USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1904-1906 > Part 23
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521
Name and Age
phe.
Brights disease
(Single, Married, Widowed or Divorced.)
Age,
62 Years, 8 Months,
24 Days. Occupation,
De 219, 906 67
2
[3.'06-37-LM.]
Permit No.
RETURN OF DEATH. BOSTON, MASS. Y
Date of Death, Jeff 9 1906
Name in full, Walter Barry Hennessy
(If marrled or divorced woman glve maiden name, also name of husband.)
Sex,
Color, ONI Condition,
(White, Black, Mixed, Chinese, Indian, etc.)
(Single, Married, Widowed or Divorced.)
Age, / Years, .. 5 Months, / 2 Days. Occupation,
Residence, * 11 Sea Hoam are
Ward,
Place of Death,
Place of Birth,
Date of Birth,
Ajustar
ElijaTich Barry
Place of Interment,
Katar.) Lane In. Undertaker.
PHYSICIAN'S CERTIFICATE OF THE CAUSE OF DEATH.
Boston, 1900.
Name and Age !
of Deceased, Plaîtci 1. semessy Age, 1/2 years.
I hereby certify that I attended deceased from 1906, to Sept
190 6 that I last saw Que
um alive on the 8 cte .day of 190 €
that .died on the Seht
day of 1906, about. 10 o'clock
A.M., or P.M., and that, to the best of my knowledge and belief, the cause of Lu .. death was as follows :
Disease - Chief cause, ..... icute Milka Infection
Contributing cause, seeks
Chief Cause,
Duration Contributing cause,. Henry S. Roven M. D.
· If an institution, state how long an Inmate and previous residence.
Bugliter Dist.
21
1
Name and Birthplace ) of Father, Maiden Name and Birthplace of Mother, Calvary bem
· (State year, month and day.)
Sept 9, 1906 68
[4.'04.37-LM.]
Permit No. ....
RETURN OF DEATH.
Winthrop BOSTON, MASS.
Date of Death,
Sept 2by 1906
Name in full, Edith a. Ringstory
(If a married or divorced woman give maiden name, also name of husband.)
Sex, Female Color White Condition, mand
(Single, Married, Widowed or Divorced.)
Age, 33 re Years, C Months, Days. Occupation,
(White, Black, Mixed, Chinese, Indian, etc.) Aumente
Residence, telesty mars
Ward,
Place of Death, 133 @heel Cheme Hantrop
Place of Birth, natick Mass Date of Birth,
(State year, month and day.)
Name and Birthplace ? of Father,
George m nelson Charleston mars
Maiden Name and
Catherine & Ruée
Dover Mass
Birthplace of Mother, Place of Interment Nordlawn Cemetery Wellesley mass Summer Floyd
Undertaker.
PHYSICIAN'S CERTIFICATE OF THE CAUSE OF DEATH.
Winthrop Boston. Sept. 2% 190.se ..
of Deceased,
Editie G. Kingsbury
Age, 33 years.
Date and Winthrop, mais. Place of Death,* L Chief cause,. ... hun as hima Disease
Sept. 2%, 1906
acute Gastrihis
Contributing cause, ...
Chief cause, about Six months
Duration Contributing cause, Five days
I certify that the above is true to the best of my knowledge and belief.
Name and Residence ? Vetro Schofield M.D. of Physician,
* If an institution, state how long an Inmate and previous residence.
Willeely, mais.
21
Name and Age ?
Je/2/ 27, 1906 69
[3.'06-37-LM.]
Permit No.
RETURN OF DEATH. BOSTON, MASS.
Date of Death,
Cect 6# 1406
Name in full, Hazel nichols
(If married or divorced woman give maiden name, also name of husband)
Sex, female .Color White
Condition, L'yle (Single, Married, Widowed or Divorced.) School Sic
(White, Black, Mixed, Chinese, Indian, ete.)
Age, 8 Years, 11 Months,
2 Days. Occupation,
Residence,* 110 Cont Road Wenche Ward, Man Place of Death, Wunschnot Mais
Place of Birth, Worthit Was Date of Birth,
(State year, mouth and day.)
Name and Birthplace ? William M. Michale
of Father, Maiden Name and 4. Schilys
Birthplace of Mother,
Place of Interment,
Undertaker.
PHYSICIAN'S CERTIFICATE OF THE CAUSE OF DEATH.
Boston,
7 1906.
of Deceased, Hazel Nichols Age, .. 8 years.
I hereby certify that I attended deceased from
190 , to
1900, that I last saw her alive on the day of. 1906
that 5ml died on the 10th day of 1906, about o'clock
A.M., or P.M., and that, to the best of my knowledge and belief, the cause of ..
death was as follows : Chief cause, Caries y Vertebra. 1
Disease Contributing cause, Extrcuestión
Chief Cause, Swen years.
Duration
Contributing cause, gradual
· If an Institution, state how long an Inmate and previous residence.
15-Princeterio 8%.
021
Name and Age ?
Hazel Nichole Det 6, 1906
1
[4-'04-37-I.M.]
Permit No.
RETURN OF DEATH. -BOSTON, MA'SS.
Date of Death,
Oct 11" 1406
Name in full,
Howard Winkteof Taylor
(If a married or divorced woman give maiden name, also name of husband.)
Condition, Z Sex, Male Color White
(White, Black, Mixed, Chinese, Indian, etc.)
(Single, Married, Widowed or Divorced.)
Age, X Years, 3 Months, > Days. Occupation,.
Residence, .. Tout Shirley
Ward,
Place of Death, Vue Dilean are
(State year, month and day.)
Place of Birth, Vur. de L'eau ave Date of Birth, July 4# 1406 Name and Birthplace Frederick H. Taylor Chelsea
of Father, Maiden Name and Birthplace of Mother,
Florence. & Thomas Charlestown
Place of Interment, Woodlawn
Te. R. Punion
Undertaker.
PHYSICIAN'S CERTIFICATE OF THE CAUSE OF DEATH.
Boston,. act 12 1906 . ..
Name and Age? Howard wollt 7 amlos
of Deceased,
Date and Point Shortly
Place of Death,* S Intention
Disease Contributing cause,
Chief cause, ..... Incrassus
Chief cause, 3 ms
Duration- Contributing cause, 2 mes
I certify that the above is true to the best of my knowledge and belief.
Name and Residence ) of Physician, S
M.D.
* If an Institution, state how long an Inmate and previous residence.
2 1
Age, ...... 3 years.
Howard Hinstrofo Taylor, Och 11, 1906
[11.'02.37-1.M.]
Permit No.
RETURN OF DEATH.
BOSTON, MASS.
Date of Death,.
Colore 19/1906
8
Name in full, Grace Of, Patchell
(If a married or divorced woman give maiden name, also name of husband.)
Sex,
Female
Color
Condition,
( White, Black, Mixed, Chinese, Indian, etc.)
(Single, Married, Widowed or Divorced.)
Age Years, 6 Months, 12 Days. Occupation, ...
Residence, Okanthropo mass
Ward,
Place of Death, 119 Shriley Street
Place of Birth, 119 Shirley SI Date of Birth,
(State year, month and day.) april 6. 1906
James Or, Patchel-Salem mars
Name and Birthplace of Father, Maiden Name and Birthplace of Mother, ) Place of Interment,
Grace Ofaringlon
Winthrop Cemetery
Summer Floyd
Undertaker.
PHYSICIAN'S CERTIFICATE OF THE CAUSE OF DEATH.
Winthrop Boston, Coloter 15". 190 G. na de
Name and Age
of Deceased , Grace Ostamington Patchett Age, -
-years. 6-12
Date and October 18 "1906-119 Shirley Steel,
Place of Death,* ) Chief cause, Probably pre-matal
Disease Contributing cause, Mal nutrition.
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, Albert B. Low au Wwithop mart. .A.D.
* If an institution, state how long an Inmate and previous residence.
Grace H. Catchet Olet 18, 1906
COMMONWEALTH OF MASSACHUSETTS
RETURN OF A DEATH
FULL NAME
Starkweather
Place of
Death *
12082 Plesant Et Winthrop mass
Residence
Winthrop mars
Age
...... .. years.
.. months.
.days
STATISTICAL DETAILS
SEX
male Orhili
COLOR
SINGLE, MARRIED,
WIDOWED, OR
DIVORCED
Single
MAIDEN NAME + HUSBAND'S NAME +
BIRTHPLACE #
Winthrop mass
NAME OF
FATHER
Walter B Stark weather
BIRTHPLACE OF FATHER+ Dover 2H
MAIDEN NAME
OF MOTHER
Olivia RCleveland
BIRTHPLACE
OF MOTHER #
margaretville n.S.
OCCUPATION
of Father Engineer
INFORMANT § Halten B Starkweather
PLACE OF BURIAL OR REMOVAL I
Nordlawn Cemetery
DATE OF BURIAL
th
Cect-19%
1906
UNDERTAKER
John In Sprague
ADDRESS
no12 Meridian
PHYSICIAN'S CERTIFICATE
1 HEREBY CERTIFY that I attended deceased during last illness, from oct 19 190 6x 190 ...... , 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 :
Still Born
Que to Fatty Degeneration
ofplacenta
.(DURATION).
.ATT.ITDAYS
...
Contributory :
(DURATION)
(Signed)
augustus S. Talkeuam
.M.D.
10-19-1906 (Address) 9 Primento Step
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 "Special Information." If In a Hospital or Institution, give its NAME instead of street and number.
t In case of married or diverced woman, or widow. - State or country ; also city, town or county, If known.
§ Name and address of person giving statistical details. Il Name of cemetery.
ALL NAMES TO BE IN FULL
Winthrop ma (CITY OR TOWN.)
.Registered No .....
Date of } Och-199
1904
Death
no /3 Starkereacher Clar 1 9, 1906
[4.'04-37. L.M.]
Permit No.
Winthrop
RETURN OF DEATH. BOSTON, MASS.
Date of Death,
October 22"1906
Name in full, Henriette Nichols
(If a married or divorced woman give maiden name, also name of husband.)
Sex, OFemale Color, White
Condition,
(White, Black, Mixed, Chinese, Indian, etc.)
(Single, Married, Widowed or Divorced.)
Age, 68 Years, Months, ~ Days. Occupation,
Residence, Or inthisto Mass
Ward,
Place of Death, 23 Beacon Street
Place of Birth, Briscoe Conn
(State year, month and day.)
Date of Birth,. May 29 " 1838
Beecher Perkins -Cristal Com
Maiden Name and Birthplace of Mother, Planteville Conn
Place of Interment,
SummerFloyd
Undertaker.
PHYSICIAN'S CERTIFICATE OF THE CAUSE OF DEATH.
Dinthato Boston, Det 22 "
190 6.
Name and Age ? of Deceased, Henratta Nichols
Age, 68 years.
Date and Cef 22 1906
Place of Death,*
Chief cause,. atprofileris Disease
Contributing cause, ... Haut Incase
Duration - Contributing cause, Heart Disease
I certify that the above is true to the best of my knowledge and belief.
Name and Residence ) of Physician, Edward 7 base M.D.
* If an Institution, state how long an Inmate and previous residence.
21
Name and Birthplace ) of Father,
Julia ann Blakeslee-Bristol Com
Chief cause,
Oct 22, 1906
..
[4.'04.37-J.M.]
Permit No.
RETURN OF DEATH. Hintero/2 BOSTON, MASS. Col
Date of Death,
Cel: 38: 1986
Name in full, Charles H. tclasses
(If a married or divorced woman give maiden name, also name of husband.)
Condition, Leconced
(Single, Married, Widowed or Divorced.)
Age, Years, Months, ~ Days. Occupation,
Residence,. Washington DC, IFard,
Place of Death, Heuttrop beach taes.
Place of Birth,
Date of Birth, رسم
Name and Birthplace ) Unknown
of Father, Maiden Name and Birthplace of Mother, Place of Interment,
Unknown
Sammen Loyd
Undertaker. 18 Stemma Plus
PHYSICIAN'S CERTIFICATE OF THE CAUSE OF DEATH.
Whiteof Boston, Q+ 28 " 190.6.
Name and Age ? Charles H. Adams
Age, .7.0 years.
Date and O+28-1906-
Place of Death,* Paresis
Disease
Chief cause, ..
Contributing cause,. Red age
Chicf cause, Two
Duration
Contributing cause,. Five a more years
I certify that the above is true to the best of my knowledge and belief.
Name and Residence )
of Physician, 5 Edward. 7, Gage M.D.
* If an institution, state how long an inmate and previous residence.
Sex, male Color 7thite (White, Black, Mixed, Chinese, Indian, etc.) Clark
(State year, month and day.)
of Deceased,
[4.'04.37-LM.]
Permit No.
RETURN OF DEATH. Hontrop. BOSTON, MASS.
Date of Death, October 29"1906
Name in full, Katherine Riley
(If a married or divorced woman give maiden name, also name of husband.)
Sex, Demale Color, White
(White, Black, Mixed, Chinese, Indian, etc.) Condition, Single
(Single, Married, Widowed or Divorced.)
Age, 29 Years, ~Months, ~Days. Occupation,.
Residence, Gestion Mass
Ward, ...
Place of Death, 32 Cottage avenue
Place of Birth, Ireland
(State year, month and day.)
Date of Birth,
Name and Birthplace ? of Father, Maiden Name and alvee mo, Guire -Apeland
Birthplace of Mother, S
Place of Interment,
Bleeley Stallon Cemetery Comeand
Summer Floyd
naes
Undertaker. ...
PHYSICIAN'S CERTIFICATE OF THE CAUSE OF DEATH.
Dranthrop Bet 30"
190 6.
Name and Age ? of Deceased, Katherine Riley
.Age, 29 years.
Date and ) October 29 " 1906632 Cottage avenue
Place of Death,* 5
Chief cause,. Tuberculão ? Lungo
Disease Contributing cause,
Chief cause,.
2 anos.
Duration
Contributing cause,
I certify that the above is true to the best of my knowledge and belief.
Name and Residence ) of Physician,
( 3) Metcal
M.D.
* If an institution, state how long an inmate and previous residence.
>21
Peter Riley
Ireland
Oct 29. 1906.
[4.'04-37-LM.]
Permit No. .....
RETURN OF DEATH.
Winthrop
-BOSTON, MASS.
Date ofDeath,
October 20 1906
Name in full, Sam La Grange
(If a married or divorced woman give maiden name, also name of husband.)
Sex, male Color While-
Condition, Stidmer
(White, Black, Mixed, Chinese, Indian, etc.)
(Single, Married, Widowed or
Divorced.)
Contractor
Age,. 85 Years, ~Months,.
Days.
Occupation,
Residence, 115, Saulhoto 5heel
Ward,.
Place of Death, Winthrop mass
Place of Birth, Newbury Of- Date of Birth,
(State year, month and day.)
Name and Birthplace ? of Father,
Stechen George- Newbury 17
Maiden Name and
3
Lydia Leighton - Necolumnl &T~
Birthplace of Mother,
Place of Interment, I interop Cemetery
Summer Floyd
Undertaker. 184 terman RI
PHYSICIAN'S CERTIFICATE OF THE CAUSE OF DEATH.
Minitrofo oston, (Qel 31" 1906
Name and Age ?
of Deceased, Sam L. George
.Age,8 5. years.
Date and October 30 " 1906 - 115 Hintenope Sheet
Place of Death,*
Chief cause, Gastric cancer
Disease
Contributing cause, Rame
Chief cause, two years
Duration tion
Contributing cause, (1
I certify that the above is true to the best of my knowledge and belief.
Name and Residence )
of Physician, S Horace / Soule M.D.
* If an institution, state how long an Inmate and previous residence.
21
-
Wer 20, 1906
[4.'04.37.LM.]
Permit No.
RETURN OF DEATH. Hiwithro BOSTON, MASS.
lac
Date of Death,
November y" 1906
Name in full, Elizabeth amy Holmes
(If a married or divorced woman give maiden name, also name of husband.)
Sex, Female
Color, White
(White, Black, Mixed, Chinese, Indian, etc.) Condition,
married
(Single, Married, Widowed or
Divorced.)
Age, 56 Years, / Months,. 21 Days.
Occupation, Hersenite
Residence, Marithol, Beach Suas .. Ward,
Place of Death, 204 Shiley Street
Place of Birth, Last Butant
(State year, month and day.)
Date of Birth,
Josefch Garrett- England
Name and Birthplace of Father, Maiden Name and Prudence Haddrone-England
Birthplace of Mother, Place of Interment, Winthrop Camere Winthrop mas Summer Floyd
Undertaker.
PHYSICIAN'S CERTIFICATE OF THE CAUSE OF DEATH.
Mintturk Boston, Amember
190.6
Name and Age )
of Deceased, Elizabeth amy Holmes
Age, 56 years.
Date and Mar. 7. Winthrop, Macd.
Place of Death,* Chief cause, Cercbral Hemorrhage
Disease
Contributing cause, Bright Die te.
Chief cause, 18 horas Duration 3 Contributing cause, Indefinite
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 res deife.
21
Elizabeth any Herlines. Im 1.1906
1
4.'04-37. LM.]
Permit No.
RETURN OF DEATH. BOSTON, MASS.
Date of Death,. November 8'1906
Name in full, frank Q, Spear
(If a married or divorced woman give maiden name, also name of husband.)
Sex, Male Color White'
Condition, Mamed
(White, Black, Mixed, Chinese, Indian, etc.)
(Single, Married, Widowed or Divorced.)
Age, 41 Years, 2 Months, 20 Days. Occupation, Clerk
Residence, Stinthrop mass
Ward,
Place of Death, Cor Bowdoin St x Willow Cheme
Place of Birth, Drentham Mass Date of Birth,.
(State year, month and day.)
ang 18'1865
John M. Spear, 1+ yanmismas
Josephnie Rhodes Wrentham Suas
Name and Birthplace of Father, Maiden Name and Birthplace of Mother, Starttrop Cemetery Winthrop mass Place of Interment, Summer Floyd Undertaker.
PHYSICIAN'S CERTIFICATE OF THE CAUSE OF DEATH.
Drathrop Boston, nor 190 6.
Name and Age Frank O, Spear
Age, 41 years.
Date and November 81 1906- Cor Bondingvilla avec Place of Death,* Diabetes
Chief cause,
....
Disease -
Contributing cause,. Come
Chicf causc, 5yrs Duration Contributing cause, 12 hours
I certify that the above is true to the best of my knowledge and belief.
Name and Residence ) of Physician, 21 Metcalle M.D.
* If an Institution, state how long an Inmate and previous residence.
2 1
of Deceased,
Frank @ Spear Mor8. 1906
COMMONWEALTH OF MASSACHUSETTS
RETURN OF A DEATH
(CITY OR TOWN.)
FULL NAME
Comelia A Minha
Registered No.
10
Date of ¿
Nov. 10
190
Death *
Residence
WirThok
Age
60
... years.
6
months. days
STATISTICAL DETAILS
SEX
termale
COLOR
Litrili
SINGLE, MARRIED,
WIDOWED, OR)
DIVORCED
Married
MAIDEN NAME +
amélia ( Guess)
HUSBAND'S NAME +
BIRTHPLACE # Iruo Krass
NAME OF
FATHER
Bartholomew Q. Guess
BIRTHPLACE
OF FATHER+
MAIDEN NAME
OF MOTHER
Bettina av. Cuturada
BIRTHPLACE
OF MOTHER #
Wellfleet
OCCUPATION
INFORMANT §
PHYSICIAN'S CERTIFICATE
I HEREBY CERTIFY that I attended deceased during las
illness, from
190.
.. to
.190 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 :
Contributory :
(Signed)
V. T Davis
.(DURATION) ......... DAY
M. D
No. 12 1906 (Address)
Aileand Mass
SPECIAL INFORMATION only for Hospitals, Institutions, Transients or Recent Residents.
How long at
Place of Death ?
.. years.
.... months.
.... day
Where was disease contracted,
If not at place of death ?
Filed Não 12 1906
Leo.
Clerk
PLACE OF BURIAL OR REMOVAL I
DATE OF BURIAL
N10.13
1906
UNDERTAKER D. F. leite
ADDRESS
Orleans
* City or town, street and number, If any. If death occurs away from USUAL RESI DENCE, give facts called for under "Special 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 details. !| Name of cemetery.
ALL NAMES TO BE IN FULL
Place of l
Cauthan
Death
1
(DURATION). .. DAY
1. 10, 700
[4.'04.37-J.M.]
Permit No.
RETURN OF DEATH. BOSTON, MASS.
Date of Death, 200 /201906
Name in full, George. M. Medios
(If a married or divorced woman give maiden name, also name of husband.)
Sex, male Color White Condition,
Manuel (Single, Married, Widowed or Divorced.)
Age, 56 Years, 9 Months, X Days. Occupation,
(White, Black, Mixed, Chinese, Indian, etc.) Barber
Residence, 18 Pleasant St Wanting
Place of Death, .....
Place of Birth, Pico azores
Date of Birth, Feb12 ,850
Name and Birthplace ? of Father,
Toney
Medios Muhamma
Maiden Name and Birthplace of Mother,
Place of Interment,
le Revenucon
-
Undertaker.
PHYSICIAN'S CERTIFICATE OF THE CAUSE OF DEATH.
Boston, nor. 15. 1906.
Name and Age )
of Deceased, Gange M. Medrar
Age, 56 years.
Date and Mar. 12. Months of.
Place of Death,* Chief cause, Labar Jums Disease
Contributing cause,
Chief cause, 5 days.
Duration Contributing cause,
I certify that the above is true to the best of my knowledge and belief.
Name and Residence ) of Physician, HI. Parker Hanthrop. M.D.
* If an institution, etate how long an inmate and previous residence.
>21
Ward,
1
(State year, month and day.)
Lenger M. medina Zur12,1906
[3.'06-37-L.M.]
Permit No.
RETURN OF DEATH. BOSTON, MASS. Willlet Man
Date of Death,. 1100. 21.1906,
Name in full,
Mary Emmily Eaton
under name} Many Emily Tourvougy Widow of Www . Salon
f married or divorced wemay give maiden name, also name of husband.)
Sex, female Color,
(White, Black, Mixed, Chinese, Indian, etc.) Condition, ... widow
alval 78 years
Age, X Years, X Months, X Days. Occupation,
Residence,* #5 Buchanan IL
Place of Death, "
(State year, month and day.)
Place of Birth, Eleworth me Date of Birth,
Name and Birthplace ? of Father, Maiden Name and 3
Birthplace of Mother,
Place of Interment, Tezcan Score
Te RIB Emisión Undertaker.
PHYSICIAN'S CERTIFICATE OF THE CAUSE OF DEATH.
Boston,
Non 2/06
1906.
Name and Age ? Mary Emily Eaten
Age, years. of Deceased,
I hereby certify that I attended deceased from Jan 14- 1905, to D'ato
19040 -190 , that I last saw
alive on the 12 Ver day of Non that the died on the 21 et
day of . Non 190 6, about 2 31) o'clock
-t.M., or P.M., and that, to the best of my knowledge and belief, the cause of
Disease Chief cause, Senility
Contributing cause, arterio ecleratis
Chief Cause, Que ye
Duration
Contributing cause, Several years
M. D.
* If an Institution, state how long an Inmate and previous residence.
621
(Single, Marricd, Widowcd or Divorced.)
her death was as follows:
mary Emily Extra Nov 21, 1906
N. B. - Every item of information should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state CAUSE OF DEATH in plain terms, so that it may be properly classified. Exact statement of OCCUPATION is very
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH
Winthrop
(No.
23
Cottage Fark Rds.
.. Ward)
Mildred Clarke.
2 FULL NAME
[If married or divorced woman or widow
give maiden name, also name of husband.]
@RESIDENCE
23 Co
tage Parto Good.
Registered No.
1
082
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
3 SEX
Vénale
4 COLOR OR RACE
White
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
Single
6 DATE OF BIRTH
February 9-1876
(Month)
(Day)
1
(Year)
7 AGE 30
.yrs.
9
mos.
12
ds.
or ...
... min. ?
& OCCUPATION
not huy-
(b) General nature of industry, business, or establishment in which employed (or employer).
9 BIRTHPLACE
(State or country)
Dorchester-Mack.
PARENTS
11 BIRTHPLACE
OF FATHER
(State or country)
Roxbury- U.H.
12 MAIDEN NAME
OF MOTHER
Sarah E Filestore.
18 BIRTHPLACE OF MOTHER (State or country)
Boston-Mars
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
Henry te Relacje
1) 2] Contage Park led-Wirthinto
16
Filed 191
REGISTRAR
16 DATE OF DEATH
2000, 27
191 >
(Month)
(Day)
(Year)
17 I HEREBY CERTIFY that I attended deceased from
191.
, to.
191
that I last saw h ...
alive on
191
and that death occurred, on the date stated above, at
......
m.
The CAUSE OF DEATH* was as follows :
Lecute Malignant Endocarditis
(Duration)
.yrs.
mos.
ds.
Contributory.
(SECONDARY)
(Duration)
.. yrs.
mos.
.........
cs.
(Signed)
M.D.
191
(Address)
* If death followed injury or violence the certificate of death must be made out by the Medical Examiner.
18 LENGTH OF RESIDENCE (FOR HOSPITALS, INSTITUTIONS, TRANSIENTS, OR RECENT RESIDENTS).
At place
of death ............ yrs.
.mos.
ds.
State
... yrs.
In the
mos.
ds.
............
Where was disease contracted, If not at place of death ?.
Former or usual residence.
PLACE OF BURIAL OR REMOVALA RATE OF BURIAL
to Mass. Crematory
Dec 10
3
191.
UNDERTAKER
al Entuan Co.
ADDRESS
25/ Fremont or
BOSTON (City or town.) [If death occurred in a hospital or institution, give its NAME instead of street and number.]
MARGIN RESERVED FOR BINDING
WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD.
important. See instructions on back of certificate.
10 NAME OF
FATHER
Henry le Clarke
(a) Trade, profession, or
particular kind of work
If LESS than
I day ......... hrs.
.....
STANDARD CERTIFICATE OF DEATH.
Statement of occupation. - Precise statement of occupa- tion is very important, so that the relative healthfulness of various pursuits can be known. The question applies to each and every person, irrespective of age. For many occupations a single word or term on the first line will be sufficient, e. g., Farmer or Planter, Physician, Compositor, Architect, Loco- motive engineer, Civil engineer, Stationary fireman, etc. But in many cases, especially in industrial employments, it is necessary to know (a) the kind of work and also (b) the nature of the business or industry, and therefore an additional line is provided for the latter statement ; it should be used only when needed. As examples: (a) Spinner, (b) Cotton mill; (a) Sales- man, (b) Grocery ; (a) Foreman, (b) Automobile factory. The material worked on may form part of the second statement. Never return " Laborer," "Foreman," " Manager," "Dealer," etc., without more precise specification, as Day laborer, Farm laborer, Laborer- Coal mine, etc. Women at home, who are engaged in the duties of the household only (not paid Ilouse- keepers who receive a definite salary), may be entered as Housewife, Housework, or At home, and children, not gain- fully employed, as At school or At home. Care should be taken to report specifically the occupations of persons engaged in domestic service for wages, as Servant, Cook, Housemaid, etc. If the occupation has been changed or given up on account of the DISEASE CAUSING DEATH, state occupation at beginning of illness. If retired from business, that fact may be indicated thus: Farmer (retired, 6 yrs.). For persons who have no occupation whatever, write None.
Statement of cause of death. - Name, first, the DISEASE CAUSING DEATH (the primary affection with respect to time and causation), using always the same accepted term for the same disease. Examples: Cerebro-spinal fever (the only definite synonym is "Epidemic cerebro-spinal meningitis") ; Diphtheria (avoid use of "Croup ") ; Typhoid fever (never re- port " Typhoid pneumonia ") ; Lobar pneumonia ; Broncho- pneumonia (" Pneumonia," unqualified, is indefinite) ; Tuber-
culosis of lungs, meninges, peritonaeum, etc , Carcinoma, Sar- coma, etc., of. ..... (name origin: "Cancer" is less definite; avoid use of "Tumor" for malignant neoplasms) ; Measles; Whooping cough ; Chronic valvular heart disease; Chronic interstitial nephritis, etc. The contributory (second- ary or intercurrent) affection need not be stated unless im- portant. Example : Measles (disease causing death), 29 ds .; Broncho.pneumonia (secondary), 10 ds. Never report mere symptoms or terminal conditions, such as " Asthenia," " An- aemia " (merely symptomatic), " Atrophy," "Collapse," " Coma," " Convulsions," "Debility " ("Congenital," "Senile," etc.), " Dropsy," " Exhaustion," "Heart failure," "Haemorrhage," " Inanition," " Marasmus," " Old age," "Shock," "Uraemia," "Weakness," etc., when a definite disease can be ascertained as the cause. Always qualify all diseases resulting from childbirth or miscarriage, as " PUER- PERAL septicemia," " PUERPERAL peritonitis," etc. State cause for which surgical operation was undertaken.
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