The volume, 1959
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ACCOUNT BOOK
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r
ORM R-301A
N.B.-THIS IS A
1MANENT RECORD
Use only
TATE APPROVED
lack ink or black
'pewriter ribbon.
INSTRUCTIONS
FOR
DICAL CERTIFICATE
In giving
JSE OF DEATH
do not enter
more than one
ause for each
(a), (b) and (c)
rhis does not mean
mode of dying,
as heart failure,
nia, etc. It means .
disease, or compli- ^
ns which caused
i.
nditions, if any,
ich gave rise to
svc cause (a),
ting the under-
ng cause last.
onditions contrib -■
to death but not
d to the terminal
e condition given
e:- Chapter 137,
of 1954, requires
Icians to print or
the cause or
s of death on
i certificates.
CHAP. 46, §§ 9 &
CHAP. 114 5145,
CHAP. 3856.)
/b
OM-1 0-58-923886
;.U±f-Qlk-
(County)
■Vint hr op
(Enmmnnumaltlj nf fHaaisarljuaett:
(City or Town)
No. _. 41.J3elcher Strait
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.
f(If death occurred in a hospital or institution,
St. 1 give its NAME instead of street and number)
2 full name T^^a .---Eol-en.--4Col-S-a-7--
(It deceased is a marriecT, widowed or divorced woman, give also maiden name.)
! PHYSICIAN — IMPORTANT
(Was deceased a
U. S. War Veteran, jjq
if so specify WAR),
St.
(If nonresident, give city or town and State)
Length of stay: In place of death^-O-years months days. In place of residence 3-Q- years months days.
MEDICAL CERTIFICATE OF DEATH
3 DATE OF T . _
death _ January 4l 5 .195.9
(Month) (Day) (Year)
4 JLk1 EREB \ CERTIFY, That I attended deceased from
L, to. 2 AN , i9 5'^
I last saw h*£«Valive on ■JA.U4 £ , 1 9a£3 , death is said to
have occurred on the date stated above, at i A
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
£ ft £ ft i? a u H e. Age.
(a)
Due To
(b)
_H ^ (3 g (l T E. N 5 L o Ai
Due To
(c)
OTHER
SIGNIFICANT ...
CONDITIONS
Was autopsy performed
INTERVAL
BETWEEN
ONSET AND
DEATH
DaV
l y in
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
female
9 COLOR
white
10a If married, widowed, or divorced
HUSBAND of
10 SINGLE (write the word)
MARRIED ni3T"T'i 0(3
WIDOWED 1UclX riea
or DIVORCED
(Give maiden name of wife in full)
(00 wife of_.. William Rooferd Kelaev
(Husband’s name in full)
11 IF STILLBORN, enter that fact here.
14 _
AGE 7 6 Years P Months .1 £2 Days
What test confirmed diagnosis?-
5 Was disease or injury in any way related to occupation of deceased?!),0
If so, specify
(Signed)
v — ... , M. D.
(Address)l^JLj_k^_S_A^T_..i_I: Pate.,l/US-..-<£ _19.Q.
13 Usual
Occupation:
If under 24 hours
Hours Minutes
.hGiis.ewife
14 Industry
or Business: OWP h Qfli-9
(Kind of work done during most of working life)
15 Social Security No.Q^.Q--l-4--= ^-4Q3-- -
16 BIRTHPLACE (City).
(State or country)
6 ,,re;v, raT^“r 3<’.-etory irijtcl, iiair
Place of Burial or Cremation (City or Town)
e
17 NAME OF
FATHER
18 BIRTHPLACE OF
FATHER (City) ...
(State or country)
a! mon Davis
.ok
19 MAIDEN NAME
OF MOTHER
511a Villa
20 BIRTHPLACE OF
MOTHER (City) _L.Qj4d$-V.ille_
(State or country) .iainO
DATE OF BURIAL.
iua,i
7 NAME OF
FUNERAL DIRECTOR.
(Address) " ZT'" Q T „ h t"f
address ---l?-4^Zin.tA_£lD At. Ji-nth-rnp"
Received and filed '
(Registrar)
satisfactory^jtandajd certificate of death
the hhyial or^ransit"permit was'issued:
f Health or other)-^*
rj J
(Date of Issue of Permit)
1/ it I J
7
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE
RANK, RATING
ORGANIZATION AND OUTFIT
SERVICE NUMBER
RULES OF PRACTICE
vTJ" •
•. ' O •//. -
o ■
// ^’ 7'" ^* v
The fulfillment of the purpose of these laws calls for the observance h( the faj'WVv fl (’ “
ing rules of practice: wp** ( O J
(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
t0(2>y BoTrcl^ of J 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. e
(3) Medical Examiners will investigate and certify to all deaths supposably
due to injurv. 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 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 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, hor a
person engaged in domestic service for wages, however, designate the occupation
by the appropriate terms, as housekeeper — private family, cook hotel, etc. tor
a person who had no occupation whatever write none.
RM R-301A
4STRUCTI0NS
FOR
CAL CERTIFICATE
In giving
JE OF DEATH
lo no: enter
ore than one
mse for each
a), (b) and (c)
is dors not mean
node of dying,
as heart failure,
la, etc. It means ^
sease, or compli- *
r which caused
i ditions, if any,
ch gave rise to
ve cause (a),
ing the under-
ig cause last.
onditions contrib-m
to death but not
'd to the terminal
se condition given
i).
>te:- Chapter 137,
; of 1954, requires
sicians to print or
i the cause or
»es of death on
th certificates.
(Ernttmomiipaltlj of fHasoarliuoftto
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.
Q
CERTIFICATE OF DEATH Registered No.
11 6 Quincy Ave.
((If death occurred in a hospital or institution,
| v . i rrs . _ J _ C n nm nor I
2 FULL NAME-
Margaret E. Lindsey
(^deceased is a married, widowed or divorced woman, give also maiden name.)
116 Quincy Ave.
(a) Residence. No.
nil aeam ottuncu ■■■ <■ -- ,
St. (give its NAME instead of street and number)
S PHYSICIAN - IMPORTANT
(Was deceased a
IU. S. War Veteran, y,-.
if so specify WAR) .
St.._
(Usual place of abode)
Length of stay: In place of death years months
days. In place of residence
(If nonresident, give city or town and State)
—.years months — — days.
MEDICAL CERTIFICATE OF DEATH
1 g£I?HOF January
(Month) (Day)
1959
(Year)
8 SEX
female
4 I HEREBY CE R T I F Y , That I attended deceased from
\ ) / , 19*'TX.-, to V- ■ — > 19uyL
I last sasir h^-alive on -X- 19-1/, death is said to
have occurred on the date stated above, at — m.
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
t / //J
(a)
Due To
(b) - -1 -X
JX_
iJeir 0 $ IS -
-7 e
Due To
(c)
A- -l/d
•Xu • X- L.
sicmFicANT kUL± (3. :_i..
CONDITIONS
INTERVAL
BETWEEN
ONSET AND
DEATH
*1 >
—
Was autopsy performed?.
What test confirmed diagnosis?
5 Was disease or injury in any way related to occupation of deceased?
If so. specify -
(Signed)
(Address)
Ta 3
>__*
I! Date..
. , M. D
_^i.:!-./-i9..
6 St Jajne_s_ Georgetown.'. P> E . 1. ._ —
Place of Burial or Crematiojp py °r Town) 59
DATE OF BURIAL 19
7 NAME OF
FUNERAL DIRECTOR J
ADDRESS
fc J. M
East BoB-ton.
Received and filed
19..
(Registrar)
PERSONAL AND STATISTICAL PARTICULARS
9 COLOR
white
10 SINGLE (write the word)
aowea
or DIVORCED
10a If married, widowed, or divorced
HUSBAND of - t
E^ePW'^TOgfe^6 ,n
(or) WIFE of — -- — -jg r — j-jjr
(Husband s name in full)
11 IF STILLBORN, enter that fact here.
12 f-7^
AGEZi^ Years Months Days
If under 24 hours
Hours Minutes
13 Usual hOUSeVfflEi i > /
ion:
Occupation. ^';n(j 0{ work done during most of working life)
14 Industry OWU hOHie
or Business
IS Social Security No — ■ - — -
,6 birthplace .-rir.cc.- Ldbara
(State or country)
17 NAME OF
FATHER
An pus Morrison
18 BIRTHPLACE OF
FATHER (City)—-
(State or country)
P^E-.-1-a-
19 MAIDEN NAME _ , „ . „
of mother hary RooG^tson
20 BIRTHPLACE OF
MOTHER (City)-.
(State or country)
P.E/L
21 informantMar £are t . K... Butler .
(Address) QTHnr.Tr ftvP ■ Wlnt.hrOP
. n. r r«sr .1 . / / nortmrofp
tEBY C]
RTIFY that a/satisfactory standard-ccertificate of death
^ORE-XMe burial or transit permit was issued:
Ktfjtnyii Board of HealtKBr other)
, Designation)^
(Date of Issue of Permit)
M *
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
l>est of his knowledge and belief the name of the deceased, his supposed age. the
disease of which he died, defined as required by section one. where same was
contracted, the duration of his last illness, when last seen alive by the physician
or officer and the date of his death. . .Gen. Laws. Chap. 46. Sec. 9.
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 towm. from one cemetery to another, or from one grave or tomb
other than the receiving tomb to another in the same cemetery, until he has
received a permit from the board of health or its agent aforesaid or from the clerk
of the town where the body is buried. Xo such permit shall be issued until there
shall have been delivered to such board, agent or clerk, as the case may be,
a satisfactory written statement containing the facts required by law to be
returned and recorded, which shall be accompanied, in rase of an original inter-
ment. by a satisfactory certificate of the attending physician . if any, as required by
law. or in lieu thereof a certificate as hereinafter provided. If there is no attending
physician, or if. for sufficient reasons, his certificate cannot be obtained early
enough for the purpose, or is insufficient, a physician who is a member of the board
of health, or employed by it or by the selectmen for the purpose, shall upon
application make the certificate required of the attending physician. If death is
caused by violence, the medical examiner shall make such certificate. If such a
permit for the removal of a human body, not previously interred, from one town
to another within the commonwealth cannot be obtained early enough for the
purpose, the certificate of death made as above provided and in the possession of
the undertaker desiring to make such removal shall constitute a permit for such
removal; provided, that such body shall be returned to the town from which it was
removed within thirty-six hours after such removal, unless a permit in the usual
form for the removal of such body has been sooner obtained hereunder. If the
death certificate contains a recital, as required by section ten of chapter forty-six.
that the deceased served in the army, navy or marine corps of the United States
in any war in which it has been engaged, such recital shall appear upon the permit.
The board of health, or its agent, upon receipt of such statement and certificate,
shall forthwith countersign it and transmit it to the clerk of the town for registra-
tion. The person to whom the permit is so given and the physician certifying
the cause of death shall thereafter furnish for registration any other necessary
information which can be obtained as to the deceased, or as to the manner or
cause of the death, which the clerk or registrar may require. — Chap. 1 14. Sec. 45.
G. L.. (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 rff ffiffc-tidjl feljaXing to occupation, or suddenly when not
disabled by recognizaolCrdtSe5se. 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 ptrsotas shall bury a human body or the ashes thereof
which have been broyght^into the commonwealth until he has received a permit
so to do from the board ofjhe<h or its agent appointed to issue such permits, or
if there is no suchboai’d. frog). Lb. e flerk qf the town where the body is to be buried
or the funeral is to' be^held. or frdm. 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).
Vi
' y . . RULES OT PRACTICE
The fulfillment of thfept^pos^of tjifese laws calls for the observance of the follow-
ing rules of practice:
(1) Attending physician* will certify to such deaths only as those of persons
to whom they have giveq 'bedside cate 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 ^s^led by frecogpiae4 disease unrelated to any form of
LicaljaUfcndance or whose physician is absent
injury, have died with!
from home when the Wtrnrc-ate dra&lnMs needed.
(3) Medical Examiners will investigate and certify to all deaths supposably
due to injury. These include not only deaths caused directly or indirectly by
traumatism (including resulting septicemia), and by the action of chemical
(drugs or poisons) thermal, or electrical agents, and deaths following abortion, but
also deaths from disease resulting from injury or infection related to occupation,
the sudden deaths of persons not disabled by recognized disease, and those of
persons found dead.
Statement of Cause of Death. — Physicians: see explanatory instructions
on face side of standard certificate of death.
Statement of Occupation. — Precise statement of occupation is very import-
ant, so that the relative healthfulness of various pursuits can be known. Make
some entry in this section for every person aged 10 years or over. If the occupa-
tion had been given up or changed, or if the deceased had retired from business,
report the kind of work done during most of working life even if retired. Children
not gainfully employed may be returned as at school or at home. For a woman
whose only occupation was that of home housework, write housework. For a
person engaged in domestic service for wages, however, designate the occupation
by the appropriate terms, as housekeeper — private family, cook — hotel, etc. For
a person who had no occupation whatever write none.
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE
RANK, RATING
ORGANIZATION AND OUTFIT
SERVICE NUMBER
RMR-301A
NSTRUCT I ONS
FOR
CAL CERTIFICATE
In giving
5E OF DEATH
lo not enter
ore than one
iuse for each
a), (b) and (c)
tis does not mean
modt of dying,
as hrart failurt,
ia, etc. It mtans ^
istast, or compli- *
s which caused
ditions, if any,
■h gave rise to
•re cause (a),
inj the under -
g cause last.
onditions contrib -
to death but not
d to the terminal
e condition given
).
e:- Chapter 137,
of 1954, requires
Icians to print or
the cause or
s of death on
i certificates.
iC
SbF rO~ K.
(County)*
2 FULL NAME
(City or Town)
ir/'Vr/i/t*'7 Cosy x //*sp
(Unmmmiuiealth of fUasHarijuaiita
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.
3
No.
SaisjL aviA/vA*..#-
f (1 f death occurred in a hospital or institution,
St. (give its NAME instead of street and number)
( PHYSICIAN — IMPORTANT
(If deceased is a married, widowed or divorced woman, give also maiden name.)
(a) Residence. No. /A1 Go lV£)t>jA/
(Usual place of abode)
' (Was deceased a
|U. S. War Veteran,
' if so specify WAR).
Length of stay: In place of death years months In place of residence J-tdyears months days.
JA
(If nonresident, give city or town and State)
MEDICAL CERTIFICATE OF DEATH
death -January 6, 1959 -
(Month) *(Day) (Year)
4 I HEREBY CERTIFY, That I attended deceased from
January 19 50, to January 6, 19 59
I last saw h^Jhlive on January— 6,-, 19-59- ’ death *s said to
have occurred on the date stated above, at 12:55 a*> interval
BETWEEN
ONSET AND
n DEATH
1 mo
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a) Acute ..myocardial inf arctic
(bT TS.amnary_a-_cl.er oai_s_
(c) _ -by.p-ertensi.y_e — heart — draec se jl 15 Social Security No.. •• - .
5 ygj BIRTHPLACE (City) ...!
Arteriosclerotic and
OTHER
SIGNIFICANT
CONDITIONS
Was autopsy performe
What test confirmed diagnosis?
Arteriosclero sis
Hypertrophic arthr-Ht-ia-
nea ?_ JOO
3 yra
clinical
5 Was disease or injury in any way related to occupation of deceased ?..
If so, sppeify HQ-
Place of ’Burial or Cremation
DATE OF BURIAL . •/4-eY
(City or Town)
Received and filed
(Registrar)
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
££AAL£
9 COLOR
10 SINGLE (write the word)
MARRIED
WIDOWED O /AlflS C~
or DIVORCED J / /V ?
10a If married, widowed, or divorced
HUSBAND of —
(Give maiden name of wife in full)
(or) WIFE of
11 IF STILLBORN,
12
AGE
& .^.Years.
13 Usual
Occupation:
14 Industry
or Business:
(Husband’s name in full)
enter that fact here.
Months __Days
If under 24 hours
Hours Minutes
Kind of work done during most of working life)
(State or country)
17 NAME OF
FATHER
ZtJLJL/
18 BIRTHPLACE OF
FATHER (City)
(State or country)
AMS
19 MAIDEN NAME
OF MOTHER
20 BIRTHPLACE OF
MOTHER (City)
(State or country)
EXTRACTS
FROM THE LAWS OF THE
COMMONWEALTH OF MASSACHUSETTS
GOVERNING THE
RETURN OF CERTIFICATES OF DEATH
A phvsician or registered hospital medical officer shall forthwith, after the
death 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 tour-
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 sh all 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, ivhich shall be accompanied, in case of an original i mer-
men t , 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. I' 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 m 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-fuado- ijbe tliefc 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 ahortion, or from diseases
resulting from injury or infection relating to occuration, 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. bit. Sec. 4, Acts of 1945.
No undertaker or other persons shall bury a hurtta'n- boljij 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 tterk 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 cahs-fet 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 durina^lMtilli^ohoniwhswsc unrelated
to any form of injury. JAf* md-J j, hl1, ... ,
(2) Board of Health physicians will certify to siTch deaths only as those of
persons vffio, though disabled by recognized disease unrelated to any form of
injury, have died without recent medical attendance or whose physician is absent
from home when the certificate of death is needed.
(3) Medical Examiners will investigate and certify to all deaths supposably
due to injury. These include not only deaths caused directly or indirectly by
traumatism (including resulting septicemia), and by the action of chemical
(drugs or poisons) thermal, or electrical agents, and deaths following abortion, but
also deaths from disease resulting from injury or infection related to occupation,
the sudden deaths of persons not disabled by recognized disease, and those of
persons found dead.
Statement of Cause of Death. — Physicians: see explanatory instructions
on face side of standard certificate of death.
Statement of Occupation. — Precise statement of occupation is very import-
ant, so that the relative healthfulness of various pursuits can be known. Make
some entry in this section for every person aged 10 years or over. If the occupa-
tion had been given up or changed, or if the deceased had retired from business,
report the kind of work done during most of working life even if retired. Children
not gainfully employed may be returned as at school or at home. For a woman
whose only occupation was that of home housework, write housework, lor a
person engaged in domestic service for wages, however, designate the occupation
by the appropriate terms, as housekeeper — private family, cook — hotel, etc. For
a person who had no occupation whatever write none.
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE
RANK, RATING
ORGANIZATION AND OUTFIT
SERVICE NUMBER
IM R-301A
B.-THIS IS A
ANENT RECORD.
Use only
TE APPROVED
:l< ink or black
•writer ribbon.
ISTRUCTIONS
FOR
:al certificate
In giving
E OF DEATH
o not enter
ire than one
use for each
i), (b) and (c)
ii does not mean
node of dying,
as heart failure,
i a, etc. It means ^
sease . or compli-
which caused
htions, if any,
h gave rise to
e cause (a),
ng the under-
’ cause last.
nditions contrib
to death but not
I to the terminal
’ condition given
).
e:- Chapter 137,
of 1954, requires
dans to print or
the cause or
s of death on
certificates.
CHAP. 46, §§ 9 &
CHAP. 114 §§45,
CHAP. 3 8 § 6.)
*
,_du f f Qlk
(County)
fiin.tiir.op.
(City or Town)
(fommumupaltlj nf fHnaaarlptaetts
EDWARD J. CRONIN
Secretary of the Commonwealth
DIVISION OF VITAL STATISTICS
STANDARD
CERTIFICATE OF DEATH Registered No.
To he filed for burial permit
with Board of Health
or its Agent.
A
no. _3a ^_jy:iaw_--Kurs J_ng - -Hxme.
2 FULL NAME
(If deceasetrls a marr
■J" wufowed or
—A. — m,
((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, fj r\
if so specify WAR) — IsAe-S
t gAe»iMfnn?n.e.)
(a) Resid^nce.^ ^No.^. "SOffiOrS-Otr “AVOnUr©- (If nonresident, give city or town and State)
Length of stay: In place of death years-^.-. months-g-Jdays. In place of residence 3£)years —.months days.
MEDICAL CERTIFICATE OF DEATH
3 death017 January . ...8 , ..19 5.9
(Month) (Day)
(Year)
4 I HEREBY CERTIF Y , That I attended deceased from
19 19^7
alive on — ~sa /ao?.. 6, 19 >57. , death is said to
I last saw lv“
have occurred on the date stated above, at m.
DEATH WAS CAUSED BY: IMMEDIATE CAUSE ^ ^ ^
(a) /7)yoc Jhtsa&jt&s* yDlMH
Due
(b)
To/#er^/£)c>c^^&7-/<L -
Due To
(c)
6CA&&&4SL.
SK3NT FI Cr ^
CONDITIONS
Was autopsy performed?
What test confirmed diagnosis ?.
ed^..
INTERVAL
BETWEEN
ONSET AND
/-
fy/onT.^-C
/f'-f'Z—
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
female
9 COLOR
white
10 SINGLE (write the word)
MARRIED , , . ,
widowed Married
or DIVORCED
10a If married, widowed, or divorced
HUSBAND of .... ........ ...
(Give maiden name of wife in full)
(or) WIFE of n
iharles Edwards
(Husband’s name in full)
11 IF STILLBORN, enter that fact here.
14 or^BuMneff eneral an4 hospital nu^-s-i-ng--
15 Social Security No 11011-3- — - -
5 Was disease or injury in any way related to occupation of decease!
If so. specify
( Si gn e d ) ...£l3^=£
(Address) tflUk
« ■Vinthfbp^G’eB
Place of Burial or Cremation
DATE OF BURIAL.
7 NAME OF
FUNERAL DIRECTOR.
ADDRESS . - l£.-finthrop^
, M. D.
7 19.57^
- >P,
(City or Town)
(State or country)
Hanacta
17 NAME OF
FATHER
UonYtT 'PVi rrps f; p-p
C/3
H
18 BIRTHPLACE OF
T7 A 'TT-T T? T?
nnkn own _
z
(State or country)
W
ca
<
19 MAIDEN NAME
OF MOTHER
Hannah ?
&4
20 BIRTHPLACE OF
MOTHER (City) —
— -unknown-
(State or country)
Received and filed .
.nformant-Mr-B-. Sarah fhorf . , ,
•Address) 94 Somflrapr Win, Tinfrzhago
I HEREBY
was
19s£?.
(Registrar)
op— ■
.tory /tAndard certificate af death
1 or .transit permit was issued:
.f-ol Health or other) Ap
-<*A_ */f jft.
(Date of Issue of Permit; /
OM - 1 0-58-923886
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE
RANK, RATING
ORGANIZATION AND OUTFIT
SERVICE NUMBER
DECEIVED
VOV'-AT*-'. • X
m % m
JAN? 9 1959 Ml
RULES OF PRACTICE
The fulfillment of the purpose of these laws calls for the observance of the follow-
ing rules of practice:
( 1 ) Attending physicians will certify to such deaths only as those of persons
to whom they have given bedside care during a last illness from disease unrelated
to any form of injury.
(2) Board of Health physicians will certify to such deaths only as those of
persons who, though disabled by recognized disease unrelated to any form of
injury, have died without recent medical attendance or whose physician is absent
from home when the certificate of death is needed.
(3) Medical Examiners will investigate and certify to all deaths supposably
due to injury. These include not only deaths caused directly or indirectly by
traumatism (including resulting septicemia), and by the action of chemical
(drugs or poisons) thermal, or electrical agents, and deaths following abortion, but
also deaths from disease resulting from injury or infection related to occupation,
the sudden deaths of persons not disabled by recognized disease, and those of
persons found dead.
Statement of Cause of Death. — Physicians: see explanatory instructions
on face side of standard certificate of death.
Statement of Occupation. — Precise statement of occupation is very import-
ant, so that the relative healthfulness of various pursuits can be known. Make
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.
i R-301 A
A,
3 Suffolk
i p (County)
,o Vinthrop
I W
U
<
yA
i fiu
(City or Town)
83
(Emttmmuuraltlii of fHaooarl|uortta
EDWARD J. CRONIN
Secretary of the Commonwealth
DIVISION OF VITAL STATISTICS
STANDARD
CERTIFICATE OF DEATH
To be filed tor burial permit
with Board of Health
or its Agent.
5
Registered No — —
No..
2 FULL NAME
Somerset Aye... st.
Michael Mahoney
RUCTIONS
FOR
L CERTIFICATE
i giving
OF DEATH
not enter
s than one
e for each
(b) and (c)
does not mean
de of dying,
heart failure,
, etc. It means
ase, or compli-
which caused
lions, if any,
gave rise to
cause (a),
g the under-
cause last.
editions contrib-
o death but not
to the terminal
condition given
e:- Chapter 137,
of 1954, requires
dans to print or
the cause or
s of death on
certificates.
(If deceased is a married, widowed or divorced woman, give also maiden name.)
83 Some rset Aye... st
((If death occurred in a hospital or institution,,
( give its NAME instead of street and number)
PHYSICIAN — IMPORTANT
(Was deceased a
U. S. War Veteran, f 1 0
if so specify WAR)
(If nonresident, give city or town and State)
(a) Residence. No
(Usual place of abode) _
In place of death!. years5. months days. In place of residence -1- years P. months days.
Length of stay :
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
DEATH ...
(Mi
onth)
(Day)
Ltd
(Year)
4 I HE RJELB Y C E^RT 1FY
/// J / , \<h>...^/..., to L
I last saw h.^ralive on j..V..V.~..^.
have occurred on the date stated above, at - m
21 attended deceased from
L.^..._ 19_.’....... "
19ji?....', death is said to
8 SEX
I 9 COLOR
Male
1 tfhite
K..A...
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
6 Art A—
(a)
Due To
(b)
?cT 7?/ o—S CL/?t 1 c
OTHER
SIGNIFICANT
CONDITIONS
INTERVAL
BETWEEN
ONSET AND
DEATH
7^
Was autopsy performed? —
What test confirmed diagnosis?.
7IA.
5 Was disease or injury in any way related to occupation of deceased?
If so, specify ..
At-
M. D.
(Signed)..:OdL4^y£
// ? Date . tj/jf 19.PJL
PERSONAL AND STATISTICAL PARTICULARS
10 SINGLE (write the word)
MARRIED
WIDOWED „ . , j
or divorced’/ 1 d eyed
10a If married, wir
HUSBAND of ..._.£
°ihl
(Give maiden name of wife in full)
(or) WIFE of..
(Husband’s name in full)
(Address).:
A
^Cambridge Catholic . Gem ,G.aM?.r1 dgfi.
Place of Burial or Cremation (City or Town)
DATE OF BURIAL J./inU&.ry. 1-7. 195-9-
7 NAME OF
FUNERAL DIRECTOR
Arthur. J..* Q.’.ilal.s.y...
ADDRESS -/ag-S-
Received and filed..
.19..
(Registrar)
11 IF STILLBORN, enter that fact here.
AGE 7. 3.. .Years Months Days
If under 24 hours
Hours Minutes
1 3 . Retired Ga rd aner.
(kind of work done during most of working life)
14 !,?dlp,7L.ss- Lan.d.a..c.an.e.
15 Social Security No._ - : —
utW5i£$0' Treisfia z
17 NAME OF, . , ,
father Jeremiah Mahoney
c n
1
18 BIRTHPLACE OF
£
(State or country)
T r>n T n
w
X
<
19 MAIDEN NAME
of mother Jul? a Hurley
P-.
20 BIRTHPLACE OF
(State or country)
T re land
21
EM Wn
at a satisfactory standard certificate of death
the bjunal or transit perrtiit was issued:
EXTRACTS
FROM THE LAWS OF THE
COMMONWEALTH OF MASSACHUSETTS
GOVERNING THE
RETURN OF CERTIFICATES OF DEATH
A phy sician 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 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
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 comnjpnwealth until he has received a permit
so to do from the board'otHeatlh dr its agent appointed to issue such permits, or
if there is no such board, from the clerk ofthe town where the body is to be buried
or the funeral is to be held,_or front a person appointed to have the care of the
cemetery or burial ground irrwhiqh .tjie 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 physician* will certify to such deaths only as those of persons
to whom they have given bedside care during a last illness from disease unrelated
to any form of injury. ..
(2) Board of Health physicians will certify to such deaths only as those of
persons who, though disabled by recognized disease unrelated to any form of
injury, have died without recent medical attendance or whose physician is absent
from home when the certificate of death is needed.
(3) Medical Examiner* 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, lorelectrical agents, and deaths following abortion, but
also deaths from disagA rtsultiqg from tn jury 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 dunng most of working life even if retired. Children
not gainfully employed may be returned as at school or at home. For a woman
whose only occupation was that of home housework, wnte 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 wnte none.
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE
RANK, RATING
ORGANIZATION AND OUTFIT
SERVICE NUMBER
Vt R-302
C*t3
> V
* « r>^
o « ;
u .
V-Z'Sl
x. %uJl
c **
c.t *
— X
•o c ^
£ * 4;
•o o
•5
V >* u
c/i ** u
«>*5 s
j;_ «
T!
•c
4-» v
t/1 T* 4>
ca fcj
u JZ <
.s:s
=-1
c *
>
0 0 '
UpS
sc«
2
ofc.-£
.gS*
o
H o
•O “ 1/)
»Js
£.5"
3 £ v
o c •
d~ £
%2\
«2-'
£ =-
_ r> •«*
C «
^ C ct
©'2
5 Id dies ex
1 ^ (County)
S Cambridge
I w
u
•<
•4
\ c.
(City or Town)
no Hol7...iihQiLt
2 FULL NAME —
®lj? <£mnm0nuu>altlj of fHafifiarljuurttH
edward j. cronin -•eambT»idzre7: r
Secretary of the Commonwealth (City «r Towfc making this return)
DIVISION OF VITAL STATISTICS
COPY OF
Registered No -
CERTIFICATE OF DEATH
6
I (If death occurred in a hospital or institution,
St. ( give its NAME instead of street and number)
(U deceTs^dl^mifried, widowed "or" divofcjed woman, give aiso maiden name.)
c^QO Shirley Court s$JLnd#l^^
(a) Residence. No ~2..2. •«* (If nonresident, give city or town and State)
(Was deceased a
U. S. War Veteran*^, (-n
if so specify WARJ.fU.......
(Usual place of abode)
Length of stay: In place of death .....years..
(If nonresident, give city or
..months—9' days. In place of residence — years months days.
MEDICAL CERTIFICATE OF DEATH
1 death01! JanmsrLXa, 1352
(Month) (Day) (Year)
4 1 HEREBY CERTIFY^ That I attended deceased Horn
January 9.,o 59 to &*-
I last saw h i ..alive on W
have occurred on the date stated above, at L..S.:..r--2.2-W....
, death is said to
m.
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a) caWTHoma to
Due To abdomen, lung and bon©
/ »*\ 9 ~ — —
(i»
Tp r*T mar y a i to un do 1 6 rmiriad
Due To
(c)
OTHER
SIGNIFICANT
CONDITIONS
INTERVAL
BETWEEN
ONSET AND
DEATH
Was autopsy performed? —
What test confirmed diagnosis?..
TTtT
S Was disease or injury in any way related to occupation of deceased?
If so, specify -
(Signed) Phllifi l„. m. d
(Address) — lT©.®.P-Wate..^®?is Jr5... 1 9.59
Hew Calvary °em.
" o : t "F T
Place of Burial or Cremation
DATE OF BURIAL
Jan, 22,
(City or Town)
.
7 NAME OF
FUNERAL
ADDRESS
Charles ?• Chap :an
J$W r8olumb‘Ia' "T?T 1 1 orc^s^er
Received and filed
1^JqlJ±JS^
.19
(Registrar of City or Town where deceased resided)
8 SEX
7 ©male
PERSONAL AND STATISTICAL PARTICULARS
9 COLOR
VVh i t o
10 SINGLE (write the word)
MARRIED
^dPvorced do wed
10a If married, widowed, or divorced
HUSBAND of - (Give maiden name of wife in fuil)
. , ( John J, Shaw
°r ° (Husband’s name in full)
11 IF STILLBORN, enter that fact here.
X38.
.Years*?. Monti
&
Days
If under 24 hours
Hours Minutes
13 ocw'mh- Housewife
CCUpa 1 ’ (Kind of work done during most of working life)
14 Industry At Home
or Business:
IS Social Security No—
'lone
16 BIRTHPLACE (CityS.O.C..t...0.n —
(State or country) .iflSa.
17 FATHERFJose :h :hedbourne
» b.rthplace <g
FATHER (City)..._r.._..“™ * -
(State or country)
19 MAIDn™“ therlne Kenney
OF MOTHER ___
20 BIRTHPLACE OF j ^ d
MOTHER (City)
(State or country)
21
.y s • Ja :°s Hoche-cou 3 in
A TRUE COPY
ATTEST:
/7 /
DATE FILED
(Registrar of City or Town where death occurred)
J.iin.. — LQ-, — 19. — £9_
, 0- &
r‘. • £•
* t C E 1 V K 0
FflnilSSSBi,
M R-301A
l.— THIS IS A
kNENT RECOfc
Jse only
E APPROVE
t ink or blactf
writer ribbon
ITRUCTIONS
FOR
\l CERTIFICAT
n giving
5 OF DEAT
not enter
re than one
se for each
I, (b) and (c)
r does not mem.
ode of dyto
s heart failur
i, etc. It means
ease, or compli-
which caused y
i tions, if any,
gave rise to
cause ( a ),
g the under-
cause last.
» ditions cot...
\o death but »</»
to the terminal
condition give
Chapter 137,
f 1954, requires
dans to print or
the cause or
of death on
certificates.
:HAP. 46,»S9&
IHAP. 114 $§45,
CHAP. 38§6.)
[< >iof±QXk
\W (County)
.'JinLhrop
(City or Town)
No 64 Bates Avenue
©fy? Olotttttw tt uir altfy nf
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.
7
Registered No.
f (If death occurred in a hospital or institution,
St. (give its NAME instead of street and number)
full name Idore Brojr- ^QrnrOSe .
(If deceased is a married, widowed or dlvorcecT woman, give al
(a) Residence. No — Bclifi-S — A.V 07111 6-
(Usual place of abode)
Iso maiden name.)
St
; PHYSICIAN — IMPORTANT
(Was deceased a
U. S. War Veteran, tt
if so specify WAR) -ILU-* —
Length of stay: In place of death— 55 ears- months.
" (If nonresident, give city or town and State)
days. In place of residence 55ears months — — days.
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
DEATH t
(Month)
.22.
(Day)
1959
(Year)
4 I H/E REBY CERTIFY. That I attended deceased from
/yL?? , 19.3 f , to. j /lt
I last saw h./.f41ilive on
19_S^ , death is said to
iscu nun
, I9^y?'
have occurred on the date stated above, at —
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a) <-' Lb
t
Ry To r^E^e^L. 3Ca Lfrtits
CL* D
Due To fr/i /0 - 3* Ct-tr/Z0 / '<£ ft £ frc?"
(c) -
J>/S
OTHER / ).n,/T
SIGNIFICANT
CONDITIONS
Was autopsy performed? — ti..
INTERVAL
BETWEEN
ONSET AND
DEATH
/ /e
What test confirmed diagnosis? — Llijic <£ ft — —
S Was disease or injury in any way related to occupation of deceaseij^fjy
If so. specify
(Signed)-
JxM
(Address )
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
9 COLOR
white,.
10 SINGLE (write the word)
married married
WIDOWED ‘DctXiXtJU.
or DIVORCED
(Give maiden name of wife in full)
(or) WIFE of —
(Husband’s name in full)
11 IF STILLBORN, enter that fact here.
\e.
AGE Q.& Years— ^..Months Q. Days
If under 24 hours
Hours Minutes
Occupation ff^orking life)
IV r ft) " ’’W
Q..QdlawTL...aene.tje.r.y-..-E ve ret t rl lass .
Place of Burial or Cremation (City or Town)
14 Industry
or Business:
: ornament-al light f- retires-
15 Social Security No 15-"" lA>Q4:-
fXD —
16 BIRTHPLACE (City)
(State or country)
1 i th_
hweden
17 NAME OF
FATHER
18 BIRTHPLACE OF
FATHER (City).. —
(State or country)
Jan I-otor 'Pornrosc-
oweden-
19 MAIDEN NAME
OF MOTHER
20 BIRTHPLACE OF
MOTHER (City) —
(State or country)
Ina Lena jlngolbr ook-t
DATE OF BURIAL
..Oliver Wt 2orsro&e-_-
557 ,/asnington r-T. i
IT r'T? n .L.I _ C tty, n/lorrl oprfi nra Ip nf
7 NAME OF
FUNERAL DIRECTOR ...
Sweeten
•Ponsme;
1/ / 1/
(Date of Issue of Permit) '
>M. 10-58-923806
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE
RANK, RATING
ORGANIZATION AND OUTFIT
SERVICE NUMBER
RULES OF PRACTICE
The fulfillment of the purpose of these laws calls for the observance of the follow-
ing rules of practice:
(1) Attending physicians will certify to such deaths only as those of persons
to whom they have given bedside care during a last illness from disease unrelated
to any form of injury.
(2) Board of Health physicians will certify to such deaths only as those of
persons who. though disabled by recognized disease unrelated to any form of
injury, have died without recent medical attendance or whose physician is absent
from home when the certificate of death is needed.
(3) Medical Examiners will investigate and certify to all deaths supposably
due to injury. These include not only deaths caused directly or indirectly by
traumatism (including resulting septicemia), and by the action of chemical
(drugs or poisons) thermal, or electrical agents, and deaths following abortion, but;* £ £. c | » (r
also deaths from disease resulting from injury or infection related to occupation, ' — f
the sudden deaths of persons not disabled by recognized disease, and those of
persons found dead. ..
T
Physicians: see explanatory instrucfiops ' . ,
' " -rV/ U..V;
— : . :
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.
Statement of Cause of Death.
on face side of standard certificate of death.
1\V\
mf x
T%
JAK 2 31359 Hi
M R-301A
TRUCT10NS
FOR
IL CERTIFICATE
n giving
; OF DEATH
not enter
e than one
se for each
, (b) and (c)
does not mean
ode of dying,
i heart failure,
j, etc. It means ^
’ase, or complt- *
which caused
lions, if any,
gave rise to
j cause (.a),
|g the under-
cause last.
ditions contrib -■
o death but not
to the terminal
condition given
- Chapter 137,
! 1954, requires
Ians to print or
the cause or
i of death on
certificates.
h Suffolk
w
Q
1 V,' in t hr op
Qltje (Efltttmmmtpaltlf of fHaaaadpaftts
EDWARD J. CRONIN
Secretary of the Commonwealth
DIVISION OF VITAL STATISTICS
(County) I
STANDARD
(City or Town) CERTIFICATE OF DEATH
/, in thro o Cora. Hosp.
To be filed for burial permit
with Board of Health
or its Agent.
h
Registered No —
No..
f (If death occurred in a hospital or institution,
j ' . »* 1 1 rr< . _ .1 _ r . i J vt I4*n hor)
2 FULL NAME
I III aeairi uauncu m a V
...St. (give its NAME instead of street and number)
I PHYSICIAN - IMPORTANT
J (Was deceased a
[Mf deceased^is~a marrird^l'TdoweT^ dTvorced woman. give also maiden name.) JU. S. War Veteran,
•John C. Higgins
1U. S. War Veteran, np
( if so specify WAR)—
r6 Pico kvi
(a) Residence. No _
(Usual place of abode)
Length of stay: In place of death ..years..
St
(If nonresident, give city or town and State)
monthsJhi- days. In place of residence— i-.U years— months days.
MEDICAL CERTIFICATE OF DEATH
3 DATE OF "T/L k/
DEATH . sj /TTY
(Month)
A3
(Day)
/9Sf
(Year)
4 I HEREBY CERT I F Y , That I attended deceased fro
_ _ 19^ to M uS)
I last saw h/^live on ^3 .19.../7. , death is said to
3 3 O
have occurred on the date stated above, at — - CJ fn.
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
vie-..
9 COLOR
’hi te
10 SINGLE (write the word)
MARRIED . .
widowed ;.&rried
or DIVORCED '
10a If married, widowed, of diyorc^d 0 ^ y. TprjP
HUSBAND of -—-l-—- *-
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(.) C
/ T'' 0A/
Due To
(b)
/9-£7"£jg/ o -SCJ-trfZoTl^
HtrWr 2>/S£7&^~
Due To
(C) ’
L /ftZT&Zf' ~sClEi4fo
INTERVAL
BETWEEN
ONSET AND
DEATH
iJ>m
sy/is.
MW
SIGNIFICANT CjfiZOKf^ B/ZOt'&ft'Jte
CONDITIONS
Was autopsy performed ? JV Q 1 • ^ (j / f AS/T M. 1 —
What test confirmed diagnosis?-
5 Was disease or injury in any way related to occupation of deceased^J^
If so. specify
(or) WIFE of—
(Give maiden name of wife in full)
(Husband’s name in full)
11 IF STILLBORN, enter that fact here.
If under 24 hours
Hours Minutes
AGE ...'hSYears Months Days
13 Usual & p V i rJ rl i C O- - l 1 )
Occupation- — : -r: T77~z
(Kind of work done during most of working life)
i4 industry Build ins: Elevators
or Business:
15 Social Security No
rcT ahcv n
16 BIRTHPLACE (City)-
(State or country)
, c; urn
c c
(Signed)
(Address)??—
Calvary Vtobui
M. D.
6 Luiyary
Place of Bunal or Cremation
DATE OF BURIAL— .2
n
(City or Town)
19
7 NAME OF
FUNERAL DIRECTOR
ADDRESS
Ms uric e V . Kirby
-’lit*
Received and filed
17 NAME OF T i r_. ; ,T ~r \ n c-
FATHER dUrJl ill f,F -Lllw
18 BIRTHPLACE OF bt. J 01,11
FATHER (City)
(State or country)
B.
19 MAIDEN NAME
OF MOTHER
i iR ■ r ' F t t BF"
.Itrry r urr^ns
20 BIRTHPLACE OF j t UTC
MOTHER (City) 1 — ——~r
(State or country) V: i S S
Elizabeth M. Hisrgins
’--6 -M~cro-^^
satisfactory standard certificate of death
he burvh or transit permit was issued:
19
(Registrar)
if Board of Health or
(Date of Issue of P
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 w'ho 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
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE
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.
X’o undertaker or other persons shall-^njry'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 flerk of thotowh'wherc 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 thfe interment is made.
. Chap. 114, Sec. 46, G. L.. (Tercentenary Edition).
V- v\ U —w xt:
RULES OP PRACTICE
-.The fulfillment qf the purpose of these laws calls for the observance of the follow-
ing rules of practice: \ J\ \\ V -2> P SMNvAk
v(l) Attending physicians will ceftify to such, deaths only as those of persons
to whom they ha\Atfiven bedside ear£ dunrtgyi.la£t jltness fro disease unrelated
to any form of injury.
(2) Board of HValth.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 .at tendance or whose physician is absent
from home when the certificate of death is needed.
(3) Medical ExamiiWayvtJl (Ciyq&qptf amhcqrtMy to all deaths sfipposably
due to injury. These include not unlV clc.it n>\ausc;t direbtlf on fodiractly by
J (including resultjtgN s^jAtT^n '»)>■, and Gjy tile ai^ioq of chemical
■tHrugsTbr poisons) thermal, or electrical agetvfs.SanjAJeiJt hs following abortion, but
also deaths from disease resulting from injury or infection related to occupation.
those of
the sudden deaths^ of pers^qs qot^di^a^)led by recej^n iz^d^l incase .
-Wl \\ -V? \CT- Vy \ v\
see explanatory instructions
Statement of Cause of Death. — Physicians
face side of standard certificate x VN y * x j
Statement of Occupation. — Precise statement of occupation is very import-
ant, so that the relative healthfulness of various pursuits can be known. Make
sofpeentry in fex eyery person aged JO. vean^or over. If the occupa-
tion nadw>een given up or changed, or if the aeceaSem haa 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 th^t of home housework, write housework. For a
persoriyeftgag^d th dcNnestid^erv4c^ ^r">yages, however, designate the occupation
by the appropriate terms, as housekeeper — private family, cook — hotel, etc. For
^ fl^rson who had no occupation whatever write none.
U X.S...XA .Vy...V.\^.:.l..:..
A;
RANK, RATING
ORGANIZATION AND OUTFIT
SERVICE NUMBER
MR-301A
TRUCTIONS
FOR
,L CERTIFICATE
n giving
OF DEATH
not enter
e than one
;e for each
, (b) and (c)
does not mean
• de ol dying,
heart failure,
etc. It means _ ^
ase. or compli- *
which caused
ions, if any,
gave rise to
cause (a),
; the under-
cause last.
ilitions contrib -■
i death but not
i to the terminal
condition given
t:- Chapter 137,
if 1954, requires
dans to print or
the cause or
Iof death on
certificates.
Suffolk
(County)
-Winlhrop
(City or Town)
(ftmmnmuuFaltl| nf iRaHaarliuartts
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.
<1
Registered No. a_i-
41 Washington Ave.„(Bay
i ~ # TT M ,
No
2 full name Winifred Go Brawley (Leonard)
(If deceased is a married, widowed or divorced woman, give also maiden name.)
its NAME instead of street and number)
Home) l PHYSICIAN -IMPORTANT
J (Was deceased a
jU. S. War Veteran, %▼
I if so specify WAR) JjLQ
<„ Residence, n„.912- Shirley-Street , Wlnthrop
(Usual place of abode)
Length of stay: In place of death years V months days.
(If nonresident, give city or town and State)
In place of residence 14: years —months days.
MEDICAL CERTIFICATE OF DEATH
(Year)
4 I HE'REBY CERTIFY, That I attended deceased from
— , 19 fy., to Y J* KIA 4/' ./ , 19
I last saw K^L£alive on — 19.5^^. , death is said to
have occurred on the date stated above, at — Y 4r /ty\m
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
Cl A W / in o yy\ A taz is..
(a) _J
Due
(b)
A Y<r i y\ <o \v\ ^ cj£ Bj'j&Ast
Due To
(c)
OTHER
SIGNIFICANT __
CONDITIONS
n.
INTERVAL
BETWEEN
ONSET AND
DEATH
y rs
^yrs
Was autopsy performed? X\jQ-
What test confirmed diagnosis?-
5 Was disease or injury in any way related to occupation of deceased ?ho
If so. opacify /)
6 Mt. Benedi'ct/Cemetery, .Boston
Place of Burial or Cremation . (City or Town)
January 26th
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
9 COLOR
Female White
10 SINGLE (write the word)
MARRIED
widowed Widowed
or DIVORCED X
10a If married, widowed, or divorced
HUSBAND of
(or) WIFE of-
(Give maiden name of wife in full)
Henry A. Brawley
(Husband’s name in full)
11 IF STILLBORN, enter that fact here.
12
AGE ..^3 Years. Months X?Days
If under 24 hours
Hours Minutes
Occupation Housewife
(Kind of work done during most of working life)
At home
15 Social Security No. .SOXlfi
14 Industry
or Business:
16 BIRTHPLACE (City).
(State or country)
Boston
ass»_
DATE OF BURIAL
i9_55
7 NAME OF
FUNERAL DIRECTOR **
Richard C, Kirby
addres£17 Bennington, St. ,E. Bos ton
Received and filed.
17 NAME OF
FATHER
John Leonard
18 BIRTHPLACE OF
Boston
(State or country)
7flass#
19 MAIDEN NAME
OF MOTHER
Mary Heffernan
20 BIRTHPLACE OF
Boston
(State or country)
Mass*
I nformant
(Address)
Harriett C. Ronan-Dau.
35 Birch Rd , . Winthrop
}Y CERTIFY that a satisfactory standard certi:
ficate of death
al or transit permit was issued:
CJLRJJIFY that a satjsf,
BEFORE the ^
...6-
of Agen(/pf/I?oard of Health"o7 ottfer)
(Official Designation)
—
(Date of Issue of Per.
‘ /*~f
’eynit) Ti
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 'or registration a standard certificate of death, stating to the
best of his knowledge and belief the name of the deceased, his supposed age. the
disease of which he died, defined as required by section one. where same was
contracted, the duration of his last illness, when last seen alive by the physician
or officer and the date of his death. . .Gen. Laws, Chap. 46. Sec. 9.
A physician or officer furnishing a certificate of death as required by the
preceding section or by section forty-five of chapter one hundred and four-
teen. shall, if the deceased, to the best of his knowledge and belief, served in the
army, navy or marine corps of the United States in any war in which it has been
engaged, insert in the certificate a recital to that effect, specifying the war, and
shall also certify in such certificate both the primary and the secondary or imme-
diate cause of death as nearly as he can state the same. For neglect to comply
with any provision of this section, such physician or officer, shall forfeit ten dollars.
For the purposes of this section and of sections forty-five, forty-six and forty-seven
of said chapter one hundred and fourteen, the word "war" shall include the China
relief expedition and the Philippine insurrection, which shall, for said purposes, be
deemed to have taken place between February fourteenth, eighteen hundred and
ninety-eight and July fourth, nineteen hundred and two. and the Mexican border
service of nineteen hundred and sixteen and nineteen hundred and seventeen.
G. L. Chap. 46. Sec. 10.
No undertaker or other person shall bury or otherwise dispose of a human body
in a town, or remove therefrom a human body which has not been buried, until he
has received a permit from the board of health, or its agent appointed to issue
such permits, or if there is no such board, from the clerk of the town where the
person died; and no undertaker or other person shall exhume a human body and
remove it from a town, from one cemetery to another, or from one grave or tomb
other than the receiving tomb to another in the same cemetery, until he has
received a permit from the board of health or its agent aforesaid or from the clerk
of the town where the body is buried. Xo such permit shall be issued until there
shall have been delivered to such board, agent or clerk, as the case may be,
a satisfactory written statement containing the facts required by law to be
returned and recorded, which shall be accompanied, in case of an original inter-
ment. by a satisfactory' certificate of the attending physician, if any, as required by
law. or in lieu thereof a certificate as hereinafter provided. If there is no attending
physician, or if, for sufficient reasons, his certificate cannot be obtained early
enough for the purpose, or is insufficient, a physician who is a member of the board
of health, or employed by it or by the selectmen for the purpose, shall upon
application make the certificate required of the attending physician. If death is
caused by violence, the medical examiner shall make such certificate. If such a
permit for the removal of a human body, not previously interred, from one town
to another within the commonwealth cannot be obtained early enough for the
purpose, the certificate of death made as above provided and in the possession of
the undertaker desiring to make such removal shall constitute a permit for such
removal; provided, that such body shall be returned to the town from which it was
removed within thirty-six hours after such removal, unless a permit in the usual
form for the removal of^such body has been sooner obtained hereunder. If the
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 f^tmislr fot registration any other necessary
information which can be obtained as to the deceased, or as to the manner or
cause of the death, which the clerk or registrar may require. — Chap. 1 14. Sec. 45,
G. L.. (Tercentenary Edition).
Medical examiners shall make examination upon the view of the dead bodies
of persons as are supposed to have died by violence, or by the action of
chemical, thermal or electrical agents or following abortion, or from diseases
resulting from injury or infection relating to occupation, or suddenly when not
disabled by recognizable disease, or when any person is found dead. — General
Laws, Chap. 38, Sec. 6., as amended by Chap. 632, Sec. 4, Acts of 1945.
No 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 tterk of the town where the body is to be buried
or the funeral is to be held, or from a person appointed to have the care of the
cemetery or burial ground in which the interment is made.
. . . Chap. 114, Sec. 46, G. L., (Tercentenary Edition).
RULES! OF PRACTICE
The fulfillment of the purpose of these laws calls for the observance of the follow-
ing rules of practice:
(1) Attending physicians will certify to such deaths only as those of persons
to whom they have given bedside care during a last illness from disease unrelated
to any form of injury.
(2) Board of Health physicians will certify to such deaths only as those of
persons who, though disabled by recognized disease unrelated to any form of
injury, have died without recent medical attendance or whose physician is absent
from home when the certificate of death is needed.
(3) Medical Examiners will investigate and certify to all deaths supposably
due to injury. These include not only deaths caused directly or indirectly by
traumatism (including resulting septicemia), and' by the action of chemical
(drugs or poisons) thermal, or electrical agents, and deaths following abortion, but
also deaths from disease resulting from injury or infection related to occupation,
the sudden deaths of persons not disabled by recognized disease, and those of
persons found dead.
Statement of Cause of Death. — Physicians: see explanatory instructions
on face side of standard certificate of death.
Statement of Occupation. — Precise statement of occupation is very import-
ant, so that the relative healthfulness of various pursuits can be known. Make
some entry in this section for every person aged 10 years or over. If the occupa-
tion had been given up or changed, or if the deceased had retired from business,
report the kind of work done during most of working life even if retired. Children
not gainfully employed may be returned as at school or at home. For a woman
whose only occupation was that of home housework, write housework. For a
person engaged in domestic service for wages, however, designate the occupation
by the appropriate terms, as housekeeper — private family, cook — hotel, etc. For
a person who had no occupation whatever write none.
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE
RANK, RATING
ORGANIZATION AND OUTFIT
SERVICE NUMBER
.M R-301A
1TRUCTI0NS
FOR
tl CERTIFICATE
n giving
! OF DEATH
not enter
e than one
se tor each
i, (b) and (c)
does not mean
ode of dying,
I heart failure,
, etc. It mean!
rase, or eompli- "
which caused
i lions, if any,
gave rise to
cause (a),
g the under-
cause last.
ditionj contrib -■
o death but not
• to the terminal
i condition given
t Chapter 137,
fit 1954, requires
:ians to print or
the cause or
; ot death on
t certificates.
W
«
Iw
/w
\o
iw
fu
\o.
Suffolk
(County)
Winth rop
(City or Town)
Wl nthrop Convelescent Home
nf fHaBflarljuBktta
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. -
f (If death occurred in a hospital or institution,
St. (give its NAME instead of street and number)
( PHYSICIAN — IMPORTANT
2 full name Theresa.- Lagonie — ~ . — —
(If deceased is a married, widowed or divorced woman, give also maiden name.)
' (Was deceased a
1U. S. War Veteran,
' if so specify WAR).
Rql
(a) Residence. No 14 — Q^Li-Q-TcL- P&r k—
(Usual place of abode)
Length of stay: In place of death— years months
St..
__Eev e r s
U
days. In place of residence— years months days.
(If nonresident, give city or town and State)
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
DEATH _
January 28. 1959
(Month)
(Day)
(Year)
4 I HEREBY CERTIFY, That I attended deceased fronu,— — — — . , , .
.1- vC tf O -W 10a If married, widowed, or divorced
JQyt'V ^ , 19^-0, to ■<- f , 19—N .y HUSBAND of
I last saw h_«*i_alive on — £~-T- » ^eat^ 's sa*d to
have occurred on the date stated above, at ^2^ — ^/.m IMTERVAL (°r) "
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a) Cj* rtO i O l\ ^ (V A
J) f A S K -
Due To
(b)
4-( y j°(T fj j p! IV s LQ JV^L
Due To
(c)
OTHER
SIGNIFICANT
CONDITIONS
INTERVAL
BETWEEN
ONSET AND
DEATH
io
1
Was autopsy performed?
What test confirmed diagnosis?
5 Was disease or injury in any way related to occupation of deceased?
If so, specify
(Address) 1 / / '> r— L.
6 Old Calvary
Place of Burial or Cremation
DATE OF BURIAL-
Bos
M. D
on. Mass »
(City or Town)
January 31 , 19 59
7 funeral director Arthur M* Pore el la
address 876 Winthrop Ave,, Revere
Received and filed
is
19
(Registrar)
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
Female
9 COLOR
White
10 SINGLE (write the word)
MARRIED
WIDOWED o-inrlp
or DIVORCED
(Give maiden name of wife in full)
(Husband’s name in full)
11 IF STILLBORN, enter that fact here.
AGE-84Ye
..Months -
Days
If under 24 hours
Hours Minutes
13 Usual
Occupation: —
_At Home
(Kind of work done during most of working life)
14 Industry
or Business:
15 Social Security No HOnS.
16 BIRTHPLACE (City).
(State or country)
Boston.
hass .
17 NAME OF
18 BIRTHPLACE OF
(State or country)
Italy
19 MAIDEN NAME
OF MOTHER
Louisa Leverone
20 BIRTHPLACE OF
MOTHER (City) —
(State or country)
Italy
Informant Fred La<
(Address) 14 Oxford 1
Revere
I HE
was<r
Designation)
IFY that a sj
BEFORE the
Ire of Age xyfMfl Board
actory standard certificate of death
al o^ transit permit was issued:
1th
(Date of Issue o
EXTRACTS
FROM THE LAWS OF THE
COMMONWEALTH OF MASSACHUSETTS
GOVERNING THE
RETURN OF CERTIFICATES OF DEATH
A physician or registered hospital medical officer shall forthwith, after the
death of a person whom he has attended during his last illness, at the 'request
of an undertaker or other authorized person or of any member of the family of
the deceased, furnish for registration a standard certificate of death, stating to the
best of his knowledge and belief the name of the deceased, his supposed age. the
disease of which he died, defined as required by section one. where same was
contracted, the duration of his last illness, when last seen alive by the physician
or officer and the date of his death. . .Gen. Laws. Chap. 46. Sec. 9.
death certificate contains a recital, as required by section ten of chapter forty-six.
that the deceased served in the army, navy or marine corps of the United States
in any war in which it has been engaged, such recital shall appear upon the permit.
The board of health, or its agent, upon receipt of such statement and certificate,
shall forthwith countersign it and transmit it to the clerk of the town for registra-
tion. The person to whom the permit is so given and the physician certifying
the cause of death shall thereafter furnish for registration any other necessary
information which can be obtained as to the deceased, or as to the manner or
cause of the death, which the clerk or registrar may require. — Chap. 1 14. Sec. 45,
G. L., (Tercentenary Edition).
Medical examiners shall make examination upon the view of the dead bodies
of persons as are supposed to have died by violence, or by the action of
chemical, thermal or electrical agents or following abortion, or from diseases
resulting from injury or infection relating to occupation, or suddenly when not
disabled by recognizable disease, or when any person is found dead. — General
Laws. Chap. 38, Sec. 6 , as amended by Chap. 632. Sec. 4, Acts of 1945.
A physician or officer furnishing a certificate of death as required by the
preceding section or by section forty-five of chapter one hundred and four-
teen. shall, if the deceased, to the best of his knowledge and belief, served in the
army, navy or marine corps of the United States in any war in which it has been
engaged, insert in the certificate a recital to that effect, specifying the war, and
shall also certify in such certificate both the primary and the secondary or imme-
diate cause of death as nearly as he can state the same. For neglect to comply
with any provision of this section, such physician or officer, shall forfeit ten dollars.
For the purposes of this section and of sections forty-five, forty-six and forty-seven
of said chapter one hundred and fourteen, the word '‘war" shall include the China
relief expedition and the Philippine insurrection, which shall, for said purposes, be
deemed to have taken place between February fourteenth, eighteen hundred and
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 towrn from which it was
removed within thirty-^ix hours after such removal, unless a permit in the usual
form for the removal of such body has been sooner obtained hereunder. If the
No undertaker or other persons shall bury a human body or the ashes thereof
which have been brought into the commonwealth until he has received a permit
so to do from the board of health or its agent appointed to issue such permits, or
if there is no such board, from the £lerk of the town where the body is to be buried
or the funeral is to be held, or from a person appointed to have the care of the
cemetery or burial ground in^vfeioh the mterment is made.
. . . Chap. 114, Sec. 46, G; L^: CTercerftefcary Edition).
RULEgfC ft* PRACTICE
The fulfillment of the p0rpo9ex>f tl>ese laws c^Us for the observance of the follow-
ing rules of practice: ’ / IJ. :i. : '\ ' \ \
( 1 ) Attending physicians Writ certify, to, su£h deaths only as those of persons
to whom they have given bedside care during a'lla&t illness from disease unrelated
to any form of injury. 1^*
(2) Board of Health physicians will certify to such deaths only as those of
persons who. though disabled by recognized disease unrelated to any form of
injury, have died without rpcent medical attendance or whose physician is absent
from home when the certificate of death is needed.
(3) Medical Examiners w^l investigate and certify to all deaths supposably
due to in jury > These include not only deathsjraused directly or indirectly by
traumatism (including resulting septicemia).' and by the action of chemical
(drugs or poisons) thermal, t>r.6Lectrical agents, and deaths following abortion, but
also deaths from disease resultin^lrom^njury or infection related to occupation,
the sudden deaths of persons not disabled by recognized disease, and those of
persons found dead.
IAN'-
Statement of Cause of Death. — .
on face side of standard certificate of death
fciaJJ: see explanatory instructions
Statement of Occupation. — Precise statement of occupation is very import-
ant, so that the relative healthfulness of various pursuits can be known. Make
spme entry in this section for every person aged 10 years or over. If the occupa-
tion had been given up or changed, or if the deceased had retired from business,
report the kind of work done during most of working life even if retired. Children
not gainfully employed may be returned as at school or at home. For a woman
whose only occupation was that of home housework, write housework. For a
person engaged in domestic service for wages, however, designate the occupation
by the appropriate terms, as housekeeper — private family, cook — hotel, etc. For
a person who had no occupation whatever write none.
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE
RANK, RATING
ORGANIZATION AND OUTFIT
SERVICE NUMBER
LM R-301A
n VO
V $
fT
V
5TRUCTI0NS
FOR
AL CERTIFICATE
:n giving
5 OF DEATH
not enter
re than one
se lor each
I, (b) and (c)
■ does not mean
ode ol dying,
is heart failure,
L etc. It means
ease, or compti - '
I which caused
|
lions, if any,
gave rise to
cause (a),
g the under-
cause last.
ditions contrib- -
o death but not
to the terminal
condition given
I - Chapter 137,
if 1954, requires
iians to print or
the cause or
i of death on
I rertificates.
t-n
1A.
(County) /JjpTy
,s. fh ro
(Eotnmmuuraltlj nf iHaaaarljuaFtta
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.
„ .. / SS _ ^ J (If death occurred in a hospital or institution,
(give its NAME instead of street and number)
/ / tS ' e ( PHYSICIAN — IMPORTANT
2 FULL N — vr /7A'<Air<? < ) \ (Was deceased a i/'
2 ‘ (If deceased is a marViedTwid'owed or divorced woman, give also maiden name.) j L. ^S. War f AR j
(a) Residence. No2 / f 7i^..^7£ee/ rfsc*' st 2 'HLMLr ? "
(Usual place of abode)
MjlAjTA
Length of stay: In place of death years months
(If nonresident, give city or town and State)
jZ days. In place of residencef^fc^jyears months- days.
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
DEATH _
^iwary
y)
(Year
4 I HEREBY CERTIFY, That I attended deceased from
Jan* 11, , 19 59. <o — Jan* 29 * . ”59
I last saw laTalive on _ Jan . 29, 19.— 5-^* death is said to
have occurred on the date stated above, at 1:12 p.
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(General carcinomatosis
INTERVAL
BETWEEN
ONSET AND
OEATH
-1 mo^
Due To lancer of-Jit erus_ and
(b)
ovaries
To Cancer of Bowel
OTHER
SIGNIFICANT
CONDITIONS
3 2 yna
mos.
no
Was autopsy performed?
What test confirmed diagnosis ?Q P0I* 3. t»XQ II ^ Pcifctl* 0XciD^»
£
W
<
Dh
5 Was disease or injury in any way related to occupation of deceased ? .HC
If so. specify
ess)/A edAA^I JA~L
, /Za/y
Place of'/Burial or Crematijm
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
9 COLOR
[aAllA
10 SINGLE (write the word)
MARRIED . /
WIDOWED . / -/ . (
or DIVORCED vY ( CfOC*' PCI
10a If married, widowed, or divorced
HUSBAND of
(or) WIFE of
(Give maiden name of wife in full)
/tf. ffjv are*/
(Husband*s' name in full)
11 IF STILLBORN, enter that fact here.
12
%\GE
^^^Years (* .Months
a
Days
If under 24 hours
Hours Minutes
Occupation : Soc/^Z U/o«(te
(Kind of work done during most of working life)
14 Industry
or Business :V
f*' _
(City or Town)
DATE OF BURIAL
7 NAME OF
FUNERAL DIRECTOR
ADDRESS
ft / L 73? a* o/> ti s e — Zf*'
Received and filed
yAW4Gi959
y /restrc
15 Social Security No..
16 BIRTHPLACE (City)
(State or country)
/ j o ^ so y
Mass
FATHER /~- /^/iS/7 /7 /V S
18 BIRTHPLACE OF
FATHER (City)
(State or country)
l/
Z/U / A? AS
19 MAIDEN NAME
OF MOTHER
20 BIRTHPLACE OF
MOTHER (City).
(State or country)
v/knB~ —
J w // /r /3s? a v? /i <zy
Z1// //<? « Z
Z* ^ JLl
Informant
(Address)
/>. £ Z f
& r r i-> Ay S Te r-j-c jjret'p
(Registrar)
EXTRACTS
FROM THE LAWS OF THE
COMMONWEALTH OF MASSACHUSETTS
GOVERNING THE
RETURN OF CERTIFICATES OF DEATH
A physician or registered hospital medical officer shall forthwith, after the
death of a person whom he has attended during his last illness, at the request
of an undertaker or other authorized person or of any member of the family of
the deceased, furnish for registration a standard certificate of death, stating to the
best of his knowledge and belief the name of the deceased, his supposed age. the
disease of which he died, defined as required by section one. where same was
contracted, the duration of his last illness, when last seen alive by the physician
or officer and the date of his death. . .Gen. Laws. Chap. 46. Sec. 9.
A physician or officer furnishing a certificate of death as required by the
preceding section or by section forty-five of chapter one hundred and four-
teen. shall, if the deceased, to the best of his knowledge and belief, served in the
army, navy or marine corps of the United States in any war in which it has been
engaged, insert in the certificate a recital to that effect, specifying the war, and
shall also certify in such certificate both the primary and the secondary or imme-
diate cause of death as nearly as he can state the same. For neglect to comply
with any provision of this section, such physician or officer, shall forfeit ten dollars.
For the purposes of this section and of sections forty-five, forty-six and forty-seven
of said chapter one hundred and fourteen, the word “war” shall include the China
relief expedition and the Philippine insurrection, which shall, for said purposes, be
deemed to have taken place between February fourteenth, eighteen hundred and
ninety-eight and July fourth, nineteen hundred and two. and the Mexican border
service 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 tc^h^v^ djed by Xj°lence* or by the action of
chemical, thermal or electrical dt jfdficfc'itA? abortion, or from diseases
resulting from injury or infection relating to occupation, or suddenly when not
disabled by recognizable disease, or w^en^oy^person is found dead. — General
Laws, Chap. 38, Sec. 6.. as amen^ejJoyX)fibp."3W2, Sec. 4, Acts of 1945.
No undertaker or other pei^nV ShjrtTTmny a 'human body or the ashes thereof
which have been brought irvtOr(h9‘c()p1ii\6nweSJtn ,pnf>l he has received a permit
so to do from the board of health 4*rvits* dgent appointed to issue such permits, or
if there is no such board, from the. cuerk of the town \0,h£?e the body is to be buried
or the funeral is to be held, or frerin 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 wilrCertifxjtCLSuch 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 physk^dns ^1V cert^gfcopiich deaths only as those of
persons who. though disabled unrelated to any form of
injury, have died without recent medical attendance or whose physician is absent
from home when the certificate of death is needed.
(3) Medical Examiners will investigate and certify to all deaths supposably
due to injury. These include not only deaths caused directly or indirectly by
traumatism (including resulting septicemia), and by the action of chemical
(drugs or poisons) thermal, or electrical agents, and deaths following abortion, but
also deaths from disease resulting from injury or infection related to occupation,
the sudden deaths of persons not disabled by recognized disease, and those of
persons found dead.
Statement of Cause of Death. — Physicians: see explanatory instructions
on face side of standard certificate of death.
Statement of Occupation. — Precise statement of occupation is very import-
ant, so that the relative healthfulness of various pursuits can be known. Make
some entry in this section for every person aged 10 years or over. If the occupa-
tion had been given up or changed, or if the deceased had retired from business,
report the kind of work done during most of working life even if retired. Children
not gainfully employed may be returned as at school or at home. For a woman
whose only occupation was that of home housework, write housework. For a
person engaged in domestic service for wages, however, designate the occupation
by the appropriate terms, as housekeeper — private family, cook — hotel, etc. For
a person who had no occupation whatever write none.
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE
RANK, RATING
ORGANIZATION AND OUTFIT
SERVICE NUMBER
M R-301A
rRUCTIONS
FOR
L CERTIFICATE
1 giving
OF DEATH
not enter
: than one
e for each
(b) and (c)
does not mean
de ot dying,
heart failure,
etc. It means
7 se. or compli-
which caused
dons, if any,
gave rise to
cause (a),
the under-
cause last.
I ritions contrib -■
death but not
;to the terminal
i condition given
Chapter 137,
1954, requires
ans to print or
he cause or
: of death on
certificates.
*
l< -Sulfolic
\W (County)
JUa
i° ..Niutiirap
W (City or Town)
8
9-4
No..
2 FULL NAME
(taunmtuiraltlj nf fUa&aarljufiFtta
EDWARD J. CRONIN
Secretary of the Commonwealth to be filed for burial permit
DIVISION OF VITAL STATISTICS with Board of Health
STANDARD or its Agent.
CERTIFICATE OF DEATH Registered No. —
| v ’ ' ' H' • r /(If death occurred in a hospital or institution,
Sfetgive its NAME instead of street and number)
! PHYSICIAN — IMPORTANT
(Was deceased a
U. S. War Veteran,
if so specify WAR)
Amy L (Nickerson) Nelson
(If deceased is a married, widowed or divorced woman, give also maiden name.)
(., Residence. No -7Q LlnCOln Street.
(Usual place of abode)
8
st. .
Length of stay: In place of death_._.-years months days. In place of residence-: .... years
39
(If nonresident, give city or town and State)
months-
days.
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
DEATH _
January
(Month)
30* _
(Day)
(Year)
4 i HEREBY CERTI F Y , That I attended deceased from
Feb* 17, \6l ., to Jan* 30, w 59
I last saw h-ejalive on Jan* 29* . & death is said to
have occurred on the date stated above, at 9 i^Q P-- m. INTERVAL
BETWEEN
ONSET AND
DEATH
20 day[
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a) Bi lateral bronchopneumonia
Due To
(c)
To Generalized arteriosclerosis^
significant Cerebral arteriosclerosis
CONDITIONS
10 yrs
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
Female
9 COLOR
White
10a If married, widowed, or divorced
HUSBAND of
10 SINGLE (write the word)
MARRIED
widowed Harried.
or DIVORCED 1 ~LCU
(or) WIFE of-
(Give maiden name of wife in full)
Ellis Nelson
(Husband’s name in full)
11 IF STILLBORN, enter that fact here.
12 70
S\GE — Years
10 yrg
5 xrg
5 19_
Months Days
If under 24 hours
_Hours Minutes
13 Usual
Occupation:
Housewife; — — — -r. — rrT
(Kind of work done during most of working life)
14 Industry
or Business:
Was autopsy performed? UO - - — _
What test confirmed diagnosis? Clinical k Laboratory
5 Was disease or injury in any way related to occupation of deceased ?NO
If so, specify
(Signed)
(Address) 73-FaX*tl€ tt
V
— ■
7
Date
, M. D.
dress) IJ lau uv vv — mu' Jan*31» 19...$.$
v; in t. hr j^!'n^iroP 52 j Mass* y; in t hr op
Place of Burial or Cremation
DATE OF BURIAL
7 NAME OF
FUNERAL DIRECTOR „
ADDRESS
Received and filed —
(City or Town)
Feb. 3 i9 39
tet- ^ ; . -M/
15 Social
Security No
•16 BIRTHPLACE (City) _D_0-C-t.0r_S--E_0.VS..
(State or country) ;JnVfi Scotia
17 NAME OF
FATHER
Thomas Nickerson
18 BIRTHPLACE OF
FATHER (City)
(State or country)
N ova Scotia
19 MAIDEN NAME
of mother Sarah Swimm
20 BIRTHPLACE of
MOTHER (City) —
(State or country)
Nova Scotia
Informant Ellis NelSOn
(Address) 70 Lincoln St. Winthrop
(Registrar)
.TIFY that a s
e Bj^C/RE 1;h,
Signature/6T Age
.Ysfactory standard certificate of death
burial or transit permit was issued:
or other)
(Official Designation)
SMJSJ-
(Date of Issue of Permity /
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 cleric
of the town where the body is buried. No such permit shall be issued until there
shall have been delivered to such board, agent or clerk, as the case may be,
a satisfactory' written statement containing the facts required by law to be
returned and recorded, which shall be accompanied, in case of an original inter-
ment, by a satisfactory certificate of the attending physician, if any, as required by
law. or in lieu thereof a certificate as hereinafter provided. If there is no attending
physician, or if. for sufficient reasons, his certificate cannot be obtained early
enough for the purpose, or is insufficient, a physician who is a member of the board
of health, or employed by it or by the selectmen for the purpose, shall upon
application make the certificate required of the attending physician. If death is
caused by violence, the medical examiner shall make such certificate. If such a
permit for the removal of a human body, not previously interred, from one town
to another within the commonwealth cannot be obtained early enough for the
purpose, the certificate of death made as above provided and in the possession of
the undertaker desiring to make such removal shall constitute a permit for such
removal; provided, that such body shall be returned to the town from which it was
removed within thirty-six hours after such removal, unless a permit in the usual
form for the removal of such body has been sooner obtained hereunder. If the
death certificate contains a recital, as required by. section ten of chapter forty-six.
that the deceased served in the army, navy or marine corps of the United States
in any war in which it has been engaged, such recital shall appear upon the permit.
The board of health, or its agent, upon receipt of such statement and certificate,
shall forthwith countersign it and transmit it to the clerk of the town for registra-
tion. The person to whom the permit is so given and the physician certifying
the cause of death shall thereafter furnish for registration any other necessary
information which can be obtained as to the deceased, or as to the manner or
cause of the death, which the clerk or registrar may require. — Chap. 1 14. Sec. 45.
G. L., (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 lifirJOfnlaV tjody 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 age n tappoai tftd to issue such permits, or
if there is no such board, from the clerk of UpT^^'nr\*herc;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 iitaermf*n.t is'madfe.
. . . Chap. 114, Sec. 46, G. L., (Tef^pptpfi^y ^ditio'ij).^^^ *
— U '
RULES OF PRACTICE vT„
The fulfillment of the purpose of these LawS calls for the observance of the follow-
ing rules of practice:
(1) Attending physicians w'ill certify^tp'^uvh deaths only as' those of persons
to whom they have given bedside care duringra'Vafct illness from disease unrelated
to any form of injury. / (\ -
(2) Board of Health physicians wilj 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 oj-Avhose physician is absent
from home when the certificate of death is needed!
(3) Medical Examiners will investigate andjeertify to all deaths supposably
due to injury. These include not only fltotrVfos capped rtijTjrttM'VAr indirectly by
traumatism, (including resulting septicegMjpfcj £Tfil JQfejaCWm 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
VI R-302
CT3
C rt
O-C V
e
rt
5 ^
X
-X,
c.!
-d -
£ *
W >. ;
rt-n :
a u <
V v o
•=£x
2 - oj
U-Z ■
•-
pi
O O „
- CM
° © X
>*T, s
ng "O t/)
4> £.0
g E a,
O «£
o c *-
•s*s
IP
vs'd a>
•£*92
-
5 o o
t V
- E s
feJafneK%is r'^u
return)
ulljr (Enmnumnirallh of fUaHHarljusftttf
EDWARD J. CRONIN
Secretary of the Commonwealth (City or
(County) r.-i 'iM l.g DIVISION OF VITAL STATISTICS
Chelsea 0m9 copy of
(City ot T^wnj" SXSf CERTIFICATE OF DEATH Registered No. .... —
_ ((If death occurred in a hospital or institution,
[J , £*N aval liflS Vjltal St. ( give its NAME instead of street and number)
16 13
Baby Cdrl Beal
2 PULL N AM widowed or divorced woman, give also maiden name.)
I (Was deceased a
U. S. War Veteran,
if so specify WAR).
86 Ear.atr.ore Ave., StethacaP^&Ae.*—
(a) Residence. No w -* - - —— -
(Usual place of abode)
(If nonresident, give city or town and State)
Length of stay: In place of death., “....years Months ldays. In place of residence C.years rt»nths
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
DEATH ....
Jan ,9*1959
(Month) (Day)
(Year)
4 I HEREBY CERT I F Y , That I attended deceased from
Jan , 9 t 19 59 t0 Jan.*. 9 19...5.9
Jan , 9 195.9, death is said to
8 SEX
9 COLOR
10 SINGLE (write the word)
MARRIED
Female
White
WIDOWED: - _. t ,,
or DIVOR6E-HiJ-o-Lfc’
I last saw h ,©..£live on
have occurred on the date stated above, at
1005 .r*.
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a)
Premia bibrd'ty
Due To
0>)
Due To
(c)
OTHER
SIGNIFICANT
CONDITIONS
INTERVAL
BETWEEN
ONSET AND
DEATH
7o- hr; ■ •AGE*
PERSONAL AND STATISTICAL PARTICULARS
10a If married, widowed, or divorced
HUSBAND of
(Give maiden name of wife in lull)
(or) WIFE of..
(Husband’s name in full)
11 IF STILLBORN, enter that fact here.
•AGE Years Months... Days
f
If undefZrt hours
Houro--— .Minutes
1 3 U sual
Occupation
(Kind of work done during most of working life)
-
14 Industry
or Business:
Was autopsy performed?.....
What test confirmed diagnosis ?.
5 Was disease or injury in any way related to occupation of deceased ?..
If so, specify
L • Mar in el li , Lt , T.JC U£N
(Signed) - y
,Md„,JSHH*Che’1 =ca I /a
M.
...!^....19...
To o J.l a v?n , : veret r „ . .a a e ,
Place of Burial or Cremation Jari . 12,^5^ovn)
DATE OF BURIAL - 19
R.C. Kirby
7 NAME OF w
funeral
ADDRESS
1 5 Social Security No—
Received and filed. .
..19..
(Registrar of City or Town where deceased resided)
16 BIRTHPLACE (Cityl-Qk-e.^e©; Jvfe-S-S V
(State or country) _
17 NAME OF
FATHER
John S*
18 BIRTHPLACE OF
FATHER (City)
(State or country)
ilot BppinfSfArk*
19 MAIDEN NA^oia I •Fernandez
OF MOTHER" A *
21
20 birthplace of Bo go ta ^Columbia
MOTHER (City) — —
(State oi country)..
John
■ e&l- father"
InformantQB 5a ariOTe
(Address)
A TRUE COPY^
ATTEST:
DATE FILED
egistrar of City or To\vn where death occurred)
Jan . 12 , 1959 19 _
X
Middlesex
(County)
Cambridge
(City or Town)
No.
Qfif? (Cmnmomnpaltl) of JHaaaarljaBrttB
EDWARD J. CRONIN
Secretary of the Commonwealth
DIVISION OF VITAL STATISTICS
COPY OF
MEDICAL EXAMINER’S
CERTIFICATE OF DEATH
W- r _ „ -i- _ /(If death occurred in a hospital or institution.
..asr.aci.use GO 9 AV* St. \ give its NAME instead of street and number)
Cambridge
(City or town making return)
llfcg. U
Registered No. .
2 FULL NAME..
Henry J. happen ( (Was deceaS£d a
(If deceased is a married, widowed or divorced woman, give also maiden name.) j U. S. War Veteran,
' « , , I ii so specuty WAK;
87 Winthrop St -inthrop, Mss,
(a) p,N° o{ a^de^ W ^^nUgive ^city ortor^and State)
...Jf-Pyears “months “days.
No
Length of stay: In place of death years months days. In place of residence..
MEDICAL CERTIFICATE OF DEATH
3 deathop. Ia.nuar.y.....3.CU.
(Month) (t)i
(Month)
)ay)
(Year)
41 HEREBY CERTIFY that I have investigated the death
of the person above-named and that the CAUSE AND MANNER thereof
are as follows: (If an injury was involved, state fully.)
.Q.Qr.ona .ry....He.ar t. ,]Di s.ea
Sudden T)eath'
13
70
—
-
AGE
Years
Months
Days
5 Accident, suicide, or homicide (specify)
Date and hour of injury 19..
Where did
Injury occur?
(City or town and State)
Did injury occur in or about home, on farm, in industrial place, or in public
place? —
Manner of
(How did injury ocfcur?)
(Specify type of place)
Injury
Nature of
Injury
While at work? Was autopsy performed?
"Bo
6 Was disease or injury in any way related to occupatic-n of deceased?
If so. specify,
(Signed) .
(Address)
No
JavTd"T".'“’’I)ow M D
..:ViQfehr.Qp......Csmfeerx .'..:l.nt.hr.Qp
Place of Burial, or Cremation. (City or Town) . ,
February 2, l9 5$
DATE OF BURIAL .
* FUNERAL DIRECTOR ...M§.y.?.i..Q..®.....^.lBhy..
ADDRESS
aas.
Received and filed 19..
(Registrar of City or Town where deceased resided)
PERSONAL AND STATISTICAL PARTICULARS
9 SEX
M
10 COLOR OR RACE
White
11 SINGLE (write the word)
MARRIED
rgflSgm Married
hJsb” sin?' A Greenfield
(Give maiden name of wife in full)
(or) WIFE of
(Husband's name in full)
12 IF STILLBORN, enter that fact here.
If under 24 hours
Hours Minutes
i4 usual . Storekeeper
Occupation : •• • • • ••:
(Kind of work done during most of working Ute)
15 Industry
or Business:
Retired
16 Social Security No.
17 BIRTHPLACE (City) Bos to n « USLS-8-j
(State or country)
18fatherf %nry A. happen
19 BIRTHPLACE OF
FATHER (City)
(State or country)
Ireland
”r«D»«therine Kennedy
21 BIRTHPLACE OP 'OStOtl, llaSSe
MOTHER (City)
(State or country)
22 Susan A. happen
Informant ...;-}7 i.l.Fjt-hrOQ- ■ fS-t -* WiflfchrOP'
(Address; * -
A TRUE COPY
ATTEST:
(Registrar of City or Town where death occurred)
DATE FILED
.feh,. 1, 19. .5.9....
7? ^ /'SB ti >
Ks-
-rtS'.'Ca ! .V‘E D
Ff£lO»;a
JM R-301A
J.— THIS IS A
*NENT RECORD.
Jse only
E APPROVED
< ink or black
writer ribbon.
■TRUCTIONS
FOR
U CERTIFICATE
n giving
! OF DEATH
not enter
e than one
se for each
, (b) and (c)
does not mean
yde of dying,
» heart failure,
etc. It means .
rase, or compli- ™
I which caused
rions, if any,
gave rise to
l| cause (a),
K the under-
| cause last.
ditions contrib - — )
■t death but not
to the terminal
condition given
I- Chapter 137,
1954, requires
: ans to print or
he cause or
! of death on
■ ertificates.
HAP. 46,55 9 &
iAP. 114 51 45,
IHAP. 3856.)
11-10-50-923886
/fa
bounty)
2 FULL NAME—
own)
(Eumttuimiiealttj nf fflaaaarljuaetta
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.
15
no 89 Somerset Avenue
/O
(If deceased is a married
-evi A — -ZL-'
, widowed or divorced
J (If death occurred in a hospital or institution,
.St. (give its NAME instead of street and number)
(PHYSICIAN — IMPORTANT
(Was deceased a
woman, give also maiden name.)) f ^ J H’ j\T Q
(a) Residence. No -r-Q-9-^-Offier-s-e-fc —Avenue--
(Usual place of abode)
St..
( if so specify WAR).
Itassa&huset ts
Length of stay: In place of death..] years 2.... months , days. In place of residence ..t^years..^e.months days.
(If nonresident, give city or town and State)
5L
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
DEATH l i
(Month)
$■ -
(Day)
(Year)
That I attended deceased from
.., 19^
, death is said to
have occurred on the da^Z stated above, at — 3-t-^JUm. INTERVAL
BETWEEN
ONSET AND
DEATH
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
,s/\b Fa/oc. (do n 4- oF_crc/y/j
C Cfrfl C/A/QM A-toS
Due To
(b)
Due To
(c)
OTHER
SIGNIFICANT
CONDITIONS
Was autopsy performed?
What test confirmed diagnosis?.
5 Was disease or injury in any way related to occupation of deceased?
If so, specifjt—^
6 _ Oal vary 2.sjA.e.t..e.r^r.....-..A_o.b.urn. r .Maas.
Place of Burial or Cremation (City or Town)
DATE OF BURIAL.
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
male
9 COLOR
white
10 SINGLE (write the word)
MARRIED 3
WIDOWED widowed.
or DIVORCED
10a If married, widowed, or divorced
HUSBAND of
TGive maiden mime of wife in full)
(or) WIFE of...
(Husband’s name in full)
11 IF STILLBORN, enter that fact here.
12 rscs
AGE ...X-DYe
llMonths... .15b
ays
If under 24 hours
Hours Minutes
13 occupation: Stat-ir bA-Bo l.iae— Of . f leer-- —
(Kind of work done during most of working life)
14
or^BusiLss : ...QA BOStOn.
15 Social Security No., .01.2_ee.05--l-49.5-
16 BIRTHPLACE (City)
(State or country)
;on~
Received and filed
(Registrar)
17 NAME OF
FATHER
18 BIRTHPLACE OF
FATHER (City)
(State or country)
Tr al end
19 MAIDEN NAME
QF MOTHER Anna-
IToonan
20 BIRTHPLACE OF
MOTHER (City)
(State or country)
IrelancL
informant....].,ir_s.* Gyr-d-i© ;w - Biekins-OSr-
(Address) qq 3 oners at Ava. n
at a satisfactory standard certificate of death
RE tjkCburi^l lo/ transit permit was 'issued:
t of Bohfd of Health or oj
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE
RANK, RATING
ORGANIZATION AND OUTFIT
SERVICE NUMBER
RULES OF PRACTICE
The fulfillment of the purpose of these laws calls for the observance of the follow-
ing rules of practice:
(1) Attending physician* will certify to such deaths only as those of persons
to whom they have given bedside care during a last illness from disease unrelated
to any form of injury.
(2) Board of Health physicians will certify to such deaths only as those of
persons who. though disabled by recognized disease unrelated to any form of
injury, have died without recent medical attendance or whose physician is absent
from home when the certificate of death is needed.
(3) Medical Examiners will investigate and certify to all deaths supposably
due to injury. These include not only deaths caused directly or indirectly by
traumatism (including resulting septicemia), and by the action of chemical
(drugs or poisons) thermal, or electrical agents, and deaths following abortion, but
also deaths from disease resulting from injury or infection related to occupation,
the sudden deaths of persons not disabled by recognized disease, and those of
persons found dead. , -
Statement of Cause of Death. — Physicians: see explanatory instructions
on face side of standard certificate of death.
*£C£'IV£»
^Tvn^;
:^1pS^VY\
m ' ' i= 3; !
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.
FEB -51959 M
1 R-301A
RUCTIONS
FOR
CERTIFICATE
giving
OF DEATH
Lot enter
than one
for each
(b) and (c)
does not mean
f of dying,
heart failure,
etc. It means ^
e. or compli- *
which caused
ns, if any,
Wave rise to
I cause (a),
the under-
cause last.
• ions contrib -■
\death but not
the terminal
edition given
Chapter 137,
1 1954, requires
cus to print or
e cause or
|if death on
•rtificates.
,_ailff_Ql]SL__
(County)
o Winthrop
(City or Town)
2 FULL NAME
(Sift (Ernttmonuiealtlf nf HHaasarlpiarttH
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.
xr-Bav View Nursing Home 41 Washington
Joseph S. Cann
(If deceased is a married, widowed or divorced woman, give also maiden name.)
i PHYSICIAN — IMPORTANT
' (Was deceased a
IU. S. War Veteran,
' if so specify WAR) •’JB —
(a) Residence. No 3 Willis Avenue , Winthrop
(Usual place of abode)
St. ._
(If nonresident, give city or town and State)
Length of stay: In place of death 1 years 3 moiiths days. In place of residence 4-. years months days.
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
DEATH _
JEt-kmA
(Month)
3
. Vl
(Day)
(Year)
4 I HEREBY CERTIFY, That I attended deceased from
JmjAik 19J Ll, to ._£ei>,
I last saw h-Lt^jilive on _ y , wsJ- , death is said to
have occurred on the date stated above, at _/jL iC_. -/in
8 SEX
Male
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
wfju i u e. i
// H&Avf L
Due To
(b)
Due To
(c)
Sicm FI CANT V^V > Si? ULcCV*
CONDITIONS
Was autopsy performed?
What test confirmed diagnosis
INTERVAL
BETWEEN
ONSET AND
DEATH
Airs.
'i
r •
5 Was disease or injury in any way related to occupation of deceased
If so, specify—.
(Signed)-
(Address)
6Woodlawn Cemetery, Everet'
Place of Burial or Cremation (City or Town)
M. D
DATE OF BURIAL
.19.55
7 fun'eral director Richard C# Kirby
ADDRESS
>917 Bennington St. ,E. Boston
Received and filed.
195T
19
(Registrar)
PERSONAL AND STATISTICAL PARTICULARS
9 COLOR
White
10 SINGLE (write the word)
MARRIED
orcecW i d owed
10a If married, widowed, or divorced
Sarepta Cox
HUSBAND of_
(or) WIFE of
(t ive maiden name of wife in full)
(Husband’s name in full)
11 IF STILLBORN, enter that fact here.
12
AGE y Years. Months Days
If under 24 hours
Hours Minutes
13 Usual
Occupation:
Proprietor Retired
(Kind of work done during most of working life)
14 Industry
or Business:
15 Social Security No
. [removed]
16 BIRTHPLACE (City)
(State or country)
Yarmouth
ova Scotia
17 NAME OF _ -.
father Jesse Cann
18 BIRTHPLACE OF
FATHER (City)
(State or country)
CBL
Nova Scotia
19 MAIDEN NAME
OF MOTHER
Mary Crosby
20 BIRTHPLACE OF
MOTHER (City)
(State or country)
CBL
Nova Scotia
Informant. Jesse q, Cann-Son
(Address)1} W1 1 1 1 fl AV-ft
W1.nthrop=
FY that a satfifac^rry standard certificate of death
EF£H$E the/burial 'or transit permit was issued:
_i_
: Board of HealTn or other)
JUJL
(Date of Issue of Permit)
EXTRACTS
FROM THE LAWS OF THE
COMMONWEALTH OF MASSACHUSETTS
GOVERNING THE
RETURN OF CERTIFICATES OF DEATH
A pbvsician 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, shaU upon
application make the certificate required of the attending physician. If death is
caused by violence, the medical examiner shall make such certificate. If such a
permit for the removal of a human body, not previously interred, from one town
to another within the commonwealth cannot be obtained early enough for the
purpose, the certificate of death made as above provided and in the possession of
the undertaker desiring to make such removal shall constitute a permit for such
removal; provided, that such body shall be returned to the town from which it was
removed within thirty-six hours after such removal, unless a permit in the usual
form for the removal of such body has been sooner obtained hereunder. If the
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 relajir^g to .occupation, or suddenly when not
disabled by recognizable disease, or \fVien an person iLfound dead. — General
Laws, Chap. 38, Sec. 6.. as amended by Chap. 632, Sec. 4, Acts of 1945.
No undertaker or other persons sbfl(£buify alhuoian body or the ashes thereof
which have been brought into the cOmhiojiivcal t h until he has received a permit
so to do from the board of health-or its _5gcrlt appointed to issue such permits, or
if there is no such board, from thefcfef it tqwji where the body is to be buried
or the funeral is to be held, or fibra-g jjertbri'appoipted tp have the care of the
cemetery or burial ground in which. thehntermenr-.is made.
. Chap. 1 14, Sec. 46, G, L„ (Tercentenary Edition);
RULES rOK PRACTICE
The fulfillment of the purpose of these laws calls (or 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 front disease unrelated
to any form of injury. ' ' ; ,
(2) Board of Health physicians will certify to such deaths only as those ot
persons who, though disabled by recognized disease unrelated to any form of
injury, have died without recent ntcCoal ^ttjffd&nse *r whose physician is absent
from home when the certificate of aastw is nqeUfCliJ j ,1'1
(3) Medical Examiners will investigate and certify to all deaths supposably
due to injury. These include not only deaths caused directly or indirectly by
traumatism (including resulting septicemia), and by the action of chemical
(drugs or poisons) thermal, or electrical agents, and deaths following abortion, but
also deaths from disease resulting from injury or infection related to occupation,
the sudden deaths of persons not disabled by recognized disease, and those of
persons found dead.
Statement of Cause of Death. — Physicians; see explanatory instructions
on face side of standard certificate of death.
Statement of Occupation. — Precise statement of occupation is very import-
ant, so that the relative healthfulness of various pursuits can be known. Make
some entry in this section for every person aged 10 years or over. If the occupa-
tion had been given up or changed, or if the deceased had retired from business,
report the kind of work done during most of working life even if retired. Children
not gainfully employed may be returned as at school or at home. For a woman
whose only occupation was that of home housework, write housework, for a
person engaged in domestic service for wages, however, designate the occupation
by the appropriate terms, as housekeeper — private family, cook — hotel, etc. hor
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
A R-301A
RUCTIONS
FOR
CERTIFICATE
giving
OF DEATH
lot enter
than one
for each
(b) and (c)
does not mean
V of dying,
heart failure,
letc. It means ^
se. or compli- ™
which caused
sns, if any,
iga ve rise to
cause (a),
the under-
cause last.
I lions contrib- ■
death but not
i the terminal
ondition given
; Chapter 137,
11954, requires
las to print or
cause or
if death on
irtificates.
5 ..Suffolk
(County)
Wi n t h r op C W
(Eammmuuraltlj nf fHasaarljuaetta
EDWARD J. CRONIN
Secretary of the Commonwealth
DIVISION OF VITAL STATISTICS
(City or Town)
Winthrop COmm. Hosp
STANDARD
CERTIFICATE OF DEATH
To be filed for burial permit
with Board of Health
or its Agent.
1.9-
Registered No.
No.
2 full name Baby Boy MacDonald
/T C J .IT. . . 5 J > . . nr i r) mir o rl nr rllvnr
f (If death occurred in a hospital or institution,
St. (give its NAME instead of street and number)
IMPORTANT
'(If deceasTd is a married, widowed or divorced woman, give also maiden name.)
(a) Residence. No. .231 Washington.. Ave. Chelsea , lass
(Usual place of abode)
1 PHYSICIAN
) (Was deceased a
j U. S. War Veteran,
f if so specify WAR)
Length of stay: In place of death years months days. In place of residence..
(If nonresident, give city or town and State)
years months days.
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
DEATH _
59
(Month)
(Day)
(Year)
4 I HEREBY CERTIFY,
_, 19 , to
I last saw h alive on —
That I attended deceased from
, 19
have occurred on the date stated above, at
19 , death is said to
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
(a) Stillborn
pb“eTo 7 mon.
cephalic
remature - hydro
Due To
(c)
OTHER
SIGNIFICANT
CONDITIONS
Was autopsy performed?.
-iftr
INTERVAL
BETWEEN
ONSET AND
DEATH
What test confirmed diagnosis?.
5 Was disease or injury in any way related to occupation of deceased?.
If so, specify
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
M
9 COLOR
White
10 SINGLE (write the word)
MARRIED
widowed fl ingle
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. STILLBORN
AGE.
Years Months _Days
If under 24 hours
Hours M inutes
13 Usual
Occupation:
(Kind of work done during most of working life)
14 Industry
or Business
15 Social Security No.
16 BIRTHPLACE (City)
(State or country)
Winthrop , Mass
6 Woodlawn Cemetery,
Place of Burial or Cremation
Feb. 5#
(City or Town)
DATE OF BURIAL
7 NAME OF TT'pripQ'tT C!
FUNERAL DIRECTOR 0 u •
Caggiano
ADDRESS
147 Winthrop St. Winthrop
Received and filed.
(Registrar)
17 fatherf Jerome MacDonald
18 BIRTHPLACE O
FATHER (City)
(State or country)
"Hass"
19 MAIDEN NAME
of mother Rose Dutra
20 BIRTHPLACE OF
MOTHER (City). hSSt
Boston
...Mas.S-
(State or country)
Informant. WAnthrOp.
(Address) j nfrhr OP
Community Hosp.
Mass.
tisfactory standard certificate of death
burial or transit permit was issued:
—
f Board of He^fi o^-other)
_
(Date of Issue of PerjmiD/ /
i
EXTRACTS
FROM THE LAWS OF THE
COMMONWEALTH OF MASSACHUSETTS
GOVERNING THE
RETURN OF CERTIFICATES OF DEATH
A physician or rcsnstercd 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 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 electricateift'iQsET \t>ltbiwng 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 amen^ed'Gy Cjiap7j532, Sec. 4, Acts of 1945.
No undertaker or other pecsbAf sbatt'bury a hurpajl body or the ashes thereof
which have been brought mtq.theK'qrtinilinivc'ilth^unril he has received a permit
so to do from the board of health* or \U'-agenT' eppouWed to issue such permits, or
if there is no such board, from.lhfe’^leni of the foyvn.\i>Herc the body is to be buried
or the funeral is to be held^'b^ from a person appyjjited to have the care of the
cemetery or burial ground in whioh the interment is made.
. Chap. 114, Sec. 46, G. L.J (Tercentenary Edition).
t -T
RULE^ PRACTICE
The fulfillment of the purpose of these laws calls for the observance of the follow-
ing rules of practice: Vvy / 1
(1) Attending physicians wilbeeitify to such deaths only as those of persons
to whom they have given bedside careauringa last illness from disease unrelated
to any form of injury.
(2) Board of Health physician* will eertify. such deaths only as those of
persons who. though disabled bj- rei&grrte^J VlhVelated to any form of
injury, have died without recent mimicahattendance or whose physician is absent
from home when the certificate of death is needed.
(3) Medical Examiners will investigate and certify to all deaths supposably
due to injury. These include not only deaths caused directly or indirectly by
traumatism (including resulting septicemia), and by the action of chemical
(drugs or poisons) thermal, or electrical agents, and deaths following abortion, but
also deaths from disease resulting from injury or infection related to occupation,
the sudden deaths of persons not disabled by recognized disease, and those of
persons found dead.
Statement of Cause of Death. — Physicians: see explanatory instructions
on face side of standard certificate of death.
Statement of Occupation. — Precise statement of occupation is very import-
ant, so that the relative healthfulness of various pursuits can be known. Make
some entry in this section for every person aged 10 years or over. If the occupa-
tion had been given up or changed, or if the deceased had retired from business,
report the kind of work done during most of working life even if retired. Children
not gainfully employed may be returned as at school or at home. For a woman
whose only occupation was that of home housework, write housework. For a
person engaged in domestic service for wages, however, designate the occupation
by the appropriate terms, as housekeeper — private family, cook — hotel, etc. For
a person who had no occupation whatever write none.
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE
RANK, RATING
ORGANIZATION AND OUTFIT
SERVICE NUMBER
R-301A
lUCTIONS
FOR
CERTIFICATE
giving
OF DEATH
ot enter
than one
tor each
(b) and (c)
toes not mean
of dying,
heart failure,
etc. It means
te, or compli-
vhicli caused
ms, if any,
lave rise to
cause (a),
the under-
cause last.
tions contrib-
death but not
the terminal
ondition given
Chapter 137,
1954, requires
ins to print or
le cause or
I of death on
I ertifleates.
A
’’/County)
(City or Tcpim)
2 FULL NAME
(a)
01ommmuufaltl| of fHasBarljUBFttB
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.
18
Registered No.
. St.
Residence. No-.A.^'...
(Usual place of abode)
or divorced woman, give also maiden name.)
((If death occurred in a hospital or institution.,
( give its NAME instead of street and number)
PHYSICIAN — IMPORTANT
(Was deceased a
U. S. War Veteran, rp7\
if so specify WAR) rTv!
i>t..
Length of stay: In place of death
’..years months... .""'’days. In place of residence*-* 'ST years months days.
Ub ,
(If nonresident, give city or town and State)
MEDICAL CERTIFICATE OF DEATH
3 DATE OF /“«, L v, /. i ^ / A,
DEATH C&M - W
(Month) / (Day)
(Year)
to..
That I attended deceased from
— 1 , 19.~...
4 I HEREBY CERTIFY,
I last saw h.rrr.alive on .-
have occurred on the date stated above, at Q m.
~., 19 , death is said to
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
■*zf S~\ttss.-sr
Due To
(b)
g3e To _(2 ^.XonATV (2c.aIu.sia
OTHER
SIGNIFICANT'
CONDITIONS
INTERVAL
BETWEEN
ONSET ANO
DEATH
i
s jlAJ ^
Was autopsy performed? I/O. ...
What test confirmed diagnosis?
rrrf
ry in any way related to occupation of deceased y..Jkl&...
_ . . -t-MUM..!
Place of Burial or Crematiorj^/
'jdtUr... £..
DATE
BURIAL
7 NAME OF
FUNERAL DIRECTOR
Received and
(Registrar)
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
9 COLOR
10-SINGLE" (write the word)
wfMw'E©- fo'&A/ii&c/
-or DIVORCED
10a If married, widowed, or divor£
HUSBAND of -
(Give maiden name
(or) WIFE of
wi fe in full)
(Husband’s name in full)
11 IF STILLBORN, enter that fact here.
12 /JlJ
AG E./..L.Y ears Months
...Days
If
under 24 hours
Hours Minutes
13 L'sual
Occupation
C )
(Kind of work done during most of working life)
14 Industry
or Business:.
AUl£Ak.L. ’/
15 Social Security No.—
16 BIRTHPLACE (City) ...
(State or country) / 4-A. — '
17 NAME OF (y JlA)
FATHER Z' 'J V
18 BIRTHPLACE OF
FATHER (City)
(State or country)
19 MAIDEN NAME
OF MOTHER
20 BIRTHPLACE OF
MOTHER (City).
(State or country)
21
Informant
(Address) ^ £
ALe.
r ,
ir Ar
I HEREBY CERTIFY that a satisfactory standard certificate of death
was filed with jnq BEFORE, the^urial pr transit permit was issued:
:heiiurial or transit
.c , A^rlAA:C<.
Agent of Board of Health or other)
(Official Designation)
ZAA&&J.
of Issfie of Permit)
(Date
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-
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 o! nineteen hundred and sixteen and nineteen hundred and seventeen.
G. L. Chap. 46. Sec. 10.
No undertaker or other person shall bury or otherwise dispose of a human body
in a town, or remove thereirom a human body which has not been buried, until he
has received a permit from the board of health, or its agent appointed to issue
such permits, or if there is no such board, from the clerk of the town where the
person died; and no undertaker or other person shall exhume a human body and
remove it from a town, from one cemetery to another, or from one grave or tomb
other than the receiving tomb to another in the same cemetery, until he has
received a permit from the board of health or its agent aforesaid or from the clerk
of the town where the body is buried. No such permit shall be issued until there
shall have been delivered to such board, agent or clerk, as the case may be,
a satisfactory written statement containing the facts required by law to be
returned and recorded, which shall be accompanied, in case of an original inter-
ment, by a satisfactory certificate of the attending physician, if any. as required by
law. or in lieu thereof a certificate as hereinafter provided. If there is no attending
physician, or if. for sufficient reasons, his certificate cannot be obtained early
enough for the purpose, or is insufficient, a physician who is a member of the board
of health, or employed by it or by the selectmen for the purpose, shall upon
application make the certificate required of the attending physician. If death is
caused by violence, the medical examiner shall make such certificate. If such a
permit for the removal of a human body, not previously interred, from one town
to another 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, oi^by the action of
chemical, thermal or electrical agents or f<n)c»'ibg'-abortibn^ 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. tJ32, See. 4. Acts of 1945.
No undertaker or other persons shall bury ’a hul^San body qr the ashes thereof
which have been brought into the commonwealth unftlh£jhas 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 ofthe towri 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: ^ ' j
( 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 deathstonly as those of
persons who. though disabled by recognized disease unr^a^^d tto any form of
injury, have died without recent medical attendance or whose physician is absent
from home when the certificate of death is needed.
(3) Medical Examiners will investigate and certify to all deaths supposably
due to injury. These include not only deaths caused directly or indirectly by
traumatism (including resulting septicemia), and by the action of chemical
(drugs or poisons) thermal, or electrical agents, and deaths following abortion, but
also deaths from disease resulting from injury or infection related to occupation,
the sudden deaths of persons not disabled by recognized disease, and those of
persons found dead.
Statement of Cause of Death. — Physicians: see explanatory instructions
on face side of standard certificate of death.
Statement of Occupation. — Precise statement of occupation is very import-
ant, so that the relative healthfulness of various pursuits can be known. Make
some entry in this section for every person aged 10 years or over. If the occupa-
tion had been given up or changed, or if the deceased had retired from business,
report the kind of work done during most of working life even if retired. Children
not gainfully employed may be returned as at school or at home. For a woman
whose only occupation was that of home housework, write housework. For a
person engaged in domestic service for wages, however, designate the occupation
by the appropriate terms, as housekeeper — private family, cook — hotel, etc. For
a person who had no occupation whatever write none.
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE
RANK, RATING
ORGANIZATION AND OUTFIT
SERVICE NUMBER...
®f ie Commontotaltf) of iHasoacijustetto
EDWARD J. CRONIN
Secretary of the Commonwealth
DIVISION OF VITAL STATISTICS
MEDICAL EXAMINER'S
OF DEATH
To be filed (or burial permit
with Board of Health
or its Agent.
Registered No.
occurred in a hospital or institution,
its NAME instead of street and number)
rPHYSICIAN — IMPORTANT
2 FULL NAME ..
deceased is a married, widowed or divorced woman, give also maiden name.)
(a) Residence. No.”7.3^.
(Usual place of abode)
{(Was deceased a
U. S. War Veteran,
if so specify WAR)
ionresident, give city or town and State)
Length of stay: In place of death years months....yF...days. In place of residence.j/jZ.... years months days.
MEDICAL CERTIFICATE OF DEATH
3 DATE OF
DEATH ...
e , ttSS
' (Year)
41 HEREBY CERTIFY that VJJ have investigated the death
of the person above-named and that the CAUSE AND MANNER thereof
are as follows: (If an injury was involved, state fully.)
toTiX#:
i<ey.r.C JSfZ. AT1L
5 Accident, suicide, or homicide (specify)
Date and hour of injury ....
..19..
Where did
Injury occur?
j(City or town and State)
Did injury occur in o'r about home, on farm, in industrial place, or in
public place ?
Manner of
(Specify type of place)
Injury
(How did injury occur?)
8 NAME OF
FUNERAL DIRECTOR
ADDRESS
MMmdML
Received and filed
(Registrar)
PERSONAL AND STATISTICAL PARTICULARS
9 SEX
10 COLOR OR RACE
££MiL£L LkttlTEi
11 SINGLE
MARRIED
WIDOWED
(write the word)
IDOWED f / ./A ,
DIVORCED <J / AuL /C
11a If married, widowed, or divorced
HUSBAND of
(Give maiden name of wife in full)
(or) WIFE of
(Husband's name in full)
12 IF STILLBORN, enter that fact here.
AGEyf^.c?.... r'ears Months Days
If under 24 hours
Hours Minutes
Usual
Occupation:
(Kind of work done during most of working life)
Industry
or Business:
16 Social Security No.
17
BIRTHPLACE (City)
(State or country )
18 NAME OF
FATHER
19 BIRTHPLACE OF
J20ALH L
FATHER (City) P/rrs H£L P ,
(State or country)
” or^THHr E yj A/, mvm
21 BIRTHPLACE OF
MOTHER (City)
(State or country)
22
I HER
.... DMO-A.fr , kjrtffr 4.
Y that a satisfact6ryVstandard certificate of death
FORE t ^TO/Puriaf q/vtgapsit 'permit was iksued:
of. Ag^lt/p^ Boar^Tof Health or othec)^'>/-^>/
ICMs^.
(Date of Issue of Permit) ' / \
EXTRACTS
FROM THE LAWS OF THE
COMMONWEALTH OF MASSACHUSETTS
GOVERNING THE
RETURN OF CERTIFICATES OF DEATH
A physician or registered hospital medical officer shall forthwith, after the
death of a person whom he has attended during his last illness, at the request
of an undertaker or other authorized person or of any member of the family of
the deceased, furnish for registration a standard certificate of death, stating to the
best of his knowledge and belief the name of the deceased, his supposed age. the
disease of which he died, defined as required by section one. where -.same was
contracted, the duration of his last illness, when last seen alive by the physician
of officer and the date of his death. . .Gen. Laws, Chap. 46. Sec. 9.
A physician or officer furnishing a certificate of death as required by the
preceding section or by section forty-five of chapter one hundred and four-
teen, shall, if the deceased, to the best of his knowledge and belief, served in the
army, navy or marine corps of the United States in any war in which it has been
engaged, insert in the certificate a recital to that effect, specifying the war. and
shall also certify in such certificate both the primary and the secondary or imme-
diate cause of death as nearly as he can state the same. For neglect to comply
with any provision of this section, such physician or officer, shall forfeit ten dollars.
For the purposes of this section and of sections forty-five, forty-six and forty-seven
of said chapter one hundred and fourteen, the word "war" shall include the China
relief expedition and the Philippine insurrection, which shall, for said purposes, be
deemed to have taken place between February fourteenth, eighteen hundred and
ninety-eight and July fourth, nineteen hundred and two. and the Mexican border
service of nineteen hundred and sixteen and nineteen hundred and seventeen.
G. L. Chap. 46. Sec. 10.
No undertaker or other person shall bury or otherwise dispose of a human body
in a town, or remove therefrom a human body which has not been buried, until he
has received a permit from the board of health, or its agent appointed to issue
such permits, or if there is no such board, from the clerk of the town where the
person died; and no undertaker or other person shall exhume a human body and
remove it from a town, from one cemetery to another, or from one grave or tomb
other than the receiving tomb to another in the same cemetery, until he has
received a permit from the board of health or its agent aforesaid or from the clerk
of the town where the body is buried. No such permit shall be issued until there
shall have been delivered to such board, agent or clerk, as the case may be,
a satisfactory written statement containing the facts required by law to be
returned and recorded, which shall be accompanied, in case of an original inter-
ment, by a satisfactory certificate of the attending physician, if any, as required by
law, or in lieu thereof a certificate as hereinafter provided. If there is no attending
physician, or if, for sufficient reasons, his certificate cannot be obtained early
enough for the purpose, or is insufficient, a physician who is a member of the board
of health, or employed by it or by the selectmen for the purpose, shall upon
application make the certificate required of the attending physician. If death is
caused by violence, the medical examiner shall make such certificate. If such a
permit for the removal of a human body, not previously interred, from one town
to another within the commonwealth cannot be obtained early enough for the
purpose, the certificate of death made as above provided and in the possession of
the undertaker desiring to make such removal shall constitute a permit for such
removal; provided, that such body shall be returned to the town from which it was
removed within thirty-six hours after such removal, unless a permit in the usual
form for the removal of such body has been sooner obtained hereunder. If the
death certificate contains a recital, as required by section ten of chapter forty-six.
that the deceased served in the army, navy or marine corps of the United States
in any war in which it has been engaged, such recital shall appear upon the permit.
The board of health, or its agent, upon receipt of such statement and certificate,
shall forthwith countersign it and transmit it to the clerk of the town for registra-
tion. The person to whom the permit is so given and the physician certifying
the cause of death shall thereafter furnish for registration any other necessary
information which can be obtained as to the deceased, or as to the manner or
cause of the death, which the clerk or registrar may require. — Chap. 114, Sec.
45. G. L. as amended by Chap. 48. Acts of 1927 and Chap. 414, Acts of 1931.
No undertaker or other person shall bury a human body or the ashes thereof
which have been brought into the commonwealth until he has received a permit
so to do from the board of health or its agent appointed to issue such permits,
or if there is no such board, from the clerk of the town where the body is to be
buried or the funeral is to be held, or from a person appointed to have the care
of the cemetery or burial ground in which the interment is made. Chap. 114,
Sec. 46, G. L., as amended.
Medical examiners shall make examination upon the view of the dead bodies
of persons as are supposed to have died by violence, or by the action of
chemfjpafl. <th|frhal 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. Chapv-T^Siec. 6.. as amended by Chap. 632, Sec. 4. Acts of 1945.
The medical examiner certifies the cause and manner of death to the best
of his knowledge and belief.
'• RULES OF PRACTICE
C ' ‘ .y'1 r/\^c's
The fulfillment of the purpose of these laws calls for the observance of the follow-
ing rutes of practice: 'f*
(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 diod without recent medical attendance or whose physician is absent
from hbrnp when the certificate of death is needed.
(3) Medical Examiners will investigate and certify to all deaths supposably
due to injury.. These include not only deaths caused directly or indirectly by
traumatism (including resulting septicemia), and by the action of chemical
(drugs or poisons) thermal, or electrical agents, and deaths following abortion, but
also rdeaths-from disease resulting from injury or infection related to occupation,
the suddfen deaths of 'periods not disabled by recognized disease, and those of
persons found dead.
STATEMENT OF CAUSE OF DEATH
Medical Examiners in certifying to a death will state the cause and manner
thereof, and will specify: (1) Under cause the nature of an injury and of its
consequences; and (2) under manner the mode of its production together with
the circumstances when these are known. For example: “Compound fracture of
the femur with ensuing septicemia (gas bacillus) caused by a steam railway
accident." "Pistol shot wound of the chest with associated hemorrhage, hom-
icidal." “Asphyxiation by suspension, suicidal." “Syncope while under the
influence of ether administered as a surgical anaesthetic." "Fracture of the
skull with associated internal injury sustained under circumstances unknown."
If disease or injury was related to occupation, specify. If investigation
shows the death to have been due to disease, specify: (l)Under cause its known
or presumable nature; and (2) under manner, indicate the circumstances leading
to medico-legal inquiry. For example: “Hemorrhage spontaneous of the brain
(basal ganglia) (found dead in bed)." “Heart disease, presumably coronary
sclerosis. (Sudden death.)"
SPACE FOR ADDITIONAL INFORMATION
DATE OF ENTERING MILITARY SERVICE
DATE OF DISCHARGE
RANK, RATING
ORGANIZATION AND OUTFIT
SERVICE NUMBER
I R-301A
MOTIONS
FOR
CERTIFICATE
giving
OF DEATH
ot enter
than one
for each
(b) and (c)
foes not mean
of dying,
heart failure,
tc. It means
e, or compli-
vhich caused
ns, if any,
ave rise to
cause (a),
the under-
tause last.
ions contrib-'
leath but not
the terminal
ndition given
Chapter 137,
>54, requires
s to print or
cause or
death on
tificates.
i
AoJh die
(County)
IV <n t h n of
(City or Tcrwn)
tyqt (Hmmnnmuealttj nf
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. W
2 FULL NAME-.
(If
W i a f h v ° f C era Vn ^ tv i -V ^ /-/« s P-
Bash Boh , 0 V- d-
(feceaseais af married, widowed or divorced woman, give also maiden
No. (b~f 2$ C6Ce ft Rd -
il place of abode)
name.)
f (I f death occurred in a hospital or institution,
St. [give its NAME instead of street and number)
! PHYSICIAN — IMPORTANT
(Was deceased a
U. S. War Veteran,
if so specify WAR)
(a) Residence
(Usual
Length of stay: In place of death
..St
..years months days. In place of residence ....
(If nonresident, give city or town and State)
-.years months days.
MEDICAL CERTIFICATE OF DEATH
DEA?H°F FEBftUAM % MSS-
(Month) / (Day) (Year)
4 I HEREBY CERTIFY
*7:
I last saw hffApive on
have occurred on the date stated above, at
That I attended deceased from
, 19 J 1
death is said to
/-15 8 S /
•{sS
U'<?4 p
DEATH WAS CAUSED BY: IMMEDIATE CAUSE
-STll LflO/T ff...
(a) __
?*rTo p(lP>y\*Toai + y
Due To
(c)
OTHER
SIGNIFICANT
CONDITIONS
INTERVAL
BETWEEN
ONSET AND
DEATH
Was autopsy performed?
What test confirmed diagnosis?
5 Was disease or injury in any way related to occupation of deceased?.
If so. specify
(Signed)
(Address'
HdSiTYl ■ _C
6 C tr? > J
Place or Burial or Cremation
DATE OF BURIAL
M. D.
f=ks % 19^71
F<s b
(City or Town)
//
19 hT?
7 NAME OF
FUNERAL DIRECTOR
ADDRESS
f- v c 4<JT • *-./< Tv
Fo. it ft* s
Received and filed
Jl ' / 0. 19 4? /
(Registrar)
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
AU/«
9 COLOR
wh i’ t-
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. ^ 1 | ^ ^
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
16 BIRTHPLACE (City)__V!^±.lV'_CTa_K--4_^?__^_ri^_S^_
(State or country)
17 NAME OF 'T /, n ,
FATHER vJ<a-Ft>^S /•/• f\ o DeP>?)
18 BIRTHPLACE OF
FATHER (City) Cr.A .'C_.. *lC
(State or country)
in o i S
19 MAIDEN NAME
OF MOTHER
^ //Za b& ^ h\ce h F
20 BIRTHPLACE OF
MOTHER (City)
(State or country)
C S Ao h
J
I nformant
(Address) i7
me. t hi Tt.4-hc.jrS.ojDL
’ fic4 c Ji u/ej 71 +■ h *j
l that a^-satisfactpi/y standard certificate of death
FORI^hj? buriaV/Or transit permit w'as issued:
of Board of Health or othpf'f
(Official Designation)
(Date of Issue of Permit,
EXTRACTS
FROM THE LAWS OF THE
COMMONWEALTH OF MASSACHUSETTS
GOVERNING THE
RETURN OF CERTIFICATES OF DEATH
A phvsician or registered hospital medical officer shall forthwith, after the
death 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 ot
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 certifv in such certificate both the primary and the secondary or imme-
diate cause of death as nearly as he can state the same, hor 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 s"all 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 cleric
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
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
phvsician. 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, “ 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 w'ar 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 jnfpction relating to occupation, or suddenly when not
disabled by recogni25l)& QisBaseVoiLwJjen any person is found dead. — General
Laws. Chap. 38, Sec. 6.. as amended by Chap. 632. Sec. 4. Acts of 1945.
No undertaker or otfier peTSonS'shall bury a human The text goes on. The rest is in the file.