Rogers, Daniel {
No. 6587
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Tity of Mustun—Braftfl ElPJtartutrut
OFFICIAL BURIAL (OR REMOVAL) PERMIT
(Issued under the provisions of chapter 114,General Laws)
All the preliminary requirements of law having been complied with,including the
filing of a satisfactory certificate of death, legibly Writt in durable black ink
mission is hereby given to I per-
Da of issue of permit,- „, / / "... 194
(Undertaker) (Name)
(Address)
o the removes from
;�...,.(To be filled out in case of remove and the interment
f
m) ^ i �'` s^0 of the
, c.)
bgod, of ! t
L (Give full name of d )
who died " Y ./ / "r
(month
(day) 1 yye ' Months days
Cause of death, •- € ' ,, '
‘,,..„4
t r
Residence at time of death, •^�),/ '" - 7/ '
(Number) (Street)
(City or To )
Was Deceased a Veteran of any U.S.War
(Specify War)
Xe.ctfja:g
/1i;y0.
Health Commissioner
AMERICAN REGISTER CO.,ROSTON * 29082
Form R-310 20m-1-41 4682
.,K. --T•-• THE COMMONWEALTH OF MASSACHUSETTS.—DIVISION OF VITAL STATISTICS
PERMIT FOR TRANSPORTATION OF CORPSE
S'lje (IItrntmonfirealtlj of Attzettcllusetts
_ OFFICE OF THE SECRETARY
W• o w J�'�]n" �an DIVISION OF VITAL STATISTICS
Z f. m t u� ILBiiintyT COPY OF
Q d M c h � 9I STANDARD
m W la----` -- CERTIFICATE OF DEATH
W > o (City or Town)
O 0 W No._ I. Baptist � m c, St.J (If death occurred in a hospital or institution,
W Q h. t give lie NAMF Instead of street and oum6er
41 O
m Q _ _
_j__ _ Was deceased a U.S.
i 0 to 2 FULL NAME _-_ ceased-_ a nfir ze__..��� �tf�� �l War Veteran,if so
(�• = la f O (If deceased is a mu ed, w! ett'vrefrort�d wdntld.:g ~S6 maiden name.) specify WAR)
Pe Y
2 Q - hi N (a) Residence. No. ----- --- 'r l T-n T r v+E-4 '; St., 7 y
W (Usual place of abode) -) nr���+. (If nonreont, give city or town and state)
= Q ...1
ce Length of stay: In hospital or institution___Zaa ___ years months as s. In this community years menthe 6days.
✓ 0 J (Specify whether)
i- Q u < PERSONAL AND STATISTICAL PARTICULARS MEDICAL CERTIFICATE OF DEATH
w BOLL 3 SEX 4 COLOR OR RACE 5 MARRIED (write the word) I8 DATE OF
t) itl ..f. WIDOWED q. DEATH ..�'' ,, =J _--
f' O N I:ale - ' U' or DIVORCED i „,-"--'1 P4 (blontlfli (Dillt'Vv>iu
, CC
Q y 5a If married, widowed, or divorced T_ 19 I HEREBY CERTIFY, That I attended deceased from
CC 0. ,� I p HUSBAND of __ L
n d'f' 1(e Yit -. -.- —
ISj U. U p (Give maiden na e ,, __ �- 1
0, 2 z al (or) WIFE of I last saw h alive on_____S l__, 19____, death is said
(Husband's name in full) -- - _
_l 0 W z W to have occurred on the date stated above, at_ m.
u. l"' z w 6 Age of husband or wife if alive 7/ years �• c� a
Q W O W Immediate cause of death - Duration
a. Q w I 7 IF STILLBORN, enter that fact here. t'""'^n '+ i h
Q Q U w ��-J.t+.l�.i'--,�-b�ixr�Crr -----. IMPORTANT
m ti! 1L p, z 8 U less than 1 day
_ AGE " __Years-... Months Days
} 3 Hours-.___ Minutes. Duo to _
..1 0 •
1-. m o g Usual Ltt� `'��a
V X IX Q I- Occupation: =1C1 �.
W W 10 Industry -�..,a Due to
O N OW m p or Business: .,,__n ._
'� �„ } TT Other conditions - -- -
1i, Q = V F• 11 Social Security No. . P (Includes pregnancy within 3 months of death)
O 0 1— W U PHYSICIAN
12 BIRTHPLACE (City) _�tr
W En Q CI Z (State or country) Major findings
U W W 0 13 NAME OF of operations _
Q = pi' W FATHER ^��:� ?e l no-=%'e'"'S Date of Underline the
,J F 'L - cause to which
D. ..l U 14 BIRTHPLACE OF .. charged atatis-
it it— death should be
W 'Q FATHER (City) Verge'e sr_` t Of autopsy
111 (K U a 0 Z (State or country) - - tinily.
Q k 0 (7 94
al IS MAIDEN NAME 1,_aj' Cannot be le:. 129,:Was disease or injury In any way related to occupation of deceasedt_____
I h. z z OF MOTHER j
W U. < - e Yf'w, specify_ T
1- m 0 K a (signed) il'1-n t`�.,j'-d_ _tC-�..' 't '-.'-E - • M. D.
0 1- IS BIRTHPLACE OF ,rt,_,. ._. T ry
Z F 0 MOTHER (City) -.+�.s,i..j-'t(�•.y--e,�-a 1=•-- 'tr?-:s (Address)_ .L.G`•Z,Lie C_E 1 n1C�--- Daw=I -5_
IL U W (State or country) T ?
(f) — C 21 __-- erl >- - Y---------
\/ Is. Relation, if any.
W .- 17 -}-.,, t,.� Place of Burial,Cremation or Removal. (City or Town)
O ',y. re informant _= r, e.-wit_-nQ. .'`V..5ir, ----(.a..i...r '----) DATE OF BURIAL. I
Q W (Address) . T, V J��z �."� T ' f1 1g .
1 HEREBY CERTIFY that a aetory stand—ad certificate of death 22 NAME OF T— L
N O FUNERAL DIRECTO$ - -=2__ u.;2—w� '-( 4z _ - _J'�a .t _—
= U =
X was tiled with me BEFORE thee burial or transit permit was tamed:
ADDRESS
H I.. `f,`xtf31`}----*' -
- (Signature of Agent of Board of Health or other)
(Official Designation) (Date of Issue of Permit)
(Official Designation) (Date of Issue of Permit)
PERMIT OF LOCAL HEALTH AUTHORITY
This Permit with above certificate must be presented to Initial Baggage or Ex e • Agent, a the case be, and d livered with
body at destination. ,/
City or Town — _ .. Date.. _-CL_.19 yj
Pension y granted o tra sport for al disposition at — . -+-.0 — - � _. ...
the body ilif- --. • ..---!'s-..— ••= • — —.--- above described,if prepared in accords with the
laws of this Commonwealth and rules made in conformity rewith, printed on the back of this permit. If cause f death be contagious or
communicable, state name of person who is authorized to ccompany the body —
.{.Signed • '
Health Offici or Town Clerk
(Check which)
REGULATIONS RELATIVE TO THE CONVEYANCE OF BODIES DEAD OF ANY DISEASE DAN-
GEROUS TO THE PUBLIC HEALTH, MADE UNDER THE PROVISIONS OF SECTION 107,CHAPTER
111 of the GENERAL LAWS, AS AMENDED BY CHAPTER 265 of the ACTS of 1938.
The following terms hereinafter used are defined as follows:
"To transport" shall mean to convey or remove a dead human body from the place of death.
"To ship" shall mean to convey a dead human body by train, boat or airplane.
RULE-1. No bodies dead of any disease dangerous to the public health stay be transported or shipped, except as provided by Rules 3 and 4, without having
been prepared for burial by thorough embalming and disinfecting.
RULE 2. Bodies dead of anthrax, glanders, leprosy, plague, smallpox or tularemia, which may produce dangerous surface lesions, and if such lesions occur on
such bodies, may not be transported unless further prepared by being enveloped in a sheet saturated with bichloride of mercury, 1:500, and securely pinned; provided
that if such lesions do not occur on head, neck or hands such parts may not necessarily be enveloped. When in doubt as to the preparation of such bodies for trans-
portation, consult with the representative of the local board of health.
RULE 3. Bodies dead of diseases dangerous to the public health but without dangerous surface lesions may be transported to the morgue of a funeral
director without arterial and cavity embalming provided that such bodies have been prepared before transportation by thorough surface washing and disinfecting and by
stopping and disinfecting of orifices and by enveloping in a sheet saturated with 1:500 bichloride of mercury and securely pinning the same, Before removal from
such morgue the body must be thoroughly embalmed and disinfected.
RULE 4. Bodies dead of any disease dangerous to the public health may be transported directly to the place of burial within twenty-four hours of death
without arterial and cavity embalming, provided such bodies are prepared before transportation by thorough surface washing and disinfecting and by the stopping
and disinfecting of orifices and by enveloping in a sheet saturated with 1:500 bichloride of mercury and securely pinning the same. Such unembalmed bodies are to
be placed in sealed caskets or cases not to be reopened, and may be shown only under sealed glass panels. If such unembalmed bodies are to be shipped, they must
be placedin h sea ermetically- led cases. __ —--- —-
RULE 5. Bodies dead of any disease dangerous to the public health shall not be accompanied by articles which have been exposed to the infection of the
disease, unless such articles have been properly disinfected.
RULE 6. No disinterment of the bodies of any persons who have died of any disease dangerous to the public health shall be allowed within six months from
date of death,except by special permission of the representative of the local board of health.
REGULATIONS RELATIVE TO FUNERALS OF PERSONS DEAD OF ANY DISEASE DANGEROUS
TO THE PUBLIC HEALTH, MADE UNDER THE PROVISIONS OF SECTION 107 OF CHAPTER
111 of the GENERAL LAWS, AS AMENDED BY CHAPTER 265 of the ACTS of 1938.
RULE 1. Funerals of those dead of anterior poliomyelitis, Asiatic cholera, diphtheria, encephalitis lethargica, leprosy, meningococcus meningitis, plague,
psittacosis, scarlet fever, smallpox, streptococcus sore throat, or typhus fever, when conducted on the premises where such deceased persons died, shall be attended
only by members of the immediate household, clergymen, undertaker and undertaker's assistants; when held from a place other than where such persons died, the
representative of the local board of health may permit a public funeral if the bodies, in his opinion, have been prepared or enclosed according to the regulations of
the Department and provided such persons as are probable carriers of the infection, by reason of contact, shall be forbidden to attend such funeral.
RULE 2. Bodies dead of anthrax, glanders, leprosy, plague, smallpox or tularemia, which may produce dangerous surface lesions, and if such lesions occur
on such bodies, after preparation for transportation as regulated by the Department, must be placed before the funeral in a sealed casket, not to be reopened, and
the funeral may be either public or private. Such bodies may be shown only under a sealed glass-paneled burial case.
(Approved by Massachusetts Department of Public Health, August 9, 1938)
RULES OF THE MASSACHUSETTS STATE BOARD OF EMBALMING AND FUNERAL DIRECTING
FOR THE TRANSPORTATION OF THE DEAD.
RULE 1E. Bodies dead of diseases that are not dangerous to public health, maybe received—Tor transports ton *hen encased in a sauced-- - -- --
coffin or casket and box, or enclosed in a strong outside wooden box; provided, they reach 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 must 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 1 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 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 2E. 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 funeral director's certificate, name of deceased, date of death, age, place of
death, cause of death, the point to which the body is to be shipped, and the name of the person or persons authorized to accompany the body. The
funeral director's certificate and paster shall be detached from the transit permit and pasted on the coffin box. The transit permit shall be handed to the
passenger in charge of the corpse. The first coupon shall be detached by the official in charge of the baggage department of the initial line.
RULE SE. Every disinterred body, dead from any disease or cause, shall be treated as dangerous to the public health, and shall not be
accepted for transportation unless said removal has been approved by the Board of Health; and all such disinterred remains shall be enclosed in a
hermetically sealed (soldered if out of state) zinc, tin or copper lined coffin or box. Bodies deposited in receiving vaults will be treated and con-
sidered the same as buried bodies, unless to be interred in the same cemetery.
RULE 4E. 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 railroad station outside the state, must be prepared and forwarded in accordance with the regulations in force in the State
of Massachusetts.