USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1900-1903 > Part 16
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{ If a Soldier or Sailor in the War of the Rebellion, give both Primary and Secondary Cause.
Countersign and transmit to the clerk of the city or town.
Agent of Board of Health. no. 6
No.
RETURN OF THE DEATH
OF
William Of Oranly at Worthuto Nase
Belcher Street
Date November 6' 190 ... 1
Filed, november y" 190/
[EXTRACTS FROM CHAPTER 444, ACTS OF 1897.]
SECTION 6. Every householder in whose house a death occurs, the oldest person next of kin present at the time of the death of any of his kindred, or the person in charge of an institution in which a deathi oceurs, shall, within five days after the date of such a death, give notice thereof to the board of health or to the clerk of the city or town in which the death occurred.
SECTION 7. The commanding officer of a vessel shall give notice of the death of any person under his charge to the board of health or to the clerk of the city or town within the Commonwealth at which his vessel first arrives after such death.
SECTION 8. Penalty for neglect to comply with the requirements of sections 6 and 7, five dollars.
SECTION 10. A physician who has attended a person during his last illness shall forthwith after the death of said person, upon request, furnish for registration a certificate setting forth the required facts.
SECTION 11. In case the deceased was a soldier who served in the war of the rebellion, give both the primary and the secondary or immediate cause of death as nearly as he can state the same. Penalty for refusal or neglect, ten dollars.
SECTION 12. Any person having charge of the funereal rites preliminary to the interment of a human body shall obtain the physician's certificate made in accordance with section 10, and return it, together with the facts required by section 1, to the board of health or to the clerk of the city or town in which the death occurred.
[EXTRACTS FROM CHAPTER 437, ACTS OF 1897.]
SECTION 1. No human body shall be buried in a city or town or removed therefrom, until a permit therefor shall have been received from the proper anthorities. No such permit shall be issned until a written statement, as required by law, has been furnished, with a physician's certificate of the cause of death. When such statement and certificate are delivered to the Board of Health, the board or agent shall forthwith countersign and transmit the same to the clerk of the city or town for registration.
" dollara.
FORM C.
Commonwealth of Classachusetts.
No.
RETURN OF A DEATH.
To the Clerk of the City or Town in which the death occurred.
Name,
Ellen Lighthill
HFILL OUT WITH INKI ALL NAMES TO BE IN FULLA
-
White
Sex Female Color,
Date of Death,
november 10
190 /; Age,
64 Years,
3
Months,
22 Days.
Ener genung - manier
Maiden Name, { If married, widowed } or divorced.
Husband's Name,
august Ponham dianthill
-Single, Married, Widowed or Divorced, Occupation,
Mentros - Hia 20 Crest. Por Musste que
"Residence, ¿ also state fully. Bastón -1 Place of Birth,
*Place of Death,
Winthrop - Quel avenue, Minttea
Name and Birthplace of Father, -
Maiden Name and Birthplace of Mother,
Place of Interment, (Give name of Cemetery),
Summer floyd
on
november 19
.190 /
Signature and place of business of Undertaker.
Winthrop Mass
PHYSICIAN'S CERTIFICATE.
Name and Age of Deceased, t
Ellen Lighthill
Place and Date of Death,
died at
Wie Titrofe
Age, 64 Y. 3. M.22 D.
2200. 19- 1901.
Primary,
IL Torin. Efecthelionica Duration, 21 mentho
Disease or Cause of Death, # Secondary, septicemia
Duration,
4 months
I certify that the above is true to the best of my knowledge and belief.
Signature and Residence
of Certifying Physician. WU , Prof. Incaso
.M. D.
Date of Certificate,
november 14
1902.
* Give also street and number, if any .. t Give sex of infant not named. If still-born, so state.
# If a Soldier or Sailor in the War of the Rebellion, give both Primary and Secondary Cause.
Countersign and transmit to the clerk of the city or town.
Agent of Board of Health.
....
Dated at
No. 58.
RETURN OF THE DEATH
OF Ellen Lighthill at brest avenue
Date, November 19.
1901.
Filed, number 19 190_L.
[EXTRACTS FROM CHAPTER 444, ACTS OF 1897.]
SECTION 6. Every householder in whose house a death occurs, the oldest person next of kin present at the time of the death of any of his kindred, or the person in charge of an institution in which a death oecurs, shall, within five days after the date of such a death, give uptice thereof to the board of health or to the elerk of the eity or town in which the death oceurred.
SECTION 7. The commanding officer of a vessel shall give notice of the death of any person under his charge to the board of health or to the elerk of the eity or town within the Commonwealth at which his vessel first arrives after such death.
SECTION 8. Penalty for negleet to comply with the requirements of sections 6 and 7, five dollars.
SECTION 10. A physician who has attended a person during his last illness shall forthwith after the death of said person, upon request, furnish for registration a certificate setting forth the required facts.
SECTION 11. In case the deceased was a soldier who served in the war of the rebellion, give both the primary and the secondary or immediate cause of death as nearly as he ean state the same. Penalty for refusal or neglect, ten dollars.
SECTION 12. Any person having charge of the funereal rites preliminary to the interment of a human body shall obtain the physician's certificate made in accordance with seetion 10, and return it, together with the faets required by seetion 1, to the board of health or to the clerk of the city or town in which the death oeeurred.
[EXTRACTS FROM CHAPTER 437, ACTS OF 1897.]
SECTION 1. No human body shall be buried in a eity or town or removed therefrom, until a permit therefor shall have been received from the proper authorities. No such permit shall be issued until a written statement, as required by law, has been furnished, with a physician's certificate of the cause of death. When such statement and certificate are delivered to the Board of Health, the board or agent shall forthwith countersign and transmit the same to the clerk of the city or town for registration.
1 .- - at sernadling fifty dollars.
-
[2-01-37-XXXM.]
Permit No.
RETURN OF DEATH.
BOSTON.
1901.
Year, 1812.
Years, 89.
Date of death Year, Month, For.
Day 20.
Birth
Month, Day Day, 140
Age Months. 6 Days, .. 6 Name in full, Lapsibeth B. Spraque Residence, Minttrofe Maiden name, Male Female.
Sex Conjugal condition
L Single. Married. Widowed.
1 Divorced. Widow of Nathaniel Cf.
Place of death Street, Hb Voltage Park Road
Place of birth,
Occupation, Name of Fathern Enjamen Birthplace of Father Nantucket
Place of interment, 2
Number, Nantucket at home Maiden Name of Mother Ruth Bunker. man. Birthplace of Mother tanteschul man antrichet mass. Dy Brown.
Undertaker.
PHYSICIAN'S CERTIFICATE OF THE CAUSE OF DEATH.
Boston,
190/ ..
Name and age of deceased JEfuit the B. pragueAse, 89
years. Date and place of death, For ro ' 1901. #Hb Goulag: Park Road
Disease S Chief cause, Capoplexy
Contributing cause, arterial Sclerosis
Chief cause,. Eight days
Duration Contributing cause,. Indefrente
I certify that the above is true, to the best of my knowledge and belief. 1
Nume and residence ? of physician, 28 Localiza h. .M D.
* If in an Institution, state how long an inmate and previous residence.
The office of the Board of Health will be open for the granting of permits for burial, as follows : - Saturdays, 9 A. M. till I P.M., except during the months of June, July, August and September, when the office will be closed on Saturdays at 12 M. ; Sundays, 10 A.M. till 12 M. ; Holidays, from 10 A.M. till 12 M .; other days, from 9 A.M, till 5 P.M.
nov 20
Holger White. Color Black (Negro or mixed). Indian. Chinese. Japanese.
Wife of ..
November 20"1901
[2-01-37-XXXM.]
Permit No.
RETURN OF DEATH. BOSTON.
Date of death
Year, 1901 Month, dec Birth
Year, 1900 Month Jame
Day, 2 Age <
Years, Months. 6
Day, 6
Days, .. 4
Name in full, .. Charles Welch
Residence, Cara et
Maiden name, Male. Female.
Sex- Conjugal condition
Single. Married. Widowed. Divorced. Widow of ..
Color
White. Black (Negro or mixed). Indan. Chinese. Japanese.
Wife of.
Place of death Street, Cara et
Place of birth,
Number, E. Button
Occupation, Name of Father, Thomas H. Maiden Name of Mother Elizabeth Taxi Birthplace of Father, E. Bastou Birthplace of Mother, E. Baston
Place of interment, Holy Cross Walden
has I have. Undertaker.
PHYSICIAN'S CERTIFICATE OF THE CAUSE OF DEATH.
Boston,.
Name and age of deceased, Charles Welch
.Age, 1- years.
Date and place of death, *.. Deceni 6'1901 Hintture Mass Scarlet Fever
Disease Chief cause,
Contributing cause,
Chiof cause,
days.
Duration Contributing cause,
I certify that the above is true, to the best of my knowledge and belief.
Name and residence ) of physician, 1
Ben it- Metcalf (cicaly M D.
* If in an institution, state how long an inmate and previous residence.
The office of the Board of Health will be open for the granting of permits for burial, as follows : - Saturdays, 9 A.M. till 1 P.M., except during the months of June ;. July, August and September, when the office will be closed on Saturdays at 12 M. ; Sundeys, 10 A.M. till 12 M. ; Holidays, from 10 A.M. till 12 M .; other days, from 9 A.M. till 5 P.M.
190 1 . 6mis- 4de
1
Unallee freech December 6 "1901,
Charles Hotel
'09 07/
[2-01-37-XXXM.]
Permit No.
RETURN OF DEATH. BOSTON.
1901
Date of death Year, Month, 12 n &. Diglow
Birth
Year, 185 rt Month, Oct Age
47
Years, Months. /
8
Name in full, Dusan
Residence,
1 Days, Winthrop Mas. White. Nack (Negro-or mixed) Indian. Clyinose. Vapunese.
Wife of ..
6 or Marin my Marshall St. Anthrop Mas.
Place of birth,
Occupation,
Name of Father,
Birthplace of Father, South
Place of interment, ARD J. GILMORE,
UNDERTAKER,
Fremont Street.
Undertaker.
ROXPHYSICIAN'S CERTIFICATE OF THE CAUSE OF DEATH.
DEc 12 190 /.
frule
Boston, ed, Susan&, Limon Age, 47
Date and place of death, DEC, 12/Por, in fir Mam Mans huacest
Disease
Chief cause, ..... Consumption
Contributing cause,
Chief cause ...... two hours
Duration Contributing cause,.
I certify that the above is true, to the best of my knowledge and belief.
Name and residence \ M. J Soule W witry Mans. M D.
of physician,
* If in an institution, state how long an inmate and previous residence.
The office of the Board of Health will be open for the granting of permits for burial, as follows : - Saturdays, 9 A.M. till | P.M., except during the months of June, July, August and September, when the office will be closed on Saturdays at 12 M. ; Sundays, 10 A.M. till 12 M. ; Holidays, from 10 A.M. till 12 M .; other days, from 9 A.M. till 5 P.M.
Mate. Female.
Sex Conjugal condition
Divorced.
Widow of
Place of death - Street, Number, marble har mass
Color
Maiden name, .. Le la fep. Single. Married. Widowed ..
Day, ..
Maiden Name of Mother Um F. Lliatt, Birthplace of Mother, Od St Comfort La.
Name and age of deceased, Susan
Dusan 6, Duhon -11 December 12"1901
FORM C.
Commonwealth of Massachusetts.
No.
RETURN OF A DEATH.
To the Clerk of the City or Town in which the death occurred.
(FILL OUT WITH INK. ALL NAMES TO BE IN FULL.)
Name,
Frederick William Walch
Sex,
male
.Color,
while
Date of Death, December 13
.190 / ; Age, 72 Years,
7
.Months,
9 Days.
Maiden Name, { If married, widowed }
or divorced.
Husband's Name,
Single, Married, Widowed or Divorced,.
married Occupation,
Retired
*Residence, { If out of town, }
Bartlett Road Winthrop man
? also state fully. 3
Place of Birth, Macclesfield. Lancashire. England
*Place of Death,
Win throp
man
Rev
John Mulch- Armskist England
Name and Birthplace of Father
Maiden Name and Birthplace of Mother, Elizabeth Lamb - Lancaster England
Place of Interment, (Glve name of Cemetery), Win hoop Cemetary
Dated at Winthrop Summa
Dic 13
190/
Signature and place of business of Undertaker.
on
PHYSICIAN'S CERTIFICATE.
Name and Age of Deccascd, t Frederick Williams Welch Age, 72 x. 7 M. 9 D.
Place and Date of Death,
died at
Winthrop Mass
December 1 3 90
3 190%.
Primary,
Brights disease
Duration,
9 euro
Disease or Cause
of Death, ;
Secondary,
Uraemia
Duration, Bex months
I certify that the above is true to the best of my knowledge and belief.
He. . Soule
M. D.
Signature and Residence S
of
Certifying Physician.
Winthrop Wines
Date of Certificate,
Dec 14h
190/ .
* Give also street and number, if any. | Give sex of infant not named. If still-born, so state.
# If a Soldier or Sailor in the War of the Rebellion, give both Primary and Secondary Cause.
Countersign and transmit to the clerk of the city or town.
.... .
Agent of Board of Health.
No. 62
RETURN OF THE DEATH
OF Orederek William Makh at Bartlett Road December 13 Date, 1901
Filed, December 14 190_/_
[EXTRACTS FROM CHAPTER 444, ACTS OF 1897.]
SECTION 6. Every honseholder in whose house a death occurs, the oldest person next of kin present at the time of the · death of any of his kindred, or the person in charge of an institution in which a death occurs, shall, within five days after the date of such a death, give notice thereof to the board of health or to the clerk of the city or town in which the death occurred.
SECTION 7. The commanding officer of a vessel shall give notice of the death of any person under his charge to the board of health or to the clerk of the city or town within the Commonwealth at which his vessel first arrives after such deatlı.
SECTION 8. Penalty for neglect to comply with the requirements of sections 6 and 7, five dollars.
SECTION 10. A physician who has attended a person during his last illness shall forthwith after the death of said person, upon request, furnish for registration a certificate setting forth the required facts.
SECTION 11. In case the deceased was a soldier who served in the war of the rebellion, give both the primary and the secondary or immediate cause of death as nearly as he can state the same. Penalty for refusal or neglect, ten dollars.
SECTION 12. Any person having charge of the funereal rites preliminary to the interment of a human body shall obtain the physician's certificate made in accordance with section 10, and return it, together with the facts required by section 1, to the board of health or to the clerk of the city or town in which the death occurred.
[EXTRACTS FROM CHAPTER 437, ACTS OF 1897.]
SECTION 1. No human body shall be buried in a city or town or removed therefrom, until a permit therefor shall have been received from the proper authorities. No such permit shall be issued until a written statement, as required by law, has been furnished, with a physician's certificate of the cause of death. When such statement and certificate are delivered to the Board of Health, the board or agent shall forthwith countersign and transmit the same to the clerk of the city or town for registration.
T: 1. . ... ... simlalinnenat avreodling fifty dollars.
FORM C.
Commonwealth of Massachusetts.
No.
RETURN OF A DEATH.
To the Clerk of the City or Town in which the death occurred.
(FILL OUT WITH INK. ALL NAMES TO BE IN FULL.)
Name,
Orany M. Johnson
Sex,
m Color,
Date of Death,
Dec 15th
190 /; Age, // Years,
4 Months,
17 Days.
Maiden Name, { If married, widowed ) or divorced.
Husband's Name,
Single, Married, Widowed or Divorced,
Occupation
*Residence, ¿ also state fully.
§ If out of town, {
151, Northrop St- Winthrop
Place of Birth, Minthato Mass
*Place of Death,
Name and Birthplace of Father,
Thomas It. Johnson 6, Boston
Maiden Name and Birthplace of Mother, Willette Richardson Brooklynd 2)
Place of Interment, (Give name of Cemetery),
Minitrop Cemetery
Signature and
Summer floyd
Dated at.
Dicenviar 161
190 /
on
place of business
of Undertaker.
MinttuolMais
PHYSICIAN'S CERTIFICATE.
Name and Age of Deceased, t
Place and Date of Death, died at.
Age, 1 1 x. 4 M. 7 D.
Dec 15 190/.
Disease or Cause
of Death, #
Secondary,
- Primary,
Vainula Heart Disease Duration,
3 years
Duration,
I certify that the above is true to the best of my knowledge and belief.
Signature and Residence of
S
(Winthrop .
Date of Certificate,
Dec. 17.
190/.
Quase :
· Give also street and number, if any. t Give sex of infant not named. If still-born, so state.
# If a Soldier or Sailor In the War of the Rebellion, give both Primary and Secondary Cause.
Countersign and transmit to the clerk of the city or town.
Agent of Board of Health.
O.SJohnson. M. D.
Certifying Physician.
No. 63
RETURN OF THE DEATH
OF
Harry Dr. Johnson 151 Winthrope Street at
e. December 15" 1901.
Filed, December 16 190 __.
[EXTRACTS FROM CHAPTER 444, ACTS OF 1897.]
SECTION 6. Every householder in whose house a death occurs, the oldest person next of kin present at the time of the death of any of his kindred, or the person in charge of an institution in which a death occurs, shall, within five days after the date of such a death, give notice thereof to the board of health or to the clerk of the city or town in which the death occurred.
SECTION 7. The commanding officer of a vessel shall give notice of the death of any person under his charge to the board of health or to the clerk of the city or town within the Commonwealth at which his vessel 'first arrives after such death. SECTION 8. Penalty for neglect to comply with the requirements of sections 6 and 7, five dollars.
SECTION 10. A physician who has attended a person during his last illness shall forthwith after the death of said person, upon request, furnish for registration a certificate setting forthi the required facts.
SECTION 11. In ease the deceased was a soldier who served in the war of the rebellion, give both the primary and the secondary or immediate cause of death as nearly as he can state the same. Penalty for refusal or neglect, ten dollars.
SECTION 12. Any person having charge of the funereal rites preliminary to the interment of a human body shall obtain the physician's certificate made in accordance with section 10, and return it, together with the facts required by section 1, to the board of health or to the elerk of the city or town in which the death occurred.
[EXTRACTS FROM CHAPTER 437, ACTS OF 1897.]
SECTION 1. No human body shall be buried in a city or town or removed therefrom, until a permit therefor- shall liave been received from the proper authorities. No such permit shall be issued until a written statement, as required by law, has been furnished, with a physician's certificate of the cause of death. When such statement and certificate are delivered to the Board of Health, the board or agent shall forthiwith countersigu and transmit the same to the clerk of the city or town for registration.
FORM C.
Commonwealth of Massachusetts.
No.
RETURN OF A DEATH.
To the Clerk of the City or Town in which the death occurred.
(FILL OUT WITH INK. ALL NAMES TO BE IN FULL.)
Name,
Harry Co. Stavle
Sex,
Color,
Date of Death,
December 26" 1901; Age, 38
Years,
2
Months,
~ Days.
Maiden Name, §
or divorced.
writer
Husband's Name,
Bertha F. Foule
Single, Married, Widowed or Dirorecd;
Occupation,
Bork-Keeper
*Residence, { If out of town, )
¿ also state fully.
15. Perkunne Street Wirtual
Place of Birth,
Beston Mars
*Place of Death,
15 Perking Street= Wintrap Mass
Name and Birthplace of Father, George Fonte-Shelley Mass
Maiden Name and Birthplace of Mother,
Susan M Joule
Place of Interment, (Give name of Cemetery),
Forest Oties Cemeley
Dated at.
Summerefloyd
on
December 26
190 /
Signature and
place of business
of Undertaker.
18 Herman @ Lises
PHYSICIAN'S CERTIFICATE.
Harry Go, Forte
Age, 38 8 2 MLD.
Place and Date of Death,
died at
15 Pestis Rx Dee 26"
190/.
Disease or Cause
of Death,#
Secondary,
Primary,
Photosis Pulmonar Putation,
2 yrs
Duration,
I certify that the above is true to the best of my knowledge and belief.
Signature and Residence S of Certifying Physician.
3: Mel cat
M. D.
Date of Certificate,
Quember 27
1900.
· Give also street and number, if any. t Give sex of infant not named. If still-born, so state.
{ If a Soldier or Sailor in the War of the Rebellion, give both Primary and Secondary Cause.
Countersign and transmit to the clerk of the city or town.
Nee 26
....
Agent of Board of Health.
Name and Age of Deceased, t
No. 64
RETURN OF THE DEATH
OF
Harry 6. Finde'
15 Perkins Street
at
Date, December 26" 1901.
Filed, ecemke 2 dy 1901.
(
[EXTRACTS FROM CHAPTER 444, ACTS OF 1897.]
SECTION 6. Every householder in whose house a death occurs, the oldest person next of kin present at the time of the death of any of his kindred, or the person in charge of an institution in which a death occurs, shall, within five days after the date of such a death, give notice thereof to the board of health or to the clerk of the city or town in which the death occurred.
SECTION 7. The commanding officer of a vessel shall give notice of the death of any person under his charge to the board of health or to the clerk of the city or town within the Commonwealth at which his vessel first arrives after such death.
SECTION 8. Penalty for neglect to comply with the requirements of sections 6 and 7, five dollars.
SECTION 10. A physician who has attended a person during his last illness shall forthwith after the death of said person, upon request, furnish for registration a certificate setting forthi the required facts.
SECTION 11. In case the deceased was a soldier who served in the war of the rebellion, give both the primary and the secondary or immediate cause of death as nearly as he can state the same. Penalty for refusal or neglect, ten dollars.
SECTION 12. Any person having charge of the funereal rites preliminary to the interment of a human body shall obtain the physician's certificate made in accordanec with section 10, and return it, together with the facts required by section 1, to the board of health or to the clerk of the city or town in which the death occurred.
[EXTRACTS FROM CHAPTER 437, ACTS OF 1897.]
SECTION 1. No human body shall be buried in a city or town or removed therefrom, until a permit therefor shall have been received from the proper authorities. No such permit shall be issued until a written statement, as required by law, has been furnished, with a physician's certificate of the cause of death. When such statement and certificate are delivered to the Board of Health, the board or agent shall forthwith countersign and transmit the same to the clerk of the city or town for registration.
Penalty for v for violation not exceeding fifty dollars.
FORM C.
Commonwealth of Massachusetts.
1902
No.
RETURN OF A DEATH.
To the Clerk of the City or Town in which the death occurred.
(FILL OUT WITH INK. ALL NAMES TO BE IN FULL.)
Name,
Edith J. M.Donald
Sex,
JemColor,
Fem Color, White
Date of Death, San. 12/ ud.
1902; Age, ... ... Years,
8 Months, 4 Days.
Maiden Name, { If married, widowed )
or divorced.
Single
Husband's Name,
Single, Married, Hidemed or Divorced, Occupation,
*Residence, { If out of town, )
¿ also state fully. 3
7 Marchall It.
Place of Birth, Winter of Mars.
*Place of Death,
Hunterofe, I Marshall It.
Name and Birthplace of Father, John Y. McDonald-Medford, Mass. Maiden Name and Birthplace of Mother, Many & Carry-Coalchester, Con
Place of Interment, (Give name of Cemetery)
Holy Cross el. - Malden.
Dated at.
Thitherofother.
Signature and
Franke J. Maloney
on
Und. day ISan. 19021
place of business of Undertaker.
PHYSICIAN'S CERTIFICATE.
Name and Age of Deccased, f Edith S.McDonald Age, - Y. 8 M. 4 D.
Place and Date of Death,
died at.
7 Marchall If.
Jan. 2nd. 1902.
Disease or Cause of Death, # Secondary,
Primary,
Dou de Primerica
Duration,
2Days
Duration,
I certify that the above is true to the best of my knowledge and belief.
Signature and Residence S of
C.SJohnson.
M. D.
Certifying Physician.
Date of Certificate, 2 190 2
* Give also street and number, if any. t Give sex of infant not named. If still born, so state.
{ If a Soldier or Sailor in the War of the Rebellion, give both Primary and Secondary Cause.
Countersign and transmit to the clerk of the city or town.
Agent of Board of Health.
No.
RETURN OF THE DEATH
OF
@dich & Mc Donald
2. Marshall Street at
.......
Date,
January 2 10/
Filed, January 3 190 ___
[EXTRACTS FROM CHAPTER 444, ACTS OF 1897.]
SECTION 6. Every householder in whose house a death occurs, the oldest person next of kin present at the time of the death of any of his kindred, or the person in charge of an institution in which a death occurs, shall, within five days after the date of such a death, give notice thereof to the board of health or to the clerk of the city or town in which the death occurred.
SECTION 7. The commanding officer of a vessel shall give notice of the death of any person under his charge to the board of health or to the clerk of the city or town within the Commonwealth at which his vessel first arrives after such death.
SECTION 8. Penalty for neglect to comply with the requirements of sections 6 and 7, five dollars.
SECTION 10. A physician who has attended a person during his last illness shall forthwith after the death of said person, upon request, furnish for registration a certificate setting forth the required facts. 1
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