The volume, 1958

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Suffolk

(County)

Winthron

(City or Town)

S St

©fye (Enmmmtutfaltlf nf fHaaflarljuiirtta

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..

2 full name Berkeley Wolff . Mossman _

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

(a) Residence. No..

n Flo^d SJ

((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)

St..

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

(If nonresident, give city or town and State)

days.

MEDICAL CERTIFICATE OF DEATH

PERSONAL AND STATISTICAL PARTICULARS

■e,

li-

3 DATE OF o

death January dy

(Month) (Day)

(Year)

4 I HEREBY CERTIFY, That I attended deceased from

?.* 19 5k, to January 2, ,9 58

I last saw hUHalive on JSIlil&iy 2^ , 19-58 * death is said to

have occurred on the date stated above, at k:3$ p.m.

8 SEX

!'. ale

9 COLOR

Wh ite

10 SINGLE (write the word)
MARRIED

WIDOWED «ied

or DIVORCED

10a If married, widowpfi, or divpijc^cL,
HUSBAND of

(Give maiden name of wife in full)

DEATH WAS CAUSED BY: IMMEDIATE CAUSE

(a) acute nyocardial infarction

(bT ^’arteriosclerotic thrombosis of
coronary artery

Due

terios clerotic heart disease

significant Generalized, arterioscler-

conditions osis

INTERVAL
BETWEEN
ONSET AND
DEATH

2 hrs

(or) WIFE of

(Husband’s name in full)

11 IF STILLBORN, enter that fact here.

AGE Years Months Days

If under 24 hours
Hours — Minutes

13 Usual

Occupation: iQT.

2 hrs

(Kind of work done during most of working life)

14 Business: L

3 yrs

15 Social Security No.

GT2-"f- -r

5 yrs

16 BIRTHPLACE (City)
(State or country)

;■ i f'.p p
_

Was autopsy performed? QO

What test confirmed diagnosis ? Gllllical & laboratory

5 Was disease or injury in any way related to occupation of deceased ?J5P
If so. specify

(Signed)

(Address)

ate ’Jan. 3, 1958

Y.Ian.

M. D.

6 ’ f 9

Place of Burial or Cremation

J SL ' •

(City or Town)

17 NAME OF
FATHER

Jose oh i ossman

18 BIRTHPLACE OF

FATHER (City)

(State or country)

Scotland

19 MAIDEN NAME
OF MOTHER

Geraldine

Wolff

20 BIRTHPLACE OF

MOTHER (City)

(State or country)

Ottawa
Canada .

DATE OF BURIAL k.

7 NAME OF

FUNERAL DIRECTOR.”

i nt.hr on

ADDRESS

Anne l oss :an

Received and filed

JAN 6 1958

(Registrar)

_ I HEREBY CERTIFY that a satisfactory standard certificate of death
^ was filed wif)l me^BEFORE the burial or transit permit was issued:

/ r “

’ (Signature of Agent alrdlo^yl (otILL»4th or other) / ^

) vl

(Oitu ial Designation) (Date ot Issue of Permit^

/ tie/

EXTRACTS

FROM THE LAWS OF THE

COMMONWEALTH OF MASSACHUSETTS

GOVERNING THE

RETURN OF CERTIFICATES OF DEATH

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

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

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

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

Medical examiners shall make examination upon the view of the dead bodies
of persons as are supposed to have died by violence, or by the action of
chemical, thermal or ejectrical^ agents pr following abortion, or from diseases
resulting from injury M jnfectlpn relatirlg 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 othe^per^iWsWll bury a human body or the ashes thereof
which have been brought into th$ commonwealth until he has received a permit
so to do from the board .rif health or'Vts' agent appointed to issue such permits, or
if there is no such board. fr6nj-‘t'he‘ele£k of the town where the body is to be buried
or the funeral is to be ti4ld;,'‘or from a p£rsc*p. appointed to have the care of the
cemetery or burial grouml'in which the-interment is made.

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

^ \ - . ,

ij 3X.ULES .OF PRACTICE

The fulfillment of the puqikse the^e faws calls for the observance of the follow-
ing rules of practice: ' /’* . tc-..

(1) Attending physicians wijty jpertify 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 bra'eppfmzed' disease unrelated to any form of
injury, have died withqijjt r^errr (jjttiridlance or whose physician is absent

from home when the certificate of aeafh 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
spme entry in this section for every person aged 10 years or over. If the occupa-
tion had been given up or changed, or if the deceased had retired from business,
report the kind of work done during most of working life even if retired. Children
not gainfully employed may be returned as at school or at home. For a woman
whose only occupation was that of home housework, write housework. For a
person engaged in domestic service for wages, however, designate the occupation
by the appropriate terms, as housekeeper — private family, cook — hotel, etc. For
a person who had no occupation whatever write none.

SPACE FOR ADDITIONAL INFORMATION

DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE

RANK, RATING

ORGANIZATION AND OUTFIT
SERVICE NUMBER

IR-301A

tUCTIONS

FOR

CERTIFICATE

giving

OF DEATH

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

loes not mean
t ol dying,
heart failure,
rtc. It meant .
e. or compli- *
vhich caused

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

ton; contrib- — ►
death but not
the terminal
ndition given

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

Suffolk

(County)

(Ulje (Immmntnu'alth nf fflasHarijUBftta

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

STANDARD

Winthrop

(CityorrSwn) CERTIFICATE OF DEATH

Winthrop Convalesant Horae
no.142 Pleasant Street, Winthrop

(Pritchard)

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

Registered No. .£■» L.

/ (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)_

2 full name Flor6BC8 Lj» 0 f Connor .

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

(a) Residence. No 139 Revere Street, Winthrop s« ,

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

Length of stay: In place of death years 2 months days. In place of residence 13 years months days.

MEDICAL CERTIFICATE OF DEATH

3 DATE OF
DEATH —

(Month) L

(Day)

V<\S*

(Year)

4 I HEREBY CERTIFY, That I attended deceased from
19'b’V, to *Va.W a.. , 19^8

I last saw h*.<alive on “V 19 . death is said to

f n

have occurred on the date stated above, at

DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a) VjuryJUvYv \ Qu ~ Uf? ETQ. t &

Due To
(b)

Due To

(c)

"Do^dew^L ULCER

INTERVAL
BETWEEN
ONSET AND
DEATH

I* VWo s

Was autopsy performed ?

What test confirmed diagnosis?..

5 Was disease or injury in any way related to occupation of deceased ?_
If so, specify p4n

(Signed).

(Address)- WaA

M. D.

Date V .**... .3L. 19

e Mt. Benedict Cemetery, Boston

Place of Burial or Cremation (City or Town i

DATE OF BURIAL J BnUBTy 4th 19. 5< >

7 FUNEERAL DIRECTOR Richard C. Kirby

address917 Bennington St» E.Boston

Received and filed H J? i-U-,

.19

(Registrar)

PERSONAL AND STATISTICAL PARTICULARS

8 SEX

Female

9 COLOR

White

10 SINGLE (write the word)
MARRIED

WIDOWED Wldowprf
or DIVORCED "J-UUWeU

10a If married, widowed, or divorced

HUSBAND of

(Give maiden name of wife in full)

William J. O'Connor

(Husband’s name in full)

(or) WIFE of....

11 IF STILLBORN, enter that fact here.

AGE.

f Years JfMonths y Days

If under 24 hours
Hours Minutes

13 Usual

Occupation:

At home

(Kind of work done during most of working life)

14 orndBulriLss: .. Housewife...

15 Social Security No..

None

16 BIRTHPLACE (City)
(State or country)

Boston

Mass

17 NAME OF _ . • *_ i ,

father Joseph Pritchard

18 BIRTHPLACE OF

FATHER (City)

(State or country)

England

19 MAIDEN NAME
OF MOTHER

Catherine (CBL)

20 BIRTHPLACE OF

MOTHER (City)

(State or country)

CBL

Informan

(Address)

, Emma F. 0 'Holloran-dau.
Revere St. /-Winthrop "I

I HEREBY CERTIFY that a satisfactory standard certificate of death
was filed^with/pie BE^TpRE the/ourial or transit permit was issued:

by/ /Sign a tore of Agent bf Board of Hqadot or other)

QZLimL. /Uxt yzt

(Official Designation)!/ // /j (Date of Issue of Permit,

EXTRACTS

FROM THE LAWS OF THE

COMMONWEALTH OF MASSACHUSETTS

GOVERNING THE

RETURN OF CERTIFICATES OF DEATH

A physician or 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^rSe{ji<Ki rWafi'ng to occupation, or suddenly when not
disabled by recognizable disease,"or wnen any person is found dead. — General
Laws, Chap. 38, Sec. 6., as amejided by Chap. 632, Sec. 4, Acts of 1945.

No undertaker or oth^r berstJn/sfh^tf bury a human body or the ashes thereof
which have been brought rpHfrtb&ftrmfnon wealth until he has received a permit
so to do from the bo^rd/oFhp^ltlfi or ite agent appointed to issue such permits, or
if there is no such board -.'froifytlte oftn^'town where the body is to be buried
• the funeral is tq-be«f]eIdl-*6f-'from a^-pe/soft appointed to have the care of the

* — — 1 — thA'ihteVmept is made.

ercerit^n^py. Edition).

cemetery or burial ferdunfLnn wbii
Chap. 114, See.T6iG. L.', <

• l 3 i

’ u?-

•v s .0'4U!LES.^ f RA£TICE

of ths'Njp^se «tf calls for t

The fulfillment of thV.b'feqf^se thf3^b& calls for the observance of the follow-
ing rules of practice: * *

(1) Attending phyeici/it^vm pert IK’ to such deaths only as those of persons
to whom they have given'be45iae’c*ai^/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

u a «-*■ uz^Ldisease unrelated to any form of

at^fYiance or whose physician is absent
£ needed.

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

SPACE FOR ADDITIONAL INFORMATION

DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE

RANK, RATING *

ORGANIZATION AND OUTFIT
SERVICE NUMBER

I R-301A

IUCTIONS

FOR

CERTIFICATE

giving

OF DEATH

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

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

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

ions contrib - — ^
death but not
the terminal
ndition given

Chapter 137,
1954, requires
as to print or
e cause or
if death on
rtificates.

(Hlj? (Emnmonuipaltli of fHaasarljuartta

Winthr.op.

(City or Town)

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. 1 J —

T.T.S v, j-T- — j tt j /(If death occurred in a hospital or institution.

No Winthrop. C. t ij.On.pit.S.jL 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. 164 London. St. st East -Boston

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

Length of stay: In place of death years.

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

MEDICAL CERTIFICATE OF DEATH

3 DATE OF
DEATH _

n/^>

Si SJ

(Month)

(Day)

(Year)

4 I H EREBY CERTIFY, That I attended deceased from

19 JZt, to 'J**' gf 19-JT*

-, 19_—.— , death is said to

I last saw hLtilalive on S...

have occurred on the date stated above, at

/? rt,

DEATH WAS CAUSED BY: IMMEDIATE CAUSE

(a)

Due To

(b)

Due To

(c)

OTHER s, ^ ^ is

SIGNIFICANT

CONDITIONS

INTERVAL
BETWEEN
ONSET AND
DEATH

Was autopsy performed ?y4-^ic5

What test confirmed diagnosis? .T7T

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

6 Holy Cross

Place of Burial or Cremation
DATE OF BURIAL

January 7,

Mald'en

(City or Town)

ftjnhral director Frederic J» -r. raoh
address Havfe St. E. Boston

Received and filed

HAN 7 wr

(Registrar)

PERSONAL AND STATISTICAL PARTICULARS

SEX

Male

9 COLOR

White

10 SINGLE (write the word)
MARRIED
WIDOWED
or DIVORCED

10a If married, widowed, or divorced
HUSBAND of

(Give maiden name of wife in full)

(or) WIFE of

(Husband’s name in full)

11 IF STILLBORN, enter that fact here.

AGE Years Months .

Days

If under 24 hours
Hours Minutes

13 Usual

Occupation:

(Kind of work done during most of working life)

14 Industry
or Business:

15 Social Security No.

Winthno

16 BIRTHPLACE (City)

(State or country)

Mass . ‘

17 NAME OF
FATHER

Edmund Orlandino

18 BIRTHPLACE OF

FATHER (City).

(State or country)

19 MAIDEN NAME
OF MOTHER

Margaret V'-gllone

20 BIRTHPLACE OF

MOTHER (City).. BOSbOll

(State or country)

jaggs.

Informant Edmund Orlandino

(Address)

184 London St. E. Boston-

I HERJEBY CERTIFY that a satisfactory standard certificate of death
^was filed with me BEFORE th^/ourial or transit permit was issued:

vW (Signature ot Ag6df t>f Board of Healtb%rTnher)

iLJ&L.

(Official Designation) (Date of Issue of Permit/

EXTRACTS

FROM THE LAWS OF THE

COMMONWEALTH OF MASSACHUSETTS

GOVERNING THE

RETURN OF CERTIFICATES OF DEATH

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

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 per son is found dead. — General
Laws, Chap. 38, Sec. 6., as amended fiy5Pta|L 6.>2,.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 commphwealtTn yptjl he has received a permit
so to do from the board of health or its age n£ appointed to issue such permits, or
if there is no such board, from the clerk of tlje town where t)ie body is to be buried
or the funeral is to be held, or from a pe^sbn app^jnfed-to have the care of the
cemetery or burial ground in which ^heJntennfc'rtt.i.s m^de-.

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

RULES OF. ^PRACTICE

The fulfillment of the purpose of these jiuys.calls for. the observance of the follow-
ing rules of practice: '

(1) Attending physicians will (^ftiTyJfo sijbh deatnsjjnly as those of persons

to whom they have given bedside care/tfurirfgF^lafiC tUntjss from disease unrelated
to any form of injury. ' • J f \ '*

(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^rteedetfr | Q P fl ' Vf

(3) Medical Examiners will invesd|(Vj4 SiftI |eftjf3 vtb aJl’deaths supposably
due to injury. These include not only deaths caused directly or indirectly by
traumatism (including resulting septicemia), and by the action of chemical
(drugs or poisons) thermal, or electrical agents, and deaths following abortion, but
also deaths from disease resulting from injury or infection related to occupation,
the sudden deaths of persons not disabled by recognized disease, and those of
persons found dead.

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

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

SPACE FOR ADDITIONAL INFORMATION

DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE

RANK, RATING

ORGANIZATION AND OUTFIT
SERVICE NUMBER

t R-301 A

RUCTIONS

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
ans to print or
he cause or
of death on
:ertificates.

Su ffolk

(County)

o Wlnthrop

(City or Town)

®ljj? Qhmtmflmimtltlj af MaBBarljuaftta

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.

No,

I^SL i © W Qjj, g{ death ^occurred in a hospital or institution,.

( give its NAME instead of street and number)

T 4 o f PHYSICIAN — IMPORTANT

2 FULL NAME — .kcr.U..i..e _J (Was deceased a

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

t if so specify WAR)

(a) Residence. No 5iL TV 1 9 W S t St

(Usual place of abode)

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

(If nonresident, give city or town and State)
In place of residence 5Qyears months days.

MEDICAL CERTIFICATE OF DEATH

deathof..._ January 6 19.5.8,..

(Month) (Day) (Year)

4 I HEREBY CERTIFY
..... 19. SS?

I last saw h.ftltr.alive on

have occurred on the date stated above, at

That I attended deceased from

k , i9f4L

Jt ..., T9..S!jj?, death is said to
H A- n

DEATH WAS CAUSED BY: IMMEDIATE CAUSE

(a)

(toilcrtAR./ X..M.fi.£j¥v£ .Hits.

Due To
(b)

Due T<?*
(c)

OTHER G , j

SIGNIFICANT

CONDITIONS '

INTERVAL
BETWEEN
ONSET AND
DEATH

Was autopsy performed? .^Vuo.

What test confirmed diagnosis? “

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

(Signed)

M. D.

(Address)^!y..ST Date _. •i9 sff.

c Holy Cross Malden

Place of Burial or Cremation (City or Town)

date of burial January 8

.19

7 NAME OF
FUNERAL DIRECTOR

ADDRESS

Arthur J., Q±

lYlnthrop.

Received and filed

Wkv ftggu

(Registrar)

8 SEX

9 COLOR

Male

77hi te

PERSONAL AND STATISTICAL PARTICULARS

10 SINGLE
MARRIED

(write the word)

WIDOWE^oWed

or DIVORf

10a If married, wijdowefl,,o£ di)jprcejJ
HUSBAND of .J.U.J

(Give maiden name 'of wife in full)

, wijdowqd,#or divorced _

Julia L Jl.ra.dy.

(or) WIFE of .

(Husband’s name in full)

11 IF STILLBORN, enter that fact here.

.8.3

AGE jt -'. Years Months.™ Days

If under 24 hours
Hours Minutes

13 Usual

occup^t s.wl.£dtaman

(Kind of work done during most of working life)

or Business: Ba.H.r.aad _

15 Social Security No.. .

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

Boston,

Maas.

17 NAME OF
FATHER

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

Anthony Enos

Azores

19 MAIDEN NAME

of mother Cannot be

learned

20 BIRTHPLACE OF

MOTHER (City). C an.no. t.....b.e._..le ar.ned

(State or country)

Informant

(Address

,t Doris... Ma.han.ey

>_0r chard Lane Essex, Mas

HEREBY CERTIFY that a satisfactory standard certificate of death
. was) filed /Vith me B^fORE the burial or transit permit was issued:

' ■’ ((Signature of ^.gent of Board of Hedlth or other)

' y /n

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

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 buned. 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 daicoip the board of health or its agent appointed to issue such permits, or
if there“ts Eo'suhh b'pard, 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. J14, Sec. 46, G. L., (Tercentenary Edition).

—

! - •! RULES OF PRACTICE

> . I.;;,' >« • - •

Tbeiatfctirrvent of t}ie purpose of these laws calls for the observance of the follow-
ing n^les.-of pt act ice: V' ■

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

(,2) Board of Health physicians will certify to such deaths only as those of
persons who’(7tht»igh disabled by recognized disease unrelated to any form of
injury .hgve diGfl wjtho'ut. recent medical attendance or whose physician is absent
from Hprne;'»«etv4he 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 tlt.fttis from disease resulting from injury or infection related to occupation,
the siradflinUfe^hSl qfi peijsons not disabled by recognized disease, and those of
persons found aead. u ,

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 lot wages, however, designate the occupation
by the appropriate terms, as housekeeper — private family, cook — hotel, etc. For
a person who had no occupation whatever write none.

SPACE FOR ADDITIONAL INFORMATION

DATE OF ENTERING MILITARY SERVICE

DATE OF DISCHARGE

RANK, RATING

ORGANIZATION AND OUTFIT

SERVICE NUMBER

1 R-301 A

RUCTIONS

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

oils, 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
ertificates.

(County)

tHr/MTH/?^

alljr (Eommnmupaltlj of Dflaooarljuarttfi

(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.

.5...

Registered No.

. ■ s>.

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

, ™ll name jmAS. 5 mm mm£Lll _r

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

L if so specify WAR).

. M..

. Hf HDfi Sr I I

‘pi abode) (If nonresident, give city or town and State)

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

(a) Residence. No..

(Usual place ^

MEDICAL CERTIFICATE OF DEATH

(Day)

3 DATE OF "fl . „ ^

death .yJ..V..L^.t.a.

TTf

(Month)

(Year)

4 I HEREBY CERTIFY, That I attended deceased frare

3.....^ 19..^...? to....^^..r\.u<aL.r:.^... La. , \A.A.

I last saw hlT^lirt on ifcUHL 31 , 19."2..'^C" death is said to

have occurred on the date stated above, at

DEATH WAS CAUSED BY: IMMEDIATE CAUSE

_______ MEDIATE cal._

(a) Gas+ro jEnttojtil-

Uw. rTv\ udj d t- ~t~i o ( o g

Due To

(b)

Due To

(c)

OTHER

SIGNIFICANT

CONDITIONS

Was autopsy performed? jS/ .O .

What test confirmed diagnosis?

INTERVAL
BETWEEN
ONSET AND
OEATH

Sdu.

Mo w %

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

?ftQ

(Signed)^

(Address)..

M. D.

...l^ST^te'SL^L Date 7-j3sL.yv i '.Ur

Place of Burial or Cremation
DATE OF BURIAL

■7b J— mrnmLitmUr

PERSONAL AND STATISTICAL PARTICULARS

8 SEX

MLF

9 COLOR

10 SINGLE
MARRIED

(write the word)

WIDOWED T/A \£/ A

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.

AGE...y..Years .....#■
13 LJsual

'.Months.- Days

If under 24 hours
Hours Minutes

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 B,RTHPLACE zj/it Sj£1M.

FATHER (City)..
(State or country)

19 MAIDEN NAME
OF MOTHER

Mil

20 BIRTHPLACE OF . *.

, M/ML

MOTHER (City)..
(State or country)

that a sati«fhctoryv standard certificate of death
<BEF QJTP the byfrjkl or transit permit wa? issued:

re/ii Agent or Board of Health idArHcitV /

, U

(Official Designation) " ~u (Date of Issue of Permi^) ,

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,
th^t 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.

A physician or officer furnishing a certificate of death as required by the No undertaker or other persons shall bury a human body -or the ashes thereof

preceding section or by section forty-five of chapter one hundred and four.- _ winch haye^been brought into the commonwealth until he has received a permit
te n, shall, if the deceased, to the best of his knowledge and belief, served in tm* Z.

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 burial ground in which the interment is made.

ie. For neglect to comply X' ■ '• hi "4, Sec. 46. G. L„ (Tercentenary Edition).

;r, shall forfeit ten dollars^ \ , ‘.V *

, forty-six and fort y-sevep jV’,* , A pttt nt? pdaptipc

” shall include the China - v‘ **</. 0 . \ . RULES OF PRACTICE

L „ 11 C .^1 Ka. I ' • V *

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. P
with any provision of this section, such physician or officer, s'

For the purposes of this section and of sections forty-five, f

of said chapter one hundred and fourteen, the word “war” suau mviuuc ^

relief expedition and the Philippine insurrection, which shall, for said purposes,, bey] v -t. , .. , ... e ..

deemed to have taken place between February fourteenth, eighteen hundred_arid * - . Thetulfillrhent qf the purpose of these laws calls for the observance of the follow-
ninety-eight and July fourth, nineteen hundred and two. and the Mexican bqrdef* S’V • • n * , , ... . .. f

service of nineteen hundred and sixteen and nineteen hundred and seventeen*' \ vl) Attehdir>gyphy*ician» will certify to such deaths only as those of persons
G L Chao 46 Sec 10 ' y£o whom they have given bedside care during a last illness from disease unrelated

, 4ofany foijm df itijdiy.

No undertaker or other person shall bury or otherwise dispose of a human body. CSrti^y to suc^ only as those of

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

has received a permit from the board of health, or its agent appointed to issue u- ^thout recent medical attendance or whose physician is absent

such permits, or if there is no such board, from the clerk of the town where the ' ^hen the certificate of death is needed.

person died; and no undertaker or other person shall exhume a human body and ~ v?) — Nledical Examiner* iwill investigate and certify to all deaths supposably

remove it from a town, from one cemetery to another, or from one grave or tomb due to injury. These include not only deaths caused directly or indirectly by

other than the receiving tomb to another in the same cemetery, until he has traumatism resulting septicemia), and by the action of chemical

received a permit from the board of health or its agent aforesaid or from the clerk t jVf*
of the town where the body u> buried. No such permit shall be issued until there JrAp
shall have been delivered to such board, agent or clerk, as the case may be, - 114
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

gs tjhej*mal, or electrical agents, and deaths following abortion, but

“tf£ajnfe«fnoiy disease resulting from injury or infection related to occupation,
sudden deaths of persons not disabled by recognized disease, and those of
persons found dead.

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

SPACE FOR ADDITIONAL INFORMATION

DATE OF ENTERING MILITARY SERVICE

DATE OF DISCHARGE

RANK, RATING

ORGANIZATION AND OUTFIT

SERVICE NUMBER

R-301A

UCTIONS

:OR

CERTIFICATE

jiving

)F DEATH

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

7es not mean

of dying,
heart failure,
tc. It means ^

. or compli- *
f hich caused

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

ons contrib- — ►
eath but not
the terminal
edition given

Chapter 137,
954, requires
is to print or
cause or
f death on
tificates.

Suffolk

(County)

lint hr op

(City or Town)

(Eomtttmtutraltlj of JHaBaarljuMtta

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.

45-

No. Ray— .Y_l a-vsL-Ilur s ing— Eome-

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

2 FULL NAME—— CharleS — trin—Safe eil .7 7~

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

(a) Residence. No..

•4;ai-n t

! PHYSICIAN - IMPORTANT

(Was deceased a

U. S. War Veteran,

if so specify WAR) —

.St..

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

Length of stay: In place of death...R.....years.— 7— months days. In place of residence ..5Gyears months days.

MEDICAL CERTIFICATE OF DEATH

3 DATE OF
DEATH _

(Day)

1958-

(Year)

4 I HEREBY CERTIFY, That I attended deceased from

J w£& to -.2^./y:

I last saw hA/uklive on

, 19..^— _ , death is said to

have occurred on the date stated above, at

DEATH WAS CAUSED BY: IMMEDIATE CAUSE

g n £ £ A y 6 tcir VSf 0 aJ

(a)

~r.

Due To

/V A2/> Z- /-j- J~

(b)j °frfZ.T£K-i o - ->c t.£:(U77Q 2>li

T~H q. ON £S r> I c F L-^lt

?>£4o &

(c)

or Lsfr

7*0

SIGNIFICANT J>,S

CONDITIONS

Was autopsy performed ?_^LC

INTERVAL
BETWEEN
ONSET AND
DEATH

/-f-i

/#/<■

What test confirmed diagnosis?—

5 Was disease or injury in any way related to occupation of deceased^!*.- ‘
If so, specify

(Signed).

(Address) ^D^ t „ 19^.

M. D.

DATE OF BURIAL J ftr> ll^r g ■ l-Q-g l 958

Received and filed

(Registrar)

PERSONAL AND STATISTICAL PARTICULARS

8 SEX

9 COLOR

-W

10 SINGLE (write the word)
MARRIED . ,

widowed widowed

or DIVORCED

married, widowed, or divorced

husband of-^^ar..-l^l-^a--Jaco5soii

(Give maiden name of wife in

full)

(or) WIFE of..

(Husband’s name in full)

11 IF STILLBORN, enter that fact here.

AGE81-- YearH_ ...Mon ths25- Days

If under 24 hours
Hours Minutes

Occupation : ratir ed.Haj7b.er

(Kind of work done during most of working life)

14 Industry
or Business:

self employed

15 Social Security No...Qg^.g-^.pg4.g

16 BIRTHPLACE (City)
(State or country)

-Rama

Italy-

17 NAME OF
FATHER

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

Angelo Saben

Italy

19 MAIDEN NAME
OF MOTHER

20 BIRTHPLACE OF

MOTHER (City)

(State or country)

Josephine Holla

Italy

I nformant... •Mrs. Ralph J. Coffman

(Address) ~ ~ ~ * *

2 OS Main St* linthropu

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

•:;lu C i

e of Agent <Jf Board of Health

i , j--. A , £

or otheti)

(Official Designation)

(Date of Issue of Permit/ si

rAL

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).

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 Cferhfydo ^uch deaths only as those of persons
to whom they have given bedside* caTe during»a last illness from disease unrelated
to any form of injury.

(2) Board of Health physicians_wjH certify to such deaths only as those of
persons who, though disabled by 'fecofcn/zed' disease unrelated to any form of
injury, have died without rec^ntViedical attendance or whose physician is absent
from home when the certificate, .of dea^th'^m^eded.

(3) Medical Examiners wilHnvestigate knd certify to all deaths supposably

due to injury. These include not ;oh‘ty de-atps caused directly or indirectly by
traumatism (including resulfidg .-septjeemiay • and '.by the action of chemical
(drugs or poisons) thermal; .or Sleoiriqal agents,\and deaths following abortion, but
also deaths from disease resulting from injury ior.infection related to occupation,
the sudden deaths of persons -Hot disabled by. recognized disease, and those of
persons found dead. ^ j's. . ' A . " ,

/f \ *•

Statement of Cause of De^itn.— r^hy§i£iafisi see explanatory instructions
on face side of standard certificate^ 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 fotAHetry pejr^on aged 10 years or over. If the occupa-
tion had been given up or waigedi of if i£He (tjece^ed had retired from business,
report the kind of work done duringTnbst* &f working life even if retired. Children
not gainfully employed may be returned as at school or at home. For a woman
whose only occupation was that of home housework, write housework. For a
person engaged in domestic service for wages, however, designate the occupation
by the appropriate terms, as housekeeper — private family, cook — hotel, etc. For
a person who had no occupation whatever write none.

SPACE FOR ADDITIONAL INFORMATION

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

R-301A

JCTIONS

:ertificate

living

)F DEATH

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

its not mean
of dying,
leart failure,

!c. ft means ^
or compli- *
hich caused

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

ons contrib -■
eath but not
the terminal
id it ion given

Chapter 137,
>54, requires
s to print or
cause or

f death
tificates.

Suffolk

(County)

finthroo

(City or Town)

121 Locust St

Qllje UkTmmmiuiraltfj nf HHajaaarlpiaptts

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..

2 FULL NAME-

Richard Irvi'

veoDer

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

( PHYSICIAN — IMPORTANT

(a) Residence. No

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

L21 Locust St

' (Was deceased a
| U. S. War Veteran,

' if so specify WAR)..

(Usual place of abode)

St.

(If nonresident, give city or town and State)

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

3 DATE OF
DEATH _

I last saw h

have occurred on the date stated above, at - ? /S' /} m

DEATH WAS CAUSED BY: IMMEDIATE CAUSE

« — CA use.s

Due

(b)

T° /P

Due To
(c)

0 <£C / <

/ U. 5 / o Y[

OTHER

SIGNIFICANT

CONDITIONS

Was autopsy performed?—.

What test confirmed diagnosis?- _

S Was disease or injury in any way related to occupation of deceased?/^/)
If so. ^

Place of Burial or Cremation
DATE OF BURIAL ...

,.1^. . ... 0.0

(City or Town) ~

Received and filed

(Registrar)

PERSONAL AND STATISTICAL PARTICULARS

8 SEX

Male

9 COLOR

White

10 SINGLE (write the word)
MARRIED
WIDOWED
or DIVORCED

10a If married, widowed, or divorced

husband of - >SR2.y)ST*. Rs

(Give maiden name of wife in full)

(or) WIFE of-

(Husband’s name in full)

11 IF STILLBORN, enter that fact here.

AGE .Years ._ Months _Days

If under 24 hours
Hours Minutes

13 usual Electrican

Occupation:

(Kind of work done during most of working life)

14 Industry

or Business:

iipvara

15 Social Security No.

16 BIRTHPLACE (City) / ^

(State or country)

17 NAME OF

FATHER .. C

18 BIRTHPLACE OF
FATHER (City)

Lable to obtain

(State or country) [Jnsble tO Obtrill

19 MAIDEN NAME
OF MOTHER

20 BIRTHPLACE OF

MOTHER (City).

Unable to obtain

(State or country) \ tO O Q_

informant Mary //ebber

(Address) - q, Q Q ' t, : .

1 HtKtbY LtKIIM that a satisfactory standard certificate of death
was fill'd yW/flyfne B&FORK the burial or transit permit was issued:

l , ; 'oJjUL.c*

y / ^(Signature of Agent of Board op^Hwlth' or other)

(Official Designation) (Date of Issue of Pernfi/)

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

Medical examiners shall make examination upon the view of the dead bodies
of persons as a*e£sUp£psety 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, S^c. 6.,' as4cnerided by Chap. 632, Sec. 4, Acts of 1945.

No undertake? or'cjtjieii f>enf<j>n$ ^hajl bury a human body or the ashes thereof
which have been l^ought-in't'b'the^cohimonwealth until he has received a permit
so to do froraLthe-bo^fid of health- or its agent appointed to issue such permits, or
if there is np -sub hU>oard, from the<Tefk<>fthe town where the body is to be buried
or the funeral is'tofbe held, or fnoih'.a person appointed to have the care of the
cemetery ot Euriahfcround in wh&h’tho, interment is made.

. . Chapel 14r Sec. 46, G. L., (Tercentenary Edition).

' L

• * • iiinv

It. '\r/ ' ' PRACTICE

The fulfillment dOfeppi-prise of these laws calls for the observance of the follow-
ing rules of practice:- * ' ' ' 1 1

( 1 ) Attending physicians will certify to such deaths only as those of persons
to whom they have given bedside care during a last illness from disease unrelated
to any form of iniurj.f "-n i n r 0 * H

(2) Board o(JU<|4|lrtr certify to such deaths only as those of

persons who, though disabled by recognized disease unrelated to any form of
injury, have died without recent medical attendance or whose physician is absent
from home when the certificate of death is needed.

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

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

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

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

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

ions contrib - — ►
ieath but not
the terminal
ndition given

Chapter 137,
954, requires
is to print or
i cause or
>f death on
-tiflcates.

Suffolk

(County)

flint hr op

(City or Town)

Qlffmmmtutmtl} at iflafmarijuarttja

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.

no. gcme-

2 FULL NAME ,

(If deceased is a marrie

widowedor 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 ,Tn

U. S. War Veteran, JM U .

if so specify WAR)

(a) Residence. No.._

-Ingleside Avenue

— St

(Usual place of abod"?) “■"0“ w **' — ~ (If nonresident, give city or town and State)

Length of stay: In place of death l_years 4:. months days. In place of residence^— -.years months days.

MEDICAL CERTIFICATE OF DEATH

3 DATE OF _ _ _

DEA™ -JsMffy— Uy. — 10M.

4 I EREBY CERTIFY, That I attended deceased from

, 19^A/to L3-. , 19j^§L.

I last saw hd/Talive on _, 19 ^ df \ death is said to

, , ■

have occurred on the date stated above, at

DEATH WAS CAUSED BY: IMMEDIATE CAUSE

y/D j _r & r

(a)

Due To
(b)

r/ o

Je j-oi

/>. l

'/ f- s?

^r-

Pc?eTo /V f perte. r? S' so yt

J2 JT g S'! Vv CL i

OTHER

SIGNIFICANT

CONDITIONS

INTERVAL
BETWEEN
ONSET ANO
DEATH

—

Was autopsy performed?

What test confirmed diagnosis?

CMC.

Date..

±z^L

M. D

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

(Sign ejt)-^?^.

(Address) Z-U'--74z<

Vlace o$£Ea?^)w.on

DATE OF BURIAL .J.

7 NAME OF
FUNERAL DIRECTOR

Tty or

FI tchbui

)r Town) v-2j¥

19 JL

ADDRESS 174 7ir t yr-OTT • hrrip , £ ass ,

Received and filed IlftklM ' _ . 19 __

« — — , — -

PERSONAL AND STATISTICAL PARTICULARS

8 SEX

9 COLOR

female white

10 SINGLE (write the word)
MARRIED widoWftd
WIDOWED vv x u u vv w u-
or DIVORCED

10a If married, widowed, or divorced
HUSBAND of

(Give maiden name of wife in full)

(or) wife of — Austin .Eugene G ar pen ter-.

(Husbantrs name in fulr)

11 IF STILLBORN, enter that fact here.

AGE .^.Ijf.Years..^ Months ^-1 Days

If under 24 hours
Hours Minutes

13 Usual

Occupation :

housewife.

(Kind of work done during most of working life)

14 Industry
or Business:

-own— heme—

15 Social Security No

-none

16 BIRTHPLACE (City).
(State or country)

Fitchburg

17 NAME OF
FATHER

David pierce

18 BIRTHPLACE OF

FATHER (City)

(State or country)

-Pitchhurg— .

19 MAIDEN NAME
OF MOTHER

Angel in e Maria Ben mi,

20 BIRTHPLACE OF
MOTHER (City) —
or country)

.Vest morel and

New Hampahire

Informant

(Address)

Mrs.-- Lawrence P. Stone
£3 Ingles ido a ve. flint hr op

! CERTIFY that a satisfactory standard certificate ot d

I HEREBY CERTIFY that a satisfactory standard certificate of death
was filed wj|h pie BEFORpihe burial or transit permit was issued:

(/Signature of Agent of Board of Health or-tf

(Registrar)

_.... / ft L/../J

(Official Designation)

(Date of Issue of Per/hit)

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 dr 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. il, ‘(Tercentenary Edition).

Vs; .

RULES OF PRACTICE

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

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

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

(3) Medical Examiners wilbinvestigate 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 el^Qtripal ag^te.an^jdeaths following abortion, but
also deaths from disease resillAjng ffonh ihjufcy'br infection related to occupation,
the sudden deaths of persoiwnot disabled by recognized disease, and those of
persons found dead.

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

SPACE FOR ADDITIONAL INFORMATION

DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE

RANK, RATING

ORGANIZATION AND OUTFIT
SERVICE NUMBER

gf?, 00

jfc i K

(County)

rqf>

W (Cityoriowr

3 4? (tatmonuiraltfy nf fHaHfiarijuai'ttjs

EDWARD J. CRONIN
Secretary of the Commonwealth

DIVISION OF VITAL STATISTICS

STANDARD

CERTIFICATE OF DEATH

No.

2 FULL NAME-

wn)

j 0 (c CD O uC dc> i f}

— IiLl23 e ^ lj..Qj^G£L, Q/Ca,.. Ujl

i ot/liv

CLO)

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

Registered No.

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

(a) Residence. No. / 0 6? 3>o*joj&q)T)

(Usual place of abode)

I PHYSICIAN — IMPORTANT

i (Was deceased a
j U. S. War Veteran,

[ if so specify WAR).-

St.

(If nonresident, give city or town and State)

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

MEDICAL CERTIFICATE OF DEATH

PERSONAL AND STATISTICAL PARTICULARS

3 DATE OF
DEATH ....

(Month)

(Day)

8 SEX

(Year)

I H E R BY CERTIF/r^» mat i attenaea aeceasea irom

-A J? , 19 to

I last S2^d\\ l/Tt^Xx ve on / J 1Q//^ ic caiH tr

have occurred on the date stated above, at

That I attended deceased from

9 COLOR

|%Ip . (-0 ij~l

~£L

10 SINGLE (write the word)
MARRIED

WIDOWED „ J

or DIVORCED I P <£, \"C ) GQ

_, 19.

death is said to

10a 'If married, widowed, or divorced/ . / ' / -

„./4^nr\<mzL triMS

DEATH WAS CAUSED BY: IMMEDIATE CAUSE

(a)

(Z Ate iho>n\ °J~\ ^

Due To

(b)

TB ronaho j <L)\ic)

Due To
(c)

OTHER

SIGNIFICANT

CONDITIONS

INTERVAL
BETWEEN
ONSET AND
DEATH

HUSBAND of
(or) WIFE of

(Give maiden name of wife in full)

(Husband’s name in full)

11 IF STILLBORN, enter that fact here.

Xjrs

12 . q

£✓ Months

AGE*/ 7 Years .1/. .Months -A Days

If under 24 hours
Hours Minutes

Occupation : O ' ) & ^ \ & Y3

(Kind of work done during most of working life)

14 Industry

or Business:

15 Social Security No...

r-, T?

16 BIRTHPLACE
(State or country)

Was autopsy performed? /">XO

What test confirmed diagnosis?..

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

17 NAME OF
FATHER

y- c0iui

18 BIRTHPLACE OF

FATHER (City)

(State or country)

<~- 1 cLff} ,9

SidKTrT

19 MAIDEN NAME
OF MOTHER

-H dyt/

20 BIRTHPLACE OF _

MOTHER (City) €L.g^lJr^

(State or country)

I nforman

u.S,

M|g|;

14 M ,

^ m&rrm?oq

(Address)//,. / ;> y/7/ , tCff n J /."

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

#5$ -19—-

(Registrar)

Agent of Board of Health or other)

'sr'

(Official Designation)

(Date of Issue of Permit)

EXTRACTS

FROM THE LAWS OF THE

COMMONWEALTH OF MASSACHUSETTS

GOVERNING THE

RETURN OF CERTIFICATES OF DEATH

A physician or officer furnishing a certificate of death as required by the
preceding section or by section forty-five of chapter one hundred and four-
teen, shall, if the deceased, to the best of his knowledge and belief, served in the
army, navy or marine corps of the United States in any war in which it has been
engaged, insert in the certificate a recital to that effect, specifying the war, and
shall also certify in such certificate both the primary and the secondary or imme-
diate cause of death as nearly as he can state the same. For neglect to comply
with any provision of this section, such physician or officer, shall forfeit ten dollars.
For the purposes of this section and of sections forty-five, forty-six and forty-seven
Df 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
n a town, or remove therefrom a human body which has not been buried, until he
das 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
•emove it from a town, from one cemetery to another, or from one grave or tomb
Dther 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
}f 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.Jiaye 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 ajhend^d by/Chap. 632, Sec. 4, Acts of 1945.

No undertaker or other pejrsops shall „bury a human body or the ashes thereof
which have been brought into jthe.tornnton wealth until he has received a permit
so to do from the board of health ‘pfits 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 h6ld,.-or from a person appointed to have the care of the
cemetery or burial ground in. which the intprment is made.

. . Chap. 1 14, Sec. 46, 'GLL., (Tercentenary Edition).

. EfUJ^fiS: OF PRACTICE

The fulfillment of the puTpo'se.of these laws calls for the observance of the follow-
ing rules of practice: / ( .

(1) Attending physicians w!ill. 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 nhys^ck»ns*vvilj; Eeftifv "to such deaths only as those of
persons who, though disatjJ^lhiy Jte^gWeflUdise^se unrelated to any form of
injury, have died without recent medical attendance or whose physician is absent
from home when the certificate of death is needed.

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

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

DATE OF ENTERING MILITARY
DATE OF DISCHARG
RANK, RATING

INFORMATION ^

ITARY SERVICE ............ 9.

... 1.1/.K »9.-_

r ^ Co )z^ ficui /i>/~ i

ORGANIZATION AND OUTFIT
SERVICE NUMBER 1 U

•- ( G ,ft .vc.pi..y

1-301A

noNs

RTIFICATE

Suffolk

2 (County)

o 'VI nth rop

W (City or Town)

(Ernttmumuraltli of HasHarijufirttB

EDWARD J. CRONIN

Secretary of the Commonwealth

DIVISION OF VITAL STATISTICS

STANDARD

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

CERTIFICATE OF DEATH Registered No.

ill

No..

156 Somerset Ave

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

J T7> O <-> f PHYSICIAN — IMPORTANT

2 FULL NAME .A.TC hi Da Id F, Campbell I (Was deceased a

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

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

156 Somerset Ave

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

(a) Residence. No ±.rrf.~. St.

(Usual place of abode)

ring

DEATH

enter
in one
r each
and (c)

: not mean
of dying,
rt failure,

It means ^
or compli-
:h caused

if any,
rise to
e (a),
under-
e last.

s contrib-
th but not
e terminal
ition given

hapter 137,
4, requires
to print or
cause or
death on
ficates.

EDICAL CERTIFICATE OF DEATH

DEATH WAS CAUSED BY: IMMEDIATE CAUSE

<*> lA tar aI Gaus-qs

Due To
(b)

Due To
(c)

Uy Cor&yiA

Occlusion

AricY/'o Jctr r o t ic

OTHER A •

SIGNIFICANT ... U /<* £3 A. <„/=>.,
CONDITIONS l-J V- ^

I last saw h/A, .alive on - 7.?....., 1 9.-TTT77T., death is said to

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

INTERVAL
BETWEEN
ONSET AND
DEATH

Was autopsy performed mo

What test confirmed diagnosis?

jury in any way related to occupation of deceased >/XU)

6 ......Grlenw.

Place of Burial or Cremation

Ever# tt Mas-a

(City or Town)

DATE OF BURIAL .J&nU & .O'. 1.7. .....19.5.6

7 NAME OF
FUNERAL DIRECTOR

Arthur J Q..'.Male.y

ADDRESS 'Y.ln.thrQp Ma..s.a

Received and filed..

UAN i

—.19.

(Registrar)

8 SEX

9 COLOR

10 SINGLE (write the word)

MARRIED

Male

Thlte

WIDOWED .

or DivoRcnMarrled

PERSONAL AND STATISTICAL PARTICULARS

10a If married, widowed, or divorced

husband of..., Anna. ...Q.l.s.e.n

(Give maiden name of wife in full)

(or) WIFE of .

(Husband’s name in full)

11 IF STILLBORN, enter that fact here.

AG ■So .Years Months™ Days

If under 24 hours
Hours Minutes

Occupation Re.tl.r.e..d Electrician

(Kind of work done during most of working life)

or Business: Auto.. Fire Alarm.

15 Social Security No 022.rlQr.8QlQ

16 BIRTHPLACE (City). E.a.S t b..0..§..t.0.n..

(State or country)

Maa a

17 NAME OF
FATHER

Angus Campbell

18 BIRTHPLACE OF

FATHER (City)

(State or country)

Nova Scotia.

19 MAIDEN NAME

OF mother Annie 0 1

20 BIRTHPLACE OF
MOTHER (City)......

(State or country)

Hanley

Conne t’3 cut

Informant.

(Address)

a. Campbell

Somerset Avs

yinthrop-

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

35^ -

/ S /i (Signature of Afrentf of Hoard of Health or other) /

A I aJ/£/_ . f'U ■■

rOfiicial Designation) (Date of Issue of JPermit)

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

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).

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 ofbqaltb oiwts agent appointed to issue such permits, or
if there is no such board .Trorn- the cl^rk ot 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 whi^h the interment is made.

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

RULES OF PRACTICE

:'i • .

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 recognised disease unrelated to any form of
injury, have died without recent medical attendance or whose physician is absent
from home when the certificate oT 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 agenris. and deaths following abortion, but
also deaths from disease rMpltinjj from *njuhy oranfection related to occupation,
the sudden deaths of pessuTlS <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

(Eammmtun'altlj of fHasaarljustftts

EDWARD J. CRONIN
Secretary of the Commonwealth

DIVISION OF VITAL STATISTICS

STANDARD

CERTIFICATE OF DEATH

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

Registered No. °

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

2 FULL NAME

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

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

i PHYSICIAN — IMPORTANT

' (Was deceased a ,

IU. S. War Veteran, A -

' if so specify WAR)

(a) Residence. No. /

(Usual place of abode)

Length of stay: In place of death years-

(If nonresident, give city or town and State)

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

MEDICAL CERTIFICATE OF DEATH

PERSONAL AND STATISTICAL PARTICULARS

3 DATE OF t a . u
DEATH . O A HitAT

(Month)

/(&

(Day)

/pzsr

(Year)

8 SEX

4 I HEREBY CERTIFY , That I attended deceased from

_ tp ^ , 19 JlJ?., to , i9.5fjf/

I last saw hi unlive on , 194^ l!t. , death is said to

9 COLOR

10 SINGLE — —(write the word)
MARRIED „ /

W4440W*« cf

-er-BfVORCED

10a If married, witkwed, or divorced

. _ - - '/9

HUSBAND of.

have occurred on the date stated above, at

DEATH WAS CAUSED BY: IMMEDIATE CAUSE

(a)

d o ycx ^Ce/u.vt6n/

Ph“e Todt y anar^f - Ax f*.rrro stkrokc
MgavM i‘ie<J6 -

Due To
(c)

OTHER

SIGNIFICANT _
CONDITIONS

yVane-

INTERVAL
BETWEEN
ONSET AND
DEATH

'/ikr.

(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 — Minutes

3urc

13 Usual
Occupat

(Kind of work done during most of working life)

14 Industry

or Business: ^

15 Social Security No.

16 BIRTHPLACE (City)_
(State or country)

Was autopsy performed? ,

What test confirmed diagnosis ? * W1 1.

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

(Signed)

(Address)

UI>_^kropt\u<ts^

Pljjre of Burial or Cremat

DATE OF BURIAL

7 NAME OF

FUNERAL DIRECTOR^
ADDRESS

Received and filed

17 NAME OF
FATHER

18 BIRTHPLACE O

FATHER (City)

(State or country)

19 MAIDEN NAME
OF MOTHER

re, )

20 BIRTHPLACE OF

MOTHER (City)

(State or country)

I nformant
(Address) ‘

I HEREBY CERTI FY that a satisfactory standard certificate of death
Was filec[ with me I^gFORE/the burial or transit permit was issued:

JlMtiX

1 // j (Signature of. Agent of Board of Health or other^

tlL t ^ t ‘//A i A

(Registrar)

(Official Designation)

(Date of Issue of Pe rpr^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 J^Qhag. -6,52, 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^ager^t ajjpdlnted to issue such permits, or
if there is no such board, from the Mettf<5f/the town where the body is to be buried
or the funeral is to be held, or from, a persotj '^pp^in ted to have the care of the
cemetery or burial ground in which the ifuerrpen.t js made.

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

. ‘ \ -- ;

RULES jQF PRACTICE

The fulfillment of the purpose of thesedaws calls for the observance of the follow-
ing rules of practice: ~

(1) Attending physicians will 'certify ttV^aUh deaths only as those of persons
to whom they have given bedside care. during a Ia5t iflqesS from disease unrelated
to any form of injury.

(2) Board of Health physicians vfrill /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 de^h is needed.

(3) Medical Examiners will afddj gh&fjy tt^all deaths supposably

due to injury. These include notMmly" deaths Hfr^ectly or indirectly by

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

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

SPACE FOR ADDITIONAL INFORMATION

DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE

RANK, RATING

ORGANIZATION AND OUTFIT
SERVICE NUMBER

1 R-301A

RUCTIONS

FOR

CERTIFICATE

giving

OF DEATH

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

toes not mean
e 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
af death on
rtiflcates.

(01 ft (Emnmmuurultlr of MaBaarlptaettH

UFFOL K

(County)

(M±A/r// AO. p

EDWARD J. CRONIN
Secretary of the Commonwealth

DIVISION OF VITAL STATISTICS

(City or Town)

STANDARD

CERTIFICATE OF DEATH

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

1 ?

Registered No.

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

PHYSICIAN — IMPORTANT

2 FULL NAME

(If deceased is a married

(a) Residence. No

(Usual place of abode)

widowed or aivorced woman, give also maiden name.)

' (Was deceased a j ^

| U. S. War Vetera_n, f

if so specify WAR)

St. — i

Length of stay: In place of death

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

3 DATE OF v f f\

MgPICAL CERTIFICATE OF DEATH

DEATH -J-

(Month)

iiAILL/

(Day)

_2_:

(Year)

4 I HEREBY CERTIFY, That I attended deceased from

, 19 . . to ' 19

I last saw b^t-alive on 7*~ . i' , 19_jf_£ , death is said to

have occurred on the date stated above, at

DEATH WAS CAUSED BY: IMMEDIATE CAUSE

(a)

4—

d i J a 'ft. Y i

•

Due To

(b)

m <f(. ( a yd 1 id

Due To
(c)

OTHER , • JL.

SIGNIFICANT

CONDITIONS

l' ! r

the: > i (i

—j-

Was autopsy performed

i .;■>

What test confirmed diagnosis?

d A.' f tjjt

INTERVAL
BETWEEN
ONSET AND
DEATH

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

(Signed)-

L Date /

(Address).

, M. D
.19

/YF/Ytr/’F TEfU-

Place of Burial or Cremation . (City or Town)

DATE OF BURIAL

\tULi* 19

(Registrar)

PERSONAL AND STATISTICAL PARTICULARS

8 SEX

9 COLOR

10 SINGLE (write the word)
MARRIED

WIDOWEI Y/Zf## /£ £)

or DIVOR

10a If married, widowed, or divorced
HUSBAND of

(or) WIFE of..

(Give maiden name of wife in full)

(Husband’s name in full)

11 IF STILLBORN, enter that fact here.

Years Months -

Days

13 Usual

Occupation:

If under 24 hours
Hours Minutes

(Kind of work done during most of working life)

14 Industry
or Business:

sfy //c/rtC-

15 Social Security No

(State or country) ity )

17 NAME O
FATHE

%Jq//M STcjjf /srjLSa <? £.

18 BIRTHPLACE OF

FATHER (City)

(State or country)

ffCi; £&

19 MAIDEN NAME
OF MOTHER

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

trgjtsit fie

C°‘ .

(Signature df Agetpl of Board of Health or other) "

/dlajn!c - uu.cmJ i >

(Official Designation) (Date of Issue of Permit) \J

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 &erk 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.

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

ulfye Ghrotmomuraltlj of fHaHHarijmsettH

| 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.

2 FULL NAME

(If deceased is a marr/fl, widovfed or divorced woman, give also ma

(a) Residence. No.

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,
ify 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 years months days. ^

MEDICAL CERTIFICATE OF DEATH

PERSONAL AND STATISTICAL PARTICULARS

3 DATE OF // ^

DEATH ^ /S' /Y

(Month)

(Day)

(Year)

8 SEX

4 I HEREBY CERTIFY, That I attended deceased from

19^X„ to 19

I last saw h£^£alive on (Jah. / f — , 19 b , death is said to

have occurred on the date stated above, at _i

DEATH WAS CAUSED BY: IMMEDIATE CATJSE

9 COLOR/

10 SINGLE (wr,
MARRIED
WIDOWED
or DIVORCE'

the word)

10a If married, widowed, or divorced
HUSBAND of

(Give maiden name of wife in full)

(a)

Due To //r /ro C ci>Aa [ljS .

'c? ) yr' a ' /?'>

Due To

(c)

OTHER

SIGNIFICANT

CONDITIONS

INTERVAL
BETWEEN
ONSET AND
DEATH

(or) WIFE of..

(Husband’s name in full)

11 IF STILLBORN, enter that fact here.

AGE-

. Years -Months ..Days

13 Usual

Occupation: —

S under 24 hours
-Hours - Minutes

(Kind of work done during most of working life)

14 Industry
or Business:

15 Social Security No

16 BIRTHPLACE (City)
(State or coun

too u , *

llLt L/jA^Jt^LA

Was autopsy performed?

What test confirmed diagnosis?

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

If so, specify/

17 NAME OF
FATHER

18 BIRTHPLACE OF

FATHER (City)

(State or country.

19 MAIDEN NAME
OF MOTHER

20 BIRTHPLACE OF
MOTHER (City) —
(State®r country)

~~yyie*<Lo

Received and filed

20 1959

I HEREBY CERTIFY that a satisfactory standar<\certificate of death
was filed with me BEFQRE the burial or transit permit was issued:

— £ * ^

(Signature of Agent of Board of Health or other)

(Registrar)

(Official Designation)

(Date of Issue of Permit)

COPY O F CERTIFICATE OF DEATH

CERTIFICATE OF DEATH

STATE OF NEW HAMPSHIRE

TOWN OR

CLERK'S NO...“^ 1L.JC.

1. NAME OF A. (FIRST)

DECEASED

(TYPE OR PRINT)

flurry

Barry

C. (LAST)

Vood

2. DATE
OF

DEATH J 1 9

19 y

3. PLACE OF DEATH

A. COUNTY

>> borough

4. USUAL RESIDENCE (WHERE DECEASED LIVED. IF INSTITUTION: RESIDENCE|

BEFORE ADMISSION

JiilL

Wsekc? -usetts

B. CITY
OR

TOWN

Manchester

C. LENGTH OF
STAY (IN THIS PLACE)

43 day a

C. CITY (GIVE ACTUAL TOWN OF RESIDENCE. NOT MAILING ADDRESS).

townM i; X* v i Ti $i C*<

D. FULL NAME OF (IF NOT IN HOSPITAL OR INSTITUTION. GIVE STREET ADDRESS OR LOCATION)

HOSPITAL OR

NST.TUTi0NVeterans ^at Hogv ital

D STREET (IF RURAL, GIVE LOCATION)

ADDRESS

8 Lancaster Court

Is Residence
on Farm?

□ NO%

YES

6. COLOR OR RACE

white

Married D |
Never Married \

jvorced □

3 Widowed CD

8. NAME OF HUSBAND OR WIFE (maiden name if wifei

9. DATE OF BIRTH

lO. AGE (IN YEARS
LAST BIRTHOAY)

IF UNDER 1 YEAR
MONTHS I DAYS

IF UNDER 24 HRS
HOURS I MIN.

11 a. Usual Occupation (kind of work

DONE DURING MOST OF WORKING LIFE. EVEN IF RETIRED)

au.ie nurse

1 1 b . Kind of Business or
Industry

Hospital"

12. BIRTHPLACE (CITY OR TOWN. STATE
OR FOREIGN COUNTRY)

Prungv’ic/.* Can*#*

13. MOTHER’S MAIDEN NAME

13. CITIZEN OF WHAT
COUNTRY?

crA

14. FATHER’S NAME

Thomas Vood

1 6. WAS DECEASED EVER IN U S. ARM ED FORCES?

Viney McKay

18A. INFORMANT

(YES. NO. OR UNANOWAIMIF YM. DAVE WAR OR DAMS OFSTRVICEI"

yes /-gy-ls To • -

1 7. Soc. Sec. No.

> unknown

18b. ADDRESS

Y»»- irtrc. Fosplfl Pecords

Saytn Bd,, Manchester, K.-H.

19. CAUSE OF DEATH (enter only one cause per line for (a), (b). and (c)
PART I DEATH WAS CAUSED BY?

IMMEDIATE CAUSE (A)J

.fiydropneutaothor&x

CONDITIONS. IF ANY. 1

WHICH GAVE RISE TO 1 DU

ABOVE CAUSE (A). <

STATING THE UNDER- I

LYING CAUSE LAST. J

Arte rlo gel erotic hypertensive cardio
cul&r disease* congestive fa i lure , cc r

XK&ife (C) occlusion

INTERVAL BETWEEN
ONJt^T .ANP DEATH

V4i S ISOS

tor.1'1 ry

PART II. OTHER SIGNIFICANT CONDITIONS CONTRIBUTING TO DEATH BUT NOT RELATED TO THE TERMINAL
DISEASE CONDITION GIVEN IN PART 1(A)

20. WAS AUTOPSY
PERFORMED?

RMED?

21 A. ACCIDENT SUICIDE HOMICIDE

□ □ □

21 B. DESCRIBE HOW INJURY OCCURRED (ENTER NATURE OF INJURY IN PART 1 OR PART II OF ITEM 19.)

21C. TIME MONTH DAY YEAR HOUR

INJURY M.

210. INJURY OCCURRED

NOT WHILE

WHILE AT

WORK □ AT WORK U

21 e. Place of Injury (e. g.. in or about

HOME. FARM. FACTORY. STREET. OFFICE BLDG.. ETC.

2 1 F . CITY. TOWN OR LOCATION COUNTY

STATE

.12-6-57 to .1-13-53

1-13-53

22. £ intended the deceased from .

Death occured at iat.35.AF. . mi on the date stated above; and to the best of my knowledge, from the causes stated

and last saw , . alive on
him

23A. SIGNATURE

F« P- peer ye thtrb*. t , l.*.

(DEGREE OR YIILEI

-I -

23b ADDRESS

VAH, March ster, If •

24 A BURIAL Qt CREMATION D
ENTOMBMENT O REMOVAL D

24B. DATE

IF ENTOMBED
24e. PLACE OF BURIAL

24 c. NAME OF CEMETERY OR
CREMATORY

Vlnthrop Cemetery

LOCATION (city. town, county)

24D. LOCATION icity. town, or county) (state)

Vinthroj. Highland f,

MslL —

DATE

25. FUNERAL DIRECTOR S SIGNATURE

ADDRESS

ATE REC'D BY TOWN OR CITY CLERK

January 20 » 1953

tc Gale, Aaesbury, Maaa.

' CLERK’S OWN SIGNATURE

M.J. Quinn

COUNTERSIGNED - AGENT (city bo. of health) DATE _ .« _ >

J i.;u l £ J« Powers, 1-1'- 1

CLERK OF

Manchester, i* • •

.-I true cof >y, Attest:

cirri , „f Manchester

VS I 1

RIV.-I*M-I1N

LMR-301A

ITRUCTIONS

FOR

XL CERTIFICATE

n giving
: OF DEATH

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

does not mtan
ode of dying,
f heart failure,

, etc. It meant ^
rate, or compli- *
which caused

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

ditiont contrib- ■
o death but not
to the terminal
condition given

> Chapter 137,
f 1754, requires
fans to print or
the cause or
of death on
certificates.

Suffolk

(County)

Winthroo

2 FULL NAME-

(City or Town) .

Bay View Nurninm Home

No.

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.

(a) Residence. No.

Laura E (McKie) Jordan

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

4l Washington Ave

/(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)

St..

(If nonresident, give city or town and State)

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

EDICAL CERTIFICATE OF DEATH

3 DATE OF
DEATH

4 I HE 5C/E BY CERTIFY

_, 19 £S-.., to |

I last saX hCralive on
have occurred on the date state

(Year)

That I attended deceased from

_, 19 .4? $ , death is said to

at / *4. S /•

DEATH WAS CAUSED BY: IMMEDIATE CAUSE

(a) — Broncho />>? e uk ynor/A

Due To
(b)

J p PA? B<zsp/Y'\tory

Z e, c£ij an Z_

Due To
(c)

OTHER

SIGNIFICANT

CONDITIONS

Geneir^iizeJ A otcrioszL

lerosn

Was autopsy performed? syLo ..

What test confirmed diagnosis?-.

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

Place of Burial or Cremation
DATE OF BURIAL

(City or Town)

Jan. 22

Received and filed

22ifg$

(Registrar)

PERSONAL AND STATISTICAL PARTICULARS

8 SEX

F ernal<

9 COLOR

White

10 SINGLE (write the word)
MARRIED
WIDOWED

or DIVORCED OV

10a If married, widowed, or divorced
HUSBAND of

(or) WIFE of

(Give maiden name of wife in full)

Robert F Jordan

(Husband’s name in full)

11 IF STILLBORN, enter that fact here.

12 8° 7

AGE — Years Months Days

If under 24 hours
Hours Minutes

13 Usual HOUflPWl f P

Occupation:

(Kind of work done during most of working life)

14 Industry
or Business:

At. ..Home-

15 Social Security No

.. one

16 BIRTHPLACE (City)

(State or country) ‘ • •

17 NAME OF ... n .

FATHER 1 1 1 ' CK 1 e

18 BIRTHPLACE 0]j
FATHER (City)

table to Obtair

(State or country) Prince Edward Inland

19 MAIDEN NAME
OF MOTHER

20 BIRTHPLACE OF

MOTHER (City)

(State or country) Tvl't)

Unable

i o Obtain

"e Fdwprr’ LLnH

informant -Heroort F tjortirin

(Address) Q l'OWQl. X Rfj . log] ay

I HEREBY CERTIFY that a satisfactory standard certificate of death
was f(le<^ With me BEFORE the burial or transit permit was issued:

...C I

frUie r)

j / ^Signature of Ag^pt of Board of Health/or

itu /AK/yj—

./. v,

(Official Designation) / (/ (Date of Issue ofTermit)

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.

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 whenany 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 internient is made..

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

RULES OF PRACTICE

The fulfillment of the purpose of these la^s^cal^ observance of the follow-
ing rules of practice: \ v- x / V' ’

( 1 ) Attending physicians will certify-!/) sudraeatf\s6n1y as those of persons
to whom they have given bedside care duripgya,- last illness from disease unrelated
to any form of injury. 1 1 " • • *_l-'

(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 atte^ul^c^pf .w^rqr^e physician is absent
from home when the certificate of death /K J y J 0 ! • »

(3) Medical Examiners will investig^mr anrf ’ 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

MR-301A

'RUCTIONS

FOR

L CERTIFICATE

i giving
OF DEATH

not enter
than one
s for each
(b) and (c)

does not mean
ie of dying,
heart failure,
etc. It means
lie. 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
mg to print or
lie cause or
of death on
ertiflcates.

T) 5

>4 •

H
C
W
Q

1 Ibu

Suffolk

(County)

'iinthroo

(Hlf? (Umiimmiwcaltli nf MassfarljuiiTttia

EDWARD J. CRONIN
Secretary of the Commonwealth

DIVISION OF VITAL STATISTICS

(City or Town)

5P Harbor View Ave

STANDARD

CERTIFICATE OF DEATH

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

Registered No.

No.

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

2 FULL NAME-

William J Anderson

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

(a) Residence. No.

(Usual place of abode)

b o H a r b o r V 1 e w A v e .

| PHYSICIAN -IMPORTANT

' (Was deceased a
I U. S. War Veteran,

'if so specify WAR)

Length of stay: In place of death -—.years

months days. In place of residence .—‘1— years months days.

(If nonresident, give city or town and State)

MEDICAL CERTIFICATE OF DEATH

3 DATE OF
DEATH _

(Month)

(Day)

(Year)

4 I HEREBY CERTIFY, That I attended deceased from

_ Jan. 4 i &k~ , to Jan. 21 ..,

I last saw h UHlive on Jan. 21 , 19... 58 , death is said to

have occurred on the date stated above, at .10 p. . n

DEATH WAS CAUSED BY: IMMEDIATE CAUSE

(a) Cerebral hemorrhage

fh)e To Cerebral arteriosclerosis

Due To Generalized arteriosclerosis

OTHER

SIGNIFICANT

CONDITIONS

Diabetes mellitus

INTERVAL
BETWEEN
ONSET AND
DEATH

10 hrd

2 yrs

U yrs

h yrs

Was autopsy performed?.

What test confirmed diagnosis?- clinical & laboratory

5 Was disease or injury in any way related to occupation of deceased ?nO
If so. ^*cify

(Signed)

M. D

(Address) 73 Bartlett Rd.

i£8

::t

-L£tidE5rtir._

Place of BurTal or Cremation
DATE OF BURIAL

Boston

(Cit y or Town )

7 NAME OF
FUNERAL DIRECTO

Received and filed

JAN 23.1988 -

PERSONAL AND STATISTICAL PARTICULARS

8 SEX

Male

9 COLOR

White

10 SINGLE (write the word)
MARRIED
WIDOWED

or DIVORCED

10a If married, widoyred-or diyonced , . - - .
HTTSRAND of UflllSllne U"1 X

HUSBAND of_.
(or) WIFE of

(Give maiden name of wife in full)

(Husband’s name in full)

11 IF STILLBORN, enter that fact here.

OQ O O

AGE .... .Years Months — Days

If under 24 hours
Hours Minutes

13 Usual

Occupation : HamesiMa1

(Kind of work done during most of working life)

14 Industry .

or Business : LSJH1.S SS-i-Lii Q.D..

15 Social Security No X OT~l e

16 BIRTHPLACE (City) „

(State or country) 1 FG L‘. . ~'.d

17 NAME OF
FATHER

George Anderson

18 BIRTHPLACE OF

FATHER (City)

(State or country) X

19 MAIDEN NAME

OF MOTHER V

20 BIRTHPLACE OF

MOTHER (City)

(State or country) I ^SlSriU

Informant pfeilS C j-QHIGrit ,XO 0.(3

rrbor V i ■: : . v .

i mui man i . -

(Address)

I HEREBY CERTIFY that ^satisfactory standard certificate of death
was W > * h me BEFORE the burial or transit permit was issued:

■L, k (Z: (Cj

(Signature of AgenJ; of Board of Heal

(Official Designation)

✓

EXTRACTS

FROM THE LAWS OF THE

COMMONWEALTH OF MASSACHUSETTS

GOVERNING THE

RETURN OF CERTIFICATES OF DEATH

A physician or registered hospital medical officer shall forthwith, after the
deathP 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, bee. 9.

A physician or officer furnishing a certificate of death as r«9u'redJ?yf ‘IF
preceding section or by section forty-five of chapter one hundred ami 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 m 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 '"Me-
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
of said chapter one hundred and fourteen, the word war shall include the China
relief expedition and the Philippine insurrection which sh,a,'vf°r,sald,pur?°*fs'
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, m case of an original inter-
merit, 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 ot 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, it death is
caused by violence, the medical examiner shall make such certificate, it 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 ror the
purpose, the certificate of death made as above provided and m the possession ot
the undertaker desiring to make such removal shall constitute a permit tor 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. It 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: , if •••*.' . ’• , , . f

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

to whom they have given bedside cafe during a last illness from disease unrelated
to any form of injury. ■ • . ... , . .. , ... f

(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 ceftfficq^e of death is needed.

(3) Medical ExariX&&^iB-lA^UTfefe(and certify to all deaths supposably
due to injury. These inclufte bbtuioly 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 ot
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 ^e 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

Y WV

r-soia/

it**

RUCTIONS

FOR

. CERTIFICATE
giving

OF DEATH

aot enter
than one
: for each
(b) and (c)

does not mean
If o I dying,
heart failure,
etc. It meant .
le. or compli- *
which caused

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

■lions contrib -•
death but not
o the terminal
ondition given

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

/ a

(•«

1°

l lut

1°

'0-

2 FULL NAME-

Suf folk

(County)

Winthrop

(City or Town)

Sty* (Emmttnmiiealtlj of UlaaHartjnapttfi

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.

1^*4

No.-

. t-t . . . f (I f death occurred in a hospital or institution

iwa.y i xOW5r -Nursing Home Winthrop ~st/ • ■ - ■ •

CL Vi

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

Formerly of 446 Western Ave. Lynn

(give its NAME instead of street and number)
PHYSICIAN — IMPORTANT
(Was deceased a
U. S. War Veteran,
if so specify WAR)

(a) Residence. No.

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

Length of stay: In place of deat&O years months days. In place of residenc0Q- years months days.

MEDICAL CERTIFICATE OF DEATH

3 DATE OF ~T
DEATH

(Month)

2 X

/ 9 r S'

(Day)

(Year)

4 I HEREBY CERTIFY, That I attended deceased from

L.SL.. , 19J^r to tJ. n ^ , wJT-E.

I last saw h.r= ,;_.«live on . y-\ , 19_b_i>, death is said to

have occurred on the date stated above, at (icstSC (P m

DEATH WAS CAUSED BY: IMMEDIATE CAUSE

(a) L j vi o & s~/~ 1 1/ q. Co v' U i a c .

f~~ (X k j sj y

To/4WeY(0 sc/^vo^i*^

Due To

gy i o c l

^YOS/ S

OTHER

SIGNIFICANT

CONDITIONS

—

<- g.f

• 3

INTERVAL
BETWEEN
ONSET AND
DEATH

X Cifty.i

Mq -ny

W CiCt Y \

IM & >iy

y -feS' y J

'X.

v ^ /c j

Was autopsy performed?-

-Lil-Xj-

What test confirmed diagnosis? ( L,.Ll3a-LXi-Gc..-L 6sJ2tlO-

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

(Signed)

(Address) il

’<•

/ A} IZ (sE-eJtL "

rVwh , M. D.

yk.4.*<L*<! 1 DateA.L.:T4.Vl l9Lj£

6 rf&ww.Az&n,

DATE OF BURIAL

Tuaiion Portsmoptfe^N.

January 25 ,£8

NAME OF W

FUNERAL DIRECTOR "• C. Goodrich

rnn. Maaa^

ADDRESS

Received and filed

Maw

19.......

(Registrar)

PERSONAL AND STATISTICAL PARTICULARS

8 SEX

Female

9 COLOR

White

10 SINGLE (write the word)
MARRIED

WIDOWED WlrtrvwpH

or divorced" laowea

10a If married, widowed, or divorced
HUSBAND of

(Give maiden name of wife in full)

(or) wife of Uharles M. Sanborn

(Husband’s name in full)

11 IF STILLBORN, enter that fact here.

12 Q2 4 25

AGE Years Months Days

If under 24 hours
Hours Minutes

13 Usual

Occupation :

(Ki^dHf^lo^fdurf^tos^^i,

ng life)

14 Industry

or Business:

15 Social Security No...

Hone

16 fsu™oycouniy)Clty)po rt s mouth, N.-H.-

17 NAME O
FATHER

franklin C. Hoyt

18 BIRTHPLACE OF

FATHER (City)

(State or country)

Unable to learn

19 MAIDEN NAME
OF MOTHER

Mary JEmix UnaJJ|^

20 BIRTHPLACE OF

mother (City) Unable

(State or country)

to learn

informanJThomas L, Ada ms ( Fr i e nd )

(A<'<lrcss, 44Q Western Ave., Lyna=

I HEREjBY CERTIFY that a satisfactory standard certificate
was yUcd with me B^0ORE the burial or transit permit was i

l/// (Signature of Agent of Board of Health, fir other)

of death

ssued :

(Official

CJaJklA. /A'U

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

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

No undertaker or other persons shall bury a human body or the ashes thereof
which have been brought into the commonwealth until he has received a permit
so to do from the board of health or its ageptr.appqin-ted to issue such permits, or
if there is no such board, from the clerk of the'towrTwh^re 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 a< 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 i's 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 agepts. and deaths following abortion, but
also deaths from disease resulting from injury or ipfebtiotrYelated to occupation,
the sudden deaths of persons not disabled* by recognized disease, and those of
persons found dead.

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

SPACE FOR ADDITIONAL INFORMATION

DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE

RANK, RATING '

ORGANIZATION AND OUTFIT
SERVICE NUMBER

\ R-301 A

RUCTIONS

FOR

. CERTIFICATE

giving

OF DEATH

not enter
than one
t lor 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),
i the under-
cause last.

litions contrib-
death but not
to the terminal
condition given

Chapter 137,
1954, requires
ans to print or
he cause or
of death on
certificates.

< Suffolk

g (County)

o Wlnthrop

w (City or Town)

(Eommcmupaltlj of fHaHaadjuartts

EDWARD J. CRONIN

Secretary of the Commonwealth

DIVISION OF VITAL STATISTICS

STANDARD

CERTIFICATE OF DEATH

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

Registered No.

No.

Wlnthrop Community Hospital _ *. {X'SftlBKt&S WS.’iftSSSr

thp'pl np F1 f physician important

2 FULL NAME - J (Was deceased a

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

28 Thornton

U. S. War Veteran, yi e\
if s

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