Kalbfleiscly, Emma Form R.110.H4n.11-14. No.2917
THE COMMONWEALTH OF MASSACHUSETTS.—DIVISION OF VITAL STATISTICS
PERMIT FOR TRANSPORTATION OF CORPSE
O ' (Eh, Cummmtmralth of *RNaarhntY2L
D F- 1' Y.' OFFICE OF THE SECRETARY
W D 3 ( 'sisal' "' '1- a DIVISION O> VITAL STATISTICS
---• I- > 1 R \.J STANDARD
I- S .._ CERTIFICATE OF DEATH
(Orr or Town)
CO W w O .'/� J Qt dusts occurred In \hospital Or Institution,
W ❑ W 0 2 No....42e.,e(46 I.24.2l'.1(/.'. .... St., I _Waard t on its YAMS instead of street end mambas
LL
2 FULL NAMEC� ? eN (,( • i d w. c. Y { (II
,WAS•
Ol O q (If deceased u a wrda� or bo:.M. .give e1n maiden n eJ l say RUD
I
0 )_.. V w a (a) Residence. No ��f'1/2 St., Ward,
in< < H (Usual place o1 abode)r/ (If noereadent,give city or town and state)
I w -I ¢ D Lama al Masan inwA M r an re ten we Mz sm. L eawr a rr.. sa oe H lee a U.S..if N awap ling rya era .t de
U a U O J PERSONAL AND STATISTICAL PARTICULARS MF.DirAI ERTIFICATE OP DEATH
= O )"' W < 8 R 4 COLOR OR
V V 16 SINUS MARRIED
(wn' words 18 DATE OF �i 94 3/ G 3 --
< 0 2 1 WARMED 4vn"i 7, /l
w w 4 WIDOWEDe Doean DUN
(Day) Near)
I- U 0 u ro _
i < W < - 6a I amnia widowed.er Awed le I H EC R EC as C re n•r T F Y. That I attended deceased from
J r a- HUSBAND a
EC 4 -
0 (Give maiden name of wife m< fun) - 19 .to.. ... _._ ,19
W IL V 0 (w)WWI W .. ..... _. ... 1 lest saw h slim a .19.. , death Is said
D. m Z 0 111 othand a name in fall)
W - W -- to have occur red on the dab Rated above,a0._._.._.__.ro.
Q x F. 2 0: 7IF SMl80RN,Bahr teat fad Mrs. the p,o,;pt mar a Wash and related puss of hapliance m order of
W W < ¢ I T If Ian than 1 day onset were as lufoos: Y4NW
01 0W I. m 3 AGE Trade olof �rpa'�n� Doll Hours M:nvin
- n _J._ -n_._ .. ..._.. _._..
m W .- A = I B Trade.profession.on,,as"saw, �f" ,1�� (/
JO Fmp oI sew. .
< f Cr F 5i 0 Irdustr,or business In which __._...-...._...._..
0
O W W a i i
work an done. Aa.a aW.
y - .._.. . . .ec.
wI - U C w ha 10 Dab deceased last worked at II Total tine(.Yarn I; -
U. )- = < Y I tale OcppHea (month and spot In OR I Cwriwwr Smarr of importance not related to DrtnctpM nuss:� .
O D I- V V —_yesr) eaaptfm
O12 NRTNPLACL(Gt7) __... _ _..
w m W - ..__
III - (State country) _... _ . ...
< 2 O HO w 19 NAME OF .... ..
_I F. H V FATHER
a J — - — Mama OI epratron
W Q a 14 BIRTNUUCL OF
W C - m p r IATHFR pity).._ tidal test conform.'diagnosis? Was there en autopsy?
Q O U a 0 W (State:r country) 20 War asoa a or Injury Is any way fslated to occupation of awned? -
I- W h• 0 Z Y 16 MAIDFN NAME If so,spwlly _
F• DT U. ¢ < OF MOTHER (SMned) _..
O O Id 0 a (Addnesr Date 19
Z 38 MW 30TXrUCEn� ^ .......
IL < W y 21 PLACE OF BURIAL, ✓ ''/- , 1 �e--, -- p/�4/(,
N O V E I (State or country) CREMATION OR RMOVAL. /err/ w i iv Or G4Lsao
W 4 � ( err/ lCSt>or town)
O 1. 2 17 _DATE OF BURIAL 8,7 19
w __ ... ._ .... . ..
O a (Address) 22 NAVE OF y
O- 0 U UNDERTAKE Y` .:4/ s
= V to I HEREBY U TIFY thate buribcto ty standard certificate of death wet
F Z filed with me BEFORE the burial or transit>ermit wn mued: ADDRESS _
d
H 7 3...
(Signature of Agent of aloud of Health or ether (Oroeml Designation) (Date of Issue of Permit)
PERMIT OF LOCAL HEALTH AUTHORITY
This Permit with above certificate must be presented to Initial Bagga e or Express Agent,as the case may a�nd delivered with
body at destination. -- - at," -
City or Town..... .-. - ate. ... .__.. 19__....
Permission is hereby grant d to tfapsp rt o al dis.o'"tion at....... .. ..... . - --- ?---
the body of._.tti-✓Hexed ft .<f.r ....... , above described, if prepared in ac dance with the
laws of this Commonwealth and rules made in c fortuity therewith, printed on the back of this permit. If cause of death be contagious or
communicable,state name of person who is aut orized to accompany the body \ /';1{�--.-..._.-...�._...._..._.._ _A
{ ( wlwa)
TRANSPORTATION OF THE DEAD
RULES OF THE MASSACHUSETTS STATE BOARD OF REGISTRATION IN EMBALMING FOR
THE TRANSPORTATION OF THE DEAD
RULE 1. The transportation of bodies dead of smallpox. Asiatic cholera, yellow fever, typhus fever or bubonic plague is absolutely forbidden. stripe
after cremation.
RULE 2. The bodies of those who have died of diphtheria (membranous croup), scarlet fever (scarlades, scarlet rash), measles, glanders, anthrax or leprosy
shall not be accepted for transportation unlem prepared for shipment by being thoroaghly disinfected by (a) arterial and cavity injection with'an approved disinfectant
fluid- (b) disinfecting and stopping of all orifices with absorbent cotton, and (c) washing the body with the disinfectant, all of which must be done by a reentered
embalmer, holding a certificate as such. After being disinfected as above such body shall be enveloped in a layer of cotton not less than one inch thick. completely
wrapped in a sheet and bandaged, and encased in an air-tight zinc. tin, copper or Irad lined coffin, or iron casket, all joints and seams hermetically soldered. and all
enclosed in strong. tight wooden box; or the body,being prepared for shipment by disinfecting and wrapping as above, may be placed in a strong coffin or casket,
and said coffin or casket encased in an air-tight tire,copper or tin case,all joints and seams hermetically soldered,and all enclosed in a strong outside wooden box.
RULE A Bodies dead of typhoid fever, p*thisis. puerperal lever, erysipelas, tuberculosis, or other dangerous communicable diseases, other than those Spostifitel
in Rules I and 2. may be received for transportation when prepared for shspmtnt by filling cavities with an approved disinfectant, washing the exterior of the body
with the same. stopping all orifices with absorbent cotton, and enveloping the entire body with a layer of cotton not less than one inch thick. and all wrapped in a
sheet and bonehead, and encased in an air-tight coffin or casket; provided, that this shall apply only to bodies which can reach their destination withinforty-eight
heves from time of death. In all ocher cases such bodies shall be prepared for transportation in conformity with Rule 2. But when the body has been prepared for
shipment by being thoroughly disinfected and arterially and cavity embalmed by a registered embalmer, the air-tight sealing and bandaging with cotton may be
dispensed with.
RULE 4. Bodies dead of diseases that an not contagious, infectious or communicable may be received for transportation when encased in a sound coffin or
casket and box, or enclosed in a strong outside wooden bog: provided, they react their destination within forty-eight hours from the time of death. If the body
cannot reach its destination within forty-eight hours from time of death, it melt be prepared for shipment by filling cavities with an approved disinfectant, washing
the exterior of the body with the same, stopping all orifices with absorbent cotton and enveloping the entire body with a layer of cotton not less than one inch thick.
and all wrapped in a sheet and bandaged, and encased in an air-tight coffin or casket. But when the body has been prepared fee shipment by being thoroughly
disinfected and arterially and cavity embalmed by a registered embalmer, the air-fight waling and bandaging with cotton may be dispensed with.
RULE 6. In cases of contagious, infectious or communicable diseases, the body must not be accompanied by persons or articles which have been exposed to
the infection of the disease, unless certified by the health officers as having been properly.disinfected: and before selling passage tickets, agents shall carefully examine
the transit permit, and note the name of the easterlies
in charge and t any others proposing to accompany the body. and see that all necessary precautions have been
taken to prevent the spread of the disease. The transit permit shall specifically state who is authorised to accompany the remains.
RULE 6. Every dead body must be accompanied by a person in charge, who must be provided with a passage ticket, also red check ticket, first section to
be retained by railroad agent issuing same, second section to be given to person accompanying body, and third section (with cord) to be attached to box containing
corpse; also a transit permit with undertaker's certificate, name of deceased, date of death, age. place of death, Cause of death, the point to which to body is to be
shipped, and the name of the person or persons authorized to accompany the body. The undertaker's certificate and pester shall be detached from the transit permit
and pasted on the coffin box. The transit permit (hall be handed to the paneneer in charge of the corpse. The first coupon shall he detached by the official in
RULE I. Every ddnterred body, dead from any disease or cause, shall be treated as infectious or dangerous to the public health, and shall not be accepted
for transportation unless said removal has been n approved by the board of health; and all such isinterred remains shall be enclosed in a hermetically sealed (soldered)
(if out of State) zinc, tin or copper lined coffin or bat. Bodies deposited in receiving vaults will be treated and considered the same as buried bodies, unless to be
interred in same cemetery.
RULE 6. The bodies of all persons who die in Massachusetts, that are to be shipped by public conveyance. even though the initial point of such shipment
be a railway station outside the State. must be prepared and forwarded in accordance with the regulations in force in the State of Massachusetts.
tiA2Itis No.
I � �I
Grid of it;nntntt— rattli Orparttnrttt
OFFICIAL BURIAL (OR REMOVAL) PERMIT
(Issued under the provisions of chapter 114. General Laws)
All the preliminary requirements of law having been compli with, including the filing
of a satisfactory certificate of death, legibly written in e black ink, permission is
hereby given to /
/L'
/� I Date of issue pe 't 193_
r
(Undertaker) Name) (Addrees)
for the removal fro and the interment
44 /y/ (To be filed set Is came to oval) `•-
y or own)
body of
, / o full name of dece
who died �ZN yv 193? . ag years months days
Cause of death �.4,i/YLL////�)J7C /�j �/�
Residence at time of death, �or are l(tP�f` "��
(Number) (Street) ty or Town)
Was Deceased a Veteran of any U.S.War
(Specify War)
J ' a4.1. . G 'IM.
Health Commissioner
3071100 an..cpew ar.:<-d:w..-.>n:.•rser�.w.a..6a.Ye.Yr. r.ro.No. t.aae.us
f No
�� RETURN COUPON
• '' (ENDORSEMENT)
To be filled in by
Cemetery or Crematory Official
I hereby certify that the body accompanying this permit was disposed of_in accordance
with its terms. n� — . •
(Name of Cemetery or Crema
G <
OR C r s �� !! d / _Certified by G
(Date) / icial gong
r
Date of issue of'emit:. tr% 193_
(Nam.ol uaderbkerrjy / e- -/ (Address)
�
for the removal from .(t"fed r ?1n and the interment
pi// VT*b r- '.
e filled out in case of;Tenn L
at e Y-1 tt� r//jle the
fi
(Cosa.) f 6t,or To
body of _ r4A/L4/Lf� . /�i i i ., , V r4.r~+ '- ,I
,�/ (Give full tame of dee w/
•
who diett %I^/t i' '/ 193�, ag years months_days
.(month) Ater) (sear)
i
Cause of death, _ .. `� ',4.e.. l ti
` .LiYiR .eft-'
Residence at time of death, "t-'L _A l.[JI ` n' af/'�(Number) (Stree Town)
Was Deceased a Veteran of any U.S.War
Return this coupon immediately properly endorsed /Specify War)
TO BOSTON HEALTH DEPARTMENT
ROOM 1112, CITY HALL ANNEX, BOSTON, MASS.
NOTE: when a body is to he removed from a cemetery the superintendent releasing
the body may keep yellow permit for his records.
i.. .,. .o. ,sasm