USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1948 > Part 58
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it has been engaged, such recitai shall appear upon the permit. The board of health, or its agent. upon receipt of such statement and certificate, shall forthwith countersign it mal transmit it to the clerk of the town for regis- tration. The person to whom the permit la so given and the physician cet- tifying 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 regiatrar may re- quire .- Chap. 114, Sec. 15, G. L., (Tercentenary Edition).
No undertaker or other person shall bury a human body or the ashes thereof which have bren brought Into the commonwealth until he has re- ceived a perunit 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 towo where the body is to be buried or the funeral is to be held, or from a per- son appointed to have the care of the centetery or burial ground in which the intermeut is made. ... Chap. 114, Sec. 46, G. L., (Tercentenary Edi- tion ).
Medical examiners shali make examination upon the view of the dead bodies of ouly such persous as are supposed to have died by violence. If a Medical examiner has notice that there is within his county the body of such a person, he shall forthwith go to the place where the body lies and take charge of the same; ... - General Laws, Chap. 3S, Sec. 6.
. . He shall in all cases certify to the town clerk or registrar in the place where the deceased ilied his name and residence, if known; otherwise a description as fuli as may be, with the cause and manner of death .- General Laws, Chap. 38, Sec. 7.
.. . The medical examiner certifies the cause and manner of death to the best of his knowledge and belief.
RULES OF PRACTICE
The fulfiliment of the purpose of these laws calla for the observance of the following rulea of practice :
(1) Attending physlolans wili certify to such deaths only aa those of persona to wlioni they have given bedside care during a last illnesa from disease uurelated to any forin of Injury.
(2) Board of Health physlolans will certify to such deaths oniy aa those of persons who, though disabled by recognized disease unrelated to any form of injury, have died without recent inedical attendance or whose physi- cian is absent froin hotne when the certificate of death la needed.
(3) Medical Examiners will investigate and certify to all deaths sup- posably due to Injury. These include not only deatha caused directly or fn- directly 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.
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: "Com- pound fracture of the femur with ensuing aepticenia (gaa bacillus) caused by a steam railway accident." "Pistol shot wound of the chest with asso- ciated hemorrhage, homicidal." "Asphyxiation by suspension, auicidal." "Syncope while under the influence of ether adininlstered as a surgical anaesthetic." "Fracture of the skull with associated internal injury sus- tained under circumstances unktulwn."
If disease or injury was related to occupation, specify. If investigation shows the death to have been due to disease, specify : (1) Under cause its known or presumahle uature; and (2) umler manner, indicate the circum- stances leading to medico-legal inquiry. For example : "Hemorrhage spon- taneous of the brain (basal ganglia ) (found dead in bed)." "Ifeart 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 met his death by violence, until a permit, signed by the Medical Examiner, has first been obtained .- General Laws, Chap. 38, Sec. 14.
THIS CERTIFICATE CONSTITUTES SUCH PERMIT
I R-303-A
1
2 FULL NAME
(a) Residence. No.
(Usual place of abode)
3 SEX
Male
4 COLOR OR RACE
White
(or) WIFE of
7 IF STILLBORN, enter that fact here.
Usual
9 Occupation :
At Home
Industry
14 BIRTHPLACE OF
FATHER (City)
(State or country)
15 MAIDEN NAME
OF MOTHER
Mary
PARENTS
16 BIRTHPLACE OF
MOTHER (City)
(State or country )
If deceased was a U. S. War Veteran, G. L. Chap. 46, Section 10, requires physiolans to Insert a reoltal to that effect
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 for
10 or Business :
Retired
5 SINGLE
(write the word)
MARRIED
WIDOWED
or DIVORCED Married
5a If married, widowed, or dlvoroed
HUSBAND of
(Give maiden name of wife in full)
Justina Jones
(Husband's name in full)
6 Age of husband or wife if allve
82
years
If less than 1 day
Hours ..........
.Minutes
11 Soolal Security No. None
12 BIRTHPLACE (City)
Ellsworth
(State or country)
Maine
13 NAME OF
FATHER
Isaac Smith
Unable to obtain
Unable to obtain
17 Melissa Downing
Daughter
Informant
( Address)
20 Thurston St East Boston
I HEREBY CERTIFY that a satisfactory standard certificate of death was filed with me BEFORE the barlal or transit permit was issued : Walter A: Wakes .
(Signature of Agent of Board & Health or other)
/ Leale thiele 8/23/48 (Official Designation) (Date of Issue of Permit)
MEDICAL CERTIFICATE OF DEATH
18 DATE OF
DEATH
lug - 19
( Month)
(Day)
(Year)
19 | HEREBY CERTIFY that I have Investigated the death of the person above-named and that the CAUSE AND MANNER thereof 1
areas follows : [{If
. arterio Vclerotic Heart Disease Dem. arterio Scleroses Fracture Rt. Fenus .
accidental
20 Accident, sulolde, or homlolde (specify).
Date of ooourrenoe.„
Rug-11 -
.. 19 ..
45
Where did
Injury ooour ?
(City or town and State)
Did Injury ooour in or about home, on farm, In Industrial place, or In publlo
place ?
(Specify type of place) .
Manner
Dell accidentally in his back
Injury
Nature of Mand on aug-11-1948
Injury
While at work?
7
.Waa there an autopsy ?.
40
21 Was disease or Injury In any way related to oooupation of deceased ?
If so, speolfy
Hu Brille
(Signed)
M. D.
(Address)
22
Woodlawn
Everett
Place of Burial, Cremation or Removal.
(City or Town)
DATE OF BURIAL.
Aug
23
23 NAME OF
FUNERAL DIRECTOR ....
Howard
ADDRESS
Unclos- mars
Reoelved and filled
AUG 25 1948
19
(Registrar)
50m- (f)-6-43-12056
PLACE OF DEATH No. illard
Boston 9/ 10/ 48
Suffolk County) Winthrop (City vor Town) Kathret Comment Hospital M Jwith
The Commonforalth of Massachusetts OFFICE OF THE SECRETARY DIVISION OF VITAL STATISTICS MEDICAL EXAMINER'S CERTIFICATE OF DEATH
To be filed for burial permit with Board of Health or Its Agent.
Registered No.
164
St. { {If death occurred in a hospital or institution, ( give ite NAME instead of street and number)
PHYSICIAN-IMPORTANT (Was deceased a U. S. War Veteran, If so speolfy WAR)
(If deceased is a married, widowed or divorced 20 Thurston St. East Busty
woman, give also maiden name.)
Length of stay: In hospital or Institution ...
( Before death)
Hosp
years
months
9
days.
(If nonresident, give city or town and State)
In this community 50
yTS.
mos.
days.
( Specify whether)
PERSONAL AND STATISTICAL PARTICULARS
1948
-
Leang-20-2048
8
AGE.8.8 ...
. Years.
6.
„Months ..
17 Days
EXTRACTS FROM THE LAWS OF THE COMMONWEALTH OF MASSACHUSETTS GOVERNING THE RETURN OF CERTIFICATES OF DEATH
A physician or registered hospital medical officer shall forthwith, after the death of a person whom he has attended during his last illness, at the request of an umlertaker or other authorizeil 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 sume 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. 16, Sec. 9.
A physician or officer furnishing a certificate of death as required by the preceding section or by section forty five of chapter one hundred and four- teen, shall, if the deceased, to the best of his knowledge and belief, served in the army, navy or marine corps of the United States in any war in which it has been engaged, insert in the certificate a recital to that effect, speci- fying the war, und shall also certify in such certificate both the primary and the secondary or immediate cause of death as nearly as he can state the same. For neglect to comply with any provision of this section, such physician or officer shall forfeit ten dollars. For the purposes of thia sec- tion and of sections forty-five, forty-six and forty seven of said chapter one hundred and fourteen, the word "war" shall include the China relief ex- pedition and the l'hilippine insurrection, which shall, for said purposea, be deented to have taken place between February fourteenth, eighteen hundred and ninety-eight and July fourth, nineteen hundred and two, and the Mexi- can border service of nineteen hundred and aixteen and nineteen hundred and seventeen. G. L. Chap. 46, Sec. 10.
No undertaker or other person shall bury or otherwise dispose of a human body in a tuwu, or remove therefrom a human body which has not been buried, until he has received a perinit froin the board of health, or its agent appointed to issue auch permits, or if there is no such board, from the clerk of tlte 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 aootlier, or from one grave or tomb other than the receiving tomb to another in the aame cemetery, until he haa received a permit from the board of health or ita agent aforesaid or front the clerk of the town where the body is buried. No auch permit shall be issued until there shall have heen delivered to such board, agent or clerk, as the case may be, a satisfactory written statement containing the facts required by law to be returned and recorded, which shall be sccompanied, in case of an original interinent, 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 tro attending physician, or If, for sufficient reasons, hia certificate cannot be obtained early enough for the purpose, or is insufficient, a physi- cian 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 re- quired of the atteinting physician. If death is causeil 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 an- other within the commonwealth cannot be obtained early enough for the purpose, the certificate of death made as above provided and in the pos- session of the undertaker desiring to make such renroval shall constitute a permit for such removal; provided, that such body shall be returned to the town from which it was removed within thirty-six hours after such re- moval, 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 required by section ten of chapter forty-six, that the deceased aerved in the army, navy or marine corps of the United States in any war in which
it has heen 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 trausnrit it to the clerk of the town for regis. tration. "The person to whom the permit is so given and the physician cer tifying 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 re- quire .- Clap. 114, Sec. 15, G. L., (Tercentenary Edition).
No undertaker or other person shall bury a human body or the ashes thereof which have been brought Into the commonwealth until he has re- ceived a permit so to do front the board of health or its agent appoluted to issue sucht perntits, or if there is no such board, from the clerk of the towo where the body is to be buried or the funeral is to be held, or from a per- son appointed to have the care of the cemetery or burial ground in which the interment is made. ... Chap. 114, Sec. 46, G. L., (Tercentenary Edi- tion ).
Medical examiners shall make examination upon the view of the dead bodies of only sucht persons as are supposed to have died by violence. If a medical examiner has notice that there is within his county the body of such a person, he shall forthwith go to the place where the body llea and take charge of the same; ... - General Laws, Chap. 3S, 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 .- General Laws, Chap. 38, Sec. 7.
... The medical examiner certifles the cause and manner of death to the best of his knowledge and belief.
RULES OF PRACTICE
The fulfillment of the purpose of these laws calls for the observance of the following rulea of practice :
(1) Attending physicians will certify to such deaths only as those of persons to whonr they have given bedside care during a last illnesa from disease unrelated to any form of injury.
(2) Board of Health physiclans will certify to such deatha only aa those of persons who, though disabled by recognized disease uurrelated to any form of injury, have died without recent inedical attendance or whose physi- cian is absent fromn hoine when the certificate of death Is needed.
(3) Medical Examiners will investigate and certify to all deatha sup- posably due to Injury. These include not only deaths caused directly or In- directly by trauinatism (including resulting septicemia), and by the action of chenrical (druga or poisons), thermal, or electricsl agenta, and deatha 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.
STATEMENT OF CAUSE OF DEATH
Medical Examilners 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 ita consequences; and (2) under manner, the mode of its production together with the circumstances when these are known. For example: "Com- pound fracture of the femur with ensuing septicemia (gaa bacillus) caused by a steam railway accident." "Pistol shot wound of the chest with asso- ciated hemorrhage, homicidal." "Asphyxiation by suspension, auicidal." "Syncope while under the influence of ether adininistered as a surgical anaesthetic." "Fracture of the skull with associated internal injury sus- tained under circumstances unknown."
If disease or injury was related to occupation, specify. If investigation shows the death to have been due to disease, specify: (1) Under cause ita known or presumahle nature; anıl (2) umuler manner, indicate the circum- stances leading to medico-legal inquiry. For example : "Hemorrhage spon- taneous of the brain (hasal ganglia ) (found dead in bed)." "Heart disease, presumably coronary sclerosis. (Sudilen 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 met his death by violence, until a permit, signed by the Medical Examiner, has first been obtained .- General Laws, Chap. 38, Sec. 14.
THIS CERTIFICATE CONSTITUTES SUCH PERMIT
M R-305
Suffolk
(County)
Boston
(City or Town)
No.
Boston City Hospital
The Commonwealth of Massachusetts OFFICE OF THE SECRETARY COPY OF MEDICAL EXAMINER'S CERTIFICATE OF DEATH
Boston
(City or town making return)
Registered No.
730865
(If death occurred in a hospital or institution, give ita NAME instead of street and number)
Sidney Low Evans
2 FULL NAME
(If deceased is a married, widowed or divorced woman, give also maiden name.)
(a) Residence. No.
57 Lincoln
(Usual place of abode)
(If nonresident, give city or town and State)
Length of stay: In hospital or Institution.
(Before death)
(Specify whether)
years
months days.
In this community
yrs.
mos.
days.
PERSONAL AND STATISTICAL PARTICULARS
3 SEX M
4 COLOR OR RACE
W
MARRIED
WIDOWED
or DIVORCED
Married
5a If married, widowed, Mat' pard L Freese
HUSBAND of
(or) WIFE of
(Husband's name in full)
6 Age of husband or wife If allve years
7 IF STILLBORN, enter that faot here.
8
AGE 56
Years
Months
Days
If less than 1 day
Hours.
.Minutos
Usual
Salesman Wholesale
9 Oocupation :
Industry
Lindermeyr & Son
10 or Business :
11 Soolal Security No.
025-09-1915.
12 BIRTHPLACE (City)
(State or country)
Chelsea, Mass:
13 NAME OF
FATHER
Robert E Evans
PARENTS
14 BIRTHPLACE OF
FATHER (City)
Bellows Falls, Vermont
(State or country)
15 MAIDEN NAME
OF MOTHER
Grace Land
16 BIRTHPLACE OF
MOTHER (City)
Rockport, Vass.
(State or country)
17 Marian L Evans
Informant. (Address)
A TRUE COPY
1
ATTEST :
RtniCelto town here wrath occurred)
19.418
18 DATE OF
(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.) Cerebral Hemorrhage Hypertension .Collapsed at work Admitted in Coma - died in hours
20 Acoldent, sulolde, or homlolde (specify)
Date of ooourrenoo 19
Where did Injury ooour? (City or town and State)
Did Injury ooour In or about the home, on farm, In Industrial place, or In publio place? (Specify type of place)
Manner of
Injury
Nature of
Injury
While at work ?
Was there an autopsy ?.
no
21 Was disease or Injury in any way related to oooupation of deceased?
If so, spoolfy ...
(Signed)
Timothy Leary
M. D.
(Address)
Date.
8/20 1948
22
Winthrop Cem.
Winthrop
Place of Burial, Cremation or Removal.
(City or Town)
23 NAME OF
FUNERAL DIRECTOR
M C Carroll
ADDRESS
22 Oak St., Hyde Park, Mass.
19
Received and filled
SEPT 1948
(Registrar of City or Town where deceased resided)
25m-(d)-6-43-12056
occurred. (See Chap. 46, Sec. 12, G. L.) of the city or town in which the deceased resided as soon as possible after the close of the month in which the death resided in another city or town at the time of death should he made forthwith and transmitted on Form R-805 to the clerk Copies of returns of deaths recorded during the previous month which occurred in your city or town in case the deceased
1
PLACE OF DEATH
St.
(If U. 8.
War Veteran,
speolfy WAR)
no
Winthrop,
Mass.
St.
MEDICAL CERTIFICATE OF DEATH
5 SINGLE
(write the word)
DEATH
Aug. 20, 1948
(Give maiden name of wife in full)
53
DATE FILED
Aug. 24
(
Relativi, fifeany
DATE OF BURIAL
Aug ....... 23
14.8
M R-302 1 ـتـ PLACE OF DEATH
(a) Residence. No.
(Usual place of abode)
3 SEX
Fema lel
4 COLOR OR RACE
white
11 Soolal Security No ..
None
12 BIRTHPLACE (City)
(State or country)
Mas s.
14 BIRTHPLACE OF
PARENTS
of the city or town in which the deceased resided. (See Chap. 46, Sec. 12, G. L.)
resided in another city or town at the time of death should be made forthwith and transmitted on Form R-808 to the clerk
Copies of returns of deaths recorded during the previous month which occurred in your city or town in case the deceased
(State or country)
Mags
5 SINGLE
(write the word)
MARRIED
WIDOWED
or DIVORCED
Widow
5% If married, widowed, or divorced
HUSBAND of
(Give maiden name of wife in full)
(or) WIFE of
Robert .........
GOVe
(Husband's name in full)
6 Age of husband or wife If allve years
7 IF STILLBORN, enter that faot here.
8
AGE.
87 Years 0
Months.
9 Days
If less than 1 day
.Hours ..........
.. Minutes
Usual
9 Ocoupatlon :
Housew fe
Industry
10 or Business :
Own home
Essox.
13 NAME OF
FATHER
Albert F. Low
FATHER (City)
Es.s.e.x
15 MAIDEN NAME
OF MOTHER
Abbie Henderson
16 BIRTHPLACE OF
MOTHER (City)
Ipswich
(State or country)
Mass.
17 Everett K.Low
Informant.
(Address) 234 Court Rd.
Winthrop,
A TRUE COPY.
ATTEST:
Egil ARyder
DATE FILED
(Registrar of city or town where death occurred) August 30
19 48
MEDICAL CERTIFICATE OF DEATH
18 DATE OF
DEATH
August
.2.0
(Month)
(Day)
(Year)
19 | HEREBY CERTIFY,
Feb
7
That I attended deceased
from
19 ...
44
to
Aug
20.
19
I last saw h ...... e.I ... alive on ..
Aug
.1.9 ....... , 19 .. 13death Is sald to
have ooourred on the date stated above, at. 3:55₽ m.
Duration
Immediate cause of death.
Broncho Pneumonia
4 days
Due to.
Chronic Myocarditis
4 yrs.
Other conditions.
(Include pregnancy within 3 months of death)
Physician
Major findIngs:
Of operations.
Date of.
Underline the cause to which death should be charged sta- tistically.
Of autopsy
What test confirmed diagnosis ?.
No
20 Was disease or Injury in any way related to occupation of deceased ?
If so, spoolfy
(Signed)
Louis ..... F .. Salerno
M. D.
(Address) 175 ..... Pleasant ... St.
Date 0 -21 -19 48
21 PLACE OF BURIAL,
CREMATION OR REMOVAL.Woodlawn-Everett
(Cemetery)
(City or Town)
19 ..
22 NAME OF
FUNERAL DIRECTOR
Howard S. Reynolds
ADDRESS
Winthrop., ..... Mas.s.
Reoelved and filed SEP-9-1948 19
(Registrar of City or Town where deceased resided)
50m-(b)-6-44-14607
Middlesex
(County)
Arlington (City or Town)
The Commonwealth of Massachusetts OFFICE OF THE SECRETARY DIVISION OF VITAL STATISTICS COPY OF CERTIFICATE OF DEATH
Arlington
(City or town making return)
Registered No.
295166
No.
12 Florence Avenue
(If death occurred in a hospital or institution, St. give its NAME instead of street and number)
2 FULL NAME
Grace W. Gove
(Low )
(If deceased is a married, widowed or divorced woman, give also maiden name.)
200 Bartlett Road
SŁ
Winthrop,
Mass.
(If nonresident, give city or town and State)
Nursing Home
4 yrs.
Length of stay : In hospital or Institution ...
(Before death)
(Specify whether)
years
months
days.
In this community
yrs.
mos.
days.
PERSONAL AND STATISTICAL PARTICULARS
(If U. S.
speolfy WAR)
1948
Due to
DATE OF BURIAL
August
23
Relation, if any (Nephon Mas
3
-301 A
extracts from the laws on back of certificate. If deceased was a U. S. War Veteran, G. L. Chap. 46, Seotion 10, requires physiolans to insert a recital to that effeot. PARENTS
100m-(g)-1-45-15510
I HEREBY CERTIFY that a Satisfactory standard oartifioate of death was filled with me BEFORE the burial or transit pormit was Issued : Walter
(Signature of Agent of Board of Health or other) Health schule
8/24/48
(Official Designation) ( Date of Issue of Permit)/
MEDICAL CERTIFICATE OF DEATH
3 SEX
4 COLOR ØR RACE
While
5 SINGLE
MARRIED
WIDOWED
( write the word) Marrecal
HUSBAND of
22 8 71 Bolicheau (Give maiden name of wife in full)
(or) WIFE of
( Husband's name in full)
6 Age of husband or wife if alive
60
years
7 IF STILLBORN, enter that fact here.
8 AGE !.
7 Years
Months Days
If less than 1 day Hours Minutes
Usual 9 Ocoupetion :
Industry 10 or Business :
11 Social Security No.
12 BIRTHPLACE (City)
(State or country)
Barton.
13 NAME OF
FATHER
Janus 71 Stade
14 BIRTHPLACE OF
FATHER (City)
(State or country)
@ pland
15 MAIDEN NAME
OF MOTHER
Eller Mccarthy
16 BIRTHPLACE OF
MOTHER (City)
(State or country)
17 informant ( Address)
Reistion, if any
21
22 NAME OF
FUNERAL DIRECTOR ..
ADDRESS
Tules Rues
Received and fled. AUG 251948
( Registrar)
1948
I last Vaw h.}.A.
alive on
Ccccx 22 , 1948, death is said to
have occurred on the dato stated above,
at.
2:40 P.
m.
Duration
Immediato cause of death.
acute Coronary Occlusion
IMPORTANT
Due tous
Hyperterenie Heart At vise years
and atouslesin.
....
Due to
Other conditions.
( Include pregnancy within 3 months of death)
MEPORTANT
Major findings:
Of operations
*
Data of
Of autopsy.
What test confirmed diagnosis ?.
clinical
20 Was disease or injury in ony way rejatad to occupation of decaased ?. if so, spoolfy.
('Signed)
( Address)
Ist Sacatia V. Data 8/24
. M. D. 19.
Place of Barial, Cremation or Removal. DATE OF BURIAL ...
(City or Town)
1
PLACE OF DEATH
Sulfalls
(County)
( City or Towns ....
The Commonwealth of Massachusetts OFFICE OF THE SECRETARY DIVISION OF VITAL STATISTICS STANDARD CERTIFICATE OF DEATH
To be filed for burial permit with Board of Health or its Agent.
16?
Registered No. $ (If death occurred in a hospital or institution, St.
{ give its NAME instead of street and number)
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