Scoval, Kezia iffIR Munnuiti illassarlptartto
FORM R-301 OFFICE OF THE SECRETARY uttraltI of
, i
DIVISION OF VITAL STATISTICS STANDARD CERTIFICATE OF DEATH - 1-k-i,-1., ),,,,t
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.0 1.. ,,,, I PLACE OF DEATH .
(City or Town)
ACLU 4 County &./04 €76 9 AC
State v2.--ez.4.L.
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Registered No..
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City or Town No Z6 0 ./*)..4%.4;1. ..
4. .. ..
St., Ward
a .a."1"--",.44.41-4-0, %-)........
(If death occurred in a hospital or institution,give its NAME instead of street and number)
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2 FULL NAME e- 4-g2t- •.60 O <-1,ril-st.. —
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(If in the Army or Navy of the United States,give rank,organization,etc.)
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1.. 0 -0 (a) Residence. No .1.0...6 9?1-CGteYN— ..St, Ward.
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> - z (Usual place of abode)
(If nonzesident give city or town and State)
dW -0 0 Length of residence in city or town where death occurred 2_. years . months days. How long in U.S.,if of foreign birth? years months days
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.c PERSONAL AND STATISTICAL PARTICULARS MEDICAL CERTIFICATE OF DEATH
0 ca = 3 SEX 4 COLOR OR RACE 5 SINGLE,MARRIED,WIDOWED,---
OR
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e" DIVORCEDOVX.:(write the word) 16 DATE OF DEATH
0
(Month) ." (Day ' (Year)
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17
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I HEREBY CERTIFY, That I attended deceased from
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5a Iftraiiiehigi.l?wed,or divc6r bc...lezi."....„
,19 ,to ,19
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thatlast saw h , ,,,..... alive on
6 DATE OF BIRTH C444 /4 i , I StlY1.,s Y.2? , 19
1(Month) (bay) (fear) and that death occurred, on the date stated above, at 047 0/tr-etan.
7 AGE Years Months Days U) et co cP if LESS than The CAUSE OF DEATH was as follow
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0 P // 1 day, hrs.E •ci . E - or.....min
1 -eat...tik,aq-04. ---A-€.41-TATL-A- t,
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- 4,,, ig ci- If STILLBORN,enter that fact here
,e 1 . = 0
8 OCCUPATION OF DECEASED
-„ .0 fa)Trade,proesfsion,or
Lt-1 Ite.13 `•" c particular kind ot work C44.7.....&..0)..Lerr (dufation).4...c. ...0.04:41 ...rs i di.
S 4: ° (b) Name of employer
CONTRIBUTORY IRA.Atele(4.--.
z a' 2 & ; (SECONDARY)
(?›.1.4%—k042404...... .2
L. ". 9 BIRTHPLACE (City)
(duration) yes mos. ds.
(.9 C'7 111 C. 0
1
X Z CI (State or country)
44. (.>/' 18 Where was disease contracted
a < ' - if not at place of death?
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10 NAME OF
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FATHER -- -i't-44;trtocL. e0°
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Did an operation precede death? #1— Date of
= ...... 1 42 66 11 FATHER BIRTHPLACE(CitY)OF it.n.04.44.4_, ..,...e.c.. . _
Was there an autopsy? h-o—
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..
z ,.. . •
co Z (State or country)
., What test confirmed diagnosis?
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?.....-- . ce 12 MAIDEN NAME , , I
••"S ° CD < OF MOTHER ,4„ k „7- 'ih....e.Ark. (signed) -(.0,4A-4 02., /-1.4-.44,' M.D.
13 BIRTHPLACE OF (Addle0)..C.9 2 tAizet
.._,Z :Ft g t't MOTHER (CinY) griellwaR4-41i-? o."- e--4-al\.11.--- ,).),. .,&,..
stc 0 1- co
2..? ,.1 9 2-I
.12 g (State or country) it d/ Date
(M o AT (Day) (Year)
CL. 42 ....
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W .0 •—. 0 14 . ... 19 PLACE OF BURIAL,CREMATION,OR REMOVAL DATE OF BURIAL
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Informant... . AL ' ' i.
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tiC e co -fril.4-1" -. .14r,A,L1%-ert.4- .›, Olst.
I, •c .= (Address) i. e .. (Cemetery) (City or town)
, ip,/1, ?s..... ,c4f ji- •
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I 15 .
CC 20 UNDERTAKER ADDRESS i
6
Filed.M0 Inteh'; (Day)- (Year)' - '
. -
REGISTRAR•k ..0'4.
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21 I HEREBY CERTIFY that a satisfactory stall. fate of Permit
dard certificate of death was filed with me Official issue
12-.20-100,000 1 BEFORE the burial or transit permit was issued!`,..,:I' position - ., i of permit "' -." No i
REVISED UNITED STATES STANDARD CERTIFICATE OF DEATH EXTRACTS
FROM THE LAWS OF THE
[Approved by U.S.Cersus and Americzn Public Health Assoeiationj COM MON WEALTH OF MASSACHUSETTS
GOVERNING THE
RETURN OF' CERTIFICATES OF DEATH
Statement of occupation.—Precise statement of occupation is very
important,so that the relative healthfulness of various pursuits can be
known. The question applies to each and every person,irrespective of A physician or registered hospital medical officer shall forthwith, xr
age. For many occupations a single word or term on the first line will after the death of a person whom he has attended during his last illness,at
be sufficient,e.g.,Farmer or Planter,Physician,Compositor,Architect, the request of an undertaker or other authorized person or of any member of
Locomotive engineer,Civil engineer,Stationary fireman,etc. But in many the family of the deceased,furnish for registration a standard certificate
cases,especially in industrial employments, it is necessary to know of death,stating to the best of his knowledge and belief the name of the
(a)the kind of work and also(b)the nature of the business or industry, deceased,his supposed age,the disease of which he died,defined as re-
and therefore an additional line is provided for the latter statement;it quired by section one,where same was contracted,the duration of his
should be used only when needed. As examples: (a)Spinner,(b)Cotton last illness,when last seen alive by the physician or officer and the date
mill; (a)Salesman, (b)Grocery; (a) Foreman, (b) Automobile factory, of his death. . . .—Gen.Laws,Chap.46,Sec.9.
The material worked on may form part of the second statement. Never No undertaker or other person shall bury a human body. . .until he
return "Laborer,""Foreman,""Manager,""Dealer,"etc.,without has received a permit from the board of health or its agent.. .or. ..
more precise specification,as Day laborer,Farm laborer,Laborer—Coal from the clerk of the town where the person died;. . .No such permit
mine,etc. Women at home,who are engaged in the duties of the house- shall be issued until there shall have been delivered to such board,
hold only(not paid Housekeepers who receive a definite salary),may be agent or clerk ...a satisfactory written statement containing
entered as Housewife,Housework,or At home,and children,not gainfully the facts required by law to be returned and recorded,which shall
employed,as At school or At home. Care should be taken to report spe- be accompanied,in case of an original interment,by a satisfactory certi-
cifically the occupations of persons engaged in domestic service for ficate of the attending physician,if any,as required by law, or in lieu
wages,as Servant, Cook, Housemaid,etc. If the occupation has been thereof a certificate as hereinafter provided. If there is no attending
changed or given up on account of the DISEASE CAUSING DEATH,state physician, or if,for sufficient reasons,his certificate cannot be
occupation at beginning of illness. If retired from business,that fact obtained early enough for the purpose,or is insufficient,a physi-
may be indicated thus: Farmer(retired,8 yrs.). For persons who have clan who is a member of the board of health,or employed by it or
no occupation whatever,write None. by the selectmen for the purpose,shall upon application make
the certificate required of the attending physician. If death is
Statement of cause of death.—Name,first,the DISEASE censure caused by violence,the medical examiner shall make such certi-
DEATH(the primary affection with respect to time and causation),using ficate. . . . The person to whom the permit is so given and the physi-
always the same accepted term for the same disease. Examples: Cere-
clan certifyingthe cause of d shall th
brospinal fever(the only definite synonym is"Epidemic cerebrospinal ' CTOp..LCL.furnish for registration
meningitis"); Diphtheria(avoid use of"Croup"); Typhoid fever(never any other necessary information which can be obtained as to the deceased,
report"Typhoid pneumonia"); Lobar pneumonia; Bronchopneumonia or as to the manner or cause of the death,which the clerk or registrar may
•("Pneumonia,"unqualified,is indefinite); Tuberculosis of lungs,men- require.—Gen.Laws,Chap.11¢,Sec. 3.
inges, peritoneum, etc., Carcinoma, Sarcoma, etc., of (name Medical examiners shall make examination upon the view of the dead
bodies of only such persons as are supposed to have died by violence.
origin;"Cancer"is less definite;avoid use of"Tumor"for malignant
neoplasms); Measles; Whooping cough; Chronic valvular heart disease; — Gen,Laws,Chap.38,Sec.8.
Chronic interstitial nephritis,etc. The contributory(secondary or inter- He shall in all cases certify to the town clerk or registrar in the
current) affection need not be stated unless important. Example: place where the deceased died his name and residence,if known; other-
wise a description as full as may be,with the cause and manner of death.
Measles(disease causing death),29 da.; Bronchopneumonia(secondary), —Gen.Laws,Chap.38,Sec.7.
10 ds. Never report mere symptoms or terminal conditions,such as
"Asthenia," "Anemia" (merely symptomatic), "Atrophy,' "Col-
lapse,""Coma,""Convulsions,""Debility"("Congenital,""Senile,"
etc.),"Dropsy,""Exhaustion,""Heart failure,""Hemorrhage,""Ina- RULES OF PRACTICE
nition,""Marasmus,""Old age,""Shock,""Uremia,""Weakness," The fulfilment of the purpose of these laws calls for the observance of
etc.,when a definite disease can be ascertained as the cause. Always the following rules of practice:
qualify all diseases resulting from childbirth or miscarriage,as"PuEH-
PENAL septicemia,""PUERPERAL peritonitis,"etc. (1)Attending physicians will certify to such deaths only as those
of persons to whom they have given bedside care during a last illness
State cause for which surgical operation was undertaken, from disease unrelated to any form of injury.
(Recommendations on statement of cause of death approved by Com- (2)Board of Health Physicians will certify to such deaths only as
mittee on Nomenclature of the American Medical Association.) those of persons who,though disabled by recognized disease unrelated
Bronchopneumonia: If primary cause, write the word "pi- to any form of injury,have died without recent medical attendance or
many"; if secondary, give primary cause. II whose physician is absent from home when the certificate of death is
needed.
(3)Medical examiners will investigate and certify to all deaths sup-
posably due to injury. These include not only deaths caused directly
Certificates will be returned for additional information which or indirectly by traumatism(including resulting septicemia),and by the
give any of the following diseases,without explanation,as the action of chemical(drugs or poisons),thermal,or electrical agents,and
sole cause of death: Abortion,cellulitis,childbirth,convulsions, deaths following abortion,but also deaths from disease resulting from
hemorrhage,gangrene,gastritis,erysipelas,meningitis,miscar- injury or infection related to occupation,the sudden deaths of
riage, necrosis, peritonitis, phlebitis, pyemia, septicemia, persona not disabled by recognised disease,and those of persona
tetanus, found dead.