USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1936 > Part 95
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I HEREBY CERTIFY that a satisfactory standard certificate of death was filed with me BEFORE the burial or transit permit was issued:
(Signature of Agent of Board of Health of other).
Health slicht 12/8/36
(Oficial Designation) (Date of Issue of Permit)
18 DATE OF
DEATH
Dec
5
(Month)
(Day)
(Year)
19 I HEREBY CERTIFY
June 16
193/, to
,1936
I last saw he alive on 1936 death Is said to have occurred on the date stated above, alo 15m. The principal cause of death and related causes of Importance in order of onset were as follows: Date of Onset IMPORTANT Chronic hydrater
Contributory causes of importance not related to principal cause:
avititia dens
antitic
Name of operation.
Date of.
What test confirmed diagnosis ?.
Was there an autopsy ?.....
5
20 Was disease or injury in any way related to occupation of deceased?
If so, specify.
(Signed)
M. D.
(Address).
21 PLACE OF BURIAL,
CREMATION OR REMOVAL .
Holywood Brook ing
DATE OF BURIAL
December 9
(City or town) 6
22 NAME OF
UNDERTAKER
m.
freely.
ADDRESS
11 melilian &t ; B.
Received and filed ....... 19
(Registrar)
1
Suffolk
No.
St., ..................
Ward
(If U. S.
War Veteran,
specify WAR)
(a) Residence. No.
(Usual place of abode)
Length of residence in city or town where death occurred 30
Srs .
MEDICAL CERTIFICATE OF DEATH
1936
That I attended deceased from
Date 12-7
19%.
19.1
Kevised 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 discase 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, soup factory, collon 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, or complication which causes death, rot the mode of dying, e. g., heart failure, asphyxia, asthenia, etc. As principal cause name the disease 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 contributory causes of importance not related to principal cause, name other important diseases.
Example
The principal cause of death and related causes of importance in order of onset were as follows:
Date of onset
Arteriosclerosis ....
Chronic interstitial nephritis
1921
Cerebral hemorrhage
July 5, 1027
...
.....
...........
Contributory causes of importance not related to principal cause:
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 cither first, second, or third position. The principal cause in the above example happens to be the second cause given.
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 such a permit for the removal of a human body. not previously interred, from one town to another within the common- wealth cannot be obtained early enough for the purpose, the certificate of death made as above provided and in the possession of the undertaker desiring to make such removal shall constitute a permit for such re- moval; provided, that such body shall be returned to the town from which it was removed within thirty-six hours after such removal, unless a permit in the usual form for the removal of such body has been sooner obtained hereunder. If the death certificate contains a recital, as rc- quired by section ten of chapter forty-six, that the deceased served in the army, navy or marine corps of the United States in any war in which it has been engaged, such recital shall appear upon the permit. The board of health, or its agent, upon receipt of such statement and certificate, shall forthwith countersiga 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 bo obtained as to the deceased, or as to the manner or cause of the death. which the clerk or registrar may require. - Chap. 114, Scc. 45, G. L., (Tercentenary Edition.)
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 .. . . Chop. 114. Sec. 46, G. L., (Tercentenary Edition.)
RULES OF PRACTICE
The fulfillment 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 un- related to any form of injury, have died without recent medical attend- ance or whose physician is absent from home when the certificate of death is needed.
(3) Medical Examiners will investigate and certify to all deaths supposably due to injury. These include not only deaths caused directly or indirectly by traumatism (including resulting septicemia), and by the action of chemical (drugs or poisons), thermal, or electrical agents, and deaths following abortion, but also deaths from disease resulting from injury or infection related to occupation, the sudden deatha of persons not disabled by recognized disease, and those of persons found dead.
2
TRACTS FROM THE LAWS OF THE
M R-301A
1 ... OCCUPATION PARENTS 17 WANIE PLAINLY, WITH UNFADING BLACK INK-THIS IS A PERMANENT RECORD. Every item of is very important. See instructions and extracts from the laws on back of certificate. CAUSE OF DEATH in plain terms, so that it may be properly classified. Exact statement of OCCUPATION information should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state year)
PLACE OF DEATH
Suffolk
(County)
Winthrop
(City or Town)
No. 31 .. Centro .. St.
.St., ................. Ward
To be filed for burial permit with Board of Health or its Agent.
Registered No.
2378
(If death occurred in a hospital or institution,
give its NAME instead of street and number)
2 FULL NAME.
Gertrude ... C ..... Ambrose
(If deceased is a married, widowed or divorced woman, give also maiden name.)
(a) Residence. No ....
31 Centre ... St.
St., .............
.. Ward,
(If nonresident, give city or town and state)
Length of residence in city er town where death occurred
10 yrs.
mos.
days. How long in U. S., if of foreign birth?
yrs.
mos.
days.
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
Female
4 COLOR OR RACE
White
5 SINGLE
MARRIED
WIDOWED
or DIVORCED
Married
18 DATE OF
DEATH
12
5
(Month)
(Day)
36
(Year)
5a If married, widowed, or divorced
HUSBAND of
(Give maiden name of wife in full)
(or) WIFE of
Thomas ............ Ambrose
(Husband's name in full)
6 IF STILLBORN, enter that fact here.
7 AGE .... 47. 7 Years. Months 16Days
If less than 1 day Hours ......... Minutes
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.
Housewife
10 Date deceased last worked at
11 Total time (years)
this occupation (month andMay 1934
spent in this
occupation
19
12 BIRTHPLACE (City)
Portland,
(State or country)
Maine
13 NAME OF
FATHER
Owen C. Murray
14 BIRTHPLACE OF
FATHER (City)
Portland,
(State or country)
Maine
15 MAIDEN NAME
OF MOTHER
Mary A. Allen
16 BIRTHPLACE OF
MOTHER (City)
Portland., ..........................
(State or country)
Maine
Relation, if any
Informant .....
Mr. Thomas H. Ambrose husband
(Address)
31 Centre St
Winthrop
I HEREBY CERTIFY that a satisfactory standard certificate of death was filed with me BEFORE the burial, or transit permit was issued:
3.
.(Signature of Agent of Board of Health of other)
12/7/36
(Oficial Designation) Date of Issue of Permity
19
I HEREBY CERTIFY, That I attended deceased fropf
3/22
19.3.5 .... to
12/5
19.3.3
I last saw h.
allva on
12/
19.36
death Is sald
to have occurred on the date stated above, at. 9,2 m. The principal cause of death and related causes of Importance In order of onset were as follows:
Cate of Cnset IMPORTANT
Lungs
Contributory causes of importance not related to principal cause:
Cerebral Harmonlage 3/24/
1 /36
Name of operation
What test confirmed diagnosis?
Date of.
Was there an autopsy?
20 Was disease or injury in any way related to occupation of deceased? If so, specify
(Signed)
M. D.
(Address)
Date ....
19
21 PLACE OF BURIAL,
CREMATION OR REMOVALCalvary Portland
(Cemetery)
(City or town)
DATE OF BURIAL A.December.9.1936. 19
22 NAME OF
UNDERTAKERC
Auchand lerky
ADDRESS
East Boston
Received and filed. 1936
........... 19
(Registrar)
226
(L U. S.
War Veteran,
specify WAR)
(Usual place of abode)
MEDICAL CERTIFICATE OF DEATH
(write the word)
The Commonwealth of Massachusetts OFFICE OF THE SECRETARY DIVISION OF VITAL STATISTICS STANDARD CERTIFICATE OF DEATH
100m-12-'34. No. 2938-f
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 qmerchants 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, or complication which causes death, not the mode of dying, e. g., heart failure, asphyxia, asthenia, etc. As principal cause name the disease 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 contributory causes of importance not related to principal cause, name other important diseases.
Example
The principal cause of death and related causes of importance in order of onset were as follows:
Date of onset
Arteriosclerosis ...
Chronic interstitial nephritis
1021
...
Cerebral hemorrhage
July 5. 1927
...
Contributory causes of importance not related to principal cause:
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.
XTRACTS FROM THE LAWS OF 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 diod, 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 such a permit for the removal of a human body. not previously interred, from one town to another within the common-" wealth cannot be obtained early enough for the purpose, the certificate of death made as above provided and in the possession of the undertaker desiring to make such removal shall constitute a permit for such re- moval; provided, that such body shall be returned to the town from which it was removed within thirty-six hours after such removal, unless a permit in the usual form for the removal of such body has been sooner obtained hereunder. If the death certificate contains a recital, as re- quired by section ten of chapter forty-six, that the deccased served in the army, navy or marine corps of the United States in any war in which it has been engaged, such recital shall appear upon the permit. The board of health, or its agent, upon receipt of such statement and certificate, shall forthwith countersign it and transmit it to the clerk of the town for 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. - Chop. 114, Sec. 45, G. L .. (Tercentenary Edition.)
Medical examiners shall make examination upon the view of the dead bodies of only such persons as are supposed to have died by violence ... . Gew. 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., (Tercentenary Edition.)
RULES OF PRACTICE
The fulfillment 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 un- related to any form of injury, have died without recent medical attend- ance or whose physician is absent from home when the certificate of death is needed.
(3) Medical Examiners will investigate and certify to all deaths supposably due to injury. These include not only deaths caused directly or indirectly by traumatism (including resulting septicemia) and by the action of chemical (drugs or poisons), thermal, or electrical agents, and deaths following abortion, but also deaths from disease resulting from injury or infection related to occupation, the sudden deaths of persons not disabled by recognized disease, and those of persons found dead.
ORM R-303 B
MARGIN RESERVED FOR BINDING
1 1. 3 SEX 4 COLOR OR RACE White Female 6 IF STILLBORN, enter that fact here. 7 AGE 60 8 Trade, profession, or particular kind of work done, as spinner, sawyer, bookkeeper, etc. OCCUPATION (State or country) Maine PARENTS Informant of Death. See reverse side for extracts from the laws relative to the return of certificates of death. information should be carefully supplied. MEDICAL EXAMINERS should state CAUSE AND MANNER OF DEATH in plain terms, so that it may be properly classified under the International Classification of Causes saw mill, bank, etc. N. B .- WRITE PLAINLY, WITH UNFADING BLACK INK-THIS IS A PERMANENT RECORD. Every item of 12 BIRTHPLACE (City) Augusta
5 SINGLE
(write the word)
MARRIED
WIDOWED
or DIVORCED
Widowed
5a If married, widowed, or divorced HUSBAND of (Give maiden name of wife in full)
(or) WIFE of
George E. Breckenridge
(Husband's name in full)
Years Months .Days
If less than 1 day Hours. .. Minutes
House work
9 Industry or business in which
work was done, as silk mill,
Own home
10 Date deceased last worked at
11 Total time (years)
this occupation (month anDec. 1936
year)
spent in this occupation.
35
13 NAME OF
FATHER
Unable to obtain
14 BIRTHPLACE OF Unable to obtain FATHER (City) (State or country)
15 MAIDEN NAME
OF MOTHER
Unable to obtain
16 BIRTHPLACE OF MOTHER (City) .... Unable to obtain (State or country)
17 Louis Breckenridge
(Address)
91 Faun Bar Ave. Winthrop
I HEREBY CERTIFY that a satisfactory standard certificate of death was filed with me BEFORE the burial or transit permit was issued:
N.m. D. Childrens
1
(Signature of Agent of Board of Health or other) Dec. 9/36
(Official Designation) (Date of Issue of Permit)
MEDICAL CERTIFICATE OF DEATH
18 DATE OF
DEATH
Dec- 7-1436
(Month)
(Day)
(Year)
19 | 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.) Right Lovar Pneumonia
Right Embuena Left Brancho Pneumonia
Collapsed & died quickly
(See reverse side for description for unknown person)
20 IN WHAT CITY OR TOWN
WAS INJURY SUSTAINED ?
Buckley
. M. D.
(Signed)
(Address)
....
Besten
DIRIC - 8 1936
21 PLACE OF BURIAL,
Forest Hills Boston
CREMATION OR REMOVAL
(Cemetery)
(City or town)
DATE OF BURIAL
December 11,
19.36
22 NAME OF
UNDERTAKER
Charles R ..... Bennison
ADDRESS
Winthrop,
Mass
Received and filed.
19
DEC 15 1936
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