USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1904-1906 > Part 6
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(FILL OUT WITH INK. ALL NAMES TO BE IN FULL.)
Date of Death, May 28" 190 4.
Full Name of Deceased, - Dennis neo Carthy
Maiden Name,
If a married or divorced woman or a widow give also
Name of Husband,
Sex, Male Color,
Single, Married, Widowed or Divorced,
Age, 3 Years, Months, Days. Occupation, Labmer
* Residence { If out of town, } Rear 91 Shirley Sweet Minutuop
Place of Death, Rear 71 Shirley Steel Minthop
Place of Birth, Queland
Name and Birthplace of Father, Jumsthy m Cathy =
eland
Maiden Name and Birthplace of Mother, Ellen Reardon == reland
Place of Burial (Give name of Cemetery), Or Josephk Cemetery (V. Rothey)
Dated at Winthrojo
Hummel Floyd
on May 28'" 190 4
Signature and place of business of Undertaker.
18 Overtar Sweet
PHYSICIAN'S CERTIFICATE.
Name and Age of Deceased, t
Dennis Mccarthy Age, 53 Y. .M. .. D.
Place and Date of Death, died at. Winthrop
May 28. 1904.
Disease or Cause of Death,# Immediate,
Primary,
Probably Heart disease Duration,
died suddenly Duration,
I certify that the above is true to the best of my knowledge and belief.
Signature and Residence of
HI. Carter
M. D.
Certifying Physician.
250 Shirley Ah
Date of Certificate, May 29. 190 4:
· Give also street and number, if any. | 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 Immediate Cause.
Countersign and transmit to the clerk of the city or town.
Agent of Board of Health.
May2
No.
RETURN OF THE DEATH
OF
Catherine 6. allison Jesiace avenue at
Date,
June 13
.. .... 190 ... 4
Filed June 22 190 4
[EXTRACTS FROM CHAPTER 29, REVISED LAWS. ]
SECTION 6. Every householder in whose honse a death oeenrs and the oldest next of kin of a deceased person in the city or town in which the death oeenrs, shall, within five days thereafter, canse notice thereof to be given to the board of health or to the town clerk.
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 sneh death.
SECTION 8. Penalty for neglect to comply with the requirements of seetions 6 and 7, five dollars.
SECTION 10. A physician shall forthwith after the death of a person whom he has attended during his last ilhiess, at the request of an undertaker or other anthorized person or of any member of the family of the deceased, furnish for registration a certificate setting forth the required facts. If of a child born dead, both the birth and death shall be reported as " stillborn ". Penalty for negleet fifty dollars.
SECTION 11. If the deceased was a soldier or sailor who served in the war of the rebellion, give both the primary and the secondary or immediate cansc of death as nearly as he ean state the same. Penalty for refusal or negleet, ten dollars.
SECTION 12. Every undertaker or other person who has charge of a funeral, shall forthwith obtain the physician's cer- tificate required by section 10, enter thereon the facts required by seetion 1, and return it to the board of health or to the elerk of the city or town in which the death occurred. The person making sneh return shall receive from the eity or town a fee of twenty-five cents.
[EXTRACTS FROM CHAPTER 78, REVISED LAWS.]
SECTION 38. No undertaker or other person shall bury a human body in a eity or town, or remove therefrom a human body which has not been bnricd, until a permit from the board of health or its agent has been received. No such permit sholl be issued until there shall have been delivered to such board a written statement, containing the facts required by law, with a physician's certificate of the cause of death. The Board of Health or agent, upon receipt of such statement and certificate, shall forth-
Penalty for violation not exceeding fifty dollars.
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.)
Date of Death, une 15" 190 4
Full Name of Deceased, Robert Ov, Our
Maiden Name,
¿ Is a married Or' divorced woman or a widow give also Name of Husband,
Sex, Color, Single, Married, Widowed or Divorced
Age, 28 Years, 2/ Months, 15 Days. Occupation, Salesman
{ If out of town, } Granitree Mass
* Residence { also state fully.
Place of Death, Winthrop, (Winthrop Beach) Old Steamboat thay
Place of Birth, Grantee Mass
Name and Birthplace of Father, William On.
Spelana relance
Maiden Name and Birthplace of Mother, Sarah Maywood Geland
Place of Burial (Give name of Cemetery), Village Cemetery Weymouth Spass
Dated at.
Signature and Summer Of loud
on
June 15' 190 4 place of business of Undertaker. 15 Herman Sheet
PHYSICIAN'S CERTIFICATE OF THE CAUSE OF DEATH.
Boston, June 190 4
Name and age of deceased, eased, RobertH@rr
Age, 28-2-15 years.
Date and place of death, *.. June 14. Dewoning C
Disease
Chief cause, .....
Contributing cause, .....
accident
Chief cause .........
Duration 3 Contributing cause,.
I certify that the above is true, to the best of my knowledge and belief.
Name and residence ! of physician,
* If in an institution, state how long an Inmate and previous residence.
Francis a Navies MIT.
tel. Sorin
The office of the Board of Health will be open for the granting of permits for buriel, es follows : - Saturdays, 9 A.M. till | P.M., except during the months of June, July, August and September, when the office will be closed on Saturdays at 12 M .; Sundays, 10 A.M. till 12 M. ; Holidays, from 10 A.M. till 12 M. ; other days, from 9 A.M till 5 P.M.
Winthrop (Harder)
No.
RETURN OF THE DEATH
OF Robert H, Oav. Winthrop Beach at
Date,.
June
190 4
Filed,
June 1 190 .. .
[EXTRACTS FROM CHAPTER 29, REVISED LAWS. ]
SECTION 6. Every householder in whose house a death occurs and the oldest next of kin of a deceased person in the city or town in which the death occurs, shall, within five days thereafter, cause notice thereof to be given to the board of health or to the town clerk.
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 shall forthwith after the death of a person whom he has attended during his last illness, at the request of an undertaker or other authorized person or of any member of the family of the deceased, furnish for registration a certificate setting forth the required facts. If of a child born dead, both the birth and death shall be reported as " stillborn ". Penalty for neglect fifty dollars.
SECTION 11. If the deceased was a soldier or sailor 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. Every undertaker or other person who has charge of a funeral, shall forthwith obtain the physician's cer- tificate required by section 10, enter thereon the facts required by section 1, and return it to the board of health or to the clerk of the city or town in which the death occurred. The person making such return shall receive from the city or town a fee of twenty-five cents.
[EXTRACTS FROM CHAPTER 78, REVISED LAWS.]
SECTION 38. No undertaker or other person shall bury a human body in a city or town, or remove therefrom a human body which has not been buried, until a permit from the board of health or its agent has been received. No such permit shall be issued until there shall have been delivered to such board a written statement, containing the facts required by law, with a physician's certificate of the cause of death. The Board of Health or agent, upon receipt of such statement and certificate, shall forth-
FORM C.
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.)
Date of Death, Day
190
Mary a. Jumble
Full Name of Deceased,
Maiden Name, Mary a Pettigrew
If a married or divorced woman or a widow give also Name of Husband, George Junhuide
Sex, Color,
Single, Married, Widowed or Divorced,
Age, 86 Years, Months, Days. Occupation,
* Residence { If out of town, } ¿ also state fully. ..
Winthrop Wase
Place of Death, 17. Sargent Steel
Place of Birth, Halifax N. S.
Name and Birthplace of Father, William Pettigrew -Scotland
Maiden Name and Birthplace of Mother, agnes Pollock-Scotland
Place of Burial (Give name of Cemetery), Dinatrop Cemetery
Dated at Winthrop
Signature and
Summer Floyd
on July 10' .190 4 place of business } of Undertaker.
18 Hemin Shut
PHYSICIAN'S CERTIFICATE.
Name and Age of Deceased, f mary a Tuemball Age, 86 Y -M -D. Place and Date of Death, died at 17 Sargent ST. Hinterof July 9 1904.
Primary, Chronic Brights Disease Duration, years
Disease or Cause of Death, } Immediate, Chrome Brylls Disease Duration, years
I certify that the above is true to the best of my knowledge and belief.
Signature and Residence
M. D.
of Certifying Physician.
Date of Certificate, July 11 1904:
· Give also street and number, if any. | Give sex of infant not named. If stifl-born, 80 state.
{ If a Soldier or Sailor in the War of the Rebellion, give both Primary and Immediate Canse.
Countersign and, transmit, to the clerk of the city or town.
Agent of Board of Health.
Commonwealth of Classachusetts.
No.
RETURN OF THE DEATH
OF
Many a. Timbale
14 Savaenl & hel
at
Date, ..
190 4
Filed, tilly 10 190 4
[EXTRACTS FROM/CHAPTER 29, REVISED LAWS. ]
SECTION 6. Every householder in whose honse a death oeenrs and the oldest next of kin of a deceased person in the oity or town in which the death occurs, shall, within five days thereafter, canse notice thereof to be given to the board of health or to the town clerk.
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 S. Penalty for neglect to comply with the requirements of seetions 6 and 7, five dollars.
SECTION 10. A physician shall forthwith after the death of a person whom he has attended during his last illness, at the request of an undertaker or other anthorized person or of any member of the family of the deceased, furnish for registration a certificate setting forth the required facts. If of a child born dead, both the birth and death shall be reported as "stillborn ". Penalty for neglect fifty dollars.
SECTION 11. If the deceased was a soldier or sailor who served in the war of the rebellion, give both the primary and the secondary or immediate canse of death as nearly as he ean state the same. Penalty for refusal or negleet, ten dollars.
SECTION 12. Every undertaker or other person who has charge of a funeral, shall forthwith obtain the physician's cor- tificate required by seetion 10, enter thereon the facts required by seetion 1, and return it to the board of health or to the clerk of the city or town in which the death occurred. The person making such return shall receive from the city or town a fee of twenty-five eents.
[EXTRACTS FROM CHAPTER 78, REVISED LAWS.]
SECTION 38. No undertaker or other person shall bury a human body in a eity or town, or remove therefrom a hnman body which has not been buried, until a permit from the board of health or its agent has been received. No such permit shull be issued until there shall have been delivered to such board a written statement, containing the facts required by law, with a physician's certificate of the cause of death. The Board of Health or agent, upon receipt of such statement and certificate, shall forth-
1
7. . @CL __ J 11. 44
COMMONWEALTH OF MASSACHUSETTS
RETURN OF A DEATH
FULL NAME
Realtimena
Das auch- Ramayan
Registered No.
Place of Death *
119 Shirley Street Monthsof Mass
Date of Death
July 7th 1904
.Age.
×
. years
months ..
>
days
STATISTICAL DETAILS
SEX Female
COLOR
SINGLE, MARRIED, WIDOWED, OR DIVORCED
MAIDEN NAME +
HUSBAND'S NAME Ť
BIRTHPLACE # 119 Shirley 511-Wanted
FATHER Sammencell mass
OF FATHER+ Frederik P. Ranagare
MAIDEN NAME OF MOTHER Cachanne Mc Sweeney
BIRTHPLACE OF MOTHER # England
OCCUPATION .
INFORMANT §
PHYSICIAN'S CERTIFICATE
I HEREBY CERTIFY that I attended deceased during last illness, from June 29 1904 to 1904, 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 :
leterus neonatorum
(DURATION)
7
DAYS
Contributory :
(DURATION) .... DAYS
(Signed)
Bysmetcale
M. D
190 ..... (Address)
SPECIAL INFORMATION only for Hospitais, Institutions, Translents, or Recent Residents.
Former or Usual Residence
How long at
Place of Death ?
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 divorced 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.
PLACE OF BURIAL OR REMOVAL II Motorn 22caso
UNDERTAKER C. R., Tennison-
DATE OF BURIAL
July 8 1904.
ADDRESS
.
July 7" 1904 Filed July 1 211904
FORM C.
Commonwealth of Itlassachusetts.
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.)
Date of Death,
"
190 4
Full Name of Deceased,
Eliga
Jane Marsters
Maiden Name,
Eliza Jane Langan
If a married or divorced woman or a widow give also (
Name of Husband,. Grelh 2. Mareleve
Sex, Color, Single, Married, Widowed or Divorced
Age, 64 Years,
Months, Days. Occupation,
* Residence { If out of town, }
( also state fully. }
Winthrop mask
Place of Death,
2
Bowdoin Steel
Place of Birth, Свой ВипенысК
Name and Birthplace of Father, Lorenzo Langan, new Brunswick
Maiden Name and Birthplace of Mother, Unknown - Unknown.
Place of Burial (Give name of Cemetery),
Winthrop Cenceley
Signature and
Summer Floyd
Dated(
quey 12
on
190
4
place of business
3
of Undertaker. 18Overmain Street
PHYSICIAN'S CERTIFICATE.
Name and Age of Deceased, t Eliga Jane Marlene Age, 64x. 11 MND.
Place and Date of Death,
died at ...
Dwithroy,
July 11'
190 4
Primary,
Disease or Cause of Death.# Immediate,
General breaking down & System Duration, 1 months
Apoplexy
Duration,
4 Weeks
I certify that the above is true to the best of my knowledge and belief.
Albal Barman M. D.
signature and Residence S of Certifying Physiclan. Writtenor man
Date of Certificate,
12th
190
4
. (i've also street and number, if any. | 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 Immediate Canse.
Countersign und transmit to the clerk of the city or toun.
Agent of Board of Health.
2
July 15-1904 Filed July 22" 1916
COMMONWEALTH OF MASSACHUSETTS
RETURN OF A DEATH
FULL NAME
13 abs neil
Registered No.
Place of Death *
10 transhall of Nunchuel
Date of Death
Age
days
STATISTICAL DETAILS
SEX female
COLOR
Mule
SINGLE, MARRIED, WIDOWED, OR DIVORCED
MAIDEN NAME +
HUSBAND'S NAME +
BIRTHPLACE #
NAME OF FATHER William. g. Mail
BIRTHPLACE OF FATHER+ England
MAIDEN NAME OF MOTHER mary mc wha
BIRTHPLACE
OF MOTHER #
Saltand
OCCUPATION
INFORMANT §
PHYSICIAN'S CERTIFICATE
04 190. 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 form
.. (DURATION). . DAYS
Contributory :
( OURATION). DAYS
(Signed)
Bismil call
M.D
190 ...... (Address)
winstorf has
SPECIAL INFORMATION only for Hospitais, Institutions, Transients, or Recent Residents.
Former or Usual Residence
How long at
Piace of Death ?
Day
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 Informatinn." 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.
ALL NAMES TO BE IN FULL
PLACE OF BURIAL OR REMOVAL il
UNDERTAKER G. R. Bemmon
DATE OF BURIAL July 19 190 S .!
ADDRESS
I HEREBY CERTIFY that I attended deceased during last illness, from 1190
to.
July 18"1904 July 20 "1906
BOSTONIA CONDITAD. 1130.
FULL NAME
CITY OF BOSTON. COMMONWEALTH OF MASSACHUSETTS.
CITY OF
RETURN OF A DEATH-1904.
BOSTO
Edward G Parker
Registered No.
6220
Place of Death l
and Residence S
Boston
Mass General Hospital
July 27
1904.
Age
46
. years
........... months.
....
days.
Date of Death
STATISTICAL DETAILS.
SEX
male
white
single.
Maiden Name
Husband's Name
Hyannis Mass
Birthplace
Name of
Joseph C
Father.
Birthplace
Hyannis Mass
of Father
Maiden Name
Arabella Harris
of Mother
Birthplace Hyannis Mass
of Mother
Bookkeeper
Occupation
Informant
PHYSICIAN'S CERTIFICATE.
I HEREBY CERTIFY that I attended deceased during last illness,
from 1904 to 1904, 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 : (
Cancer of Stomach 4 mos
(Duration)
Contributory : 2.
Gastro Enterostomy
(Duration)
8 days
(Signed).
F A Washburn Jr
M.D
July 28904
SPECIAL INFORMATION from Hospitals, Institutions, Transients, or Recen Residents.
Place of Burial Mass Crematory Ashes to HyannisResidence 28 Prospect Av Winthrop
or removal.
Mass
Undertaker
Lewis Jones & Son
Filed
July 30
1904.
A true copy.
Attest :
ErMSlenen
Registrar.
COLOR
SINGLE, MARRIED, WID., DIV.
1
RA
R S PATRIBUS, SIT DEUS N
R
CITY
NOBIS
OFFICE
BOSTONIA CONDITA A.
A.1822
8 ISREGIMINE DONATAA. 1630.
T
N. MASS.
FORM U.
Commonwealth of Classachusetts.
Perly 30
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.)
Date of Death, ... July 30 190 .
Full Name of Deceased, William Ewest Wood
Maiden Name,.
If a married or divorced woman or a widow give also Name of Husband,
Sex, m Color,
Single, Married, Widowed or Divorced,
Age, .23 Years,
5
Months,
4 Days. Occupation,
Cliente
* Residence ( also state fully. ) .
It are Way are. Withcop
Have Thay ane.
Place of Death,
Place of Birth, Sidney, New South Wales, australia
Name and Birthplace of Father, Eduard J. Wood, London, Eug.
Maiden Name and Birthplace of Mother, annie M. Brenan, Sidney 98. H. aus
Place of Burial (Give name of Cemetery), ..... . Winthrop Cemetery
Dated at Winthrop
Summer Floyd.
on
July 30,
190 ×
Signature and place of business of Undertaker.
Frutticop Mais
PHYSICIAN'S CERTIFICATE.
Name and Age of Deceased, t
Place and Date of Death,
Primary,
Disease or Cause of Death, ţ Immediate,
wmE wood Age,2 3 x 5 M. 4 D.
died at
Wave Way any
July 30
190 4
Tuberculosis of 10 mp
Duration,
3 Jens
Duration,
I certify that the above is true to the best of my knowledge and belief.
Signature and Residence
of
Certifying Physician.
Date of Certificate,
190 4
· Give also street and number, if any. | 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 Immediate Cause.
Countersign and transmit to the clerk of the city or town.
Chas R Sacchi
Agent of Board of Health.
M. D.
{ If out of town, }
No.
RETURN OF THE DEATH
OF William & Wood
....
DareSay are at
Date, July 30
190
Filed,
July 31 190 4
[EXTRACTS FROM CHAPTER 29, REVISED LAWS. ]
SECTION 6. Every householder in whose house a death occurs and the oldest next of kin of a deceased person in the city or town in which the death occurs, shall, within five days thereafter, canse notice thereof to be given to the board of health or to the town elerk.
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 shall forthwith after the death of a person whom he has attended during his last illness, at the request of an undertaker or other authorized person or of any member of the family of the deceased, furnish for registration a certificate setting forth the required faets.
SECTION 11. If the deceased was a soldier or sailor 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 negleet, ten dollars.
SECTION 12. Every undertaker or other person who has charge of a funeral, shall forthwith obtain the physician's eer- tifieate required by seetion 10, enter thereon the facts required by section 1, and return it to the board of health or to the clerk of the eity or town in which the death occurred. The person making such return shall receive from the city or town a fee of twenty-five cents.
[EXTRACTS FROM CHAPTER 78, REVISED LAWS.]
SECTION 38. No undertaker or other person shall bury a human body in a city, or town or remove therefrom a human body which has not been buried, until a permit from the board of health or its agent has been received. No such permit shall be issued until there shall have been delivered to such board a written statement, containing the facts required by law, with a physician's certificate of the cause of death. The Board of Health or agent, upon receipt of such statement and certificate, shall forth-
Daseller for violation not exceeding_fifty dollars.
COMMONWEALTH OF MASSACHUSETTS/
ingham Grammar
RETURN OF A DEATH
NAME OF TOWN.
FULL NAME
Caroline A Stuart
Registered No.
111
Place of Deat
Framingham Hospital
Date of Death ...
Augusty
1904
Age
62
. years. .. months
............... .days
STATISTICAL DETAILS
SEX
COLOR
Female while
STOLE, MARRIED,
WIDOWED, OR
DIVORCED
MAIDEN NAME +
Caroline Wright
HUSBAND'S NAME +
Amos Stuart
BIRTHPLACE İ
NAME OF
FATHER
Hermon Wright
BIRTHPLACE
OF FATHER+
Nafeur che
MAIDEN NAME
OF MOTHER
Elizabeth Richardson
BIRTHPLACE
OF MOTHER #
Bangor che
OCCUPATION
INFORMANT §
PLACE OF BURIAL OR REMOVAL II
DATE OF BURIAL Aug 2 4
UNDERTAKER
ADDRESS
PHYSICIAN'S CERTIFICATE
I HEREBY CERTIFY that I attended deceased during last 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 :
Railroad Imperier
41/2 hours
.. (OURATION). .. DAY8
Contributory :
(DURATION). DAYS
(Signed
Level Palmer
M.D.
May 200 (Address) So franningham
SPECIAL INFORMATION only for Hospitals, Institutions, Transients, or Recent Residents.
Former or
Usual Residence
Withrol chart
w long at
Place of Death ?
41/2 Days
Where was disease contracted,
If not at place of death ?
Filed
Sept6
1904 Frank Eftermenu
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 divorced 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.
Lawere a. Stewart august 1"1904 Filed aug H" 1904
BOSTONIA CONDITA.D. 1330.
IMINE DO
CITY OF BOSTON. COMMONWEALTH OF MASSACHUSETTS.
CITY OF
RETURN OF A DEATH-1904. BOSTO
FULL NAME Arthur D Allen
Registered No. 6.410
Place of Death and Residence S
Boston Carney Hospital
Date of Death
Aug 1
1904.
Age.
2.9
- years
8
.months
24 .... days.
STATISTICAL DETAILS.
SEX
COLOR
SINGLE, MARRIED, WID., DIV.
male
white
married
Maiden Name ..
.......
Husband's Name
Birthplace
Name of
Father
George ... H
Birthplace of Father
Charlestown Mass
Maiden Name
Marion
Hauchett
of Mother
Birthplace Lexington Mass
of Mother
Laundryman
Occupation
Informant.
PHYSICIAN'S CERTIFICATE.
I HEREBY CERTIFY that I attended deceased during last illness,
1904, from 1904 to 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 : {
Pul ..... Embolism.3 .... min
(Duration) 3
Contributory : 2 Pleurisy with effusion (Duration)
17 days
(Signed).
W A Thompson
M.D.
August .... 2904
...
SPECIAL INFORMATION from Hospitals, Institutions, Transients, or Recent Residents.
Place of Burial
Cambridge Cem. Cambridge
or removal
Undertaker John E Rouke
Usual Residence
Winthrop Mass
Filed
August .... 4
1904.
A true copy.
Attest :
ErMSlenen
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