USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1900-1903 > Part 25
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l Days. 14
Divorced. Widow of.
[5.'02-37-XXM.]
Permit No.
RETURN OF DEATH. BOSTON.
190 2
Year, 1829
Years, 73
-- Day,
. Age< Months, Valencia, Days, ... .
Name in full, Mary O'Connor, Residence, 28 Baudoin et Maiden name, Mary Kelly.
Single
Male.
Sex Conjugal condition
Married. Widowed.
Color
White. Black (Negro or mixed). Indian. Chinese. Japanese.
Wife of.
Widow of ...
128 Bourdain RT W sulteron
Place of birth,
Occupation,
Maiden Name of Mother, Margaret Gleason
Name of Father,
Birthplace of Father, Ireland Birthplace of Mother, Fredand
Place of interment, St. Pauli Country arlington
Thos, J. Diane.
Undertaker.
PHYSICIAN'S CERTIFICATE OF THE CAUSE OF DEATH.
For 2 - 190 2
Name and age of deceased,
Boston, Maus Donner 2 Age,. 13 years.
Date and place of death,* 28 Bowdown So Mutrap Por. 1, 1902 Tomic Someletis - Chief cause,
Disease
Contributing cause,
Chief cause Onlypar Patent (deceased) once
Duration
Contributing cause Ley (6 ) marks ag
I certify that the above is true, to the best of my knowledge and belief.
Name and residence of physician,
Oflaw Amentul
M.D.
* If in an institution, state how long an inmate and previous residence.
Ohr Endocarditis
Tha offica of tha Board of Health will ba open for the granting of permits for burial, as follows : - Saturdays, 9 A. M. till I P.M., excapt during the months of Juna, July, August and September, when the offica will be ciosad 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.
i
Divorced.
Denn's
Place of death Street,
Number, Ireland
Female.
Date of death Year, Month, nav, Birth - Month Unknown Day, ..
FORM C.
Commonwealth of Massachusetts.
2200 16
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.)
Date of Death, Novenite (FILL
16 190 2
Full Name of Deceased, many of Reading
Maiden Name, May & Sichatt
¿ = = married of divorceal
woman or a widow give also
r
Name of Husband,
John Reating
Sex,
Color,
Single, Married, Widowed or Divorced,
Age, 0 Years,
Months,
Days.
Occupation,
* Residence ( If out of town, { ( also state fully. S
Place of Death,
Minitrope mass
Place of Birth, Ireland
Name and Birthplace of Father,
Ireland:
Maiden Name and Birthplace of Mother, Catherine Keenan Ireland
Place of Burial (Give name of Cemetery)
OHoly Cross Cemetery
Summer Floyd
Dated at
Signature and
Mircunha 4/6 11 1902
place of business
on
of Undertaker.
180termas Sheet
PHYSICIAN'S CERTIFICATE.
Name and Age of Deceased, t
Mary J. reating
Age,.
JOIN MIND.
Place and Date of Death,
died at
Winthrop (November 16" 1902
Cancer of Stomach
Duration,
2400
Duration,
I certify that the above is true to the best of my knowledge and belief.
Signature and Residence S
of
(3) Metcalf
1
M. D.
Certifying Physician.
2
Date of Certificate,
November 17
190 2.
* Give also street and number, if any. f 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 Immediate Cause.
Countersign and transmit to the clerk of the city or town.
Agent of Board of Health.
-
Primary,
Disease or Cause
of Death, }
Immediate,
Main Street
No.
RETURN OF THE DEATH
OF Mary J. Keating ........... Winthrop mass at Warculler 16 1902. Date,-
Filed, .... November 17
[EXTRACTS FROM CHAPTER 29, REVISED LAWS. ]
SECTION 6. Every householder in whose house a death ocenrs and the oldest next of kin of a deceased person in the city or town in which the death occurs, shall, within five days thereafter, canse notice thereof to be given to the board of health or to the town clerk.
SECTION 7. The commanding officer of a vessel shall give notice of the death of any person nnder his charge to the board of health or to the elerk 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 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 certificate setting forth the required faets.
SECTION 11. If the deceased was a soldier or sailor who served in the war of the rebellion, give both the primary and the secondary or immediate canse of death as nearly as he can state the same. Penalty for refusal or negleet, ten dollars.
SECTION 12. Every undertaker or other person who has charge of a funeral, shall forthwith obtain the physician's cer- tificate required by section 10, enter thereon the facts required by section 1, and return it to the board of health or to the clerk of the city or town in which the death occurred. The person making snch return shall receive from the city or town a fee of twenty-five cents.
[EXTRACTS FROM CHAPTER 78, REVISED LAWS. ]
SECTION 38. No undertaker or other person shall bury a human body in a city, or town or remove therefrom a human body which has not been buried, until a permit from the board of health or its agent has been received. No such permit shull be issued until there shall have been delivered to such board a written statement, containing the facts required by law, with a physician's i's certificate of the cause of death. The Board of Health or agent, upon receipt of such statement and certificate, shall forth-
4
7 :..
FORM C.
Commonwealth of Massachusetts.
Two 24
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.)
Date of Death, November 24"
190.2.
Full Name of Deceased, ackland D, Gardiner
Maiden Name,
If a married woman or a widow give also
or divorced
Name of Husband,
Sex, Color,
Single, Married, Widowed or Divorced, Hidone
Age, / Years, 6 Months, 12 Days. Occupation, Electrician * Residence houten Park ( Dirittop Mask { If out of town, { ( also state fully. ) Thorsten Park Dintuof Mars Place of Death,
Place of Birth,
Otisco (new your,
Name and Birthplace of Father, James Q, Gardiner Lafayette NY,
Maiden Name and Birthplace of Mother, Lovisa M. Dowd Otisco WY
Place of Burial (Give name of Cemetery) Oakwood Cemetery Syracuse Wy,
Dated at
Summer Floyd
on
november 2.5
190 2
Signature and place of business of Undertaker. 18 Ofermon Stret
PHYSICIAN'S CERTIFICATE.
Name and Age of Deceased, t ackland D. Gardiner Age, 51 x. 6 M. 12D. died at & thouten Park Nov 24 190 2
Place and Date of Death,
Disease or Cause - Primary,
Chrome Brights de1 26
Duration,
2420
Duration,
-
of Death, #
Immediate,
I certify that the above is true to the best of my knowledge and belief.
Signature and Residence of Certifying Physician.
Ş
M. D.
Date of Certificate, 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 Immediate Cause.
Countersign and transmit to the clerk of the city or town.
No.
RETURN OF THE DEATH
OF Ockland D, Jardines at .... y Thontar Park
Date,- Doncneler 24" 1902
Filed, November 2.5 1902
[EXTRACTS FROM CHAPTER 29, REVISED LAWS. ]
SECTION 6. Every householder in whose house a death occurs and the oldest next of kin of a deceased person in the city or town in which the death occurs, shall, within five days thereafter, cause notice thereof to be given to the board of health or to the town clerk.
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 shall forthwith after the death of a person whom he has attended during his last illness, at the request of an undertaker or other anthorized person or of any member of the family of the deceased, furnish for registration a certificate setting forth the required facts.
SECTION 11. If the deceased was a soldier or sailor 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. Every undertaker or other person who has charge of a funeral, shall forthwith obtain the physician's cer- tificate required by section 10, enter thereon the facts required by section 1, and return it to the board of health or to the clerk of the city or town in which the death occurred. The person making such return shall receive from the city or town a fee of twenty-five cents.
[EXTRACTS FROM CHAPTER 78, REVISED LAWS. ]
SECTION 38. No undertaker or other person shall bury a human body in a city, or town or remove therefrom a human body which has not been buried, until a permit from the board of health or its agent has been received. No such permit shall be issued until there shall have been delivered to such board a written statement, containing the facts required by law, with a physician's certificate of the cause of death. The Board of Health or agent, upon receipt of such statement and certificate, shall forth-
FORM C.
27 25
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.)
Date of Death,. november 25
Full Name of Deceased, marjorie terings Need
Maiden Name,
¿ T = married or divorcea woman or a widow give also Name of Husband, ,
Sex, Color, 24 Single, Married, Widowed or Divorced,
Age, Years, Months, 3 Days. Occupation,
* Residence { If out of town, } 84 Pauline Street Winthrop Mas { also state fully. §
Place of Death, 84 Pauline Street Winthrop Suass
Place of Birth, Winthrop Mass
Name and Birthplace of Father, Herbert & a Reed Porthuy
Maiden Name and Birthplace of Mother, Edith a. Jennings = Chelsea
Place of Burial (Give name of Cemetery) Winthrop Cemeley
Dated at. It interop
Summer Floyd
on
November 25℃
190 2
Signature and place of business of Undertaker. 18 Herman Street
PHYSICIAN'S, CERTIFICATE.
Name and Age of Deceased, t Marjorie Jennings Read
Age, Y. LM
3
D.
Place and Date of Death,
died at.
Winthrop Paulicell Nor 2,5
190 2
Primary,
Duration,
Disease or Cause of Death, # Immediate, Congenital hydro epi
Duration,
3 days
I certify that the above is true to the best of my knowledge and belief.
Signature and Residence of Certifying Physician.
M. D.
Date of Certificate, June att 1903.
* 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 Immediate Cause.
Countersign and transmit to the clerk of the city or town.
Agent of Board of Health.
1
No.
RETURN OF THE DEATH
OF Wayang Derings Feed at
Date,- November 2
190 2
Filed, ....
Meneer 25 1902
[EXTRACTS FROM CHAPTER 29, REVISED LAWS. ]
SECTION 6. Every householder in whose house a death occurs and the oldest next of kin of a deceased person in the eity or town in which the death occurs, shall, within five days thereafter, eause notice thereof to be given to the board of health or to the town elerk.
SECTION 7. The commanding officer of a vessel shall give notice of the death of ary 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 negleet to comply with the requirements of sections 6 and 7, five dollars.
SECTION 10. A physician 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 certificate setting forth the required faets.
SECTION 11. If the deceased was a soldier or sailor who served in the war of the rebellion, give both the primary and the secondary or immediate cause of deathi as nearly as he ean state the same. Penalty for refusal or negleet, ten dollars.
SECTION 12. Every undertaker or other person who has charge of a funeral, shall forthwith obtain the physician's cer- tifieate required by seetion 10, enter thereon the facts required by seetion 1, and return it to the board of health or to the clerk of the eity or town in which the death occurred. The person making sneh return shall receive from the city or town a fee of twenty-five eents.
[EXTRACTS FROM CHAPTER 78, REVISED LAWS. ]
SECTION 38. No undertaker or other person shall bury a human body in a eity, or town or remove therefrom a human body which has not been buried, until a permit from the board of health or its agent has been received. No such permit shall be issued until there shall have been delivered to such board a written statement, containing the facts required by law. with a
use of death. The Board of Health or agent, upon receipt of such statement and certificate, shall forth-
orliticut rute ofthe cuuy
Deal
[11.'02.37.1M.]
Permit No.
RETURN OF DEATH. BOSTON, MASS.
Date of Death, ..
Jec 1" 1902
Name in full, Theobald 71. 711 Gowan
(If a married or divorced woman give maiden name, also name of husband.)
Sex,.
Color,
av
Condition, Married
White, Black, Mixed, Chinese, (Single, Married, Widowed or Divorced.)
Age. 48 Years, A Months, ~Days. Occupation,
Indian, etc.) Grocer
Residence, 39 Illain It Willnot
Hard,
Place of Death,
Place of Birth,
Date of Birth, Feb. 17-1854
Name and Birthplace of Father,
William R. 711 Gaman
Teland
Maiden Name and 1 Quary U. Dermody.
Birthplace of Mother, ) "Holy Cross" halle
Place of Interment,
Undertaker.
PHYSICIAN'S CERTIFICATE OF THE CAUSE OF DEATH.
Boston, Dee 32 190 .... 3.
Name and Age Theobald & M'SPro
Age, 48 years.
of Deceased,
Date and Lee1 1902 34 Mario V1 1till
Place of Death,*
Valorcar deixea x of hard
Disease
Contributing cause, Ordena of Lice To
Chief cause,
Duration
Contributing cause,.
6 cours
I certify that the above is true to the best of my knowledge and belief.
Name and Residence } Chf Francegen M.D.
of Physician,
* If an institution, state how long an inmate and previous residence. 408 Vendia
Chief cause, .
(State year, month and day.)
Dec .3
RETURN OF DEATH.
CHELSEA.
Date of Death Year, Month, alec. Birth Month, af.
Year, 1848 Age, Months, 6
Years, 54
Day, 3
Day, Blaisdell
2/wach.com.
Maiden Name, Smith Residence,. Chelsea muss. White. Male. Color Sex Black (Negro or mixed). Indian, Chinese. Female. Conjugal condition Japanese.
Wife of Grange R.
Place of death 3 Number,
Street, 3.6 2 cvis Cer.
Place of birth, sudhir
Occupation,
Name of Father,
Maiden Name of Mother, Olive Image
Birthplace of Father, Sudbury
Birthplace of Mother Sudbury.
Cem.
Place of interment, le. de Chanel Undertaker.
PHYSICIAN'S CERTIFICATE OF THE CAUSE OF DEATH.
20 m Thuh Chelsea,
1902. Name and age of deceased, ab elena &. Blais dell Age, 54 years. Date and place of death,* alle, 3ª 1902 Winthrop
Disease* 1 Chief cause, Lancer
Contributing cause,
Chief cause, Probably Several years
Duration, Contributing cause,
I certify that the above is true, to the best of my knowledge and belief.
Name and residence of physician, M. D.
*If in an institution, state how long an inmate and previous residence.
#If a Soldier or Sailor in the War of the Rebellion, give both Chief and Contributing Cause.
The office of the Board of Health will be open for the granting of permits for burial, as follows :- Saturdays, 8 A.M. till 1 P.M .; Sun- days and Holldays, from 10 to 11 A.M .; other days, from 8 A.M. till 4 P.M.
-
Days, 28
Name in full, Helena 6.
Single. Married. Widowed. Divorced. Widow of
FORM C.
Commonwealth of Classachusetts.
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.)
Date of Death, .. December 11 " 1902
Full Name of Deceased, Lillian Louise Sheer
Maiden Name, ...
If a married or divorced woman or a widow give also Name of Husband,
Sex, F Color, Single, Married, Widowed or Divorced,.
Age, 2 Years, 8 Months, 25 Days. Occupation,
* Residence ( If out of town, } { also state fully. S .
* Fremont Street Winthrop
Place of Death, Winthrop Mass
Place of Birth,
Name and Birthplace of Father, Patrick Sheerin = CAusland
Maiden Name and Birthplace of Mother, Susan Shee Key-veland
Place of Burial (Give name of Cemetery), ..... Otoly Ons Coudey (Walden)
Dated at
Decenta /
190 2
Signature and place of business of Undertaker.
Huittrop Mass
PHYSICIAN'S CERTIFICATE.
Name and Age of Deceased, t Lillian Louise Sheerin
Age, 2 x. 8 M 25 D.
Place and Date of Death,
died at
Winthrop( Fremunt RI- Dec 11 " 1902
Disease or Cause of Death, # Immediate,
Primary,
Pneumonia .
Duration,
3 mis
Meningitis cute
Duration,
24 hrs
I certify that the above is true to the best of my knowledge and belief.
signature and Residence S of Certifying Physiclan. 1 Date of Certificate,
Bismilcall
M. D.
190 2.
* 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 Immediate Cause.
Countersign and transmit to the clerk of the city or town.
Agent of Board of Health.
11
Die 11
No.
RETURN OF THE DEATH
OF
Lillian Louise Sheuns at
Date, December !!
.190 2_
Filed, 190 2
[EXTRACTS FROM CHAPTER 29, REVISED LAWS. ]
SECTION 6. Every householder in whose honse a death occurs and the oldest next of kin of a deceased person in the city or town in which the death occurs, shall, within five days thereafter, canse notice thereof to be given to the board of health or to the town clerk.
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 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 certificate setting forth the required facts.
SECTION 11. If the deceased was a soldier or sailor who served in the war of the rebellion, give both the primary and the secondary or immediate canse of death as nearly as he can state the same. Penalty for refnsal or neglect, ten dollars.
SECTION 12. Every undertaker or other person who has charge of a funeral, shall forthwith obtain the physician's cer- tificate required by section 10, enter thereon the facts required by section 1, and return it to the board of health or to the clerk of the eity or town in which the death occurred. The person making such return shall receive from the city or town a fee of twenty-five cents.
[EXTRACTS FROM CHAPTER 78, REVISED LAWS.]
SECTION 38. No undertaker or other person shall bnry a human body in a city, or town or remove therefrom a hnman body which has not been buried, nutil a permit from the board of health or its agent has been received. No such permit shall be issued until there shall have been delivered to such board a written statement, containing the facts required by law, with a physician's certificate of the cause of death. The Board of Health or agent, upon receipt of such statement and certificate, shall forth- with countersign and transmit it to the elerk of the city or town for registration. Penalty for violation not exceeding fifty dollars.
Dec 15
[11-'02.37-1M.]
Permit No.
RETURN OF DEATH. BOSTON, MASS.
Date of Death, Dec. 15- 190%
Name in full, 1. MateriellCall
(If a married or divorced woman give maiden name, also name of husband. )
Sex,.
Color, While ( White, Black, Mixed, Chinese, (Single, Married, Widowed or Divorced.)
Indian, etc.)
Age, Months, .. 19 Years, 19 Days. Occupation,
Ward, Winthrop.
Place of Death, May Cont, Monthsof (State year, month and day.) Place of Birth, Gast Baston Date of Birth, Jefx 26, 1883 Name and Birthplace Edward P. Maine of Father,
Maiden Name and Julia . Donovan Eng Canal
Birthplace of Mother, )
Place of Interment,. Holy Cross Maliten Pho. 4. Kane Undertaker.
PHYSICIAN'S CERTIFICATE OF THE CAUSE OF DEATH.
Slimtrop Dec 15
Name and Age
of Deceased, Frederick D Call Age, / 9 years.
Date and 11 Taylor ST
Place of Death,* ) Chief cause,. Pulmonary ? uberculosis
Disease < Contributing causer, Chief cause, 2. 40 1
Duration Contributing cause,
I certify that the above is true to the best of my knowledge and belief.
Name and Residence ? of Physician, Bis Metcalf M.D.
* If an institution, state how long an inmate and previous residence.
21
1902
Residence, playcaret
Condition, efendte
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.)
Date of Death, Die 16 "
1902.
Full Name of Deceased, James Bacon.
Maiden Name, ...
If a married or divorced woman or a widow give also ( Name of Husband,
Sex, Mal Color, Mule Single, Married, Widowed or Divorced, 21
Age, 1/4 Years, 8 Months, / 8 Days. Occupation, Pativad
* Residence { If out of town, { ? also state fully. ! 124 Henttrop Shout Here trop Mais
Place of Death,
Place of Birth,
Charlestera
Julian to - Am. Namichin
Name and Birthplace of Father, Janne Bacon, Dudley Mars
Maiden Name and Birthplace of Mother, Federa Goyer- Charlestes Ir H
Place of Burial (Give name of Cemetery)
....
Signature and
Summerfloyd
Dated at ..
December 16"
190 2
place of business
of Undertaker.
Stintinote Mass
on
PHYSICIAN'S CERTIFICATE.
Name and Age of Deceased, t
James Bacon
Age, 748. 8 M /8D.
Place and Date of Death,
died at
Hvidtund December/6
190 2
-
Primary,
Cancer of Bowels
Duration,
8 mas
Disease or Cause of Death, ¿ Immediate,
Lancer of Bowels
Duration,
8 mas
I certify that the above is true to the best of my knowledge and belief.
Signature and Residence of Certifying Physician.
Thuisterat M. D.
Date of Certificate, December 17 190.2.
* 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 Immediate Cause.
Countersign and transmit to the clerk of the city or town.
Agent of Board of Health.
No.
RETURN OF THE DEATH
Same Bacon OF
...
Winthrop Mase at ....
Date, ..
e December 16" 1902
Filed, . December 17 "
.190 2.
[EXTRACTS FROM CHAPTER 29, REVISED LAWS. ]
SECTION 6. Every householder in whose house a death occurs and the oldest next of kin of a deceased person in the city or town in which the death occurs, shall, within five days thereafter, cause notice thereof to be given to the board of health or to the town clerk.
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 shall forthwith after the death of a person whom he has attended during his last illness, at the request of an undertaker or other anthorized person or of any member of the family of the deceased, furnish for registration a certificate setting forth the required facts.
SECTION 11. If the deceased was a soldier or sailor who served in the war of the rebellion, give both the primary and the secondary or immediate canse of death as nearly as he can state the same. Penalty for refusal or neglect, ten dollars.
SECTION 12. Every undertaker or other person who has charge of a funeral, shall forthwith obtain the physician's cer- tificate required by section 10, enter thereon the facts required by section 1, and return it to the board of health or to the clerk of the city or town in which the death occurred. "The person making such return shall receive from the city or town a fee of twenty-five cents.
[EXTRACTS FROM CHAPTER 78, REVISED LAWS. ]
SECTION 38. No undertaker or other person shall bury a human body in a city, or town or remove therefrom a human body which has not been buried, until a permit from the board of health or its agent has been received. No such permit shall be issued until there shall have been delivered to such board a written statement, containing the facts required by law, with a physician's certificate of the cause of death. The Board of Health or agent, upon receipt of such statement and certificate, shall forth- ales oud transmit it to the clerk of the city or town for registration. Penalty for violation not exceeding fifty dollars.
FORM C.
Commonwealth of Classachusetts.
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.)
Date of Death, December 18" 190 2.
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