USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1904-1906 > Part 9
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Age, 58 years.
Date and Sept 16th
Grover Ave. Winthrop Highland,
Place of Death,* Cancer of the beast. Disease
Chief cause, General Weakness following operation Contributing cause, with probable concursos infiltrations of Chief cause, Que to live your. Duration Contributing cause,. five or sig mouthes.
1the lungs
I certify that the above is true to the best of my knowledge and belief.
Name and Residence ? of Physician,
6. H. bobb
M.D.
* If an institution, state how long an Inmate and previous residence.
Hotel Oxford Boston
and Winthrop Highlands
2
Permit No.
Condition,. manual
Place of Birth, Iwill ME Brown
bejelental 6"1904 Filed Gyel 18' 1904
[11.'02.37.LM.]
Permit No.
RETURN OF DEATH. BOSTON, MASS.
Date of Death, September 22, 1904.
Name in full, Miriam
Married
(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, 27 Years, Months, Days. Occupation,
Residence, Pencere
Ward,
Place of Death, Winthrop thilands.
(State year, month and day.)
Place of Birth, Boston man Date of Birth, October 19 1877
Name and Birthplace Judah Levez London Eng of Father,
Maiden Name and Roce Hambre London Eng
Birthplace of Mother, )
Place of Interment, Hand in and Heat. Roy vagy Edward & Koch Undertaker.
PHYSICIAN'S CERTIFICATE OF THE CAUSE OF DEATH.
Winthrop, 1cp. 22h
1904.
Name and Age ) of Deceased, miriam Levysnu Age, 27. years.
Date and 1 Acp. 22d Chevere St. Wanthropo Place of Death,* S Chief cause, .. Oulm mary
Disease
Contributing cause, mitral Atemacis
Chief cause, 5 hours.
Duration Contributing cause, Indefinite
I certify that the above is true to the best of my knowledge and belief.
Name and Residence ) of Physician, 1
He. Porter
M.D.
* If an Institution, state how long an Inmate and previous residence.
nunam Levert ice Fixed Sefer 23 11964
FORM C.
Commonwealth of Classachusetts.
No.
RETURN OF A DEATH.
To the Clerk of the City or Town in which the death occurred.
Date of Death,. Doplember
(FILL OUT WITH INK. ALL NAMES TO BE IN FULL.)
24" 190 4
Full Name of Deceased,. Prinified Floyd Gilmore
Maiden Name,
Name of Husband,
Sex, Color,
Single, Married, Widowed or Divorced,
Age, 9 Years, 3 Months, / 7 Days. Occupation,
* Residence ( If out of town, } { also state fully. 74 Edwin Street. Dorchester Mass
Place of Death, 17 Gross Street Winthrop wass
Place of Birth, East Boston Mass
Name and Birthplace of Father, Harry & Gilmore Nova Scotia
Maiden Name and Birthplace of Mother, Ida M. Floyd = Winthrop
Place of Burial (Give name of Cemetery), Or inthrop Cemetery = Minitrope Mass
Dated at Winthrop
Signature and Summer Floyd
on Desetember 24 1904
place of business
of Undertaker.
18 Otermon Street
Venterop mas
PHYSICIAN'S CERTIFICATE.
Name and Age of Deceased, + Winifred of Gilmore Age, 9 × 3 M. ITD.
Place and Date of Death,
died at 17 Gross Sweet Defet 24 190 4
Primary,
Disease or Cause of Death, ¿ Immediate,
Duration,
7 weeks
Duration,
I certify that the above is true to the best of my knowledge and belief.
(3) met calf
M. D.
Signature and Residence § of Certifying Physician.
waltrop man
Date of Certificate,
Sepil 25
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 und transmit to the clerk of the city or town.
Agent of Board of Health
woman or a widow give also a married or divorced
No.
RETURN OF THE DEATH
OF
Winifred Floyd Fiemme
4
at
Date, .. September 24
1904
Filed,
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, 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 undertakef 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 shull be issued until there shall have been delivered to such board a written statement, containing the facts required by law, with a
[4.'04-37.I.M.]
Get 9
Permit No.
RETURN OF DEATH. BOSTON, MASS. 1
Date of Death,
Det 9 1904
Name in full,
Comeline . Cleary
(If a married or divorced woman give maiden name, also name of husband.)
Sex, male Color Intile
Condition, married
(White, Black, Mixed, Chinese, (Single, Married, Widowed or Divorced.)
Age, 4 Years, - Months, ~ Days. Occupation,
Residence, # / Gay Head
Ward, 22
Place of Death, Collage Park Road Withwok
Wase
Place of Birth, Besten wasDate of Birth,
(State year, month and day.) 18.59
Daniel Cleary
Roland
4
Place of Interment,
Edward & Rouch
Undertaker.
PHYSICIAN'S CERTIFICATE OF THE CAUSE OF DEATH.
Boston,
9
190 4.
Name and Age ?
of Deceased, Cornelius I Cleary.
Collage
Date and
Age, 45 years. & Road Was Place of Death,* S Chief cause, Disease
Cheerice Interstial replante's
Contributing cause, Cerebral Hammontage
Chief cause, Probaly 13 years
Duration Contributing cause,. 16 hours.
I certify that the above is true to the best of my knowledge and belief.
Nume und Residence } Francis J. Wennentrega of Physician,
* If an Institution, state how long an Inmate and previous residence.
863 Boylston Sr. M.D.
21
Indian, etc.) Police officer
Name and Birthplace ) of Father, Maiden Name and Birthplace of Mother, S men Calvary
Celater q'1900f Filed October 13 "1964
6 at 15
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.)
Date of Death, October
1.5 " 190 4.
Full Name of Deceased, Edward Origins
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, 27 Years,
9
Months,
Days.
Occupation,
U S. Soldiers
* Residence { If out of town, } { also state fully. For Banks- Winthrop mask ofat Banks. Hintof Maso Place of Death,
Place of Birth, Brownlow, mare.
Name and Birthplace of Father, George W. Higgins, Brockton, Maso.
Maiden Name and Birthplace of Mother, Willis X. Reach, Brocolton, mars.
Place of Burial (Give name of Cemetery), Brockton Mars
Dated at anthropo
Signature and
on October 15 1900
place of business
of Undertaker.
18 Sterman Sweet
PHYSICIAN'S CERTIFICATE.
Name and Age of Deceased, t
Edward Etigan's
Age, 27 x. 9 M. ~ D.
Place and Date of Death,
died at For Banks October 1.5 1904.
Incident
Duration,
semating solorio of hor 1
Duration,
I certify that the above is true to the best of my knowledge and belief.
BAmetcalf
Signature and Residence of Certifying Physicinn.
M. D.
Date of Certificate, 0 190
· (Five also street and number, if any. | Give sex of Infant not named. If still-born, so sinte.
{ 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.
Primary,
Disease or Cause of Death.# Immediate,
No.
RETURN OF THE DEATH
OF
at
Date,
190 ..
Filed,
190
..
[EXTRACTS FROM CHAPTER 29, REVISED LAWS. ]
SECTION 6. Every houscholder 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 fec 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 shull be issued until there shall have been delivered to such board a written statement, containing the facts required by law, with a
ant unou ropoint of such statement and certificate, shall forth-
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.)
Date of Death, Deliler 1.5''
.190 4.
Full Name of Deceased, James It. Kelley
Maiden Name,.
If a married or divorced woman or a widow give also -
Name of Husband,
Sex, Color, 27 Single, Married, Widowed of Divorced,
Age, , 3 ) Years,
8 Months,~ Days. Occupation, 1
UL B. Soldier
* Residence { If out of town, ) ( also state fully. ) .
For Banks Printtrop mass.
Place of Death, Fall Banks Winthrop mars
Place of Birth, albany, newyork.
Name and Birthplace of Father,
Maiden Name and Birthplace of Mother, notknown.
Place of Burial (Give name of Cemetery), .... Fork Revive Hall, mars.
Dated at Printhop
Summer Gfloyd
on
October 1.5''
190 4
Signature and place of business of Undertaker.
18 Herman Sheet
PHYSICIAN'S CERTIFICATE.
Name and Age of Deceased, t
James Dr. Kelley Age, 3188 M.D.
Place and Date of Death,
died at.
Fal Banks Colores 15 9904
Disease or Cause of Death, #
Primary, Immediate,
Premature Sidosion of porter
Duration,
I certify that the above is true to the best of my knowledge and belief.
Signature and Residence of
S
Certifying Physician.
Date of Certificate, oct 167
190 Y.
· Give also street and number, if any. | Give sex of infant not named. If still-born, so state.
{ If a Soldler or Sailor in the War of the Rebellion, give both Prlinary and Immediate Cause.
Countersign and transmit to the clerk of the city or town.
Agent of Board of Health.
Celso
31 Mel call
M. D.
lecident
Duration,
No.
RETURN OF THE DEATH
OF
.......
at
Date,
190
Filed,
.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, 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 clerk of the city or town within the Commonwealth at which his vessel first arrives after snch 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.
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 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 fec 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, nntil 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-
6 at 15
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, Delore 15 190 %
Full Name of Deceased, Serge J. Nevins
Maiden Name,
If a married or divorced woman or a widow give also Name of Husband,
Sex, Color, 2 Single, Married, Widowed or Divorood,
Age, 40 Years, 9 Months, Days. Occupation, W.S. Soldier
* Residence { If out of town, ) [ also state fully. )
For Banks Winthrop. Mars
Place of Death, For Banks Worthing, mass
Place of Birth, Con County, Salare.
Name and Birthplace of Father, For Known.
Maiden Name and Birthplace of Mother, not Known.
Place of Burial (Give name of Cemetery), .. Holy broek Converting, Malora, mass.
Dated at Winthrop
Summer Floyd
on
October 15 1904
Signature and place of business of Undertaker.
18 Overmon Sheet
PHYSICIAN'S CERTIFICATE.
Name and Age of Deceased, t Large J, nevis
Age, 404.9 MND.
Place and Date of Death,
died at OFart Banks
Oct 15
190 4.
Disease or Cause Primary, of Death, ţ Immediate,
accident
Duration,
Prematuro explosión 1 rotates
Duration,
Instanth
I certify that the above is true to the best of my knowledge and belief.
Signature and Residence of Certifying Physician.
M. D.
Date of Certificate, - 190 4.
· Give also street and number, if any. | Give sex of Infant not named. If still-born, so state.
1 1f a Soldler or Sailor In the War of the Rebellion, give both Primary and Immediate Cause.
Countersign and transmit to the clerk of the city or toun.
Agent of Board of Health.
No.
RETURN OF THE DEATH
OF
.
at
190.
Date,
Filed,
190
[EXTRACTS FROM CHAPTER 29, REVISED LAWS. ]
SECTION 6. Every householder in whosc 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 S. 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 snch 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, nntil 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
wagging of auch statement and certificate shall forth-
COMMONWEALTH OF MASSACHUSETTS
6
RETURN OF A DEATH
(CITY OR TOWN.)
FULL NAME
Julia Stuart Short
Registered No ...
Place of )
Death *
5
36 Somerset avenue
Residence
36
Somerset avenue
Age
.5
... years.
1
.months 6 days
STATISTICAL DETAILS
SEX
Female
COLOR
While-
SINGLE, MARRIED, WIDOWED, OR DIVORCED
MAIDEN NAME Ť
HUSBAND'S NAME +
BIRTHPLACE +
cultof mass
NAME OF
FATHER
Ovary @ It Dorf
BIRTHPLACE
OF FATHER #
Delfeest mass
MAIDEN NAME
OF MOTHER
Sarah Les
BIRTHPLACE
OF MOTHER +
milford marine
OCCUPATION
INFORMANT § Donner ofloyd
PLACE OF BURIAL OR REMOVAL !
Winthrope Ceruster
DATE OF BURIAL
Oct 19" 1904
ADDRESS
UNDERTAKER Dimmer Floyd
PHYSICIAN'S CERTIFICATE
I HEREBY CERTIFY that I attended deceased during last
t illness, from. Och. 30℃ 190.7.to Oct. 15th 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 : Pneumonia
(DURATION)
10
. DAYS
Contributory :
.(DURATION). ...... DAY8
3
(Signed).
A. B Downan
M.D.
Cech. 18th
1904 (Address)
SPECIAL INFORMATION only for Hospitals, Institutions, Transients, or Recent Residents.
How long at Place of Death ? .. years.
.... ... months.
day
S
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. r
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. || Name of cemetery.
4
Death )
Date of l
6 cl 1.5
190
easec the
r his res af
is la: nish rted
›th t it, te the wealth city
: the
Hire Artifi
COMMONWEALTH OF MASSACHUSETTS
RETURN OF A DEATH
FULL NAME
Maria Patron sutter
Registered No.
Place of Death *
Shirley Primi winthrop
Date of Death
Qc5- 16 904
Age
63
. years
6
.. months
23, days
STATISTICAL DETAILS
SEX
Female
COLOR
White
SINGLE, MARRIED, WIDOWED, OR DIVORCED
MAIDEN NAME +
Maria Juliana
HUSBAND'S NAME +
Horacio 9. harter
BIRTHPLACE # Fitchburg Mass
NAME OF
FATHER
James P. Putnam
nam
BIRTHPLACE
OF FATHER +
Fitchburg Mass.
MAIDEN NAME
OF MOTHER
affie S. Upton
BIRTHPLACE
OF MOTHER +
Fitchburg mass
OCCUPATION House wife
INFORMANT §
Edwin R. Curtis
PLACE OF BURIAL OR REMOVAL !!
DATE OF BURIAL Partipiece N.y. De 19 190. 4
UNDERTAKER
ADDRESS la Naturanon Boston
PHYSICIAN'S CERTIFICATE
| HEREBY CERTIFY that I attended deceased during last iliness, from. cel TIK. .190.V.to Cel 15th 904 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 : Heart disease.
.. (DURATION)
?
Contributory :
Embolism
(DURATION).
DAYS
(Signed)
A. B. Orman
M.D.
act. 16CF 1909 (Address)
Weuthor Mann
SPECIAL INFORMATION only for Hospitals, Institutions, Transients, 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
* Clty or town, street and number, If any. If death occurs away from USUAL RESI- DENCE, give facts calied 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 detalls. |1 Name of cemetery.
ALL NAMES TO BE IN FULL
COMMONWEALTH OF MASSACHUSETTS
RETURN OF A DEATH
FULL NAME
May Hos Syman
Registered No.
Place of Death *.
Corps Street Car demand Minttut. Mars
Date of Death
Delatec
(511/904
Age
82
years
months
19
.days
STATISTICAL DETAILS
SEX female
COLOR White
SINGLE, MARRIED, WIDOWED, OR DIVORCED
married
MAIDEN NAME +
many Hoyes March
HUSBAND'S NAME + George H. Hyman
BIRTHPLACE # Newburyport mais
NAME OF FATHER I sech march
BIRTHPLACE OF FATHER$ amberel n, Or
MAIDEN NAME
OF MOTHER
Elizabeth Hoyes
BIRTHPLACE
OF MOTHER +
Harbury mass
OCCUPATION Otorenfe
INFORMANT §
PHYSICIAN'S CERTIFICATE
| HEREBY CERTIFY that I attended deceased during last illness, from ST251 1904 to
Oct31 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 : mitral Insur, unay.
Primary : J
old als
1
(DURATION).
DAYS
Contributory :
.. (DURATION). .. DAYS
(Signed)
M.D.
1904 (Address)
Ponstirol
SPECIAL INFORMATION only for Hospitals, Institutions, Transients, 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
PLACE OF BURIAL OR REMOVAL"
DATE OF BURIAL
Nov 2
190
4
UNDERTAKER
Summer Ofland
ADDRESS
* 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. Withund Name of cemetery.
ALL NAMES TO BE IN FULL
0031
1
COMMONWEALTH OF MASSACHUSETTS
RETURN OF A DEATH
FULL NAME
Maria Gutmann sutter
Registered No.
Place of Death *
Shirley Primi Winthrop
Date of Death
Qui-16/1904
Age
63
.years
.months
23, days
STATISTICAL DETAILS
SEX
Female White
COLOR
SINGLE, MARRIED, WIDOWED, OR DIVORCED
MAIDEN NAME Ť
Maria Juliana
HUSBAND'S NAME +
Horacio G. hatte
BIRTHPLACE + Fitchburg Mass
NAME OF
FATHER
BIRTHPLACE
OF FATHER#
Fitchburg mass.
MAIDEN NAME
OF MOTHER
artie S. Leblon
BIRTHPLACE
OF MOTHER +
Fitchburg Mars
OCCUPATION House wife
INFORMANT §
Edwin R. Curtis
PHYSICIAN'S CERTIFICATE
I HEREBY CERTIFY that I attended deceased during last illness, from cel 71190 4 to Ceel 1stk 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 : Heart disease.
(DURATION)
?
Contributory :
Embolia
(DURATION)
8
DAYS
(Signed)
A. B. Orman
M.D.
act. 16 90% (Address)
wrathof Mann
SPECIAL INFORMATION only for Hospitals, Institutions, Transients, 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
PLACE OF BURIAL OR REMOVAL !!
Pistafie Ge Ny.
DATE OF BURIAL
190 4. La Naturanon Boston UNDERTAKER ADDRESS
* City or town, street and number, If any. If death occurs away from USUAL RESI- DENCE, glve facts called for under "Special Information." If In a Hospital or Institution, give Its NAME Instead of street and number.
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