USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1904-1906 > Part 13
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Chinthropo
Boston, March 6" 1905
Name and Age ? of Deceased,
hunthy
Age, 6 years.
Date and march 6"1905, to Focus St. Withno, mas Place of Death,*
Disease Contributing cause,.
Chief cause, .... artic Stenosis. n Chief cause, Duration Contributing cause, 11
I certify that the above is true to the best of my knowledge and belief.
Name und Residence } Francis . Wenneleng of Physician,
* If an institution, state how long an Inmate and previous residence.
863 Boylston S. M.D.
D21
+ years
Maiden Name and Birthplace of Mother, OHoly Cross, Malden
٦
[11.'02-37.I.M.]
Permit No.
RETURN OF DEATH.
BOSTON, MASS.
Date of Death,.
March 17 "1905
Name in full, martha a movely
(If a married or divorced woman give maiden name, also name of husband.)
Sex,. Female
Color, Mile
Condition, Hidirect
White, Black, Mixed, Chinese, (Single, Married, Widowed or Divorced.)
Indian, etc.)
Age, 78 Years,~ Months,
Days. Occupation, ..
Residence, Hintliof mass Ward,
Place of Death, 134 Pleasant Street
Place of Birth, Portland Me
(State year, month and day.)
Date of Birth, Name and Birthplace Francie Calley - fora Scotia of Father,
Maiden Name and Mary Collins -Nova Scotia
Birthplace of Mother, ) Place of Interment, Evergreen Cemetery Portland que Summer efloyd
Undertaker 18 Odemar Street
PHYSICIAN'S CERTIFICATE OF THE CAUSE OF DEATH.
Winthrop March 18" 1905. Boston ,. Martha a moody
Age, /8 years.
Date and March 14. 190.5- 3,4 Pleasant Street
Place of Death,* Chief cause, Cerebral Haemorrhage
Disease Contributing cause, Chief cause,
3 days
Duration Contributing cause,
I certify that the above is true to the best of my knowledge and belief. Name and Residence ) а.К. телу АС A1.D.
of Physician,
* If an institution, state how long an Immate and prevlons residence.
Name and Age of Deceased,
2.3
[4.'04.37.L.M.]
Permit No.
RETURN OF DEATH. BOSTON, MASS.
March 1 9-19/05
Name in full, ...
Date of Death, Robinson Ancora Trovo nite John Robinson 7 Female Color, Black (If a married or divorced woman give maiden name, also name of husband.)
Sex,
(White, Black, Mixed, Chinese, Indian, etc.)
(Single, Married, Widowed or Divorced.) Housemost
Residence, 131 Shirley Lr. Winthrop-Mass- Ward,
Place of Death, 13, Shirley Ir - Winthrop -
Place of Birth, Halifax n.J.
(State year, month and day.)
Name and Birthplace ? of Father,
Abram Provo.
Maiden Name and Birthplace of Mother,
annova Cofield.
antigoniche- n.J. France
Place of Interment, Cedar Grove
EWIS JONES & SON, UNDERTAKERS, O La Grange St., Boston,
Levis Jones In Undertaker?7 .
PHYSICIAN'S CERTIFICATE OF THE CAUSE OF DEATH.
annova
Boston, Mch. 19. 1905.
of Deceased, annie Prova Robinson Age, 39 years.
Date and Winthrop, Mass, Ich. 19. 1905
Place of Death,* ( Chief cause, Epitelioma of Corvin Where
Disease <
Contributing cause, General Debility
Chief cause,
Duration Contributing cause, . Then months
I certify that the above is true to the best of my knowledge and belief.
Name and Residence of Physician, 1 Il Partir, Winthrop M.D.
* If an Institution, state how long an inmate and previous residence.
Unnora als. annie Provo.
Condition, married
Age, 38 Years, 11 Months,
Days. Occupation,
Date of Birth, Upril- 1866
Name and Age? als
1
-
4-'04-37-LM.]
Permit No.
RETURN OF DEATH. BOSTON, MASS.
Date of Death, March 20" 1905
Name in full,
Ralph 9, howard
(If a married or divorced woman give maiden name, also name of husband.)
Sex, male Color, White
Condition, married -
(White, Black, Mixed, Chinese, Indian, etc.)
(Single, Married, Widowed or Divorced.)
Age.3.9 Years, / .. Months, .. 9 Days.
Occupation, Dentiel
Residence, Winthrop mass
Ward,
Place of Death, 128 Winthrop Steel
(State year, month and day.)
Place of Birth, Union manie
Date of Birth,
Senge Norwood-Landene que
Name and Birthplace ? of Father, Maiden Name and Clara av. Coulter-Union me
Birthplace of Mother, Place of Interment, Wordlawn Quetery -Erect Mars Summer Floyd Undertaker. 18 Oftermandlied
PHYSICIAN'S CERTIFICATE OF THE CAUSE OF DEATH.
Winthrop March 20" 1905790.
Name and Age ? of Deceased, Rauch 9, Nonword
Age, 39 years.
Date and March 20" 1905 +23 Winthrop Sheet
Place of Death,* Chief cause, Pulmonary Labuculación. Disease
Contributing cause,. asitema
Chief cause,
One and one half of care.
Duration Contributing cause,
I certify that the above is true to the best of my knowledge and belief.
Name and Residence ? Vercy 9 home M.D.
of Physician,
* If an institution, state how long an Inmate and previous residence.
1
21
20
COMMONWEALTH OF MASSACHUSETTS
RETURN OF A DEATH
(CITY OR TOWN.)
FULL NAME
Place of )
Death * S
is Platz
Residence
Age
43
years
10
months
2€
.days
STATISTICAL DETAILS
SEX
COLOR
SINGLE, MARRIED, WIDOWED, OR DIVORCED
MAIDEN NAME +
HUSBAND'S NAME t
BIRTHPLACE #
NAME OF FATHER
BIRTHPLACE
OF FATHER+
MAIDEN NAME
OF MOTHER
BIRTHPLACE
OF MOTHER#
Hallorue
OCCUPATION
INFORMANT §
PLACE OF BURIAL OR REMOVAL !!
DATE OF BURIAL
190 5
UNDERTAKER
ADDRESS
1
PHYSICIAN'S CERTIFICATE
I HEREBY CERTIFY that I attended deceased during last iliness, from 15 190.4 ... to Mch. 26, 1905, that to the best of my knowledge and belief death occurred on the date stated above, and that the CAUSE OF DEATH was as follows : Primary : Pernicious anamicia
uncertain
Unato (DURATION). .DAYS
Contributory :
Pulmonary Ordina
.(DURATION) 6 OAYS
(Signed)
M.D.
Mck, 27 1905 (Address)
SPECIAL INFORMATION only for Hospitals, Institutions, Transients, or Recent Residents.
How long at Place of Death ? .years
. months. days
Where was disease contracted, If not at place of death ?.
Filed
190
Clerk
* City or town, street and number, If any. If death occurs away from USUAL RESI- DENCE, give facts called for under "Speclal Information." If in a Hospital or Institution, give Its NAME Instead of street and number.
t In case of married or divorced woman, or widow. # State or country; also city, town or county, If known.
§ Name and address of person giving statistical detalls. Il Name of cemetery.
Registered No.
Date of ¿
March 26
190 5
Death 1
هر
[4.'04.37.L.M.]
Permit No. 86
RETURN OF DEATH. BOSTON, MASS.
Name in full,
Date of Death, nuauch 26"1905 Dijelom Dunham
(If a married or divorced woman give maiden name, also name of husband.)
Sex, male Color Orbite Condition,
.
(White, Black, Mixed, Chinese, Indian, etc.)
(Single, Married, Widowed or Divorced.)
.Age, Years, Months, Days. Occupation, ..
Residence, 136 Revere Street Hinteno/ Ward,
Place of Death, 1.36 Perce Street Simtrop
Place of Birth, 136 Revie Sv HinchDate of Birth,
(State year, month and day.)
March 26-1905
Name and Birthplace Charlee In, Dunham-Yarmouth Suas of Father,
Maiden Name and Many Murray May Arland
Birthplace of Mother,
Place of Interment, Minttuose Cemetery- Huittrop mass Temporary Defect inthe Tank Summer FloydUndertaker. Ibitermanet-
PHYSICIAN'S CERTIFICATE OF THE CAUSE OF DEATH.
Name and Age?
Monthof March 27" 190.5. years. Boston, Stiteln (Dunham) Age ...
Date and march 26 " 1905-136 Revere R1.
Place of Death,*
Chief cause, .... Still Born
Disease Contributing cause, .... -
Chief cause,
Duration Contributing cause,
I certify that the above is true to the best of my knowledge and belief.
Name and Residence ? of Physician,
M.D.
· If an institution, state how long an Inmate and previous residence. 682 Wruttuch cave
Bevare.
of Deceased,
,[4.'04-37-LM.]
Permit No.
RETURN OF DEATH. BOSTON, MASS.
Date of Death,
March 30th 1903
Name in full, .. Mary A. Rogero Mary A Burns
Edward F, Burns
(If a married or divorced woman give maiden name, also name of husband.)
Sex, Color,
Condition,
(White, Black, Mixed, Chinese, (Single, Married, Widowed or Divorced.)
Indian, etc.)
Age, 13 Years, 9 Months, 13 Days. Occupation,. muss
None
Residence,
34 Cenystal Goog St Anthrop Ward,
Place of Death,
00
20
Place of Birth,
Portland, ME
(State year, month and day.)
Date of Birth, 1831-3-17
James Burns,
Portland, Mr.
Eunice Prudham, New castle, N. 76.
Place of Interment,(
Name and Birthplace of Father, Maiden Name and Birthplace of Mother, Mot Lohe Cemetery Boston, Mais George Hill
Undertaker.
PHYSICIAN'S CERTIFICATE OF THE CAUSE OF DEATH.
Boston,. March 30 190 8 .- Name and Age Chlu Many Of RagenAge, 73 years. 9-15 of Deceased,
Date and Mar 30 Crystal Conecte Winttuch Place of Death,* Chief cause, Cirrhosis of Liver Disease ‹ Contributing cause, ... .
Chief cause, Que to huis years a une
Duration Contributing cause,. unknown
I certify that the above is true to the best of my knowledge and belief.
Name and Residence ) of Physician, 's . Edward 7. Sage M.D.
* If an institution, state how long an Inmate and previous residence.
21
1.2
4-'04-37-LM.]
Permit No.
RETURN OF DEATH. BOSTON, MASS.
Date of Death,
avere 2"1905
Name in full,
Louisa Com Haggerelan
(If a married or divorced woman give maiden name, also name of husband.)
Sex, Female Color, Mile-
Condition, married
(White, Black, Mixed, Chinese, Indian, etc.)
(Single, Married, Widowed or Divorced.)
Age, 64 Years, Q Months, 22 Days.
Occupation, Otorisente
Residence,. Shirley Street Point Shirley.
Ward ,
Place of Death,
Place of Birth, Chelsea
Date of Birth, March 1"1841
Barry Newshuy Chelsea
Name and Birthplace ? of Father, Maiden Name and ? Birthplace of Mother,
Martha amn Burrice Chelsea
Place of Interment, Winthrop Cemetery
Summer Ofloyd Undertaker. 18 HermanQueel
PHYSICIAN'S CERTIFICATE OF THE CAUSE OF DEATH.
Boston,.
190.5 ..
Name and Age ? of Deceased, 5
Louisa amis Haggerstar Age, 64 years. 21 days
Date and Place of Death,*
Disease
Chief cause, .. Tichuban distas of Heart.
Contributing cause, - Chief cause,
. ....
Duration Contributing cause,
I certify that the above is true to the best of my knowledge and belief.
Name and Residence ) idence Insign Carpenter of Physician,
M.D.
· If an institution, state how long an Inmate and previous residence.
Fromactuator Bu. 8.
021
"
(State year, month and day.)
FORM C.
Commonwealth of Massachusetts.
No.
RETURN OF A DEATH.
To the Clerk of the City or Town in which the death occurred.
(FILL OUT WITH INK. ALL NAMES TO BE IN FULL.)
Name,
Sarah B. Spraque
Sex,.
Color,
Date of Death Chris 18%
(1905; Age, 19b Year
rs,
~ Months,
Days.
Maiden Name, If married, widowed ) or divorced.
Husband's Name,
Single, Married, Widowed or Divorced,
Occupation,
Of Home
*Residence, If out of town,
¿ also state fully.
146 Cottage Ph Road Winthrop
Place of Birth, Cantuchet
*Place of Death, 46 Collage the Road Starthich
Name and Birthplace of Father Nathaniel a- Back Me. Maiden Name and Birthplace of Mother Hepsibeth Folge Nantucket
Place of Interment, (Give name of Cemetery), Nantucket
Dated at
East Bratr
E. G. Brown
on 13
190 5
Signature and place of business of Undertaker. 286 Mendia Sr&B.
PHYSICIAN'S CERTIFICATE.
Name and Age of Deceased, t
Apraque Age,
Y.C.C.M. .... ......... D.
Place and Date of Death, died at Cottage De. Road Mentheo
pafrie . /0190 5.
Disease or Cause ! of Death, ± Secondary,
Primary,
Duration,
6 days.
Duration,
I certify that the above is true to the best of my knowledge and belief.
Signature and Residence S of Certifying Physician.
28 Lacologa
M. D.
Date of Certificate, apr. 11 1905.
· Give also street and number, if any. | Givo sok of infant not named. If atill-born, so state.
{ If a Soldier or Sailor In the War of the Rebellion, give both Primary and Secondary Cause.
Countersign and transmit to the clerk of the city or town.
Agent of Board of Health.
No ..
RETURN OF THE DEATH
OF
Sarah OSpraque at 4.6 Cottage Park Rd
Date, ajerie 10"
190 05.
Filed, aferie 17 " 1900
[EXTRACTS FROM CHAPTER 444, ACTS OF 1897.]
SECTION 6. Every householder in whose house a death occurs, the oldest person next of kin present at the time of the death of any of his kindred, or the person in charge of an institution in which a death oceurs, shall, within five days after the date of such a death, give notice thereof to the board of health or to the clerk of the city or town in which the death occurred.
SECTION 7. The commanding officer of a vessel shall give notice of the death of any person under his charge to the board of health or to the clerk of the city or town within the Commonwealth at which his vessel first arrives after such death.
SECTION 8. Penalty for neglect to comply with the requirements of sections 6 and 7, five dollars.
SECTION 10. A physician who has attended a person during his last illness shall forthwith after the death of said person, upon request, furnish for registration a certificate setting forth the required facts.
SECTION 11. In case the deceased was a soldier who served in the war of the rebellion, give both the primary and the secondary or immediate cause of death as nearly as he can state the same. Penalty for refusal or neglect, ten dollars.
SECTION 12. Any person having charge of the funereal rites preliminary to the interment of a human body shall obtain the physician's certificate made in accordance with section 10, and return it, together with the facts required by section 1, to the board of health or to the clerk of the city or town in which the death occurred.
[EXTRACTS FROM CHAPTER 437, ACTS OF 1897.]
SECTION 1. No human body shall be buried in a city or town or removed therefrom, until a permit therefor shall have been received from the proper authorities. No such permit shall be issued until a written statement, as required by law, has been furnished, with a physician's certificate of the cause of death. When such statement and certificate are delivered to the Board of Health, the board or agent shall forthwith countersign and transmit the same to the clerk of the city or town for registration.
[4.'04-37-LM.]
Permit No.
RETURN OF DEATH. Ormit BOSTON, MASS.
Date of Death,
Opere 15 " 1905
Name in full,
Marie L'agne
(If a married or divorced woman give maiden name, also name of husband.)
Sex,
Ofemale
Color
White
Condition,
Stevebon Infant
Indian, etc.)
(White, Black, Mixed, Chinese,
(Single, Married, Widowed or
Divorced.)
Age,
Years, Months, Days.
Occupation,
Residence,
Winthrop mass.
Ward.
Place of Death,
30 Read & heel
(State year, month and day.)
Place of Birth,
30 Read Sheet Date of Birth,.
alene 15.1905
Name and Birthplace \ Eugene Gagne - Canada
of Father,
Maiden Name and marie o herren - Canada
Birthplace of Mother,
Place of Interment,
Old Catholic Cemetery-Cambridge Mass
Summer Of love
Undertaker. 18 Oderman @ heel
PHYSICIAN'S CERTIFICATE OF THE CAUSE OF DEATH.
Ministrop alanie 15"
1905.
Name and Age ? Marie Gagne
of Deceased,
Stregon d'enfant
Dyears.
Date and Place of Death,* S ? - Merie 1304, 905 - 30 Read Steel
Chief cause,
Disease ' Contributing cause,. Chief cause,
Duration
Contributing cause, ..
I certify that the above is true to the best of my knowledge and belief.
Name and Residence ? of Physician, M.D.
* If an institution, state how long an Inmate and previous residence.
D21
Boston,!
4.'04-37- LM.]
Permit No.
RETURN OF DEATH. BOSTON, MASS.
Date of Death,
ajaril 18"1905
Name in full,
Sophia Andem
(If a married or divorced woman give maiden name, also name of husband.)
Sex, Female Color, White
Condition, Manied
(White, Black, Mixed, Chinese, Indian, etc.)
(Single, Married, Widowed or Divoreed.)
Age, 43 Years,.
Months, Days.
Occupation, Odensenije
Residence,. 81, Paulie Steel
Ward,
Place of Death, 81. Pauline Street
Place of Birth,
Date of Birth, Get 3/1861
Dobrodin Rovenny -
Norway.
Name and Birthplace ? of Father, Maiden Name and anna , askeland - Nouray
Birthplace of Mother,
Place of Interment, Orinthose Cemetery Printtrope mass Summer Floyd
Undertaker. 18 Herman Duces
PHYSICIAN'S CERTIFICATE OF THE CAUSE OF DEATH.
Boston,
Mere 19'
1905.
Name and Age )
of Deceased, $ Sophia Inudson
Age, 43 years.
Date and Place of Death,* ajene 18" 1905- 8, Pauline Street, Or entity
Chief cause, .. Double Precisiona
Disease < Contributing cause, ... Chief cause,. Seven days
Duration ‹ Contributing cause,
I certify that the above is true to the best of my knowledge and belief.
Name and Residence ? of Physician, M.D.
* If an institution, state how long an Inmate and previous residence.
21
(State year, month and day.)
A
[4.'04-37-LM.]
Permit No. ...... ....
RETURN OF DEATH. Printhop BOSTON, MASS.
Date of Death,
May 4" 1905
Name in full, Jane Hamilton
(If a married or divorced woman give maiden name, also name of husband.)
Sex, Female Color, White
Condition, Widowed
(Single, Married, Widowed or Divorced.)
Age, 89 Years, Months
(White, Black, Mixed, Chinese, Indian, etc.) Days. Occupation, Ward,
Residence,
Winthrop mass
Place of Death,
11 Prospect avenue
Place of Birth,
Malerloro me
(State year, month and day.)
. Date of Birth, June 24"1816
Joshua Odice, - Hateitoro me
Name and Birthplace ) of Father, Maiden Name and Betsey Lord - Water tow me
Birthplace of Mother,
Place of Interment, Waterboro maine
Summer Ofloud
Undertaker 18. Hermai Queel
PHYSICIAN'S CERTIFICATE OF THE CAUSE OF DEATH.
Printhop Boston, May 1905.
Name and Age ) of Deceased, Jane Granillon
Age, 89 years.
Date and
May 5" 1905-11 Parfeed avenue
Place of Death,* L Chief cause,. apoplexy
Disease Contributing cause, Senility
Chief cause, Immediate
Duration
Contributing cause,.
I certify that the above is true to the best of my knowledge and belief.
Name and Residence ? of Physician, M.D.
* If an Institution, state how long an inmate and previous residence.
4-'04-37-LM.]
Permit No.
RETURN OF DEATH. BOSTON, MASS.
Date of Death, May 5'1905
Name in full,
Samuel L. Larney
(If a married or divorced woman give maiden name, also name of husband.)
Sex, male Color White
Condition, manière
Age, 34 Years, / Months, 10 Days.
(White, Black, Mixed, Chinese, (Single, Married, Widowed or Divorced.) Indian, etc.) Occupation, Celegrafen Operator
Residence, Or Beach Road y Hawhom
Wardr.
Place of Death,
11 12
(State year, month and day.)
Place of Birth,
Gummik me Date of Birth,
James Varney-Grunemik me
Name and Birthplace of Father, Maiden Name and 1 Elizabeth Hing Bunnik me
Birthplace of Mother,
Place of Interment, Winthrop Cemetery
Gammel Floyd
Undertakers 18Sterman@let
PHYSICIAN'S CERTIFICATE OF THE CAUSE OF DEATH.
Boston, May 6 1905.
Name and Age ?
of Deceased, Samuel H. Vary.
Age, 54 years.
Date and May S. 1905 Winthrop, mais
Place of Death,*
Chief cause, abdominal Carcinoma
Disease
Contributing cause,. Dropsy.
Chief cause,
Duration - Contributing cause, . ..
I certify that the above is true to the best of my knowledge and belief.
Name and Residence ? of Physician, M.D.
* If an Institution, state how long an inmate and previous residence
DZI
60
[4.'04.37-LM.]
Permit No ..
RETURN OF DEATH. BOSTON, MASS.
Date of Death,
May 11 h 1905
Name in full, Mary Elizabeth been Mary Elizabeth Power- William J tceen (If a married or divorced woman give maiden name, also name of husband.) Condition, hvidon
Sex, Female Color, Inte
(White, Black, Mixed, Chinese, (Single, Married, Widowed or - Divorced.)
Age, 8 2 Years, 1 .Months, 18 Days. Occupation,
Indian, etc.) Pouremite -
Residence, Nunthrow, mark Ward,
Place of Death, 81 Train It Finithrow more
Place of Birth, Cambridgehort. Date of Birth,.
(State year, month and day.)
march 2 $ 1800
Name and Birthplace \ Jonathan Tower Laventa mare
of Father,
Maiden Name and mary Lo Hictranne Cambridge fost Inves /
Birthplace of Mother,
Place of Interment, Btanthrop Cemetery Summer verildi)
Undertaker.
PHYSICIAN'S CERTIFICATE OF THE CAUSE OF DEATH.
Boston, may 12 190 5.
Name and Age ? mary Elizabeth Keen
Age, 82 years.
of Deceased,
Date and may 1 05 81 main st worthop mas
Place of Death,*
Chief cause, Chronic Interstitial heplantes
Disease Contributing cause, ...
Chief cause, one year
Duration Contributing cause,.
I certify that the above is true to the best of my knowledge and belief.
Name and Residence ? Bis Mit call
of Physician,
* If an institution, state how long an Inmate and previous residence.
worship mars M.D.
021
سرحى
COMMONWEALTH OF MASSACHUSETTS
RETURN OF A DEATH
(CITY OR TOWN.)
FULL NAME
Fame
3. Ryan
Registered No.
Date of ¿ May 23 .190 3
Death
Residence
Age
15-
.. years.
.. months 16 .days
STATISTICAL DETAILS
SEX
71.
COLOR
20
SINGLE, MARRIED, WIDOWED, OR DIVORCED
Sujee
MAIDEN NAME +
HUSBAND'S NAME +
2
BIRTHPLACE +
Isadora ME
NAME OF
FATHER
Edward. D. Ryan
BIRTHPLACE
OF FATHER
VE Ganala
MAIDEN NAME
OF MOTHER
Mary A. LEware
BIRTHPLACE
OF MOTHER +
Brandon It
OCCUPATION
School Line
INFORMANT §
Filed
190
Clerk
* City or town, street and number, if any. If death occurs away from USUAL RESI- DENCE, give facts called for under "Speclal Information." If in a Hospital or Institution, give Its NAME Instead of street and number.
t In case of married or divorced woman, or widow.
* State or country; also city, town or county, if known.
§ Name and address of person giving statistical detalls. il Name of cemetery.
PLACE OF BURIAL OR REMOVAL II toly Cross Malden
DATE OF BURIAL
May 2G,05
ADDRESS
UNDERTAKER le. R. Presión
PHYSICIAN'S CERTIFICATE
I HEREBY CERTIFY that I attended deceased during last illness, from thmay 1905 .. to
1 may 23 ..... 190.5., that to the best of my knowledge and belief death occurred on the date stated above, and that the CAUSE OF DEATH was as follows : Primary : acute Endocarditis
Contributory :
articulay Khematismos
(DURATION). 3 mm
i. i (Signed). 631Met cal M.D.
1mg 23
1905 (Address
SPECIAL INFORMATION only for Hospitais, Institutions, Transients, or Recent Residents. How long at ..... .months .. days Place of Death ? years ....... ......
Where was disease contracted, If not at place of death ?.
30
... ( DURATION).
DAYS
Place of } Death * ) ..
36
[4.'04-37.L.M.]
Permit No.
RETURN OF DEATH. Winthrop BOSTON, MASS.
Date of Death,
May 26"1905
Name in full, ... Charles , Palle
(If a married or divorced woman give maiden name, also name of husband.)
Sex, quale
Color White Condition, Single
(White, Black, Mixed, Chinese, Indian, etc.)
(Single, Married, Widowved or Divorced.) Lawyer
Age, 62 Years, C Months,
Days.
Occupation,
Residence,
mass
Ward,
Place of Death, 25 Buchanan heel
Place of Birth,. Charleston Mass Date of Birth,
(State year, month and day.)
Name and Birthplace of Father,
alea 10, Partie"-
_
Maiden Name and Laura @,
Hanau@F.O
Birthplace of Mother,
Place of Interment, arlington Cemetery Wellington Mass Summer Floyd Undertaker.
PHYSICIAN'S CERTIFICATE OF THE CAUSE OF DEATH.
Boston, May 26, 1906.
Name and Age ? Charles Q Patter
Age, ... 62 years.
Date and May 26 "1905-25 Buchanan Klied
Place of Death,* Chief cause, Chronic Interstitial heplantio Disease . Contributing cause, mitral regurgitation
Chief cause, one year
Duration Contributing cause,
I certify that the above is true to the best of my knowledge and belief.
Name and Residence ? of Physician,
Bethel call M.D.
* If an institution, state how long an Inmate and previous residence.
021
of Deceased,
37
FORM C.
Commonwealth of Classachusetts.
No.
RETURN OF A DEATH.
To the Clerk of the City or Town in which the death occurred.
(FILL OUT WITH INK. ALL NAMES TO BE IN FULL.)
Name,
Laurener Alden Ihily
Sex,
nate Color,
Date of Death,
.190€; Age,
1
Years, ~ Months,
.Days.
Maiden Name, { If married, widowed ) or divorced.
Husband's Name,
Single, Married, Widowed or Divorced, Final4/ Occupation,
*Residence, { If out of town, ) ¿ also state fully. Winthrop Hlaso
Place of Birth,
*Place of Death,
Name and Birthplace of Father,.
Maiden Name and Birthplace of Mother, .. DEsonicant. Gada, Wodon.
Place of Interment, (Give name of Cemetery),
Dated at ...
frank J. Malonu
on
1905
Signature aud place of business of Undertaker.
(x146 Winthrop IL.
PHYSICIAN'S CERTIFICATE.
Name and Age of Deceased, t --
2 Alder Itute Age,
Y. M. D.
Place and Date of Death, died at. Afinturas
Disease or Cause { of Death, #
Primary, Secondary,
Branche. Primo
Duration, 3 days
malnutrition
Duration, 1 year
I certify that the above is true to the best of my knowledge and belief.
Signature and Residence of Certifying Physician.
M.M. Partir
M. D.
Date of Certificate, 2 190 5.
· Give alno street and number, if any. f Give sex of infant not named. If still-born, so state.
If a Soldier or Sailor in the War of the Rebellion, give both Primary and Secondary Cause.
Countersign and transmit to the clerk of the city or town.
Agent of Board of Health.
No.
RETURN OF THE DEATH
OF
at
Date,
190.
Filed,
190.
[EXTRACTS FROM CHAPTER 444, ACTS OF 1897.]
SECTION 6. Every householder in whose house a death occurs, the oldest person next of kin present at the time of the death of any of his kindred, or the person in charge of an institution in which a death occurs, shall, within five days after the date of such a death, give notice thereof to the board of health or to the clerk of the city or town in which the death occurred.
SECTION 7. The commanding officer of a vessel shall give notice of the death of any person under his charge to the board of health or to the elerk of the city or town within the Commonwealth at which his vessel first arrives after such death.
SECTION 8. Penalty for neglect to comply with the requirements of sections 6 and 7, five dollars.
SECTION 10. A physician who has attended a person during his last illness shall forthwith after the death of said person, upon request, furnish for registration a certificate setting forth the required facts.
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