USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1928-1930 > Part 157
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9 Industry or business in which
work was done, as silk mill,
saw mill, bank, etc .....
AGENT
INSURANCE CO.
10 Date deceased last worked at
this occupation
year) .
APRIL 1929
11 Total time (years)
spent in this
occupation
50
12 BIRTHPLACE (City)
(State or country)
NEW YORK
13 NAME OF
FATHER
CANNOT BE LEARNED
PARENTS
14 BIRTHPLACE OF
FATHER (City)
(State or country)
15 MAIDEN NAME
OF MOTHER
16 BIRTHPLACE OF
MOTHER (City)
(State or country)
MRS. . PETER GAFFNEY
esifx WAR)
(If nonresident, give city or town and state)
apr. 9. 1930.
1
1
$02
Suffolks
The Commonwealth of Massachusetts OFFICE OF THE SECRETARY DIVISION OF VITAL STATISTICS STANDARD CERTIFICATE OF DEATH
(City or town making return)
Registered No.
3362 68
5 (If death occurred in a hospital or institution, give its NAME instead of street and number)
2 FULL NAME
ROSE P. PHIPPS
(If deceased is a married, widowed or divorced woman, give also maiden name.)
(a)
Residence. No
304 PLEASANT
St.,
Ward,
(Usual place of abode)
Length of residence in city or town where death occurred
yrs.
mos.
days.
How long in U. S., if of foreign birth?
yrs.
mos.
days.
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
F.
4 COLOR OR RACE
5 SINGLE
MARRIED
WIDOWED
or DIVORCED
(write the word)
DIVORCED
5a If married, widowed, or divorced
HUSBAND of
(or) WIFE of
HARRY S.
majelen name of wife in full)
(Husband's name in full)
6 IF STILLBORN, enter that fact here.
7 AGE 50 Years .7 Months.
6 Days
If less than 1 day
.. Hours.
.Minutes
OCCUPATION!
8 Trade, profession, or particular kind of work done, as spinner, sawyer, bookkeeper, etc.
JEWELRY CLERK
9 Industry or business in which work was done, as silk mill, saw mill, bank, etc.
10 Date deceased last worked at
this occupation (month and
year)
11 Total time (years)
spent in this
FEB 1.
1930upation.
6
BOSTON
12 BIRTHPLACE (City)
(State or country)
MASS.
13 NAME OF
FATHER
JAMES T. KNOWLES
14 BIRTHPLACE OF
FATHER (City)
CENTER HARBOR
(State or country) N. H.
15 MAIDEN NAME
OF MOTHER
ELIZABETH DOHERTY
16 BIRTHPLACE OF
MOTHER (City)
HUNTER POINT
(State or country)
N Y.
17
MARION
(Address)
304 PLEASANT
n PHIPPS ST. WINTHROP
I HEREBY CERTIFY that a satisfactory standard certificate of death was
filed with me BEFORE the burial or transit permit was issued:
A ...... E ..... CRAMP.TON
(Signature of Agent of Board of Health or other)
APRIL 10, 1930
(Date of Issue of Permit)
MEDICAL CERTIFICATE OF DEATH
18 DATE OF
DEATH
APRIL 10. 1930
(Month)
(Day)
(Year)
3.0
19 I HEREBY CERTIFY, That I attended deceased from
APRIL 5
30
APRIL 10
19
I last saw h.
ER alive on
APRIL 10, 1930
death is said
to have occurred on the date stated above, at
3 A
m.
The principal cause of death and related causes of importance in order of
onset were as follows:
ACUTE YELLOW ATROPHY
3. MTAlsfonset
Contributory causes of importance not related to principal cause:
CHRONIC ... NEPHRITIS
ASCITES.
3 MTHS ..
Name of operation
CHOLECYSTECTOMY
Date of2-7-20
What test confirmed diagnosis? Was there an autopsy? YES
20 Was disease or injury in any way related to occupation of deceased? If so, specify.
(Signed)
H. FRANKLIN WOOD
MD
(Address)
Date
4-10 19 .30
21 PLACE OF BURIAL,
CREMATION OR REMOVAL .
WINTHROP
.WINTHROP
(Cemetery)
(City or town)
DATE OF BURIAL
APRIL 13, 1930
19
22 NAME OF
UNDERTAKER
C ...... R. .... BENNISON
ADDRESS
Received and filed
APRIL 12, 1930
19
A TRUE COPY, ATTEST:
apr.16.19
(Registrar)
1
PLACE OF DEATH
(County)
(City or Town)
No MASS. GEN HOSPITAL
St.,
Ward {
(If U. S.
War Veteran,
specify WAR)
WINTHROP
MASS.
(If nonresident, give city or town and state)
PARENTS
Important. 50M-11-'29. No. 7180-b
(Official Designation)
apr. 10. 1930
302
Suffolk
PLACE OF DEATH
(County)
Boston
(City or Town)
The Commonwealth of Massachusetts OFFICE OF THE SECRETARY DIVISION OF VITAL STATISTICS STANDARD CERTIFICATE OF DEATH
(City or town making return)
Registered No 3374 60
(If death occurred in a hospital or institution,
give its NAME instead of street and number)
2 FULL NAME
(If deceased is a married, widowed or divorced woman, give also maiden name.)
WINTHROP, MASS.
& WAR
(a)
Residence. No
(Usual place of abode)
7 LOCUST
St.,
Ward,
(If nonresident, give city or town and state)
Length of residence in city or town where death occurred
yrs.
mos.
days. How long in U. S., if of foreign birth?
yrs.
mos. days.
PERSONAL AND STATISTICAL PARTICULARS
3 SEX F.
4 COLOR OR RACE
5 SINGLE
MARRIED
WIDOWED
or DIVORCED
(write the word)
MARRIED
5a If married, widowed, or divorced
HUSBAND of
(or) WIFE of
DOMENTC
me of wife in full)
(Husband's name in full)
6 IF STILLBORN, enter that fact here.
7 AGE 43 Years Months Days
If less than 1 day
Hours
Minutes
OCCUPATION
8 Trade, profession, or particular kind of work done, as spinner, sawyer, bookkeeper, etc.
AT HOME
9 Industry or business in which work was done, as silk mill, saw mill, bank, etc.
10 Date deceased last worked at
this occupation (month and
year)
APR 1'930
Total time (years)
occupation.
WINTHROP
12 BIRTHPLACE (City)
(State or country)
MASS.
13 NAME OF
FATHER
PATRICK COUGHLIN
14 BIRTHPLACE OF
FATHER (City)
PARENTS
(State or country)
BRIDGEWATER
MASS.
15 MAIDEN NAME
OF MOTHER
EVELYN KAY
16 BIRTHPLACE OF
MOTHER (City)
(State or country)
NOVA SCOTIA
17
Informant
(Address)
7 LOCUST ST. WINTHROP
I HEREBY CERTIFY that a satisfactory standard certificate of death was filed with me BEFORE the burial or transit permit was issued: A. SULLIVAN
(Signature of Agent of Board of Health or
4-10230
(Official Designation) (Date of Issue of Permit)
MEDICAL CERTIFICATE OF DEATH
18 DATE OF
DEATH
APRIL 10, 1930
(Month)
(Day)
(Year)
19
I HEREBY
APRIL 9'
19
CERTIFY, That Lattended deceased from
30
APRIL 10
30
19
I last saw h ERalive on APRIL 10
., 19 ... 30. death is said
to have occurred on the date stated above, at
5Pm.
The principal cause of death and related causes of importance in order of onset were as follows:
Dateofonset
LOBAR PNEUMONIA 4-7-30
Contributory causes of importance not related to principal cause:
Name of operation
Date of
What test confirmed diagnosis?
Was there an autopsy?
20 Was disease or injury in any way related to occupation of deceased? If so, specify
(Signed)
A. M. STIFFLE
M. D.
(Address)
Date
4-1.019 .30
22 PLACE OF BURIAL,
CREMATION OR REMOVAL
CALVARY ,BROCKTON
(Cemetery)
(City or town)
DATE OF BURIAL
APRIL. 14, 1930
19
22 NAME OF
UNDERTAKER
C. M. HICKEY
ADDRESS
Received and filed.
APRIL 14, 1930
19
A TRUE COPY, ATTEST: 1. 11 1024
(Registrar)
1
No. CARNEYHOSPITAL. MARY E. FULGER
St.,
Ward
(If U. S. War Veteran,
important. 50M-11-'29. No. 7180-b
HUSBAND
10
apr. 10.19 C virgen
--- - - -
02
I
PLACE OF DEATH
(County)
(City or Town)
The Commamuralth of Massachusetts OFFICE OF THE SECRETARY DIVISION OF VITAL STATISTICS STANDARD CERTIFICATE OF DEATH
(City or town making return)
Registered No ..
Ward
S
(If death occurred in a hospital or institution,
(If U. S. War Veteran,
(If deceased is a married, widowed or divorced woman, give also maiden name.)
WINTHROP, MASS ..
(a)
Residence. No.
38 BANKS ST
St.,
Ward,
(If nonresident, give city or town and state)
Length of residence in city or town where death occurred yrs.
mos.
days.
How long in U. S., if of foreign birth?
yrs.
mos. days.
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
M.
4 COLOR OR RACE
5 SINGLE
MARRIED
WIDOWED
or DIVORCED
(write the word)
MARRIED
5a If married, widowed, or divorsed
HUSBAND of
DOMENICA PESCE
(or) WIFE of
(Husband's name in full)
6 IF STILLBORN, enter that fact here.
AGE
7
49
Years
Months
30
Days
If less than 1 day Hours. Minutes
OCCUPATION
8 Trade, profession, or particular kind of work done, as spinner, sawyer, bookkeeper, etc.
WAITER
9 Industry or business in which work was done, as silk mill, saw mill, bank, etc ....
O ..... MAN.G.I.N.I
10 Date deceased last worked at
11 Total time (years)
this occupation
year) ..
JAN and1 1, 1930
spent in this
occupation
2º
12 BIRTHPLACE (City)
(State or country)
ITALY
13 NAME OF
FATHER
UNKNOWN
PARENTS
14 BIRTHPLACE OF
FATHER (City)
(State or country)
ITALY
15 MAIDEN NAME
OF MOTHER
16 BIRTHPLACE OF
MOTHER (City)
(State or country)
ITALY
17
Informant
(Address)
38 BANKS ST. WINTHROP
I HEREBY CERTIFY that a satisfactory standard certificate of death was filed with me BEFORE the burial or transit permit was issued: HENRY F. RILEY
(Signature of Agent of Board of Health or other) 4-12-30
(Official Designation) (Date of Issue of Permit)
MEDICAL CERTIFICATE OF DEATH
18 DATE OF
APRIL 11, 1930
DEATH
(Month)
(Day)
(Year)
19
JAN 13
HEREBY
CERTIFY,
30
APRIL19
19
19
to.
I last saw h 1. Mive on APRIL 11, 1930. death is said to have occurred on the date stated above, at A m. The principal cause of death and related causes of importance in order of onset were as follows:
Dateofonset
LUNG ... ABSCESSES
LOCAL PLEURITIS
WEEKS. ..?
Contributory causes of importance not related to principal cause: ·CIRRHOSISOF LIVER
MONTHS ?
1
Name of operation
RESECTION.
Date of
3-20
What test confirmed diagnosis?
AUTOPSY
Was there an autopsyYES
20 Was disease or injury in any way related to occupation of deceased? If so, specify
(Signed)
C. L. CLAY
M. R.
(Address)
Date.
1-1/19:30
21 PLACE OF BURIAL,
CREMATION OR REMOVAL
ST MICHAELS. BOSTON
(Cemetery)
(City or towa)
DATE OF BURIAL
APRIL 13, 1930
19
22 NAME OF
UNDERTAKER
M. J. PORCEĻLA
ADDRESS
Received and tiled,
APR 15, _1930
19
2. Sarl
A TRUE COPY, ATTEST:
(Registrar)
Important.
50M-11-'29. No. 7180-b
WIEE
No. PETER ... BENT BRIGHAM HOSPITAL
give its NAME instead of street and number)
2 FULL NAME
ANTONIO P
BUFFA
(Usual place of abode)
(Give maiden name of wife in full)
That I attended deceased from
Unitario 1. 10mff
apr. 1: 1930
305
1
PLACE OF DEATH
Worcester (County)
Grafton .............. (City or Town) No Grafton State Hospital
The Commonwealth of Massachusetts OFFICE OF THE SECRETARY DIVISION OF VITAL STATISTICS MEDICAL EXAMINER'S CERTIFICATE OF DEATH
Grafton
(City or town making return)
Registered No.
-44 71
(If death occurred in a hospital or institution,
give its NAME instead of street and number)
2 FULL NAME
Sarah J. Hobday
(It deceased is a married, widowed or divorced woman, give also maiden name.)
(a)
Residence. No.
(Usual place of abode)
Length of residence in city or town where death occurred
13yrs. 8
mos.
17 days. How long in U. S., if of foreign birth? 49
yrs.
mos. days.
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
Female
4 COLOR OR RACE
White
5 SINGLE
MARRIED
WIDOWED
or DIVORCED
Married
5a If married, widowed, or divorced
HUSBAND of
(Give maiden name of wife in full)
(or) WIFE of
William Hobday
(Husband's name in full)
6 IF STILLBORN, enter that fact here.
7 AGE 7.9 Years 6 Months 25 Days
If less than 1 day
Hours
Minutes
OCCUPATION
8 Trade, profession, or particular kind of work done, as spinner, sawyer, bookkeeper, etc.
Housework
9 Industry or business in which work was done, as silk mill, saw mill, bank, etc.
10 Date deceased last worked at
this occupation (month and
year)
11 Total time (years)
spent in this
occupation.
12 BIRTHPLACE (City)
(State or country)
England
PARENTS,
14 BIRTHPLACE OF
FATHER (City)
(State or country)
England
15 MAIDEN NAME
OF MOTHER
Anna Lancaster
16 BIRTHPLACE OF
MOTHER (City)
(State or country)
England
17
Informant Grafton State Hosp. Record (Address) North Grafton Mass
I HEREBY CERTIFY that a satisfactory standard certificate of death was filed with me BEFORE the burial or transit pefmit was issued Robert S. Leonard
(Signature of Agent of Board of Health or other)
Agt . B .H.
April 18 1930
(Official Designation)
(Date of Issue of Permit)
MEDICAL CERTIFICATE OF DEATH
18 DATE OF
DEATH
April 14. 1930
(Month)
(Day)
(Year)
19 I 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) Apoplexy cerebral
( Following subluxation left
shoulder accidentally sustained by falling on floor March 19 ,1930)
20 If death was due to external causes (VIOLENCE) fill in the following :
Accident,
Suicide or
no relation to death,
Date of injury
Mar .19.1930
Homicide ?
al
Where did
injury occur ?
Grafton Mass. (State Hospit
(City or town and State)
Manner of
Injury
Fall on floor
Nature of
Subluxation left shoulder
Injury
21 Was disease or injury in any way related to occupation of deceased? no
If so, specify
(Signed)
Roland S. Newton
M. D.
(Address) 19 Central ... St.
Date
4/14 /9.30
Westboro, Hass
22 PLACE OF BURIAL,
N OR REMOVAL Hillcrest ... No. Grafton
(Cemetery)
(City or town)
DATE OF BURIAL.
April 18
30
19
23 NAME OF
UNDERTAKER
MiltonE.Temple
ADDRESS
North Grafton Mass.
Received and filed
may 6
.19.30
A TRUE COPY, ATTEST: (Registrar)
1
St.,
.Ward
(If U. S. War Veteran, specify WAR)
1
St.,.
Ward,
Winthrop.
Mass
(If nonresident, give city or town and state)
(write the word)
25M-11-29. No. 7180-d
13 NAME OF
FATHER
Thomas Didson
Sarah J. Holiday apr. 14. 1930.
01
Juffolx
(County)
Tinthrop
(City or Town) No.139 ashincton ive
The Commonwealth of Massachusetts OFFICE OF THE SECRETARY DIVISION OF VITAL STATISTICS STANDARD CERTIFICATE OF DEATH
Winthrop
(City or town making return)
Registered No. 12
(If death occurred in a hospital or institution,
give its NAME instead of street and number) - (If U. S. War Veteran, specify WAR)
(If deceased is a married, widowed or divorced woman, give also maiden name.)
(a)
Residence.
No
(Usual place of abode)
Length of residence in city or town where death occurred
yTs.
139 Washington Ave.
St.,
......
Ward,
(If nonresident, give city or town and state)
days.
How long in U. S., if of foreign birth?
yrs.
mos.
days.
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
3 SEX
Female
4 COLOR OR RACE
White
5 SINGLE
(write the word)
MARRIED
WIDOWED
or DIVORCED
Widowed
5a If married, widowed, or divorced HUSBAND of
(or) WIFE of
(Give maiden name of wife in full)
Herbert Granville Flinn
(Husband's name in full)
6 IF STILLBORN, enter that fact here.
7
71
AGE Years. Months Days
If less than 1 day
.Hours
Minutes
OCCUPATION|
8 Trade, profession, or particular kind of work done, as spinner, sawyer, bookkeeper, etc ..
Housewife
9 Industry or business in which work was done, as silk mill, saw mill, bank, etc.
10 Date deceased last worked at
this occupation (month and
year)
11 Total time (years)
spent in this
occupation
eston
12 BIRTHPLACE (City)
(State or country)
mas's
PARENTS
14 BIRTHPLACE OF
FATHER (City)
Ireland
(State or country)
15 MAIDEN NAME
OF MOTHER
Celia Corbett
16 BIRTHPLACE OF
MOTHER (City)
(State or country)
Ireland
17
Informant
Eleanor G. Flinn
(Address)
139 Washington Ave.
I HEREBY CERTIFY that a satisfactory standard certificate of death was filed with me BEFORE the burial or transit permit was issued:
William 10-Childress
(Signature of Agent of Board of Health or other)
agent afine 12/30
(Official Doaignation) (Date of Issue of Permit)
19 I HEREBY CERTIFY, That I attended deceased from
16
1915 ^
, to
I last saw h alive on
April.
1.4 . 19.30 death is said
to have occurred on the date stated above, at .. 5= P. m. The principal cause of death and related causes of importance in order of onset were as follows: Dateofonset Chiama Endocarditis
1928
Contributory causes of importance not related to principal cause:
Name of operation
Date of
What test confirmed diagnosis?
Was there an autopsy?
20 Was disease or injury in any way related to occupation of deceased?
If so, specify.
Edward , Franger
(Signed)
(Address)
476 Sturdy
M. D.
Date Hp I :. 1/19.3.0.
21 PLACE OF BURIAL,
CREMATION OR REMOVAL
St. Josephs
Boston
DATE OF BURIAL ...
n April 18
22 NAME OF
UNDERTAKER
ADDRESS
Received and filed
april 21,
A TRUE COPY, ATTEST: (Registrar)
I
1
PLACE OF DEATH
St.,
.Ward
2 FULL NAME
Celia E. Casey Flinn
mos.
18 DATE OF
DEATH
abril
16 1930
(Month)
(Day)
(Year)
13 NAME OF
FATHER
Michael 7. Casey
200'M-11-'29. No. 7180-a
(Cemetery) (City or town) 19.30
apr. 16. 1930.
Revised United States Standard Certificate of Death
Statement of occupation .- Precise statement of occupation is very important, 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 occupation had been given up or changed on account of the disease causing death, report the occupation prior to illness. If the deceased had retired from business, report the occupation prior to retirement. 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 in answer to Question 8 and own home in answer to Question 9. 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 what- ever write none.
To be complete, an occupation return must state:
8 .- The trade, profession, or particular kind of work done.
9 .- The industry or business in which the work was done.
10 .- The month and year the deceased last worked at the occupation.
11 .- The number of years the deceased followed the occupation.
In stating the occupation, avoid the use of such indefinite terms as "employee, " "worker. "" 'operative," etc. Find out the parti- cular kind of work done and return that, as spinner, weaver, etc.
In stating the industry or business, avoid the use of such general terms as "store," "factory,' mill." etc. State the particular kind of store, factory, mill, etc., as grocery store, soap factory, cotton mill, etc.
Distinguish carefully the different kinds of engineers by stating the full descriptive titles, as civil engineer, mechanical engineer, mining engineer, stationary engineer, etc. Avoid the term "laborer" when a more precise statement of the occupation can be secured. Do not use the word "mechanic, " but give the exact occupation, as carpenter, painter, machinist, etc. Distinguish carefully between retail merchants and wholesale merchants. A person who sells goods should be called a salesman and not a clerk.
Statement of cause of death .- Cause of death means the disease, injury, or complication which causes death, not the mode of dying, e. g., heart failure, asphyxia, asthenia, etc. As principal cause name the disease or injury causing death. As related causes, name earlier morbid conditions, if any, related to the principal cause and any important complication of the principal cause. Under contri- butory causes of importance not related to principal cause, name other important diseases or injuries.
Example
The principal cause of death and related causes of importance in order of onset were as follows: Arteriosclerosis
Date of onset
1915
Chronic interstitial nephritis
1921
Cerebral hemorrhage
July 5, 1927
Contributory causes of importance not related to principal cause : Fracture of arm Automobile accident
May 3, 1927
In a group of causes containing the principal cause and related causes, the causes should be given in the order of onset, so that in a group of three causes the principal cause may appear in either first, second, or third position. The principal cause in the above example happens to be the second cause given.
EXTRACTS FROM THE LAWS OF THE COMMONWEALTH OF MASSACHUSETTS GOVERNING THE RETURN OF CERTIFICATES OF DEATH
A physician or registered hospital medical officer shall forth- with, 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.
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 satis- factory written statement containing the facts required by law to be returned and recorded, which shall be accompanied, in case of an original interment, 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 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 state- ment and certificate, shall forthwith countersign it and transmit it to the clerk of the town for registration. 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.
Medical examiners shall make examination upon the view of the dead bodies of only such persons as are supposed to have died by violence .... Gen. Laws, Chap. 38, Sec. 6.
... He shall in all cases certify to the town clerk or registrar in the place where the deceased died his name and residence, if known; otherwise a description as full as may be, with the cause and manner of death .- Gen. Laws, Chap. 38, Sec. 7.
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 ceme- tery or burial ground in which the interment is made .. . Chap. 114. Sec. 46, G. L., as amended.
State cause for which surgical operation was undertaken.
Bronchopneumonia: If primary cause, write the word "primary"; if secondary, give primary cause.
Certificates will be returned for additional information which give any of the following diseases, without explanation, as the sole cause of death: Abortion, cellulitis, childbirth, convulsions, hemorrhage, gangrene, gastritis, erysipelas, meningitis, mis- carriage, necrosis, peritonitis, phlebitis, pyemia, septicemia, tetanus.
01
Is very important. See instructions and extracts from the laws on back of certificate. PARENTS
200M-11-'29. No. 7180-a
I HEREBY CERTIFY that a satisfactory standard certificate of death was filed with me BEFORE the burial or transit permit was issued: Vom D Childress
Health officer . a
Signature of Agent of Board of Health or other
april 18/1930
(Official Designation) (Date of Issue of Permet)
MEDICAL CERTIFICATE OF DEATH
3 SEX
Male
4 COLOR OR RACE
5 SINGLE
MARRIED
WIDOWED
or DIVORCED
(write the word)
Widowed
5a If married, widowed, or divorces
HUSBAND of
Jesuis ada Cram
(Give maiden name of wie in fun,
(or) WIFE of
(Husband's name in full)
6 IF STILLBORN, enter that fact here.
7 AGE 64
Years
3
.Months
6
.Days
If less than 1 day
Hours
Minutes
OCCUPATION|
8 Trade, profession, or particular kind of work done, as spinner, sawyer, bookkeeper, etc ..
Grocer
9 Industry or business in which work was done, as silk mill, saw mill, bank, etc.
10 Date deceased last worked at this occupation (month and year) ..
June
@1929
11 Total time (years) spent in this occupation .. 40 years
12 BIRTHPLACE (City)
Dunning
(State or country)
Scotland
13 NAME OF
FATHER
William tienduson
14 BIRTHPLACE OF
FATHER (City)
Scotland
(State or country)
15 MAIDEN NAME
OF MOTHER
Not Known
16 BIRTHPLACE OF MOTHER (City) (State or country)
17
Daughter Mm Ruth Handen Roach
(Address) 306 Ruene It Winthrop Mars
DATE OF BURIAL
18-
22 NAME OF
UNDERTAKER
7. Valter S. Invite
ADDRESS
Received and filed
A TRUE COPY, ATTEST: (Registrar)
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