Griffith, Elbert THE COMMONWEALTH OF MASSACHUSETTS.—DIVISION OF VITAL STATISTICS
PERMIT FOR TRANSPORTATION OF CORPSE
p I!PLACE OF DEATH
} Z o County
— --- --- State MASSACHUSETTS. No. /6,j—(
o G�_ City or Town__ No, St,, Ward
r C L. j ,/r a iif death occur in a hospital or institutio ,give its NAME instead of street and number)
Q :...i 2FULL NAM ..)y
1 m O 0 , /' - �/v (if U.S.War Veteran,specify WAR)
W o (a)Residence. No,.,-0.3 JY-14L -o-1
_F- — St., Ward,II 12 (Usual place a abode) / (If non-resident give city or town and state)
0 0 W Length of residence in city or town where death occurred / years (� months Q days. How long in U.S.,if of foreign birth? years months days.
N
1 W V vi a PERSONAL AND STATISTICAL PARTICULARS MEDICAL CERTIFICATE OF DEATH
, X 0 Q i 0 3 SEX 4 COLOR OR RACE 15 SINGLE,MARRIED,WIDOWED,OR p
V L. J 0 )4..,.,,e,. .. DIVORCED(write the word) 15 DATE OF DEATH A / 2 p _
I = O IL.U > (Month) /(Day) Year)
3 w dg.H p a16 I HEREBY CERTIFY, That I attended deceased from
U V. divorced
L HUSBAND of `' 19__ to — — 19
Z a married,widowed or
i .J W IIt 9 m oaf ,
that I last saw h alive on _, 19
Ix ea J . >. 6 AGE Years Mon hs Days II`LESS n
O Z 0 1/h� and that E OF occurred,EATH othe dateo s: (State fully)
— m.
0.111 1 {`, U 0 hrs. The CAUSE OF DEATH was as follows: (State fully)
W Et fp i Or. , MI a
ctI. Z X IF STILLBORN, nterfthat fact here- .1 U
Q ° W h,;r,L-
D W W 3 7 OCCUPATION OF DECEASED l
m �, IL n, Z (a)Trade,profession,or
O } 3 particular kind of work. ( uration)_ _yrs. _- _mos.__ ds.
Q v fr m 0 (b)Name of employer /� c n
U W w CONTRIBUTORY c (�CeeCp�er� il ?z `�'�
C Ul U 0 8 BIRTHPLACE(City) ���CQ cy,(Secon ary) -2
,-d = a >.. (State or country) ./f€may -��f� (duration)/ - —yrs._ mos. / l S.
>" 17 Where w disease contracted , KJ• i
LL D E" U U 9 NAME OF 7 &7
O Q W co Did an operation precede death For what__- {�—
w 0 tr 1 0 BIRTHPLACE OF �,� ---
Date of operation
Q I+I J H U (I) FATHER (City)
I I=„ Q ini I I W (State or country) .7p_e,/-- Was there an autopsy
w w V w 0 Ir I I MAIDEN NAME/6/yz What test con_rme diagnosi
Y (K 1 a. ..9 d OF MOTHER r
Q O IL M.D.
iH
IL IL (State or country) •---- Date ✓/'o�p D . I f/ �-5f
F• w
Z 0 U 13 A 18 PLACE OF BURIAL,CREMATION,OR REMOVAL DATE OF BURIAL
Informant //// tt l.oYn2 r, f 7a
w;- (Address; ) - �� //� � r
• Q' V � ��l/Tt�4%C�/1iYL-(�, (Cemetery) (City or town) � /��� �
Ll U I I UNDERTAK AD RESS
,16061, _
N Filed
N n r (Month) (Day) (Year) REGISTRAR
t 20 I HEREBY CERTIFY that a satisfactory Stan- Date of
1—w ry 6 dard certificate of death was filed with me > Official issue �� Permit
1 BEFORE the burial or transit permit was issued �7Yi•�, position ( of permi No. jOS�
PERMIT OF LOCAL HEALTH AUTHORITY
This Permit with above certificate must be presented to Initial Baggage or Express Agent, as the case may be, and delivered with body
at destination. //City or T '-- Date ✓ ` ' 19 2.8'
Permiss• n i her by grant t9 t spo for final disposition at... /` u /.[� /�1eu� .
the body of Ili( , above described if p epared accordance with the
laws of this Commonwealth and rules made in conformity therewith,printed on the b ck of tls p tt. use of death contagious or commu-
nicable state name of person who is au orized to accompany the body �' `2//t-i !J" t C
SiAl i4'Siw
Healtly Official or Town Clerk'
(Check which)
.,.. ..s...nsss....s.............s•s.s•Ora s.
THE COMMONWEALTH OF MASSACHUSETTS
THIS PASTER TO BE FILLED OUT BY A REGISTERED EMBALMER
This certificate,with the Paster below,must be detached and PASTED on the Box. Transit Permit No....../.k.
CERTIFICATE tOF1 UNDER�,(� AK E n _
I hereb rtify ththe ompanying dead body of /..y L' consigned to
l own/ Of �/ State oft • County of
has been prepared for transportation in conformity with Rule No - - of the Rules printed with this-permit,-and-that I-hold
Embalm 's tificat Register d No 7//f
issued by the Board of Registration in Embalming of the State as uusee s.
' O-0--,_ Ship • g Undertaker yrof L...
Place of Business. City or Town of County of L tate of Massachusetts.
PASTER
The Railroad or other Transportation Agent must enter hereon a description of the ticket held by the passenger in charge of the corpse,the exact
route, and VIA WHAT JUNCTIONAL POINTS it reads.
SPECIAL INSTRUCTIONS.—A burial case containing a corpse must not be received for transportation unless the person in charge presents
a permit from t-ie local Board of Health or person authorized to issue same, and an undertaker's certificate that the body has been prepared <,
for shipment in accordance with the Laws of the State; nor will it be received even then if any fluids or offensivefe odors are escaping from the case.
at ' e'7- /e`er 19-g
From .. State of Massachusetts, to. ... .� State of / -
No. of Escort's Ticket Form No. of Escort's Ticket 5
�j r
No. of Co e Ticket ('""-4..- Form No. of Corpse Ticket 45 1�.
Via V ..�ay� To7"-- `.
Via - To
Via / ' To -
Via
Name of Passenger in charge
Ali•U�IiY'v/` , To Place of Residesf / /� �'�P/LLL (�r�!'p-4-h.--y-t&
Signed Shipping Agent.
S
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, except
after cremation.
RULE 2. The bodies of those who have died of diphtheria(membranous croup),scarlet fever(scarlatina,scarlet rash),measles,glanders,anthrax or leprosy
ected
fshall not be luid,(b)disinfects for
and stopping of all orifices with absorbentred for entco ton,andt(c)rwashing the body with the ardisinfects t alrial and l of injection whih must be done by a disinfectant
registe registered
embalmer,holding a certificate as such. After being disinfected as above,such boder or y shall be enveloped in a layer of cotton not less than one inch thick, completely
enclosed in a strong,tight wooden box;eorcthe body,being prepareht d for shipment by diad sinfects g and wrappinned coffin,or iron g as abt,all ove,may be placed in aoints and seams tstrol hermetically
or cask t,
and said coffin or casket encased in an air-tight zinc,copper or tin case,all joints and seams hermetically soldered,and all enclosed in a strong outside wooden box.
RULE 3. Bodies dead of typhoid fever,phthisis,puerperal fever,erysipelas,tuberculosis,or other dangerous communicable diseases,other than those specified
in Rules 1 and 2,may be received for transportation when 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; provided,that this shall apply only to bodies which can reach their destination within forty-eight
death.hours from time of all
bodiesprepared transportationconformity with
the bhas on dy
ared for
shipment by being horoughlydisinfected and arterially and cavity embalmed byegistered embalmer, he air-tight sealing and bandaging with cotton may be
dispensed with.
RULE 4. Bodies dead of diseases that are 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 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 one inch thick,
and all wrapped in a sheet and bandaged,and encased in an air-tight coffin or casket.Se Butt whenan thee bodydq y hhatslisottprepared
rreeptaY d for lhipmeenwt b being thoroughly
disinfected ard-.. w ered embalmer,-the air-,-
RULE 5. 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 passenger in charge and of 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 authorized 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 the 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 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 7. Every disinterred 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 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 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 conveyanc 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 the State of Massachusetts. •
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