The volume, 1954
Town Clerk, Winthrop · from the Internet Archive · 564 pages · 39.3 MB
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https://archive.org/details/townofwinthropre1954wint
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SUFFOLK
■BQSSON
(City or Town)
^ammanuipaltti of iS9aa0act;ufiPttB
EDWARD J. CRONIN
Secretary of the Commonwealth
DIVISION OF VITAL STATISTICS
COPY OF
CERTIFICATE OF DEATH
BOSTON
(City or town making return)
Registered No.
66 ...
No.
Maas. ...Geno.ral. .Eo.api.t.al ^
(If death occurred in a hospital or institution,
give its NAME instead of street and number)
2 FULL NAME .MI.NN.I.E....SAi;-3JrS.p.N 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) .
(a) Residence. No
(Usual place of abode)
.l4.S-apgont st
Length of stay: In place of death years months.5 days. In place of residence 50 ..years months days.
MEDICAL CERTIFICATE OF DEATH
PERSONAL AND STATISTICAL PARTICULARS
^ DEATH*^.... Janiuary 2 X954
(Month) (Day) (Year)
4 1 H E R E B
E B Y C 1
12/29
1 last saw h
er
E R T I F Y .
19. .5.3
alive on
to..
That I attended deceased from
1/2 19.....54
8 SEX
F
9 COLOR OR RACE
w
10 SINGLE (write the word)
MARRIED
WIDOWED
or DIVORCED
19
64
death is said tc
have occurred on the date stated above, at
DISEASE OR CONDITION
DIRECTLY LEADING
TO DEATH (a)
6 >25p»
myocariUal InTarction
ANTE Due To
copo-nary aptory diso aee
CAUSES « auricular fiprillablon
Due To
(c)
SmcANT .. .ChQ.le li.thla.S.l.S.....& . Qy.3
CONDITIONS polyps of the colon
INTERVAL BE
TWEEN ONSET
MD DEATH
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.
2Ctolr
ag^.Q... .Years Months .?
13 Usual
Occupation;
10
Days
If under 24 hours
Hours Minutes
during most of working life)
-lOyra
14 Industry
or Business:
15 Social Security No...
Own home
bitis
16 BIRTHPLACE (City)..
(State or country)
t i^Os ton
Major findings;
Of operations oholeli thiaBi s & oy s t i t ld
Date of operation . .1.0../XQ.yg.X. Was autopsy performed? no.
What test confirmed diagnosis? S.tO.n© S Penipy.Q.d
S Was disease or injury in any way related to occupation of deceased? HO
If so. specify
(Signed) Gt....RljCna^aOO M. D,
(Address) Date IaO 19 ..Q^
unal or^remation
DATE OF BURIAL .
.Jan .5
7 NAME OF
FUNERAL DIRECTOR..
Received and filed
(Registrar of City or Town where deceased resided)
17 NAME OF
FATHER Kenr‘y L Sa.'^ipson
iAb.S 3
18 BIRTHPL.ACE OF
FATHER (City)
(State or country)
.Uuxbury.
19 MAIDEN NAME
OF MOTHER
Tt*r&S-
20 BIRTHPLACE OF
MOTHER (City).
(State or country)
Hath Low
Sas t ik>3 ton
-tttasa
ftes"/ - ■Sampson-
A TRUE COPY ~p
ATTEST: :.
(Registrar of City or Town where death occurred)
Jan 6
DATE FILED 19
54
1/.
f..
<1
1.
3 Hiits
if
/'T-# f- ' ^ -«.-- / - . r V* . \.
n
^'f’v'
J St-
L-
He
^ ■
f Lf
25M-(H)n-Sl-90S8tJ7
A
! mmi£
I
-U i ^ '
f
(City or Town)
No
QII|r (Sommantoraltt; of IHaaaartfnsrttfl
EDWARD J. CRONIN
Secretary of the Commonwealth
DIVISION OF VITAL STATISTICS
COPY OF
CERTIFICATE OF DEATH
F«<OBTON
(City or town making return)
78
Registered No.
St. “ hospital or institution.
give its NAME instead of street and number)
2 FULL NAME L.izzi.e....A ..Fif^feer
(If deceased is a married, widowed or divorced woman, give also maiden name.)
(Was deceased a
U. S. War Veteran,
if so specify WAR)..
(a) Residence. No TKP St- St.. -l-
(Usual place of abode) ^ (If nonresident, giVe city or town and State)
Tn Tilarp nf rf»sidpnr^ -..ilr..
v^inthrco.-Mass- .
nonresident, give ci
Length of stay: In place of death years months.. ..“S', days. In place of residence 4r..years months .
..days.
MEDICAL CERTIFICATE OF DEATH
PERSONAL AND STATISTICAL PARTICULARS
3 DATE OF
DEATH ...
(Month)
(Day
8 SEX
(Year)
41 HEREBY CERTIFY
That I attended deceased from
’
Jam3 ^
have occurred on the date stated above, at . <»... m, m.
I last saw h..
Dac.1-9’ ^’3
...alive on..
DISEASE OR CONDITION
DIRECTLY LEADING p, ^
DEATH (a) .Geni..erali5,e ,ar^
TO
■gcI'^osiS'
ANTE Due To
CEDENT (b)
CAUSES
Due To
(c)
OTHER
SIGNIFICANT
CONDITIONS
IITERIU. IE
TWEEi oisn
UD BEATI
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) Louis M. D
<Address) PrOOkl 1 . 19
Place of Buriai or Cremat'^P081aYfn - Gen-i^^
DATE OF BURIAL *jaHa.6/^.
19
7 NAME OF ,, o r. T
FUNERAL DIRECTOR id .S. Heyn.cQ.da..
ADDRESS j^.n.thrQD-Mass..w.
Received and filed .l.v/...-;
19 .
(Registrar of City or Town where deceased resided)
'e Male
9 COLOR OR RACE
Vthi t.e
10 SINGLE (write the word)
MARRIED
WIDOWED y, , j
or DIVORCED Vfici owed
10a If married, widowed, or divorced
HUSBAND of ,
(Give maiden name of wife in full)
(or) WIFE of Frederic G Fiah.er..
(npsba!!ii>BWTaffwe Ml’ lull)——™-'
11 IF STILLBORN, enter that fact here.
AGE 11
Years ^...Month^Q Days
If under 24 hours
Hours Minutes
13 Usual
Occupation: u:
(Kind of woi’WftjS'dii^^^ost of working life)
14 Industry
or Business:.
Own BofnQ"
IS Social Security No..
16 BIRTHPLACE (City)..
(State or country)
Mane
Niverille New York
17 NAME OP
FATHER
18 BIRTHPL.\CE OP
^;id T
FATHER (City) ..
(State or country)
•■■New York
19 MAIDEN NAME
OF MOTHER
Enuna House
20 BIRTHPLACE OF
MOTHER (City) ..
(State or country)
21
Informant.,
f Address)
y^agmon ^
.c^traF of City or Town where death occurred)
Jan. 6/^
DATE FILED - 19..
M R-301A
.7
ntuaiONS
FOR
1 CERTIFICATE
1 fivinf
; OF DEATH
I
not enter
e than one
le for each
, (b) and (c)
s does not mean
t of dying, such
ailure. asthenia, ■
tans the disease,
lications which
tath,
bid conditions, .
iving rise to the '
use (a) stating
lerlying cause
ditions contrib- ■
the death but not
0 the disease or
1 causing death.
(Sammanmpalttf of ^aBaati;uaEttB
EDWARD J. CRONIN
Secretary of the Commonwealth
DIVISION OF VITAL STATISTICS
STANDARD
CERTIFICATE OF DEATH
Registered No
To be filad for burial -permit
with Board of Health
or it» Aaent.
3
2 FULL NAME
(If-<leceased is a mame^ widowed or dtvorcei
(a) Residence.
(Usual place of abode)
/
Length of stay: In place of death. /.../...y<
I (If death occurred in a hospital or institution,
St. \ give its NAME instead of street and number)
PHYSICIAN — IMIfORTANT
(Was deceased a
S. War Veteran,
specify WAR) .
dlTORTANT
nonresident, giye city or town and State)
(1... months days. In place of residence years months days.
EDICAL CERTIFICATE OF DEATH
3 DATE OF I
DEATH
' (Year)
4A H E RE BY CERTIF Y^ 77That I attended deceased fro
\90...
I last saw alive on 19.^!?^^ death is said to
have occurred on the date stated above, at . m.
DISEASE OR CONDITION
DIRECTLY LEADI
TO DEATH (a)
NDITION ^
ANTE Due To
CEDENT (b)
CAUSES
OTHER
SIGNIFICANT .
CONDITIONS
IRTERVU BE
TWEEN ONSET
MO DEATH
Major findings:
Of oi>erations
Date of operation Was autopsy performed?..
What test confirmed diagnosis?
5 Was disease or injury in any way related to occupation of deceased?.
PERSONAL AND STATISTICAL PARTICULARS
8/SEX
10a If married, widpwed, or divorced
.HUSBAND of.
(Giva^mali
(or) WIFE of
^ in fullL
(Husband^ name in full)
11 IF STILLBORN, enter that fact here.
12
AGE ..^.y!. Years .^ Months Days
If under 24 hours
.Hours Minutes
14 Industry fj
or Business: .W^*rr
(Kind of work done during most of working life)
15 Social Security No...
16 BIRTHPLACE (City)..
(State or country)
17 NAME OF
FATHER
18 BIRTHPL.ACE OF
FATHER (City)
(State or country)
19 MAIDEN NAME
OF MOTHER
..
^n( of Board of Hc<hor 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 registered hospital medical officer shall forthwith, after the
rleath of a pereon 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
iiest 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
!X)ntracted. the duration of his last illness, when last seen alive by the physician
>r 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 decea^d. 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
png.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
vith any pro%*ision of this section, such phj^ician or officer, shall forfeit ten dollars.
For the purposes of this section and of sections forty-five, forty-six and forty-seven
jf 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,
j. L. Chap. 46. Sec. 10.
No undertaker or other person shall bury or otherwise dispose of a human body
n a towm. or remove therefrom a human body which has not been buried, until he
las received a permit from the board of health, or its agent appointed to issue
»uch permits, or if there is no such board, from the clerk of the town where the
Derson died; and no undertaker or other person shall exhume a human body and
•emove it from a town, from one cemetery to another, or from one grave or tomb
jther than the receiving tomb to another in the same cemetery, until he has
•eceived a permit from the board of health or its agent aforesaid or from the clerk
>f the town where the body is buried. No such permit shall be issued until there
»hall have been delivered to such board, agent or clerk, as the case may be,
i satisfactory written statement containing the facts required by law to be
'etumed 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
af 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 w’ithin 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 w'ar in which it has been engaged, such recital shall appiear upon the permit.
The board of health, or its agent, upon receipt of such statement and certificate,
shall forthwith countersign it and transmit it to the clerk of the town for registra-
tion. The person to whom the permit is so given and the physician certifying
the cause of death shall thereafter furnish for registration any other necessary
information which can be obtained as to the deceased, or as to the manner or
cause of the death, which the clerk or registrar may require. — Chap. 1 14, ^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, thermal or electrical agents or following abortion, or from diseases
resulting from injury or infection relating to occupation, or suddenly when not
disable by fecognizable disease, or when any person is found dead. .. — General
Laws, Ch'apr38. Sec. 6., as amended by Chap. 632. Sec. 4. Acts of 1945.
No undertaker or other persons shall bury a human body or the ashes thereof
which have been brought into the commonwealth until he has received a permit
^ to do froth 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 funesal.is.to be held, or from a person appointed to have the care of the
cemetei^ or burial ground in which the interment is made.
. (^hap. 114,..^c. 46, G. L., (Tercentenary Edition).
’ : V . ■
RULES OF PRACTICE
Thp fiijfiUmetit df the purpose of these laws calls for the observance of the follow-
ing rules pfaciice:
( 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
^^^henme when the Certificate of death is needed.
C3) Medical Examiners will investigate and certify to all deaths supposably
due to injury. These include not only deaths caused directly or indirectly by
traumatism (including resulting septicemia), and by the action of chemical
(drugs or poisons) thermal, or electrical agents, and deaths following abortion, but
also deaths from disease resulting from injury or infection related to occupation,
the sudden deaths of persons not disabled by recognized disease, and those of
persons found dead.
Statement of Cause of Death, — Physicians: see explanatory instructions
on face side of standard certificate of death.
Statement of Occupation. — Precise statement of occupation is very import-
ant, so that the relative healthfulness of various pursuits can be known. Make
spme entry in this section for every person aged 10 years or over. If the occupa-
tion had been given up or changed, or if the deceased had retired from business,
report the kind of work done during most of working life even if retired. Children
not gainfully employed may be returned as at school or at home. For a woman
whose only occupation was that of home housework, write housework. For a
person engaged in domestic service for wages, however, designate the occupation
by the appropriate terms, as housekeeper — private family, cook — hotel, etc. For
a person who had no occupation whatever write none.
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE
RANK, RATING
ORGANIZATION AND OUTFIT
SERVICE NUMBER
R-303 A
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/< ^ ®l?«* (Cammomopaltli of fKaBoarlfUBPttH
/ EDWARD J. CRONIN
Iv a HEbb secretary of the commonwealth
To bo fiUd for burial parmit
with Board of Haalth
or It* Acant.
DIVISION OF VITAL STATISTICS
MEDICAL EXAMINER’S
CEF^FICATE OF DEATH
^ _ ) (If death octmired in a hospital or institution,
Registered No..
St. { give its NAME instead of street and number)
2 PULL NAME,
(a) Residence. No,
(Usual place of abode) y ^
^ ^ ..Y. .,.(
If deceased is a marriedTmdowed or divorced woman, give also
PHYSICIAN — IMPORTANT
Was deceased a ^ /
S. War Veteran,
ifjo specify WAR)..
^ , (If nonresident,
Length of sLy: In place of death years months *... days. In place of residence.. .T..,:.... years jnonths days.
or town and State)
3 DATE OP
DEATH ..
DICAL CERTIPICATE OP DEATH
,
' (Year)
4 I H E 9^'A/d Y CERTIPY thaf^ I have investigated the deatt
of the ptKWi above-named and that the CAUSE AND MANNER thereol
; follows: (If an injury was involved, state fully,)
XLcZ^.d
S Accident, suicide, or homicide (specify)
Date and hour of injury 19..
Where did
Injury occur?..
(C^ty or town and State)
Did injury occur in or about home, on farm, in industrial place, or in public
J
6
Manner of
Injury
(Specify type of place)
C
1
Nature of
Injury
(How did injury occur?)
While at work? Was autopey performed?
7
Place of Burial, or Cremation.
(City or Town)
DATE OP BURIAL :.. 19.....’
8 NAME OP
PUNERAL DIRECTOR
ADDRESS.
Received and filed..
..3w^..u.«mil^....^..., i95T?i
(Registrar)
PERSONAL AND STATISTICAL PARTICULARS
9 SEX
10 COLOR OR PJtCE
^ i.
11 SINGLE
MARRIED
WIDOWED
or DIVORCED
(write the word)
11a If married, widowed, or divorced
HUSBAND of......
(Give maiden name of wife in full)
(or) WIPE of..:....: =!:
(Husband's name in full) /
12 IP STILLBORN, enter that fact here.
13 .
AGE Years Months Days
If under 24 hours
Hours Minutes
14 Usual / /
Occupation
(Kind of work i$one during most of working life)
15 Industry
or Business:.
^ ^ , i.
16 Social Security Ho.S!^'.4
17 BIRTHPLACE (City)..
(State or country)
18 NAME OP , ,
PATHER ; . ^
19 BIRTHPLACE OP
PATHER (City)
1
(State or country)
20 MAIDEN NAME ■
OP MOTHER '
21 BIRTHPLACE OP
MOTHER (City)
X....^7.;^.T..:...^a.C.....
(State or country)
2
Informant
(Address)
I HEREBY CERTIPY that a satisfactory standard certificate of death was
filed^with ine/9EPORE the or (isQlsit perom was issued:
of HtaXthHCVjDt^^
(Date of Issue of Permit^ / .
EXTRACTS
FROM THE LAWS OF THE
COMMONWEALTH OF MASSACHUSETTS
GOVERNING THE
RETURN OF CERTIFICATES OF DEATH
A physician or rejjistered 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 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 decea^. 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 negl^t 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.
\o undertaker or other person shall bury or otherwise dispose of a human body
in a town, or remove therefrom a human body which has not been buried, until he
has received a permit from the board of health, or its agent appointed to issue
such permits, or if there is no such board, from the clerk of the town where the
person died; and no undertaker or other person shall exhume a human body and
remove it from a town, from one cemetery to another, or from one grave or tomb
other than the receiving tomb to another in the same cemetery, until he has
received a permit from the board of health or its agent aforesaid or from the clerk
of the town where the body is buried. No such permit shall be issued until there
shall have been delivered to such board, agent or clerk, as the case may be,
a satisfactory \\Titten statement containing the facts required ^y 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 wthin 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 engag^, such recital shall appear up>on the permit.
1110 ^ard 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 rci^istra-
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 l>oard, front 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 Nnew of the dead bodies
of persons as are supposed to have died by riolence. 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
L^ws, Chap. 38, Sec. 6., as amended by Chap. 632. Sec. 4, Acts of 1945.
The medical examiner certifies the cause and manner of death to the best
of his knowledge and belief.
RULES OF PRACTICE
The fulfillment of the purpose of these laws calls for the observance of the follow-
ing rules of practice:
(1) Attending physicians will certify to such deaths only as those of persons
to whom they have given bedside care during a last illness from disease unrelated
to any form of injury. .
(2) Board of Health physicians will certify to such deaths only as those of
persons who, though disabled by recognized disease unrelated to any form of
injury, have died ^^^thout recent medical attendance or whose physician is absent
ffom home when the certificate of death is needed.
rti .(3) Medical Examiners will investigate and certify to all deaths supposably
due to injury. These include not only deaths caused directly or indirectly’ by
traumatism (including resulting septicemia), and by the action of chemical
(drugs or poisons) thermal, or electrical agents, and deaths following abortion, but
also deaths from disease resulting from injury or infection related to occupation,
the sudden deaths of persons not disabled by recognized disease, and those of
persons found dead.
STATEMENT OF CAUSE OF DEATH
Medical Examiners in certifying to a death will state the cause and manner
thereof, and will specify: (1) Under cause the nature of an injury and of its
consequences; and (2) under manner the mode of its production together with
the circumstances when these are known. For example: “Compound fracture of
the femur with ensuing septicemia (gas bacillus) caused by a steam railway
accident.” “Pistol shot wound of the chest with associated hemorrhage, hom-
icidal.” “Asphyxiation by suspension, suicidal.” “Syncope while under the
influence of ether administered as a surgical anaesthetic.” “Fracture of the
skull with associated internal 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
Vf R-301A
'luaioNS
FOR
L CERnFlCATE
giving
OF DEATH
not enter
I then one
B for each
(b) end (c)
: does not mean
of dying, such
lilure, asthenia, .
tans the disease,
'.icalions which
ath.
iid conditions, .
ring rise to the “
tse (a) slating
erlying cause
iitions contrib- •
he death but not
I the disease or
causing death.
,L.U.F...^A.Irrr.K
(County)
(City or Town)
Qllfp OlammamDPaltt; of AaBsartjnBfttB
EDWARD J. CRONIN
Secretary of the Commonwealth
DIVISION OF VITAL STATISTICS
STANDARD
Registered No.
To be filed for burial permit
with Board of Health
or its Agent.
5
No,
CERTIFICATE OF DEATH
ie-s j\ \ / f :t A z' / y' i-J. /) /\z\ X I (If death occurred in a hospital or institution,
/u' St. \ give its NAME instead of street and number)
PHYSICIAN — IMPORTANT
(Was deceased a
U. S. War Veteran,
if so specify WAR)
2 FULL NAME....A;'.y./)...f'^...T.
(If deceased is a married, widowed or divorced woman, give also maiden name.)
•X’
(a) Residence. No.
(Usual place of abode) (If nonresident, give city or town and State)
Length of stay: In place of death years /^...months days. In place of residence /f.. . years ..months days.
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
DEATH /
.X.
(Day)
(Year)
4 1 H E R E B Y CERTIFY, That I attended deceased from
19^.f^.... to
^ylast saw hr^<L: alive on .pl.CiAOrr... ... death is said to|
have occurred on the date stoned above, at . llf.JO.X...
DISEASE OR CONDITION
DIRECTLY LEADING
TO DEATH (a)
ANTE DuifTo
CEDENT (b)
CAUSES
Due To
(c)
OTHER
SIGNIFICANT .
CONDITIONS
INTERVAL BE
TWEEN ONSET
MD DEATH
12 „
If under 24 hours
AGE ,Jr.i^..Years
Months
Days
Hours Minutes
Major findings: ^
Of operations
Date of operation wrrrrr. Was autopsy performed?..
What test confirmed diagnosis? n—'.r.
S Was disease or injury in any way related to occupation of deceased?.
If so. specify .......y . y'’/? Z- -Z—.
(Signed) M._D.
(Address) Date 19„;. f-^
\MA ^
6 .\:^uLa..D.L./^.w.a MAS-dMA, MX..,.-.
Place of Burial or Cremation (City or Town)
DATE OF BURIAL ....19/.^
Received and filed.
O^OA^yvJMUftjMJ^ Si 1 19'^^
(Registrar)
PERSONAL AND STATISTICAL PARTICULARS
8 SEX 9 COLOR OR RACE
/>V//fz/r vv^/y /r /:
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.
13 Usual
Kation: ZX/hC.XCJl
(Kind of work done during most of working life)
14 Industry
Sess:/?.d./.^./<../../V../../.A'J:.^.?f.z:..</.z.^..
IS Social Security No /V,.t./V../!?T..
16 BIRTHPLACE (City)
(State or country) A xc A J ‘i
(Address) ( ' , Zi c^' ^ /f /' .
10 SINGLE (write the word)
MARRIED
WIDOWED .
or DIVORCEDj"//A/Z- Z,,/
17 NAME OF
FATHER / ,Z H rO /)/ A/ S
18 BIRTHPL.^CE OF
FATHER (City)
( / / \ . V 0 a/
(State or country)
19 MAIDEN NAME
OF MOTHER
\A- /i Z 1 /i ^
20 BIRTHPLACE OF
MOTHER (City) ..
U X N O' /s/
(State or country)
I HEREBY CERTIFY that a satisfactory standan^ certificate of death was
filgd with me BEFORE the burial or transit perraV was issued:
. . A
oafd of Healtlv«t6tireT) —
(Date of Issue of Permit)
I
EXTRACTS
FROM THE LAWS OF THE
COMMONWEALTH OF MASSACHUSETTS
GOVERNING THE
RETURN OF CERTIFICATES OF DEATH
A physician or registered hospital medical officer shall forthwith, after the
death of a 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 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-si*
that the deceased served in the army, navy or marine corps of the United States
m any war in which it has been engaged, such recital shall appear upon the permit.
^ard of health, or its agent, upon receipt of such statement and certificate
s^ll 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
«use of the death, which the clerk or registrar may require. — Chap. 1 14. &c. 45
G. L.. (Tercentenary Edition).
Medical examiners shall make examination upon the view of the dead bodies
of pei^ns 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
^Lav^-'Chap. 38, Sec. 6.. as amended by Chap. 632, Sec. 4. Acts of 1945.
A physician or officer furnishing a certificate of death as required by the
preceding s^tion 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
eng.iged. insert in the certificate a recital to that effect, specifying the war, and
shall also certify in such certificate both the primary and the secondary or imme-
diate cause of death as nearly as he can state the same. For neglect to comply
with any provision of this section, such physician or officer, shall forfeit ten dollars.
For the purposes of this section and of sections forty-five, forty-six and forty-seven
of said chapter one hundred and fourteen, the word "war" shall include the China
relief expedition and the Philippine insurrection, which shall, for said purposes, be
deemed to have taken place between February fourteenth, eighteen hundred and.
ninety-eight and July fourth, nineteen hundred and two. and the Mexican border
service of nineteen hundred and sixteen and nineteen hundred and seventeen.
G. L. Chap. 46. Sec. 10. /
No undertaker or other person shall bury or otherwise dispose of a human body^
in a town, or remove therefrom a human body which has not been buried, until he
has received a permit from the board of health, or its agent appointed to issue
such perniits. or if there is no such board, from the clerk of the town where tlifec
person died; and no undertaker or other person shall exhume a human body abSi
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 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
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
^ to do from the board of health or its agent appointed to issue such permits, or
if tl)ere is no such board, from the clerk of the town where the liody is to be buried
or the funergl is to be held, or from a person appointed to have the care of the
cemetexy or burial ground in which the interment is made.
Chap. 114, Sec. 46, G. L.. (Tercentenary Edition).
RULES OF PRACTICE
The fulfillment of the purpose of these laws calls for the observance of the follow-
^iftgr.iiles of practice;
• 'R physicians will certify to such deaths only as those of persons
to.wnom they have given bedside care during a last illness from disease unrelated
to any form of injury.
-.1. (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
c jfror^ome when the certificate of death is needed.
(drugs or poisons) thermal, or electrical agents, and deaths following abortion, but
also deaths from disease redhlting from injury or infection related to occupation,
the sudden deaths of persons not disabled by recognized disease, and those of
persons found dead.
Staternent 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
% Middlesex
2 (County)
o Medfoi^
U (City or Town)
(EammontoraUt; of AaaaadinHPtta
EDWARD J. CRONIN
Secretary OF THE Commonwealth
DIVISION OF VITAL STATISTICS
COPY OF
CERTIFICATE OF DEATH
Medf p.i^
(City or town making return)
Registered No
B
O 4-V. Q „ _ rr I (If death occurred in a hospital or institution.
No j. tlolll.© St. \ give its NAME instead of street and number)
T j %stic St. f
2 FULL NAME .Lepnar d, JB., .An..dP3W.S. I (Was deceased a
(If deceased is a married, widowed or divorced woman, give also maiden name.) 1 U. S. War Veteran. „ _
I if so specify WAR) R.Q..
(a) Residence. No 17.6...B.QwdP.m St Win thp pp
(Usual place of abode) (If nonresident, give city or town and State)
Length of stay: In place of death years months 2 ...days. In place of residence . 5.1.. years months days.
MEDICAL CERTIFICATE OF DEATH
PERSONAL AND STATISTICAL PARTICULARS
10 SINGLE (write the word)
MARRIED
WIDOWED '■•1 ClOV/e Q
or DIVORCED
3 DATE OF
DEATH ...
JanuarY 8 1954
(Month) (Day) (Year)
8 SEX
male
9 COLOR OR RACE
v/hi t e
That I attended deceased from
..J.&.n 8 19 5.4
4 1 HEREBY CERTIFY.
& 19... .5.4, to..
Jan 8
have occurred on the date stated above, at ...l..#..P.Q.....-A-..
I last saw h..l.??^....alive on 19...5.^ death is said to
DISEASE OR CONDITION
TO^DEATH ^ly!^^..9..?...t?.§.M..?......Pn.®.'L™
cedInt °b) ^ ancinoma o f s t omach
CAUSES
'^°C a rc 1 noma of Re.ctum
OTHER
SIGNIFICANT
CONDITIONS
IITERVAL BE
TWEEN ONSET
AND DEATH
IdY
2yrs
3yrs
St.pmach..A....Ra.ctum
Date of operation Was autopsy performed?.... n.Q.
What test confirmed diagnosisP.Q.l.l.n-lr.P.a.l
S Was disease or injury in any way related to occupation of deceased?..
If so. specify....
TIXT
(Address) . .9?* Date 11.9. 19. .5^
6 .Winthrpp ,11 .'.Yin.t.hr.o..p..
Place of Burial or Cremation (City or Town)
DATE OF BURIAL .*i.a.n,,..l.l , 1954 19
^ FUNERAL DIRECTOR .4.1.f..n0.d..,B ...... M
ADDREss..l.7..4...M.nthrpp.....S M.nthrpp,,
Received and filed..
.19..
(Registrar of City or Town where deceased resided)
10a If married, widowed, pr divprced „
HUSBAND of .Mar’jP,r.i..p.,...L.Q.m.xn.0,..,B.rayn.Q..
(Give maiden name of wife in full)
(or) WIFE of
(Husband’s name in full)
11 IF STILLBORN, enter that fact here.
12
AGE... 8.3. Years .5. Months 9... Days
If under 24 hours
Hours Minutes
13 Usual
Kation:..Re.t.ire.d .
(Kind of work done during most of working life)
of Bt7ness:.G.amb..r.idg;.e .G.a.s &....E.l..e.c..tri.,c..
IS Social Security No P.P..^^^..
16 BIRTHPLACE (City)..
(State or country)
17 NAME OF
FATHER
Leonard Andre-.vs
18 BIRTHPLACE OP
FATHER (City)
(State or country)
19 MAIDEN NAME
OF MOTHER Maiy Gavel
Npva Scotia
20 BIRTHPLACE OF
MOTHER (City) ....
(State or country)
Nova SoQtla
Informant L.o.s.t .ep ....J.»,..,..An.d.re.^
fAddressj 17 6 MoVifdOJ
A TRUE COPY
ATTEST:
a — ---rr-
(Registrar oiCity or^^wn where death occurred)
^ Oitfj Cf§rk
DATE FILED 19
Y
M R-301A
AUCTIONS
FOR
L CERTIFICATE
I giving
OF DEATH
not enter
i than one
e for each
(b) and (c)
f does not mean
r of dying, such
ailure, asthenia, •
eans the disease,
lications which
'ath.
bid conditions. ,
iving rise to the
4se (a) staling
erlying cause
iitions contrib'
he death but not
> the disease or
causing death.
No.
Suffolk
(County)
’^Inthrop
(City or Town)
4 Atkinson Circle
(Hi|p (Eammanmpalt^ of HQaBBartjUBfttB
EDWARD J. CRONIN
Secretary of the Commonwealth
DIVISION OF VITAL STATISTICS
STANDARD
CERTIFICATE OF DEATH
Registered No
To be filed for burial permit
with Board Health
or it* Agent.
7
2 FULL NAME Gladys G. Atkinson
(If deceased is a married, widowed or divorced woman, give also maiden name.)
(a) Residence. No. 4 Atkinson Circle st.
(Usual place of abode)
In place of residence 25
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)
Length of stay: In place of death years months
days.
(If nonresident, give city or town and State)
years months days.
MEDICAL CERTIFICATE OF DEATH
^ DEATiP^' January 3 1954
(Month) (Day) (Year)
I HEREBY CERTI F Y , T^at I attended^ deceased frorp
« ..•r#
I last saw h ..TrrtL— <Slive , 19fc! death_Js_said_^
have occurred on the date st'ated above, at ii.
DISEASE OR CONDITION
DIRECTLY LEADIN’
TO DEATH
ANTE Due To
CEDENT (b)
CAUSES
Due To
(e)
OTHER
SIGNIFICANT
CONDITIONS
mTERVU BE
TWEEN ONSET
MO DEATH
do
Major findings:
Of operations
Date of operation Was autopsy performed? .
What test confirmed diagnosis?
5 Was disease or injury in any way related to occuj&tion of deceased^
If so. specify..
Received and filed
(Registrar)
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
Female
9 COLOR OR RACE
■■7hite
10 SINGLE
MARRIED
WIDOWED
or Dimggpled
10a If married, widowed, or divorced
HUSBAND of
(Give maiden name of wife in full)
(or) WIFE of . Harry M- Atkinson
(Husband's name in fulO
11 IF STILLBORN, enter that fact here.
AGe52
Years
Months Days
If under 24 hours
Hours Minutes
13 Usual
Occupation:.
Housewife
(Kind of work done during most of working life)
14 Industry
or Business:
Own Home
15 Social Security No.
16 BIRTHPLACE (City)..
(State or country)
East lioston
Mass
17 NAME OF
FATHER
Robert Black
18 BIRTHPLACE OF
FATHER (City)
(State or country)
Boston
Mass
19 MAIDEN NAME
OF MOTHER Bossle Hsllyer
20 BIRTHPLACE OF
MOTHER (City) ....
(State or country)
Boston
Mass
21
(write the word)
I HEREBY CERTIFY that a satisfactory st^dard certificate of death was
' BEFORE Reburial oi>tfansiL^rmit was issued:
nt ofnoard or Heal
(Date of Issue
e of Permit)^
1/
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 remstration 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, dehned 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 s^tion 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,
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 imrae^
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, ninet^n hundred and two. and the Mexican border - '
service of nineteen hundred and sixteen and nineteen hundred and seventeen.
G. L. Chap. 46, Sec. 10.
No undertaker or other person shall bury or otherwise dispose of a human body
in a town, or remove therefrom a human body which has not been buried, until he
has received a permit from the board of health, or its agent appointed to issue
such permits, or if there is no such board, from the clerk of the town where the^*
person died; and no undertaker or other person shall exhume a human bo^y -
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 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, 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 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 bv Chap. 632, Sec. 4. Acts of 194.S.
No undertaker or other persons shall bur>'^ a hum.an body or the a.shos thereof
which have l>een 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 l>ody is to l>e buried
or the funeral is to Ih‘ held, or from a person appointed to have the care of the
cemetery or burial ground in which the interment is made.
. Chap. 114, Sec. 46. G. L.. (Tercentenary Edition),
RULES OF PRACTICE
The fulfillment of the purpose of these laws calls for the observance of the follow*
.ing rules of practice:
(1) Attending physicians will certify to such deaths only as those of persons
) to *whom they have given bedside care during a last illness from disease unrelated
to any form of injury.
(2) Board of Health physicians will certify to such deaths only as those of
persons who, though disabled by recognized disease unrelated to any form of
injury, have died without recent medical attendance or whose physician is absent
from home. when the certificate of death is needed.
- * (3) Medical Examiners will investigate and certify to all deaths supposably
. jdue to injury. These include not only d^ths 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 E>eath. — 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 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
Vf R-301A
HUCTIONS
FOR
L CERTIFICATE
riving
OF DEATH
lot enter
I than one
) for each
(b) and (c)
does not mean
of dying, such
tilure. asthenia, •
!ans the disease,
ications which
ath,
>id conditions, .
ring rise to the ’
ise (a) slating
erlying cause
■itions contrib- ■
ie death but not
the disease or
causing death.
Lli
Qltfr QlammonmEaltt; of fflasoactiuorttB
EDWARD J. CRONIN
Secretary OF THE Commonwealth
DIVISION OF VITAL STATISTICS
STANDARD
CERTIFICATE OF DEATH
Registered No.
To ha filed for burial permit
with Board of Health
or its Asent.
8
2 FULL NAME
I (If death occurred in a hospital or institution.
St. \ give its NAME instead of street and number)
(a) Residence. No / I /
(Usual place of abode)
Length of stay: In place of death years months days. In place of residence
{PHYSICIAN —
(Was deceased a
U. S. War Veteran
if so specify WAR)
I REPORT ANT
)
(If nonresident, give city or town and State)
years months days.
MEDICAL CERTIFICATE OF DEATH
TO DEATH (a)
ANTE Due To/
CEDENT (b) . I.
OTHER
SIGNIFICANT
3 DATE OF . 4
DEATH .. .W..
(Month)
S' (Yj-y
(Day) (Year)
41 HEREBY CERTIFY, T^at I attended deceased from
({j... I’l
I last saw h alive on death_is^aid_^c|
have occurred on the date statea/above, at •.0.0.^. m. IRTEIIVAL BE
TWEEN ONSET
MD DEATH
.8 SEX 9 COLOUR RACE
DISEASE OR CONDITION
DIRECTLY LEADIN
CONDITIONS
J /WHj
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?.
ft so, specify..^—
(Signed) H ' M. D
Vddres^
Received and filed..
;
(Registrar)
PERSONAL AND STATISTICAL PARTICULARS
10 SINGLE I (write the word)
MARRIEDly.
WIDOWEdI^^ > ,
10a If marriedlwidovred.or^divor
HUSBAND of .
Allive maiden name'of wife in full)
(or) WIFE of .U
(Husband’s name in full)
11 IF STILLBORN, enter that fact here.
12
AGE
6/
13 Usual
Occupation f
Yeys f.. Months Days
If under 24 hours
Hours Minutes
14 Industry
or Businesi
(Kind of \^rk done during most of working life)
,aw«!
15 Social Security No.
0 3LZ-' l'6~6 ^
16 BIRTHPLACE (City) . .
(State or country)
17 NAME OF
FATHER
18 BIRTHPL.AC^
FATHER (Cjjty
(State or country)
19 MAIDEN NA
OF MOTHERi
20 BIRTHPLACE OF
MOTHER (City)
(Stbte or country) -
tx I KAU I iD
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
eath of a person whom he has attended during his last illness, at the request
f an undertaker or other authorized person or of any member of the family of
ie deceased, furnish for registration a standard certificate of death, stating to the
est of his knowledge and belief the name of the deceased, his supposed age. the
isease of which he died, defined as required by section one. where same was
mtracted. the duration of his last illness, when last seen alive by the physician
r 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
receding section or by section forty-five of chapter one hundred and fbur-
*en, shall, if the deceased, to the best of his knowledge and belief, served in the
rmy, navy or marine corps of the United States in any war in which it has been
ng.'iged, insert in the certificate a recital to that effect, specifying the war, and
I’all also certify in such certificate both the primary and the secondary or imme-
iate cause of death as nearly as he can state the same. For neglect to con)ply
ith any provision of this section, such physician or officer, shall forfeit ten dollars,
or the purposes of this section and of sections forty-five, forty-six and forty-seven.
' said chapter one hundred and fourteen, the word “war” shall include the China
ilief expedition and the Philippine insurrection, which shall, for said purpo^s, be
semed to have taken place between February fourteenth, eighteen hundred and
nety-eight and July fourth, nineteen hundred and two, and the Mexican border
•rvice of nineteen hundred and sixteen and nineteen hundred and seventeen.
. L. Chap. 46. Sec. 10.
No undertaker or other person shall bury or otherwise dispose of a humairbo^
a town, or remove therefrom a human body which has not been buried^ un^lheL^
as received a permit from the board of health, or its agent appointed to issue
ich permits, or if there is no such board, from the clerk of the town where the
rson died; and no undertaker or other person shall exhume a human body and
move it from a town, from one cemetery to another, or from one grave or tomb
her than the receiving tomb to another in the same cemetery, until he has
ceived a permit from the board of health or its agent aforesaid or from the clerk
the town where the body is buried. No such permit shall be issued until there
lall have been delivered to such board, agent or clerk, as the case may be,
satisfactory written statement containing the facts required by law to be
turned and recorded, which shall be accompanied, in case of an original inter-
,ent, by a satisfactory certificate of the attending physician, if any. as required by
w. 9r in lieu thereof a certificate as hereinafter provided. If there is no attending
tiysician. or if. for sufficient reasons, his certificate cannot be obtained early
lough for the purpose, or is insufficient, a physician who is a member of the board
' health, or employed by it or by the selectmen for the purpose, shall upon
pplication make the certificate required of the attending physician. If death is
lused by violence, the medical examiner shall make such certificate. If such a
srmit for the removal of a human body, not previously interred, from one town
) another within the commonwealth cannot be obtained early enough for the
urpose. the certificate of death made as above provided and in the possession of
le undertaker desiring to make such removal shall constitute a permit for such
;moval; provided, that such body shall be returned to the town from which it was
amoved within thirty-six hours after such removal, unless a permit in the usual
)rm for the removal of such body has been sooner obtained hereunder. If the
death certificate contains a recital, as required by. section ten of chapter forty-six,
that the deceased served in the army, navy or marine corps of the United States
in any war in which it has been engaged, such recital shall appear upon the permit.
The board of health, or its agent, upon receipt of such statement and certificate,
shall forthwith countersign it and transmit it to the clerk of the town for registra-
tion. The person to whom the permit is so given and the physician certifying
the cause of death shall thereafter furnish for registration any other necessary
information which can be obtained as to the deceased, or as to the manner or
cause of the death, which the clerk or registrar may require. — Chap. 1 14, Sec. 45,
G. L.. (Tercentenary Edition).
Medical examiners shall make examination 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 (^hap. 632, Sec. 4, Acts of 1945.
No undertaker or other persons shall bury a human body or the ashes thereof
which have been brought into the commonwealth until he has received a permit
so to do from the board of health or its agent appointed to issue such permits, or
if there is no such board, from the clerk of the town where the body is to be buried
or the funeral is to be held, or from a person appointed to have the care of the
cemetery or burial ground in which the interment is made.
. . . (2hap. 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.
>PACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE
^ANK, RATING
DRGANIZATION AND OUTFIT
SERVICE NUMBER
\ SUFFOLK
) ia^oN
(Sommamiiraltt) of flaasarlfnBrtls
EDWARD J. CRONIN
Secretary of the Commonwealth
DIVISION OF VITAL STATISTICS
COPY OF
CERTIFICATE OF DEATH
OOSTON
(City or town making return)
Registered No
(City or Town) ■ if ii :zi ■ e- c za ■ ii
_ *1 / (R death occurred in a hospital or institution.
St. \ give its NAME instead of street and number)
2 FULL NAME EQ.5?.e...S6
(If deceased is a married, widowed or divorced woman, give also maiden name.)
(a) Residence. No .233.. St. ,
(Usual place of abode)
(Was deceased a
U. S. War Veteran,
if so specify WAR) .
’«in.th,r o p. . . Maas. .•
(If nonresident, give city or town and State)
Length of stay: In place of death years months|| days. In place of residence."]^.^ ...years months days.
MEDICAL CERTIFICATE OF DEATH
PERSONAL AND STATISTICAL PARTICULARS
3 DATE OF T n /r1
DEATH .osm.»9./Sh
(Month) (Day) (Year)
8 SEX
F
41 HEREBY CERTIFY, That I attended deceased from
19 to Jan«.9. i9.f3i
I last saw h 0{t..alive on Jaci*9 19. . death is said tc|
have occurred on the date stated above, at , .
9 COLOR OR RACE
It
(write the word)
10 SINGLE
MARRIED
WIDOWED » ^ J
or DIVORCED Marrica
10a If married, widowed, or divorced
HUSBAND of
(Give maiden name of wife in full)
DISEASE OR CONDITION
DIRECTLY LEADING
TO DEATH
ANTE Due To
CEDENT (b)
CAUSES
Due To
(c)
OTHER
SIGNIFICANT
CONDITIONS
inERVU IE
TWEE! OISET
(or) WIFE of..
UD aUTI
11 IF STILLBORN, enter that fact here.
AGE....^..Years
..Months Days
If under 24 hours
Hours Minutes
13 Usual
Occupation:
(Kind
.. ManasOT:
of work done dun
during most of working life)
14 Industry
Busmess: .Tedr.o....Qo.«InQ»
15 Social Security No..
Major findings:
Of operations..
Date of operation Was autopsy performed?..
What test confirmed diagnosis?
..N.Q..
S Was disease or injury in any way related to occupation of deceased?..
If so, specify
(Signed) H RQtfehBrS
(Address) . .
M. D
6 0^1 Jacob
Place of Burial or Cremation
ptw.Date 19^
b Wobum‘7^9
Jan* ll/!^
(City or Town)
1
6 blKTHFLACE (City)
(State or country)
Bos ton ■**a ss*
17 NAME OF
Harry J Bowers
FATHER
CO
18 BIRTHPLACE OP
H
FATHER (City)
2
u
(State or country)
19 MAIDEN NAME
<
OF MOTHER
Sarah F^tdwan
P4
20 BIRTHPLACE OF
MOTHER (City)
(State or country)
Austria
21
DATE OF BURIAL 19
Informant.,
f Address)
Tlieodore . iS.QllQsy..
7 NAME OF
FUNERAL DIRECTOR
ADDRESS
A Golov
^ookline Ma3S»
it Ci»!J%r Town
Received and filed..
(Registrar of City or Town where deceased resided)
.19..
DATE
FILED iJ.an/.lZ/Sk.
,.19
• ♦- ,• • - w
>•
'4i •
L'a.;,c‘-'
i .. '■!,?« JS*. .
'■^-CC/Vr.r:,..
, * ^ i
^y4 /:'/ E??;
*W%^' <^/ ' ■
rtof Vr V
/f}
V \ . . '^ ■ • ' '“^ .
... - ■*■% J
* -.-aaac^sr::— ;„ -x;. -. tx ,. _ -;.us,rf3Ks*f,
• .‘.•’j:..: ■ ■' . --jiCDar^ywr N ’
, • r - - ' ' ir
,'^.4»i.
MJ •
i^- p
. ft
■W'l'^ ■ -V -*6' *1/1
r S«-
*»»»r W *:»'*. g
..>*■•■? -C' ;.,
•ii' i' li^ux
.*# ,*
l>.^■
fi.
TVa* i- ,. L'
<«v»tii4.\.<
': •Iwn »r»r. r » »».■
■ r» ~n‘i “ ■ I I y I ■ I
.• '<>
[ R-301A
:UCTIONS
FOR
CERTIFICATE
jivins
3F DEATH
>t enter
than one
for each
b) and (c)
lots not mean
)/ dying, such
lure, asthenia, •
ns the disease,
ations which
•h.
d conditions, .
ng rise to the “
e (a) stating
lying cause
ions contrib- •
death but not
he disease or
ausing death.
(Sammomiipaltt; of fmasBactfUBEttB
EDWARD J. CRONIN
Secretary of the Commonwealth
DIVISION OF VITAL STATISTICS
STANDARD
CERTIFICATE OF DEATH
To be filed for burial -permit
with Board of Health
or its A^ent.
Registered No.
iO
2 FULL NAME
(a) Residence. No.
(Usual place (
j (If death occurred/Tn J^^ospital oA institution.
' A ^d number)
r PHVSfCIAN ^imPORTdlMT
I (Was deceased k /
is a married, widowe3^r divorceci womam-gi^e^also n^fflen name.) 1 U. S. War Veteran. // ^
/ ' / ./ lif so specify WAR)
A 9. / ^ St.
5 of abode) • (If nonresidenygive c»fy or town a
Length of stay: In place of dedth .. 4^-fyears months days. In place of residence years months days.
en name.)
. and State)
DICAL CERTIFICATE OF DEATH
PERSONAL AND STATISTICAL PARTICULARS
/d
'XDay)^'
f ^hat r
(Year)
8 SEX
:b Y CERTIFY, -J-Jt hat I attended deceased from|
/Cj tjXgferv^. /.a
"^last saw h— Arr2;;^ive on 19. death is said to
have occurred on the ia^^s\aXe^r^hove, at
DISEASE OR cciNDmeli
DIRECTLY LEA'DINgJ_,
TO DEATH (a) 4[:-*
9 COLOR OR RACE
10 SINGLE
MARRIED
WIDOWED
or DIVORCE
rite the word)
10a If married, widowed, or divorced
HUSBAND of
(Givejaaiden name of wife in full)
Liive maiden name ot w
(Husband's name in
or 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 registered hospital medical officer shall forthwith, after the -
leath of a person whom he has attended during his last illness, at the request
:>f 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
:ontracted, the duration of his last illness, when last seen alive by the physiciao |
5r 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. ^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, 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 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
irmy, navy or marine corps of the United States in any war in which it has been
^ng.nged. insert in the certificate a recital to that effect, specifying the war, and
ihall also certify in such certificate both the primary and the secondary or imm^;
liate cause of death as nearly as he can state the same. For neglect to comply
vith any provision of this section, such physician or officer, shall forfeit ten dollars.
Por the purposes of this section and of sections forty-five, forty-six and forty-seven
)f said chapter one hundred and fourteen, the word “war” shall include the China
'elief expedition and the Philippine insurrection, which shall, for said purposes, be
ieemed to have taken place between February fourteenth, eighteen hundred and
linety-eight and July fourth, nineteen hundred and two, and the Mexican bo;
^rvice of nineteen hundred and sixteen and nineteen hundred and sevei)
j. L. Chap. 46, Sec. 10.
No undertaker or other person shall bury or othen\’ise dispose of a human body
n a town, or remove therefrom a human body which has not been buried, until he
las received a permit from the board of health^^or its agent appointed to issue
uch permits, or if there is no such board, from the clerk of the town where the
lerson died; and no undertaker or other person shall exhume a human body and
emove it from a town, from one cemetery to another, or from one grave or tomb
ither than the receiving tomb to another in the same cemetery, until he has
eceived a permit from the board of health or its agent aforesaid or from the clerk
>f the town where the body is buried. \o such permit shall be issued until there
hall have been delivered to such board, agent or clerk, as the case may be,
I satisfactory written statement containing the facts required by law to be
etumed and recorded, which shall be accompanied, in case of an original inter-
nent, by a satisfactory certificate of the attending physician, if any. as required by
aw. or in lieu thereof a certificate as hereinafter provided. If there is no attending
)hysician. or if, for sufficient reasons, his certificate cannot be obtained early
jnough for the purpose, or is insufficient, a physician who is a member of the board
)f health, or employed by it or by the selectmen for the purpose, shall upon
ipplication make the certificate required of the attending physician. If death is
caused by violence, the medical examiner shall make such certificate. If such a
jermit for the removal of a human body, not previously interred, from one town
o 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
he undertaker desiring to make such removal shall constitute a permit for such
emoval; 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
1^0 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
» 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 thfe funeral is to be held, or from a person appointed to have the care of the
cemetery or burial ground in which the interment is made.
.*• .'> Chap. 114, Sec. 46. G. L., (Tercentenary Edition).
RULES OF PRACTICE
The fulfillment of the purpose of these laws calls for the observance of the follow-
ing rules of practice:
* 0(1) Attending physicians will certify to such deaths only as those of persons
.L ito whom they have given bedside care during a last illness from disease unrelated
to any form of injury.
(2) Board of Health physicians will certify to such deaths only aS those of
persons who, though disabled by recognized disease unrelated to any form of
injury, have died without recent medical attendance or whose physician is absent
from home when the certificate of death is needed.
(3) Medical Examiners will investigate and certify to all deaths supposably
due to injury. These include not only deaths caused directly or indirectly by
traumatism (including resulting septicemia), and by the action of chemical
(drugs or poisons) thermal, or electrical agents, and deaths following abortion, but
also deaths from disease resulting from injury or infection related to occupation,
the sudden deaths of persons not disabled by recognized disease, and those of
persons found dead.
Statement of Cause of Death. — Physicians: see explanatory instructions
on face side of standard certificate of death.
Statement of Occupation. — Precise statement of occupation is very import-
ant, so that the relative healthfulness of various pursuits can be known. Make
some entry in this section for every person aged 10 years or over. If the occupa-
tion had been given up or changed, or if the deceased had retired from business,
report the kind of work done during most of working life even if retired. Children
not gainfully employed may be returned as at school or at home. For a woman
whose only occupation was that of home housework, write housework. For a
person engaged in domestic service for wages, however, designate the occupation
by the appropriate terms, as housekeeper — private family, cook — hotel, etc. For
a person who had no occupation whatever write none.
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE
RANK, RATING
ORGANIZATION AND OUTFIT
SERVICE NUMBER
R-301A
CTIONS
)R
ERTIFICATE
iving
F DEATH
: enter
lan one
or each
) and (c)
tts noi mean
dying, such
\re, asthenia, .
s the disease,
tions which
conditions,
g rise to the
(a) stating
fing cause
yns conlrih" •
lealh but not
r disease or
using death.
A
Olommomnraltl; of ^assarl^nBPtla
OFFICE OF THE SECRETARY
DIVISION OF VITAL STATISTICS
Suffolk
(County)
W inthrop
(City or Town)
'.’7 i n 'I'.TtT’Ci O o, nrnrnnn i + tr T-Tn QTTI "h O T /(if death occurred in a hospital or institution.
St. \ give its NAME instead of street and number)
STANDARD
CERTIFICATE OF DEATH
Registered No.
To be filed for burial permit
with Board of Health
or its Afent.
11
No.
nhpQtp-p S TTr’PPmP'n r physician — important
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)
(.) R.,a„c.. N. s.
(Usual place of abode) (If nonresident, give city or town and State)
21
Length of stay: In place of death years months days. In place of residencX.4^ years months days.
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
DEATH
(V4r)
B X^C E R T I F Y .
19 f A..., to
That I attended deceased from
19
I last saw hy^<^, ..alive //.... 19.5T^ death is said to|
have occurred on the date ^i^ed above, at ^ . ^ ^ m
DISEASE OR CONDITION
DIRECTLY LEADI
TO DEATH (a)
OTHER
SIGNIFICAN
CONDITIONS
Major findings:
Of operations.
Date of operation. - . . .—. ".■* Was autopsy performed?. yyiQ
What test confirmed diagnosis?
5 Was disease or injury
If so, Spi
(Signei
(Addn
t any way related t<3^i(^cupation of deceased?,
Date/A \9S^
6 .linth.r.Qp
Place of Burial or Cremation
DATE OF BURIAL .
(City or Town)
S;n. • 1]5 19^^
7 NAME OF
FUNERAL
Received and filed
(Registrar)
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
I-Iale
9 COLOR OR RACE
■.■rnite
(write the word)
10 SINGLE
MARRIED
WIDOWED . , , , ^
or DIVORCE^ ig O U/fi P
10a If married.
HUSBAND of ..
C4“rtSii®“‘' A Lent
(Give maiden name of wife in full)
(or) WIFE of..
(Husband’s name in full)
1 1 IF STILLBORN, enter that fact here.
age72.
.Years . .Months .5 Days
If under 24 hours
Hours Minutes
Oc^pation: Salesman (retired.}
(Kind of work done during most of working life)
14 Industry
gess: Mens ...G.lc) thins..
15 Social Security No. 010-07-18^.
16 BIRTHPLACE (City) {.(.in.O.hrO.P..
(State or country) naSS
17 NAME OF„ ,
FATHER iLdwarCLFree.man
18 BIRTHPLACE OF
FATHER (City) y.-^.?'..P.l®. .. .tl Q (?..Q.t'..&.i.n .
(State or country)
19 MAIDEN NAME
OF MOTHER
Hannah n Belcher
20 BIRTHPLACE OF
MOTHER (City) Un.a.D.1.6 t..Q Q.b.t.aln..
(State or country)
21
Eleanor Lehman
Informant ....
(Address) dO DOUglaS fit
iVlnthro^^
(Official Designation)
i of Board ox other)
(Date of Issue of Permit)
1
I HEREBY CERTIFY that a satisfactory standard certificate of death was
fiUy with/^n^ BEFORE ^e burialjoo tran^ permit was issued:
EXTRACTS
FROM THE LAWS OF THE
COMMONWEALTH OF MASSACHUSETTS
GOVERNING THE
RETURN OF CERTIFICATES OF DEATH
A physician or re^stered 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
b^t 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.
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
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 fortv-five, forty-six and forty-scfven
of said chapter one hundred and fourteen, the word “war” shall include the China
relief expedition and the Philippine insurrection, which shall, for said purposes, be
deemed to have taken place between February fourteenth, eighteen hundred and^
ninety-eight and July fourth, nineteen hundred and two, and the Mexican border
service of nineteen hundred and sixteen and nineteen hundred and seventeen.
G. L. Chap. 46. Sec. 10.
No undertaker or other person shall bury or otherwise dispose of a human body
in a town, or remove thereirom a human body which has not been buried, until he
has received a permit from the board of health, or its agent appointed to issue
such permits, or if there is no such board, from the clerk of the town where the
person died; and no undertaker or other person shall exhume a human body and
remove it from a town, from one cemetery to another, or from one grave or tomb
other than the receiving tomb to another in the same cemetery, until he has
received a permit from 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 ^nthin the commonwealth cannot be obtained early enough for the
purpose, the certificate of death made as above provided and in the possession of
the undertaker desiring to make such removal shall constitute a permit for such
removal; provided, that such body shall be returned to the town from which it was
removed within thirty-six hours after such removal, unless a permit in the usual
form for the removal of such body has been sooner obtained hereunder. If the
death certificate contains a recital, as required by section ten of chapter forty-six,
that the deceased served in the army, navy or marine corps of the United States
in any war in which it has been engaged, such recital shall appear upon the permit.
The board of health, or its agent, upon receipt of such statement and certificate,
shall forthwith countersign it and transmit it to the clerk of the town for registra-
tion. The person to whom the permit is so given and the physician certifying
the cause of death shall thereafter furnish for* registration any other necessary
information which can be obtained as to the deceased, or as to the manner or
cause of the death, which the clerk or registrar may require.— Chap. 114, Sec. 45,
G. L., (Tercentenary Edition).
Medical examiners shall ,make examination upon the view of the dead bodies
of only such persons as are supposed to have died by violence. If a medical
examiner has notice that there is within his county the body of such a person, he
shall forthwith go to the place where the body lies and take charge of the same;
. . . General Laws, Chap. 38, Sec.6.
Np 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 thete is nb such board, from the clerk or the town where the body is to be buried
ot the funeral is to be held, or from a person appointed to have the care of the
cemeteiT or-t)urial ground in which the interment is made.
. . (Jhap, |14, Sec. 46, G. L., (Tercentenary Edition).
i ' O
RULES OF PRACTICE
* TThe^Utfilfin^t of the purpose of these laws calls for the observance of the follow-
^ •
, Attending physicians will certify to such deaths only as those of persons
't6 they have given bedside care during a last illness from disease unrelated
to a«y‘.form of injury.
(2) ^ard of Health physicians will certify to such deaths only aS those of
persons who, thoi^h disabled by recognized disease unrelated to any form of
[ ^mhout recent medical attendance or whose physician is absent
Irtfin^Anie 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 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
[ R-301A
UCTIONS
FOR
CERTIFICATE
fiving
>F DEATH
>t enter
than one
for each
b) and (c)
ioes not mean
if dying, such
lure, asthenia. ■
ns the disease^
ations which
h.
i conditions,
ng rise to the *
? (a) stating
lying cause
ions contrib‘ •
death but not
he disease or
ausing death.
A
No.
Suffolk
(County)
Vinthrop
(City or Town)
138 Main Street
(Lift (Sommonnipaltii nf illIaBHarl)UBPttB
EDWARD J. CRONIN
Secretary of the Commonwealth
DIVISION OF VITAL STATISTICS
STANDARD
CERTIFICATE OF DEATH
Registered No
To be filed for burial permit
with Board of Health
or it* Agent.
o
.JJ
I (If death occurred in a hospital or institution,
St. \ give its NAME instead of street and number)
2 FULL NAME
Mary
15^
Markey
PHYSICIAN — IMPORTANT
(Was deceased a
U. S. War Veteran.
if so specify WAR)
(If deceased is a married, wjdowed or divorced woman, give also maiden name.)
138 Main Street
(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.
(a) Residence. No.
(Usual place of abode)
St.
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
DEATH .
a r «
(Month)
(Day)
/9
(Year)
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
41 HEREBY CERT IJ Y ,
J>C<Y
I last saw h alive on
That I attended deceased from
Female
9 COLOR OR RACE
(write the word)
'<Vhlte
10 SINGLE
MARRIED
WIDOWED
or DivoR^qngle
19
19 deal
/^6T 4 4T
have occurred on the date stated above, at
. dejith is said to
10a If married, widowed, or divorced
HUSBAND of
(Give maiden name of wife in full)
DISEASE OR CONDITION
DIRECTLY LEADING
TO^EATIF (a/ y y
^ ^ bed
ANTE Due To
CEDENT (b)
CAUSES
OTHER
SIGNIFICANT
CONDITIONS
INTERVU BE-
TWEEN ONSET
AND DEATH
(or) WIFE of
(Husband’s name in full)
11 IF STILLBORN, enter that fact here.
12
AGE
Years Months.
Days
If under 24 hours
Hours Minutes
13 Usual
Occupation: .
At Home
(Kind of work done during most of working life)
14 Industry
or Business:
15 Social Security No.
16 BIRTHPLACE (City).
(State or country)
East Boston
Ma s a
Major findings:
Of operations.
17 NAME OF
FATHER
Date of operation. . . . Was autopsy pei^rme^..'^*^^*f.
What test confirmed diagnosis?. ^
18 BIRTHPLACE OF
FATHER (City)
(State or country)
5 Was disease or injury in any wa'
If so, specify. .V
(Signed)
(Address)
,ted to occupation of deceased?
X .
Holy Cross
Place of Burial or Cremation
3^
Date
DATE OF BURIAL
ini
7 NAME OF
FUNERAL DIRECTOR
ADDRESS
jy t h r op , s s
Ask -1^'^
Received and filed /..JbW.t*:....* 19
Patrick Markey
Ireland
19 MAIDEN NAME
OF MOTHER Cecella Terrell
20 BIRTHPLACE OF
MOTHER (City) . ..
(State or country)
Ireland
rop
REBY CERTIFY that a satisfactorv standard certificate of death was
with me BEFORE the burialT)r trai^it permit was issued:
(Registrar)
Designation)
of Board o^^ealth or other)
(Date of
Issue ofA’ermit)'
EXTRACTS
FROM THE LAWS OF THE
COMMONWEALTH OF MASSACHUSETTS
GOVERNING THE
RETURN OF CERTIFICATES OF DEATH
A physician or rci^istcred 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 aiithorized person or of any member of the family t)f
the deceased, furnish for registration a standard certificate of death, stating to the
best of his knowledge and l>elicf the name of the (leceased. 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. *>.
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 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 grav'e 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 rase of an original inter-
ment, by a satisfactory certificate of the attending physician, if any, as required by
law, 9r in lieu thereof a certificate as hereinafter provided. If there is no attending
physician, or if, for sufficient reasons, his certificate cannot be obtained early
enough for the purpose, or is insufficient, a physician who is a member of the board
of health, or employed by it or by the selectmen for the purpose, shall upon
application make the certificate required of the attending physician. If death is
caused by violence, the medical examiner shall make such certificate. If such a
permit for the removal of a human body, not previously interred, from one town
to another within the commonwealth cannot be obtained early enough for the
purpose, the certificate of death made as above provided and in the possession of
the undertaker desiring to make such removal shall constitute a permit for such
removal; provided, that such body shall be returned to the town from which it was
removed within thirty-six hours after such removal, unless a permit in the usual
form for the removal of such body has been sooner obtained hereunder. If the
death certificate contains a recital, as required by sec 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 phvsician 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*, frorp injury or infection relating to occupation, or suddenly when not
disabled In’lrecdgnizablc disease, or when any person is found dead. . — General
Laws. Chap.jIH, Sec. 6.. as amended by Chap. 6.12, Sec. 4. Acts of 1945.
No undertaker or other persons shall bury a human body or the ashes thereof
which have been brought into the commonwealth unril he has received a permit
.so .to do|frcint_the board of health or its agent appointed to issue such permits, or
if there is pOiiuoH board, from the clerk of the town where tV? body is to be buried
or tne'/uheral I's^tp-Le held, or from a person appointed to have the care of the
cemetery pr^buraa'i krx)und in which the interment is made.
ChipiT J !4, 46, G. L.. (Tercentenary- Edition).
Vp/v. ' RULES OF PRACTICE
^ T^/ ^rnlfment;»r^he purpose of these laws calls for the observance of the follow-
ing if e :
Cl) ' physicians will certify to such deaths only as those of persons
to \\*Ii6m.lhey have given bedside care during a last illness from disease unrelated
to any frTrm of in jury.
(2) Board of Health physicians will certify to such deaths only as those of
per^ps ^’h^ though disabled by recognized disease unrelated to any form of
Jiy^fvjKjiv^ d ied withc&Mrecent medical attendance or whose physician is absent
fmfrf nfime twen the c^fnicate of death is needed.
(5) Medical Examiners will investigate and certify to all deaths supposably
due to injury. These include not only deaths caused directly or indirectly by
traumatism (including resulting septicemia), .and by the action of chemical
(drugs or poisons) thermal, or electrical agents, and deaths following abortion, but
also deaths from disease resulting from injury or infection related to occupation,
the sudden deaths of persons not disabled by recognized disease, and those of
persons found dead.
Statement of Cause of Death. — Physicians: see explanatory instructions
on face side of standard certificate of death.
Statement of Occupation. — Precise statement of occupation is very import-
ant. so that 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 no.ie.
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE
RANK, RATING
ORGANIZATION AND OUTFIT
SERVICE NUMBER
Copiei of returns of deaths which occurred in your city or town in case the deceased resided in another city or town at the time
of death should be transmitted on Form R-302 to the clerk of the city or town in which the deceased resided as soon as possible,
after the close of the month in which the death occurred. (See Chap. 46, Sec 12, G. L.)
VI R-302
A
Tr
'-jXi.
(CouhtjJ)
(City or Town)
No y.e.t.Qr.ana.....4di]ai
(Sammamoraltt; of tflaaaarl^nBrttB
.-EDWARD J. CRONIN
Secretary OF THE Commonwealth
DIVISION OF VITAL STATISTICS
COPY OF
CERTIFICATE OF DEATH
- - ,'N
(City or town making return)
569 13
Registered No. .
death occurred in a hospital or institution.
St. \ give its NAME instead of street and numtwr)
2 FULL NAME RU!SS.ELL ,FLO.YD, | (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)..
25 Marshall c.
iU 1
(a) Residence. No.
(Usual place of abode)
8 26
Length of stay: In place of death years months days.
St. .
60
(If nonresident, give city or town and State)
In place of residence years months..
..days.
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
DEATH ...
4 1 HEREBY CERTIFY
4/22 „ 53
ga^j,a.P,
That VAtteru led deceased fronJ
Attended dece
.l/l7
„54
i9...^f.y... to 19
I ]^t saw j|. — alive— on — — — _ death is said tc
have occurred on the date stated above.
AM KAT*
DISEASE OR CONDITION
DIRECTLY LEADING
TO DEATH (a) Chponlc- glomerulo*-
nephritis with uretn|La».’'Aca
CAUSES
ANTE Due To ^ ^ ...
CEDE.NT (b) .warainoaia .. pr.t_.the.
prostate with car-
clnomatosis
Due To
(c)
OTHER
SIGNIFICANT .
CONDITIONS
linifU IE
TWEEI oisn
Major findings:
Of operations..
Date of operation Was autopsy performed?..
What test confirmed diagnosis? autopey
yea
no-
5 Was disease or injury in any way related to occupation of deceased?
If so, specify .
(Signed) R . JJllight M. D.
(Address) VAK Date 19 ^
6 Win thro p C ejn .Winthro p, M&.s s w.
Place of Burial oi^remation _ _ XCity or Town) ,,
Jan 26^
DATE OF BURIAL .7 19
5-!
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
9 COLOR OR RACE
w
10 SINGLE
MARRIED
(write the word)
Wdot^d Married
or DIVORCED ^
10a If married, widowed, or divorced
HUSBAND of Eo len Tewksburx
(Give maiden name ol ^le
(or) WIFE of .
e in full)
(Husband’s name in full)
1 1 IF STILLBORN, enter that fact here.
AG^.P.
.Years Months..
9
Days
If under 24 hours
Hours Minutes
13 Usual
Occupation
,.iuxpre.3.sra.an
(lOnd of
work done during most of working life)
14 Industry
Business: T9wk3bury.....£.xpre.g.3 Gq».
IS Social Security No .<■. ..>«<
16 BJRTHPLAC^(City) WinthTOp^y
ass
(State or country)
17 NAME OP
father .viiiiam Floyd
18 BIRTHPLACE OP
; FATHER (City) Jif lntl-r Op ■
(State or country)
Mass
19 MAIDEN NAME
OF MOTHEitiarrie t Tucker
20 BIRTHPLACE OF
MOTHER (City) .W.l,n.t!.ht’.QP.
(State or country) Mft ,q a
21
7 NAME OP U
FUNERAL DIRECTOR i±....3.e.ynOldS.
ADDRESS.
|l{j^Sthl*Qp-y:-J4a&8 ■»'
Received and filed .U.ts^.^7 19..
(Registrar of City or Town where deceased resided)
Informant VA..Eosni.t3.1....xiec.Q.r.da..
(Address!
A TRUE COPY
ATTESTS
(Re^strar of City or Town where death occurred)
DATE FILED .Jah....S.l 19 .5.4..
iiii
DATE OF ENTERING MILITARY SERVICE
- 7/27/17
” ” DISCHARGE
3/24/20
RANK, RATING
Cpl
ORGANIZATION & OUTFIT
^ S Army
SERVICE NUMBER
--^52249
SERVICE NUMBER
X
(Sanunamopalttf of IBaBsarifnBrttB
EDWARD J. CRONIN
Secretary OF THE Commonwealth
DIVISION OF VITAL STATISTICS
COPY OF
CERTIFICATE OF DEATH
(City or town making return)
Registered No. .
No.
..Pe.t.er. ...j^.Qnt...Brigh.am...Ec;£ip..l.t.al xad:^ give its NAME instead of street and number)
m. death occurrecl in a hospital or institution.
2 FULL NAME. .. WILLI.M...im3SE.y,.,JR
(If deceased is a married, widowed or divorced woman, give also maiden name.)
(a) Residence. No Jf.
(Usual place of abode)
(Was deceased a
U. S. War Veteran,
if so specify WAR)..
(If nonresident, grve city or town
Length of stay: In place of death years monthsX. days. In place of residence. .. .9. ..years months days.
^d State)
MEDICAL CERTIFICATE OF DEATH
PERSONAL AND STATISTICAL PARTICULARS
" January 17 1954
(Month) (bay) (Year)
HEREBY CERTIFY, ThaV^ attended deceased from
....1/16 19 to 1/17 195.4
I last saw h Im.. .alive on &4,.
death is said tc|
8 SEX
M
9 COLOR OR RACE
W
10 SINGLE (write the word)
MARRIED
WIDOWED ..
or DIVORCElPln^le
have occurred on the date stated
above, alg
DISEASE OR CONDITION
DIRECTLY LEADING _ ,
TO DEATH (a) U.r.Qaj.la
;iirla
Qligi
cedInt *(b) ..^°iiJ.ong.e.s..tiy,0 ..hear .t..
CAUSES failure
Due To
Due
(c) .^?Ch.r.Q.n.iQ...&lQ.raQm
nephritis
OTHER
SIGNIFICANT .
CONDITIONS
IRTERTU IE
TWEEI ORSET
go DERTR
wks
4days
lOa 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
age14
Years 5 Month? ^ Days
29
If under 24 hours
Hours Minutes
2days
13 Usual
ork done during most of working life)
or Business:. Jimiop..H.i.gh School
3yrs
IS Social Security No..
16 BIRTHPLACE (City)
(State or country)
^omewllle r'Masg.
Major findings:
Of operations
Date of operation Was autopsy performed? nO..
What test confirmed diagnosis?... clinical
S Was disease or injury in any way related to occupation of deceased?
If so, specific-.
(Signed) .y y.a.S.S M. D
(Address). -PBBH-:::: y^:::,^..,,::,.Date l/l8
6 .Winthrop .,®in.thro.p..
Place of Burianjr Cremation (City or Town)
Jan 19 ,§4
17 NAME OP
FATHER XI jam R FuaaellftSr.
18 BIRTHPLACE OP
FATHER (City)....
(State or country)
19 MAIDEN NAME
OF MOTHER '/©ra 11 Colucci
H.J.
20 BIRTHPLACE OF
MOTHER (City) ....
(State or country)
ias-t- ■Bo.s .ton ■
Maas
21
DATE OF BURIAL .
Informant
(Address! X’aWlcr
7 NAME OF Q
FUNERAL DIRECTOR lt...lLi.PDy
ADDRESS E....B.o..at.o.n..
Received and filed
.19..
(Registrar of City or Town where deceased resided)
A TRUE COPY ) a;
ATTEST:
■ (Registrar of City or Town where death occurred)
Jan 20 54
DATE FILED 19
X
I R-301A
lUCTIONS
FOR
CERTIFICATE
pivinflf
OF DEATH
>t enter
than one
for each
b) and (c)
ioes not mean
>/ dying, such
lure, asthenia, •
ns the disease,
ations which
\h.
d conditions, .
ing rise to the’
e (a) staling
lying cause
Hons contrib-
’ death but not
he disease or
ausing death.
X
UJ (City or T^wn
Sit;? C!Iammonm?altt; of jl]laBaad;a0?ttB
EDWARD J. CRONIN
Secretary OF THE Commonwealth
DIVISION OF VITAL STATISTICS
STANDARD
CERTIFICATE OF DEATH
To bo lil«d for burial parmil
with Board of Health
or its Agent.
Registered No.
..1.5
No.
2 FULL NAME.
|(If death occuired in a hospital or institution.
^I^Aceased is a married, widowed or divorced woman, give also ijj^iden name.) ^
ised IS a married, widowed or divorcBd woman, give also maiden name.;
6 (■
abode) g (
5 7/
Length of stay: In place of death years months^..y jlays
give its NAME instead of street and number)
PHYSICIAN — IMPORTANT
(Was deceased a
No
U. S. War Veteran.
[ if so specify WAR) .
(a) Residence. No.^.
(Usual place of abode)
(If nonresident, give city or town and State)
In place of residence .8. years months days.
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
DEATH ...
/ 7 // fSY:
(Month) f (Day) ' (Year)
eE'B Y C E R T I F Y , a That I attended deceased from
if 0_ 19*^^, t^^*^ * 19
h,. ..alive on .^^R. .)^eath is said tcj
have occurred on the date stored above, at ..^.O .m. INTERVAL BE-
TWEEN ONSET
DISEASE OR CONDITION . MO DeItH
DIRECT
TO DEA'
5 OR CONDITION .
ANTE Due
C^^T^(b)
Due
Major findings:
Of operations
Date of operation Was autopsj^erfctfmed?
What test confirmed diagno jCid^ 4i
3 ot.o-4 o
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
Male
9 COLOR OR RACE
White
10 SINGLE (write the word)
MARRIED HI . j
WIDOWED Marne (I
or DIVORCED
10a If married, widowed, or divorced. „ . . _
HUSBAND of Minn.i .e .J.^y.ger^
(Give maiden name of wife in full)
(or) WIFE of
(Husband’s name in full)
1 1 IF STILLBORN, enter that fact here.
AGE "7.7 Years Months Days
If under 24 hours
Hours Minutes
13 Usual
Occupation :
Retired
(Kind of work done during most of working life)
14 Industry _ j. j.
or B usiness : R. 6. S- J .6. IS . t.S. t .0. .
15 Social Security No.
16 BIRTHPLACE (City) R.U.S.S.i.d..
(State or country)
5 Was disease or injury in any way related to occupation^
If so. h
(Signe^)/*^^'^'^
(Ad<l-
Ohel Jacob
ased?
Place of Burial or Cremation (City or Town)
DATE OF BURIAL J.a.h.U.a..h.ii 1.6 iQ^.li..
’’ FUNERAL DIRECTOR Iieiir.^’.....L.e..Y.i.ne.
addressL7Q ■ H.ar..v^d.....S.t...., Br.Q.Q.klin.e
Received and filed..
.19
(Registrar)
17NAMEOF Vvolf Saperstein
FATHER
18 BIRTHPL.4.CE OF
FATHER (City)
(State or country)
Russia
19 MAIDEN NAME
OF MOTHER
Rachael (unknown)
20 BIRTHPLACE OF
MOTHER fCitvT
Rus s i a
(State or country)
Informant Mr.s...,......M j. nH 1 G S 3.^.6 r s.t 6 In
(Address) A 7i 1 .<a t on ^t., Rrlffliton
I HEREBY CERTIFY that a satisfactory standard certificate of death was
filed with me BEFORE the buriahdt transit permit was issued:
^ ■
(Sig^^yfidti P Agent of Bjja^d of Health or other)
(Official Designation)
of Issue of Permit)
EXTRACTS
FROM THE LAWS OF THE
COMMONWEALTH OF MASSACHUSETTS
GOVERNING THE
RETURN OF CERTIFICATES OF DEATH
A physician or registered hospital medical officer shall forthwith, after the
eath of a person whom he has attended during his last illness, at the request
f an undertaker or other authorized person or of any member of the family of
he deceased, furnish for registration a standard certificate of death, stating to the
lest of his knowledge and belief the name of the deceased, his supposed age, the
isease of which he died, defined as required by section one, where same was
ontracted, the duration of his last illness, when last seen alive by the physician
r 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, &c. 4.S,
G. L.. (Tercentenary Edition).
Medical examiners shall make examination upon the view of the dead bodies
of persons as are supposed to have died by violence, or by the action of
chemical, thermal or electrical agents or following abortion, or from diseases
resulting from injury or infection relating to occupation, or suddenly when not
disabled by recognizable disease, or when any person is found dead. .. — General
Laws. Ghap. 38, Sec. 6., as amended by Chap. 632, Sec. 4, Acts of 194.S.
V 1 xJi tvt,. L - * X * * v «
r officer, shall forfeit ten dollars.* .;J V: • ^
y-five, forty-six and forty-seven ^ 7
1 "war" shall include the China ^
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 therris 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
■ cepv^tefy or burial ground in which the interment is made,
fx^hap* If**. Sec. 46, G. L., (Tercentenary Edition),
A physician or officer furnishing a certificate of death as required by the
receding section or by section forty-five of chapter one hundred and four-
een. shall, if the deceased, to the best of his knowledge and belief, served in the
rmy, navy or marine corps of the United States in any war in w’hich it has been
ng.aged. insert in the certificate a recital to that effect, specifying the war. and
hall also certify in such certificate both the primary* and the secondary or imme-
iate cause of death as nearly as he can state the ^me. For neglect to comply
ith any provision of this section, such physician or (
‘or the purposes of this section and of sections forty-i
f said chapter one hundred and fourteen, the word ‘‘
slief expeditkm and the Philippine insurrection, which shall, for said purposes, be e a 2-^1 1 p 1 , , a „
eemed to have taken place between February fourteenth, eighteen hundred and ^ purpose of these laws calls for the observance of the follow-
inety-eight and July fourth, nineteen hundred and two, and the Mexican border
.... mteerf.y^. Atoetkrtdirig pi-
RULES OF PRACTICE
rvice of nineteen hundred and sixteen and nineteen hundred and seventeerf.//
L. Chap. 46. Sec. 10.
/ -—s physicians will certify to such deaths only as those of persons
have given bedside care during a last illness from disease unrelated
a^Tb'rm of injury.
No undertaker or other person shall bury or otherwise dispose of a human body Health physicians will certify to such deaths only as those of
i a town, or remove therefrom a human body which has not been buried, until he persons who. though disabled by recognized disease unrelated to any form of
as received a permit from the board of health, or its agent appointed to issu& -p ,JpJnr^have died without recent medical attendance or whose physician is absent
ich permits, or if there is no such board, from the clerk of the town where tlJ i. certificate of death is needed. ,, , , , ,
erson died; and no undertaker or other person shall exhume a human body ana * -CiX-^IVledical.^iammers will investigate ^d certi^ to all deaths supposably
?move it from a town, from one cemetery to another, or from one grave or tomb
ther than the receiving tomb to another in the same cemetery, until he has
jceived a permit from the board of health or its agent aforesaid or from the clerk
f the town where the body is buried. No such permit shall be issued until there
nail have been delivered to such board, agent or clerk, as the case may be,
satisfactory written statement containing the facts required by law to be
^turned and recorded, which shall be accompanied, in case of an original inter-
lent, by a satisfactory certificate of the attending physician, if any, as required by
iw. or in lieu thereof a certificate as hereinafter provided. If there is no attending
hysician. or if, for sufficient reasons, his certificate cannot be obtained early
nough for the purpose, or is insufficient, a physician who is a member of the board
f health, or employed by it or by the selectmen for the purpose, shall upon
pplication make the certificate required of the attending physician. If death is
aused by violence, the medical examiner shall make such certificate. If such a
ermit for the removal of a human body, not previously interred, from one town
5 another within the commonwealth cannot be obtained early enough for the
urpose. the certificate of death made as above provided and in the possession of
^le undertaker desiring to make such removal shall constitute a permit for such
?moval; provided, that such body shall be returned to the town from whichit was
emoved within thirty-six hours after such removal, unless a permit in the usual
orm for the removal of such body has been sooner obtained hereunder. If the
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 — prisate family, cook — hotel, etc. For
a person who had no occupation whatever write none.
JPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE
MNK, RATING
DRGANIZATION AND OUTFIT
SERVICE NUMBER
..Suffolk....
(County)
Bpsjton
(City or Town)
No.
(Sammantoraltt; of AaBBartfuarttB
EDWARD J. CRONIN
Secretary OF THE Commonwealth
DIVISION OF VITAL STATISTICS
COPY OF
CERTIFICATE OF DEATH
Bostcn
(City or town making return)
Registered No m
^ ??®* S institution.
give its NAME instead of street and number)
2 FULL NAME 1 (Was deceased a
(If deceased is a married, widowed or divorced woman, give also maiden name.) 1 U. S. War Veteran,
I if so specify WAR)..
(if c^^M^wn and State)
Length of stay: In place of death years.. ^ month«^ days. In place of residence... years months days.
(a) Residence. No
(Usual place of abode)
, St.
MEDICAL CERTIFICATE OF DEATH
PERSONAL AND STATISTICAL PARTICULARS
3 DATE OF
DEATH ....
(Month)
8 SEX
(Year)
4 1 HEREBY CERTIFY.
I last saw h alive on....
have occurred on the date stated above, at..
That I attended deceased from
4aru 19 ^
19 death is said to
9 COLOR OR RACE
10 SINGLE (write the word)
MARRIED , ,
WIDOWED Widowed
or DIVORCED ^
DISEASE OR CONDITION
DIRECTLY LEADING
TO DEATH (a) ?:^;sor4ary- c<xiges;t.l.ani
e&mm
CEDENT "?bi Brouchof^nio ^cjna »
CAUSES ^ ^ ^ ^
Due To
(c)
!SBtastaa«8
sdrt^nal d a
OTHER
SIGNIFICANT ,
CONDITIONS
IRTERVAL BE-
TWEEN ONSET
MD DEATH
and
Dsyg
lOa If married, widowed, or divorced
HUSBAND of ; ~~
(Give maiddB 'BSW8T5f wife in full)
(or) WIFE of
(Husband's name in full)
1 1 IF STILLBORN, enter that fact here.
AGE. .. Years ,§..^ Months Days
If under 24 hours
Hours Minutes
13 Usual
Occupation:,
(Kind o!
working life)
Major findings:
Of operations
Date of operation Was autopsy performed?. ...Xes..
What test confirmed diagnosis?
5 Was disease or injury in any way related to occupation of deceased?..
If so, specify
(Signed) .]L....J..
(Address).
Place of
DATE OF BURIAL
Buriai or Cmmaiffly^ ^
4fan^3/^ 1
7 NAME OF
FUNERAL DIRECTOR
M W Kirby
ADDRESS .Wintihr.Qp...^..3.s.*...
Received and filed .?r...t;:™. 19..
(Registrar of City or Town where deceased resided)
14 Industry ^ ,
ot Business: f
IS Social Security No..
16 BIRTHPLACE (City)..
(State or country)
17 NAME OP
FATHER
18 BIRTHPLACE OF ^CbSel
FATHER (City)
(State or country) % I'SlSBo
'IBS ten
19 MAIDEN NAME
OF MOTHER
20 BIRTHPLACE OF
MOTHER (City) ....
(State or country)
Ifar^ Mitghcll
Iriiland
Informant .y....A....H.QSP.i.
^(Ac^ess, /} ^ t^L,Bo3too.,30
A'frEST:
(Registrar of City or Town where death occurred)
Jan«25/5U
DATE FILED 19 - -
■ ■T.- ?
*»
* V
i '
FES
O
Entered Service 6-29-lS
Discharged U-23-19
Capt. CMC US Amy
25M*3.53>909098
A
2 FULL
! SUFFOLK
No.
(City or Town)
The Childreif
(Sammamtiraltlf of AaBoart^narttB
EDWARD J. CRONIN
Secretary OF the Commonwealth
DIVISION OF VITAL STATISTICS
COPY OF
CERTIFICATE OF DEATH
3 I .WiLSi
(City or town making return)
589 i "y
Registered No JL-*.
ospital
(If death occurred in a hospital or institution,
give its NAME instead of street and number)
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)
.321....l*le.a.a.an.t. st .Wlnthrop,, Mass*..
(a) Residence. No.
(Usual place of abode) (If nonresident, give city or town and State)"
Length of stay: In place of death years months., days. In place of residence.. ...W... years months days.
In place of death years months., days. In place of residence.. ...W... years
Hnapltala»19hra»4ftmins
MEDICAL CERTIFICATE OF DEATH
PERSONAL AND STATISTICAL PARTICULARS
3 gATE^oF Ja nuary 20
(Month) (Day) (Year)
8 SEX
P
41 HEREBY CERTIFY
....1/.I9 19 ,
I last saw h or alive on X,
have occurred on the date stated above, at
That I attended deceased , from
64
9 COLOR OR RACE
a
10 SINGLE (write the word)
MARRIED wj *
WIDOWED IngXO
or DIVORCED
X/2Q
/m
19 V.”
5* X'5a"*"
, 19!
death is said to
DISEASE OR CONDITION
‘■;?IWte3tlnal obatruetlbn
c atrangutated small
ANTE Due To
CEDENT (b)
CAUSES
Due To
(c)
bowel
Post operative ad-
he s Ions
OTHER
SIGNIFICANT .
CONDITIONS
UTERVU IE
TNEEN OISET
UO OEATK
10a If married, widowed, or divorced
HUSBAND of , ,
(Give maiden name of wife in full)
(or) WIFE of
(Husband’s name in full)
1 1 IF STILLBORN, enter that fact here.
12
AGE..
8 28
..Years Months Days
If under 24 hours
Hours Minutes
13 Usual
Occupation:.
(Kind of work done during most of working life)
14 Industry
or Business:.
Student
IS Social Security No..
16 BIRTHPLACE (City)..
(State or country)
Boston
Major findings:
Of operations.
Qa.ngro.no.U9. s.ogment...iloum..
Date of operation .X/f^2.Q/^5.4.Was autopsy performed?
What test confirmed diagnosis?
S Was disease or injury in any way related to occupation of deceased? •
If so, specify..
(Signed) V.....^.iy.V^...V,«..4::.^ ^ J!nr\ “•
_____
(Address).. ate..
.W.inthr.o.p .W.lnldar.o.p.
Place of Burial otTlremation _ XCity or Town)
Jan 22
DATE OF BURIAL 19
1
7 NAME OF
FUNERAL DIRECTOR..
ADDRESS.
J_0!.Mal©y
Received and filed 19..
(Registrar of City or Town where deceased resided)
17 NAME OP
FATHER
Mass
Cheater S Barnard
18 BIRTHPLACE OP
FATHER (City)
(State or country)
Boston
Mass
19 MAIDEN NAME
OF MOTHER Dorothy WeQ. ling
20 BIRTHPLACE OF I.' « „ ^ ^
MOTHER (City) '
(State or country)
Informant.,
f Address I
..C.Barnard..
A TRUE COPY
ATTEST;
(Registrar of City or Town where death occurred)
Jan 22 „ 54
DATE FILED - - 19
X
riBu
2 FULL NAME
(Sommonotralttf of ^assartfUBPttB
OFFICE OF THE SECRETARY
DIVISION OF VITAL STATISTICS
STANDARD
CERTIFICATE OF DEATH
To bo fiUd for burial pormit
with Board of Haalth
or it* Afont.
Registered No. .
18.
an, give also maiden name.)
I (If death occurred in a hospital or institution.
St. I give its NAME instead of street and number)
, PHYSICIAN — IMPORTANT
I (Was deceased a
I U. S. War Veteran,
I if so specify WAR)
deceased is a Carried, ^dowed or divorced
(a) Residence. No. / ^ ^ St
(Usual place of ^ode) / ' (If nonresident, give city or town and State)
/ . n 4
Length of stay: In place of death y^rs months days. In place of residence .sfe.T years months days.
DICAL CERTIFICATE OF DEATH
PERSONAL AND STATISTICAL PARTICULARS
3 DATE OF
DEATH
4 I H
I last saw h
(Month)
Y C E R TJ F Y ,
19,^. Jl..
.alive on .
J9X±
8 SEX
9 COLOR 09r RACE
(Year)
hat I attended deceased from
r .
... 19\l^^^eath is said to||
10 SI.NGLE
MARRIED
WTDOWED
or DIVORCE
(\^te the word)
/.’4to/«fm.
have occurred on the date staTCd above, at
DISEASE OR CONDITION
DIRECTLY LEAQB'.’G
TADEAT^
ANTE Due To
CEDENT (b)
CAUSES
OTHER
SIGNIFICANT .
CONDITIONS
^ ^ V i
5 Was disease or injury in any way related ^occupation of deceased
10a If married, /vI35>^ed,/)r^ivorced
HUSBAND of . _
(Give maiden name"of wife in full)
(or) WIFE of
(Husband’s name in full)
11 IF STILLBORN, enter that fact here.
1
AGE A2.Years .
Months Days
If under 24 hours
Hours Minutes
13 Usual
Occupation:..
und of work done during most of working life)
14 Industry , .
or Business: .
15 Social Securit^No.
16 BIRTHPLACE (City)..._,
(State or country)
17 NAME OF
FATHER
18 BIRTHPL^E OF
FATHERlCity)
(State or country)
19 MAIDEN NAMEvi.
fy\
or other)
(Date of Issue of Permit)
u
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 authonzed 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. 4d. 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, 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, ninetren hundred and two. and the Mexican border
service of nineteen hundred and sixteen and nineteen hundred and seventeen.
G. L. Chap. 46. Sec. 10.
No undertaker or other person shall bury or otherwise dispose of a human body
in a town, or remove therefrom a human body which has not been buried, until he
has received a permit from the board of health, or its agent appointed to issue
such permits, or if there is no such board, from the clerk of the town where the
person died; and no undertaker or other person shall exhume a human body and
remove it from a town, from one cemetery to another, or from one grave or tomb
other than the receiving tomb to another in the same cemetery, until he has
received a permit from the board of health or its agent aforesaid or from the clerk
of the town where the body is buried. No such permit shall be issued until there
shall have been delivered to such board, agent or clerk, as the case may be.
a satisfactory written statement containing the facts required by law to be
returned and recorded, which shall be accompanied, in case of an original inter-
ment. by a satisfactory certificate of the attending physician, if any. as required by
law, or in lieu thereof a certificate as hereinafter provided. If there is no attending
physician, or if. for sufficient reasons, his certificate cannot be obtained early
enough for the purpose, or is insufficient, a physician who is a member of the board
of health, or employed by it or by the selectmen for the purpose, shall upon
application make the certificate required of the attending physician. If death is
caused by violence, the medical examiner shall make such certificate. If such a
permit for the removal of a human body, not previously interred, from one town
to another within the commonwealth cannot be obtained early enough for the
purpose, the certificate of death made as above provided and in the possession of
the undertaker desiring to make such removal shall constitute a permit for such
removal; provided, that such body shall be returned to the town from which it was
removed within thirty-six hours after such removal, 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 SKtion ten of chapter forty-six.
that the deceased served in the army, navy or marine corps of the United States
in any war in which it has been engaged, such recital shall appear upon the permit.
The board of health, or its agent, upon receipt of such statement and certificate,
shall forthwith countersign it and transmit it to the clerk of the town for registra-
tion. The person to whom the permit is so given and the physician certifying
the cause of death shall thereafter furnish for- registration any other necessary
information which can be obtained as to the deceased, or as to the manner or
cause of the death, which the clerk or registrar may require.— Chap. 114, Sec. 45,
G. L.. (Tercentenary Edition).
Medical examiners shall. make examination upon the view of the dead bodies
of only such pei^ns 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
M to do from the boar4 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 tc hpld. q'r from a person appointed to have the care of the
cemeteiy or burial grOuad in which the interment is made.
. . . Chap. 114, S^.46. G. L„ (Tercentenary Edition).
RULES OF PRACTICE
.l.'fJC' 1 ■
The fulhllmm^aCt^ purpose of th^ 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) ^ard of Health physicians will certify to su:h 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. Th^ 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 disable 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
R-301A
UCTIONS
[EKTinCATE
'ivinc
)F DEATH
it enter
:han one
For each
b) and (c)
lots not mean
f dying, such
ure. asthenia. ■
It the disease,
ations which
h.
I conditions,
ng rise to the'
’ (d) stating
ying cause
ions contrib- ■
death but not
le disease or
lusing death.
3u f folk.
(County)
o ’Vint hr op,,
(City or Town)
120 Banks Stree
dammantnpalttf of maBBactjuarttB
EDWARD J. CRONIN
Secretary of the Commonwealth
DIVISION OF VITAL STATISTICS
STANDARD
CERTIFICATE OF DEATH
To bo 6lod for burial -pormlt
with Board oi Haaith
or Its A^nte
Registered No.
19
I (If death occurred in a hospital or institution.
No Frr..V:r...~' _ V. St. \ give its NAME instead of street and number)
A - f. »» a ( physician — IMPORTANT
2 FULL NAME Anna S . MC GU lgan 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)
(a) Residence. No. .1 ?0 , 3,anks S ;tre.e,t St. ,
(Usual place of abode)
Length of stay: In place of death years months days. In place of residence
(If nonresident, give city or town and State)
years months days.
MEDICAL CERTIFICATE OF DEATH
DEATH®' January 27. 195,4.
(Month) (Day) (Year)
4 I HEREBY CERTIFY, That I attended deceased from
iq/'X:.. to ..2/..7 iqXjK
I last saw alive .. 27f i«ry. death is said
have occurred on the date stami above, at 7,0 P
DISEASE OR CONDITION. KfiinOi, > 3
to
DIRECTLY LEADING
TO DEATH (a)
ANTE Due To
CEDENT (b)
CAUSES
Due To
(c)
OTHER
SIGNIFICANT
CONDITIONS
IRTERVU BE
TWEEN ONSET
MD DEATH
Major findings;
Of operations..
Date of operation Was autopsy performed?.
What test confirmed diagnosis?
S Was disease or injury in any way related to occupation of deceased?.
(Address)/.fr4 ^UUv>.«X!Ct!v4CS^‘..C ^ * Date /.~ .X^ ** 19
6 Qalv,ary 3.oston Mass
Place of Burial or Cremation (City or Town)
.Jkniiary
DATE OF BURIAL
(City or Town)
3a ,95 4
7 NAME OF
FUNERAL DIRECTOR
ADDRESS V in t h r* Op Ma, s s ,«
Received and filed..
•
.19..
(Registrar)
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
Female
9 COLOR OR RACE
Vhi te
10 SINGLE (write the word)
MARRIED
WIDOWED.,.- , ,
or DIVORCBU (1OW0Q
10a If married, widowed, or divorced
HUSBAND of
(Give maiden name of wife in full)
(or) WIFE of B ernard . J . McGuigan .
(Husband's name in full)
11 IF STILLBORN, enter that fact here.
63
AGE Years Months Days
If under 24 hours
Hours . Minutes
13 Usual
Kation:.. .School Teacher
(Kind of work done during most of working life)
14 Industry
or Business:..
Schools
15 Social Security No.
16 BIRTHPLACE (City) .
(State or country)
Fast Boston^ >
Mass
17 NAME OF
FATHER Frank E. Shields
18 BIRTHPLACE OF
FATHER (City) B Q.S.t.P.n
(State or country) g g
19 MAIDEN NAME
OF MOTHER
Mary A- 'Valsh
20 BIRTHPLACE OF
MOTHER (City) 3..Q.S.t,0n
(State or country) g g
Informant . ..M,r,3 „, Jo, s,ep,h . ,,p,e,ve raux, .. .
(Address) 120 Banks St. TVlnthrop
I HEREBY CERTIFY that a satisfactory stan^rd certificate of death was
"^ea with ^j^^BEFORE^e burial o|>t^nsit ppohit was issued:
>n) y J (Date of Issue of Permit)
EXTRACTS
FROM THE LAWS OF THE
COMMONWEALTH OF MASSACHUSETTS
GOVERNING THE
RETURN OF CERTIFICATES OF DEATH
A physician or registered hospital medical officer shall forthwith, after the
eath of a person whom he has attended during his last illness, at the ’request
P an undertaker or other authorized person or of any member of the family of
le deceased, furnish for registration a standard certificate of death, stating to the
est of his knowledge and belief the name of the deceased, his supposed age. the
isease of which he died, defined as required by section one. where same was
mtracted. the duration of his last illness, when last seen alive by the physician
r 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.
Q. 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.
A physician or officer furnishing a certificate of death as required by the
receding section or by section forty-five of chapter one hundred and four-
?en, shall, if the deceased, to the best of his knowledge and belief, served in the
rmy, navy or marine corps of the United States in any war in which it has been
igaged. insert in the certificate a recital to that effect, specifying the war. and
fall also certify in such certificate both the primary and the secondary or imme-
iate cause of death as nearly as he can state the same. For neglect to comply ■, .
ith any pro\nsion of this section, such physician or officer, shall forfeit ten dollars,
or the purposes of this section and of sections forty-five, forty-six and forty-seven j
‘ said chapter one hundred and fourteen, the word “war” shall include the China ..
lief expedition and the Philippine insurrection, which shall, for said purposes, be
?emed to have taken place between February fourteenth, eighteen hundred and
nety-eight and July fourth, nineteen hundred and two. and the Mexican border
rvice of nineteen hundred and sixteen and nineteen hundred and seventeen.
. L. Chap. 46, ^c. 10.
No undertaker or other person shall bury or otherwise dispose of a human bod^.,
a town, or remove therefrom a human body which has not been buried, untfl/he*^;.'
is received a permit from the board of health, or its agent appointed to issue (>
ich permits, or if there is no such board, from the clerk of the town where the. .
jrson died; and no undertaker or other person shall exhume a human body and, . !
move it from a town, from one cemetery to another, or from one grave or tomb
her than the receiving tomb to another in the same cemetery, until he has
ceived a permit from the board of health or its agent aforesaid or from thg cl^rk
the town where the body is buried. No such permit shall be issued unlii^thfe^ J
lall have been delivered to such board, agent or clerk, as the caseTna^ TOv' ^
satisfactory written statement containing the facts required by law to be
turned and recorded, which shall be accompanied, in case of an original inter-
ent, by a satisfactory certificate of the attending physician, if any. as required by
w. or in lieu thereof a certificate as hereinafter provided. If there is no attending
"lysician. or if. for sufficient reasons, his certificate cannot be obtained early
lough for the purpose, or is insufficient, a physician who is a member of the board
health, or employed by it or by the selectmen for the purpose, shall upon
Dplication make the certificate required of the attending physician. If death is
lused by violence, the medical examiner shall make such certificate. If such a
?rmit for the removal of a human body, not previously interred, from one town
) another within the commonwealth cannot be obtained early enough for the
urpose. the certificate of death made as above provided and in the possession of
le undertaker desiring to make such removal shall constitute a permit for such
:moval; provided, that such body shall be returned to the town from which it was
jmoved within thirty-six hours after such removal, unless a permit in the usual
)rm 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 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 ^lerk 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.
. 4 . (3hap. 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:
(O* 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
-froynhome 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.
)PACE FOR ADDITIONAL INFORMATION
)ATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE
lANK, RATING
DRGANIZATION AND OUTFIT ..
>ERVICE NUMBER,.
(City or ToMi)
No. /.o2 JP
Olijr CSaimnanmraltt|i nf fHaaaartfUBrtta
EDWARD J. CRONIN
Secretary OF THE Commonwealth
DIVISION OF VITAL STATISTICS
MEDICAL EXAMINER’S
CERTIFICATE OF DEATH
To bo filod for burial parmlt
with Board of Haalth
or Its Agant«
Registered No. .
I (If death occurred in a hospital or institution,
St. \ give its NAME instead of street and number)
2 FULL NAME
(If deceased is a married, widowed or divorced woman, give also maiden name.)
I U. S. War Veteran,
(a) Residence. No.
(Usual place of
/,a, o
F abode) f (If nwresident, give city or town and
and State)
Length of stay; In place of death years months days. In place of residence. .. 2..... years months days.
DICAL CERTIFICATE OF DEATH
PERSONAL AND STATISTICAL PARTICULARS
3 DATE OF
DEATH
(Month)
[(Day)
9 SEX
1 ernal
4 1 HERE CERTIFY that I have investigated the death
of the person above-named and that the CAUSE AND MANNER thereof
as follows: (If an injury was involved, state fully.)
10 COLOR OR RACE
vjhite
11 SINGLE (write the word)
MARRIED
WIDOWED rnarripH
or DIVORCED 1 -LCU
^^«re as tollows: (U an inpiry was involved, s
^i-rrTr
11a If married, widowed, or divorced
HUSBAND of.....
(Give maidep.,name of wife in full)
(or) WIFE of ^ ee ran
(Husband’s name in full)
...T.
12 IF STILLBORN, enter that fact here.
13
S Accident, suicide, or homicide (specify)
Date and hour of injury
i9...X...?^...
own and State) !
AGE. Years Months Days
If under 24 hours
Hours Minutes
Occupation: .SU.yCr.Y.i.S.Q.r
(Kind of work done during most of working life)
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?
(Speciijf ijfj
Injury ...
Nature of
Injury
mX\7ness:...;.lQ.ib..n .Han c.o.ck....:r..a£f.....In.s.... .^.o..,.
16 Social Security No... 1.103.0-20-7^71
17 BIRTHPLACE (City) L!.?..ft.!Q.Q.dy;.....*!j-.a
(State or country)
While at work? Was autopsy performed? ..
If so. S]
(Signed) '...,
(Address)
M. D.
7 .^..0..?.
Place of Burial, or Cremation. (City or Town)
DATE OF BURIAL .■^..6.b..s..l..».L.9..3..4.
18 NAME OF
FATHER
John E, Hayeo
19 BIRTHPLACE OF
FATHER (City)
(State or country)
Peabody --^ass.
20 MAIDEN NAME |v"jj , /
OF MOTHER t iargarot £. ^ayes^'
21 BIRTHPLACE OF
MOTHER (City) ....
(State or country)
Danvers .^‘*a s s •
22
19..
informant.j.'ur.s.* J..».V.i,jn-c.en.b....i-i,u..rrav
(Address) H. 0 V G r G r:; Q •>
Cx O V.J •
8 NAME OF
FUNERAL DIRECTOR
ADDRESS
I HEREBY CERTIFY that a satisfactory stwdard certificate of death was
y with me BEFORE the burial or,.Xransit jMrmit was issued:
Received and filed..
m
..19..
(Registrar)
(Official Designation)
•e of
■^ther)
(Date of Issue of Permit)
EXTRACTS
FROM THE LAWS OF THE
COMMONWEALTH OF MASSACHUSETTS
GOVERNING THE
RETURN OF CERTIFICATES OF DEATH
A physician or rei^istered 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-sev;en
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 l^tween February fourteenth, eighteen hundred and
ninety-eight and July fourth, nineteen hundred and two. and the Mexican border
service of nineteen hundred and si.xteen and nineteen hundred and seventeen.
G. L. Chap. 46, &c. 10.
Ko undertaker or other person shall bury or otherwise dispose of a human body
in a town, or remove therefrom a human body which has not been buried, until he
has received a permit from the board of health, or its agent appointed to issue
such permits, or if there is no such board, from the clerk of the town where the
person died; and no undertaker or other person shall exhume a human body and
remove it from a town, from one cemetery to another, or from one grave or tomb
other than the receiving tomb to another in the same cemetery, until he has
received a permit from the board of health or its agent aforesaid or from the clerk
of the town where the body is buried. No such permit shall be issued until there
shall have been delivered to such board, agent or clerk, as the case may be.
a satisfactory written statement containing the facts required by law to be
returned and recorded, which shall be accompanied, in case of an original inter-
ment, by a satisfactory certificate of the attending physician, if any. as required by
law, or in lieu thereof a certificate as hereinafter provided. If there is no attending
physician, or if, for sufficient reasons, his certificate cannot be obtained early
enough for the purpose, or is insufficient, a physician who is a member of the board
of health, or employed by it or by the selectmen for the purpose, shall upon
application make the certificate required of the attending physician. If death is
caused by violence, the medical examiner shall make such certificate. If such a
permit for the removal of a human body, not previously interred, from one town
to another within the commonwealth cannot be obtained early enough for the
purpose, the certificate of death made as above provided and in the possession of
the undertaker desiring to make such removal shall constitute a permit for such
removal; provided, that such body shall be returned to the town from which it was
removed within thirty-six hours after such removal, unless a permit in the usual
form for the removal of such body has been sooner obtained hereunder. If the
death certificate contains a recital, as required by section ten of chapter forty-six,
that the deceased served in the army, navy or marine corps of the United States
in any war in which it has been engaged, such recital shall appear upon the permit.
The board of health, or its agent, upon receipt of such statement and certificate,
shall forthwith countersign it and transmit it to the clerk of the town for registra-
tion. The person to whom the permit is so given and the physician certifying
the cause of death shall thereafter furnish for registration any other necessary
information which can be obtained as to the deceased, or as to the manner or
cause of the death, which the clerk or registrar may require. — Chap. 114, Sec.
45, G. L. as amended by Chap. 48. Acts of 1927 and Chap. 414, Acts of 1931.
No undertaker or other person shall bury a human body or the ashes thereof
which have been brought into the commonwealth until he has received a permit
so to do from the board of health or its agent appointed to issue such permits,
or if there is no such board, from* the clerk of the town where the body is to be
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 \new of the dead bodies
of persons as are suppr^sed to have died by violence, or by the action of
chemical, thermal or electrical agent5 or following abortion, or from diseases
resulting from injury or infection relating to occupation, or suddenly when not
disabled b>' recognizable disease, or when any person is found dead. ... — General
Laws, Chap. 38, Sec. 6., as amended by Chap. 632. Sec. 4. Acts of 1945.
The medical examiner certifies the cause and manner of death to the best
of his knowledge and belief.
RULES OF PRACTICE
The fulfillment of t{ie 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 ba\;e given bedside care during a last illness from disease unrelated
to any form injury. •
(2) ^ Board ,bf Health physicians will certify to such deaths only as those of
persons Whot^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
ffitiumatisin* (including^ resulting septicemia), and by the action of chemical
f poisons) thqrrdal, or electrical agents, and deaths following abortion, but
also deaths from disease resulting from injur>' or infection related to occupation,
the sudden deaths of persons not disabled by recognized disease, and those of
persons found dead.
STATEMENT OF CAUSE OF DEATH
Medical Examiners in certifying to a death will state the cause and manner
thereof, and will specify: (1) Under cause the nature of an injury and of its
consequences; and (2) under manner the mode of its production together with
the circumstances when these are known. For example: “Compound fracture of
the femur with ensuing septicemia (gas bacillus) caused by a steam railway
accident.*’ “Pistol shot wound of the chest with associated hemorrhage, hom-
icidal.” “Asphyxiation by suspension, suicidal.” “Syncope while under the
influence of ether administered as a surgical anaesthetic.” “Fracture of the
skull with associated internal 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
I R-301A
lUCTIONS
FOR
CERTIFICATE
fivinf
OF DEATH
at enter
than one
for each
b) and (c)
does not mean
>/ dying, such
lure, asthenia, •
n; the disease,
:alicms which
Ih,
d conditions,
Ing rise to the '
e (a) staling
lying cause
'ions contrib- •
death but not
he disease or
ausing death.
.Suffolk
(County)
Winthrop
(City or Town)
dammonniFaltl? of j^aBoadiuorttB
EDWARD J. CRONIN
Secretary OF THE Commonwealth
DIVISION OF VITAL STATISTICS
STANDARD
CERTIFICATE OF DEATH
Registered No
To be filed for burial -permit
with Board of Health
or its Agent.
21
TIT.: in” I (If death occurred in a hospital or institution.
No v.JrPTnrop l^QQy0X.S.C..6Tl.v .. H.Qin.6 St. \ give its NAME instead of street and number)
{PHYSICIAN — IMPORTANT
(Was deceased a
U. S. War Veteran,
if so specify WAR) .
(a) Residence. No. ... Ase.,. Revere, Iviass*
(Usual place of abode) (If nonresident, give city oi
Length of stay: In place of death years months. 3S.. days. In place of residence years months days.
or town and State)
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
DEATH ..
yj (Month)
B Y C E R
(Day)
/
(Year)
■ Y CERTIFY
st saw h*4?4<,.. alive on
have occurred on the date stated above, at
That I attended deceased from
\<iS^
1
death is said to
DISEASE OR CONDITION
DIRECTLY LEADI
TO DEATH (a)
ANTE Due To
CEDENT (b)
CAUSES
Due To
(c)
OTHER
SIGNIFICANT
CONDITIONS
INTERVAL BE-
TWEEN ONSET
AND DEATH
/O
Major findings:
Of operations..
Date of operation Was autopsy performed? .
What test confirmed diagnosis?
5 Was disease or injury in any way re
If so,
(Signed)
(Addn
to occupation of deceased?.
Place of Burial or Cremation
DATE OF BURIAL . 3Q.
den
(City or Town)
7 NAME OF
FUNERAL DIRECTO;
ADDRESS
876 Winthrop Ave, , Revere, Mass.
Received and filed..
AilW 1954
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
female
9 COLOR OR RACE
white
(write the word)
10 SINGLE
MARRIED
WIDOWED . .
or DIVORCED Widowed
10a If married, widowed, or divorced
HUSBAND of
(Give maiden name of wife in full)
(or) WIFE of . .FrederidH Van D^usen
(Husband’s name in full)
11 IF STILLBORN, enter that fact here.
AGE 78
Years Months ...
Days
If under 24 hours
Hours Minutes
Occupation:.. Housewife
(Kind of work done during most of working life)
14 Industry
or Business: .
15 Social Security No.
16 BIRTHPLACE (City) Albany
(State or country) ^
17 NAME OF
FATHER James Swift
18 BIRTHPLACE OF
FATHER (City)
(State or country)
Ireland
19 MAIDEN NAME
OF MOTHER Ellen Casey
20 BIRTHPLACE OF
MOTHER (City)
(State or country) Ireland
21
Informant l5p.g.....E§t.elle....B.arnes
(Address) 98 Summer St., Revere, Mass.
(Registrar)
I HEXEBY certify that a satisfactory st^dard certificate of death was
^d with n« BEFORE th^'bijrial or t^nsit.^rmit was issued:
(Signature oT AgentraLBoard of Health brother)
^ '
(Date of Issue of PermiQ
signation)
X
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.
death certificate contains a recital, as required by section ten of chapter forty-six,
that the deceased served in the army, navy or marine corps of the United States
in any war in which it has been engaged, such recital shall appear upon the permit.
The board of health, or its agent, upon receipt of such statement and certificate,
shall forthwith countersign it and transmit it to the clerk of the town for registra-
tion. The person to whom the permit is so given and the physician certifying
the cause of death shall thereafter furnish for registration any other necessary
information which can be obtained as to the deceased, or as to the manner or
cause of the death, which the clerk or registrar may require. — Chap. 1 14. ^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, 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 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, nay>' or marine corps of the United States in any war in which it has been
engaged, insert in the certificate a recital to that effect, specifying the war, and
shall also certify in such certificate both the primary and the secondary or imme-
diate cause of death as nearly as he can state the same. For neglect to comply
with any provision of this section, such physician or officer, shall forfeit ten dollars.
For the purposes of this section and of sections forty-five, forty-six and forty-seven
of said chapter one hundred and fourteen, the word "war" shall include the China
relief expedition and the Philippine insurrection, which shall, for said purposes, be
deemed to have taken place between February fourteenth, eighteen hundred and
ninety-eight and July fourth, nineteen hundred and two, and the Mexican border
service of nineteen hundred and sixteen and nineteen hundred and seventeen.
G. L. Chap. 46. Sec. 10.
No undertaker or other person shall bury or otherwise dispose of a human body
in a town, or remove therefrom a human body which has not been buried, until he
No undertaker or other persons shall bury a human body or the ashes thereof
which have been brought into the commonwealth until he has received a permit
so to do from the board of health or its agent appointed to issue such permits, or
if there is no such board, from the clerk of the town where the body is to be buried
or the funeral is to be held, or from a person appointed to have the care of the
cemetery or burial ground in which the interment is made.
. . . Chap. 114, Sec. 46, G. L.. (Tercentenary Edition).
I , .
I f
RULES OF PRACTICE
. The fulfillment of the purpose of these laws calls for the observance of the follow-
„ ing rules of practice:
;(!).“ Attending physicians will certify to such deaths only as those of persons
to whorn they have given bedside care during a last illness from disease unrelated
'to any form oGnjury.
:J Board of Health physicians will certify to such deaths only aS those of
. yfho. 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 ^^yi^uri^^ave-died without r^ medical attendance or whose physician is absent
such permits, or if there is no such board, from the clerk of the town where the^*' trt^ lldme. when the certificate of death is needed.
person died; and no undertaker or other person shall exhume a human body and Medical Exanr%iners will investigate and certify to all deaths supposably
remove it from a town, from one cemetery to another, or from one grave or tomb ^9® include not only deaths caused directly or indirectly by
other than the receiving tomb to another in the same cemetery, until he has traumatism (including resulting septicemia), and by the action of chemical
• - * ... ... (drugs or poi^ns) thermal, or electrical agents, and deaths following abortion, but
or infection related to occupation,
by recognized disease, and those of
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
p^fsbns found d'eM.
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
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
1 R-301A
4-
tUCTIONS
FOR
CERTIFICATE
giving
OF DEATH
ot enter
than one
for each
tb) and (c)
does not mean
of dying, such
Uure. asthenia, .
ins the disease,
cations which
th.
id conditions,
ing rise to the '
■e (a) stating
'lying cause
ticms contrib- •
! death but not
he disease or
:ausing death.
'ni
A
^ ^.uff.o.lk
Q (County)
o .Wl.n.t.hrop..
(C^ity or "ftwn)
Qltfr (dammanmEaltl; of fnaBoadinoFttB
EDWARD J. CRONIN
Secretary of the Commonwealth
DIVISION OF VITAL STATISTICS
STANDARD
CERTIFICATE OF DEATH
Registered No,
To be filed for burial permit
with Board of Health
or its Agent.
o
,«w..
,2i
ir.? V. 4- TT.,v • j. -1 /(If death occurred in a hospital or institution.
No iV.in..Unr.Q.p....G..O.nQni,Un.X.t.y....HO.S.p.l.tal St. [ give Us name instead of street and number)
I PHYSICIAN — IMPORTANT
name Margaret IsaDel Dalrvmple J (Was deceased .
(If decea^d is a married, widowed or divorced womatiT give also maiden name.) ) U. S. War Vete:
2 FULL
Veteran,
if so specify WAR) .
(a) Residence. No. . 11.6. ..B.Qwd.o in ... S treet.
(Usual place of abode)
St.
Length of stay: In place of death years months ...W days. In place of residence ...^.Vyears months
40,
(If nonresident, give city or town and State)
days.
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
DEATH
(Year)
BY CERTIFY
last saw alive on
have occurred on the date st^ed above, at
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
attended deceased from
\9^
19.„f...^ death is said to
9 COLOR OR RACE
white
10 SIN’CjLE (write the word)
MARRIED 71.Tqt*T*T .arl
WIDOWED iviarrx‘3a
or DIVORCED
10a If married, widowed, or divorced
HUSBAND of
(Give maiden name of wife in full)
DISEASE OR CONDITION
DIRECTLY
TO DEATH (a) ,
ANTE Due To ^
CEDENT (b)
CAUSES
Due Ti
(c)
OTHER
SIGNIFICANT
CONDITIONS
(or) WIFE of .
Arthur Balrymple
(Husbano^s name in full)
11 IF STILLBORN, enter that fact here.
12
AGE
73
.Years
Months
29
Days
If under 24 hours
Hours .. Minutes
13 Usual
Occupation:..
housewife
(Kind of work done during most of working life)
14 Industry
or Business:
own home
15 Social Security No..
16 BIRTHPLACE (City) Rlo. e ...p.oin t
— (State or country) ^r-ln06 El Ward Islaud
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?
' ^ Date / - \9S^
(Signed)
(Address)/
17 NAME OF
FATHER
-Neil Mac 3ao hern
18 BIRTHPL.\CE OF
FATHER (City) Ric.e. . poin t
(State or country) prj^^OQ ]^(jWard TSlftTld
19 MAIDEN NAME
OF MOTHER Mary MacDougall
20 BIRTHPLACE OF
MOTHER (City) RiCS ...PO ln t
(State or country) Pr jnC 6 MWfl.r(3 TRlflYli^
DATE OF BURIAL
Informant Arthur JDa.l.rym.p.le.
(Address) H5 Bowdoln St, ;vinthrop-
1
I HEREB^Y CE^'nPY that a satisfactory st^dard certificate of death was
,1 or ^ansit.|iermit was issued:
oi Board of Healin or other)
iC'frk-
(Date of Issue of Permit)
EXTRACTS
FROM THE LAWS OF THE
COMMONWEALTH OF MASSACHUSETTS
GOVERNING THE
RETURN OF CERTIFICATES OF DEATH
A physician or registered hospital medical officer shall forthwith, after the
death of a person whom he has attended during his last illness, at the request
of an undertaker or other authorized person or of any member of the family of
Y 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
j, 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
jj, 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
Iy 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
y with any provision of this section, such physician or officer, shall forfeit ten dollars,
p 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
Pg relief expedition and the Philippine insurrection, which shall, for said purposes, be
deemed to have taken place between February fourteenth, eighteen hundred and
P,j ninety-eight and July fourth, nineteen hundred and two, and the Mexican border
service of nineteen hundred and sixteen and nineteen hundred and seventeen.
3 G. L. Chap. 46. ^c. 10.
No undertaker or other person shall bury or otherv- ise dispose of a human body
P 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
5^* 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
Pj 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
P( 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
5^ 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
Ig law. or in lieu thereof a certificate as hereinafter provided. If there is no attending
p physician, or if. for sufficient reasons, his certificate cannot be obtained early
e- enough for the purpose, or is insufficient, a physician who is a member of the board
Q of health, or employed by it or by the selectmen for the purpose, shall upon
a application make the certificate required of the attending physician. If death is
c caused by violence, the medical examiner shall make such certificate. If such a
p permit for the removal of a human body, not previously interred, from one town
t, to another within the commonwealth cannot be obtained early enough for the
P purpose, the certificate of death made as above provided and in the possession of
X the undertaker desiring to make such removal shall constitute a permit for such
p removal; provided, that such body shall be returned to the town from which it was
r removed within thirty-six hours after such removal, unless a permit in the usual
f form for the removal of such body has been sooner obtained hereunder. If the
death certificate contains a recital, as required by section ten of chapter forty-six.
that the deceased served in the army, navy or marine corps of the United States
in any war in which it has been engaged, such recital shall appear upon the permit.
The board of health, or its agent, upon receipt of such statement and certificate,
shall forthwith countersign it and transmit it to the clerk of the town for registra-
tion. The person to whom the permit is so given and the physician certifying
the cause of death shall thereafter furnish for registration any other necessary
information which can be obtained as to the deceased, or as to the manner or
cause of the death, which the clerk or registrar may require. — Chap. 1 14, Sec. 45,
G. L/, (Tercentenary Edition).
Medical examiners shall make examination upon the view of the dead bodies
of persons as are supposed to have died by violence, or by the action of
chemical, thermal or electrical agents or following abortion, or from diseases
resulting from injury or infection relating to occupation, or suddenly when not
disabled by recognizable disease, or when any person is found dead. .. — General
Laws, Chap. 38, Sec. 6., as amended by Chap. 632, Sec. 4. Acts of 1945.
No iindertaker 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 /uilCTal- iV to be held, or from a person appointed to have the care of the
cemeteny or^^buri^l ground in which the interment is made.
. . . Oh^; 144. Sec. 46. G. L., (Tercentenary Edition).
RULES OF PRACTICE
^jf»e4vlfillTp®nt of the pup^ose of these laws calls for the observance of the follow-
ing ^ ^actice: I
(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 — pri\ate family, cook — hotel, etc. For
a person who had no occupation whatever write none.
; SPACE FOR ADDITIONAL INFORMATION
; DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE
RANK. RATING
ORGANIZATION AND OUTFIT
SERVICE NUMBER
R-301A
UCTIONS
'OR
CERTIFICATE
giving
)F DEATH
»t enter
:han one
For each
b) and (c)
tori not mean
i dying, such
ure, asthenia, .
ns the disease,
ations which
h.
i conditions,
ng rise to the
r (a) slating
tying cause
death but not
le disease or
tusing death.
-/A'
Xs
Qlt;? fflammomopalt!|i of
EDWARD J. CRONIN
Secretary OF THE Commonwealth
DIVISION OF VITAL STATISTICS
STANDARD
CERTIFICATE OF DEATH
2 FULL
JHlnthroB
(City or TThe text goes on. The rest is in the file.