
CERTIFICATE OF DEATH
Registered No.
To be Bled for burial permit
with Board of Health
or its Agenta
" 4
2 FULL NAME
Length of stay:
.
idowed or divorced woman, give also maiderjrname.)
V ^
In place of death years /... months days. In place of residence
I (If death occurred in a hospital or institution,
St. \ give' its NAME instead of street and number)
(If deceased is a ma
(a) Residence. No.
(Usual place of abode)
St.
PHYSICIAN — IMPORTANT
(Was deceased a
U. S. War Veteran.
if so specify WAR)
(If nonresident, give city or town and State)
(..years months days.
EDICAL CERTIFICATE OF DEATH
3 DATE OF
DEATH
BY CERTIFY
/.>-
^'T^at I attended deceased from
19 \a 19?^.
I last saw h .r^.f.. . .alive on
have occurred on the date (Stated above, at . ..Z:
19 .:^...'^yeath is said to
DISEASE OR CONDI
DIRECTLY LEADl/(
TO DEATH (a)
ANTE Due To
CEDENT (b)
CAUSES
Muiva.
OTHER
SIGNIFICANT .
CONDITIONS
Major findings:
Of operations.
kAGE
Date of operation. autojjsy performed?.
What test confirmed diagnosis!
■y-f
5 Was disease or^njury in any way related to occuj^ation of deceased?.
If so, specifyf../
(Signed) M. D
(Address) . . . . .,^^.^w<lLr^C^r.w..5C^^i..^?'wate.^..../. . .T. . .T . 1 9s/. . .
lace of BUTfil or Cremat]
DATE OF BURIAL
(City or Town)
Received and filed ........'...‘.7. !...'.^^y. 19
(Registrar)
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
9 COLOR OR RACE | mARrPeD
WLz:
WIDOWED
or DIVORCE
10a If married, widowed, or divorced
HUSBAND of
(Giv^eyn^den
/I tLjiv^eyn^clen r^me of wife in full) ^ ^
WIFE
(Husband’s name in full) t
(or)
1 1 IF STILLBORN, enter that fact here.
' V \
Years Months Days
13 Usual
Occupation:
If under 24 hours
Hours Minutes
14 Industry
or B usmess : ^ ^
(Kind of work done during most of working life)
15 Social Security No.
16 BIRTHPLACE (City)..
(State or country)
17 NAME ^ •
FATHE i-Al- .
18 BIRTH
FATHER (City)
(State or country)
19 MAIDEN NAME
OF MOTHER
20 BIRTHPLACE OF
MOTHER (City)
(State or country)
I HEREBY CERTIFY that a satisfactor^standard certificate of death was
file^with jne BEFORE Me/burial.«r trai^t permit was issued:
of Board of-^ealt'h or other)
z
(Date of Issue of Perftit,
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
lx^st of his knowledge and belief the name of the decea^d. his supposed age. the
disease of which he died, defined as required by section one. where same %yas
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 fumi.>hing a certificate of death as required by the
preceding section or by sectior: forty*five of chapter one hundred and four-
teen. shall, if the deceased, to ihe 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
w’ith 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 ‘aken 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 hury 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 towm. from one cemetery to another, or from one grave or tomb
other than the receiving tomb to another' in the same xemetery. 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. Xo 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, w'hich shall be accompanied, in case of an original inter-
ment, by a satisfactory certificate of the attending physician, if any, as required by
law. or in lieu thereof a certificate as hereinafter provided. If there is no attending
physician, or if. for sufficient reasons, his certificate cannot be obtained early
enough for the purpose, or is insufficient, a physician who is a member of the board
of health, or employed by it or by the selectmen for the purpose, shall upon
application make the certificate required of the attending physician. If death is
caused by violence, the medical examiner shall make such certificate. If such a
permit for the removal of a human body, not previously interred, from one town
to another w’ithin the commonwealth cannot be obtained early enough for the
purpose, the certificate of death made as above provided and in the possession of
the undertaker desiring to make such removal shall constitute a permit for such
removal; provided, that such body shall be returned to the town from which it was
removed within thirty-six hours after such removal, unless a permit in the usual
form for the removal of such body has been sooner obtained hereunder. If the
death certificate contains a recital, as required by. section ten of chapter forty-six,
that the deceased served in the army, navy or marine corps of the United States
in any war in which it has been engaged, such recital shall appear upon the permit.
The board of health, or its agent, upon receipt of such statement and certificate,
shall forthwith countersign it and transmit it to the clerk of the town for registra-
tion. The person to whom the permit is so given and the physician certifying
the cause of death shall thereafter furnish for registration any other necessary
information which can be obtained as to the deceased, or as to the manner or
cause of the death, which the clerk or registrar may require. — Chap. 114, Sec. 45,
G. L.. (Tercentenary Edition).
Medical examiners shall make examination upon the view of the dead bodies
of persons as are supposed to have died by violence, or by the action of
chemical, thermal or electrical agents or following abortion, or from diseases
resulting from injury or infection relating to occupation, or suddenly when not
disabled by recognizable disease, or when any person is found dead. .. — General
Laws, Chap. 38, Sec. 6.. as amended by Chap. 632, Sec. 4, Acts of 1945.
Xo 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 frort] the board of health or its agent appointed to issue such permits, or
if there is no^uch 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.
. . . Chapi 114, Sec. 46, G. L.. (Tercentenary Edition).
I . V r tr
" *- 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 the^ have giyen bedside care during a last illness from disease unrelated
to any form of -jn jury;, ‘
(2) Board of Heal th, 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 certificat’e'.of death is needed.
(3) Medical Examiner<>vill investigate and certify to all deaths supposably
due to injury. '»*.These incliidp not only deaths caused directly or indirectly by
traumatism Xi9Clitdipg.,r^ulung septicemia), and by the action of chemical
(drugs or poifems) ’t*hfem1ih of electrical agents, and deaths following abortion, but
also deaths fronu^tofease resulting from injury or infection related to occupation,
the sudden deathsTof^^sons not disabled by recognized disease, and those of
persons found dead. .
Statemeri^.of Cause of Death. — Physicians: see explanatory instructions
on face gte (>/ standard certificate of death.
Statement of Occupation. — Precise statement of occupation is very import-
ant. so that the relative healthfulness of various pursuits can be known. Make
spme entry in this section for every person aged 10 years or over. If the occupa-
tion had been given up or changed, or if the deceased had retired from business,
report the kind of work done during most of working life even if retired. Children
not gainfully employed may be returned as at school or at home. For a woman
whose only occupation was that of home housew'ork, write housework. For a
person engaged in domestic service for wages, however, designate the occupation
by the apprcjpriate terms, as housekeeper — private family, cook — hotel, etc. For
a person who had no occupation whatever write none.
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE
RANK. RATING
ORGANIZATION AND OUTFIT
SERVICE NUMBER
25M-(H)Ilol-9f)5807
A
Suffolk
(County)
Boston
(City or Town)
{Hir (Sammamtipaltii of HaooarliuarttB
EDWARD J. CRONIN
Secretary OF THE Commonwealth
DIVISION OF VITAL STATISTICS
COPY OF
CERTIFICATE OF DEATH
(City or town making return)
Registered No.
^
Q
§
ui
u
eu
2 FULL NAME ^ TVOmO . 1 (Was deceased
(If deceased is a married, widowed or divorced woman, give also maiden name.) I U. S. War Veteran,
I if so specify WAR)
Boston
^ 1 U death occurred in a hospital or institution,
iftSlSSa-GsnjGX^Sll- St. \ give its NAME instead of street and number)
(a) Residence. No.
y if so specify W
Charles St- st •
(Usual place of aWOe) **“ (If nonresident, give city or town and State)
Length of stay: In place of death years months days. In place of residenl3 years months days.
MEDICAL CERTIFICATE OF DEATH
PERSONAL AND STATISTICAL PARTICULARS
3 DATE OF
DEATH ...
(Month)
8 SEX
(Year)
41 HEREBY CERTIFY, That I attended deceased from
•• 19.53
I last saw h 0^ive on Jaxu9 19 53 death is said tc|
have occurred on the date stated above, at .. 2t3SM«
9 COLOR OR RACE
W
10 SINGLE (write the word)
MARRIED
WIDOWED Married
or DIVORCED
DISEASE OR CONDITION
DIRECTLY LEADING
TO DEATH (a) i^llnOnaTy . ^ ^
ANTE Due To
CEDENT (b)
CAUSES
Due To
(c)
SIGNIFICANT ,Cc)r...p!ulr[ipnale .
CONDITIONS
IRTERVU (E
TWEER OHSET
RRO OERTR
10a If married, widowed, or divorced
HUSBAND of
(Give maiden name of wife in full)
(or) WIFE of
Oner ; P.oulin
IHusband s name in
full)
11 IF STILLBORN, enter that fact here.
12 I
AGE Months .IwUi
Days
If under 24 hours
Hours Minutes
13 Usual
Occupation:
(Kind
Shoe Worker
ind of work Gone during most of
working life)
14 Industry
or Business:.
.Shoe Factor
15 Social
Security No ,,.0Q7UQ34i3li6
3 Wo{ ;
16 BIRTHPLACE (City) Maine
^ (State or country)
Major findings:
Of operations liOfie
Date of operation Was autopsy performed ?I.e8 .
What test confirmed diagnosis?..
mitcpay:
5 Was disease or injury in any way related to occupation of deceased?....
If so. specify
(Signed) C (34iy- if ^
<Address) Maea»0flneral
M.
19..
!.'....% J
^ Pl^e of Burial or
DATE OF BURIAL
19
7 NAME OF
FUNERAL DIRECTOR.,
ADDRESS
HjS....Re3^
Ui
Received and filed --
(Registrar of City or Town where deceased resided)
.19..
17 NAME OF
FATHER
Joseph Tardif
18 BIRTHPLACE OF
FATHER (City)
Can^xia
(State or country)
19 MAIDEN NAME
OF MOTHER
Mary Labrie
20 BIRTHPLACE OF
MOTHER fCitvl
lilncoln Maine
(State or country)
1
O
f Address) — - ^
A TWUE COPY
/A
DATE FILED
(Registrar of City or Town where death occurred)
Ja«wJ-2./5.3 19 -
REOElVt- P
FEBr2,l^5«
r
. "1 .
>
1 R-301A
tUCTIONS
FOR
ttRTIFICATE
giving
OF DEATH
ot enter
than one
for each
(b) and (c)
dots not mtan
of dying, such
Hurt, asthenia, ,
ms the disease,
cations which
th.
id conditions,
ing rise to the
'■e (o) slating
'tying cause
lions conirib- •
death but not
the disease or
tausing death.
0
c» CSammonturaltl; of AasBartiufirttB
< Suffolk
Q (County)
o .Winthrop
jij (City or Town)
OFFICE OF THE SECRETARY
DIVISION OF VITAL STATISTICS
STANDARD
CERTIFICATE OF DEATH
Registered No,
To be filed for burial permit
with Board of Health
or its Afent.
B
— jj_TT i (If death occurred in a hospital or institution.
No YlXntiU’Op COnilllUUl ty—XlOSpi'tS/l St. | give its name instead of street and number)
, PHYSICIAN — IMPORTANT
2 FULL NAME FTcUicis A e. Leduy I (Was deceased a
(If deceased is a married, widowed or divorced woman, give also maiden name.) j U. S. War Veteran.
I if so specify WAR) Jj.Q
(a) Residence. No. .. 86....Beal St ..Winthrop st
(Usual place of abode) (If nonresident, give city or town and State)
Length of stay: In place of death years months days. In place of residence 6 . years months days.
MBDICAL CERTIFICATE OF DEATH
3 DATE OF
DEATH ...
H E R E B
io - /
(Month) ■■ (Day) (Year)
CERTIFY, ^ That I attended deceased from
last tiaw alive on
19
( 0
19
rj.
death is said tc
have occurred on the date stated above, at
W ir-
DISEASE OR CONDITIO
DIRECTLY LEADING
TO DEAJH (a)
ANTE Due To
CEDENT (b)
CAUSES
T
Due To
(c)
OTHER
SIGNIFICANT
CONDITIONS
Major findings: [ ,
Of nnerations
INTERVAL BE
TWEEN ONSET
AND OERTN
Of operations
Date of operation
■Was autops>^erforme<^
What test confirmed diag^sis?
7u7
S Was disease or injuty
If so, specify..-./;!
any way related to occupation of deceased?:
(Address) Dat?>^.» ...
6 Holy .Cross...
Place of Burial or Cremation (City or/Town)
M. D
19
(City or/Town)
DATE OF BURIAL .J.a.nuary.M 19
^ FUNERAL DIRECTOR . .Richar.d....C..» Kir.hy.
ADDRESS 91.7....B.ennin.g.t.Qix...S..t. ..Ms..t. ...BQS^^
Tmtrx
Received and filed 19
(Registrar)
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
male
9 COLOR OR RACE
white
10 SINGLE
MARRIED
(write the word)
WIDOWED
or DIVOR
cEijaarried
10a If married, widowed, or divorced
HUSBAND of Laura 3ur ette
(Give maiden name of wife in full)
(or) WIFE of
(Husband’s name in full)
II IF STILLBORN, enter that fact here.
12
AGE 5:Q Years ..., 7. Months ...2 3l^ays
If under 24 hours
Hours Minutes
13 Usual
Occupation:. . ..General for eman
(Kind of work done during most of working life)
orX^Tness: ..G.e.neral Sl.ectric . Lamp ..Ylorks
Social Security No G.1..SL..
BIRTHPLACE (City)..
(State or country)
tias.t....B.o.stQn.
Mass
17 NAME OF
FATHER
John Leddy
18 BIRTHPL.\CE OF
FATHER (City)
(State or country)
Ireland
19 MAIDEN NAME
OF MOTHER
Mary Sullivan
20 BIRTHPLACE OF
MOTHER (City) ..
(State or country)
Ireland
f ^■SS‘
wif.e..
on
I HEREBY CERTIFY that a satisfactory standard certificate of death was
filed witif me BEFORE the bur^^r transit permit was issued:
(Bigifature oLA^^^^f B^ard of Health or^tlie
(Date of Issue of Per/hit) y
ncial Designation)
EXTRACTS
FROM THE LAWS OF THE
COMMONWEALTH OF MASSACHUSETTS
COVERNINO THE
RETURN OF CERTIFICATES OF DEATH
A physician or reijistered 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 d^eased. to the best of his knowledge and belief, sepred in the
army, navy or marine corps of the United States in any war in which it has been
eng.nged. 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. &c. 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, uivtil 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 f^ts 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 exaininer 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, unle^ 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 s^tion 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 hosiTd of health, or its agent, upon receipt of such statement and certificate,
shall forthwith countersign it and transmit it to the clerk of the town for registra-
tion. The person to whom the permit is so given and the physician certifying
the cause of death shall thereafter furnish for- registration any other necessary
information which can be obtained as to the deceased, or as to the manner or
cause of the death, which the clerk or registrar may require. — Chap. 114, Sec. 45,
G. L.. (Tercentenary Edition).
Medical examiners shall _make examination upon the view of the dead bodies
of only such persons as are supposed to have died by violence. If a medical
examiner has notice that there is within his county the body of such a person, he
shall forthwith go to the place where the body lies and take charge of the same ;
. . . General Laws. Chap. 38, Sec.6.
No undertaker or other persons shall bury a human body or the ashes thereof
which have been brought into the commonwealth until he has received a permit
so to do from the board of health or its agent appointed to issue such permits, or
if there is no such board, from the clerk of the town where the body is to be buried
or the funeral is to be held, or from a person appointed to have the care of the
cemeteiy or burial ground in which the interment is made.
. . . (ihap. 114, Sec. 46. G. L.. (Tercentenary Edition).
■ “ - R-ULES 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. I ,
(2) Board of Health physicians will certify to such deaths only as those of
persons who. though disabled by recognized disease unrelated to any form of
injury, have died without -recent medical attendance or whose physician is absent
from home when the certificate of death is needed.
(3) Medical Examiners will investigate and certify to all deaths supposably
due to injury. These include npt only deaths caused directly or indirectly by
traumatism (including resulting s^ticemia), and by the action of chemical
(drugs or poisons) tbertnal,' or electrical agents, and deaths following abortion, but
also deaths from diseai^ ros.ulting from injury or infection related to occupation,
the sudden deaths of persons riot disabled by recognized disease, and those of
persons found dead.
Statement of CpyM of Death. — Physicians; see explanatory instructions
on face side of stg^a^-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 perMn aged 10 years or over. If the occupa-
tion had been given up or changed, or if the deceased had retired from business,
report the kind of work done dunng most of working life even if retired. Children
not gainfully emplo>;ed may be returned as at school or at home. For a woman
whose only occupation wm 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-302
Suffolk
(County)
Boston
(City or town)
<SammantoraU4 AaasarlynBPttB
EDWARD J. CRONIN
Secretary OF THE Commonwealth
DIVISION OF VITAL STATISTICS
COPY OF
CERTIFICATE OF DEATH
j
.Bos.tpn
(City or town making return)
Registered No. .
JIS..
i(If death occurred in a hospital or institution.
No St. \ give its NAME instead of street and numt^r)
2 FULL NAME j^.ther Mele | (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 l^SI....ShQro.Dil:ro gt iSinthrop Mas.a*
(Usual place of abode) (If nonresident, give city or town and State)
Length of stay: In place of death years months....^ . ..days. In place of residence years .Ij ..months days.
MEDICAL CERTIFICATE OF DEATH
3 DATE OF T •%
DEATH van.*I.0/.53
(Month) (Day) (Year)
41 HEREBY CERTIFY, That I attended deceased from
9 ■. 19 5-3 • lo .Jon.*.. .10 19 53
I last saw h...4jy..... alive on JaxulQ 19 53 death is said tcj
11«3U m
have occurred on the date stated above, at
DISEASE OR CONDITION
DIRECTLY LEADING
TO DEATH (a)
abscess of ,
l? L t Tilth lieffib ge
ANTE
Due To
CEDENT
CAUSES
(b)
I(jft
Due To
(c)
OTHER
SIGNIFICANT
cor pulnonale
CONDITIONS
tiypertroptiy
IITEIVU IE
niEEi Msn
UO lEATN
? Moa
Xoairs
Year a
Major findings;
Of operations
Date of operation Was autopsy performed?. ...Yea
What test confirmed diagnosis? • aH’tOpay -
5 Was disease or injury in any way related to occupation of deceasedK.i;^^?..
If so, specify..
(Signed)
(Address)
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
9 COLOR OR RACE
10 SINGLE (write the word)
MARRIED
WIDOWED w
or DIVORCED l«U*I*ieCl
DATE OF BURIAL
Jan/13/53.
.19
7 NAME OF
FUNERAL DIRECTOR.
ADDRESS.
J H Grans tr cm.
Bostcxi ttass.
Received and filed UfJLuLi -ij—ji
(Registrar of City or Town where deceased resided)
,.19..
lOa If married, widowed,
HUSBAND of
fori WIFE of
or divorced
(Give maiden name of wife in full)
..Alexander. ..A .Mel®.
(Husband's name in full)
11 IF STILLBORN, enter that fact here.
12
AGE .JtT7..Years^^ Month J.9 Days
If under 24 hours
Hours Minutes
• 13 Usual
(Kind <}#W{>H?®Jil^fllflng most of working life)
14 Industry
or Business:
At. Hoina
15 Social Security No
16 BIRTHPLACE fCitvV.
(State or country)
J3O3X0n waaue
17 NAME OF
FATHER
fUmnar* FI
75
h
18 BIRTHPLACE OF
FATHER fCitvl
2
U
Of
<
(State or country)
19 MAIDEN NAME
OF MOTHER
S-i ma T,nnf^PiT
1^ BIRTHPLACE OF
^*^febTHER (City) ..
1*
(State or country)
Dtiecien
21
fAddressj
Axc3can(ler ■ A - -Heie
A TRUE, COPY
hen
Jan/ 111/ 53
of C^y or Town where death occurred)
DATE PILED 19
IAN'
LM R-302
« «T
^3
ft
•<=*0
II
'W
"Sld
3 Gf^
5'i-
III
:ss
ai-ft
"•C&
•s«5
5°^
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!?“■?
•r «> E
oji b
Hi
§fc-g
|°l
U-
«ic
a 9 o
^§6 ^
:jit ?
E-o o
III 5
Oj: « J.
t a5 5
-
r
Q[ifr (Dantmamoraltii of ^^aoaarlfnBrttB
EDWARD J. CRONIN
BOSTO-
Secretary of the Commonwealth
f DIVISION OF VITAL STATISTICS
(City or town making return)
8
1 :....
1 COPY OF
447
Registered No ;.
[...BQSTQH.
TCSyorTown)
^ . T T n _ I (If death occurred in a hospital or institution.
No <D.d.uii -Ai.S-Z^&&.a....Xi'0-S-P^>L-b&X 'XJdS^' ^ NAME instead of street and number)
2 FULL NAME \Vl.LLXAM.,..LAiiDS.;.d-^ | (Was deceased a
(If deceased is a married, widowed or divorced woman, give also maiden name.) | U. S. War Veteran,
. ~-j~ I if so specify WAR)
(a) Residence. No. ... ,5.0.1....Shi..r.le.,y....Aw.<r..« xx3c
(Usual place of abode) Xlr nonresidenT, five city or town and State)
33
Length of stay: In place of death years months.. V.V... days. In place of residence years months days.
MEDICAL CERTIFICATE OF DEATH
DEATH*^.... Jan lap J 15 19.53
(Month) (Day) (Year)
41 HEREBY CERTIFY, That I attended deceased from
12/lA., 19 .52. to , 1/15. i6.3
I last saw h... im .alive on 1/16 33 death is said toj
have occurred on the date stated above, at. 10a25pa
DISEASE OR CONDITION
DIRECTLY LEADING
TO DEATH (a) h.yper.t.e.n3lvQ li0art
di aaaae
ANTE Due To
CEDENT (b)
CAUSES
uremia
^^To malignant h^ertension
OTHER
SIGNIFICANT .
CONDITIONS
laTERVU IE
TWEER RRSn
UD RUTR
Major findings:
C>f operations
Date of operation Was autopsy performed?. ..y.e..8
What test confirmed diagnosis?
5 Was disease or injury in any way related to occupation of deceased?..
If so, specify
(Signed) J ...Rublnst-ein
(Address) 33Q Br kI . Aye w D^te
M. D
>^53
DATE OP BURIAL..
sn ^V^^^^yor^wn)
.Jan Ig 19
7 NAME OF
FUNERAL DIRECTOR
H Tqrf
ADDRESS Qialsea^ Maaa«--
Received and filed..
Iffi
.19..
(Registrar of City or Town where deceased resided)
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
u
9 COLOR OR RACE
w
10 SINGLE (write the word)
MARRIED
WIDOWED **^arr*led
or DIVORCED
10a If married, widowed, or divorced
HUSBAND of "11.11 an . Gre©.n
(or) WIFE of
(Give maiden name of wife in full)
(Husband's name in full)
11 IF STILLBORN, enter that fact here.
*2 42
AQE.?. Years Months Days
If under 24 hours
Hours Minutes
13 Usual
Occupation:
Proprietor
(Kind of work Bone during most of working life)
or BuSness:.. ...R.^.tall g.QQ.d.a.^
IS Social Security No... 0X.lrQ3-.095.1
16 BIRTHPLACE (City) .5pS t OH
(State or country) ' MaSS ■
17 NAME OP , - ,
FATHER harry Landasian
18 BIRTHPLACE OF
FATHER (City)
(State or country)
Hiissi'a’
19 MAIDEN NAME
OF MOTHER J OHnl© Beckerrflan
20 BIRTHPLACE OF
MOTHER (City) ....
(State or country)
Hussia
21
Informant
(Address)
A TRUE
ATTEST:
L- Landsman
(Registrar of City or Town where death occurred)
Jan 19 53
DATE PILED - 19
V
seceivi;d
!
«
]
j
s
I
J
\
\
lO
R-301A
RUCTIONS
FOR
. CERTIFICATE
flrtving
OF DEATH
lot enter
than one
I for each
(b) and (c)
does not mean
of dying, such
ilure, asthenia, >
the disease,
icalions which
Uh,
id conditions, .
nng rise to the *
se (a) stating
flying cause
itions contrib- •
e death but not
the disease or
causing death.
2 FULL NAME
\ . (County)
(dammontDFalt^ of USttBaadinoFtto
EDWARD J. CRONIN
Secretary OF THE Commonwealth
DIVISION OF VITAL STATISTICS
STANDARD
C^TIFICATE OF DEATH
jP
(City or Tow^) •
No. . I
(If deceased is a married, |widowed or divorced woman, give also maiden name.)
! 3^'\)i&sWinc^v)
Registered No.
To be filed for burial permit
with Board of Health
or Its Agent.
9
__ I (If death occurred in a hospital or institution,
give its NAME instead of street and number)
(a) Residence. No
(Usual place of abode)
PHYSICIAN — IMPORTANT
(Was deceased a
U. S. War Veteran,
if so specify WAR)
Length of stay: In place of death years months days. In place of residence
36
(If nonresident, give city or town and State)
years months days.
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
DEATH
77
(bay)
^I HEREB7 CERT I P^^^pA^hat I attended deceased from
/ 2 19 <5**3.., \o y. I94>3i
I last saw h fc<^ alive on ■“" / 7 19 death is said tc|
// ^
have occurred on the date stated above, at
DISEASE OR CONDITION
DIRECTLY LEAD
TO DEATH (a)
cedInt "(b)
CAUSES
Due To
(c)
OTHER
SIGNIFICANT
CONDITIONS
IRTERm BE-
TWEEII ONSET
AND OEAJN
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) ^ / , M. D
idress)^ • JU^t^ ,
DATE OF BURIAL
m
rematinn | (City or Town]If
"dttYX’aBrU AQ i9vS^
7 NAME OF
FUNERAL DIRECTOR..^
ADDRESS
’i
Received and filed..
lVVl95>
mM
.19
(Registrar)
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
rOA\g
9 COLOR OR RACE
10 SINGLE
MARRIED
WIDOWED
or DIVORCED
(write the word)
V3(iou?ei
lOa If married, a
HUSBAND of . V
1 (Gire maiden name
if wife in lull)
(or) WIFE of
(Husband’s name in full)
1 1 IF STILLBORN, enter that fact here.
AGE - Years
Months fio Days
If under 24 hours
Hours Minutes
13 Usual
Occuoation:....
'OfiATvA^er
(Kind of wo^ done during most of working life)
14 Industry
or Business: ..
vA 0 YV\C tJr 0^uS^$)
15 Social Security No. CD \ 0 .* Cf. 3 . ^
'f 9 Sdi
16 BIRTHPLACE (City) . "I ..t^ O .Vw h.U. ^ U
(State or country) ' P^aSS t
17 NAME OF
—
FATHER
18 BIRTHPL.ACE OF
FATHER (City)
(State or country)
n Vit>V) kuWo
19 MAIDEN NAME
OF MOTHER
n A 0 u e_r
yv^a&s
20 BIRTHPLACE OF
MOTHER (City) ....
(State or country)
21
Informant
(Address)
Or. n I ~
f,st
I HEREBY CERTIFY that a satisfactory standard certificate of death was
filed with me BEFORE t^e burial or transit permit w^s i^ued:
, / tSignature^/JSbeBt^f Board of Health of other) —
#^.....v..
(Official Designation) (Date of Issue<6/ Permit)
y
EXTRACTS
FROM THE LAWS OF THE
COMMONWEALTH OF MASSACHUSETTS
GOVERNING THE
RETURN OF CERTIFICATES OF DEATH
A physician or rcipstcrcd hospital medical officer shall forthwith, after the
death of a penum whom he has attended during his last illness, at the request
of an undertaker or other authonzed person or of any member of the family of
the deceased, furnish for registration a standard certificate of death, stating to the
l>est of his knowledge ancl 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 furriishing 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. ^c. 10.
No undertaker or other person shall bur>- or othen\ ise 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 t'he 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 reasems, 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 the selectmen for the purpose, shall upon
application make the certificate'roiuired 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
.SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE
death certiheate contains a recital, as required by srction 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 i^rmit.
The board of health, or its agent, upon receipt of such statement and certificate,
shall Lrthwith countersign it and transmit it to the clerk of the town for registra-
tion. The person to whom the permit |s 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 \new 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. .18. Sec. 6..tis 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
3P HD dp frqradhe board of health or its agent appointed to issue such permits, or
if 'ttrei¥ 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 “pi" burial ground in which the interment is made.
. . ' . Cbap.;il4, Sec. 46, G. L.. (Tercentenary Edition).
Yi
RULES OF PRACTICE
:n .••••• L;., . , ,
‘ J'Ffie fulfillmentici \he purpose of these laws calls for the observance of the follow-
'.-jilg rules of OTa^ce;
. r Xt'teiidias^physicians will certify to such deaths only as those of persons
to.V'hdnV^ejfTtaVe given bedside care during a last illness from disease unrelated
ny form of'InjuiV.
.Juiji^tlalv^dleq wi
. froiti npfnd^wpen the certificate of death is needed.
' (3) , r^dlcaL^xaminers will investigate and certify to all deaths supposably
due tD-ih#»ry." These include not only deaths caused directly or indirectly by
. traumatism {including resulting septicemia), and by the action of chemical
J(du^ or poisons) thermal, or electrical agents, and deaths following abortion, but
JsiJ^0affls from di^ftfee resulting from injury or infection related to occupation.
deaths of persons not disabled by recognized disease, and those of
persons found dead.
Statement of Cause of Death. — Physicians: see explanatory instructions
on face side of standard certificate of death.
Statement of Occupation. — Precise statement of occupation is very import-
ant. so that the relative healthfulness of various pursuits can be known. Make
some entry in- this section for every person aged 10 years or over. If the occupa-
tion had been given up or changed, or if the deceased had retired from business,
report the kind of work done dunng most of working life even if retired. Children
not gainfully employed may be returned as at school or at home. For a woman
whose only occupation was that of home housework, write housework. For a
person engaged in domestic service for wages, however, designate the occupation
by the appropriate terms, as housekeeper — private family, cook — hotel, etc. For
a person who' had no occupation whatever write none.
T
1
I
RANK, RATING
ORGANIZATION AND OUTFIT
SERVICE NUMBER
Suffolk
(Sotumomnrallif of HaooarliaBrtla
^ EDWARD J. CRONIN
Secretary OF THE Commonwealth
DIVISION OF VITAL STATISTICS
COPY OF
CERTIFICATE OF DEATH
10
B.QS.tQn
(City or town making reti
Registered No
+ m CM nOSTytja death occurred in a hospital or institution,
■k™... St. \ give its NAME instead of street and number)
2 FULL NAME Her'i3ert Hich.,
(If deceased is a married, widowed or aivorced woman, give also maiden name.)
(a) Residence. No ll...Ihsl^.t...St..
(Usual place of abode)
w w #1
(Was deceased a
U. S. War Veteran.
1 if so specify WAR) ...
Dorch<3Ster
(If nonresident, give city or town and State)
Length of stay: In place of death years months !3ays. In place of residence 3 years months days.
St. .
MEDICAL CERTIFICATE OF DEATH
PERSONAL AND STATISTICAL PARTICULARS
10 SINGLE (write the word)
MARRIED
WIDOWED Tfa-rrl fri
or DIVORCED
’ irnmm
(Month) (Day) (Year)
41 HEREBY CERTIFY. That I attended deceased from
Jan/l6 19 .$3 to
I last saw h... ve on tIsXl«X8l... 19 .p3^th is said tcj
$l30Am
8 SEX
If
9 COLOR OR RACE
w
have occurred on the date stated above, at .
inERVU lE-
DISEASE OR CONDITION TM^Srir
DIRECTLY LEADING _ „ ^,1 <4
TO DEATH (a) PliljaQna.?y
Hannr
Mon
adVMioedaactivB
ANTE Due To
CEDENT (b)
CAUSES
Due To
(c)
ilG^^FICANT .Cir^.QSia of ^
CLaennec*a;
CONDITIONS
10a If married, widowed, or divorced it • n j H __ .j —
HUSBAND of . Milctrod “ari’13
(Give maiden name of wife in full)
(or) WIFE of
(Husband's name in full)
11 IF STILLBORN, enter that fact here.
12
Jtl B
? 11 P
AGE :rs Months... Days
If under 24 hours
Hours Minutes
' 13 Usual
Occupation:..
(Kind of
uring most of working life)
14 Industry
or Business:..
IS Social Security No..
Heme
Tra
16 BIRTHPLACE (City)..
(State or country)
Bos ton H;5SS *
Major findings:
Of operations
Date of operation Was autopsy performed?... No...
What test confirmed diagnosis? IxayB -Of .. .Cliea.t...antl...P '
5 Was disease or injury in any way related to occupation of deceased? 3put IsS
If so. specify... No r
(Signed) ■ M. JX
(Address) 5
rop COTr^nthrop »a 38
17 NAME OF
FATHER
Gilbert W Ri<di
18 BIRTHPLACE OF
FATHER (City)
East Boston Miss.
t'1 country)
19 MAIDEN NAME
OF MOTHER
Elizabeth V/ilacai
20 BIRTHPLACE OF
MOTHER (City)
(State or country)
Horth Tpupo Mass .
Place of Burial or Cremation
DATE OF BURIAL
7 NAME OF
FUNERAL DIRECTOR..
Jan
■ xM
City or Town)
19
M.Mdi..
ADDRESS.
^
Wto^jbh^p Mass*
A TRUE COPY
ATTEST: -
■' (Registrar
of City or Town where death occiin^')
Received and filed 19
(Registrar of City or Town where deceased resided)
DATE
FILED .Ja.a.....21/.5-3-.-
i
FEB>9 . ffl
i«tered Service Dec .26,1917
DladiarRed Sept. 30,1921 at Boston
Musician lat Class
U S Naval Hosorve
• l83-33-^ at Boston Hass*
25m-(h)-10-48-24658
5 E s sex
Q (County)
o Beverly
((iity or Towti)
111
U
& No.
(Eommanwraltlf of ^aaarliiiBrttB
OFFICE OF THE SECRETARY
DIVISION OF VITAL STATISTICS
COPY OF
MEDICAL EXAMINER’S
CERTIFICATE OF DEATH
Beverly
(City or town making return)
' 11
Bayerly Hospital
Registered No. .
curred in a ho .
St. 1 give its NAME instead of street and number)
I (If death occurred in a hospital or institution,
t. I ■
FULL N A M E 8,81111,116 1. , , , ,HsL.lp,e,rxi.
(If deceased is a married, widowed or divorced woman, give also maiden name.)
{(Was deceased a
U. S. War Veteran,
if so specify WAR)
__ p^. Mass.
(If nonresident, giveTity or town ana State)
Length of stay: In place of death years months days. In place of residence.. 20 . .years months days.
(a) Residence. No. 150 Shore Drive
(Usual place of abode)
MEDICAL CERTIFICATE OF DEATH
’ January 29. 19!
(Month) (Day) (Year)
41 HEREBY CERTIFY that I have investigated the death
of the person above-named and that the CAUSE AND MANNER thereof
are as follows; (If an injury was involved, state fully.)
5 Accident, suicide, or homicide (specify)
Date and hour of injury 19..
Where did
Injury occur?..
(City or town and State)
Did injury occur in or about home, on farm, in industrial place, or in public
place?
Manner of
(How did injury occur?)
(Specify type of place)
Injury
Nature of
Injury
While at work? Was autopsy performed?
6 Was disease or injury in any way related to occupation of deceased?
N'6
W
j£ SO, specify ..(I
(Signed) . lESnanl^
(Address) ..B.ey e.r.ly .». .M666 Date...l/3.Q.....195.3
7 .B.e.s.s.ambij^^
Place of Burial, or Cremation. _ _ (City or Town)
DATE OF BURIAL... Feh. I.. 19..
PERSONAL AND STATISTICAL PARTICULARS
9 SEX
Male
10 COLOR OR RACE
White
11 SINGLE
(write the word)
MARRIED
WIDOWED Marni®
or DIVORCED
11a If married, widowed, or divorced
HUSBAND of
(Give maiden name of wife in full)
(or) WIFE of..
(Husband’s name in full)
12 IF STILLBORN, enter that fact here.
If under 24 hours
AGE ....D>^'ears
Months
Days
1 Hours Minutes
tion. M.i.l..l..ih®.ry.. .S'tore
Occupation!,
15 Industry
or Business:.
(Kind of work done during most of working life)
For himself
16 Social Security No. .
0U-05^;i771
17 BIRTHPLACE (City) ^ «
(State or country) XtUSSXa
18 NAME OF
FATHER
Jacob Halpem
19 BIRTHPLACE OF
FATHER (City)
(State or country)
Russia
20 MAIDEN NAME
OF MOTHER
Bessie Cannot be loarnei
21 BIRTHPLACE OF
MOTHER (City) a a 4 0
(State or country) IiUSS Xa
22
B Informant..
(Address)
vers
8 NAME OF
FUNERAL
ADDRESS
Reel
FUNERAL DIRECTOR B.enjamin.Bimback
lQ....Ia,shingt.o,n. ...St...., D.o.r.che.s,
and filed..
.19..
k -; ' -l953 - -
(Registrar of City or Town where deceased resided)
A TRUE COPY, ^ .
i^JTEST: ..;.......T..'?^.?^.S.....H.*..
^ (Registrar of City or Town where death occurred)
Agent 1/30/53
DATE FILED 19
fffllo rn
I i.
I
‘I
1
'Vr inr
^ R-301A
RUCTIONS
FOR
. CERTIFICATE
giving
OF DEATH
lot enter
than one
> for each
(b) and (c)
does not mean
of dying, such
\ilure, asthenia, ,
ans thediseasCt
ications which
Uh.
'id conditions, .
ving rise to the
se (a) stating
'flying cause
itions contrib- •
\e death but not
the disease or
causing death.
E
o
O
Suffolk
(County)
, -h
v: .a: ^
o Win.tlix.Qp.
•*1 (Ciity or Town)
(HtfF QlammornDFaltt) of fH3aBBarl)UBFttB
EDWARD J. CRONIN
Secretary OF THE Commonwealth
DIVISION OF VITAL STATISTICS
2 FULL NAME
STANDARD
CERTIFICATE OF DEATH
To be filed foP'-burial permit
with Board of Health
or ita Agent.
Registered No „
, . . I (If death occurred in a hospital or institution.
No .Winturop-Comrauni ty iio-ij-pital St. \ give its NAME instead of street and number)
.PHYSICIAN — IMPORTANT
EleanO T B » G-Q ll ins (Ard ini ) ] (Was deceased a
eased is a married, widowed or divorcea woman, give also maiden name.) | U. S. War Veterar
I if so specify W'AR
(If deceased i
(a) Residence. No. .87 G O t t -- AV-0 -, j
(Usual place of abode) f
li
■ Veteran,
I'AR)
Revere
(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.
3 DATE OF
DEATH
EDICAL CERTIFICATE OF DEATH
31
(Day)
/9 ^ 3
(Year)
i 1 HEREBY CER TJ_F Y
II ,g b %■
I last saw h'^i'^S^.. alive on
have occurred on the date s
I attended deceased from
.3/
IQtA .r^death is said to
i.S.Fm.
DISEASE OR CONDITI:
DIRECTLY LEADIN'
TO DEATH (a)
ced|nt
CAUSES
Due To
(c)
OTHER
SIGNIFICANT .
CONDITIONS
INTERVU BE
TWEEN ONSET
MO OEtTH
/
//4Avd4.
Major findings:
Of operations..
^
tr
Date of operation..
What test confirmed diagnosis?..
..V^.Wa
Was autopsy performed?.
5 Was disease/5r)injury in any way related to occupation of deceased?,
Was disease/yninjury in any way^lated to occu]
If so. speciAr/..^.
(Signed)
Date
fe::
(Signed)
(Addr^)
, M. _D.
19.^3
6 ...Holy G.r o.sa .Malii.en
Place of Burial or Cremation (City or Town)
DATE OF BURIAL . Reb». 4, 1.9.55 19
7 NAME OF
FUNERAL DIRECT
ADDRESS .8.76 \l‘/
Received and filed..
,ro.D ^ Rever.Q
1
(Registrar)
12
If under 24 hours
AGE 4.4 Years
. Months...
Days
Hours . Minutes
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
Female
9 COLOR OR RACE
V/hite
10 SINGLE (write the word)
MARRIED
WIDOWED
or DivoRcMarried
10a If married, widowed, or divorced
HUSBAND of
(Give maiden name of wife in full)
(or) WIFE of Daniel J. Collins
(Husband s name in full)
11 IF STILLBORN, enter that fact here.
13 Usual
Occupation;.. . . Ho U 3 eWife
(Kind of work done during most of working life)
14 Industry
or Business:
at iiQiae
15 Social Security No. .
none
16 BIRTHPLACE (City) .
(State or country)
17 NAME OF
father
Ardini
18 BIRTHPLACE OF
FATHER (City)
Bos.ton
(State or country)
Mass
19 MAIDEN NAME
OF MOTHER Louis® Gunso
20 BIRTHPLACE OF
MOTHER (City)
Boston
(State or country)
Informant .. Daniel J. Collins
_(Addr_ess>__^7 ^nd j 0 0 1 1. Avo > , Revei»e=
I HEREBY CERTIFY that a satisfactory standard certificate of death was
filei^u^h me BEFORE the buri^l^r transiVPtrmit y^s issued:
EXTRACTS
FROM THE LAWS OF THE
COMMONWEALTH OF MASSACHUSETTS
eoVERNINC THE
RETURN OF CERTIFICATES OF DEATH
A physician or re^stercd 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 remstration a standard certificate of death, stating to the
best of his knowledge and belief the name of the decea^d, his supposed ag^ the.
disease of which he died, defined as required by section one, where ^am^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.
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 e.\aminers shall make examination upon the view of the dead bodies
of persons as arc supposed to have died by violence, or by the action of
chemical, thermal or electrical agents or following abortion, or from diseases
resulting from injury or 'infection relating to occupation, or suddenly when not
disabled by recognizable disease, or when any person is found dead — General
Laws, Chap. 38, Sec. 6.. as amended bv Chap. 632, Sec. 4. Acts of 1945.
' ' I ... No iinflertakcr or other persons sh.all bury a human body or the ashes thereof
A physician or officer furnishing a certificate of death as required by th6 ■' .which have been brought into the commonwealth until he has received a permit
preceding section or by section forty-five of chapter one hundred ^nd f6ur»; so. to do from the board of health or its agent appointed to issue such permits, or
teen, shall, if the deceased, to the best of his knowledge and belief^ seiwed H fhere is no such board, from the clerk of the town ryherc the body is to be buried
army, navy or marine corps of the United States in any war in which it has,p6eh'‘-.'.’^r tjhe funeral is to be held, or from a person appointed to have the care of the
engaged, insert in the certificate a recital to that effect, specifying thc'WaTl’and ctgniitory or burial ground in which the interment is niade.
shall also certify in such certificate both the primary and the secondary dr.-.imm*<-'2> . %■. , .'Chap. 1 14, Sec. 46, G. L.. (Tercentenary Edition).
diate cause of death as nearly as he can state the same. For neglect- to Comply ■' ‘i '
with any provision of this section, such physician or officer, shall forfeit (en.jJolli^. •} .
For the purposes of this section and of sections forty-five, forty-six andforty-;seven ' ,y: i / RULES OF PRACTICE
of said chapter one hundred and fourteen, the word "war” shall include tJi6-Gbina , ■
■ • — ,.;\\ fulfillment of the purpose of these laws calls for the observance of the follow-
uig^les of practice;
relief expedition and the Philippine insurrection, which shall, for said pi
deemed to have taken place between February fourteenth, eighteen huhi
ninety-eight and July fourth, nineteen hundred and two, and the Mexican-'
Attending physician* will certify to such deaths only as those of persons
service of nineteen hundred and sixteen and nineteen hundred and sevenleerui .- to T»hom they have given bedside care during a last illness from disease unrelated
G. L- Chap- 46, Sec. 10. ■ ■ ' • ' •tb-^ny form of injury.
(2) Board of Health physicians will certify to such deaths only as those of
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 buriecL until he
(2) Board of Health physicians will certify to such deaths only £
persons who. though disabled by recognized disease unrelated to any form of
injury, have died without recent medical attendance or whose physician is absent
has received a permit from the board of health, or its agent appointeifth isoff ,• 3 from home when the certificate of death is needed,
such permits, or if there is no such board, from the clerk of the town whetenhe
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 2is 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
Iiermit 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, unle^ a permit in the usual
form for the removal of such body has been sooner obtained hereunder. If the
(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 ^ known. Make
some entry in this section for every per^n 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 emploijed 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
I certify that this is a true copy of the certificate received for record.
CONMEC I'ICilT STA’I’E DEPARTMENT OF HEALTH
Bureau of Statistics Hartfonl, Connecticut, L. S. A.
COPY
1. I’L.uii OK Dkaih:
(a) State of Connecticut: (li) County
tc) To» a # t
iveuj
I Certificate of Death
'l; Length of stay
in town
'! 2. VscAL Kesiop.nce of Deci.ased:
j ^a) State - (b) County.
ii-
i ;t. Nami: ok
1)1 I KASI o
I Type or print)
(First)
c) fown> . (d) (City or 3>rou^;
^/A7 rArop
. - . - . (liTural. Kive location)
<5ir. A/4m/ Qpifiiyi e
(Middle) _ ' (UW
a4
(It nut in hoKpital Ktve street no. or location}
(c) Name of U ispital^
nr InstitulHin
U
a. Sex
PERSONAI. AM) STATISTICAL PARTICULARS
. Si NCI, ;, Widowed.
MARRlkl)«DlV0RCi:D
4. Social Sbcukity Nl'mber
MEUiCAL certification,
li. Race
8. If Married. Widowed or Divorced, c.ive .maiden name of
Wife or Husiiand
.^arme Coiieri,
22. Cause of Dea.'H fTntgrvor.lv one came per 1it;e I6r (4). (b) and (c)
(a) Disease or CosDtTioN DtREcTEv Leaping to Death
Thi7 floes ffQt m-'j-f the tni>de r.j dying, ruck tss kcU't
fai'furr., ast^rki. Ic. It means the disease, injury or
complicalKftt u’hi^ caused death
/
9. Date of
Death
(Month)
_VAa/v
(Day)
(Year)
INTERVAL
BETWEEN
ONSET AND
DEATH
/I r \ ' ' '
f 'I
i 10. Date of Birth
Age (in years 1 If under 1 year Ifundcrlday ^
! 1
last birthday) | I'
i i
1 Months! Days Hours | Mins. '
iDec. 1, 1393
c'n ' ' ! 1
59 1 i 1 . r
Antecedent CAt.sirs, , ..
Morbid cvndihons, if any, ghing rise to the clove
cause (a) .staling thg underlying cause last.
11. 13m nii'LAcii
(City or town)
(State or I j.-ei„'n country) 'i ^ ^ *
. ^ I TO.
1:2. (a) Usual OccvPvVTiON (Give kind of work done durir. : rrtost of
working life even if retired)
Salesman
Due
C) TO.
I
(b) Ir.dustO' or Business
)
Knitted Wear
13. (a) Was Deceased a Veteran? Yes or N'qNq
(b) If yes. give war
Unit or Ship
I =
14. Name,
(City or town)
1.5. Birthplace New York
(State or foreifin country)
N^..
16. nwme"^ Theresa Glinsky
(City or town)
17. Birthplace MeW York
(State or foreign country)
Ne Y.
23. Other Significant Conditions i
Conditions contributing to the death but not related |
to the disease or condition causing death
24. Operation, Date and Major Findings
autopsy
(Yes or No)
OOCi
25. If Death was due to E.xternal Causes. Fill in the Following:
, ... . ... . (b) Date of occurrence
(a) Accident, suicide. '
homicide (specify)
(c) City or Town and State
Where injury occured
18. Informant’s N’a.mk
Donald Newman
j (d) Did injury occur in or about home, factory,
farm, office, street, etc.?
fO How did it occur?
(e) While at work?
19. Burial. Dat ■ Jan. 9. 10
Cemetery f>r _Kebr.ew Cenietery
Place Bostonj I'^iass
26. I HEREBY' CERTIFY', 11:^1 i
— — -III . ' '
I
20. Name of E-mbalmer if H(»uv was Emualaikd
iiarry Weller
21. SiC.NATl
D Emualmer
Liceii'C n-.inibcr
65Q-
ifClV JL. i. VV
OR Licensed Funeral Director I> 07^ SicNATuk); of Piiy:
ri-
RECli-
at death is sr.id to have occurred on
at
'Tiys3'
Ml ii K
vren 11, Cenn. ^
)■; . \ ' l-> IK ivi'iC’ IKD ( >N
27. SicNATukr OF Physician ^ CyV<r^
■m-' ' I "114'aa
1-*Tvm VS- 1 (.5-RO
' /
)anv ( /
By
"This copy of Certificate recelTS®
for record at
this d*f of ..
Registrar'*
RECEIV t i)
/
k.
\ '■ '
v:
2 FULL NAME.
(City or Town)
^t|r (Sammonmraltt; of iKasBart|UBPttB
EDWARD J. CRONIN
Secretary OF THE Commonwealth
DIVISION OF VITAL STATISTICS
COPY OF
MEDICAL EXAMINER’S
CERTIFICATE OF DEATH
(If death occurred in a hospital or institution.
..Danvers.;
(City or town making return)
Registered No. .
14
f (If death occurred in a hospital or institution,
No DaiW-ePS " •St’atre- Hathorne ^ name instead of street and number)
or divorced woman, give also maiden name.)
(Was deceased a
U. S. War Veteran,
if so specify WAR) .
(a) Residence. No ^
(Usual place of abode'
Length of stay: In place of death years. .. J month^.g days. In place of residence .
^(Sf fthl-tiiftetrO^ve city or town and State)
years months days.
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
DEATH
41 HEREBY CERTIFY that I have investigated the death
of the person above-named and that the CAUSE AND MANNER thereof
are as follows: (If an injury was involved, state fully.)
•Pharyngitis
-■•■Bronehopneufaonia-
5 Accident, suicide, or homicide (specify)
Date and hour of injury 19..
Where did
Injury occur?
(City or town and State)
Did injury occur in or about home, on farm, in industrial place, or in public
place?
Manner of
Injury
Nature of
Injury
(Specify type of place)
(How did injury occur?)
While at work? Was autopsy performed?
6 Was disea.se or injury in any way related to occupation of deceased?
If so. specify
(Signed) .MLOi...McC.iim M. D.
(Address)P..ea.b.od.y:.y....l.ia.ss« Patei./i.6/...i9 5.3
7 Q.$.d>9.r.....Gr.o.y.!e.....G.ei;i* D.~.r.ch.es.ter
Place of Burial, or Cremation. (City or Town)
DATE OF BURIAL... January 24.^
* FUNERAL DiRECTORl’I^ir j.Qr.le.....J.Dhn.a.an
ADDRESS .ilas.s.>
Received and filed 19
(Registrar of City or Town where deceased resided)
PERSONAL AND STATISTICAL PARTICULARS
9 SEX
10 COLOR OR RACE
11 SINOLE (write the word)
MARRIED
F e f "ja 1 e Negro ^dd^ceeS i n r>
lla If married, widowed, or divorced
HUSBAND of ;
(Give maiden name of wife in full)
(or) WIFE of
(Husband’s name in full)
12 IF STILLBORN, enter that fact here.
13
AGE 46 ..Years ■■ Months ,»... Days
If under 24 hours
Hours Minutes
14 Usual
Occupation:,
..H.o.t H.1 .. .V.50 r k e r
(Kind of work done during most of working life)
IS Industry
or Business:..
16 Social Security No..
17 BIRTHPLACE (City)..
(State or country)
18 NAME OF
FATHER
19 BIRTHPLACE OF
FATHER (City) ...
(State or country)
John JTcl:sbn
X
.Canada
20 MAIDEN NAME
OF MOTHER Canoot be learned
21 BIRTHPLACE OF
MOTHER (City)
(State or country) f.f
^
Canada
22
(Add^^T
mm
orne
A TRUE COP"^- ^
ATTEST:
''^Registrar of City or Town where death occurred)
0 ^
DATE FILED ^.^.J 19 5.X
CoDiei 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. 4d, Sec. 12, G. L.)
A R-302
>C
1/
1 SUFFOLK
[BOfT&H
(City or Town)
Veterans AdmiS
BOSTON
(City or town making return)
Registered No,
604-
Qlifr (Sommomoraltt; of AaBoarifoorttB
EDWARD J. CRONIN
Secretary OF the Commonwealth
DIVISION OF VITAL STATISTICS
COPY OF
CERTIFICATE OF DEATH
iration Hospital
No T...Y..“.^^..^.“.r.^r..........~.::..“”. st,
CHARLES E BURRILL r
2 FULL NAME I (Was deceased a i»r »' T
(If deceased is a married, widowed or divorced woman, give also maiden name.) | U. S. War Veteran, H >4 JL
365 Wlnthiop
(a) Residence. No St
(Usual place of abode) • ft (If nonresident, give city or town and State)
P Q ^3. 1 a
Length of stay: In place of death years S?.... months ?. ...days. In place of residence years months days.
io
I (If death occurred in a hospital or institution.
. \ give its NAME instead of street and number)
MEDICAL CERTIFICATE OF DEATH
PERSONAL AND STATISTICAL PARTICULARS
’ Bffin ' January 18 1953
(Month) (bayj (Year)
8 SE^
attended deceased from
1/18 ,o 531
41 HEREBY CERTIFY. ThatV
I-I/Q- 19 53 to 19
I last saw h alive on 19 death is said tc
have occurred on the date stated above, at ? • QQ.P.* m.
9 COLQ^ OR RACE
10 SINGLE teritethe^or^
MARRIED Marrlea
WIDOWED
or DIVORCED
DISEASE OR CONDITION
DIRECTLY LEADING ^ .
TO DEATH (a) hepatio coma
ANTE Due To
CEDENT (b)
CAUSES
cirrhosis
pogt-IrirQC
Due To
(c)
OTHER
SIGNIFICANT
CONDITIONS
ga a t r Q.r 1 nt © s t Im
hamorrnage
e so ph.ag.a aI Y ar i 9.® s ^ s .
bronchial phauinonia hays
IITERVU. lE-
TWEER RRSET
UD RERTR
hrs.
(Give maiden name of wife in full)
(or) WIFE of
(Husband's name in full)
11 IF STILLBORN, enter that fact here.
12
AGE
65
1 13
..Years Months Days
13 Usual
Occupation:.,
yp3,
days
"‘c^oS^s pprt^c.^al
Date of operation l/.lQ/5^^^as autopsy performed? !?.?.?..
What test confirmed diagnosis?
5 Was disease or injury in any way related to occupation of deceased?,..
(Signed) .. :B:::AchahbMh'ZZZ^^^^ ^1^
(Address) VAH Date 1/ Xw 5 5
WinthJ^ ^inthrppV MasB
Place of Burial or Cremation (City or Town)
DATE OF BURIAL Jatl 2X 19 *3
7 NAME OF
FUNERAL DIRECTOR..
A ^arsh
ADDRESS
>roivod and AIaH i 6 1 _ ' 5 !
Maas.
Received and filed 19..
14 Industry
or Business;.
If under 24 hours
_ Hours Minutes
Supt.-fVater Dept.
(Kind of work done during most of working life)
Winthrop, Mass*
IS Social Security No..
16 BIRTHPLACE (City)..
(State or country)
17 NAME OF
FATHER
Frank Borrill
Wlnthrop,
18 BIRTHPLACE OF _ . ,
FATHER (City) .^.S.?..*.
(State or country)
19 MAIDEN NAME , ,
OF MOTHER ^ aiinah Mann
21
20 BIRTHPLACE OF
MOTHER (City)
(State or country)
V A hospital Records
Surrey
Maine
Informant
f Address)
A TRUE COPY
ATTEST:
7^
(Registrar of City or Town where deceased resided)
(Registrar of City or Town where death occurred)
DATE FILED J.ail....33 19 5.3.
DATj. op entering military service
DATE OP DISCHARGE
rank, RATING
ORGANIZATION AND OUTFIT
SERVICE NUMBER
H £ C E I V :
i
p]-
' ^r> •
■loi
FEBiG Pit
- f ■
• 6/24/17
4/28/19
i"vt Mach Gun Co
101 st infantry
62880
i
CONNKCTICUT ST A IE DEPARI'MEHI'r OF HEALTH
Bureau of Vital Statistics — Hartford, Connecticut, U, S. A.
Certificate of Death
f
II 1. Place «>F Dkatii: // ;'i
*' (n) State of Connecticut: (b) County.
/ — I t,d) Ceiii^th of stay
(c) Town I* ii '"i in town
■^toa-r ' nr icu
(if nut in hospital v!ivc street no. or location)
(e) Name of Hospital , . . .. > a
or Institution
2. Usual Rksidencr op Deceased:
sut...
(b) County.
(d) (City or B^u. hj
3. N.t.MK oi-' (First)
Dl.tl-ASMI . /T
(1 ype or print)
(Middle)
J.
I’ERSONAL AND STATISTICAL FAKTIOCLAKS
7. sixxixxxxxacxx
5. Si;.\f \ (>. R.ack MAKKiiii). IXJCS2CS
i 4. Social Seci^tv Numbbk
LK
S. Ip Marrii-.d. Widovveu or Divorced, c.ivic .maiden name of
Wife or Hcsiiand
(Month)
Ann J. BropiBn
9. Date of
Death
T/?M
(Day)
DiO
10. Date of Birth
3/^//y 7
?/3(/9
Ace (in years | If under 1 year
last birthday)
55
Months I Days
(Vear)
If under I day
Hours I Mins.
11. Birthplace (City or town)
(State or (oroii;n country)
MaP8»
•MEDICAL CEKTIFIC.ATION •
22, Cause of Death (Enter only one cause per line for fal, (b) and (c)
(a) Disease OR Condition Directuy Leading TO Death i interval
does not mean mode of dying, SHck as heart between
failure, asthenia, etc. It means the disease, injury or onset and
complication which caused death \ death
'Cl,
Antecedent Causes.
Siorhid conditions, if any, giring rise to the atore
cause (u) .staling the underlying cause last.
Due ^ ^ *
(b) TO. . . .W
12. (a) Usual Occupai ION (Give kind of work done during most of
working life even if retired)
Inspector
(b) Industry or Butiness
U. S. A^nny ^ /
Due
ic) TO.
13. (a) Was Deceased a Veteran? Yes or X
(b) If yes
Unit or
CfcA<- Wt//cc
"sh!p~u i Q4\4^ r
14. X’ame
(lerlck Adans
« a I
(City or town)
15. Biriiii'Lac'K at. Joh,n
(State or foreign country)
Brums'wlek:
23. Other Significant Conditions
Conditions contributing to the death but not related
to the disease or condition causing death
Maiden
1(1. N'ame
24. Operation, Date and Major Findings
autopsy
(Yes or No)
ClTtb
25. If Death was due to External Causes, Fill is the Following:
, , , . , ... . (b) Date of occurrence
(a) Accident, suicide. '
homicide (specify)
(City or town)
17. niRTiiPLAtf Bgston
(State or foreign country)
MggS.
18. Iniok.mant's Na.me
John F. MbIpv (gurernl Direct or)
(c) City or Town and State
Where injury occured
(d) Did injury occur in or about home, factory.
farm, office, street, etc.?
(f) How did it occur?
j (e) While at work?
19. Burial. Crem.ation or Removal Date
Jpn , 24 1,, 53
1120.1 HEREBY CERTIFY. 4~'hat'4-
Cemetery or Crematory ?_
Place Winthrop ,
^u-4t>_
20. Name oe E.mhai.mek ie Hodv was E.mhai.mi.d
^dw-^rfi L. M’D^'^rott
License number
♦))-,» 1 In .t >li. 4... ■Mil i i —
. that death is said to have occurred on
iSm
_J .1410 ^
Jl. SiGNATi.'itE OF Licensed Emuai.mer or Lice.nsed Funeral Director
27. (jiCNATURE OF PHYSICIAN 4 ^
: -w.vf‘.4 N -- Xj. -
Ho’ie .
A^ircss ’ , .New Havpn,CO’',n.' Addn-s^y,_^_. Hby
thTs" ceiuITfi t^A nrRircEfvTj; TT kor r lcor 1) 0 x , ' ~ “rk
JAN 2 1 (953
By
Form VS- 4 (5-60)30M
”Thia copy of Certificate peceired
for record at
this
d*y of
Baglfltrar
HECElVir:}
I
FEBIG
^
o
th
o
u
u
fc No.
2 FULL NAME
....Suffolk.....
(County)
..Bos-ton.
(City or Town)
Jevd-Sh
(SamtnomoFaUii of MlaBoart^oortta
EDWARD J. CRONIN
Secretary of the Commonwealth
DIVISION OF VITAL STATISTICS
COPY OF
CERTIFICATE OF DEATH
orial Hospt.
Boston
(City or town making return)
■6?r 17
Registered No
I (If death occurred in a hospital or institution.
St. i give its NAME instead of street and number)
(if deceased is a woman, give also maiden name.)
122-Washtngtcai..AY.e*
Length of stay: In place of death years months.. Uj days. In place of residence.
(Was deceased a
U. S. War Veteran,
if so specify WAR)..
(a) Residence. No
(Usual place of abode)
St
n
(if c^^?3i1^n and State)
..years months days.
MEDICAL CERTIFICATE OF DEATH
PERSONAL AND STATISTICAL PARTICULARS
3 DATE OF
DEATH ...
(Month)
(Year)'
4 1 HEREBY CERTIFY.
to
Jan/13 ’ 53 ■
I last saw h alive on JaH '^21
have occurred on the date stated above, at
DISEASE OR CONDITION
DIRECTLY LEADING
TO DEATH (a) int«i abdoBtinal
That I attended deceased from
19
8 SEX
E_
9 COLOR OR RACE
-4S-
10 SINGLE (write the word)
MARRIED
WIDOWED . ,
or DIVORCEW'i.ciOTfSO
. 19.jf*J, death is said tc
ANTE Due To
CEDENT (b)
CAUSES
neoplasa
Due To
(c)
OTHER
SIGNIFICANT
CONDITIONS
Ai^rio s clerotic
ear^o vaao.diseaaft
IITEIIVU IE
TWEEN onn
MD 0E4TN
10a If married, widowed, or divorced
HUSBAND of
(Give maiden name of wife in full)
(or) WIFE of
■ Lc)uia
in full)
11 IF STILLBORN, enter that fact here.
12
If under 24 hours
AGByiJ Years
Months
Days
Hours Minutes
13 Usual
Occupation:
H^'4iaewo.rk
(Kind of workdone during most of working life)
14 Industry
or Business:..
At Home
IS Social Security No..
lione
16 BIRTHPLACE (City) TtoSsiA
(State or country)
Major findings:
Ck operations
Date of operation Was autopsy performed?..
What test confirmed diagnosis?
5 Was disease or injury in any way related to occupation of deceased? Nys-
If so, specify V. .
(Signed) J F M. D,
(Address) 19
Place of Burial or 9hsJ.,o(?aoob
DATE OF BURIAL t
17 NAME OF
FATHER
Tarael Kaplan
18 BIRTHPLACE OF
FATHER (City)
(State or country)
Rueaia
19 MAIDEN NAME
OF MOTHER
Cannot be learned
20 BIRTHPLACE OF
MOTHER (City)
(State or country)
• Russia
19
7 NAME OF
FUNERAL DIRECTOR B ^mbSOl
Informant..
(Address)
Igyer-Krla
ADDRESS
: BcrehOTter Itaggi —
REBig
^TTJ
Received and filed
.1.953
(Registrar of City or Town where deceased resided)
!
(Registrar of City or Town where death occiined)
Jan *26/53
DATE FILED 19
-
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T^^.'fjii
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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-30S 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.)
M R-305 y
(CiiminomDFaltii of IffiaaBarlTUBrttB
^ EDWARD J. CRONIN
BOSTON”
(City or Town)
No * a .
2 FULL NAME
Secretary of the Commonwealth
DIVISION OF VITAL STATISTICS
COPY OF
MEDICAL EXAMINER’S
CERTIFICATE OF DEATH
boston
(City or town making return)
815 18
Registered No. .
St
I (If death occurred in a hospital or institution,
. \ give its NAME instead of street and number)
(if deceased is a m^^^e^or divorced wSman, give also maiden name.)
.U65....wtattirQp. st. .
(Was deceased a
U. S. War Veteran,
if so specify WAR) .
(a) Residence. No
(Usual place of abode)
Winthrop Mass#
iresioent, give city or town ai
’k
(If nonresio
Length of stay: In place of death years months days. In place of residence years months days.
and State)
MEDICAL CERTIFICATE OF DEATH
3 DATE OF _
(Month) '^^^ay)
(Year)
41 HEREBY CERTIFY that I have investigated the death
of the person above-named and that the CAUSE AND MANNER thereof
are as follows: (If an injury was involved, state fully.)
GeneraUziad..artiarl.Q....ftC?X.or^^
proa.tatiam pyB.X.onepiiriU
i!ra.c.te®....pf..MP....?.c^iS^
,.19..
5 Accident, suicide, or homicide (specify)
Date and hour of injury 12-89-$2
Where did
Injury occur?
(City or town and State)
Did injury occur in or about home, on farm, in industrial place, or in public
place?
13
If under 24 hours
AGe82 Years
Months
Days
Hours Minutes
Manner of
Injury
Nature of
Injury
(Specify type of place)
(How did injury occur?)
While at work? Was autopsy performed?
6 Was disea.se or injury in any way related to occupation of deceased?
If so, specify ;
(Signed) Rlchai?ci...Fapd. m. d.
(Address) Date.... ..19
7
Place of Burial, or Cremation. (City or Town)
DATE OF BURIAL..
8 NAME OF
FUNERAL DIRECTOR
Jsn.29/S3
.19..
J F 0‘Mal«y
ADDRESS.
ep llayffi
Received and filed J..
(Registrar of City or Town where deceased resided)
,.19..
PERSONAL AND STATISTICAL PARTICULARS
9 SEX
u
10 COLOR OR race! “SINGLE^
I WIDOWED
i or
w
(write the word)
DO WE D w • j
DIVORCED WiflOWeCl
1 la If married, widowed, or divorced
HUSBAND of Usiria l<ennon
(Give maiden name of wife in
(or) WIFE of .
(Give maiden” name of 'wife in full)
(Husband's name in full)
12 IF STILLBORN, enter that fact here.
14 Usual
Occupation:..
(Kind of work done
ifMfSit oVwSki^^'
15 Industry
or Business:..
16 Social Security No
17 BIRTHPLACE (City)..
(State or country)
Ireland
18 NAME OF
FATHER
Andrew Iiolloy
19 BIRTHPLACE OF
H
FATHER (City)
Ireland
Z.
(State or country)
Cd
<
20 MAIDEN NAME
OF MOTHER
Aim Heavey
Os
21 BIRTHPLACE OF
Ireland
MOTHER (City)
(State or country)
22
(Ate?/ Anna -Foley Daughte
(Registrar of City or Town where death occurred)
Jan. 29/^3
DATE PILED 19..
I
1
*.£0£1V r
1.
iiitGred Service 11-1^1913
I pia charged llrlli-1920
Sgt» C*A*C»
U S Amy
Senrlcje No. Ili8608
Copie* of return* of death* which occurred in your city or town in c**e 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 poss^le,
after the close of the month in which the death occurred. (See Chap. 46, Sec. 12, G. L.)
Vf R
-302
SUFFOLK
(City or Town)
Qllf' (SatnmontDraUl} of AaaaarlinBPttii
EDWARD J. CRONIN
Secretary OF THE Commonwealth
DIVISION OF VITAL STATISTICS
COPY OF
CERTIFICATE OF DEATH
(City or town making return)
Registered No. 19
No.
_ _ 4. _ _ « « a. „ Ti L.'Ts a. _ n / (If death occurred in a hospital or institution.
.P.Q..9.!v..QI).....W.J>.b.^....ll.Q.Hp.X..URX St. \ give its NAME instead of street and number)
2 FULL NAME ?......‘.‘l9.9.?....,. ) (Was deceased ;
(If deceased is a married, widowed or divorced woman, give also maiden name.) | U. S. War Veteran,
1 if so specify WAR)..
(a) Residence. No lS.2.....Si..r.!9.ii St. ,
(Usual place of abode)
i'lvPithropj 4as»w ;•
(If nonresidenf, pve city or town and State)
Length of stay: In place of death years month^ days. In place of residence. ...4 years months days.
MEDICAL CERTIFICATE OF DEATH
PERSONAL AND STATISTICAL PARTICULARS
3 DATE OF
DEATH ...
(bj^’7
8 SEX
iA
41 HEREBY CERTIFY, That ||^^tei|gedp^]^^ised from
1/27 1’ to l/g.7 153
I last saw h alive on 19 , death is said tc
,.m.
9 COLOR OR RACE
w
10 SINGLE
MARRIED
WIDOWED
or
(write the word)
DOWED
DIVORCED ^ X ng le
have occurred on the date stated above, at r
DISEASE OR CONDITION
DIRECTLY LEADING
TO DEATH (a) tnyocardial i nTarct ic n
ANTE Due To
CEDENT (b)
CAUSES
pulmonary Congo stior ,
fidema
Due To
(c)
OTHER
SIGNIFICANT .
CONDITIONS
rnTEum IE
TWEEI oisn
IHD BEATN
10a If married, widowed, or divorced
HUSBAND of
(Give maiden name of wife in full)
(or) WIFE of
(Husband's name in full)
1 1 IF STILLBORN, enter that fact here.
12
A9E;5& Years Month^.3 Days
If under 24 hours
Hours Minutes
13 Usual
OccuPationA-dmi^S^^Sor^-yifei,
g most of working life)
s»hrs
14 Industry
or
Bu\7nes^.iia.rpo...,&...^
IS Social Security Ni
16 BIRTHPLACE (City)
(State or country) gu D p ^ ^
Sw-
Major findings:
Of operations
Date of operation Was autopsy performed? .ye.fl.
What test confirmed diagnosis?
autopay
5 Was disease or injury in any way related to occupation of deceased?
If so. specify
>5S
Cremation
DATE OP BURIAL
17 NAME OP
FATHER J©orK©
K rVocxi
18 BIRTHPLACE OP
FATHER (City)
East Boston
(State or country)
19 MAIDEN NAME
OF MOTHER Susau G Plerc®
20 BIRTHPLACE OF
MOTHER (City)
Everett^
(State or country)
A . 4 .p .a _
21
J m 90
Informant..
(Address)
Sister
^ FUNi^RAL DIRECTOR .sr....^....^.e.nde.r.s.Qn....G.o.*..
ADDRESS ■,;Evgx»jOtt-^"--^aaav'
Received and filed..
xrett,
jCEli.. 19..
A TRUE COPY
ATTEST:
(Registrar of City or Town where deceased resided)
(Registrar of City or Town where death occurred)
Jan 50 S5
DATE FILED 19.....^,.
^co. |.
:M R-301A
TRUCTIONS
FOR
il CERTIFICATE
n giving
I OF DEATH
not enter
'e than one
le for each
, (b) and (c)
is does not mean
e of dying, such
failure, asthenia, .
leans the disease,
Plications which
eath.
'bid conditions,
\iving rise to the
use (a) staling
ierlying cause
ditions conirib- •
the death but not
0 the disease or
1 causing death.
X
Suffolk
(County)
Tlrt^rop
(City or Town)
4 Pa^ne Street
QlammonuiFalt^ of iKaBBartfuaPttB
EDWARD J. CRONIN
Secretary OF THE Commonwealth
DIVISION OF VITAL STATISTICS
STANDARD
CERTIFICATE OF DEATH
Registered No.
To be filed for burlel permit
with Board of Health
or its Aaent.
20
No.
St
I (If death occurred in a hospital or institution,
. \ give its NAME instead of street and number)
(a) Residence. No 4 Pa.lne Street,
(Usual place of abode)
PHYSICIAN — IMPORTANT
2 FULL NAME Y.,... M,C3^1 11 l.CU^ f a
(If deceased is a married, widowed or divorced woman, give also maiden name.) | U. S. War Veteran,
if so specify WAR) .
St.
(If nonresident, give city or town and State)
Length of stay: In place of death years months days. In place of residence5.5. .years months days.
MEDICAL CERTIFICATE OF DEATH
' deIth February 2 .
(Month) (Day)
(Year)
41 HEREBY CERTIFY.
I last saw h ..'f:?f... alive on ...5^
That I attended deceased from
death is said to
have occurred on the date stated above, at
DISEASE OR CONDITION
DIRECTLY LEAQraO i /P
TO DEATH (a)
CUi-o<y*t a-*vt <
ANTE Due To
CEDENT (b)
CAUSES
Due To
(c)
OTHER
SIGNIFICANT .
CONDITIONS
INTERVAL BE-
TWEEN ONSET
AND DEATH
S ^
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?. ...>!^CT^...
If so, specify.,,,^— ytt. ^
(Signed) M. D
Pate 19 ^3
(Address)
6 .S.t.^.LP.a-ul.'s,.
Place of Burial or Cremation ‘
DATE OF BURIAL .
.February 5.
n
(City or Town)
7 NAME OF
FUNERAL DIRECTOR.
ADDRESS
-I
Received and filed..
T5x...
q.'q....1^s..s.s
19-:'
(Registrar)
PERSONAL AND STATISTICAL PARTICULARS
9 G^qR(^ RACE
10 SINGLE
MARRIED
WIDOWED
or DIVORCED
^fnil
word)
e
10a If married, widowed, or divorced
HUSBAND of
(Give maiden name of wife in full)
(or) WIFE of .
(Husband’s name in full)
11 IF STILLBORN, enter that fact here.
70
AGE Years Months Days
If under 24 hours
Hours Minutes
occupation:.Re..t.ir.ed.... 3up..e.r¥.;5..s..Qr
(Kind of work done during most of working life)
14 Industry COUrt PlOUSG
or Business:
15 Social Security No.,
16 BIRTHPLACE (City) 3.P..S.t.0n
(State or country) M3.SS ,
17 NAME OF
FATHER
<1
Daniel 2 .McG-5 llicudy
18 BIRTHPLACE OF
n
FATHER (City) .
Boston
(State or country)
Mass
19 MAIDEN NAME
OF MOTHER
Catherine Conlev
20 BIRTHPLACE OF
MOTHER (City) ...
....3.o.s..t.o.n
(State or country)
M fT
21
Informant ... ».nni..e.....Kc.3;i.Il.l..Q.u.dy..
4 PaVna Street
I HEI^BY CERTIFY that a satisfactory standard certificate of death was
filed Wh me BEFORE the burial or transit-permit^as issued:
t of Bottrc^of Health oe^ti
(Date of Issue of
E J^rmit)
EXTRACTS
FROM THE LAWS OF THE
COMMONWEALTH OF MASSACHUSETTS
GOVERNING THE
RETURN OF CERTIFICATES OF DEATH
A physician or retfistered 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 meml>er of the family of
the deceased, furnish for registration a standard certificate of death, stating to the
l>est 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,
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 an<l 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 upon the view of the dead bodies
of persons as are supposed to have died by violence, or by the action of
chemical, therrnal 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.
A physician or officer furni shing a certificate of death as required by the
preceding section or by sectioti forty-five of chapter one hundred and four-
teen, shall, if the deceased, to ihe best of his knowledge and belief, served in the
army, navy or marine corps of the United States in any war in which it has been
engaged, insert in the certificate a recital to that effect, specifying the war. and
shall also certify in such certificate both the primary and the secondary or imme-
diate cause of death as nearly as he can state the same. For neglect to comply
with any pro\dsion 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 *aken place between February fourteenth, eighteen hundred and
ninety-eight and July fourth, nineteen hundred and two, and the Mexican border
ser\'ice of nineteen hundred and sixteen and nineteen hundred and seventeen.
G. L. Chap. 46, Sec. 10.
No undertaker or other person shall bur>’ 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 satisfactor>’ 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 w’hichit 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
No undertaker or other persons shall bury a human body or the ashes thereof
which^hSvi6;ljeen brought into the commonwealth until he has received a permit
so to aoTronnne’ 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 f^erat is to be held, or from a person appointed to have the care of the
cemeteiy oilbjufial ground in which the interment is made.
, . . (Jhflrp.' M4, Sec. 46, G. L., (Tercentenary Edition).
' . ’'‘U'r. 'I - ■
. ry RULES OF PRACTICE
'Thyiui^Ifnient ofetI\e purpose of these laws calls for the observance of the follow-
ing'nnes 6rptaJt|Ber '
1 (i)A Attcnl^IngijKvsicians will certify to such deaths only as those of persons
.tOjAyfi^i they hav^J^ven bedside care during a last illness from disease unrelated
to
(/^L physicians will certify to such deaths only as those of
personSt^^H^tteiigh disabled by recognized disease unrelated to any form of
in jur>'.'ha^^dieT Without recent medical attendance or whose physician is absent
froffi-qprae jV^l^pb the certificate of death is needed.
(3) 'M^ieaK Examiners will investigate and certify to all deaths supposably
due to injury. These include not only deaths caused directly or indirectly by
^fcw^tism. ^(including resulting septicemia), and by the action of chemical
(pira^o^^ofsons) thermal, or electrical agents, and deaths following abortion, but
als^Tieath^rom 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
LM R-301
SUCTIONS
FOR
L CERTIFICATE
Chrinc
OF DEATH
lot enter
I then one
I for each
(b) and (c)
dots not mean
of dying, such
lilure, asthenia, •
uaj the disease,
icalions which
jih.
>id conditions, .
ring rise to the *
se (a) stating
trlying cause
itions contrib- •
le death but nob
the disease or
causing death.
<
5 Suffolk
2 (County)
Id (City or Town)
Oi
(SommomuFaltl) of AaBBadiuarttB
EDWARD J. CRONIN
Secr-etary of the Commonwealth
DIVISION OF VITAL STATISTICS
STANDARD
CERTIFICATE OF DEATH
vyinthrop
(City or to»n making return)
2 FULL
Registered No 21,,..
No.iyint.hr..Qp.....aon.yol.c.©nt.....IIar.sing.^^ ... St. { give its NAME instead of street and number)
NAME....S op hia Georg.i anna Bennett
(If deceased is a married, wMowed or divorced woman, give i
: also maiden name.)
(a) Residence. No 369 S.hlrl.0.y...Bt.r.0et st.
(Usual place of abode)
(Was deceased a
U. S. War Veteran,
if so specify WAR) .Jf
(If nonresident, give city or town and State)
Length of stay: In place of death years months. 4; days. In place of residenc^.5 years months days.
MEDICAL CERTIFICATE OF DEATH
3 DATE OF „ , rz
DEATH „..E.0.D ruar.y. 3
(Month) (Day)
.1953.
(Year)
4 EREBY CERTIFY, That I attended deceased from
..afcl.., z. i,X3. 3iM. 3. ..YS
I last saw h.«S^^..alive on.. 19^^., death is said toj
the date stated above, at. mrcp
have occurred on
DISEASE OR CONDITION
DIRECTLY LEADING ^ ^
TO DEATH (a)
ANTE Due To
CEDENT (b)
CAUSES
Due To
(c)
OTHER
SIGNIFICANT
CONDITIONS
Date of operation Was autopsy.perfor
INTUfAL IE
niEEl ONSn
ftND DEATR
3(^
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
f emal a
9 COLOR OR RACE
White
10 SINGLE (write the word)
MARRIED— { j ^ j
widowedWICL OWSU.
or DIVORCED
10a If married, widowed, or divorced
HUSBAND of
(Give maiden name of wife in full)
(or) WIFE of .Yiilliam. Blacks t one Benne t t
(Husband’s name in full)
11 IF STILLBORN, enter that fact here.
12
r
AGE Q3 - Years. .3 Months....*/ Days
If under 24 hours
Hours Minutes
mi
Major findings:
Oi operations
/dyait
/Yd
What test confirmed diagnosis?
S Was disease or injury in any way related to' occupation of deceased?
If so. specify#. ff .t.
(Signed) /
(Address!
dGr eamati.an .Jro odlawn....;! em* E-vef e tt ...LI iss . (state or country) q ^ m «r i r» n
Place of Burial ortlrlmation (CKy or Town) ' AUiaJ.
,^21 « ^ ■*
DATE ■ g'
(City or Town)
.3 X y J9.J
7 NAME OF
FUNERAL DIRECTOR. ,, .
^ ’ filed with ^e B
ADDRESS .1 74.....iyint Ja.r..op....B t Wint hr on . M i s s «
Received and filed /!...
.19..
13 Usual
Kation: EPUS eWi f 0
(Kind of work done during most of working life)
A TRUE COPY ATTEST:
(Registrar)
or Business:... .Qwn.Eom.©
IS Social Security No H QI10
16 BIRTHPLACE (City,
(State or country) H '
.Santiago
,a0a AMerica
17 NAME OP
FATHER
18 BIRTHPLACE OF
FATHER (City)
(State or country)
.Qeprge Hayden
19 MAIDEN NAME
OF MOTHER
P.itzwilliatn
New Hampshire
20 BIRTHPLACE OP
MOTHER (City) .
u nah 1 e t-a ob taia
Informant... Mr.s.*.Se.th...Newt.on. Manning
(Address, 2^^ Pegnoeg Ave, Athol .^Mass
I HEREBW CERTIFY uiat a satisfactory standard certificate of deatl
I satisfactory i
death was
f Board of Health or other
(Date of Issue
or otherV , /
of PCTmit)
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
ser\’ice 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 pennits, 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
removea 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, na\*y or marine corps of the United States
in any war in which it has been engaged, such recital shall appear upon the permit.
'I'he 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 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. .58, 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.
. . . (5hap. 114. Sec. 46, G. L., (Tercentenary Edition).
RULES OF PRACTICE
The fulfillment of the purpose of these laws calls for the observance of the follow-
ing rules of practice:
(1) Attending physicians will certify to such deaths only as those of persons
to whom they have given bedside care during a last illness from disease unrelated
to any form of injury.
(2) Board of Health physicians will certify to such deaths only as those of
persons who, though disabled by recognized disease unrelated to any form of
injury, have died without recent medical attendance or whose physician is absent
from home when the certificate of death is needed.
(3) Medical Examiners will investigate and certify to all deaths supposably
due to injury. These include not only deaths caused directly or indirectly by
traumatism (including resulting septicemia), and by the action of chemical
(drugs or poisons) thermal, or electrical agents, and deaths following abortion, but
also deaths from disease resulting from injury or infection related to occupation,
the sudden deaths of persons not disabled by recognized disease, and those of
persons found dead.
Statement of Cause of Death. — Physicians: see explanatory instructions
on face side of standard certificate of death.
Statement of Occupation. — Precise statement of occupation is very import-
ant, so that the relative healthfulness of various pursuits can be known. Make
some entry in this section for every person aged 10 years or over. If the occupa-
tion had been given up or changed, or if the deceased had retired from business,
report the kind of work done during most of working life even if retired. Children
not gainfully employed may be returned as at school or at home. For a woman
whose only occupation was that of home housework, write housework. For a
person engaged in domestic service for wages, however, designate the occupation
by the appropriate terms, as housekeeper — private family, cook — hotel, etc. For
a person who had no occupation whatever write none.
SERVICE NUMBER
LM R-302
• «r
'^'1
«= §
5
.3
SUFFOLK
BOS^W
(City or Town)
<Sammomoralll| of HaBaartfuertlB
EDWARD J. CRONIN
Secretary OF THE Commonwealth
DIVISION OF VITAL STATISTICS
COPY OF
CERTIFICATE OF DEATH
(City or town maldng return)
lees 32
Registered No.
— /(If death occurred in a hospital or institution,
.,5.91....MD.r.to.n st.V-g '
2 FULL NAME
No o.yx....iflo.r!.LO.ii st. v give its NAME instead of street and number)
J (Wm deceased a
(If deceased is a married, widowed or divorced woman, give also maiden name.)
U. S. War Veteran, -jm.- x
if so specify WAR)
(if n'feld?.fetv^ |{t^f town and State)
Length of stay: In place of death years months.^ days. In place of residence.. 4 years months days.
(a) Residence. No St.
(Usual place of abode)
MEDICAL CERTIFICATE OF DEATH
^ Eeath*^. ^.©br.uary. .9. .1953.
(Month)
(Day)
(Year)
41 HEREBY CERTIFY. That I attended deceased from
2/1 19 to ......2./3 1<)5.3.
I last saw h... ira alive on 2^^ ifiS -t death is said tc|
have occurred on the date stated above, at m.
DISEASE OR CONDITION
DIRECTLY LEADING
TO DEATH (a) CanC«E i Of ; th«
i!£P^8Pfegg§g?ll8i
to liver
ANTE Due To
CEDENT (b)
CAUSES
Due To
(c)
OTHER
SIGNIFICANT
CONDITIONS
UTERVAl IE
TWEE! OISET
MO OUTI
-6mo
plUl I AGEV..?....Years
Major findings:
Of operations..
Date of operation Was autopsy performed?. ..yes
What test confirmed diagnosis?
5 Was disease or injury in any way related to occupation of deceased?
If so, specift.....„
(Signed) S....ii.Unt.
no
M. D
(Address) . 591 Morton" ^ ^te....fl./a. i9fi:‘,
6 J*inthrQp Cem* WintiiTop
DATE OF BURIAL Fe1> - 6-
1163
7 NAME OF
FUNERAL DIRECTOR..
J....J....G.Q.o.d. .& Sg.ns
ADDRESS
Boxbm*y-
Received and filed ...ly,.-.;..;.......^
(Registrar of City or Town where deceased resided)
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
9 COLOR OR RACE
ti
10 SINGLE (write the word)
MARRIED
WIDOWED J
or DIVORCED aPEXO Q
10a If married, wic^wed. or divorced _ , _
HUSBAND of Margaret 0*Brien
(.GsVc niaide ■ ame e wut m full)
(or) WIFE of..
(Husband's name in full)
11 IF STILLBORN, enter that fact here.
*12
54
..Months Days
If under 24 hours
Hours Minutes
13 Usual
Occupation:
w-hemist
(Kind of work doi
done during most of working life)
14 Industry
or Business:.
8os tan Health
15 Social Security No..
16 BIRTHPLACE (City)
(State or country) Uatn OEXQ »
17 NAME OF
Thomas ^olan
Ma s s .
18 BIRTHPLACE OF
FATHER (City)
(State or country)
■CambridiTt'-
19 MAIDEN NAME
OF mother I^iizabeth i.lcDonald
Mas a 4!
20 BIRTHPLACE OF
MOTHER (City) .S*».a.',4)
(State or country)
21
Informant..
/Address)
lassi
A TRUE COPY // / , -■ j
ATTEST: 4
' (Registrar of City or Town where death occurred)
..J£.
DATE FILED
.Fefe...,5 19....53..-
DATE OP ENTERING MILITARY SERVICE - 9/27/18
DATE OF DISCHARGE 11/29/18
RANK, RATING . Naval Aviation
ORGANIZATION & OUTFIT
SERVICE NUMBER
I
Dlst Detail Office Boston N T Charleston, N C
95844
nsoEiv::
.n
' • . j '
tM R-302
Suffolk
(County)
Boston
(City or Town)
(Sommomtiraltt) of ISaaoartiuorttB
EDWARD J, CRONIN
Secretary OF THE Commonwealth
DIVISION OF VITAL STATISTICS
COPY OF
CERTIFICATE OF DEATH
Boston
No.
(City or town making return)
Registered No. . .1251, 23
Uasfl.“eiiuHc«itS; 3. )«1
give its NAME instead of street and number)
2 FULL NAME I (Was deceased a
(If deceased is a married, widowed or divorced woman, give also maiden name.) | U. S. War Veteran,
I if so specify WAR) .
Corinha Beach st Winthrop Mass*
(a) Residence. No St. ,
(Usual place of abode)
Length of stay: In place of death years months 7 ...days. In place of residence..
(If nonresident, give city or town and State)
.i2jXyears months days.
MEDICAL CERTIFICATE OF DEATH
^ Eilfr Feb*^$3
(Month) (Day) (Year)
41 HEREBY CERTIFY.
to.*.29.., 19.53 to..
I last saw he]? alive on
have occurred on the date stated above, at
That I attended deceased from
Feb.*5 19.53.
Ffib.5 ... 19.53. death is said tcj
6l30P rr
DISEASE OR CONDITION
DIRECTLY LEADING Acufte Eiyocarclial
TO DEATH (a) ^
infarction
ANTE Due To
CEDENT (b)
CAUSES
CofTonary arbcrio
aclerbsta
Due To
(c)
OTHER
SIGNIFICANT
CONDITIONS
Hyper
UTERVU IE-
TWEEI OISET
AND DEATH
12 Da:
^ith
1 Mon'
Major findings:
Of operations IlOne
Date of operation Was autopsy performed?.. ...No
What test confirmed diagnosis?... E...K...C.,kib.*aild....cl.ini.caa
S Was disease or injury in any way related to occupation of deceased?.. No
If so. specify T ■n* •«»
(Signed) HI . .E....fUCaa M. D.
(Address) ^ Boatma Maaa> Date 2-5 53
6 Crenatiai.HoDfilam^^E^
Place of Burial or Cremation ■c» /»<*»(City or Town)
* eb*9/53
DATE OF BURIAL .
19
7 NAME OF
FUNERAL DIRECTOR .
ADDRESS
A B Marsh
Wiiiithro^^
Received and filed..
icro
.19..
(Registrar of City or Town where deceased resided)
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
F
9 COLOR OR RACE
(write the word)
10 SINGLE
MARRIED
WIDOWED UnrrHFlfl
or DIVORCED®*""^®®
10a If married, widowed, or divorced
HUSBAND of
(Give maiden name of wife in full)
Charles H PuHei'ton
(Husband’s name in full)
(or) WIFE of..
11 IF STILLBORN, enter that fact here.
12
f AGE $8 -Yearslj. Month!?. Days
If under 24 hours
Hours Minutes
13 Usual
Occupation:..
Htuser^fe
(Kind of work done during most of working life)
14 Industry ^
or Business: OwA HOfaft
IS Social Security No..
Mona
birthplace (City) Evorett Maso *
n (State or country)
17 NAME OF
FATHER
Pet^ Hanson
18 BIRTHPLACE OF
FATHER (City) j^Eland,.
(State or country)
19 MAIDEN NAME
OF MOTHER Mary v/agiier
20 BIRTHPLACE OF
MOTHER (City) BQs.t.on...Ma3.a*..
33 * (State or country)
21
Informant Douixtlas .FiQ.le3?t.csi
fAddress) ,
ATRUECX)Py^ ^
ATTEST:
(Registrar of City or 'Town where death occurred)
Peb/lO/53
DATE FILED - 19....
RECEIVED
TOr9 «I
)
1
»- -.. ’■> - I
IV' --M
K'
; ;t
it‘
i"
, ./ .*-■
'^-
1
>/ .1
■•f r
- V ^ —
,»i<.
-. ■ "ST*
!'y >
' ■ ■ ^:
i( >•; 'j
• ■' * <1
■- \ ■ r
. : , 'j
'4
"I • ‘ ■ 1a '
•;•-..•■• ‘ ;l
• i
'»■■■ .^r"^ ■(
25M(H)-n-5I-905807
No.
Suffolk
(County)
5ost<m
(City or Town)
Peter 3ont
(Sommonniraltt; of 4laBaarl|nBrttB
EDWARD J. CRONIN
Secretary of the Commonwealth
DIVISION OF VITAL STATISTICS
COPY OF
CERTIFICATE OF DEATH
Hoant#
Boston
(City or town making return)
1253 2 i
Registered No.
I (If death occurred in a hospital or institution,
St. l give its NAME instead of street and number)
2 FULL NAME tAe^ f (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)
7^.* st.Winthrop Mas
(Usual place of abode) (If nonresident, give city or town and State)
Length of stay: In place of death years months ^..days. In place of residence years months lO ..days.
(a) Residence. No.
MEDICAL CERTIFICATE OF DEATH
PERSONAL AND STATISTICAL PARTICULARS
3 DATE OF *T /ff*a
DEATH ^ 0!Pi*.7/.53.
(Month) (Day) (Year)
41 HEREBY CERTIFY, That I attended deceased from
Fel?*3. 19 53, to Feb*7 1953
.....Fsl).*.? i9vJ,
8 SEX
F
9 COLOR OR RACE I *9 SINGLE (write the word)
MARRIED
I last saw h.....6r . alive on..
, death is said tc
10a If married, widowed, or divotte'^ m-
HUSBAND of Entra •I'noBipsoa
(Give maiden name of wife in full)
have occurred on the date stated above, at lOiOUPM
UD OEATN
1 1 IF STILLBORN, enter that fact here.
DISEASE OR CONDITION
DIRECTLY LEADING Brain "tijraor
TO DEATH (a)
gliotiilagtcana 101111'. forno 6 Moll»A.GE g6....Years .9 Months 0 Days
ANTE Due To
CEDENT (b)
CAUSES
Due To
(c)
OTHER
SIGNIFICANT
CONDITIONS
Broncho nnetmonia bil iteral
- TertaJ
lanRvu lE-
T«EEI OaSET
(or) WIFE of .
(Husband's name in full)
12
If under 24 hours
Hours Minutes
13 Usual
Occupation:..
Houa.o'i'iife
(Kind of work done during most of working life)
Of operations.. Crard.aton]y ..aR!5 M
Date of operation. ..Was autopsy performed? X(5a
What test confirmed diagnosis?
: autopsy
5 Was disease or injury in any way related to occupation of deceased?
If so, specify
(Signed) V...M....CaS8.....*™.......... „ ^... ^
(Address)
6 Q^tia ...Glmpe.k
Place of Burial or Cremation (City or TowftSII XW
Fefe. 12/53
DATE OF BURIAL .
19
7 NAME OF
FUNERAL DIRECTOR
ADDRESS.
A B Ifarek
mi
Received and filed 19
(Registrar of City or Town where deceased resided)
14 Industry
Bu^ess; Own ...Hope,.
IS Social Security No..
Hone
16 BIRTHPLACE (City)..
(State or country)
17 NAME OF
FATHER
laaty
Kentucky
18 BIRTHPLACE OF
FATHER (City)
(State or country)
Dixon Burrfiard
Gravea <^*Kentucky:.
19 MAIDEN NAME
OF MOTHER
El izabeth Camey
20 BIRTHPLACE OF
MOTHER (City) Gi*avos Gouiitiy.K^ntticks
(State or country)
Informant..
(Address)
A'T^ COPY /:/. g/
A-rfKT:' ......rc..rr:!?. .<3...*.
(Registrar of City or Town where death occurred)
Feb.iO/53
DATE FILED 19...
<2. K. 10 O ^ ) © --TCP
ilAR-8 nil
M*% • •
f
V< R-301A
AUCTIONS
FOR
L CERTIFICATE
civinc
CF DEATH
!>ot enter
I than one
> for each
(b) and (c)
does not mean
of dying, such
lilure, asthenia, •
!ans the disease,
ications which
ath.
>id conditions, .
ving rise to the ‘
\se (a) slating
trlying cause
'itions contrib- •
le death but not
the disease or
causing death.
fflammamoFaltt) of
EDWARD J. CRONIN
Secretary OF THE Commonwealth
DIVISION OF VITAL STATISTICS
STANDARD
CERTIFICATE OF DEATH
2 FULL NAME..
(City orTown)
deceased is a mi^ied. ^^owed or divo^ed wor
^ 2r2er.
)f abode) f
Length of stay; In place of death years ^j^ .months days. In place of residence . years
Registered No
To be 6Iad for burial parmit
with Board of Health
or Its Agent.
25
IMAYFLQWER
(If<
(a) Residence. No. . X. ..
(Usual place of abode)
HOME
woman, give also maiden name.)
give its NAME instead of street and number)
PHYSICIAN — IMPORTANT
(Was deceased a
U. S. War Veteran,
if so specify WAR) ..
(If nonresident, give city or town and State)
^ months days.
MEDICAL CERTIFICATE OF DEATH
PERSONAL AND STATISTICAL PARTICULARS
3 DATE OF
DEATH
8 SEX
9 COLOR OR RACE
(Month)
(Year)
41 HEREBY CERTIFY, That I attended deceased from
. 19 -f . -7 to 19.1^....^.
I last saw ...alive on ... death is said to|
have occurred on the date stated above, at^^ l^.
DISEASE OR CONDITION
DIRECTLY LEA
TO DEATH (a) I
10 SINGLE (write the word)
MARRIET
10a If married, wi^
HUSBAND of..
7 NAME OF
FUNERAL DIRECTO
ADDRESS
Received and filed..
i£B....l2 i.^£a..
.19.
(Registrar)
I HEREBY CERTIFY
filed wkn me BEFORE
(,Sigi)^vire of
(Official Designation)
certificate of death was
uyial j>r traWsil, permiy W;
. permiy W2is issued:
^ard of HeaWi (n^otHeriT
(Date of Issue of Pehifiit)
■' \
EXTRACTS
FROM THE LAWS OF THE
COMMONWEALTH OF MASSACHUSETTS
GOVERNING THE
RETURN OF CERTIFICATES OF DEATH
A ph ysician or registered hospital medical officer shall forthwith, after the
death of a persrm 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
l>est 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 \yas
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.
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 pereons 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.
A physician or officer fumi.ffiing a certificate of death as required by the'^ ^ J)»o^rider^ker or other persons shall bury a human body or the ashes thereof
preceding section or by sectiot: forty-five of chapter one hundred and four- which have been brought into the commonwealth until he has received a permit
teen, shall, if the deceased, to ihe best of his knowledge and belief, served in the ‘^o,from the hoard of health or its agent appointed to issue such permits, or
army, navy or marine corps of the United States in any war in which it has been ^ such boarcL ^hc clerk of the town where the body is to be buried
eng.Tged, insert in the certificate a recital to that effect, specifying the war. and thejuaeral is to be h^d, or from a person appointed to have the care of the
shall also certify in such certificate both the primary and the secondary or imme- o JP which the interment is made,
diate cause of death as nearly as he can sta^ the same. For neglect to comply. rT.u 1 Edition).
with any provision of this section, such physician or officer, shall forfeit ten dolla^. ^ .%••'**“* ****./^ O • ' -
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 Cbin^ s /T*l.
RULES OF PRACTICE
relief expedition and the Philippine insurrection, which shall, for said purposes, ‘be^ 1 , n
deemed to have *.aken place between February fourteenth, eighteen hundred and.>' *;!. Trie fulfillrn^nf of the purpose of these laws calls for the observance of the follow-
ninety-eight and July fourth, nineteen hundred and two. and the Mexican border
Ired and seventeen.'. , / vAi2
ser\'ice of nineteen hundred and sixteen and nineteen hundred
G. L. Chap. 46. ^c. 10.
1%
No undertaker or other person shall bury or otherw’ise 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
physicians will certify to such deaths only as those of persons
,ve given bedside care during a last illness from disease unrelated
ny^^rr»^g^ m jury.
rp 'of Health physicians will certify to such deaths only aS those of
/ pe^^n€\ w^.% ''.bough disabled by recognized disease unrelated to any form of
nijuiTs 4iavcdied without recent medical attendance or whose physician is absent
fromiroTfi^ when the certificate of death is needed.
(3) Medical Exarniners will investigate and certify to all deaths supposably
Fdp^t^ ip^ry. The^ include not only deaths caused directly or indirectly by
Gal^ti^pa (includmg resulting septicemia), and by the action of chemical
♦dro^^r 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:
on face side of standard certificate of death.
see explanatory instructions
Statement of Occupation. — Precise statement of occupation is very import-
ant, so that the relative healthfulness of various pursuits can be known. Make
spme entry in this section for every person aged 10 years or over. If the occupa-
tion had been given up or changed, or if the deceased had retired from business,
report the kind of work done during most of working life even if retired. Children
not gainfully employed may be returned as at school or at home. For a woman
whose only occupation was that of home housework, write housework. For a
person engaged in domestic service for wages, however, designate the occupation
by the appropriate terms, as housekeeper — private family, cook — hotel, etc. For
a person who had no occupation whatever write none.
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE
RANK, RATING
ORGANIZATION AND OUTFIT
SERVICE NUMBER
V
NV -
La
-f
R-301A
UCTIONS
■OR
CERTIFICATE
riving
)F DEATH
»t enter
:han one
For each
b) and (c)
hes not mean
/ dying, such
ure, asthenia, «
rt5 the disease,
ations which
h,
i conditions, .
ng rise to the *
? (a) stating
■ying cause
ions contrib- •
death but not
te disease or
lusing death.
A
(County)
(City or Town)
(Hommonoiralttf of AaBBarliasRtts
EDWARD J. CRONIN, SECRETARY
DIVISION OF VITAL STATISTICS
STANDARD
CERTIFICATE OF DEATH
Registered No,
To be filed for burial permit
with Board of Health
or its Afent.
23
No.
17 Hillside Aye,
2 FULL NAME ? ( Hyd®. X . Spinii©
(If deceased is a married, widowed or divorced woman, give also maiden name.)
(a) Residence. No XI....K 1 llS St.
(Usual place of abode)
I (If death occurred in a hospital or institution.
... St. \ give its NAME instead of street and number)
PHYSICIAN — IMPORTANT
(Was deceased a
U. S. War Veteran,
if so specify WAR)
12
(If nonresident, give city or town and State)
Length of stay: In place of death years months days. In place of residence ^._^ears months days.
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
DEATH ..
(Month)
(Day)
6 ^
(Year)
41 H_EREBY CERTIFY, That I attended deceased from
19-S~ J, /Oy I ^ 19
I last saw h_A*:fL. alive on^l!^,<^ . V'C? 19J....J7 death is said to
have occurred on the date stated above, at ^
DISEASE OR CONDITION
DIRECTLY LEAPi?iG
TO DEATH (a)
14 Industry
^ or Business:
OTHER
SIGNIFICANT .
CONDITIONS
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, specif....." .,. .JJ.
, M. D
(Addres^ Jyy
6 rlinthrgpl L. ..Kintlir.Q.p.
Place of Burial or Cremation
DATE OF BURIAL
(City or Town)
Feb, 12 „5:
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
Female
9 COLOR OR RACE
V/hite
10 SI.N'GLE (write the word)
MARRIED
WIDOWED ...
or DIVORCED .VICLOV/
10a If married, widowed, or divorced
HUSBAND of
(Give maiden name of wife in full)
(or) WIFE of .F re de r i <3k
(Husband's name in full)
1 1 IF STILLBOR.V, enter that fact here.
(Registrar)
>2 Qp Q pr-
AGE Years ... r Months . ^ Days
If under 24 hours
Hours Minutes
13 Usual
Occupation:..
Kousev/if e
(Kind of work done during most of working life)
At. home
15 Social Security No. 9.99.
16 BIRTHPLACE (City) ^’.^.i.rhaV On
(State or country) t
17 NAME OF
FATHER 0
harles
Hyde
18 BIRTHPLACE OF
FATHER (City) ....
(State or country)
Unable
to obtain
19 MAIDEN NAME
OF MOTHER
Bet 33^
Nichols
20 BIRTHPLACE OF
MOTHER (City) ....
South
Dartmouth
(State or country)
Mas.s .
, , . Heleae Sr’.'/in
iT-nlllside Ave-;- -yiiitihV-nh-
I HEREBY CERTIFY that a satisfactory standard certificate of death was
filed with me BEFOB?^ J^e burial or transit p^mit was issued:
Signaturj,
(Oflficial Designation)
or transit p^mit was issuec
'oard of Heal^i or other), .
^ /l/oO
(Date o^ssue of^ermit)
EXTRACTS
FROM THE LAWS OF THE
COMMONWEALTH OF MASSACHUSETTS
GOVERNING THE
RETURN OF CERTIFICATES OF DEATH
A physician or reijistercd hospital medical officer shall forthwith, after the
death oi a person whom he has attended during his last illness, at the request
of an undertaker or other authonzed person or of any member of the family of
the deceased, furnish for re^stration 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, wliere 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.
Xo 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 the board of health or its agent aforesaid or from the clerk
of the town where the body is buried. Xo 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 uathin 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 s^tion 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 shalTmakc examination upon the view of the dead bodies
of persons as are supjwscd to have died by violence, or by the action of
chemical, thermal ot’"^e<tj’lc3l agents or following abortion, or from diseases
resulting from injury- oriiitfecridn relating to occupation, or suddenly when not
disabled by rccoghi^«ibl€'t)i§r®isc, or when any person is found dead — General
Laws. Chap. 38. Sec.',^. 4.s^mcfKied by Chap. 632, Sec. 4. Acts of 1945.
Xo undertaker :dr qlh*er peMqns.'shall bury a human body or the ashes thereof
which have be^ fcfoli^t into fbe tiommonwealth until he has received a permit
so to do fromTtne board of- fi^ltf^fjts agent appointed to issue such permits, or
if there is no suerf'^ard, from th^c^ric'of the town where the body is to be buried
or the funeral is t^^be held, or (fom a person appointed to have the care of the
cemeteiy or bi^iA'^pund in wj^i^ tme interment is made.
. . . (3hap;‘'l!^Sec;J^. {^^centenary Edition),
'7>^7 ' d
OF PRACTICE
The fulfillment onbeputpose of these laws calls for the observance of the follow-
ing rules of practice:
(1) Atten<Uj^ phy^sicians will certify to such deaths only as those of persons
to whom they Mvew^n'S^dside carjIfduring a last illness from disease unrelated
to any form ofnr^!^.*— ,
(2) Board of Health physicians will certify to such deaths only as those of
persons who. though disabled by recognized disease unrelated to any form of
injury, have died without recent medical attendance or whose physician is absent
from home when the certificate of death is needed.
(3) Medical Examiners will investigate and certify to all deaths supposably
due to injury. These include not only deaths caused directly or indirectly by
traumatism (including resulting septicemia), and by the action of chemical
(drugs or poisons) thermal, or electrical agents, and deaths following abortion, but
also deaths from disease resulting from injury or infection related to occupation,
the sudden deaths of persons not disabled by recognized disease, and those of
persons found dead.
Statement of Cause of Death. — Physicians: see explanatory instructions
on face side of standard certificate of death.
Statement of Occupation. — Precise statement of occupation is very import-
ant, so that the relative healthfulness of various pursuits can be known. Make
some entry in this section for every per^n aged 10 years or over. If the occupa-
tion had been given up or changed, or if the deceased had retired from business,
report the kind of work done dunng most of working life even if retired. Children
not gainfully employed may be returned as at school or at home. For a woman
whose only occupation w^ that of home housework, write housework. For a
person engaged in domestic service for wages, however, designate the occupation
by the appropriate terms, as housekeeper — private family, cook — hotel, etc. For
a person who had no occupation whatever write none.
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE
RANK, RATING
ORGANIZATION AND OUTFIT
SERVICE NUMBER
25M-(H)Il-51-9058l)7
I jSwXJrolk..
Q (County)
lb
O
u
u
No.
y or Town)
Mac3*Hen'"rj.a!
QIl}r (SomtnantDraltIf of AaoBartinortto
<f"\ EDWARD J. CRONIN
Secretary OF THE Commonwealth
DIVISION OF VITAL STATISTICS
COPY OF
CERTIFICATE OF DEATH
Bos.t.oji
(City or town making return)
.M*?:. 2?
St
I (If death occurred in a hospital or institution,
. \ give its NAME instead of street and number)
2 FULL NAME / (Was deceased a
I U. S. War Veteran,
I if so spe(^y WAR).
N„ s.. 'SlnthropT&as.
(Usual place of abode)
(If deceased is a married, widowed or divorced woman, give also maiden name.)
7 Seafoani Ave.
(If nonresident, give city or town and State)
Length of stay: In place of death years months.. .X days. In place of residence.X years months days.
MEDICAL CERTIFICATE OF DEATH
PERSONAL AND STATISTICAL PARTICULARS
’ Feb.12/53
(Month) (Day)
8 SEX
(Year)
41 HEREBY CERTIFY,
F-ebw X2> 19 .$3 . to
I last saw h 43j»..alive on
have occurred on the date stated above, at
DISEASE OR CONDITION
DIRECTLY LEADING r. x
TO DEATH (a)
ANTE Due To
CEDENT (b)
CAUSES
That I attended deceased from
F.Cba ...X2 19....!^3
Feb. 12. ., 19. 53 death is said tc|
7555f^m. lnTERVU BE-
TVEEI OISET
MD DEATH
? Days
9 COLOR OR RACE
IS
10 SINGLE (write the word)
MARRIED
WIDOWED Widowed
or DIVORCED
Kemorrhagic cyst.it.i8
Due To
(c)
OTHER. •
SIGNIFICANT jBroncbo. .piieuroc^..ia;.
CONDITIONS
10a If married, widowed, or divorced
HUSBAND of
(Give maiden name of wife in full)
(or) WIFE of t . Villani
(Husband's name in full)
11 IF STILLBORN, enter that fact here.
12
ageIiX Years .. IX
Months..
..27.Days
If under 24 hours
Hours Minutes
13 Usual
Occupation:
(Kind of work none during most of working life)
14 Industry
or Business:..
..Roatauranta..
Major findings:
Cif operations.
Date of operation Was autopsy performed?.. ...Na.
What test confirmed diagnosis?... cXini.csaX.
5 Was disease or injury in any way related to occupation of deceased?..
If so, specify
(Signed) P -D-
(Address) Date c“JLX.
M.
19
oaaMfiiaXden MassgT
Place of Burial or Credlation— , x (City or Town)
DATE OF BURIAL 19
7 NAME OF
FUNERAL DIRECTOR..
ADDRESS
Received and filed
R....Q...Klrl33r.
E— t Boatm Ifagg*
...•i
(Registrar of City or Town where deceased resided)
.19..
IS Social Security No
16 BIRTHPLACE (City) -Port X^Xcolm K.S,
(State or country)
17 NAME OF
FATHER
V
James H ing
18 BIRTHPLACE OF
FATHER fCitvl
Po-rt !4alcoXm N,.S*
(State or country)
19 MAIDEN NAME
OF MOTHER
Annie L McLean
20 BIRTHPLACE OF
MOTHER (City)
Port Haficsbirrg N.S,
(State or country)
21
Informant..
(Address)
..Mr3....A ...li...KijriE Mother.
ArfEST:
(Registrar of City or Town where death occurred)
Febei6/53
DATE FILED - 19
MS >
■ ■- -
4 ^ 'll.* I4-
■>. 1^ .Jt&s -s. i .' J ■ " T’ ■- ,t_- ..-^
■ “ •* t ■>;; ”,1
)
■vv
'V
received*
'!* '
Aj»h,
•J •
C^'Vi ,ffr
voT'ii r ’
.«5Pif rr»t»r>£ >fj^
I R-301A
tUCTIONS
FOR
CERTIFICATE
giving
OF DEATH
ot enter
than one
for each
[b) and (c)
does not mean
5/ dying, such
lure, asthenia, ,
in^ the disease,
:ations which
Ih,
d conditions,
ing rise to the '
e (a) slating
lying cause
lions conirib- •
■ death but not
he disease or
ausing death.
A
I Sv^f olk ^
(County)
(SammomiiFaltif of inasBartfnBRttB
EDWARD J. CRONIN
Secretary of the Commonwealth
DIVISION OF VITAL STATISTICS
STANDARD
CERTIFICATE OF DEATH
To be filed for burial permit
with Board ot Health
or its A|«nt.
Registered No
I (If death occurred in a hospital or institution.
No St. \ give its NAME instead of street and number)
At n 1 o no*ii c c 1 oni f physician - important
FULL NAME ^ V V VS 4 ^ I (Was deceased a
(If deceased is a married, widowed or divorced woman, give also maiden name.)
(a) Residence. No 1.9.6 Glads St.* st.
(Usual place of abode)
IS
U. S. War Veteran,
if so specify W'AR) .
Length of stay: In place of death years months days. In place of residence .'..t . years months days.
(If nonresident, give city or town and State)
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
DEATH ...
(Month)
/s3
(Day)
(Year)
.HEREBY CERTIFY
'X.P. 19 to.
'last saw h . .alive on.,
have occurred on the date stated above, at
r I F Y , That I attendi
to
attended deceased from
. 19..^
195?..r., death is said to
DISEASE OR CONDITION
DIRECTLY LEADING
TO DEATH (a)
DaV C. T/ t.
ANTE Due To
CEDENT (b)
CAUSES
Due To
(c)
OTHER
SIGNIFICANT ..
CONDITIONS
IHTFIIVU BE
TWEEN ONSET
UD DEATH
Major findings:
Of operations. f
Date of operation. .^../
What test confirmed diagnosis?
i l&MOl
y . Was autopsy performed?. /M
5 Was disease or injury in any way related to occupation of deceased?
If so, specify
(Signed) . A , M, D
(Addre^).. ,j^^inJ..\pate F4/r..-.. 19
6 Holy Urog g , .C.em.et ^*4lcieri
Place of Burial or Cremation (City or Town)
DATE OF BURIAL ? • 1.6 * 1.95.3 19 .
7 NAME OF
FUNERAL DIRECTOR.
William E Pepi
ADDRESS .
liEB I b T
Received and filed .N?7w“*r.....*...y.....!.V.h^.)r! 19
S ~b « E » R *
(Registrar)
8 SEX
fele
PERSONAL AND STATISTICAL PARTICULARS
9 COLOR OR RACE
White
10 SINGLE
MARRIED
WIDOWED
or DIVORCED
(write the word)
Married
10a If married, widov^. or divorced / i • \
HUSBAND of Jvrarc elTa , (Ouili anp)
(or) WIFE of..
(Give maiden name of wife in full)
(Husband's name in full)
11 IF STILLBORN, enter that fact here.
AGE
61
13 Usual
Occupation:
Yeaii. Months
Days
If under 24 hours
Hours . Minutes
(Kind of work done during most of working life)
14 Industry
or Business:.
15 Social Security No.
16 BIRTHPLACE (City),.
(State or country)
Italy
18 BIRTHPL.ACE OF
FATHER (City) ...
(State or country)
.Italy
19 MAIDEN NAME
OF MOTHER Maria { Pollato)
20 BIRTHPLACE OF
MOTHER (City)
(State or country)
Informant Wi.f.e
(Address)
I HEREBY CERTIFY that a satisfactojy staruferd certificate of death was
filled BEFORE the ^upal or t^^it p^f^nit was issued:
■
oard of Hea4*Kor other) ^
(Date of Issue of Permit)
EXTRACTS
FROM THE LAWS OF THE
COMMONWEALTH OF MASSACHUSETTS
GOVERNING THE
RETURN OF CERTIFICATES OF DEATH
A physician or reijistercii 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 niemlwr 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 requirei^'bT Th? ' undertaker
preceding section or by section forty-five of chapter one hundred and 'four;
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 Spates
m any war m which it has been engaged, such recital shall appear upon the permit
n f ‘-’.L '*®.®8cnt. 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 cau^ 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, whi^ch the clerk or registrar may require.— Chap. 1 14 Sec 4S
O. L., (Tercentenary Edition). ^
.^fedical examiners shall make examination upon the view of the dead bodies
ol 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 194.S.
or other persons shall bury a human body or the ashes thereof
whK'h have been brought into the commonwealth until he has received a permit
teen, shall, if the deceased, to the best of his knowledge and belief, served in^p . i^i^o ‘lo from the board of health or its agent appointed to issue such permits or
army, navy or rnanne corps of the United States in any war in which it has beeA ^ ^ >f. there is no such board, from the clerk of the town where the body is to be buried
engaged, insert in the certificate a recital to that effect, specifying the war/a«tr,r,)i“ funeral is to be held, or from a person appointed to have the care of the
shall also certify in such certificate both the primary and the secondary qr li6mfe- l.f.camfetery or burial ground in whic^the interment is made
• For neglect td ebmipyi'A'dfff.v;, • > ' "
. tdri ’
114, Sec. 46, G. L., (Tercentenary Edition).
diate cause of death as nearly as he can state the same t-.j.
with any provision of this section, such physician or officer, shall forfeit ten
For the purposes of this section and of sections forty-five, forty-six and forty-g^-en
of said chapter one hundred and fourteen, the word "war" shall include the Qiina
relief expedition and the Philippine insurrection, which shall, for said puriSsej, b
deemed to have ‘aken place between February fourteenth, eighteen hurufred;an
ninety-eight and July fourth, nineteen hundred and two, and the .Mexican ^ ‘
service of nineteen hundred and si.\teen and nineteen hundred and sev
G. L. Chap. 46, Sec. 10.
No undertaker or other person shall bury or otherwise dispose of a humart body/ irs ^ard of Health physicians will certify to such deaths only as those of
in a town, or remove therefrom a human body which has not been buried, untilpW > I'pesspRS who, though disabled by recognized disease unrelated to any form of
has received a permit from the board of health, or its agent appointed to issue ™jury, have died without recent medical attendance or whose physician is absent
such permits, or if there is no such board, from the clerk of the town where the home when the certificate of death is needed.
person died; and no undertaker or other person shall exhume a human bodv ajul ^ ExaminersThe text goes on. The rest is in the file.