The volume, 1955

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THOMAS 6ROOM&CO.

<**CO»^0»ATtO.

STATIONERS ,
((105 State Street; i

BQ3TOy,y

TO OUPLICATt THIS BOOK SCN»

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-301A

IONS

TIFICATE

DEATH

nter
n one
each
ind (c)

not mean
ring, such
, asthenia, .
he disease,
ns which

indilions,
rise to the '
) stating
g cause

conlrib-
th but not
Usease or
rig death.

apter 137.
I. requires
to print or
e or causes
on death

2
Q
u.
O
u
u

Suffolk

(County)

(Cmitmonniralth of fHaaBar^UBPtte

JU EDWARD J. CRONIN

Secretary of the Commonwealth
DIVISION OF VITAL STATISTICS

STANDARD

CERTIFICATE OF DEATH

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

No.

2 FULL NAME

ft inthrop Comm Hospital _... st

Elizabeth DeLauretis -Bee Eortini

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

85 Bowtfoin St. Winthrop

Registered No.

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

PHYSICIAN — IMPORTANT

(Was deceased a

U. S. War Veteran.

if so specify WAR)

(a) Residence. No.

(Usual place of abode)

7 -

St.

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

(If nonresident, give city or town and State)

MEDICAL CERTIFICATE OF DEATH

PERSONAL AND STATISTICAL PARTICULARS

3 DATE OF
DEATH ...

Jan 1 1955

(Month) (Day)

(Year)

4 I HEREBY CERTIFY. That I attended deceased fro

Jan 1 1955 _ to Jan 1 J56.

I last saw h er ..alive on Jan 1 i<£5

have occurred on the date stated above, at 8.05 p

8 SEX 9 COLOR OR RACE

female White

10a If married, widowed, or divorced
HUSBAND of..

10 SINGLE (write the word)
MARRIED

^mvoRCE^a rri ed

death is said tc

DISEASE OR CONDITION
DIRECTLY LEADII
TO DEATH (a)

hemorrhage

IN£erehrul

cedInt °b) To Hypertension

CAUSES

Due To

(c)

Chronic Nephritis

OTHER

SIGNIFICANT

CONDITIONS

INTERVAL BE
TWEEN ONSET
AND DEATH

8hrs

>5yrs

Major findings:

Of operations T7T.

Date of operation .77!?..... Was autopsy performed?

What test confirmed diagnosis?.. Clinical

S Was disease or injuj
If so. specify
(Signed)

i any way related t occupation of deceased?

lio

jhr

M. D

(Address! » l / X, WjTsT

Holy T3ross Mpiripp'

Place of Burial or Cremation (City or Town)

date of burial Jan 4 1955

.19

7 NAME OF

funeral DiRECTOF^rnest £ ^aggienc

ADDRESS 147 ftinth rop St ft Inthrop

Received and filed.”.... .3

(or) WIFE of

(Give maiden name

John DeLauretis

me of wife in full)

(Husband's name in full)

11 IF STILLBORN, enter that fact here.

AGE Years §

Months

Days

If under 24 hours

Hours Minutes

13 Usual

Occupation:

Housewife

(Kind of work done during most of working life)

14 Industry
or Business:

^t Home

15 Social Security No.

16 BIRTHPLACE (City) .
(State or country)

Boston

Maas

17 NAME OF
FATHER

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

Joseph Port ini

Italy

19 MAIDEN NAME

oFMOTHERMary Cuneo

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

Boston

Mas 8

informant John DeLauretis

(Address) ft Bnwdoln St Winthrop Mass

1955

(Registrar)

I HEREBY CERTIFY that a satisfactory standard certificate of death was
fijeff witlyroe BEFORE /(hg buriaK? transit permit was issued:

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 uniled S dates _

in any war in which it has been engaged, such recital shall appear upcfl ttnCp&liK u »
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
tion. The person to whom the permit is so given and the physici

the cause of death shall thereafter furnish for registration any g;

information which can be obtained as to the deceased, or as to'thV'p»«jTr>*ricS,‘v ■ *
cause of the death, which the clerk or registrar may require. — Chip. J’liTseli<45 "i \

G. L., (Tercentenary Edition). //*?> JfiPWjW \ .

icr;.. \Z\

Medical examiners shall make examination upon the viewjbF the SEadflxxfies V
of persons as are supposed to have died by violence, or by jili? actibn Of
chemical, thermal or electrical agents or following abortion, oi\fnrAi diseases , - ,
resulting from injury or infection relating to occupation, or sudd^ifltf/when not
disabled by recognizable disease, or when any person is found dead. J

Laws, Chap. 38, Sec. 6., as amended by Chap. 632, Sec. 4, Acts gfrMyJy /'

No undertaker or other persons shall bury a human body or theisji’e^hefeofl''
which have been brought into the commonwealth until he has receivhd^/pgmtJt
so to do from the board of health or its agent appointed to issue such penfltt sj. '^Tr
if there is no such board, from the fterk of the town where the body is to be buried
or the funeral is to be held, or from a person appointed to have tfiexare of ^Ue
cemetery or burial ground in which^ the intermenj is made. TmTT«“ ,

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

EXTRACTS

FROM THE LAWS OF THE

COMMONWEALTH OF MASSACHUSETTS

GOVERNING THE

RETURN OF CERTIFICATES OF DEATH

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

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

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

RULES OF PRACTICE

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

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

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

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

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

Statement of Occupation. — Precise statement of occupation is very import-
ant, so that the relative healthfulness of various pursuits can be known. Make
some entry in this section for every person aged 10 years or over. If the occupa-
tion had been given up or changed, or if the deceased had retired from business,
report the kind of work done during most of working life even if retired. Children
not gainfully employed may be returned as at school or at home. For a woman
whose only occupation was that of home housework, write housework. For a
person engaged in domestic service for wages, however, designate the occupation
by the appropriate terms, as housekeeper — private family, cook — hotel, etc. For
a person who had no occupation whatever write none.

SPACE FOR ADDITIONAL INFORMATION

DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE

RANK, RATING

ORGANIZATION AND OUTFIT

SERVICE NUMBER

RM R-301

STRUCTIONS

FOR

M. CERTIFICATE

n giving

E OF DEATH

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

is does not mean
le of dying, such
failure, asthenia, .
neans the disease,
plications which
\eath.

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

iditions contrib - -
the death but nob
o the disease or
n causing death.

FFourf

g (County)

o 1 WLUdOf.

U (City or Town)

3 no.

Sty? (ttmmnamnpaltlj of fHaBaarljUBPttB

EDWARD J. CRONIN

Secretary of the Commonwealth

DIVISION OF VITAL STATISTICS

STANDARD

CERTIFICATE OF DEATH

(City or town making return)

Registered No. .

:M. Sr! ^ g j^. death occuired in a hospital or institution.

give its NAME instead of street and number)

2 FULL NAME V-Y V\ ^ f (Was deceased a

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

^ _ l >f so specify WAR)

(a) Residence. No. \.A.J...T. A..3...F. St

(Usual place of abcwe) - (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

DATE OF
DEATH ...

LVSSV.M.
(Month) '

(Day)

\ <\ u sr

(Year)

41 HEREBY CERTIFY, That I attended deceased from

JM..1 19 ssr.... to 19

I last saw h./. /lrJ ..alive on 1"7.., 19.5^7 death is said to

O _ n

have occurred on the date stated above, at.. Z> ^..CT.rn.

ATde.C

DISEASE OR CONDITION

DIRECTLY LEADING ^ _

TO DEATH (a) /A7 /J~C. y C. /

^SInt 3>/s

CAUSES

Due To

(c)

OTHER

SIGNIFICANT

CONDITIONS

INTERIM. BE-
TWEER ONSET
AND DEATH

PERSONAL AND STATISTICAL PARTICULARS

8 SEX

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

MnRRIbD

V>=>V\A«_^

WIDOWED
or DIVORCED

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.

AGE

Years

Months

Days

Major findings:

Of operations

Date of operation Was autopsy performed?

What test confirmed diagnosis?.. J.. .1.1.1. ,Y..

yss

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

( Address^W:'/^ <T- y ifr'ffpg.maU ' f V 19 £f„

Place of Burial or Cremation (City or Town)

DATE OF BURIAL..TrZ/F./K.....^r.

Received and filed.

A TRUE COPY ATTEST:

(Registrar)

If under 24 hours

Hours Minutes

13 Usual

Occupation:.

(Kind of work done during most of working life)

14 Industry
or Business:

15 Social Security No.

16 BIRTHPLACE (City).. \io..ysn\Wo C? , XYiO.'VS
(State or country) ’

17 NAME OF ^

FATHER

18 BIRTHPLACE OF

FATHER (City) ' a sA © \c\. ,

(State or country)

XVi (XQ.S

19 MAIDEN NAME
OF MOTHER \J

\ c>_

20 BIRTHPLACE OF

MOTHER (City)

(State or country) 'A

■ \£)j

, \CVCL -S ■£>

Informant

(Address) C 0 T f 4 /( & r ft Th! ill, />

I HEREBY CE/RTIFY that a satisfactory standard certificate of death was
filed With .me BEFORE fche buriyl or T/ynsit permit was issued:

;h or other) ,

////.*.

(Date of Issue of'Perrnit)

EXTRACTS

FROM THE LAWS OF THE

COMMONWEALTH OF MASSACHUSETTS

GOVERNING THE

RETURN OF CERTIFICATES OF DEATH

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

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

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

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

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

No undertaker or other persons shall bury a human body or the ashes thereof
which have been brought into the commonwealth until he has received a permit
so to do from t!& Cotfrcfcof health- or its agent appointed to issue such permits, or
if there is no suen tToTrdr from Hdie'' 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^gt^TjdTft^svhich the interment is made.

. . . Chap. !L4CSec\ O.rC-, (Tercentenary Edition).

■ V •» »

» ‘•RTJLES OF PRACTICE

The fulfillment of .tile purj30&6 q£ these laws calls for the observance of the follow-
ing rules of praciice;’ : ^

(1) Attending physitiai^wil) certify to such deaths only as those of persons

to whom they given beetside care during a last illness from disease unrelated
to any form *»"

(2) Board /leafjH physicians will certify to such deaths only as those of
persons who. tnpi^^^sa^Ieq by recognized disease unrelated to any form of
injury, have died svTOob^jechnt 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 (i^adyding^resulting septicemia), and by the action of chemical
(drugs or pwofis} thermal, or electrical agents, and deaths following abortion, but
also deathstfo^trdisease resulting from injury or infection related to occupation,
the sudden deaths of persons not disabled by recognized disease, and those of
persons found dead.

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

SPACE FOR ADDITIONAL INFORMATION

DATE OF ENTERING MILITARY SERVICE

DATE OF DISCHARGE

RANK, RATING >.

ORGANIZATION AND OUTFIT

SERVICE NUMBER

M R-301A

■RUCTIONS

FOR

L CERTIFICATE

giving
OF DEATH

lot enter
than one
s for each
(b) and (c)

does not mean
of dying, such
i ilure. asthenia, .
tons the disease,
ications which
ath.

iid conditions, .
ving rise to the
se (a) stating
orlying cause

Uions conlrib- ■
te death but not
the disease or
causing death.

M (County)

(City or Town)

No u

Cflommmtmraltl) of ffflaBBartjuBrtta

EDWARD J. CRONIN

Secretary of the Commonwealth

DIVISION OF VITAL STATISTICS

STANDARD

CERTIFICATE OF DEATH

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

Registered No. .

t £tjL C.S. C /?} Cm S { ^ death ^occurred in a hospital or institution.

give its NAME instead of street and number)

'^7 ' „ ( PHYSICIAN — IMPORTANT

2 FULL NAME ^ K 5 CL (^. U A >*<? >T ^ I (Was deceased a

(If deceased is a married, widowed or divorced woman, give also maiden name.) \ tt o tit — tr_*

(a) Residence. No. / 76. S£..

(Usual place of abode)

St.

»U. S. War Veteran,
if so specify WAR)

(It nonresident, give city or town and State)

Length of stay: In place of death

.eSL

years months days. In place of residence years months days.

MEDICAL CERTIFICATE OF DEATH

3 DATE OF
DEATH ...

Month)

(Day)

(Year)

That I attended deceased from

. i9 ss-

41 HEREBY CERTIFY,

■3?Le..0 19j7.fi... to J/4 A ..)

I last saw hC.TV^.alive on O V 19 S.S, death is said to

have occurred on the date stated above, at S. m.

DISEASE OR CONDITION

DIRECTLY LEADING/i , I ^

TO DEATH (a) TgSKi O ^ m

hiL^gg «,T SI Jfe/q -.C , t: IkAN

ANTE Due To

CEDENT (b)

CAUSES

Due To

(c)

OTHER

SIGNIFICANT

CONDITIONS

INTERVAL BE
TWEEN ONSET
AND DEATH

Major findings:

Of operations

Date of operation Was autopsy performed? .

What test confirmed diagnosis?

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

m. Dj

6 Jtf./cAct.*. U

Place of Burial or Cremation
DATE OF BURIAL .... xj O. >1

J0 O S/^0 Art,...
(City or Town)

7 NAME OF . i . Si V . „ . )

FUNERAL DIRECTOR.. VC..J.... LL.r.

"?4^ t 7>*LC^

ADDRESS

Received and filed

.19 .

(Registrar)

PERSONAL AND STATISTICAL PARTICULARS

8 SEX

9 COLOR OR RACE

7uA //T -c

10 SINGLE
MARRIED
WIDOWED
or DIVORCED

(write the word)

fUJ

10a If married, widowed, or divorced
HUSBAND of

(or) WIFE of .

Vj£a.

(Give maiden name of wife in full)

4 ? y~6 *..< ..

(Husband’s name in full)

11 IF STILLBORN, enter that fact here.

AGE

Years Months

Days

If under 24 hours
Hours Minutes

13 Usual

Occupation:

4 U S C te / /~ .Z

(Kind of work done during most of working life)

14 Industry
or Business:

15 Social Security No. *l d/h <.

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

17 NAME OF
FATHER

c^4>v-

J=Sh*

Jl. jr"

vTcrvjie Nldcw

>et 7t C o

18 BIRTHPLACE OF

FATHER (City)

(State or country)

19 MAIDEN NAME
OF MOTHER1

20 BIRTHPLACE OF

MOTHER (City) ^

(State or country)

0 5 C

c si.

Informant ///e..Z..A

(Address) ^ j 'yfcs ,r J 4 /F t 3h £>

b X.

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

( (Signature of Agent of Board of Health or pther)'

—

(Official Designation) (Date of Issue/of 'Permit)

EXTRACTS

FROM THE LAWS OF THE

COMMONWEALTH OF MASSACHUSETTS

GOVERNING THE

RETURN OF CERTIFICATES OF DEATH

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

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

No undertaker or other person shall bury or otherwise dispose of a human body
in a town, or remove therefrom a human body which has not been buried, until he
has received a permit from the board of health, or its agent appointed to issue
such permits, or if there is no such board, from the clerk of the town where the
person died; and no undertaker or other person shall exhume a human body and
remove it from a town, from one cemetery to another, or from one grave or tomb
other than the receiving tomb to another in<he 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. 1 14, Sec. 45,
G. L.. (Tercenfenary Edition).

Medical examiners shall make examination upon the view of the dead bodies
C 2>frp§sbrt£ Us* 'are supposed to have died by violence, or by the action of
* Themical. thermal or electrical agents or following abortion, or from diseases
resuUjLxig^^om injury or infection relating to occupation, or suddenly when not
dtSafcfed'by ^cognizable disease, or when any person is found dead. — General
£aw4, Onap. 38, Sec. 6.. as amended by Chap. 632, Sec. 4, Acts of 1945.

./ ' No Undertaker or other persons shall bury a human body or the ashes thereof
_whi^h'haK’<e/peqn brpught into the commonwealth until he has received a permit
, “so.^o do from.th'e board of health or its agent appointed to issue such permits, or
• if\bere ij^o such board, from the clerk of the town where the body is to be buried
r. eff tte -funeral ts £0 be held, or from a person appointed to have the care of the
opmetery or burial ground in which the interment is made.

. Chap. 4 H. 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 giv^n bedside care during a last illness from disease unrelated
txvajiy form of injury.

.1 ( 1 ) Board of Health physicians will certify to such deaths only as those of
'perSbfis who, though disabled by recognized disease unrelated to any form of
injury, have died without recent medical attendance or whose physician is absent
from home when the certificate of death is needed.

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

Statement of Occupation. — Precise statement of occupation is very import-
ant, so that the relative healthfulness of various pursuits can be known. Make
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

RM R-301A

NSTRUCTIONS

FOR

CAL CERTIFICATE

In giving
SE OF DEATH

o not enter
ore than one
use for each

a), (b) and (c)

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

\ or bid conditions.

, giving rise to the
cause (a) stating
underlying cause

onditions contrib- •
o the death but not
to the disease or
on causing death.

Suffolk

(County)

(Eljr (Eummonmealtlj of fHaBoarljuapna

EDWARD J. CRONIN
Secretary of the Commonwealth

DIVISION OF VITAL STATISTICS

Vinthrop

(City or Town)

No. Mount ' s -Re-&t Home

STANDARD

CERTIFICATE OF DEATH

Registered No.

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

2 FULL NAME

(a) Residence. No.

(Usual place of abode)

Length of stay: In place of death

Margaret Greaves Patton

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

90 Sagamore Ave.

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

PHYSICIAN — IMPORTANT

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

months

days. In place of residence

St.

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

MEDICAL CERTIFICATE OF DEATH

3 DATE OF
DEATH

J/hN

(Month)

(Day)

rt Sf~

(Year)

PERSONAL AND STATISTICAL PARTICULARS

8 SEX I 9 COLOR OR RACE

Female Thlte

41 HEREBY CERTIFY. That I attended deceased from

stA-aj ... i9 ^ ja/v $ v,sf

I last saw h £72. alive on cr/w r ... lQ^'^'death is said to|

10 SINGLE (write the word)
MARRIED

WIDOWED-. , ,

or DivoRotlbaowea

have occurred on the date stated above, at

DISEASE OR CONDITION
DIRECTLY LEAD
TO DEATH (a)

/fo4~r f *

ANTE Due T,
CEDENT (b)
CAUSES

SCCCAJTTC.

J>/ $ GArf£7

Due To
(c)

other 11 „ .r pr

SIGNIFICANT /V 0 1* L~
CONDITIONS

INTERVAL BE
TWEEN ONSET
AND DEATH

lift.

Cl#

Major findings:

Of operations

Date of operation.^ ^ ^

Was autopsy performed? ft 6

What test confirmed diagnosis?.

5 Was disease or injury in any way related to occupation of deceased ? ft/ 0
If so, specify V.

’/Vlnthrop

Place of Burial or Cremation

DATE OF BURIAL

Janu?

'.VlnthroD

(City or T<5wn)

Received and filed

(Registrar)

10a If married, widowed, or divorced
HUSBAND of

(Give maiden name of wife in full)

John Patton

(Husband’s name in full)

(or) WIFE of

11 IF STILLBORN, enter that fact here.

age79

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) liOg la nd

17 NAME OF _ , . ,

father Frederick Greaves

18 BIRTHPLACE OF

FATHER (City)

(State or country) England

19 MAIDEN NAME

of mother Marla Curley

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

England

informant Qbarle s Greaves

(Address) 89 Concord St.. Lowell Mass

I HEREBY CERTIFY that a satisfactory standard certificate of death was
filed 'with me BEFORE the burial oFotransit/fier mi t was issued:

^g^nt of Board of or o)4ier) ✓

/ . /

ficiai Designation) j (Date of Issue pi Fernet)

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.

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
disaUed by recognizable disease, or when any person is found dead. — General
>-*' £ 06’! 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, 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 imino-. ^
diate cause of death as nearly as he can state the same. For neglect to comply^
with any provision of this section, such physician or officer, shall forfeit ten dollars. '
For the purposes of this section and of sections forty-five, forty-six and forty-seven
of said chapter one hundred and fourteen, the word “war" shall include the China
relief expedition and the Philippine insurrection, which shall, for said purposes, be
deemed to have taken place between February fourteenth, eighteen hundred and
ninety-eight and July fourth, nineteen hundred and two, and the Mexican border
service of nineteen hundred and sixteen and nineteen hundred and seventeen.
G. L. Chap. 46, Sec. 10.

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

Noundertaker or other persons shall bury a human body or the ashes thereof
w UacjTTmvorC^^Tv Jjrough t into the commonwealth until he has received a permit
do »mmit»'c*board of health or its agent appointed to issue such permits, or

1 c ‘he c]erk 0f the town where the body is to be buried

from a person appointed to have the care of the
the interment is made.

(Tercentenary Edition).

RULES OF PRACTICE

. •• Jifaef u 1 fi 1 1 m.Q»h t»$f the purpose of these laws calls for the observance of the follow-
tp g fykfi f>$ ’J^Yac ter :

ten'di nq physicians will certify to such deaths only as those of persons
<td wtaMfcj vp given bedside care during a last illness from disease unrelated
to anyd-or-nrpf injury.

(21 Board of Health physicians will certify to such deaths only as those of
persons '^vlrbT though disabled by recognized disease unrelated to any form of
injury, have died without recent medical attendance or whose physician is absent
f ttcjriii JyjqiC when the certificate of death is needed.

lj(j) < Medical Exanhiners will investigate and certify to all deaths supposably
due fo injury. ThWe 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

IM R-301

AUCTIONS

FOR

L CERTIFICATE

i (Wins
, OF DEATH

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

s does not mean
i of dying, such
ailure, asthenia, .
eons the disease,
licalions which
‘ath.

bid conditions,
iving rise to the '
tse (a) slating
erlying cause

titions conlrib- -
he death but not
i the disease or
causing death.

s Suffolk

q (County)

Winthrop

(City or Town)

Oil;? (Enmntomnraltf) of fflaaBarljUBfttB

EDWARD J. CRONIN
Secretary of the Commonwealth

DIVISION OF VITAL STATISTICS

STANDARD

CERTIFICATE OF DEATH

(City or town making return)

Registered No _

No. .

Winthrop Comm Hospital St. ^ ^ de?th m a h?spltal or ‘nStltutlon’

\ give its NAME instead of street and number)

FULL NAME..

(If deceased is a married, widowe

. /a a.

ed or divotgey woman, give also maiden name.)

wm. No. . 488 Jinthrop St.

(Usual place of abode)

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

. St.

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

MEDICAL CERTIFICATE OF DEATH

3 DATE OF
DEATH ...

(Month)

(Day)

/ 4 f •

(Year)

41 HEREBY CERTIFY,

.5 19..^i

2 ?

.t I attended deceased from

i*....j3.

I test saw h...... alive on 7. 19 death is said to]

have occurred on the date stated above, at m.

disease OR condition pr emat ur i t V

PP^CTLY LEADING , rJj *

TO DEATH (a) //f..V:

S A- '

Vvn. O i

ANTE Due To C C V <i Q W) *. VcJ Va Pr k

CEDENT (b)

CAUSES

Due To
(c)

OTHER

SIGNIFICANT

CONDITIONS

INTERVAL BE-
TWEEN ONSET
AND DEATH I

PERSONAL AND STATISTICAL PARTICULARS

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, sp<

(Signed) M._ Q.

" “■ "dl,-~K-!t5 ~ts*Zt» , _ ,

(Address) . ../^^^amn^./^...i/i^^'.pate..../..Z^. 19.V.1

6 Winthrop

Place of Burial or Cremation

DATE OF BURIAL J.m 10 1955

19..

7 name of Ernest P Ga^ffiano

FU N ERAL DIRECTOR aOD .+. aL1 Y

winthrop St Winthrop

ADDRESS

Received and filed..

.19.

A TRUE COPY ATTEST:

(Registrar)

8 SEX,

Male

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

MARRIED

White

WIDOWED
or DIVORC

10a If married, widowed, or divorced

HUSBAND of

(Give maiden name of wife in full)

EDSingle.

(or) WIFE of..

~Y~

(Husband’s name in full)

AGE.

13 Usual

Occupation:

..Years Months Days

If under 24 hours
Hours Minutes

(Kind of work done during most of working life)

14 Industry
or Business:

15 Social Security No.

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

Stvl^ 2:

17 NAME OF , T

father Buster Inza

18 BIRTHPLACE OF
FATHER (City)

Lakeville

(State or country)

19 MAIDEN NAME p fvLS Q. iCr

OF MOTHER Mopw STY 1 nfl

20 BIRTHPLACE OF
MOTHER (City)

East Boston

(State or country)

Mass

(Address) UlS? rwJnlfirop St Winthro

I HEREBY CERTIFY that a satisfactory standard certificate of death was
filg4 with mg ^JJEFORE the bm^l or tntnsit agrmit was issued:

Ature of of Board of Health brother), /

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
contra .ted, 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. an.d
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 neglec 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.

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 pf 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 .tte 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 prexnously interred, from one town
to another within the commonwealth cannot be obtained early enough for the
purpose, the certificate of death made as above provided and in the possession of
the undertaker desiring to make such removal shall constitute a permit for such
removal’ provided, that such body shall be returned to the town from which it was
removed within thirty-six hours after such removal, unless a permit in the usual
form for the removal of such body has been sooner obtained hereunder. If the

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

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

No undertaker or other persons shall bury a human body or the ashes thereof
whic hdTive brought into the commonwealth until he has received a permit
so ttifdo ijrcfrj the board of health or its agent appointed to issue such permits, or
if thci^i©nTO.s^ch board, from the clerk of the town where the body is to be buried
or.ttfie fune/aljs.to be held, or from a person appointed to have the care of the

x d in which the interment is made.

G. L.. (Tercentenary Edition).

c^gieterY,Qri'hufiaVground i
. . >‘*'Chap.'‘VJ4,/Sec. 46, <

-A

c*;\ RULES OF PRACTICE

i /*

. the purpose of these laws calls for the observance of the follow-

' i f^r/ 1 e ^

erring physicians will certify to such deaths only as those of persons
to whorO'tTfSy *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
ruajury^ have died without recent medical attendance or whose physician is absent
^ f^oirhorfi^ w'hen the- certificate of death is needed.

‘{Sy Medical Examiners will investigate and certify to all deaths supposably
due to injury. These include not only deaths caused directly or indirectly by
traumatism (including resulting septicemia), and by the action of chemical
(drugs or poisons) thermal, or electrical agents, and deaths following abortion, but
also deaths from disease resulting from injury or infection related to occupation,
the sudden deaths of persons not disabled by recognized disease, and those of
persons found dead.

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

SPACE FOR ADDITIONAL INFORMATION

DATE OF ENTERING MILITARY SERVICE

DATE OF DISCHARGE

RANK, RATING i

ORGANIZATION AND OUTFIT

SERVICE NUMBER [

IM R-301

ructions

FOR

L CERTIFICATE

giving

OF DEATH

not enter
i than one
d for each

(b) and (c)

: does not mean
of dying, such
lilure, asthenia, .
tans the disease,

' icalions which
ath.

Hd conditions,
ring rise to the '
i se (a) stating
trlying cause

liiions contrib- -
ie death but nob
the disease or
causing death.

unty)

(County)

0 p...

U (City or T6wn)

OHjp (Cmnmmtnrralttf of fHaaaarljuaftta

EDWARD J. CRONIN

Secretary of the Commonwealth

DIVISION OF VITAL STATISTICS

STANDARD

CERTIFICATE OF DEATH

/ / _ /V . , s /[ . , (tit aeatn occurrea in a Hospital or institution.

No. . ..^67 . 3CT Yr/./S,. te.y ..~r ? *??.. ,<r/ 7^ . . . PP.. . St . \ give its NAME instead of street and number)

2 FULL NAME & / <SU ~ W/P XV +XQ

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

(City or town making return)

Registered No Gl

(If death occurred in a hospital or institution.

(Was deceased a
0. S. War Vetera
if so specify WAR)

(a) Residence. No. /...Bt. J.. f$..z£r.)C...L6?..!:jL St.

(Usual place of abode) (If nonresident, give city oi

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

U. S. War Veteran, q

MEDICAL CERTIFICATE OF DEATH

3 DATE OF

DEATH J5. fX. (X /9 /i.y zYV

(Month)

(Day Y

. '9s£>Afi~

(Year)

41 HEREBY CERTIFY, That I attended deceased from

..-Jatsry.*...././.. to Jp3t/rY.. // 191^0

I Last saw h./.it£?..... alive on 19LJC5Tdeath is said to

have occurred on the date stated above, at... L:,*>v. p

DISEASE OR CONDITION
DIRECTLY LEADING

LUKiSLiLY LKAD1NU m

TO DEATH (a)

ANTE Due To

CEDENT (b)

CAUSES

Due To
(c)

OTHER

SIGNIFICANT

CONDITIONS

INTEim BE
TWEE! ONSET
AMD OEATB

Major findings:
Of operations..

/VL

Date of operation Was autopsy performed?

What test confirmed diagnosis?

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

(sJiX^Q , Qia ~i^ Ju d

(Address). I U r J) ^ *1

.^o/y S S

Place ol > . .ui or ion

/«Z

toity or iown)

DATE OF BURIAL /..X. / .W 19 Jt.S'

/..bSZ ~

7 NAME OF
FUNERAL

ADDRESS

Received and filed.

DIRECTOR...

tz ftw

r.kkcC...

.19 .

A TRUE COPY ATTEST:

(Registrar)

PERSONAL AND STATISTICAL PARTICULARS

8 SEX

9 COLOR OR RACE

(write the word)

10 SINGLE
MARRIED
WIDOWED

or DIVORCED Serve e. ^

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.

If under 24 hours

AGE

Years

Months

Days

y. Hours M inutes

13 Usual

Occupation:..

M. 1

(Kind of work done during most of working life)

14 Industry
or Business:

IS Social Security No.

16 BIRTHPLACE (City).. f/J./.r/.. TX P. */?. /?J /95*S -

(State or country) ' y

17 NAME OF
FATHER

18 BIRTHPLACE OF ^

FATHER (City) P./9S.X P? S r 0 ...

(State or country) r

19 MAIDEN NAME

OF MOTHER ^ « C C , af.-v )

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

Informant P*.*,
(Address; / ' / Mr_? ^ f;

{V V t,\' \ . F- f-). ' *a>U£-l' O

’"3y. spi.

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

(Official Designation).

of Board of Health or other)

(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 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

death certificate contains a recital, as required by section ten of chanter 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).

^ - Ttffci £a^ ^tatfiiners 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
.aRSflES^SMn^notice that there is within his county the body of such a person, he
^ J <haH\fct^itHW'gp to the place where the budy lies and take charge of the same;

... HP __ ’ Laws, Chap. 38, Sec. 6.

contracted, the duration of his last illness, when last seen alive by the physician . jf* 1 '\ £ ,• l

or officer and the date of his death. . .Gen. Laws. Chap. 46, Sec. 9. ' ! Naiutytoftarorxnr other persons shall bury a human body or the ashes thereof

“■ w'.Mch ha^e^been.bjought into the commonwealth until he has received a permit
A physician or officer furnishing a certificate of death as required b£ the * . so tqd^rqrtjl^' board of health or its agent appointed to issue such permits, or
preceding section or by section forty-five of chapter one hundred and Tour- - .' nf thqre’v^nd Such board, from the clerk of the town where the l>ody is to be buried
teen, shall, if the deceased, to the best of his knowledge and belief, served in the./ -£or tliet£neral“i£.'to be held, or from a person appointed to have the care of the
army, navy or marine corps of the United States in any war in which it has been , /cenletery or |>tinal ground in which the interment is made,
engaged, insert in the certificate a recital to that effect, specifying the war. and . . Ch^pC lf14. Sec. 46. G. L., (Tercentenary Edition),

shall also certify in such certificate both the primary and the secondary or imme- r

diate cause of death as nearly as he can state the same. For neglect to comply - x ** -

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. *•’

RULES OF PRACTICE

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 w-ithin the commonwealth cannot be obtained early enough for the
purpose, the certificate of death made as above provided and in the possession of
the undertaker desiring to make such removal shall constitute a permit for such
removal; provided, that such body shall be returned to the town from which it was
removed within thirty-six hours after such removal, unless a permit in the usual
form for the removal of such body has been sooner obtained hereunder. If the

^Fhe-ftrifrllment of the purpose of these laws calls for the observance of the follow-
ing rules of practice:

I r f ftP Attending physicians will certify to such deaths only as those of persons
' ‘ td whom they have fciven bedside care during a last illness from disease unrelated
td any-form of injitfy.

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

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

see explanatory instructions

SPACE FOR ADDITIONAL INFORMATION

DATE OF ENTERING MILITARY SERVICE

DATE OF DISCHARGE

RANK, RATING

ORGANIZATION AND OUTFIT

SERVICE NUMBER

M R-301

IUCTIONS

FOR

CERTIFICATE

giving
OF DEATH

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

does not mean
if dying, such
ilure, asthenia,
ns the disease,
rations which
th.

bid conditions, y
ing rise to the
e (a) stating
rlying cause

'itions contrib- >
• death but not
the disease or
ausing death.

Suffolk

(County)

Winthrop

(City or Town)

89 Circuit Road

QJIjp (Crnmnoninpaltlj of ffiaHBarliUHPttfl

EDWARD J. CRONIN

Secretary of the Commonwealth

DIVISION OF VITAL STATISTICS

STANDARD

CERTIFICATE OF DEATH

w:nthrop

(City or town making return)
Registered No „

((If death occurred in a hospital or institution.
No ™2....™..*3..™^.r^..y.. St. \ give its NAME instead of street and number)

2 FULL A^.S.Q....8.i.C^ard....D.ani6......C.h,aS.^ (Was deceased a

(If deceased is a married, widowed or divorced woman, give also maiden name^* ™ ’l U. S. War Veteran, WW 1

On ns . A , l if so specify WAR)

No. .89 circuit Road Sl

(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 ..Tr.-tr. years months days.

MEDICAL CERTIFICATE OF DEATH

3 date of J anuarv i?, i c re

DEATH ±<r.

(Month) (Day) (Year)

♦ I HEREBY CERTIFY, That I attended deceased from

August 7 „34 toJ.ann.ary. 1.3 W....55

I last saw' h ^ ... alive on J.®P.U. &Py I.,' 19.38, death is said to

have occurred on the date stated above, at - .•...Q..Q. A

DISEASE OR CONDITION

toRdeath L(^.eNminai Brpnc.hppngiJ n

ANTE Due To , , , .

cedent (b) ....^.e-t-astati-G Carei-nama

Generalized

To 3r one ho genic

Car 6 i noma- Left

OTHER

SIGNIFICANT

CONDITIONS

UTERTAL BE-
TWEEI ONSET
ABO OEATI

3 day

o mos

PERSONAL AND STATISTICAL PARTICULARS

8 SEX

Male

9 COLOR OR RACE

White

10 SINGLE (write the word)
MARRIED
WIDOWED

or pivoRCEfoarried

10a If married,
HUSBAND of . .

(or) WIFE of

widpwed, oiLdivorcedr*

...hazel Me lean Chase .

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

II IF STILLBORN, enter that fact here.

12 6 7

AGE I...

6 1

Years Months Days

If under 24 hours

Hours Minutes

13 Occupation : Traffic Manager

(Kind of work done during most of working life)

14 Industry Wool CO»

or Business: v

,[removed]

..Wo..

Major findings:

Of operations

Date of operation Was autopsy performed? Ix.Q.

What test confirmed diagnosis? and BPGnch.Q.S.P©

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

(Signed)

(Add ress) / Y /

Oakland

Place of Burial or Cremation
DATE OF BURIAL

7 NAME OF
FUNERAL DIRECTC

Medway

., M. D

,.19.;5<5l

ADDRESS
Received and filed

(City or Town)

Ja.nu.ary 1? ,,55

.19..

A TRUE COPY ATTEST

(Registrar)

15 Social Security Nor.

16 BIRTHPLACE (City) _ _ ® £'a4l

New York

(State or country)

17 NAME OF ,r ,

father Walter Chase

18 BIRTHPLACE OF TT . _

father (city) Juab 1© to obtain

(State or country) Maine

19 MAIDEN NAME

of mother Alice E McElroy

20 BIRTHPLACE OF

MOTHER (City)

(State or country) Massachusetts

Inf0rmant^.OQe.i,..^.9.4!a.^.P. Q.haSe

(Address) 89 ClPCUlt R . Wlnt.}-|

XXLP-

CERTIFY that a satisfactory standard certificate of death was
IEFORE the burial of transit petmit was issued:

EXTRACTS

FROM THE LAWS OF THE

COMMONWEALTH OF MASSACHUSETTS

GOVERNING THE

RETURN OF CERTIFICATES OF DEATH

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

A physician or officer furnishing a certificate of death as required by the
preceding section or by section forty-five of chapter one hundred and four-
teen, shall, if the deceased, to the best of his knowledge and belief, served in the
army, navy or marine corps of the United States in any war in which it has been
engaged, insert in the certificate a recital to that effect, specifying the war, and
shall also certify in such certificate both the primary and the secondary or imme-
diate cause of death as nearly as he can state the same. For neglect to comply
with any provision of this section, such physician or officer, shall forfeit ten dollars.
For the purposes of this section and of sections forty-five, forty-six and forty-seven
of said chapter one hundred and fourteen, the word “war” shall include the China
relief expedition and the Philippine insurrection, which shall, for said purposes,
be deemed to have taken place between February fourteenth, eighteen hundred
and ninety-eight and July fourth, nineteen hundred and two. and the Mexican
border service of nineteen hundred and sixteen and nineteen hundred and seven-
teen. 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, bis 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 chanter forty-six,
that the deceased served in the army, navy or marine corps of the United States
in any war in which it has been engaged, such recital shall appear upon the
permit. The board of health, or its agent, upon receipt of such statement and
certificate, shall forthwith countersign it and transmit it to the clerk of the town
for registration. The person to whom the permit is so given and the physician
certifying the cause of death shall thereafter furnish for registration any other
necessary information which can be obtained as to the deceased, or as to the
manner or cause of the death, which the clerk or registrar may require. — Chap.
114, Sec. 45, G. L., (Tercentenary Edition).

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

No undertaker or other persons shall bury a human body or the ashes thereof
which have been brought into the commonwealth until he has received a permit
so to do from the board of health or its agent appointed to issue such permits, or
if there is no such board, from the clerk of the town where the body is to be
buried or the funeral is to be held, or from a person appointed to have the care
of the cemetery or burial ground in which the interment is made.

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

RULES OF PRACTICE

The fulfillment of the purpose of these laws ca or &d observance of the
following rules of practice:

(1) Attending physicians will certify to such death£-oxUy~as those of persons
to whom they have given bedside care during a last illness, f pom disease unrelated
to any form of injury.

(3) Medical Examiners will investigate and certify to all deaths supposably
due to injury. These include not only deaths caused directly Or indirectly by
traumatism (including resulting septicemia), and by the action of chemical
(drugs or poisons) thermal, or electrical agents, and deaths following abortion,
but also deaths from disease resulting from injury or infection related to occupa-
tion, the sudden deaths of persons not disabled by yecb^fuize^ 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 appiopriate 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.....^ Hjt/fiir

RANK, RATING

ORGANIZATION AND/OUTFIT

SERVICE NUMBER f

Essex

(County)

Haverhill

No.

(City or Town)

Hale Hospital

(Eomtnonmraltl) of HlaBBarfiuBrttB

EDWARD J. CRONIN

Secretary of the Commonwealth

DIVISION OF VITAL STATISTICS

COPY OF

CERTIFICATE OF DEATH

(City or town making return)

Registered No. .

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

2 FULL NAME ®. { (Was deceased a

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

gotof-Shlrtey £4+ WCfe tfinthr^” WAR>

(a) Residence. No.

(Usual place of abode)

(If nonresident, give city or town and State)

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

MEDICAL CERTIFICATE OF DEATH

PERSONAL AND STATISTICAL PARTICULARS

3 DATE OF
DEATH ...

January

(Month)

(Day)

1953

(Year)

8 SEX

Male

II HE RJEJJ Y CERLI1

Dec.^rg lo54

F Y

Tin

That I attended deceased from

Jan. 13 10

C E R

19."'..: to....”.""'*. 19

I last saw h....T.*“. alive on. Jan.. 13 ,<,55 , death is said tol

O p *

have occurred on the date stated above, at — ' * m.

9 COLOR OR RACE

White

(write the word)

10 SINGLE
MARRIED

rSP^EJflidowed

10a If married, widowed, or divorced

HUSBAND of... Flora B. Nichols

(Give maiden name of wife in full)

DISEASE OR CONDITION
DIRECTLY LEADING UreHlia

TO DEATH (a)

lee:

ANTE Due J
CEDENT (b) .
CAUSES

._ imhosxs-Cerebral
;nrombosls Pulmonary

Due To

(c)

Old Rheumatic
heart disease

OTHER

SIGNIFICANT

CONDITIONS

INTERVAL BE-
TWEEN ONSET

(or) WIFE of..

(Husband's name in full)

AND DEATH

48 hr

Major findings:

Of operations No

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 N -B- • Mi r ier

Haverhill -7T/14

Ila v e rhj.13.

No-

Place of Burial or Cre
DATE OF BURIAL

majion (City or Town)

January 15 1955

7 NAME OF
FUNERAL DIRECTOR..

ADDRESS

Received and filed..

Earle W. Graffam

Haverhill

vjaa =

.19

(Registrar of City or Town where deceased resided)

11 IF STILLBORN, enter that fact here.

AGE 16 Years IQ .. Months^

If under 24 hours
Hours Minutes

13 Usual

Occupation:

Real Estate Operator

(Kind of work done during most of working life)

14 Industry
or Business:

IS Social Security No.

[removed]

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

New London

;onn.

17 NAME OF
FATHER

Daniel

18 BIRTHPLACE OF

FATHER (City)

(State or country) Q OUTl

19 MAIDEN NAME
OF MOTHER

Ida Smith

20 BIRTHPLACE OF

MOTHER (City)

(State or country) Conn.

Informant .
( Address,

Emma Nichols
Haverhill

A TRUE COPY

ATTEST: -

(Regis ‘r- .

Jan. 18 5.5.

DATE FILED

OFF/

RECEIVED

M R-301A

TRUCTIONS

FOR

LL CERTIFICATE

n giving
i OF DEATH

not enter
e than one
le for each

. (b) and (c)

ij does nol mean
e of dying, such
failure, asthenia, .
teans the disease,
Plications which
eath.

rbid conditions,
living rise to the '
use (a) stating
ierlying cause

ditions contrib- ■
the death but not

0 the disease or

1 causing death.

OUommomDPaltlf of illaaBariiUBPttB
EDWARD J. CRONIN
Secretary of the Commonwealth

DIVISION OF VITAL STATISTICS

2 FULL NAME

S£££iK

J ^(Couitfy)

M±!A.t:.kR£&

(City or Town) '

a. e a.L J~ ,v..JM„.l4.c:dfek. , f

STANDARD

CERTIFICATE OF DEATH

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

Registered No

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

| (If death ^occurred in a hospital or institution.

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

(a) Residence. No. =?■?£ I 71.A.IJ1

(Usual place of abode)

PHYSICIAN — IMPORTANT

(Was deceased a . /

] U. S. War Veteran, N 0 U >e_

l if so specify WAR)

St.

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

(If nonresident, give city or town and State)

MEDICAL CERTIFICATE OF DEATH

3 DATE OF
DEATH

//rr

8 SEX

9 COLOR OR RACE
( / / - ,

/ / (Month) /

(Day)

(Year)

4 I H E R

Y C E R T I F

I last saw h ".“...alive on ., 19 ..rrr., death is said to

S A- „.

have occurred on the date stated above, at

DISEASE OR CONDITION
DIRECTLY LEADING
TO DEATH (a) ./.J/.

cedent T>T°/^hS..4..KMA.Ll.

CAUSES

Due To CoroY] AV'V

<c> / J v

o c C [ u. -s l O In

OTHER

SIGNIFICANT

CONDITIONS

INTERVAL BE
TWEEN ONSET
AND OEATH

Major findings:
Of operations.

Date of operation 7. Was autopsy performed? yTVQ

What test confirmed diagnosis?

7 NAME OF
FUNERAL DIRE£'

ADDRESS

tlZz&g.

Received and filed V..*?. 19

(Registrar)

PERSONAL AND STATISTICAL PARTICULARS

10 SINGLE (write the word)
MARRIED ■* '

WIDOWED/
or

10a If married,,
HUSBAND of.

-JZ StmYh

(or) WIFE of

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

11 IF STILLBORN, enter that fact here.

AGE1

Years Months Days

If under 24 hours
Hours Minutes

Occupation: ^ r l\ «. p

(Kind of work 'done during most of working life)

15 Social Security No. 0 6 ~ 7* 7 d

16 BIRTHPLACE (City)

(State or country)

17 NAME OF "N. * j /lAc!^,^

FATHER [) ft ( //Tj C H

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

Pic So* i'lk.

19 MAIDEN NAME
OF MOTHER

iff! nr

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

Informant ......

(Address)

- . i , Woi'YL Jco tfe

£fkrl...X. t

'&3l ci f yyinhUficp

“JrtSL. R.e±.vk<?d I

I HEREBY CERTIFY that a satisfactory standard certificate oi death was
fil<i<Vjfoth BEFORE the bprial or t?£nlit perrmt was issued:

EXTRACTS

FROM THE LAWS OF THE

COMMONWEALTH OF MASSACHUSETTS

GOVERNING THE

RETURN OF CERTIFICATES OF DEATH

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

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

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

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

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

No undertaker or other persons shall bury a human body or the ashes thereof
which have been brought iwt<^ the commonwealth until he has received a permit
so to do from the board bf T?e»ltXL (jrgt^agfcnt appointed to issue such permits, or
if there is no such board, from the clerk ofihe town where the body is to be buried
or the funeral is to be helgLop-frogja person appointed to have the care of the
cemetery or burial groundin interment is made.

. . . Chap. 114, Sec. 46, GJ^(Tercen tenary Edition).

\ ■

"1 »tTLfiS.;DF PRACTICE

The fulfillment of the .’purpose ot the^elaws calls for the observance of the follow-
ing rules of practice:. ^ v

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

to whom they have giVeo^bedside care during a last illness from disease unrelated
to any form of injury,-' '%v '■

(2) Board of Healtly p4»y siciai ris\irill certify to such deaths only as those of
persons who, though ak^ble^by.^ecbgnized disease unrelated to any form of
injury, have died without reuenfcmedical attendance or whose physician is absent
from home when the certificate of death is needed.

(3) Medical Examihers willjiivestigate 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), tftdfm&h'oif etectrical agents, and deaths following abortion, but
also deaths from ens'ease resulting from jnjhry or infection related to occupation,
the sudden deaths of persons not disablfed by recognized disease, and those of
persons found dead.

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

SPACE FOR ADDITIONAL INFORMATION

DATE OF ENTERING MILITARY SERVICE

DATE OF DISCHARGE

RANK, RATING

ORGANIZATION AND OUTFIT

SERVICE NUMBER

LM R-301

■RUCTIONS

FOR

L CERTIFICATE

giving

OF DEATH

lot enter
i than one
i for each
(b) and (c)

does not mean
of dying, such
Mure, asthenia, .
•ans the disease,
ications which
ath.

>id conditions,
ring rise to the "
sc (a) staling
rrlying cause

itions contrib- -
te death but nob
the disease or
causing death.

QJtjr dlommnmnpaltlj of fSaoBar^UHEttH

EDWARD J. CRONIN

Secretary of the Commonwealth

DIVISION OF VITAL STATISTICS

STANDARD

CERTIFICATE OF DEATH

(City or town making return)
Registered No 10

Suffolk

(County)

Winthrop

(City or Town)

Winthrop Community Hospital I (If death ocoyred in . ihospital or institution

.tT. y. .7. St. \ give its NAME instead of street and number)

Elizabeth E (Fullerton) Simson

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

80 Somerset Ave .

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

No.

2 FULL NAME

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

(a) Residence. No.

(Usual place of abode)

Length of stay: In place of death years months., ft....... days. In place of residence ."'.years months

MEDICAL CERTIFICATE OF DEATH

3 DATE OF
DEATH ...

~TSS..

(Month)

//'f

(Day)

TIES.

(Year)

4 1 HERE B CERTIFY,

6 erPl toS>

That I attended deceased from

19.y...C.t to

I last saw h...£T.(?r.alive on.... XfUL 19.™^death is said to]

il il

have occurred on the date stated above. aX...~. r.r.m.

DISEASE OR CONDITION
DIRECTLY LEADI
TO DEATH

'jz /> 7 - z> y/ryx

cedInt

CAUS^S

B.AL<r.±fS..<Tr...

OTHER ^ ^ . -~i

SIGNIFICANT &. W..I..QM IT. .

CONDITIONS

INTERVAL BE-
TWEEN ONSET
AND DEATH

3/£f-

J6 iK)

PERSONAL AND STATISTICAL PARTICULARS

8 SEX

Female

9 COLOR OR RACE

White

10 SINGLE (write the word)
MARRIED
WIDOWED W 4 ^
or DIVORCES' J-UOW

10a If married, widowed, or divorced

HUSBAND of

(Give maiden name of wife in full)

John W Simson

(Husband's name in full)

(or) WIFE of..

11 IF STILLBORN, enter that fact here.

12 77 o 1

AGE Years Months Days

If under 24 hours
Hours Minutes

13 Kation:...Hpusewif e

(Kind of work done during most of working life)

14mdBu^ess: Own. Home ,

15 Social Security No ^ 0ne

16 NovS%cotla

Major findings: if/, I /S'
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? ITT

6 Winthrop Winthrop.

Place of Burial or Cremation (City or Town)

17 NAME OF
FATHER

Alexander Fullerton

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

Advocate

Nova Scotia

19 MAIDEN NAME

op M0THER Linda Alen

20 BIRTHPLACE OF

mother (city) Advocate

(State or country) ^Qya SCOt.j P

Informan tPri X.li.l.S. rOOk S

(Address) OU Somerset A

Ave «. Winthrop

I HEREBY CERTIFY that a satisfactory standard certificate of death was
1 .rtrith me, BEFORE tha burial or'tihnsit/riernnt was issued:

Received and filed 19

S2SO 1

A TRUE COPY ATTEST:

(Registrar)

EXTRACTS

FROM THE LAWS OF THE

COMMONWEALTH OF MASSACHUSETTS

GOVERNING THE

RETURN OF CERTIFICATES OF DEATH

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

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

No undertaker or other persons shafTbury a human body or the ashes thereof
which have been brought into the commop»4#tWL4jntil he has received a permit
so to do from the board of health or if appended to issue such permits, or

if there is no such board, from the clerk of tn^O'Vn where the body is to be buried

or the funeral is to be held, or frpnTaj.
cemetery or burial ground in which ,tJ?C i
. . . Chap. 114, Sec. 46. G. L., (Tercent^na^

ted to have the care of the
ptbs made.

RULES Of. PRACTICE 1

' A'Ai

The fulfillment of the purpose of these^laVf^ calls, for the observance of the follow-
ing rules of practice: . W*ff MJa*

(1) Attending physicians will certify £o siAh deaths only as those of persons
to whom they have given bedside care during?-* 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 who§£ physician is absent
from home when the certificate of death *Sf«peded.'

(3) Medical Examiners will investigate and certify to all deaths supposably
due to injury. These include not onTV' deaths caused directly or indirectly by
traumatism (including resulting septicemia), and by the action of chemical
(drugs or poisons) thermal, or electrical agents, and deaths following abortion, but
also deaths from disease resulting from injury or infection related to occupation,
the sudden deaths of persons not disabled by recognized disease, and those of
persons found dead.

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

SPACE FOR ADDITIONAL INFORMATION

DATE OF ENTERING MILITARY SERVICE

DATE OF DISCHARGE

RANK, RATING ■

ORGANIZATION AND OUTFIT

SERVICE NUMBER

M R-301A

"RUCTIONS

FOR

L CERTIFICATE

i giving
OF DEATH

not enter
i than one
b for each

(b) and (c)

does not mean
of dying, such
lilure. asthenia, .
r ans the disease,
ications which
ath.

>id conditions, .
ving rise to the
i se (a) slating
trlying cause

'itions contrib- •
te death but not
the disease or
causing death.

.Suffolk...

(County)

o •lintfef.ofl

Jd (City or Town)

QUjp (Eommamopaltlj of fflaBBarljUBrttB

EDWARD J. CRONIN

Secretary of the Commonwealth

DIVISION OF VITAL STATISTICS

STANDARD

CERTIFICATE OF DEATH

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

Registered No,

. I (If death occurred in a hospital or institution.

fWint -hr OP-. -O OmmUnl ty HOSpi tal St. \ give its NAME instead Of Street and number)

2 FULL NAME

(If deceased is Surname

"or divorced woman, give also maiden name.)

PHYSICIAN — IMPORTANT

(Was deceased a

U. S. War Veteran.

if so specify WAR)

(a) Residence. No. 166 Bowdoin .St ...

(Usual place of abode)

St.

Length of stay: In place of death years months

.a..

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

MEDICAL CERTIFICATE OF DEATH

3 DATE OF
DEATH ...

U (Month) L (Day)

(Year)

41 HEREBY CERTIFY,

<3> vn l 'b 19 6" , to

I last saw h / vw. alive on 5*. Vv
have occurred on the date stated above, at

That I attended deceased from
19 v> ^

!..t. , i9vT5^ death is said to|

(p • IP A m

DISEASE OR CONDITION

NC . _i I j

C o vaewiTtxA is. . .

DIRECTLY LEADING
TO DEATH (a)

ANTE Due To I i _ -

CEDENT (b) . C.e.V<e’bY'A t A VO X L^X.
CAUSES

Due To
(c)

OTHER

SIGNIFICANT

CONDITIONS

INTERVAL BE
TWEEN ONSET
AND DEATH

AGE

Years

Months ... . g Days

Major findings:
Of operations..

Date of operation Was autopsy performed? hj/

What test confirmed diagnosis?

5 Was disease or injury in any way related to occupation of deceased? Vs. 6.

(Signerl)00**" D

(Address) , VyiCL-l-tp' ft)4te 5? 19 St>

Plaice of ^ ® ® r y

DATE OF BURIAL Ji-lnU- Ar V -1-7 . 1y9]5 & / 19

7 NAME OF
FUNERAL DIRECTO

— address 174 j nt hr op -6 1 . V/int hr on,

Received and filed r i

(Registrar)

PERSONAL AND STATISTICAL PARTICULARS

8 SEX

J.lal e

9 COLOR OR RACE

^hite

10 SINGLE (write the word)
MARRIED r, . ,

widowed b ins 1 e

or DIVORCED °

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.

If under 24 hours

Hours Minutes

13 Usual

Occupation:

(Kind of work done during most of working life)

14 Industry

or Business: !*.

IS Social Security No. !!..

16 BIRTHPLACE (City) IVinthTOp

(State or country)

17 NAME OF
FATHER

W ’

-J-ames Hersey

:;aoo.

18 BIRTHPLACE OF

FATHER (City) l( ^hOtlrfeh BOStOn.

(State or country) r T T.S S

19 MAIDEN NAME
OF MOTHER

20 BIRTHPLACE OF
MOTHER (City) ....
jfeg (jState or country)

..Irene Hamit on

..Bast. Boston..

'.'ass.

Informant .
(Address)

J.arn.e.s... Kersey.

166 Bowdoin Sfe=

I HEREBY i
filed with me

hrop

FY that a satisfactory standard certificate of death was
RE urial or trafxsiLperrrut-jvas issr]

of Board of He4Kh or other) '

u/..Z/.^.€X.

(Date of Issue of Permit) ‘ ^

EXTRACTS

FROM THE LAWS OF THE

COMMONWEALTH OF MASSACHUSETTS

GOVERNING THE

RETURN OF CERTIFICATES OF DEATH

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

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

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

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

Medical examiners shall make examipaiiqn _iiDqn tb«Lview of the dead bodies
of persons as are supposed to havttdtefi hy \ttotcrtoe. or by the action of
chemical, thermal or electrical agents or following abortion, or from diseases
resulting from injury or infection relating^o occupation, or suddenly when not
disabled by recognizable disease, or when any*i5e$-$on IsTound dead. — General
Laws, Chap. 38, Sec. 6.. as amended by ChajN 632, Sfec. 4, Acts of 1945.

No undertaker or other persons shall Bury a'hum'^n body or the ashes thereof
which have been brought into the commonwea1‘rh;'u^tilr“he has received a permit
so to do from the board of health or it$ agent appointed Jto issue such permits, or
if there is no such board, from the clerk of the town where the body is to be buried
or the funeral is to be held, or from a person appointed to have the care of the
cemetery or burial ground in which the interment is made.

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

RULES OF PlriqflGE

The fulfillment of the purpose of these laws calls for the observance of the follow-
ing rules of practice: 1

(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. | R f f •

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

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

SPACE FOR ADDITIONAL INFORMATION

DATE OF ENTERING MILITARY SERVICE

DATE OF DISCHARGE

RANK, RATING

ORGANIZATION AND OUTFIT

SERVICE NUMBER

[ R-301A

UCT10NS

FOR

CERTIFICATE

jiving

DF DEATH

»t enter
than one
for each
b) and (c)

ioes not mean
>/ dying, such
lure, asthenia, .
ns the disease,
ations which
h.

i conditions,
ng rise to the
e (a) stating
lying cause

ions contrib- ^
death but not
he disease or
ausing death.

Chapter 137.
1954, requires
ns to print or
rause or causes
h on death
:es.

| V'V-PdIS^

. (County)

LoTVito

QIljp (Eommmunraltl) of DHaBBarljuBPttB

EDWARD J. CRONIN

Secretary of the Commonwealth

DIVISION OF VITAL STATISTICS

STANDARD

CERTIFICATE OF DEATH

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

Registered No.

2 FULL NAME

(City or rbwn)r ,

. 2 A pC6Lueii^T)oad

~wi\\ iSAyi H ■ .ulc^,n.§e.n

(If deceased is a married, widowed or divorced woman, give also maiden nar

y^-gCouJell /?cdd.

ibode)

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

I (If death occurred in a hospital or institution.
./-8F. \ give its NAME instead of street and number)

PHYSICIAN — IMPORTANT

(Was deceased a ~

U. S. War Veteran. VI A Va
if so specify WAR) ...LLSO.I.d ..-

(a) Residence. No.

(Usual place of abode)

Str.

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

MEDICAL CERTIFICATE OF DEATH

3 DATE OF
DEATH ...

(Month)

/ L ,

(Day)

(Year)

41 HEREBY CERTIFY. That I attended deceased from

J h/y 3m w Sy., to JV*i ,/4. i 19 .sTJi.

I last saw h ../ Mf alive on . J*..* ts ../.JT... 19 .Jt.O, death is said toj

have occurred on the date stated above, at

DISEASE OR CONDITION
DIRECTLY LEADING y)
TO DEATH (a) C

of tfroykii

ANTE Due To

CEDENT (b)

CAUSES

Due To

(c)

SIGNIFICANT oyc/o to
CONDITIONS h + Ob-t- d

fl't

INTERVAL BE
TWEEN ONSET
AND DEATH

X frf\’

l ' /opr

Major findings:
Of operations.

Pro > t-tf / c

Date of operation^^..„ autopsy performed? .... A/O

What test confirmed diagnosis? fMth- rtfiert

5 Was disease or injury ii/Nnv wav refeted toT
If so, specify. _ _ _

(Signed) . '.Jh ,

(Address) , >««

Place of Burial or -Cremation

ffationof^Ieceased ?

j ate S?

,ty or Town)

DATE OF

BURIAL \ j.5j.. i

7 NAME OF
FUNERAL DIREpTOR

ADDRESS

Received and filed .

JAN 1

.19 .

(Registrar)

PERSONAL AND STATISTICAL PARTICULARS

8 SEX

/x)d./e rixivvT

9 COLOR OR RACE

10 SINGLE (write the word)

WmOWED W) <L V I
or DIVORCED

10a If married., widowed, or. divorced- * — _>

HUSBAND Sp....s35V

(Give maiden name of wife in full)

(or) WIFE of

(Husband's name in full)

11 IF STILLBORN, enter that fact here.

j 12

'age.

A Years Months ZL Days

13 okUon3r..^. 1.4

If under 24 hours

Hours Minutes

(Kind of w'ork done during most of working life)

15 Social Security No Q.I. ( ~ Q lB

16 BIRTHPLACE (City) .
(State or country)

.2&£b..'o..

Wi a.

17 NAME OF

inamu ur / \ / „

!A™.ER m 1 j t j

VAa ob+Ari

k —

18 BIRTHPLACE OF

FATHER (City) .... ....... r,.

(State or country) yy\

19 MAIDEN NAME
OF MOTHER

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

Ha.VYoA.Vi lybenan

_..A dto

Informant^S _A!L.

(Address) 7 » O CM <5. 1\ IK JTl V Q/f3

I HEREBY CERTIFY that a sat.isfach^ry standard certificate of death was
filejl Jrith me BEFORE the/6una! oy transit, permit was issued:

cial Designation)

EXTRACTS

FROM THE LAWS OF THE

COMMONWEALTH OF MASSACHUSETTS

GOVERNING THE

RETURN OF CERTIFICATES OF DEATH

A ph vsician 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.

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. 3$..,§qe. fr.,|a^/apifipded 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, navy or marine corps of the United States in any war in which it has been
engaged, insert in the certificate a recital to that effect, specifying the war. and
shall also certify in such certificate both the primary and the secondary or imme-
diate cause of death as nearly as he can state the same. For neglect to comply
with any provision of this section, such physician or officer, shall forfeit ten dollars.
For the purposes of this section and of sections forty-five, forty-six and forty-seven
of said chapter one hundred and fourteen, the word “war” shall include the China
relief expedition and the Philippine insurrection, which shall, for said purposes, be
deemed to have taken place between February fourteenth, eighteen hundred and
ninety-eight and July fourth, nineteen hundred and two. and the Mexican border
service of nineteen hundred and sixteen and nineteen hundred and seventeen.
G. L. Chap. 46. Sec. 10.

No undertaker or other person shall bury or otherwise dispose of a human body
in a town, or remove therefrom a human body which has not been buried, until he
has received a permit from the board of health, or its agent appointed to issue
such permits, or if there is no such board, from the clerk of the town where the
person died; and no undertaker or other person shall exhume a human body and
remove it from a town, from one cemetery to another, or from one grave or tomb
other than the receiving tomb to another in the same cemetery, until he has
received a permit from the board of health or its agent aforesaid or from the clerk
of the town where the body is buried. No such permit shall be issued until there
shall have been delivered to such board, agent or clerk, as the case may be,
a satisfactory written statement containing the facts required by law to be
returned and recorded, which shall be accompanied, in case of an original inter-
ment, by a satisfactory certificate of the attending physician, if any, as required by
law. or in lieu thereof a certificate as hereinafter provided. If there is no attending
physician, or if, for sufficient reasons, his certificate cannot be obtained early
enough for the purpose, or is insufficient, a physician who is a member of the board
of health, or employed by it or by the selectmen for the purpose, shalJ 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, the commonwealth until he has received a permit

so to do from tK^boaVdfgjf JJealth or its agent appointed to issue such permits, or
if there is no such boartfc fri#n the Merk of the town where the body is to be buried
or the funeral isjrt£> jbd)f)£l(LjO* from a person appointed to have the care of the
cemetery orburialiirpupid.vii which the interment is made.

. . . Chap, ‘Sec, .46, ‘Qv I/v '(Tercentenary Edition).

r, V-1

LV .j RlitgS OF PRACTICE

The fulfilliiidhti>f the purpocetifAhese laws calls for the observance of the follow-
ing rules of *sV * :

(1) Atte
to whom th^i^TiL.
to any form ozApj

(2) Board of
persons who. thouj

physicians will certify to such deaths only as those of
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, fcfajfn friers will iiMfctigate and certify to all deaths supposably
due to injur^» tTleafe include not only deaths caused directly or indirectly by
traumatism (inc’uding 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.

HI certify to such deaths only as those of persons
Jte care during a last illness from disease unrelated

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

SPACE FOR ADDITIONAL INFORMATION

DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE
RANK, RATING

ORGANIZATION AND OUTFIT

SERVICE NUMBER

M R-301

IUCTIONS

FOR

CERTIFICATE

giving
OF DEATH

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

does not mean
f dying, such
lure, asthenia, -►
ns the disease,
ations which
h.

rid conditions , ^
rig rise to the
e (a) stating
■lying cause

itions contrib- ■
death but not
he disease or
ausing death.

Suffolk

(County)

Wlnthrop

(City or Town)

QHjp (Commonroraltli of fllaBBarljuBFttB

EDWARD J. CRONIN

Secretary of the Commonwealth

DIVISION OF VITAL STATISTICS

STANDARD

CERTIFICATE OF DEATH

(City or town making return)

Registered No.

No.

jTsnoV-e Pff Ave • <’ Xl \ fO /<H death occurred in a hospital or institution,

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

2 FULL NAME

Ethel Rene (Perkins) Bartlett

(If deceased is a married, widoweia?r divorced woman, give also maiden name.)

79 Sumit Ave.

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

(a) Residence. No.

(Usual place of abode)

St.

40.

(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

E£?Hord±H2*Ky LI /.SSI..

(Month) / (Day) (Year)

41 HEREBY CERTIFY, That I attended deceased fron),

.JA.rtis/±tiy L.2 jJl

I last saw1 alive on A/f±(. fXS h is said tcJ

above, at fc.L IITERTAL IE

t — '".f TWEE I ONSET

AID OUT!

have occurred on the date stated

DISEASE OR CONDITION
DIRECTLY LEAPING ^ ^ . r-

TO DEATH 9...E

T~o /V *==•

cedInt 'teCi-eHc-RA-l.

causESC' A7?(l i No H ft TV S i I

Due To
(c)

OTHER
SIGNIFICANT/
CONDITIONS

Or/

L(...

PERSONAL AND STATISTICAL PARTICULARS

8 SEX

Female

9 COLOR OR RACE

White

10 SINGLE (write the word)
MARRIED

WIDOWED *»M /-m r

or DIVORCED >«ldOW

i2 77 2. IQ

i ^AGE Years Months . Days

MbTo q£ To.ri.CrEA

Date of o QLkoT.'n.^—A Was autopsy performe< 1} tAo J

What test confirmed (

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

If so, specify y—fl

(SignedWCL tlSr- ■

(Address) V&..Z..

6 Winthrou '. Winthrop

Place of Burial or Cremation (City or Town)

DATE OF BURIAL * A 1

7 NAME OF
FUNERAL DIRECTOR

TRUE COPY ATTEST

10a If married, widowed, or divorced

HUSBAND of

(Give maiden name of wife in full)

Edward J Bart lett

(Husband’s name in full)

(or) WIFE of..

11 IF STILLBORN, enter that fact here.

If under 24 hours

Hours Minutes

13 usual . Housewife

Occupation;

(Kind of work done during most of working life)

industry Own home

or Business:

None

IS Social Security No.

16 BIRTHPLACE (City).

(State or country) !•'_ fj. S S

S tone ham

17 NAME OF -n , .

father Perkins

18 BIRTHPLACE OF _ . , „ TT

father (city) B..9.9.^bBay Harbor

(State or country) i-laine

19 MAIDEN NAME

OF mother Susan Sibley

20 BIRTHPLACE OF

mother (city) ...Booth Bay . Harbor.

(State or country) Mfijne

Informan t^^ anne , „ — . .w..*

(Address) ( S Sunn t Ave . W int.h rnp

^REBY CERTIFY that a satisfactorystandard certificate of death was
with/fn# BEFORE jtfteyburiaVtt? transit permit was issued:

IX /

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 ot his last illness, when last seen alive by the physician
or officer and the date of his death. . . Gen. Laws, Chap. 46, Sec. 9.

A physician or officer furnishing a certificate of death as required by the
preceding section or by section forty-five of chapter one hundred and four-
teen, shall, if the deceased, to the best of his knowledge and belief, served in the
army, navy or marine corps of the United States in any war in which it has been
engaged, insert in the certificate a recital to that effect, specifying the war, and
shall also certify in such certificate both the primary and the secondary or imme-
diate cause of death as nearly as he can state the same. For neglect to comply
with any provision of this section, such physician or officer, shall forfeit ten dollars.
For the purposes of this section and of sections forty-five, forty-six and forty-seven
of said chapter one hundred and fourteen, the word “war” shall include the China
relief expedition and the Philippine insurrection, which shall, for said purposes,
be deemed to have taken place between February fourteenth, eighteen hundred
and ninety-eight and July fourth, nineteen hundred and two. and the Mexican
border service of nineteen hundred and sixteen and nineteen hundred and seven-
teen. 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 boar,d 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 registration. The person to whom the permit is so given and the physician
certifying the cause of death shall thereafter furnish for registration any other
necessary information which can be obtained as to the deceased, or as to the
manner or cause of tjie death, which the clerk or registrar may require. — Chap.
114, Sec. 45, G. L., (Tercentenary Edition).

examiner has notice,
shall forthwith t<

. . . General Cj

No und^2keT*t>}
which baVe’^
so to d^Ti^V**,
if thefe^’is mo ,3rich bo;
buried toT fK$ fpne
of the ceyiete rjt or ^

Medical exafiJin*tv fiatlvfa£ki: examination upon the view of the dead bodies
of only such persons as are supposed to have died by violence. If a medical
* ere is within his county the body of such a person, he
where the body lies and take charge of the same;
fSec. 6.

1 ■

ipjps shall bury a human body or the ashes thereof
*itL commonwealth until he has received a permit
l or its agent appointed to issue such permits, or
W- clerk of the town where the body is to be
Ilf- -«r from a person appointed to have the care
ili^Which the interment is made.

^?cehtenary Edition).

ES OF PRACTICE

The of these laws calls for the observance of the

following ruIe^^fTyAflR^' *

(1) Attend 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) Physicians will certify to such deaths only as those of
persons \%V^i*l<^ift;h^JAisabled ojyjrecognized 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 occupa-
tion, 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 appiopriate 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-301 A

UCTIONS

FOR

CERTIFICATE

jiving

3F DEATH

>t enter
than one
for each
b) and (c)

ioes not mean
>/ dying, such
lure, asthenia, .
ns the disease ,
at ions which
h.

i conditions, .
ng rise to the"
? (a) stating
lying cause

ions conlrib-
death but not
ie disease or
jusing death.

Chapter 137,
954, requires
is to print or
ause or causes
ti on death
es.

3-ljr (Eummanmralth of fHaBHarijuartta

EDWARD J. CRONIN

Secretary of the Commonwealth

DIVISION OF VITAL STATISTICS

STANDARD

CERTIFICATE OF DEATH

Registered No.

To b« fil«d for burial -parmit
with Board of Hoalth
or its Agant.

2 FULL NAME

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

PHYSICIAN — IMPORTANT

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

(a) Residence. N _

(Usual place of

Length of stay: In place of death years months..:*?... days. In place of residen

(Was deceased a
U. S. War Veteran,
if sq_specify WAF

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

MEDICAL CERTIFICATE OF DEATH

PERSONAL AND STATISTICAL PARTICULARS

BeA?H°F ' J A n /.S’. /. <3l.- JZ..

(Month) (Day) (Year)

4 I__H EREBY CERTIFY, That I attended deceased from

/3 19.C.£. to C-.C...

I last saw h alive on ...2^, i ...l .., 19 .i.4, death is said tcj

have occurred on the date stated above, at . \..t..l.Q....tZ.. m.

^jLSEX 9 COLOR OR I

RACE

10 SINGLE
MARRIE
WT DO W
or DIVORC

(write the nordY,

iRCED

10a If married, widowed, or divorced
HUSBAND of..

DISEASE OR CONDITION
DIRECTLY LEADING
TO DEATH (a) ,

yiC ±,t,£

.n..

D1 1

1 C «-■ /<? A.f..

ANTE Due To
CEDENT (b)
CAUSES

Due To
(c)

OTHER

SIGNIFICANT

CONDITIONS

Of operations. is »

Date of operation. ..j.J. Was autopsy performed?

Date

What test confirmed diagnosis?

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

Date /// cf

v » CL o uucaJV, ui iiijui j tii an/ » cl y i i,iav\,u c\j uvv upaw

If so, specify^

(Signed). ..c^v.X'. r

(Address), f.Jl.ti,- !- / .. D;

fe of Burial
DATE OF BURI

7 NAME OF
FUNERAL DIRECT

ADDRESS/>y

Received and filed Jp IN 21 I3b:,

(Registrar)

EXTRACTS

FROM THE LAWS OF THE

COMMONWEALTH OF MASSACHUSETTS

GOVERNING THE

RETURN OF CERTIFICATES OF DEATH

A physician or reipstered 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, w'hen 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 js so given and the physician certifying
the cause of death shall thereafter furnish for registration any other necessary
information which can be obtained as to the deceased, or as to the manner or
cause of the death, which the clerk or registrar may require. — Chap. 114, Sec. 45,
G. L., (Tercentenary Edition).

Medical examiners shall make examination upon the view of the dead bodies
of persons as are supposed to have died by violence, or by the action of
chemical, thermal or electrical agents or following abortion, or from diseases
resulting from injury or infection relating to occupation, or suddenly when not
disabled by recognizable disease, or when any person is found dead. — General
Laws, Chap. 38, Sec. 6., as amended by Chap. 6 32, 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, 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 fprfeict^ii^iglqns.
For the purposes of this section and of sections forty-five. fortyt^ix-aTurforty-seven
of said chapter one hundred and fourteen, the word "war" shall include the China
relief expedition and the Philippine insurrection, which shall, for ^»«tturp'o5es. be
deemed to have taken place between February fourteenth, eighfirenquborjea' and
ninety-eight and July fourth, nineteen hundred and two. and' tJfe\Nje«w^i*hqrder
service of nineteen hundred and sixteen and nineteen hypdr)

G. L. Chap. 46. Sec. 10.

No undertaker or other persons shall bury a human body or the ashes thereof
which have been brought into the commonwealth until he has received a permit
so to do from the board of health or its agent appointed to issue such permits, or
if there is no such board, from the clerk of the town where the body is to be buried
or the funeral is to be held, or from a person appointed to have the care of the
cemetery or burial ground in which the interment is made.

. . . 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
“ i -• bedside care during a last illness from disease unrelated

en hupdrti'^^'tVycmt&en;^ G) Attending physic

“<// X< to wbom they have given

' C V/a cy ' O i any form of injury.

No undertaker or other person shall bury or otherwise dispbipFaiKuman 4 - ' (2) Board of Health physicians will certify to such deaths only as those of

... .i /_ l u , j u • u nersnns who t.hnncm nisanlen nv tp<

ap jftQ pp o iiftfcd 'to' issxxtV ,
erETqf- tnecJowrr\vTTere t^e 2

in a town, or remove therefrom a human body which has hiatfceejcbu
has received a permit from the board of health, or its apeif*
such permits, or if there is no such board, from the cletC^i ^ v ^

person died; and no undertaker or other person shall exhbmiafK*J«pan body^Ticj, : y.
remove it from a town, from one cemetery to another. or*fr^pfll^
other than the receiving tomb to another in the same cemejtu
received a permit from the board of health or its agent afore§aj&
of the town where the body is buried. Xo such permit shall
shall have been delivered to such board, agent or clerk,
a satisfactory written statement containing the facts required
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

0^13^- 1 .persons who, though disabled by recognized disease unrelated to any form of
* .v-IzL-? injury, have died without recent medical attendance or whose physician is absent
frbm home when the certificate of death is needed.

(3) Medical Examiners will investigate and certify to all deaths supposably
XmtLv ^ue 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.

law, or in lieu thereof a certificate as hereinafter provided. If thef
physician, or if, for sufficient reasons, his certificate cannot 1_
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

f ^Statement of Cause of Death. — Physicians:
urrface side of standard certificate of death.

see explanatory instructions

SPACE FOR ADDITIONAL INFORMATION

DATE OF ENTERING MILITARY SERVICE

DATE OF DISCHARGE

RANK, RATING

ORGANIZATION AND OUTFIT

SERVICE NUMBER

I R-301 A

IUCTIONS

FOR

CERTIFICATE

giving
OF DEATH

t»t enter
than one
for each

lb) and (c)

does not mean
5/ dying, such
lure, asthenia, ,
ns the disease,
rations which
th.

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

lions contrib-
1 death but not
he disease or
ausing death.

■ Chapter 137.
1954, requires
ns to print or
cause or causes
th on death
tes.

•WY

0 *

Suffolk

(County)

5 Winthrop

u (City or Town)

No.

SUf* (Eommomupaltlj of fflaaaadiUHPttH

EDWARD J. CRONIN

Secretary of the Commonwealth

DIVISION OF VITAL STATISTICS

STANDARD

CERTIFICATE OF DEATH

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

Registered No.

0*7 ll Plpoaonf /(If death occurred in a hospital or institution.

1. 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. —Cbc 1 G (Dig® low ) Hall

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

(.) Residence. n» 2?^ Pleasant Street,

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

20 55

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

St. .

MEDICAL CERTIFICATE OF DEATH

3 DATE OF
DEATH ...

i/AtWAfey (f /$Jl$L

(Month)

1 (Day)

(Year)

I attended deceased from

„ , — . Jf,

I last saw hJLj*. alive on vl A A , J#, , 19 crt7death_ is said td

4#I HEREBY C E R T IF Y . That

i9sJCX”., to uAM

have occurred on the date stated above, at

/i#r P-

DISEASE OR CONDITION

DIRECTLY LEA D/NG* _ „

TO DEATH (a) H .

AfcCiKo&ATXLffS

ANTE Due To.
CEDENT (b)
CAUSES

'C4K<\*QNA of J'G-Hob
CoLQH

Due To
(c)

OTHER

SIGNIFICANT

CONDITIONS

INTERVAL BE-
TWEEN ONSET
AND OEATH

<9-y#

8 b-MiEtA

Major findings:

Of operation

Date of operation.. \l0HEiy fcffrWas autopsy performed?. He,

What test confirmed diagnosis?... C l i hr i4ai~ + LA&o/tA'to&y.

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

(Signed)

(Address)

yj- A- Hr -jbi9

6 Winthrop ' Winthrop

Place of Burial or Cremation (City or Town)

DATE OF BURIAL

Jan 22 19 5

7 NAME OF
FUNERAL DIRECTOR

ADDRESS

Received and filed .

. ...

iMMlflTfeS

(Registrar)

PERSONAL AND STATISTICAL PARTICULARS

8 SEX

Female1

9 COLOR OR RACE

White

10 SINGLE
MARRIED
WIDOWED

(write the word)

or DIVORCED

Married

10a If married, widowed, or divorced

HUSBAND of

(Give maiden name of wife in full)

(or) wife of Herbert Dwight Hall

(Husband’s name in full)

11 IF STILLBORN, enter that fact here.

!2 74 0 2

AGE Years Months Days

If under 24 hours

Hours Minutes

13 Usual

Occupation :

Housewife

(Kind of work done during most of working life)

14 Industry
or Business:

Own Home

15 Social Security No HPP®

16 BIRTHPLACE (City) .
(State or country)

Boston

Mas s

WSf BIRTHPLACE of
FATHER (City)
(State or country)

17 NAME OF

FATHERheslie E Bigelow

Boston

Mass

19 MAIDEN NAME

— of M0THER Anna 0 Eliot

20 BIRTHPLACE of

MOTHER (City) B.O.S.t.O.h

(State or country) MflS S

Informant .
(Address)

IEBY CERTIFY that a satisfactory standard certificate of death was
ith rp« JS EFORE the, -burial or transit permit was issued:

Jfficial Designation)

EXTRACTS

FROM THE LAWS OF THE

COMMONWEALTH OF MASSACHUSETTS

GOVERNING THE

RETURN OF CERTIFICATES OF DEATH

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

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.

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

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 £ierk 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.

C Sec. k*’ (Tercentenary Edition).

RULES OF PRACTICE

r ^ i^pfitnfihp purpose of these laws calls for the observance of the follow-

ninety-eight and July fourth, nineteen hundred and two, and the Mexican border P a . . ... .. , .

service of nineteen hundred and sixteen and nineteen hundred and seventeen. // , , certify to such deaths only as those of persons

G L Chap 46 Sec 10 , wnft^Trfey/ija vp> given bedside care during a last illness from disease unrelated

form of mtufy^'*

No undertaker or other person shall bury or otherwise dispose of a human body T”" . * P^y**c*ans w^) certify to such deaths only as those of

in a town, or remove therefrom a human body which has not been buried, until ^lis^bled by recognized disease unrelated to any form of

has received a permit from the board of health, or its agent appointed to issue-*r
such permits, or if there is no such board, from the clerk of the town where theC^ 1
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

ve died xrijhfcut recent medical attendance or whose physician is absent
(Certificate of death is needed.

inerswrill investigate and certify to all deaths supposably
include not only deaths caused directly or indirectly by
resulting septicemia), and by the action of chemical
rmal, or electrical agents, and deaths following abortion, but
5s6a.se resulting from injury or infection related to occupation,
of persons not disabled by recognized disease, and those of

t bf Cause of Death. — Physicians:
standard certificate of death.

see explanatory instructions

SPACE FOR ADDITIONAL INFORMATION

DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE

RANK, RATING

ORGANIZATION AND OUTFIT
SERVICE NUMBER

A R-301A

RUCTIONS

FOR

. CERTIFICATE

giving
OF DEATH

■ot enter
than one
i for each
(b) and (c)

does nol mean
of dying, such
ilure, asthenia, •
ans the disease,
ications which
Uh.

id conditions,
>ing rise to the
se (a) staling
rlying cause

ittons conlrib-
e death but nol
the disease or
causing death.

Suffolk

(County)

° .Winthrop

5*1 (City or Town)

Glummomoraltl? of fHasBarljuBPtlfi

EDWARD J. CRONIN

Secretary of the Commonwealth

DIVISION OF VITAL STATISTICS

STANDARD

CERTIFICATE OF DEATH

Registered No,

To bo fiUd for burial permit
with Board of Health
or Its Arant.

No 158 Winthrop St. St. { give its NAME instead of street and number)

f (If death occurred in a hospital or institution.

2 full name Belle Augus fca Floyd

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

PHYSICIAN — IMPORTANT

(Was deceased a

U. S. War Veteran,

if so specify WAR)

(a) Residence. No. 1 5 8 -Win t hr Op St. St.

(Usual place of abode)

Length of stay: In place of death years months.

days.

(If nonresident, give city or town and State)
In place of residence 65 years months days.

MEDICAL CERTIFICATE OF DEATH

3 DATE OF

death Jarjjjary 2S,195J>

(Year)

4 I

EREBY CERTIFY, /That I attended deceased from

19 ..fS/jfc, l9.Jnr:

I last saw h&'./rT... alive onjfx gfcrTrA'..... 'Se.s?....., 19 aTA death is said

have occurred on the date stated above, at (T”

DISEASE OR CONDITION
DIRECTLY LEADING
TO DEATH (a)

h C- Cl. r j" of

INU

cedInt r(b) T°.

CAUSES

£-/?-& YZZ*' J t

TV - ## V

Due To
(c)

A U / A J/

OTHER

SIGNIFICANT

CONDITIONS

INTERVAL BE-
TWEEN ONSET
AND DEATH

rs.

Major findings:
Of operations..

Date of operation Was autopsy performed?

What test confirmed diagnosis? rrr

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

If so. specify Q A

(Signed) , M. D

(Add*£s)/<?y Date /~i- c ^ j/ 19^>r3,

Win t hr op 0 eme t er y -j V/in t hr op

ce of Burial or Cremation (City or Town)

Place

DATE OF BURIAL

7 NAME OF
FUNERAL DIRECTOR

ADDRESS 1.74 Win

Received and filed

• .Winthrop,

N 26 1355

(Registrar)

PERSONAL AND STATISTICAL PARTICULARS

8 SEX

Female

9 COLOR OR RACE I 10 SINGLE (write the word)
MARRIED rir-i Qwp t
.,,r_ -l. WIDOWED tV-1-U.Lme J.

wmre | or DIVORCED

10a If married, widowed, or divorced

HUSBAND of

(Give maiden name of wife in full)

(or) WIFE of paVii

» 2nd.»- ,

usoand s name in full)

11 IF STILLBORN, enter that fact here.

J\GE 88.. Years 0 Months 12 Days

If under 24 hours

Hours Minutes

Occupation: . housewife

(Kind of work done during most of working life)

14 Industry

or_ Business: QWH tlO EBQ

15 Social Security No. ZlOriQ

16 BIRTHPLACE (City)
(State or country)

..JEJxet er

Maine

17 NAME OF
FATHER

Charles Thompson seavey

18 BIRTHPLACE OF

father (city) C one ord N • H*

(State or country)

19 MAIDEN NAME
OF MOTHER

Emily Fast man Fernald

20 BIRTHPLACE OF

MOTHER (City) .. .Bast Gone ord, U.H»

g 9 (State or country)

Informant . At t y. Edward. H . . Thomas

-184 De-vanshire St . Boston

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

uas s .

rd of "Health or other W‘,

•/. 4> 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
death of a person whom he has attended during his last illness, at the request
of an undertaker or other authorized person or of any member of the family of
the deceased, furnish for registration a standard certificate of death, stating to the
best of his knowledge and belief the name of the deceased, his supposed age, the
disease of which he died, defined as required by section one, where same was
contracted, the duration of his last illness, when last seen alive by the physician
or officer and the date of his death. . .Gen. Laws. Chap. 46. Sec. 9.

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

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

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

No undertaker or other persons shall bury a human body or the ashes thereof
which have been brought into the commonwealth until he has received a permit
so to do from the board of health or its agent appointed to issue such permits, or
if there is no such board, from the clerk of the town where the body is to be buried
or the funeral is to be held, or from a person appointed to have the care of the
cemetery or burial ground in which the interment is made.

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

RULES OF PRACTICE

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

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

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

SPACE FOR ADDITIONAL INFORMATION

DATE OF ENTERING MILITARY SERVICE

DATE OF DISCHARGE

RANK, RATING

ORGANIZATION AND OUTFIT

SERVICE NUMBER

A R-301A

RUCTIONS

FOR

CERTIFICATE

3 iif f o lk

(County)

o 'Winthrop

U (City or Town)

Qlommomnpaltlf of fffinHflarljuflptiH

EDWARD J. CRONIN

Secretary of the Commonwealth

DIVISION OF VITAL STATISTICS

STANDARD

CERTIFICATE OF DEATH

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

Registered No

No lint hr op .g.P.m.ia^ity. Hospital St. {‘gweTu nTm? InJtlad ofS?UeetOaUnnumbe0

2 full name Maud Candace Lincoln

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

(a) Residence. No

(Usual place of abode)

PHYSICIAN — IMPORTANT

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

52. Ma in Street St. Franklin , Ma s s .

(If nonresident, give city or town and State)

giving

OF DEATH

tot enter
than one
for each
(b) and (c)

does not mean
of dying, such
ilure, asthenia, .
a ns the disease,
'■cations which
ith.

id conditions,
<ing rise to the
se (a) staling
rlying cause

itions conlrib- ■
e death but not
the disease or
causing death.

Length of stay: In place of death years months. 18 days. In place of residenc8 2 years months days.

MEDICAL CERTIFICATE OF DEATH

3 DATE OF
DEATH ...

Janaary 25 1955

(Month) (Day)

(Year)

41 HEREBY CERTIFY

That I attended deceased from

P.r^rlrr. ... le. S'. , ItoT.fi.., 19 J.rJ

I last saw h alive on — • 19.3. J death is said to

have occurred on the date stated above, at 2> . / .^ Mi

DISEASE OR CONDITION
DIRECTLY LEAD
TO DEATH (a)

CvRotj/tfi'Y

'7?o m r? 5 r rs / n

ANTE Due
CEDENT (b)
CAUSES

T^Tji s c L e Tio/t C .
tj R r j?tJ£/ we

Tos. e n i a t t y

significant if y. p CRTt. <yj / •’ (V

CONDITIONS «

INTERVAL BE
TWEEN ONSET
ANO DEATH

AGE 8 4 Year!)

Months 20 Days

fid

3 fa oS

I y-*4

Major findings: . - a i

Of operations. ...Xj...Q....C>l.XT.

Date of operation. Was autopsy performed? J'i. S'

confirmed diagnosisCLl .‘Vl.l.C.R. ./ ..-t' La. b e ,

What test (

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

If so, specify !i IT.

(Signed»fc.c4^\> i'h. /, M., D

(Addr^gQ \ vL-L.LLv... yi — Datg' Vvi » 1 /

6 .... Union 0 erne t efy, s Hbank i in , Mas

Place of Burial or Cremation (City or Town)

DATE OF BURIAL J

7 NAME OF
FUNERAL DIRECTOR.

Received and filed

ADDRESS 17 4 Win t hr op 3 1 . T/ in t hr op

iLftfC264966

.19

(Registrar)

PERSONAL AND STATISTICAL PARTICULARS

8 SEX

Female

9 COLOR OR RACE

’.Vhite

10 SINGLE
MARRIED
WIDOWED
or DIVORCED

sTngle

word)

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.

If under 24 hours

Hours Minutes

13 Usual

Occupation:

, Treasurer

(Kind of work done during most of working life)

14 o?dBusr.yness: Franklin Savings sank

15 Social Security No.

16 BIRTHPLACE (City)
(State or country)

.051r-Q5-0651-A
Bath

Maine

17 NAME OF

father Oliver Webster Lincoln

18 BIRTHPLACE OF

'Washington

FATHER (City)

(State or country)

Maine

19 MAIDEN NAME

OF MOTHER

Narcissa 'Williams

20 BIRTHPLACE OF

Bath

MOTHER (City) ...

(State or country)

Maine

(Address)" 9 Q OoHn ' ^

Informant

ew s

Tint hr op"'

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

ss .

/ / (Signature of 4 of Health or other) _

..ok* jl 'Z.&4Z*. *

if Issue of IJerm

(Official Designation)

(Date ol

rmit)

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 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
!J ^1pf(^jiiati°r._ which can be obtained as to the deceased, or as to the manner or
’ ~cwi£l fify t£ <j£ath, which the clerk or registrar may require. — Chap. 114, Sec. 45,
G. L.. (Tercentenary Edition).

death of a person whom he has attended during his last illness, at the request''*- "TfO-1 •_ „■ , ,, . . ...

of an undertaker or other authorized person or of any member of the family nf\Y MfeJW examiners shall make exammat.on upon the view of the dead bodies
the deceased, furnish for registration a standard certificate of death, stating tqjhe /'v aS are SUDDOSe“ to have died bv violence, or hv the action of

best of his knowledge and belief the name of the deceased, his supposed age. j be" iTjf

disease of which he died, defined as required by section one, where same^yaffl ,0.
contracted, the duration of his last illness, when last seen alive by the ph5fsi<3att'.y' ‘
or officer and the date of his death. . .Gen. Laws. Chap. 46. Sec. 9,

if , as are supposed to have died by violence, or by the action of

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