The volume, 1957

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VI R-301 A

rRUCTIONS

FOR

L CERTIFICATE

l giving
OF DEATH

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

does not mean
de of dying,
heart failure,
, etc. It means
use, or compli-
which caused

ions, if any,
gave rise to
cause (a),
i the under-
cause last.

'itions contrib-
dcath but not
o the terminal
:ondition given

• Chapter 137,
1954, requires
ins to print or
lie cause or
of death on
ertlflcates.

^ o FFcx /\

(County)

W'/AsrniiDP

(C.ty or Town) jjj f CERTIFICATE

®1?£ (Hommonuipaltl) nf iKaHHarljuBPlla

EDWARD J. CRONIN

Secretary of the Commonwealth

DIVISION OF VITAL STATISTICS

STANDARD

TIFICATE OF DEATH

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

Registered No

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

2 FULL NAME... ./.....U.UyT... fj 0 U/j C A IAJl L 0 jV/l A O f ™YSI,CIAN ~ IMPORTANT

(fl deceased is a married wiHmvpH nr /Tisrnm»/T uromo^ : \ < S. as 5"cea??^ a

deceased is a married, widowed or divorced woman, givl aiso maiden name.)

(a) Residence. No Z2± S Hi 'UP f. • ST

(Usual place of abode)

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

f (

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

(If nonresident, give city or town and State)

..months days.

3 DATE OF
DEATH ....

MEDICAL CERTIFICATE OF DEATH

zmt / /fsr

(Month)

(Day)

(Year)

Due To

(b)

k L7tr&i0-JC £C acT/c- a. * <k
rf HPt^a reti WcT jfe r v/j,

Due To
(c)

OTHER

SIGNIFICANT

CONDITIONS

4 . 1 HEREBV CERTIFY, That I attended deceased from

CCT ? */ «. J-J <t.N / y£Z

I last saw h-^^live on . TJTtr/^ /..... ■-£ T.J, death is said to

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

DEATH WAS CAUSED BY: IMMEDIATE CAUSE

(a) ±

INTERVAL
BETWEEN
ONSET AND
DEATH

A *•><$

xy^.

8/SEX

PERSONAL AND STATISTICAL PARTICULARS

9 COLOR

p L

Xctj

10 SINGLE (write the word)
MARRIED

WIDOWED t J ,

or DIVORCED LAs (/m'c-X'U

Was autopsy performed ?..Af...C,...'.

What test confirmed diagnosis L..jC~/tLJ..A'.../..C...^...T.

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

(Signed) ^ ’ /C^V

(Address).k?:ir:./,.A J..J ^

— ~r i£:r*j riHltrf —

10a If married, widowed, or divorced

HUSBAND of ,

<TTT^- (Give maiden tjame of (wife in fuiij / J

(or) wife of Ud^u&jfcs.s. !.1!<l LTTrniLiCef

(Husband’s name in full)

11 IF STILLBORN, enter that fact here.

AGE/....(j...Years...(r. Months.-^ Days

13 Usual
Occupatio:

If under 24 hours
Hours Minutes

(Kind of work 4tme during most of working life)

14 ™xiLnJETl TTT

15 Social Security No._„

16 BIRTHPLACE (City)_(^....‘r..'X..^V . C;.

6 " ~ ' . tL1 jvvA/tu yf

Place of Burial W Cremation 1 (City of Town) T.

„.jL.Tvyl. i

DATE OF BURIAL

7 NAME OF

FUNERAL DIRECTOR ,t %

ADDRESS

Received and filed..

nm.

19..

(Registrar)

ri ki nrLAUL , ,

(State or country) j) j fa /jQx 1 V

17 NAME OF / . ' // / f' /

FATHER

cl v y /

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

19 MAIDEN NAME
OF MOTHER

20 BIRTHPLACE
MOTHER (City)'

^VHHcO T^ Y'^AtAlU.'

MEp / ~A~ f

£ OF //; / / ///

country ) T'TJl VLtTJ

Informant—:

(Address)

pte or cou

Trie

Satisfactory standard certificate of death
burial or transit. permit was issued:

^(S||tnat»ir^ of Ajrmt of Hoard of llvnlth or o

,ijk.

(("fficial Designation)

(Date of Issue of

EXTRACTS

FROM THE LAWS OF THE

COMMONWEALTH OF MASSACHUSETTS

GOVERNING THE

RETURN OF CERTIFICATES OF DEATH

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

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

No undertaker or other person shall bury or otherwise dispose of a human body
in a town, or remove theretrom a human body which has not been buned, until he
has received a permit from the board of health, or its agent appointed to issue
such permits, or if there is no such board, from the clerk of the town where the
person died; and no undertaker or other person shall exhume a human body and
remove it from a town, from one cemetery to another, or from one grave or tomb
other than the receiving tomb to another in the same cemetery, until he has
received a permit from tne board of health or its agent aforesaid or from the clerk
of the town where the body is, buried. No such permit shall be issued until there
shall have been delivered to such board, agent or clerk, as the case may be,
a satisfactory written statement containing the facts required by law to be
returned and recorded, which shall be accompanied, in case 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 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.

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

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

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

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

SPACE FOR ADDITIONAL INFORMATION

DATE OF ENTERING MILITARY SERVICE

DATE OF DISCHARGE

RANK, RATING

ORGANIZATION AND OUTFIT.....

SERVICE NUMBER

[ R-301 A

AUCTIONS

FOR

CERTIFICATE

giving

OF DEATH

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

does not mean
e of dying,
heart failure,
etc. It means
se, or compli-
which caused

ons, if any,
gave rise to
cause (a),
the under-
cause last.

itions contrib-
death but not
o the terminal
ondition given

• Chapter 137,
1954, requires
ins to print or
le cause or
of death on
ertlflcates.

<?,

i a

1°

►4

> Oi

2 FULL NAME.

(County)

(Eflmmmtuifaltl) of fHaasarijuarttB

EDWARD J. CRONIN

Secretary of the Commonwealth

DIVISION OF VITAL STATISTICS

STANDARD

CERTIFICATE OF DEATH Registered No

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

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

W/A/r# ro /°

(city orlrown) CERTIFICATE OF DEATH

A^/^r /H*.S'//oWDQ/l/' _f (Was deceased a

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

J J77 _ , {^qalASM ^ —

(If nonresident, give city or town and State)

(a) Residence. No

(Usual place oi abode)

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

MEDICAL CERTIFICATE OF DEATH

3 DATE OF
DEATH ...

(Month)

-2rz. /...XS..J.....

(Day) (Year/

4 I HEREBY CERTIFY, That I attended deceased from

i9i.l:!_to ,

I last saw h.fjKalive on Q&V......:**?.. 19l., Y, death is said: to j

have occurred on the date stated above, at m

DEATH WAS CAUSED BY: IMMEDIATE CAUSE

(a)

fb1)6 To o -SCfii-E/ZtT/C //£*&!

3><s.

Due t° ^ s-fi/re,# u /jt e Tire- > * ~SC/.£ esJO

OTHER ^ S 0 J / £ (!)

SIGNIFICANT

CONDITIONS ^ e r/jdif S T'e SP'Ae t5 ( kdi'U'

>.k..!7L

A/ if (kp!

INTERVAL
8ETWEEN
ONSET AND
DEATH

2^X3*

I VtL.

u y ru

i ui;<*

Was autopsy performed?.... AJ...C

What test confirmed diagnosis?.., C-A.l.M..LQ..±L. -

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

(Signed).

M. D

). V\ ^

(Addre»»)>l;>r:^^^^^^^^ Date...^/^. 193,./7

Place of Burial or Cremation

DATE OF BURIAI

7 NAME OF
FUNERAL DIRECTOR

ADDRESS W/.ArryX'W

(Registrar)

PERSONAL AND STATISTICAL PARTICULARS

8_SEX

9 COLOR

J/ jUJ.JlM

10 SINGLE (write the word)
MARRIED n
WIDOWED ) /

or DIVORCED^ ^ L y

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.

12
AGE

SA Years // Months S.L

Days

If under 24 hours
Hours Minutes

13 Usual S7*

Occupation

(Kind of work done during most of working life)

14 S*g£»., ty. stdiv^:

'Kind ot wort

15 Social Security No.. 1

16 BIRTHPLACE (CityYC

( S t ate or country) //.L 06

ZZ Z O^' ~

FATHER14^1/ tLjivri •! > n Oi "pL fl

(State or country) ,jX. /rj sbLQ'Yl, <^u(r -U

18 BIRTHPLACE OF
FATHER (City)

19 MAIDEN NAME
OF MOTHER

t Cjl >

20 BIRTHPLACE OF
MOTHER (C
(State or country

JhXM..

ity) . *■ — * ^

try) 7Ivir jj W

sLtt^kLL^-s .s

C , lm/.l u-

RTIFY that /satisfactory standard certificate of death
e BEBORE tne burial or transit' permit was issued:

; I

;(ire of4Ajf<hy^f Board of Hoalpi or^other )/

(Official Designation (Date of Issue of Per/iit)

EXTRACTS

FROM THE LAWS OF THE

COMMONWEALTH OF MASSACHUSETTS

GOVERNING THE

RETURN OF CERTIFICATES OF DEATH

A nhvsician or registered hospital medical officer shall forthwith, after the
deathkif 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 fam'ly 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 ahveby 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 icbon or bv section forty-five of chapter one hundred and four-
ten shall if the deceased, to the best of his knowledge and belief, served m tho
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
sHalUlso certify in such certificate both the primary and the secondary or ‘^me-
diate ca^se 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 di ollare.
For the purposes of this section and of sections forty-five, forty-si^and forty seven
of said chapter one hundred and fourteen, the word war shall include the China
relief enpe<£tion 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 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 ?o^n 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 ?han 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 thecase may b .
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
physieikn! or if. for Sufficient reasons. h,s certificate cannot be obtained ear y
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. shaU upon
application make the certificate required of the attendmgph^ician. Ifdeath is
caused by violence, the medical examiner shall make such certificate. If sucha
permit for the removal of a human body, not previously interred,
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
fheundertaker desiring to make such removal shall constitute a permit f? L “
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 m the usual
form for the removal of such body has been sooner obtained hereunder, it tne

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, bee. 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 ot
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 194S.

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 ot 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-

mg J jng 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 of1 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 mdirrctly by
traumatism (including resulting septicemia), and by the action ^chemical
(drugs or poisons) thermal, or electrical agents, and deaths following abortion .but
also deaths from disease resulting from lnjuiy 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^ntry in t^is section for every person aged 10 years or over If ‘heoccupa-
tion had been given up or chanced, or if the deceased had retired from
report the kind^f workdone dunng most of working life evemf retired Children
not gainfully employed may be returned as at school or athome. Fora woman
whose only occupation was that of home housework, write housework. For a
person engaged in domestic service for wages, however, designate the occupation
K^he appropriate terms, as housekeeper-private family, cook-hotel, etc. For
a person who had no occupation whatever write none.

SPACE FOR ADDITIONAL INFORMATION

DATE OF ENTERING MILITARY SERVICE

DATE OF DISCHARGE

RANK, RATING

ORGANIZATION AND OUTFIT

SERVICE NUMBER..

[ R-301 A

-Jb

IUCTIONS

FOR

CERTIFICATE

giving

OF DEATH

lot enter
than one
lor each
(b) and (c)

does not mean
e of dying,
heart failure,
etc. It means
se, or compli-
which caused

ons, if any,
lave rise to
cause (a),
the under-
cause last.

i tions contrib-
death but not
•> the terminal
ondition given

Chapter 137,
1954, requires
ns to print or
te cause or
of death on
srtificates.

mi&M£

(City or Town) .... _ _

_. _ *.{<&$

AMJ=d£ 1 A, AliRALt. (2 r <TssSI-,IMP0RtA''T

©Ije (Emammutiealtlj of Maonarljuartta

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

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

-2 FULL NAME

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

(a) Residence. No. 77 CoTAER

(Usual place of abode)

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

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

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

A1EDICAL CERTIFICATE OF DEATH

I last saw h.Tr.alive on

have occurred on the date stated above, at

DEATH WAS CAUSED BY: IMMEDIATE CAUSE

(a) /{

Due To
(b)

CALUTi

,MAhLY.. L ..atahAhy..

&<-£■ (U. 3 j oh , — 7—

Due Ti

(C)

OTHER

SIGNIFICANT

CONDITIONS

J) is

Was autopsy performed?

What test confirmed diagnosis? .^£*1

l a

5 Was disease or injury in any way related to occupation of deceased ?-/9r*4--

^ ^ Ji~— Zpat eA..JLg&4!} 1 9^..

Place of Burial or Crlrmation ^City or Towifl

DATE OF BURIAL

7 NAME OF
FUNERAL DIRI

ADDRESS r

Received and filed...

.19...?.../

:FJTOR/^S^iZ

.19.

(Registrar)

PERSONAL AND STATISTICAL PARTICULARS

8 SEX

9 COLOR

VMM \AmiTl-

10 SINGLE
MARRIED
WIDOWED
or DIVORCED

(write the word)

M QOK/

10a If married, widowed, or divorced

HUSBAND of.... . -

, — - — (Give maiden name of wife in full)

(or) WI FE 0id.AMkS .

(Husband’s name in full)

11 IF STILLBORN, enter that fact here.

AGE

81)

Years Months... Days

If under 24 hours
Hours Minutes

U Occupation:. A~C U 6. £. Alll.t.

(Kind of work done during most of working life)

° was H-o a) l-

15 Social Security No A.\A...2. ‘A. . . A..

16 BIRTHPLACE (City

(State or country) p<j /V /

17 FATHER** j// ^ LJ Ml l.l'l. 7 0 ,S* / (?K~

18 BIRTHPLACE OF
FATHER (City)

(State or country) Pft / /v c, A i70 id /l if )1 ru

19 MAIDEN NAME
OF

[DEN NAME „ A. ‘

MOTHER / t/ A A, X HO AVV/^t )U

20 BIRTHPLACE OF “‘j U "2--6

MOTHER (City).......... ’..1^.

(State or country) /Is /T /L / /,7 A 0 A'A & / C-->T

T'd A A’ Z7?

(Address) / C» j, / Zj iL~ I). 5 7T t'C / jb__L

REay CERTIFY that ylatisfactory standard certificate of death
lit)( me B^pRE tfir buriaj or transit permit was issued:

EXTRACTS

FROM THE LAWS OF THE

COMMONWEALTH OF MASSACHUSETTS

GOVERNING THE

RETURN OF CERTIFICATES OF DEATH

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

A physician or officer furnishing a certificate of death as required by the
preceding section or by section forty-five of chapter one hundred and four-
te n, 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

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

RULES OF PRACTICE

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

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

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

Statement of Occupation. — Precise statement of occupation is very import-
ant, so that the relative healthfulness of various pursuits can be known. Make
spme entry in this section for every person aged 10 years or over. If the occupa-
tion had been given up or changed, or if the deceased had retired from business,
report the kind of work 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

Eerson engaged in domestic service for wages, however, designate the occupation
y the appropriate terms, as housekeeper — private family, cook — hotel, etc. For
a person who had no occupation whatever write none.

SPACE FOR ADDITIONAL INFORMATION

DATE OF ENTERING MILITARY SERVICE

DATE OF DISCHARGE

RANK, RATING

ORGANIZATION AND OUTFIT

SERVICE NUMBER

R-301 A

UCTIONS

FOR

CERTIFICATE

giving

OF DEATH

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

loes not mean
? of dying,
heart failure,
etc. It means ^
c , or compli-
vhicli caused

»ts, if any,
mve rise to
cause (a),
the under-
cause last.

tions contrib-
dcath but not
i the terminal
mdition given

Chapter 137,
1954, requires
ns to print or
e cause or
>f death on
rtiflcates.

(Eommnnuifaltlj of JflaaaarijusFtts

EDWARD J. CRONIN

Secretary of the Commonwealth

DIVISION OF VITAL STATISTICS

STANDARD

i (County)

lUt A/tH /tV/°

(City or "Town) P . CERTIFICATE OF

nW/A^ffi ftur Oc/M MU A/ Ilf /r #5/. £ | XViaSKti

ZTcH-y , f? CdUA/TAiVAr'

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

CERTIFICATE OF DEATH Registered No.

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

PHYSICIAN — IMPORTANT
(Was deceased a
U. S. War Veteran,
if so specify WAR).!.™...

mt/j:

2 FULL NAME...

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

(a) Residence. No /A SF/'A?0L,rt SI. _ ~ r _

(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 residenceT^.years months days.

MEDICAL CERTIFICATE OF DEATH

3 DATE OF
DEATH ....

January 3. 1.95.7

(Month) (Day) (Year)

That I attended deceased from

4 I HEREBY CERTIFY,

Mar ch j> 3, 19 45 t0 January. 3 19.5.7

I last saw hlTDalive on . ...Jan..*. .3 , 19... 5.7 death is said to

have occurred on the date stated above, at .9:45 a.

DEATH WAS CAUSED BY: IMMEDIATE CAUSE

(a) HhQ.uma.ti.tt ...he art disease

Due To
(b)

Due To
(c)

significant Chronic pylo nephr.i.tid3 7yrs

CONDITIONS

INTERVAL
BETWEEN
ONSET AND
DEATH

IQyrs

Was autopsy performed ?...i3LQ. **...* + ~ _ —

What test confirmed diagnosis? Q..1..1.R.1..Q &.X -

5 Was disease or injury in any way related to occupation of deceased? — a.o
If so, specify

(Signed M. D.

(Address). .562 Shirley St , Date 1/3. 19 5.7

/Jinthrop

Place of Burial or Cremation

DATE OF BURIAL

Winthroo

(City or Town)

,.J.§.7.r. 5..... 1 9...5.J

7 NAME OF
FUNERAL DIRECTOR

. /LCSasvwC /\y

ADDRESS

Received and filed

ZIMZ, Z. las.1

(Registrar)

PERSONAL AND STATISTICAL PARTICULARS

8 SEX

9 COLOR

IMa l Wit i L u

10 SINGLE
MARRIED

(write the word)

MARRIED i\ . ., On

widowed / 7 /r If Jr I V)

or DIVORCED J

10a If married, wj^owe;
HUSBAND of.

7. frrftn t.E’d $ T±. <■ n a £

(Give maiden name of wife in full)

(or) WIFE of..

(Husband’s name in full)

11 IF STILLBORN, enter that fact here.

AG Ai . Years... C. Months.. LL ..Days

If under 24 hours
Hours Minutes

13 Usual

Occupation :

Electrician

(Kind of work done during most of working life)

14 !"d BusLess : C..Q.at.r..a.c.t..Q2".

15 Social Security No—.

1 6 BIRTHPLACE (City ) _....C SOe iaPle I.S 1.6

(State or country) j\ QV Q, S C 0 1 1 8.

17 NAME OF
FATHER

Samuel Count away

18 BIRTHPLACE
FATHER (City)..

(State or country) i'jQVa SCOtia

SlMMLtJl (-■ QIAia

19 MAIDEN NAME y

OF MOTHER f /to /r

Am.

7 /<J 5

20 BIRTHPLACE OF
MOTHER (City)

Ua/A BL/.r tii OjUAl/kf

(State or country) /ff /f ,5 fj /j L. /~t Q‘

ATT S

21 informant.1^.Aur.ll.la....d.pnatava-y.s.

(Address) 1? Seymour st. lint]

jiroD.

I HEREBY CERTIFY that a satisfactory standard certificate of death
was filejLpvith me BEFORE (he by rial ^or transit permit was issued:

filecLwith me BEFORE the by rial or transit permit was issued:

M c4a&.£. _ JpfiLi

H.O

(Signature of Agent of Board of Health or other)

■ !/f/b

(Official Designation)

(Date of Issue of Permit)

ih!/

EXTRACTS

FROM THE LAWS OF THE

COMMONWEALTH OF MASSACHUSETTS

GOVERNING THE

RETURN OF CERTIFICATES OF DEATH

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

No undertaker or other person shall bury or otherwise dispose of a human body
in a town, or remove therefrom a human body which has not been buried, until he
has received a permit from the board of health, or its agent appointed to issue
such permits, or if there is no such board, from the clerk of the town where the
person died; and no undertaker or other person shall exhume a human body and
remove it from a town, from one cemetery to another, or from one grave or tomb
other than the receiving tomb to another in the same cemetery, until he has
received a permit from tne board of health or its agent aforesaid or from the clerk
of the town where the body is buried. No such permit shall be issued until there
shall have been delivered to such board, agent or clerk, as the case may be,
a satisfactory written statement containing the facts required by law to be
returned and recorded, which shall be accompanied, in case 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, shaU 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

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

RULES OF PRACTICE

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

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

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

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

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

Statement of Occupation. — Precise statement of occupation is very import-
ant, so that the relative healthfulness of various pursuits can be known. Make
some entry in this section for every person aged 10 years or over. If the occupa-
tion had been given up or changed, or if the deceased had retired from business,
report the kind of work done 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
t>y 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 3J.XfJ.Xf...

DATE OF DISCHARGE ...3/12/19

RANK, RATING Seaman

ORGANIZATION AND OUTFIT..../

SERVICE NUMBER.

R-301A

JCTIONS

CERTIFICATE

jiving

)F DEATH

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

ies not mean
of dying,
\eart failure,
tc. It means ^
or compli- *
hick caused

\s, if any,
we rise to
ause (a),
the under-
ause last.

ons contrib -•
eath but not
the terminal
tdition given

Chapter 137,
J54, requires
s to print or
cause or
f death on
tificates.

(Stje (Eflmtttmtutealtfi nf fHassrarljusrtta

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. , .A>

2 FULL NAME-

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

A/OAI&

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

(a) Residence.

(Usual

0-7 y

! PHYSICIAN — IMPORTANT

(Was deceased a ,

U. S. War Veteran, / ]

if so specify WAR) -A.

No SJ-JL
place of abode)

..St..

Length of stay: In place of death.

..years..

. months

(If nonresident, give city or town and State)

days. In place of residence. -TT?:- years months-

days.

MEDICAL CERTIFICATE OF DEATH

CERTIFY, That I attended deceased from

H , 19.j5 (b. , to y 19.S...Z

I last saw h relive on ' M , i9-J-'7, death is said to

have occurred on the date stated above, at __ y.'jteA i_m. I INTERVAL

BETWEEN
ONSET AND
DEATH

DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a) (2.&y cLt'Ji-S. j) fiCc q/>' om...

PK"eTo/f r/’gVt,Qge/e^rg/.Nc //e*rh
} 5 j~c ■

Due To
(c)

OTHER
SICNIFICAN
CONDITIONS.

JLVUJjAA #_

a '

JLJu/'uS -

Was autopsy performed?- ,

What test confirmed diagnosis ?QiiMSJLAl hhd ope .

S Was disease or injury in any way related to occupation of deceased ?A ff.
If so, specify •'0

M. D.

Date J CiK ? A 19 i 7

(Address)

Place of Burial or Crem;

Received and filed

(Registrar)

PERSONAL AND STATISTICAL PARTICULARS

8*S£X

9 COLOR

10 S’hNOLK** (write the word)

M-*rR R HvB ) r / /;

WI DOWED l*

ji mVORCED

10a If married, wLdbhved, or divorce^/ •

HUSBAND of

(Give maiden name of wife in full)

(or) WIFE of

(Husband’s name in full)

11 IF STILLBORN, enter that fact here.

AGE Si Years

Months Days

If under 24 hours
Hours Minutes

13 Usual

Occupation:

(Kind of work done during most of working life)

14 Industry
or Business:

15 Social Security No

16 BIRTHPLACE (City)

(State or country)

17 NAME OF
FATHER

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

19 MAIDEN NAME
OF MOTHER

20 BIRTHPLACE OF

MOTHER (City)

(State or country)

I HEREBY CERTIFY that a satisfactory standard certificate of death
was filed wd^h me BEFORE the ht^rial or transit permit was issued:

f, q_

(Signature of Agent of Hoard of Health or other)

(Official Designation)

EXTRACTS

FROM THE LAWS OF THE

COMMONWEALTH OF MASSACHUSETTS

GOVERNING THE

RETURN OF CERTIFICATES OF DEATH

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

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.

. . . 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

1 R-301A

RUCTIONS

FOR

CERTIFICATE

giving

OF DEATH

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

lots not mean
t of dying,
heart failure,
etc. It means -
e. or compli- ~ ^
which caused

ns, if any,
’,ave rise to
cause (a),
the under-
cause last.

ions c ontr ib- ■
death but not
i the terminal
sndition given

Chapter 137,
1954, requires
ns to print or
>e cause or
of death on
rtiflcates.

IM
H
<
W
Q
f*
O
w
u

..dill fork:

(County)

a ^ x'

--Wl-nt-faro-p

(City or Town)

ull|? Qlmnmmtuintltlj nf fHasfiarljUMtta

EDWARD J. CRONIN

Secretary of the Commonwealth

DIVISION OF VITAL STATISTICS

STANDARD
CERTIFICATE OF DEATH Registered No.

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

Jh_

No Community Hospital

2 FULL NAME Cl &T3. 3©1-1-© ( Y> Q ) Bl3?4 -

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

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

! PHYSICIAN - IMPORTANT

(Was deceased a

U. S. War Veteran, .T~.

if so specify WAR) Jjl.U*--

(a) Residence. No

(Usual place of abode)

Cedar Lane

St. .

- Ma«s. --- — -

Tlf nonresident, give city or town and State)
Length of stay: In place of death years months^ Q days. In place of residence .^.Qyears months days.

MEDICAL CERTIFICATE OF DEATH

3 DATE OF
DEATH __

January

(Month)

(Day)

HEREBY C E R T I F That I attended deceased from

JilQd/k.. , 19--?._/T to ./^^1'. ..■/ 19_£%.

last saw bSflalive o ' 19-!2-_^, death is said to

have occurred on the date stated above, at

DEATH WAS CAUSED £Y: I^EDIATE CAUS^

M y oU 0 I \L_ G | I o

(a) jA*. Uf' 1

l\s

INTERVAL
BETWEEN
ONSET AND
DEATH

*-> (JL3 t- STi V
Due To ^ V,~, 1 _

VA \r i (? f ^ ^

to ^ C^L -S IS

Due To

(c)

OTHER

SIGNIFICANT

CONDITIONS

Was autopsy performed? —

What test confirmed diagnosis?-. SL/cletA. . .£.Jn,8L*er-Tj\Q-..k rft.R.L)./B...

' ^ ^ l\ /l^

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

If so, specify... JNI.O..

6 iVi nt.hr on Tomh

Place of Burial or Cremation
DATE OF BURIAL —

— , M. D

Date")^^:^] -19'

Winthr^n. Mas «

(City or Town)

7 NAME OF
FUNERAL DIRECTOR

AUDRESS 17A fflnthro^ at, Winthrnn

Received and filed JAN 9 1957

(Registrar)

PERSONAL AND STATISTICAL PARTICULARS

8 SEX

female

9 COLOR

white

10 SINGLE (write the word)
MARRIED ijrj 4 .3 toTTftor'3

widowed wiaowea

or DIVORCED

10a If married, widowed, or divorced
HUSBAND of

(Give maiden name of wife in full)

(or) wife of Everett Bird

(Husband’s name in full)

11 IF STILLBORN, enter that fact here.

AGE -O-Q^ears .1 Months ...2— Days

If under 24 hours
Hours Minutes

13 Usual

Occupation:

kitchen work

(Kind of work done during most of working life)

14 Industry
or Business:.

15 Social Security No

restaurant

012- 24-2208- a*

16 BIRTHPLACE (City)

(State or country)

Sagamore

Mass .

17 NAME OF
FATHER

fflnfiaiii Sentt ponne

18 BIRTHPLACE OF

FATHER (City)

(State or country)

Eagtham

Ma«s.

19 MAIDEN NAME
OF MOTHER

Phoebe Rnth Tribna-

20 BIRTHPLACE OF

MOTHER (City)

(State or country)

Norton

Ma«s

Informant

(Address)

E^len M- Doane

51 gremont ^

I HEREBY CERTIFY’ tha ya satisfactory standard certificate of death
was filed with me/T^FQRJv'tHe buriaPor transit permit was issued:

Mas a » X ■ pJ i ’

of Board of Health or other)

Designation)

4 [HMCUeU.

t ' 1/

(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

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

RULES OF PRACTICE

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

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

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

SPACE FOR ADDITIONAL INFORMATION

DATE OF ENTERING MILITARY SERVICE

DATE OF DISCHARGE

RANK, RATING

ORGANIZATION AND OUTFIT

SERVICE NUMBER

IM R-303 A

)

% '

f l

'I°-

** U, «

EfS

3&u

tlex

li!3

UJ ? *

oSSjs j

|_ • 0 U

l5n

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ii-:<

ill • s •

a-wf x

<2s:

251 :

mill

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Id j »

*0“.S
"0“ ?
r“ £-

;-s s

:“.i i

CSb.
3 • *2
■Pa
zlii

2T 3 C 3

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air

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Eigj

JHi

Z 6

(Zlljf (Emnmomnraltlj of MaaaarljitBrttH
EDWARD J. CRONIN
Secretary of the Commonwealth

DIVISION OF VITAL STATISTICS

MEDICAL EXAMINER’S
CERTIFICATE OF DEATH

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

Registered No.

(City or To+n)

St. { give its NAME insi

hospital or institution,
instead of street and number)

2 FULL NAME.

ijSSSSr

' ’ * ' ’ ’ 1 U. S. War Veteran.

I if so specify WAR).

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

(a) Residence. No,

(Usual place of abode)

of abode) «

IMPORTANT

(If nonresident, give city or town and State)

Length of stay: In place of death ...5. years months days. In place of residence. .!*?. years months days.

MEDICAL CERTIFICATE OF DEATH

3 DATE OF
DEATH ...

7 — tj)S"7

lonth) {Pay) (Year) /

41 HEREBY CERTIFY that I have investigated the death
of the perscm above-named and that the CAUSE AND MANNER thereof
are as follows: (Irah injyffy was involved. State fully.

<Z/t

5 Accident, suicide, or homicide (specify)

Date aiyl-hour of injury 19..

Where did

Injury occur?

(City or town and State)

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

place?

I * (How dj4 injury occur?) f

Injury*

While at work? Was autopsy performed?

6 Was disease or injury in
If so, specify
(Signed) r.Y W

(Address) ... M

i related to occupation of deceased?

&Vt-

s concon

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

DATE OP BURIAL :.. .J^.HUt!Xy.....l.O. 19....2

* FUNERAL DIRECTOR !?. *......M.?2.22.™™.

East Boston

ADDRESS

Received and filed .

JM J U lab./

(Registrar)

PERSONAL AND STATISTICAL PARTICULARS

9 SEX

male

10 COLOR OR RACE

white

(write the word)

11 SINGLE
MARRIED
WIDOWED irnwvij - j
or divorced ^rr led

11a If married, widi
HUSBAND of

(or) WIFE of..

>B&r<anf. Bradley

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

12 IF STILLBORN, enter that fact here.

AGE

IQ.

Years Months Days

If under 24 hours
Hours Minutes

14 Usual

Occupation:

Captain

(Kind of work done during most of working life)

15 o?dBus7ne£:Oston Fire Dept, retired

16 Social Security No..

Charlestown

17 BIRTHPLACE (City) V.U.S'A.*.'?.. ^.!..V.y..”.7.t?fr.#s.,

(State or country)

Mass",

18 NAME OF _ ,
FATHER John

J. Phelan

19 BIRTHPLACE OF

FATHER (City)

(State or country)

South Acton

Macs.

20 MAIDEN NAME

OF MOTHER

Mary A . Donovan

21 BIRTHPLACE OF

MOTHER (City)

(State or country)

Ireland

Informant

(Address)

Helen A. Phelan
’ '5 " ' B d 'T T d'xnjo' ' ' ’ m'a'r’r . h f ,h r n h

riFY that a satisfactory standard certificate of death was
)RE the burial or. transit permit was issued:

(Signature of Agent^Erf Board of Health oc.

... jrFJf .

(Official Designation)*""^ "*"jb (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
of 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 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

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

of the cemetery -or burial-ground in which the interment is made Chap. 114,

Sec. 46. G. L., as amended.

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

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

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

RULES OF PRACTICE

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

(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

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

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

SPACE FOR ADDITIONAL INFORMATION

DATE OF ENTERING MILITARY SERVICE

DATE OF DISCHARGE

RANK, RATING

ORGANIZATION AND OUTFIT

SERVICE NUMBER

f R-301A

AUCTIONS

FOR

CERTIFICATE

giving

OF DEATH

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

loes not mean
f of dying,
heart failure,
etc. It means ^
e , or compli-
which caused

ns, if any,
\ave rise to
cause (a),
the under-
cause last.

ions contrib -■
death but not
the terminal
indition given

Chapter 137,
1954, requires
ns to print or
e cause or
of death on
rtificates.

L\<

(County)

° IaJ I Nrfrlo -

(City orJTown)

Olfyp (Enmmomupaltlj nf fHaairartyuupttii

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. s— 7.

No...

2 FULL NAME- sfc'.l

VOifcVWvkVv 14-oVvi'

" ; J Vl^'

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

(a) Residence. No

(Usual place of abode)

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

I PHYSICIAN — IMPORTANT

J (Was deceased a

I U. S. War Veteran,

' if so specify WAR)

__ st. _W 'irs\\\\r_p )[ —

(If nonresident, give city or town and State)

Length of stay: In place of death X- . years— months days. In place of residence^?. — years months days.

AL CERTIFICATE OF DEATH

(Year)

4 1 H EREBY CERTIFY, T)»at I attended deceased from

. 1— , i9-£T, to Sah. n _J_3L^l 7, 19

I last saw h A* alive on K ^ 19 , death is said to

1,0

have occurred on the date stated above, at J. *._• T ) m.

8 SEX

9 COLOR /

DEATH WAS CAUSED BY: IMMEDIATE CAUSE

(a) CTe.WC,VAl-l'z.g, o

g .j. fe_r v o * i' a

Due To
(b)

Due To
(c)

QLj iv Q i tv iB try H & IVj'*

OTHER

SIGNIFICANT \ A tS ^

CONDITIONS /V\ U-V-v’-T- V $

INTERVAL
BETWEEN
ONSET AND
DEATH

1*%

Was autopsy performed ? — — _ i-

What test confirmed diagnosis?- ^ V m ^ ^ ^ ^ ^ ^

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

(Signed) XBr ^" M *y C3^T’'E. L-VJ M D

(Address) t4— T) I'V) b ate -S?

6 C - : .

Place of Burfal or Cremation

DATE OF BURIAL

7 NAME OF
FUNERAL DIRECTOR

(City or Town)

19.1’ '

ADDRESS £-L

Received and filed

.JAILS1 1957

£52 1//ZS'

(Registrar)

PERSONAL AND STATISTICAL PARTICULARS

10 SINGLE (write the word)
MARRIED
WIDOWED

or DIVORCED . ' - k-

10a If married, widowed, or divorced
HUSBAND of

(Give maiden name of wife in full)

(or) WIFE of

(Husband’s name in full)

11 IF STILLBORN, enter that fact here.

AGE -1 ' Y

ears Months —I)ays

If under 24 hours
Hours Minutes

13 Usual

Occupation:

7^T~1

(Kind of work done during most of working life)

14 Industry
or Business:

i/1/

15 Social Security No

16 BIRTHPLACE (City).
(State or country)

17 NAME OF

. y

126=:^.

18 BIRTHPLACE OF

FATHER (City)..

(State or country)

JC -3_

.• y /?

■

19 MAIDEN NAME
OF MOTHER

v^JL

/)k a-

N yf

20 BIRTHPLACE OF

MOTHER (City)

(State or country)

Informant

(Address)

.. — t

I HEMBY.Cf
was^led

(Official Designation)

IFY that a satisfactory standard certificate of death
TEFQRlE the burial or transit permit was issued:

3oard of Health or tyfUt/)

(./.$// *

(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. 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

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

R-301 A

ICTIONS

CERTIFICATE

jiving

IF DEATH

t enter
han one
for each
i>) and (c)

ies not mean
of dying,
tart failure,
!c. It means
or compli-
fetch caused

is, if any,
ve rise to
ause (a),
'he under-
juse last.

ons contrib- -►
cath but not
the terminal
edition given

Chapter 137,
954, requires
is to print or
! cause or
I death on
rtificates.

.Suffolk

(County)

Winthrop

(City or Town)

115 U^l^nd- RojacL

(EflmmRttuiraltlj nf Haasarljuartts

EDWARD J. CRONIN
Secretary of the Commonwealth

DIVISION OF VITAL STATISTICS

STANDARD

CERTIFICATE OF DEATH

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

Registered No _

No..

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

2 FULL NAME..

r PHYSICIAN — IMPORTANT

„ , Wal ter , Har old, S i ft er .. J (Was deceased a

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

l if so specify WAR)

(a) Residence. No. 1.15 upland Road st

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

Length of stay: In place of death....<i.Qyears months days. In place of residence 25 years months days.

MEDICAL CERTIFICATE OF DEATH

3 DATE OF
DEATH ....

- 10 19.57

(Day) (Year)

4 I HEREBY CERTIFY,

1. , 19....7T:..., to

That I attended deceased from
I! , 19....ZL.

DEATH WAS CAUSED BY: IMMEDIATE CAUSE

w CJUdS&S

Due To

(b)

fi./.xesu-

t C~ .a. to- n s y •

Due To
(c) -

£)cc/hs/o^\

OTHER

SIGNIFICANT

CONDITIONS

I last saw h Talive on 1 , 19 , death is said to

have occurred on the date stated above, at n

INTERVAL
BETWEEN
ONSET AND
DEATH

Was autopsy performed I

What test confirmed diagnosis?

C r emafcd on . jif-oodl a

Place of Burial or Cremation
DATE OF BURIAL

7 NAME OF
FUNERAL DIRECTOR

#yfSss®*«*

PERSONAL AND STATISTICAL PARTICULARS

8 SEX

male

9 COLOR

white

10 SINGLE (write the word)
MARRIED

widowed married

or DIVORCE#1 J"t L

10a If married, widowed, or divorced

husband of...,, jn«.. Vera Min er-.

(Give maiden name of wife 1

(or) WIFE of..

in full)
(Husband’s name in full)

11 IF STILLBORN, enter that fact here.

AGE 70 Years. ^..Months.l.fi.Days

If under 24 hours
Hours Minutes

13 Usual

re §l^worft^)ne tfurtng^riost stums***

14 Industry

or Business :.wkol a sal e jf a rdWar 8 Q »

15 Social Security No..

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

Iowa

17 NAME OF
FATHER

G-eorge W^Rhington sialer

:e of

18 BIRTHPLACI

FATHER (City) ^.t-ORWOOd

(State or country)

19 MAIDEN NAME
OF MOTHER

ADDRESS

174 H int hrorv Sir, Wtnt hro^ ;

Received and filed.

JAN -ff-jg:

19..

ElL

(Registrar)

20 BIRTHPLACE
MOTHER (City).
!l, Mas or country)

ganr let ta ^Be&eTTr

..P..e..or.la_....- Molina

in inoi-a

Informant Mlf-Rv 1 0F H « 6P

(A.hircss) ^^ RQaeLffirvb hroo

I HEREBY JGJLRTIFW that a satisfactory s^ndard certificate of t(path
as filed with /nie/B EF E the IrUfial or t/ansit permit was issued:

EXTRACTS

FROM THE LAWS OF THE

COMMONWEALTH OF MASSACHUSETTS

GOVERNING THE

RETURN OF CERTIFICATES OF DEATH

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

A physician or officer furnishing a certificate of death as required by the
preceding section or by section forty-five of chapter one hundred and _ four-
ten, 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 tne board of health or its agent aforesaid or from the clerk
of the town where the body is buried. No such permit shall be issued until there
shall have been delivered to such board, agent or clerk, as the case may be,
a satisfactory written statement containing the facts required by law to be
returned and recorded, which shall be accompanied, in case of an original inter-
ment, by a satisfactory certificate of the attending physician, if any, as required by
law. or in lieu thereof a certificate as hereinafter provided. If there is no attending
physician, or if, for sufficient reasons, his certificate cannot be obtained early
enough for the purpose, or is insufficient, a physician who is a member of the board
of health, or employed by it or by the selectmen for the purpose, shall upon
application make the certificate required of the attending physician. If death is
caused by violence, the medical examiner shall make such certificate. If such a
permit for the removal of a human body, not previously interred, from one town
to another within the commonwealth cannot be obtained early enough for the
purpose, the certificate of death made as above provided and in the possession of
the undertaker desiring to make such removal shall constitute a permit for such
removal: provided, that such body shall be returned to the town from which it was
removed within thirty-six hours after such removal, unless a permit in the usual
form for the removal of such body has been sooner obtained hereunder. If the

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
cemeteiy or burial ground in which the interment is made.

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

RULES OF PRACTICE

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

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

(2) Board of Health physicians will certify to such deaths only as those of
persons who, though disabled by recognized disease unrelated to any form of
injury, have died without rgcen<£ 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 jiot only deaths caused directly or indirectly by
traumatism (including reiultmg 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. ' V.

'' ■ V * ">T:

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 orchanged. br if the deceased had retired from business,
report the kind of work dbne 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 ckvnestia servfee-fof wages, however, designate the occupation
by the appropriat^f^p. 4-s Housekeeper— —private family, cook — hotel, etc. For
a person who had no occupation whatever write none.

SPACE FOR ADDITIONAL INFORMATION

DATE OF ENTERING MILITARY SERVICE

DATE OF DISCHARGE

RANK, RATING

ORGANIZATION AND OUTFIT

SERVICE NUMBER

[ R-301A

UCTIONS

FOR

CERTIFICATE

giving

DF DEATH

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

oes not mean
of dying,
heart failure,
tc. It means
r. or compli- '
yhich caused

is, if any,
ive rise to
'ause (a),
the under -
ause last.

i ons contrib - — ^
leath but not
the term-inal
ndition given

Chapter 137,
954, requires
is to print or
cause or
t death on
tlflcates.

Suffolk

(County)

~.7i nth.ro o

(City or Town)

Cmitmmtuiralth of HaaHarljUflrtta

EDWARD J. CRONIN
Secretary of the Commonwealth

DIVISION OF VITAL STATISTICS

STANDARD

CERTIFICATE OF DEATH

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

Registered No.

No inthrop Community Hospital

2 full name Michael PLi__„Hay.es..

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

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

i PHYSICIAN — IMPORTANT

J (Was deceased a

J U. S. War Veteran,
f if so specify WAR)— xiQ

(a) Residence. No. 902 Winthrop Avenue, Revere 51 y Massaeliujetta

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

Length of stay: In place of death years months /— 5 days. In place of residence .56 _ years months days.

MEDICAL CERTIFICATE OF DEATH

3 DATE OF
DEATH _

(Month)

(Day)

.1957..

(Year)

4 I HEREBY CERTIFY, That I attended deceased from

December 29, 1956 t() January 11 w 57

I last saw h_lIBlive on ..January.. 1L_, i957_ , death is said to

have occurred on the date stated above, at 4:02. p

DEATH WAS CAUSED BY: IMMEDIATE CAUSE

(a) -Congestive Car_dia_c.._J

fh)eTo Arteriosclerotic Heart Dis^a

°)c--— -Generalized Arteriosclerosl s

significant . Se condary Anemia

CONDITIONS

Was autopsy performed ?.

INTERVAL
BETWEEN
ONSET AND
DEATH

2 wks.

5 yrs

£ yrs,

2 yrs

What test confirmed diagnosis? NQ T.e St

ary in any w;

5 Was disease or injury in any way related to occupation of deceased ?No
If so. specify.—^}. — ^ —

— f/7 . Y /V

(Signed)..— ^ .

(Address)2.7_ nill.n gt.ftP Date JaH» 12 19 5j

h<-£

, M. D.

6 Holy Cross

Place of Burial or Cremation

date of burial January la.

7 NAME OF
FUNERAL DIRECTO

Malden..

(City or Town)

_i£L

address 876 Yfinthrop Ave. . Revere. Pass ,
; — -3

* i

Received and filed

(Registrar)

PERSONAL AND STATISTICAL PARTICULARS

8 SEX

male

9 COLOR

y/hite

10 SINGLE (write the word)
MARRIED

WIDOWED . ,

or divorced Biarned

10a If married, widowed, or divorced..

Rose E. Dolan

HUSBAND of

(or) WIFE of

(Give maiden name 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 M inutes

13 Usual

Occupation:

Ret. Compositor

(Kind of work done during most of working life)

14 or business : Newspaper

15 Social Security No...

032,0^9301

16 BIRTHPLACE (City)— QjMRridge

(State or country) ’ T TaS S .

17 NAME OF

18 BIRTHPLACE OF
FATHER (City)

(State or country)

Newfoundland

19 MAIDEN NAME
OF MOTHER

Mary Roacn

20 BIRTHPLACE OF

MOTHER (City)

(State or country)

Boston

Pass .

Informant.. lies «... Michael iL ...Hayes

(Address) 9Q2 ~ rinthrop Ave«r Revere

1 HEftEBY CERTIFY that a saK&factory standard certificate of death
^ wav filed /nc BEFtlJJE tha^Dtifial or* transit permit was issued:

... L .

(^si^nature g£^/\|fcnt of Board ot Health-dV otK^r)

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

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 shaU, be accompanied, in case of an original inter-
ment, by a satisfactory certificate of the attending physician, if any, as required by
law, or in lieu thereof a certificate as hereinafter provided. If there is no attending
physician, or if, for sufficient reasons, his certificate cannot be obtained early
enough for the purpose, or is insufficient, a physician who is a member of the board
of health, or employed by it or by the selectmen for the purpose, shall upon
application make the certificate required of the attending physician. If death is
caused by violence, the medical examiner shall make such certificate. If such a
permit for the removal of a human body, not previously interred, from one towrn
to another within the commonwealth cannot be obtained early enough for the
purpose, the certificate of death made as above provided and in the possession of
the undertaker desiring to make such removal shall constitute a permit for such
removal; provided, that such body shall be returned to the town from which it was
removed within thirty-six hours after such removal, unless a permit in the usual
form for the removal of such body has been sooner obtained hereunder. If the

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 &erk of the town where the body is to be buried
or the funeral is to be held, or from a •person appmnted to have the care of the
cemetery or burial ground in which the1 interment is made.

. Chap. 1 14, See.'46; G. L., (Tercentenary Edition).

traumatism (including resulting septicemia), and by the action of chemical
(drugs or poisons) thermal, or electrical agents, and deaths following abortion, but
also deaths from disease resulting from injury or infection related to occupation,
the sudden deaths of persons not disabled by recognized disease, and those of
persons found dead.

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

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

SPACE FOR ADDITIONAL INFORMATION

DATE OF ENTERING MILITARY SERVICE

DATE OF DISCHARGE

RANK, RATING . ,

ORGANIZATION AND OUTFIT
SERVICE NUMBER

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

R-302

Suffolk

(County)

Chelsea

(City or Town)

TJ.S. Naval

No..

QJIjf (EnmmmuuFaitlj cf iEaasarljufiFtta

EDWARD J. CRONIN CholSeft •

Secretary of the Commonwealth (City or Town making this return)

DIVISION OF VITAL STATISTICS

COPY OF

CERTIFICATE OF DEATH Registered No

spital

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

Nomia Ruth Ratliff r

2 FULL NAME • _J (Was deceased a

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

97 Locust Winthrop°,Wa^su.AR)

(a) Residence. No - - St . ..

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

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

MEDICAL CERTIFICATE OF DEATH

3 DATE OF
DEATH ....

Jan. 11, 1957

(Month) (Day)

(Year)

Jan. 8

4 I H E R Ej! Y CERTIFY, That I attended deceased from

57 to Jan. 11, 19 57

Jan . 11 19 57

8 SEX

9 COLOR

Female

White

19..

I last saw h ...T&flve on
have occurred on the date stated above, at

, 19.....V. f death is said to

7: Op R

DEATH WAS CAUSED BY: IMMEDIATE CAUSE

(a)

Transposition of great

Due To vessels

(Conftehi tal heart disease

Due To

(O -

OTHER

SIGNIFICANT

CONDITIONS

INTERVAL
BETWEEN
ONSET AND
DEATH

3 das

Was autopsy performed? jea

What test confirmed diagnosis?

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

If so, specify - .. ...

BiH' 5*1 .0. Cornwell M. d.

Dt.NHf Chelsea D,„ .1/14/ ,,57

Vanhouse Cem . , Patrick, Ky •

Place of Burial or Cremation (City or Town)

DATE OF BURIAL ^.7

.19.

7 NAME OF
FUNERAL DIRE

ADDRESS

Received and filed

Marsh Fun. Horae
Winthrop St . ,Wihthrop

(Registrar of City or Town where deceased resided)

PERSONAL AND STATISTICAL PARTICULARS

10 SINGLE (write the word)
MARRIED ,

widowed Single

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.

12 _ 3

AGE Years Months... Days

If under 24 hours
Hours Minutes

13 Usual
i Occupation :..

(Kind of work done during most of working life)

14 Industry
or Business:

15 Social Security No._..

16 B(S^eHor^AounVy?ty)- Cholfl i

17 NAME OF 1

FATHER i UgXX

18 BIRTHPLACE OF

FATHER (City)

(State or country)

Pat rick, Ky ,

19 MAIDEN NAME

OF MOTHER

Sarah Meade

20 BIRTHPLACE OF

MOTHER (City).....

(State or country)

West Virginia

, , , Tdgil Ratliff

(Address) 97 Locust St .^Winthrop

A TRUE COPY

'j-ijiAtO

ATT EST : /. JL.

^^^gistrar of City or Tow^whcre death occurred)

Jan. 14,1957 19

DATE FILED

OFF/

FEB $61957 HI

25m-(h>- 10-48-24658

..Middlesex..

(County)

OFFICE OF THE SECRETARY

DIVISION OF VITAL STATISTICS

COPY OF

MEDICAL EXAMINER’S
CERTIFICATE OF DEATH

...Cambridge

(City or town making return)

M i

Registered No. .

..Cartb^dg^.

. ry * • I (If death occurred in a hospital or institution.

No. ..dQl^....uJlOS.t< dO.S.p.X.T.e.X. St. \ give its NAME instead of street and number)

2 FULL NAME.

M.‘

ar.y....E* Gorman , ,. I (Was deceased

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

| U. S. War Veteran,
if ^

l if so specify WAR)

124- ...Circuit Hoad st. .Winthrop, :’assac’-usettp

(a) Residence. No.

(Usual place of abode) 0 G

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

(If nonresident, give city or town and State)

days. In place of residence years months days.

MEDICAL CERTIFICATE OF DEATH

3 DATE OF ,
DEATH J.

•12*(Day)9^“

(Year)

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

.....Teminal.-^ronch,opnsninonia

• Intertrochanteric Frac.t.ur.e....jaf*.

Hight--Hip.^I.n.J.ury....rec.Qivfid....in....F£ill.

fife 'hoinfti Accident : -

5 Accident, suicide, or homicide (specify).. Ac..c..x.d0H.tt

Date and hour of injury .D.ac..*......6.» .19 56

Where did ... .

Injury occur? -••InthrOp * ■ -LaSS-*

(City or town and State)

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

If under 24 hours

AGE.

Years

Months

Days

Hours Minutes

place? i.n....horae

(Specify type of place)

Injury of Accidental rail

(How did injury occur?)

Injury 0tn^ert.r..Q.c..han.tcr.i.c Fracture....pf

- •iFal^&P. ...£±P ... Ho .. Was autopsy performed? Ho

Whi

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

If so, specify

(Signed) .PS V I d... * DOW M. D.

(Addres.) Cambridge. , r.as3.» Date 1-12, ,5.7

Holy . Cemetery .';la.?.den,4aa

Place ofminal, or Cremation. (City or Town)

DATE OF BURIAL JanU-.rX 1.5 r 19 57

8 FUNERAL DIRECTOR ..^r.thUI,....jJ.» D f..ll.&l.QX.

:d.nthr.Qp.# Mas. a.«

ADDRESS

Received and filed

££ 19

(Registrar of City or Town where deceased resided)

PERSONAL AND STATISTICAL PARTICULARS

9 SEX

Female

10 COLOR OR RACE

White ;

(write the word)

11 SINGLE
MARRIED
WIDOWED ^ Twry-s

or DIVORCED . 1 0.0 WO I

1 la If married, widowed, or divorced

HUSBAND of

« JGive maiden fame ef wife in full)

\.ilixam J. “orraan

(or) WIFE of

(Husband’s name in full)

12 IF STILLBORN, enter that fact here.

14 Usual

Occupation:..

Housewife

(Kind of work done during most of working life)

IS Industry
or Business:

Own Home

none

16 Social Security No.

17 BIRTHPLACE (City)
(State or country)

Chelsea-

18 NAME OF
FATHER

Jeremiah Driscoll

19 BIRTHPLACE OF

FATHER (City) ■#* ** *n

(State or country) Inland

20 MAIDEN NAME

of mother lien Carey

21 BIRTHPLACE OF

MOTHER (City) Ireiand
(State or country)

Laura

Informan

(Address)

3 Dorman
Circuit Rd» ■■.Inthvop

A TRUE COPY.
ATTEST:

(Registrar of City or Town where death occurred)

DATE PILED

Jan. IV

OFF/.

TOIVa

/. v-rr'9 r v

- %

w% i m

VWW0r'*-

';/4?7 -rntfi''

FEB-41S57 ««

[ R-301A

UCTIONS

FOR

CERTIFICATE

giving

OF DEATH

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

oes not mean
of dying,
heart failure,
tc. It means
e. or compli- *
vhich caused

ns, if any,
ave rise to
cause (a),
the under -
ause last.

ions contrib -■
ieath but not
the terminal
ndition given

Chapter 117,
954, requires
is to print or
t cause or
if death on
rtlflcates.

2 FULL NAME-

Su f folk

(County)

Jlnthrop

(Hty? (ftnmmmmtealtli rtf JHaBHarlpjaetta

EDWARD J. CRONIN
Secretary of the Commonwealth

DIVISION OF VITAL STATISTICS

STANDARD

CERTIFICATE OF DEATH

(City or Town)

Ellen Gertrude Ca-rthorne

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

1 1

Registered No.

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

(a) Residence. No.

59 Sunny side Ave_ _ st

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

! PHYSICIAN - IMPORTANT

(Was deceased a

U. S. War Veteran,

if so specify WAR)

(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 ..JQ years months days.

MEDICAL CERTIFICATE OF DEATH

(Day)

(Year)

4 I HEREBY CERTIFY, That I attended deceased from

, 19..^._5., to l._? , 19l“l

I last saw h.5£alive on — r. JL* , 19. — , death is said to

have occurred on the date stffted above, at n

DEATH WAS CAUSED BY: IMMEDIATE CAUSE

*£ Jh C<ir 7~~ £$9/ f

Due To
(b)

Due To
(c)

OTHER

SIGNIFICANT

CONDITIONS

INTERVAL
BETWEEN
ONSET AND
DEATH

Was autopsy performed?

What test confirmed diagnosis?

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

6 Holy C ros •;

Place of Burial or Cremation
DATE OF BURIAL

(City or Town)

January 17,

" FUNERAL DIRECTOR ^^tbUT J ...0 * .\'U 1 -y

ADDRESS

flnthrop, Ma

s .

Received and filed _ . JAN 1" 1957

(Registrar)

PERSONAL AND STATISTICAL PARTICULARS

8 SEX

Farnali

9 COLOR

'/hi te

10a If married, widowed, or divorced
HUSBAND of

10 SINGLE (write the word)
MARRIED
WIDOWED

or DIVORCED A 1 n ? 1 f*

(Give maiden name of wife in full)

(or) WIFE of

(Husband’s name in full)

11 IF STILLBORN, enter that fact here.

12 7Q_

AGE1 Years Months _Days

If under 24 hours
Hours Minutes

13 Usual

Occupation :

UP.LL£..2.lLe_eiL2.r..

(Kind of work done during most of working life)

14 Industry
or Business:.

15 Social Security No

16 BIRTHPLACE (City)

(State or country)

u as s

17 NAME OF
FATHER

/1111am R. Cawthorn?

18 BIRTHPLACE OF

FATHER (City)

(State or country)

island

19 MAIDEN NAME

of mother Mary Fellehsr

20 BIRTHPLACE OF

MOTHER (City)

(State or country)

Ireland

Informant Hit a Goughian

(Address) 34 Riverside :

Ave .Gad ford

IFY that a satisfactory standard certificate of death
ttf^burial. or transit permit was issued:

of Aij^nrof Hoard of Ikvuth or other)

'/( 6 /£ Z-l

(Official Designation^ // / / (Date of Issue of Permit) <

A A t

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.

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.

. . . 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

R-301 A

UCTIONS

FOR

CERTIFICATE

giving

OF DEATH

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

toes not mean
! of dying,
heart failure,
etc. It means
le, or compli-
uhich caused

ms, if any,
mve rise to
cause (a),
the under-
cause last.

tions contrib-
death but not
i the terminal
mdition given

■ Chapter 137,
1954, requires
ins to print or
le cause or
of death on
ertificates.

4 I HEREBY CERTIFY, That I attended deceased from

19 .... , to , 19..J. — ......

I last saw h.£../!aiive on Jxatesa&t: Lji , 19.J..Z, death is said to

Suffolk

(County)

Winthrop

(City or Town)

ulljf (Eommommdtlj of fHaaMrlmarttH

EDWARD J. CRONIN
Secretary of the Commonwealth

DIVISION OF VITAL STATISTICS

STANDARD

CERTIFICATE OF DEATH

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

Registered No.

No..

Winthrop Community Hospital

2 FULL NAME.

Maud E (Lownsbro) Lochhead

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

56 Loring Rd .

Residence. No.

(Usual place of abode)

(a)

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

:e. ti..

((If death occurred in a hospital or institution,,

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

PHYSICIAN — IMPORTANT

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

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

IEDICAL CERTIFICATE OF DEATH

3 DATE OF
DEATH

(Month)

zzz

(Day)

7SZ

(Year)

have occurred on the date stated above, at 7..:...y..°.£....

DEATH WAS CAUSED BY: IMMEDIATE CAUSE

e- »7 ^ r r a ? <S-

(a)

8 ™I0....Ck....J&..£-...^

OTHER
SIGNIFICANT ..fe
CONDITIONS

INTERVAL
BETWEEN
ONSET AND
DEATH

Was autopsy performed? .6^.

What test confirmed diagnosis

F-

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

6 Win_t.lir.PT2 I

Place of Burial or Cremation
DATE OF BURIAL

Winthrop

(City or Town)

Jan . 21 i5!Z...

7 NAME OF

FUNERAL DIRECTOR. V
ADDRESS >....* i\- „

J...L.C..

Received and filed..

.4AN~2i495L

.19..

(Registrar)

PERSONAL AND STATISTICAL PARTICULARS

8 SEX

Fema

9 COLOR

White

10 SINGLE (write the word)
MARRIED

WIDOWED

or DIVORCEOV ld.OV/

10a If married, widowed, or divorced

HUSBAND of...

(Give maiden name of wife in full)

John L Lochhead

(Husband’s name in full)

(or) WIFE of..

11 IF STILLBORN, enter that fact here.

12 78 5 22

AGE... Years.. Months... Days

If under 24 hours
Hours Minutes

13 occuUtion:.H.otts.ewif .e

(Kind of work done during most of working life)

or Business: Qwn home...

15 Social Security No._ ■kl.pnP... ....... .—....

16 BIRTHPLACE (City). 2..y..h.LPli..

(State or country) MaS S •

17 NAME OF -

father George Lownsbro

,8 BIRTHPLACE OF

fath er ( city) r.h.t .r.r.r.r...

(State or country) Quebec

19 MAIDEN NAME

of mother Mary E Anderson

20 BIRTHPLACE
MOTHER (City)
(State or country)

E OE

ity£.9.9ihbay Harbor..

.aine

n formant .M.|.?li...E..LOQ.hLead^. t_.

(Address) 5o Loring Rri . Hinu hr op

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-
te n, 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
removea within thirty-six hours after such removal, unless a permit in the usual
form for the removal of such body has been sooner obtained hereunder. If the

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 acpqjrvtetjctp issue such permits, or
if there is no such board, from the clerk of the town-where thfc 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 Editio|i)(. J 1/ -

RULES OF PRACTICE. '[ >>

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

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

to whom they have given bedside care during, a last illness front disease unrelated
to any form of injury. j C i'-/- '

(2) Board of Health physicians will certify to'.-suijh. deaths only as those of
persons who, though disabled by recognized dtse4se''tnir6latgA( to_ any form of
injury, have died without recent medical attendptlcepr^Wiose physician is absent
from home when the certificate of death is needed, y ]"

(3) Medical Examiners will investigate and certify td ^11 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 iAfuedfScrii r|(^£eijf t£ hfccupation,
the sudden deaths of persons not disabled by'rmdgs'ired. disease, anti those of
persons found dead.

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

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

SPACE FOR ADDITIONAL INFORMATION

DATE OF ENTERING MILITARY SERVICE

DATE OF DISCHARGE

RANK, RATING

ORGANIZATION AND OUTFIT

SERVICE NUMBER

R-301 A

UCTIONS

CERTIFICATE

giving
)F DEATH

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

oes not mean
of dying,
eart failure,
tc. It means
e, or compli-
'kick caused

ns, if any,
iv e rise to
ause (a),
the under-
ause last.

ions contrib-
'.cath but not
the terminal
ndition given

Chapter 137,
1954, requires
ns to print or
e cause or
if death on
rtiflcates.

< Suffolk

q (County)

o Winthrpp

W (City or Town)

3 „ Moimtlifea:

No..

2 FULL NAME..

(If

(Emmwimuealtl| of iHaHiiarljuofttH

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.

j*.

deceased is'a married, wi

I/-/. TJ ((If death occurred in a hospital or institution

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

number)
PHYSICIAN — IMPORTANT

(Was deceased a

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

(a) Residence. No 78.1 ifestem. Avenue - St Lynn

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

Length of stay: In place of death years... 6 months days. In place of residence. 69- years months days.

MEDICAL CERTIFICATE OF DEATH

(Day)

/*r 7

(Year)

have occurred on the date stated above, at

DEATH WAS CAUSED BY: IMMEDIATE CAUSE

(a) .4

o,r..To.Ci./>^i..^.^...^ ...m..

Is a <2 /eA

Due To
(c)

UJ • +K- a-s,L t -Fes

OTHER , _ /

SIGNIFICANT

CONDITIONS AXyV

Was autopsy performed?

What test confirmed diagnosis?..

4 I HEfifEBY C E R T I FT , That I attended deceased from

<s9.Cc..#..gr. - , 1 9.j'..C> , I9..1.<f.

I last saw hL^talive on - A5- , 19 cSZ/., death_ is said to

” " INTERVAL

BETWEEN
ONSET AND
DEATH

¥-

5 Was/tfiseaslp or injury in any wayj-elated to occupation of deceased?

If /to, spedfy

;t. Josephs -Cemetery-- *- Lynn „

rlace of Buriar or Cremation (city or Town)

date of burial jJanuary....2li.» _ i9...5t.7

funeral DiRECTORLonovan. Furieml.....Ho.rae...

adores^ Gchool L> Cole

Received and filed -

jjflM lag/-

.19..

(Registrar)

8 SEX

9 COLOR

male

white

PERSONAL AND STATISTICAL PARTICULARS

10 SINGLE (write the word)
MARRIED

WIDOWED T.T-i HmroH

or divorced widowed

10a If married, widowed, or divorced

husband of Mary Scanlon

(Give maiden

(or) WIFE of .

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

11 IF STILLBORN, enter that fact here.

ag£?..

Years Months... Days

If under 24 hours
Hours Minutes

13 Usual

Occupation :

Retired

(Kind of work done during most of working life)

14 Industry

or Business:

L.RQUc.emn..

15 Social Security No., 01^0.9.^61+7..

16 BIRTHPLACE (City). Lynil,

(State or country) " 3 Ha c; c; A

17 fathLr5^ Michael Gallagher

18 BIRTHPLACE OF

father (City) Iceland.

(State or country)

19 MAIDEN NAME

OF MOTHER

■lary Healy

20 BIRTHPLACE OF

mother (City) lt eland .

(State or country)

Informant Joseph ...E.t.JS.canlQii..

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 tho 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).

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-
te n, 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

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, frqn^the clerk of the town where the body is to be buried
or the funeral is to be held, fcr ttc^i^.p^fson appointed to have the care of the
cemetery or burial ground in which the interment is made.

. . . Chap. 114, Sec. 46, G. L.^Oercentenary Edition).

—

PRACTICE

The fulfillment of the^uroo^e.tjf thejsejlaws calls for the observance of the follow-
ing rules of practice: yj. ;* v. O\ .

(1) Attending physicians will ceftify. to such deaths only as those of persons
to whom they havejjjyen: bedside care during ajast illness from disease unrelated
to any form of injury* t ^ \J ^

■> * -Syeiciane will certify to such deaths only as those of

recygniied disease unrelated to any form of
dtoal attendance or whose physician is absent
iatfi is'n^eded.

'jite.and certify to all deaths supposably
deaths caused directly or indirectly by
jjticemia), and by the action of chemical
■fcal agents, and deaths following abortion, but
also deaths from disease resulting from injury or infection related to occupation,
the sudden deaths of persons rip t-disa bled by recognized disease, and those of
persons found dead. j/VTf / fll

(2) Board of Heal

persons who. though
injury, have died witho;
from home when the ci '

(3) Medical Exai
due to injury. These
traumatism (including
(drugs or poisons) thermal,

Statement of Cauie 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.-301 A

1TI0NS

ERTIFICATE

lying

? DEATH

enter
an one
3r each
) and (c)

•s not mean
of dying,
irt failure,
\ It means
or compli-
ich caused

i, if any,
>e rise to
use (a),
te under-
use last.

ns contrib-
ath but not
he terminal
iition given

Chapter 137,
54, requires
: to print or
cause or
death on
liflcates.

3 DATE OF
DEATH

DICAL CERTIFICATE OF DEATH

h - 3. a

(Month) (Day) (Year)

I _ B Y C E R T I F Y/J That I attended deceased from

, XI'J.PT, to *Z....Z^, , 19.3_.1Z

( /i last saw iZZ/aTive n , 19. Zy/ death is said to

have occurred on the datZstated abdve, at .... &A.9..A

Suffolk

(County)

Winthrop

(City or Town)

No.

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.

St.

Registered No

(iF’dea'th occurred in a hospital or institution,,
give its NAME instead of street and number)

2 FULL NAME..

Helen J (Grady )_ Cushman

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

v)65 Norwood St .

Residence. No .rG rj. 1 .7h. St...

(Usual place of abode)

(a)

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

PHYSICIAN — IMPORTANT

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

Sharon

(If nonresident, give city or town and State)

PERSONAL AND STATISTICAL PARTICULARS

4 I H E RC

8 SEX

9 COLOR

10 SINGLE (write the word)

MARRIED

Female

White

WIDOWED tr. ,
or DIVORCED* 10. OW

INTERVAL
BETWEEN
ONSET AND
DEATH

1 3 Occupation : Housewife

(Kind of work done during most of working life)

" At home

10a If married, widowed, or divorced

HUSBAND of

(Give maiden name of wife in full)

(or) wipiofon P. .. Cushman

(Husband’s name in full)

11 IF STILLBORN, enter that fact here.

12 81

If under

24 hours

AGE Years Months..- Days

Hours

Minutes

15 Social Security No i.,..Q.IlS. _

16 BIRTHPLACE (City)_ St d.Q.Iin

(State or country) 1.6 V/ U11S V/j CK

17 NAME OF T

father Jonn G-raay

18 BIRTHPLACE OF.

FATHER (City).... Unable t...Q o..b..t.ain..

(State or country) . . Q , J TUllSV/iCk

19 MAIDEN NAME

of mother Sarah

J 0 1 Lie 1 1

20 BIRTHPLACE OF .

MOTHER (City).....^. ....’. U.Q./.IQ,

(State or country) -.QX! Lj h UUS V/X C K

2i Sarah J Risk

(Address) t~~WTn+~i

iiQP^.a

satisfactory standard certificate of death
The Inyrial or transit permit was issued:

(Registrar)

(Official Dcsignat

f ... rr'-jy — — tlii^r other)

djLlJsi

lion) il l (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.

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, Ghgpr*3£, Sec. <6., fts 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-
te n, 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 tne board of health or its agent aforesaid or from the clerk
of the town where the body is buried. No such permit shall be issued until there
shall have been delivered to such board, agent or clerk, as the case may be,
a satisfactory written statement containing the facts required by law to be
returned and recorded, which shall be accompanied, in case of an original inter-
ment, by a satisfactory certificate of the attending physician, if any, as required by
law. or in lieu thereof a certificate as hereinafter provided. If there is no attending
physician, or if, for sufficient reasons, his certificate cannot be obtained early
enough for the purpose, or is insufficient, a physician who is a member of the board
of health, or employed by it or by the selectmen for the purpose, shall upon
application make the certificate required of the attending physician. If death is
caused by violence, the medical examiner shall make such certificate. If such a
permit for the removal of a human body, not previously interred, from one town
to another within the commonwealth cannot be obtained early enough for the
purpose, the certificate of death made as above provided and in the possession of
the undertaker desiring to make such removal shall constitute a permit for such
removal: provided, that such body shall be returned to the town from which it was
removed within thirty-six hours after such removal, unless a permit in the usual
form for the removal of such body has been sooner obtained hereunder. If the

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 ^fronTjhji poasd of health or its agent appointed to issue such permits, or
if thereT^'no such board, from the clerk of the town where the body is to be buried
or the fajifcral )>e Jield, or from a person appointed to have the care of the

as.- which the interment is made.

(Tercentenary Edition).

cemetery or ^burial gtouncHn whi<

. . .\ vjhapt’liv^c. 46; G. L-, 1

i -Ly \'t. \ \ v

-L|94f fr-y.R'CisS OF PRACTICE

The fulWnient of the purpose of these laws calls for the observance of the follow-
ing,TuUsrf oTpractjce^V ~

(IV. ArtyiWtjij' pSytloiam will certify to such deaths only as those of persons
^tcpedside care during a last illness from disease unrelated

pfcf rf er 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) IftUiAl^jIACaeAfi'ill investigate and certify to all deaths supposably
due tVfnjilrjfc' (DheeklacltMt 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 Ciuie 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
t>y the appropriate terms, as housekeeper — private family, cook — hotel, etc. For
a person who had no occupation whatever write none.

SPACE FOR ADDITIONAL INFORMATION

DATE OF ENTERING MILITARY SERVICE

DATE OF DISCHARGE

RANK, RATING

ORGANIZATION AND OUTFIT

SERVICE NUMBER

R-301A

UCTIONS

CERTIFICATE

giving

)F DEATH

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

>es not mean
of dying,
heart failure,
tc. It means
. or compli- '
'hick caused

\s, if any,
ive rise to
ause (a),
the under -
ause last.

ons contrib -■
rath but not
the terminal
edition given

Chapter 137,
>54, requires
s to print or
cause or
f death on
tiflcates.

Suffolk

(County) ^ ,

V >

v/inthrop

(City or Town'

Qhimmflmtipaltfy nf fHaaaarijuarttfi

EDWARD J. CRONIN
Secretary of the Commonwealth
DIVISION OF VITAL STATISTICS

STANDARD

* of Town) CERTIFICATE OF DEATH

vV i nth rch C:- ,\ va U^ceyct
. .rl42_.. rlfea sant Street 1

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

Registered No.

Jinthrop

2 full name- J.ame s I' Crowley..

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

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

{PHYSICIAN — IMPORTANT

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

(a) Residence. No 12_.__T hur3.toii-S.tr .ee_t-

(Usual place of abode)

st East Boston

(If nonresident, give city or town and State)
Length of stay: In place of death years 4 months 11 days. In place of residence Shears months days.

MEDICAL CERTIFICATE OF DEATH

3 DATE OF
DEATH _

(j(onth)

(Day)

(Year)

4 I HEREBY CERTIFY, That I attended deceased from

wJBfc to 19^:7

I last sawhli»,alive on , 19 ’ ~2., death is said to

have occurred on the date stated above, at j£~. n

DEATH WAS CAUSED BY: IMMEDIATE CAUSE

(a) 'B'/fd/l/LM j -

Due To
(c)

OTHER

SIGNIFICANT

CONDITIONS

INTERVAL
BETWEEN
ONSET AND
DEATH

2-/)^

Was autopsy performed?

What test confirmed diagnosis? C/

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

Holy. Cross lialden

Place of Burial or Cremation (City or Town)

DATE OF BURIAL .. _JSJO._2_8— 1.957 19

7 NAME OF . , „ „ _ _

funeral DiRECTORHlchar-d-C Kirby -
ADDRESS 912.fBsxiniiig.tQn Cl. East Bos to

Received and filed

BUI 1957

(Registrar)

PERSONAL AND STATISTICAL PARTICULARS

8 SEX

male

9 COLOR

white

10 SINGLE (write the word)
MARRIED

WIDOWED ,.rAA*-,,r~A

or divorced widowed

10a If married, widowefl, or divorce^

HUSBAND of

(Give maiden name of wife in full)

(or) WIFE of

widowed, or divorced

Agnes . I Bonner ...

(Husband’s name in full)

11 IF STILLBORN, enter that fact here.

AGE .8.2 Years.4 Months 11 Da

If under 24 hours
Hours Minutes

13 Usual

Occupation: X).e.c.k.. hand.

(Kind of work done during most of working life)

14 Industry
or Business:

15 Social Security No...

[removed]

16 BIRTHPLACE (City) Bast Boston

(State or country)

Massachusetts

17 NAME OF
FATHER

Thomas J Crowley

18 BIRTHPLACE OF

FATHER (City)

(State or country)

Ireland

19 MAIDEN NAME
OF MOTHER

Catherine Regan

20 BIRTHPLACE OF

MOTHER (City)

(State or country) 7* ~p p>*| a

I nformant John Mchei]

(Address) Thurston Bt East Boston

I HEREBY CER^TlE^ that a satisfactory standard certificate of death
was filed vritlrrae B/CFORE/ft>c burijtfj/or transit permit ^as issued:

h 77// ^ -

Agent bf Board of Health oYfcthcr)

(Official Designation)

(Date of Issue of Permit)

EXTRACTS

FROM THE LAWS OF THE

COMMONWEALTH OF MASSACHUSETTS

GOVERNING THE

RETURN OF CERTIFICATES OF DEATH

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

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

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 <Merk 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).

~ iRCLES OF PRACTICE

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

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

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

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

JaIT & i n —

SPACE FOR ADDITIONAL INFORMATION

DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE

RANK, RATING

ORGANIZATION AND OUTFIT

SERVICE NUMBER

October 15 1.898

March 8 18.9.9

Private 1st Battery F
U.S . Army 2nd Reg - Artillery
Cannot be learned

\ R-301 A

RUCTIONS

FOR

. CERTIFICATE

giving

OF DEATH

not enter
than one
5 tor each
(b) and (c)

does not mean
ie of dying,
heart failure,
etc. It means
ise, or compli-
which caused

ions, if any,
gave rise to
cause (a),
the under-
cause last.

itions contrib- ^
death but not
o the terminal
•ondition given

Chapter 137,
1 1954, requires
ans to print or
he cause or
of death on
:ertifi

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