USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1919-1921 > Part 51
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R-303
The Commonwealth of Massachusetts
MEDICAL EXAMINER'S CERTIFICATE OF DEATH
OFFICE OF THE SECRETARY DIVISION OF VITAL STATISTICS
Registered No. .......
No.
25 Looomet are
St.,
Ward
2 FULL NAME
Charles Para
(If in the Army or Navy of the United States, give rank, organization, etc.)
20- Sorryset are.
St.,
.Ward.
(If non-resident give city or town and State)
Length of residence io city or towo where death occorred
3
years
months
days
How long in U. S., if of foreign hirth?
years
months days
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
Left
20)
(Month)
(Day)
(Year)
17 I HEREBY CERTIFY that I have investigated the death of the person above-named and that the CAUSE AND MANNER thereof are as follows:
Peritonite Following rupture of
Ciccide st ally struck by a plande.
(Sce reverse sldc for description for unknown person)
18 Where was injury sustained
if not at place of death?
(Sigoed)
.. , M.D.
(Address).
Medical Examiner for
Left
1919
Date
(Month)
(Day)
( Year)
19 PLACE OF BURIAL, CREMATION, or REMOVAL
quethrop Cent
(Cemetery)
(City or town)
20 UNDERTAKER
M.C.Skaggs
DATE OF BURIAL
9-22
(Month) (Day) (Year)
ADDRESS
Withop
21 Burial permit issued by S. T. Manuel
Official position.
22 Date of / 6.291
issue ...
Permit No.
33
1 PLACE OF DEATH
County
Sulfora
City or Town
(a) Residence.
No.
(Usual placc of abode)
3 SEX
m
5a If married, widowed, or divorced
HUSBAND of
(or) WIFE of
6 DATE OF BIRTH .
( Month)
If STILLBORN, eoter that fact here
If STILLBORN, state period of uterogestatioo.
8 OCCUPATION OF DECEASED
(a) Trade, profession, or
particular kiod of work
Hampton
FATHER
12 MAIDEN NAME
OF MOTHER
PARENTS
(State or country)
Informant ..
(Address) 25 Som
should be carefully supplied. MEDICAL EXAMINERS should state CAUSE AND MANNER OF DEATH in plain terms,
for extracts from the laws relative to the return of certificates of death.
so that it may be properly classified under the International Classification of Causes of Death. See reverse side
(h) General nature of industry,
business, or establishment io
which employed (or employer)
(c) Name of employer
N. B. - WRITE PLAINLY, WITH UNFADING BLACK INK -THIS IS A PERMANENT RECORD. Every item of information
(Statc or country)
Cam.
25- (Day)
1854
(Year)
7 AGE
65 Tears
5
Months
25 Days
If LESS than
1 day, ...... hrs.
or ....... min.
.months
130+ Smaken
9 BIRTHPLACE (City)
(State or country)
team.
10 NAME OF
Charles para
11 BIRTHPLACE OF
FATHER (City)
Sherbrooke
Laplus
13 BIRTHPLACE OF
MOTHER (City)
montreal
14 Mr. Charles pacco
15 Scht 26,1919 Sitalie Churchill Filed (Month) (Day) (Year)
Quel REGISTRAR
(ISSUED UNDER THE PROVISIONS OF REVISED LAWS, CHAPTER 24)
State
(If death occurred in a hospital or institution, give its NAME instead of street and number)
PERSONAL AND STATISTICAL PARTICULARS
4 COLOR OR RACE
5 SINGLE, MARRIED, WIDOWED OR
DIVORCED (write the word)
married
191
EXTRACTS FROM THE LAWS OF THE COMMONWEALTH OF MASSACHUSETTS GOVERNING THE RETURN OF CERTIFICATES OF DEATH
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 stand- ard certificate of death, stating to the best of his knowledge and belief the name of the deccased, his supposed age, the disease of which he died [defined so that it can be classified under the international classification of causes of death], where contracted, the duration of his last illness, when last seen alive by the physician, and the date of his death. . . . - Revised Laws, Chap. 29, Secs. 10 and 1, as amended by Acts of 1910, Chap. 322.
No undertaker or other person shall bury a human body .
. until he has received a permit from the board of health or its agent, . . . or ... from the clerk of the city or town in which the person died; . no such permit shall be issued until there shall have been delivered to such board, agent or clerk, . . a satisfactory written state- ment containing the facts required by law to be re- turned and recorded, which . . . shall be accompanied by a satisfactory certificate of the attending physician, if any, as required by law, or in lieu thereof a certificate as herein- after 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, the chairman of the board of health, if a physician, or any physician employed by said board or by the selectmen for the purpose, shall upon application make such certificate as is required of the attending physician. If death is caused by violence, the medical examiner only shall make such certificate. ... The person to whom the permit is so given and the physician who certifies to 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. - Revised Laws, Chap. 78, Sec. 38.
Medical examiners shall, in all cases, certify to the city or town clerk or to the city registrar in the place where the deceased died, his name and residence, if known, otherwise
a descriptio, of such person, as full as may be, with the cause and manner of his death, and shalt make examination upon the view of thic dead bodies of only such persons as are sup- posed to have come to their death by violence. - Revised Laws, Chap. 24, Sec. 8.
RULES OF PRACTICE
The fulfilment of the purpose of these laws calls for the observance of the following 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 in- 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
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, homi- cidal." "Asphyxiation by suspension, suicidal." "Syn- cope while under the influence of ether administered as a surgical anæsthetic." "Fracture of the skull with associated internal injury sustained under circumstances unknown."
If investigation shows the death to have been due to dis- ease, specify: (1) 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 gangloid) (found dead in bed)." "Heart disease, presumably coronary sclerosis. (Sudden death.)"
DESCRIPTION (for unknown person)
NOTICE TO UNDERTAKERS : No embalming fluid, or any substitute therefor, shall be injected into the body of any person supposed to have come to his death by violence, until a permit in writing, signed by the Medical Examiner, has first been obtained. - Revised Laws, Chap. 24, Sec. 20.
THIS CERTIFICATE CONSTITUTES SUCH PERMIT
€
MR-303
The Commonwealth of Massachusetts
MEDICAL EXAMINER'S CERTIFICATE OF DEATH
OFFICE OF THE SECRETARY DIVISION OF VITAL STATISTICS
1 PLACE OF DEATH
(ISSUED UNDER THE I'ROVISIONS OF REVISED LAWS, CHAPTER 24)
County
Suffolk
State man
Registered No.
No. mescal Hospital
St., .......
. Ward
(If death occurred in a hospital or institution, give its NAME instead of street and number)
(a) Residence.
No ..
189
Shrily
St.
Ward.
(Usual place of abode)
Length of residence io city or towo where death occurred years
mooths
days
How long io U. S., if of foreigo hirth?
years
mooths
days
PERSONAL AND STATISTICAL PARTICULARS
4 COLOR OR RACE
White
5 SINGLE, MARRIED, WIDOWED OR
DIVORCED (write the word)
manuel
5a If married, widowed, or divorced
HUSBAND Jf
(or) WIFE of
ald. P. Mac Hadde
Nov 23 - 1872
(Day)
(Month)
(Year)
Years
Months
Days
If STILLBORN, enter that fact here
If STILLBORN, state period of uterogestatico ..
.mooths
t
8 OCCUPATION OF DECEASED
(a) Trade, professioo, or
particular kind of work.
House Wife
at Home
9 BIRTHPLACE (City)
(State or country)
John. Towers
11 BIRTHPLACE OF FATHER (City) (State or country)
Atalafax
12 MAIDEN NAME
OF MOTHER
Ellen Sullivan
13 BIRTHPLACE OF
MOTHER (City)
(State or country)
14 Donald- M. Mac tadde
(Address)
189 Those Pha. Wanda
15 Sept 23, 1919 Eulalie Churchill (Month) (Day) ( Year)
aist REGISTRAR
21 Burial permit issued by 1. A. Maury.
Official position ....
Health AV:
22 Date of Lept-23 C& c issue
Permit No ..
DATE OF BURIAL Jeff-24 .... (Month) (Day) (Year)
ADDRESS
20 UNDERTAKER C.R Ben.
1919
Date
Medical Examiner for .. 22
(Month)
(Day)
( Year)
19 PLACE OF BURIAL, CREMATION, or REMOVAL
(Cemetery) Withers (City of town)
21
16 DATE OF DEATH
(Monthy
(Day)
1919
(Year)
17 I HEREBY CERTIFY that I have investigated the death of the person above named and that the CAUSE AND MANNER thereof are as follows :
Multiple injuries including rupture d'adrenal gland
Auto accident
(See reverse side for description for unknown person)
18 Where was injury sustained
if not at place of death?
20 88 Weather
(Signed)
...
... , M.D.
(Address).
2 FULL NAME 3 SEX 6 DATE OF BIRTH 7 AGE (h) Geoeral nature of industry, (c) Name of employer 10 NAME OF FATHER PARENTS Informant should be carefully supplied. MEDICAL EXAMINERS should state CAUSE AND MANNER OF DEATH in plain terms, Filed N. B .- WRITE PLAINLY, WITH UNFADING BLACK INK-THIS IS A PERMANENT RECORD. Every item of information for extracts from the laws relative to the return of certificates of death. so that it may be properly classified under the International Classification of Causes of Death. See reverse side business, or establishment in which employed (or employer)
DO Winthro
City or Town
(If in the Army or Navy of the United States, give rank, organization, etc.)
( If non.resident give city or town and State)
MEDICAL CERTIFICATE OF DEATH
If LESS thao I day, ...... hrs. or ....... min.
EXTRACTS
FROM THE LAWS OF THE COMMONWEALTH OF MASSACHUSETTS GOVERNING THE RETURN OF CERTIFICATES OF DEATH
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 stand- ard 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 so that it can be classified under the international classification of causes of death], where contracted, the duration of his last illness, when last seen alive by the physician, and the date of his death. . . . - Revised Laws, Chap. 29, Secs. 10 and 1, as amended by Acts of 1910, Chap. 322.
No undertaker or other person shall bury a human body . until he has received a permit from the board of health or its agent, . . . or . . from the clerk of the city or town in which the person died; . no such permit shall be issued until there shall have been delivered to such board, agent or clerk, . . . a satisfactory written state- ment containing the facts required by law to be re- turned and recorded, which . . . shall be accompanied by a satisfactory certificate of the attending physician, if any, as required by law, or in lieu thereof a certificate as herein- after 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, the chairman of the board of health, if a physician, or any physician employed by said board or by the selectmen for the purpose, shall upon application make such certificate as is required of the attending physician. If death is caused by violence, the medical examiner only shall make such certificate. . .. The person to whom the permit is so given and the physician who certifies to 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 eause of the death, which the clerk or registrar may require. - Revised Laws, Chap. 78, Sec. 38.
Medical examiners shall, in all cases, certify to the city or town clerk or to the city registrar in the place where the deceased died, his name and residence, if known, otherwise
a descriptio, of such person, as full as may be, with the cause and manner of his death, and shall make examination upon the view of the dead bodies of only such persons as are sup- posed to have come to their death by violence. - Revised Laws, Chap. 24, Sec. 8.
RULES OF PRACTICE
The fulfilment of the purpose of these laws calls for the observance of the following 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 in- 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
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, homi- cidal." "Asphyxiation by suspension, suicidal." "Syn- cope while under the influence of ether administered as a surgical anæsthetic." "Fracture of the skull with associated internal injury sustained under circumstances unknown."
If investigation shows the death to have been due to dis- ease, specify: (1) 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 gangloid) (found dead in bed)." "Heart disease, presumably coronary sclerosis. (Sudden death.)"
DESCRIPTION (for unknown person)
Sept. 20 1919
NOTICE TO UNDERTAKERS : No embalming fluid, or any substitute therefor, shall be injected into the body of any person supposed to have come to his death by violence, until a permit in writing, signed by the Medical Examiner, has first been obtained. - Revised Laws, Chap. 24, Sec. 20.
THIS CERTIFICATE CONSTITUTES SUCH PERMIT
ORM R-303
The Commonwealth of Massachusetts
MEDICAL EXAMINER'S CERTIFICATE OF DEATH
OFFICE OF THE SECRETARY DIVISION OF VITAL STATISTICS
1 PLACE OF DEATH
(ISSUED UNDER THE PROVISIONS OF REVISED LAWS, CHAPTER 24)
State man
Registered No.
City or Town
00 Winthrop
No.
mosca Hostal at
St.,
Ward
(If death occurred in a hospital or institution, give its NAME instead of street and number)
2 FULL NAME
Fathersu mas fanden
(If in the Army or Navy of the United States, give rank, organization, etc.)
(a) Residence.
No.
1.89
thrity
St.
Ward.
( If non-resident give city or town and State)
(Usual place of abode)
Length of residence in city or town where death occurred
11 years
months
days
How long in U. S., if of foreign birth?
years
months
days
PERSONAL AND STATISTICAL PARTICULARS
4 COLOR OR RACE
White
5 SINGLE, MARRIED, WIDOWED OR
DIVORCED (write the word)
manuel
5a If married, widowed, or divorced
HUSBAND Of
(or) WIFE of
Donald Y. Mac Hadde
nov 23-1872
( Month)
(Day)
7 AGE
«>
Years
Months
Days
If LESS than
1 day, ...... brs.
or ....... min.
months
t
8 OCCUPATION OF DECEASED
(a) Trade, profession, or
particular kind of work
House Wife
(b) General nature of industry,
business, or establishment in
which employed ( or employer)
at Home
9 BIRTHPLACE (City).
(State or country)
man
Totur. Towers
11 BIRTHPLACE OF FATHER (City) (State or country)
Halafax
U.S.
12 MAIDEN NAME
OF MOTHER
Ellen Sullivan
13 BIRTHPLACE OF MOTHER (City) (State or country)
Vreeland
14 Donald. M. Mac tadde
(Address)
289
15 Sept. 23, 1919 Eulalie Churchill Filed (Month) (Day) ( Year) aist REGISTRAR
20 UNDERTAKER
ADDRESS
21 Burial permit issued by 1. L. Maury. Official position ..
Health ML;
22 Date of
Lept-23
Permit No ...
.. , M.D.
(Address)
Medical Examiner for ..
22
1919
Date
(Month)
(Day)
( Year)
19 PLACE OF BURIAL, CREMATION, or REMOVAL
(Cemetery) Withers (City or town)
21
(Day)
1919
(Year)
17 I HEREBY CERTIFY that I have investigated the death of the person above-named and that the CAUSE AND MANNER thereof are as follows :
(Year) 2 Multiple injuries including rupture of adrenal gland
Auto accident
(See reverse side for description for unknown person)
18 Where was injury sustained
if not at place of death?
(Signed) ...
DATE OF BURIAL
Left-24
(Month) (Day) (Year)
-10- 13. 20,000.
3 SEX 10 NAME OF FATHER PARENTS Informant for extracts from the laws relative to the return of certificates of death. so that it may be properly classified under the International Classification of Causes of Death. See reverse side should be carefully supplied. MEDICAL EXAMINERS should state CAUSE AND MANNER OF DEATH in plain terms, N. B .- WRITE PLAINLY, WITH UNFADING BLACK INK-THIS IS A PERMANENT RECORD. Every item of information (c) Name of employer
MARGIN RESERVED FOR BINDING
6 DATE OF BIRTH
If STILLBORN, enter that fact bere
If STILLBORN, state period of uterogestation ..
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH ..
(Monthy
County
Suffolk
EXTRACTS FROM THE LAWS OF THE COMMONWEALTH OF MASSACHUSETTS GOVERNING THE RETURN OF CERTIFICATES OF DEATH
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 stand- ard 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 so that it can be classified under the international classification of causes of death], where contracted, the duration of his last illness, when last scen alive by the physician, and the date of his death. . . . - Revised Laws, Chap. 29, Secs. 10 and 1, as amended by Acts of 1910, Chap. 322.
No undertaker or other person shall bury a human body . . until he has received a permit from the board of health or its agent, . . . or . . . from the clerk of the city or town in which the person died; . no such permit shall be issued until there shall have been delivered to such board, agent or clerk, . a satisfactory written state- ment containing the facts required by law to be re- turned and recorded, which . . . shall be accompanied by a satisfactory certificate of the attending physician, if any, as required by law, or in lieu thereof a certificate as herein- after 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, the chairman of the board of health, if a physician, or any physician employed by said board or by the selectmen for the purpose, shall upon application make such certificate as is required of the attending physician. If death is caused by violence, the medical examiner only shall make such certificate. ... The person to whom the permit is so given and the physician who certifies to 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. - Revised Laws, Chap. 78, Sec. 38.
Medical examiners shall, in all cases, certify to the city or town clerk or to the city registrar in the place where the deceased died, his name and residence, if known, otherwise
a descriptio, of such person, as full as may be, with the cause and manner of his death, and shall inake examination upon the view of the dead bodies of only such persons as are sup- posed to have come to their death by violence. - Revised Laws, Chap. 24, Sec. 8.
RULES OF PRACTICE
The fulfilment of the purpose of these laws calls for the observance of the following 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 in- 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
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, homi- cidal." "Asphyxiation by suspension, suicidal." "Syn- cope while under the influence of ether administered as a surgical anæsthetic." "Fracture of the skull with associated internal injury sustaincd under circumstances unknown."
If investigation shows the death to have been due to dis- ease, specify: (1) 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 gangloid) (found dead in bed)." "Heart disease, presumably coronary sclerosis. (Sudden death.)"
DESCRIPTION (for unknown person)
NOTICE TO UNDERTAKERS : No embalming fluid, or any substitute therefor, shall be injected into the body of any person supposed to have come to his death by violence, until a permit in writing, signed by the Medical Examiner, has first been obtained. - Revised Laws, Chap. 24, Sec. 20.
THIS CERTIFICATE CONSTITUTES SUCH PERMIT
M R-301
The Commonwealth of Massachusetts STANDARD CERTIFICATE OF DEATH
OFFICE OF THE SECRETARY DIVISION OF VITAL STATISTICS
1 PLACE OF DEATH
County .........
Suffered
City or Town
Wilbert
No ...
State.
Registered No.
St ..
Ward
(If death occurred in a hospital or institution, give its NAME instead of street and number)
2 FULL NAME Ealcune; Towers Mas Tradden
(If in the Army or Navy of the United States, give rank, organization, etc.)
(a) Residence.
No.
189 thely
( Usual place of abode)
Length of residence in city or town where death occorred
"
years
months
days.
How long in U. S., if of foreign birth ?
years
months days
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH.
(Month)
(Day)
-
(Year)
17 I HEREBY CERTIFY, That I attended deceased from
, 19
... , to ..
,19
that I last saw h
alive on
, 19
-
and that death occurred, on the date stated above, at
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