USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1907-1909 > Part 17
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Primary :
(OURATION). DAY&
Contributory : ...
(OURATION) . DAY&
(Signed)
M.D.
Feb. 10 1909 (Address).
SPECIAL INFORMATION only for Hospitais, 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
PLACE OF BURIAL OR REMOVAL II
DATE OF BURIAL
2/8
190.
UNDERTAKER
ADDRESS
* City or town, street and number, If any. If death occurs away from USUAL RESI DENCE, give facts called for under "Speclai information." if in a Hospital o 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.
FILL OUT WITH INK. - THIS IS A PERMANENT RECORD
ALL NAMES TO BE IN FULL
Still Bar
Date of l
teb 7F
190 %
Death
S
15 Francis D. Kunaly JEb 7-1909.
!
COMMONWEALTH OF MASSACHUSETTS
RETURN OF A DEATH
(CITY OR TOWN.)
FULL NAME
nellie. E. Wheeler
Registered No.
Date of ¿
2/9
190G
8
5
months.
days
STATISTICAL DETAILS
SEX Female
COLOR
SINGLE, MARRIED, WIDOWED, OR DIVORCED
MAIDEN NAME +
HUSBAND'S NAME t
Lewis. a. Wheeler
BIRTHPLACE #
NAME OF FATHER
BIRTHPLACE OF FATHER#
..
MAIDEN NAME
OF MOTHER
BIRTHPLACE
OF MOTHER #
OCCUPATION Hommage
INFORMANT § Luis. G. Wheeler
PLACE OF BURIAL OR REMOVAL !!
DATE OF BURIAL
2/11
190. 9
UNDERTAKER
ADDRESS
PHYSICIAN'S CERTIFICATE
I HEREBY CERTIFY that I attended deceased during las illness, from 190 ..... to
Heb 9. 1909 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 : Eryspelar
(DURATION)
9
DAY
Contributory :
. (DURATION). DAY
(Signed)
M.D
Och. 11 1909 (Address).
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
190
Cler
* 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 o 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.
FILL OUT WITH INK .- THIS IS A PERMANENT RECORD
ALL NAMES TO BE IN FULL
Place of l
Death *
62 Beacon th
Death
Residence
Age
64
.years.
16 Nellie 6. wheeler 726-9-1909
COMMONWEALTH OF MASSACHUSETTS.
RETURN OF A DEATH-1909.
CITY OF BOSTON.
FULL NAME
Herbert W Davis
......
Registered No.
1753
Place of Death ¿
Boston
Nass. Gen .Hospt
and Residence S
Date of Death
Feb,11
1909.
Age
47
years
5
months.
9
days.
STATISTICAL DETAILS.
SEX
COLOR
SINGLE, MARRIED, WID., DIV.
M
Maiden Name
Husband's Name
Birthplace Portland , Me.
Name of
Father William Davis
ISREGIMINT
B Q.S'T
MASS.
Contributory : !
Miliary Tub. of Lungs -
(Duration)
Maiden Name
of Mother
Anna Doughty
Birthplace of Mother ..
Windham, Me ,
Royal Hatch
M.D.
Feb,12
1909
SPECIAL INFORMATION from Hospitals, Institutions, Transients, or Recent Residents.
Admitted to hospital Jan.27,1909
Usual Residence
Winthrop(8 Trident avel
Filed
1909.
A true copy,
Attest :
ErMSlenen
Registrar.
.HATTAATTAT STAT CHASINGATT ATTESTETAY
Place of Burial
or removal
Winthrop
Undertaker
C . Bennison
winthrop
PHYSICIAN'S CERTIFICATE.
I HEREBY CERTIFY that I attended deceased during last illness,
1909
from 1909, 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 :
STRAR'S
CITY
PATRIBUS SIT DEES - Prima (Dura tion)
Tuberculosis of Adrenals -
FFICE
(Addisons dis,) 2 yrs
BOSTONIA CONDITA ML
CIVITATISR
1831.
DONATA A.
Birthplace
of Father
Durham, Me
mos .
(Signed)
Occupation
Chemist
Informant
Feb.13
Herbert Nr Dorio
METBE -1018 Feb 11-09
COMMONWEALTH OF MASSACHUSETTS
RETURN OF A DEATH
(CITY OR TOWN.)
FULL NAME
Robert R. MC dead
Registered No.
Place of )
14 deivis cere
Death *
5
Residence vincent
Age
.. years.
×
.months. × .days
STATISTICAL DETAILS
SEX
Male
COLOR
SINGLE, MARRIED, WIDOWED, OR DIVORCED
MAIDEN NAME +
HUSBAND'S NAME +
BIRTHPLACE # Westfield. M.S.
NAME OF
FATHER
James . MC Loud
BIRTHPLACE
OF FATHER$
Liverpool U.S.
MAIDEN NAME
OF MOTHER
anna. Suit
BIRTHPLACE
OF MOTHER #
Liverpool U.S.
OCCUPATION
INFORMANT §
Filed
190
..... Clerk
PLACE OF BURIAL OR REMOVAL II
DATE OF BURIAL
2/ 14
190.7.
UNDERTAKER la. R.Bennison.
ADDRESS
PHYSICIAN'S CERTIFICATE
I HEREBY CERTIFY that I attended deceased during las illness, from Feb-11 Fet /2" .190.9. 190.9 ... 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 :
mitral insufficiency
f
4 40 .(DURATION)
Contributory :
angñas Pectoris
(DURATION)
1
DAY8
(Signed)
M.D.
Je/13 /909 (Address)
170 mm shop st
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 ?.
* 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. 1 State or country ; also city, town or county, if known.
§ Name and address of person giving statistical details. Il Name of cemetery.
FILL OUT WITH INK .- THIS IS A PERMANENT RECORD
ALL NAMES TO BE IN FULL
Date of ¿
2/12
190
Death S
9
1 Robert a ms Lead_ Feb 12-1909.
[1-'09-37-XXXM.]
Permit No.
RETURN OF DEATH. BOSTON, MASS.
Date of Death, Solomon Jacobs
Fibrewany 13th 1909.
Name in full,
(If married or divorced woman give maiden name, also name of husband.)
Sex, Quale
Color,
Condition,
(White, Black, Mixed, Chinese, Indian, etc.)
(Single, Married, Widowed
Divorced.)
Retired
Age, 79 Years, Months, ... Days. Occupation,
Residence,*
25 Coral ave Willnot Ward,
Place of Death,
(State year, month and day.) Place of Birth, andtardano HollandDate of Birth,
Jacob Jacobs. Holland
Holland
Place of Interment,
* If an institution, state how long an inmate and previous residence.
Undertaker.
PHYSICIAN'S CERTIFICATE OF THE CAUSE OF DEATH.
Bostonl feb 1x 4
19.09.
Name and Age ! Solomon Jacobs Age, .. 79 years. of Deceased,
I hereby certify that I attended deceased from. 19 Oy, to. Feb- 13h
1909, that I last saw him alive on the. day of. .19 0 9
Le
that died on the 133
day of Fulmay 1909, about 1:20 pm .o clock
.
A.M., or P.M., and that, to the best of my knowledge and belief, the cause of huso death was as follows:
Disease Chief cause,
Fatty elecmeration of the Hurt.
Contributing cause,. Inppe
Chief Cause, Queda years
Duration
Contributing cause,
2 weeks
(310met cal) M. D.
PHYSICIANS BEFORE STATING CAUSE OF DEATH ARE REQUESTED TO SEE THE OTHER SIDE OF THIS BLANK.
821
Name and Birthplace } of Father, Maiden Name and Birthplace of Mother, Hand in Hand Ceno W. I fox tury
13 ml
LIST OF INDEFINITE TERMS WHICH SHOULD BE AVOIDED IN GIVING CAUSES OF DEATH.
Acute gastritis. State cause. Was it due to some irritant poison ?
Ascites. Name disease causing ascites. See "Dropsy."
Asphyxia. How? Was it accidental? If so, state fully the nature of the accident. If by gases or poisonous vapors, give particulars. Was it a case of "overlying" (child) ? What disease caused this condition ?
Asthenia. A practically worthless statement. See "Debility." What was the cause?
Atrophy. What caused the atrophy? Was it tuberculous wasting (phthisis) ? Was it syphilis? What organ or part atrophied ?
Blood poisoning. Do you mean septicemia, syphilis, or any other definite disease? If septicemia, what was the cause? Was it puerperal ?
Chronic pneumonia.
Was this not pulmonary tuberculosis?
Congestion of lungs.
Was it acute bronchitis, broncho-pneumonia, or lobar- pneumonia? If so, state definitely. Was it passive or hypostatic congestion ? If so, name disease causing the condition.
Convulsions.
What caused the convulsions? Were they epileptic, puerperal, or caused by diarrhea or enteritis (infants) ? Name the disease in which the convulsions occurred. "Convulsions" are mere symptoms and should not be given as equivalent to a proper statement of cause of death.
Debility.
What caused the debility? Name the acute or chronic disease. Debility might follow typhoid fever, diph- theria, tuberculosis, Bright's disease, and a host of other causes. The return is worthless and should never be made.
Dentition.
What was the disease causing death of the teething child ? "Dentition" is not a proper cause of death, and, like "infantile" and "old age," does little except to mark the approximate age of decedents.
Dropsy.
Name the disease in which the "dropsy" occurred.
Dyspepsia. Was there organic disease of the stomach or other organs? If so, name the disease causing death.
Eclampsia. Give cause of convulsions. Were they puerperal?
Edema of lungs.
Give cause. See "Congestion of lungs."
Gastric fever.
A worthless return. Was it acute gastritis (q. v.) or some
definite form of fever, as typhoid, malarial, etc .?
Gencral paralysis.
If extended paralysis resulted from cerebral hemorrhage, the cause should be given and the expression "general paralysis" should be avoided. "General paralysis" should be written only for "general paralysis of the insane," or paretic dementia, and the statement of the fact of insanity should always be included.
Heart failure.
What disease caused the "heart failure"? The heart always "fails" before death from any cause. Be par- ticularly careful that deaths from diphtheria, tubercu- losis, etc., are not so reported. If organic heart disease is meant it should be so stated.
Hemorrhage of lungs.
Was this not due to pulmonary tuberculosis? If so, the primary cause should be reported without fail.
Hypostatic congestion.
Name the disease causing the passive or hypostatic con- gestion.
Imperfect nutrition.
State name of disease causing imperfect nutrition. Did it follow some disease? If so, give name of disease.
This is a particularly pernicious term and is responsible for a multitude of worthless certificates. It sounds as if it meant something definite, but, in the majority of cases, it does not. What disease caused the inanition? Was it syphilis, tuberculosis, cholera infantum? inability to take food, state cause.
Infantile asthenia. See " Asthenia."
The term "infantile" adds no precision to an indefinite statement.
Infantile atrophy. See "Atrophy."
Malassimilation.
What disease caused the malassimilation ?
Malnutrition. What disease caused the malnutrition?
Marasmus. What disease caused the "marasmus" ? Was it due to tuberculosis, syphilis, or cholera infantum? State fully, as this return in itself is practically worthless for compilation.
Meningitis. Was it epidemic cerebro-spinal meningitis? If so, write exactly in this form. Did it follow scarlet fever, pneu- monia, or some acute infection? If so, name the pri- mary disease. Was it traumatic? If so, state thc nature of the violence which caused the meningitis. Was it tuberculous meningitis ?
Nephritis. Was it acute or chronic? If acute, occurring in the course of some disease, name the disease causing death.
Old age.
This is not a satisfactory return. The influence of age is shown by the statement of age in years, months, and days. To this the statement of "old age" as a cause of death adds nothing of value. Name the disease to which the old person succumbed.
Peritonitis. What was the cause of the peritonitis? "Idiopathic peri- tonitis" should be rarely returned. Was it puerperal or traumatic? In the latter case, state mode of injury
Pernicious anemia. If any definite cause can be assigned for the anemia, it should be reported. Anemia due to tuberculosis, syph- ilis, etc., should be returned under the primary disease.
Pneumonia. Specify definitely whether broncho-pneumonia or lobar pneumonia. If sequel to influenza, state that fact.
Pyemia. What caused the pyemia? Was it puerperal or trau matic? If traumatic, state nature of accident causing injury.
Senile asthenia. See "Old age" and "Asthenia." death.
Give disease causing
Senile atrophy. See "Old age" and "Atrophy." death.
See "Old age."
State disease causing death.
Senile decline.
See "Old age." Name the disease, if any, that caused the
decline.
Senile marasmus.
See "Old age" and "Marasmus." Name disease causing
death.
Shock. What caused the shock? If from injury, state nature o accident. If from surgical operation, state disease o injury requiring the operation.
Surgical
operation.
Surgical shock.
Always state the disease or injury requiring operation Unless the operation was improper or unskilfully per formed, it should not be given as the primary cause o death.
Teething. Name the disease affecting the teething child. See "Den tition."
Toxemia. Was this acute or chronic poisoning due to some externa agent? Was it auto-intoxication, due to poisons gen erated in the body by disease? If so, state the nam of the disease.
Tuberculosis. State organ affected. Do not fail to state as pulmonar tuberculosis if lungs were affected.
Tumor.
Was it a cancer? Whether a cancer or tumor, do not fa
to specify organ or part of body affected.
Typhoid condition.
Avoid this term as it is likely to be mistaken for typhoid
fever.
Typhoid pneumonia.
Was the primary disease typhoid fever or pneumonia ?
Inanition.
Typho-malarial fever. If
Was it typhoid fever? Was it malarial fever? A mix ture of these diseases rarely occurs, the great majorit of cases of so-called "typho-malarial fever" being noth ing more nor less than typhoid fever.
State disease causing
Senile decay.
COMMONWEALTH OF MASSACHUSETTS-
Winthrop
(CITY OR TOWN.)
FULL NAME
Place of l 117 Locual IL
Date of l
Death *
Residence
Winthrop Mass
Age
20
.. years ..
months.
16 .. days
STATISTICAL DETAILS
SEX
Male
COLOR
white
SINGLE, MARRIED, WIDOWED, OR DIVORCED
manai
MAIDEN NAME t
HUSBAND'S NAME +
L
BIRTHPLACE #
NAME OF
FATHER
lohn. dr. Favor.
BIRTHPLACE
OF FATHER#
Box con Mars
MAIDEN NAME
OF MOTHER
Sarah. Simmons
BIRTHPLACE OF MOTHER#
OCCUPATION Latente in Sonhar Port offri
INFORMANT § wife
PHYSICIAN'S CERTIFICATE
I HEREBY, CERTIFY that I attended deceased during last illness, from ..... 700-16 1909, 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 :
angina Pectoris
(DURATION)
2 mm
.DAYS
Contributory :
(Signed)
7416
190(4.(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
PLACE OF BURIAL OR REMOVAL !!
Reading Commuting
DATE OF BURIAL
2/19
1907
UNDERTAKER G.R. Benmoi
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 detalls. Il Name of cemetery.
FILL OUT WITH INK .- THIS IS A PERMANENT RECORD
ALL NAMES TO BE IN FULL
RETURN OF A DEATH John. S. LE. Favor.
Registered No.
Death S
190 9
to te
ite
ise
31-
.(DURATION). ..... .DAY8
M.D.
19 John 8. LE Farm Jeb 16-1909
1
p e
€
a
f
t.
[12.'08-VC.]
Med
JUNTERSIONESBY THE VARD OF HEALTH, FEB 23 1909
aminer's No. 1232
RETURN OF A DEATH.
BOSTON, MASS.
Name in full,
James & Doherty
husband by Susan
( If married or divorced woman give maiden name, also name of husband.)
Condition, manned
(Single, Married, Witowet of Divorced)
Age, 50 Years, - Months,
Days.
Occupation,
Residence, 202 friend
Place of Death, winthrop
mass
Place of Birth, Ireland
(State year, month and day.) Date of Birth Unknown.
Cheland
Name and Birthplace of Father,
Elizabeth Doherty ee .
Maiden Name and Birthplace of Mother, S Haly, Cross: Cemetery, Malden Place of Interment, Edward Cannes & FLon
Undertaker.
Certificate of the Medical Examiner.
I hereby certify that James S. Doherty
age 50 yrs residence, 202 2 Friend SO .
who died on the 19 th day of February 1969,
came to his death from
Cause :
Dilatation
of the Heart.
Manner :
FER 23 1900
ARTE
Permit No. 26266
SECRETARY.
Date of Death,
Cheb 19. 1909
Sex, male Color, .. white
(White, Black, Mixed, Chinese, Indian, etc.) Labourer #
Ward
6.
John Doherty
..
M. D., Medical Examiner for Suffolk County.
James S. Sahang Feb 19-1909
COMMONWEALTH OF MASSACHUSETTS.
RETURN OF A DEATH-1909.
CITY OF BOSTON.
FULL NAME
Bridget Irving
..........
Registered No. 1741
Place of Death
Boston
Mass. Gen. Hospt
and Residence S
Date of Death
Feb.23
1909.
Age
61
years
.... .months. days.
STATISTICAL DETAILS.
SEX
COLOR
SINGLE, MARRIED, WID., DIV.
F
Maiden Name ..
Murray
Husband's Name John J Irving
Ireland
Birthplace
Name of
Richard Murray
Father
Birthplace of Father
Ireland
Maiden Name of Mother ..
Margaret Powers
Birthplace of Mother ..
Ire land
Occupation
At Home
Informant
PHYSICIAN'S CERTIFICATE.
I HEREBY CERTIFY that I attended deceased during last illness,
.1909,
from 1909, 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 :
AR'S
T PATRIBUS
SIT DE Prima (Duration)
Purulent Salpingitis, Genl.
Peritonitis: 3 wks
BOSTONTA" A).1823 CONDITA AL.
183D.
DONATA A
MASS. Contributory : } Broncho-Pneumonia - 1 wk (Duration)
(Signed) J I Belknap M.D.
Feb.24 1909
SPECIAL INFORMATION from Hospitals, Institutions, Transients, or Recent Residents.
Admitted to hospital Feb.8,1909
Winthrop Hds. (405 Revore Usual Residence Feb. 25
Filed ... 1909
A true copy.
Attest :
ErMSlenen
Registrar.
R
CITY
SIC
CIVITATI
TIS REGIMUNE BOSTON
Place of Burial or removal.
Brookline"Holyhood"
Undertaker .
J L Burke
Budget String Feb 23 - 09
COMMONWEALTH OF MASSACHUSETTS
124
Bruttinfo (CITY OR TOWN.)
RETURN OF A DEATH
FULL NAME
Bertha o. Russell
Place of
Winthrop (metcalf Hos Ital)
Death *
S
Residence
138 Bowdoin St.
Age
.years.
.months.
.days
STATISTICAL DETAILS
SEX tenale
COLOR
White.
SINGLE, MARRIED, WIDOWED, OR DIVORCED
haved
MAIDEN NAME Ť
Bertha T. Rourke.
HUSBAND'S NAME t George H. Quase
BIRTHPLACE#
Gambudge. maso.
NAME OF
FATHER
Peter Filhouke.
BIRTHPLACE
OF FATHER$
Ireland
MAIDEN NAME
OF MOTHER
Elizabeth. Walsh
BIRTHPLACE
OF MOTHER$
Italifor
OCCUPATION
INFORMANT §
.
PLACE OF BURIAL OR REMOVAL !! l'auto Wertungen
DATE OF BURIAL
190 ....... .
UNDERTAKER
ADDRESS
219 Boundary
Dorchester lunes
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 :
multiple
burns
128 2d, a 3d
.(DURATION). ... DAYS
Contributory :
ac dental origin
(DURATION) ... DAY8
(Signed)
Serge Buyers Igrala
M.D.
190 (Address)
) med. Exam
Suitable to -
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 divorced woman, or widow.
# Stato or country; also city, town or county, if known.
§ Name and address of person giving statisticai dotails. Il Name of cemetery.
FILL OUT WITH INK .- THIS IS A PERMANENT RECORD ALL NAMES TO BE IN FULL
Registered No.
Date of l
tel. 25
.190 9
Death 1
29
22 21 Bertha J. Russell Feb. 20,1909
is it 3-201 COMMONWEALTH OF MASSACHUSETTS
RETURN OF A DEATH
(CITY OR TOWN.)
FULL NAME
Mary
y. Kelly
Registered No.
Place of )
77 atlantic IS. Wirthoof Mass
Death *
S
Date of : Act 26
190
9
Residence
77 atlantic St.
Age
23
.. years.
.. months ..
.days
STATISTICAL DETAILS
SEX
COLOR
SINGLE, MARRIED,
WIDOWED, OR"
DIVORCED
Single
MAIDEN NAME Ť
HUSBAND'S NAME }
BIRTHPLACE#
East Boston Maas.
NAME OF
FATHER
Patrick
BIRTHPLACE
OF FATHER*
Ireland
MAIDEN NAME
OF MOTHER
Bridget Keough
BIRTHPLACE
OF MOTHER #
Ireland
OCCUPATION
Clerk
INFORMANT §
Bridget Robin
PHYSICIAN'S CERTIFICATE
I HEREBY CERTIFY that I attended deceased during last illness, from Sehr. 4 190.9 ... to Feb. 26 1909, 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 : abscess y lung
(DURATION).
22
DAYS
Contributory :
Empyema
(OURATION)
4
DAYS
(Signed)
Edward J. Fragen
M.D.
Fel. 28 1909 (Address)
304 W welterbe SV.
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 caso 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 cemotery.
FILL OUT WITH INK. - THIS IS A PERMANENT RECORD ALL NAMES TO BE IN FULL
PLACE OF BURIAL OR REMOVAL I
Holy Geross walden
UNDERTAKER
Thos ti Lave
ADDRESS
120 Havre St
E Boston
DATE OF BURIAL
1/ . 190
190 9
Death
5
21 22 Mayr. Kelly JEb 26 1909
COMMONWEALTH OF MASSACHUSETTS
Mintvol.
(CITY OR TOWY.)
FULL NAME
Many
Orallón
Registered No ...
Date of l
March 1"
Death
S
190
Death *
S
Residence
56 mare Street
Age
... years.
6
.months.
18
.days
STATISTICAL DETAILS
SEX Female
COLOR
SINGLE, MARRIED,
WIDOWED, OR
DIVORCED
Single
MAIDEN NAME t
Mary Mallon
HUSBAND'S NAME t
BIRTHPLACE+
Bach Livermore me
NAME OF FATHER Irillian Halton,
BIRTHPLACE OF FATHER$ Boston mars
MAIDEN NAME
OF MOTHER
Sabina Hallan
BIRTHPLACE OF MOTHER $ Earl Luimme me
OCCUPATION
INFORMANT §
Stillian Walton
Brother
PLACE OF BURIAL OR REMOVALI
DATE OF BURIAL
... 190
UNDERTAKER
ADDRESS
1
Dummer floyd
PHYSICIAN'S CERTIFICATE
I HEREBY CERTIFY that I attended deceased during last illness, from. 726-27 . 1909 to 1909, 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 : Carcinoma ? Strinach
Contributory :
(OURATION) .............. 0AY8
(Signed)
315href call
M.D.
1909 (Address)
SPECIAL INFORMATION only for Hospitals, Institutions, Transients, or Recent Residents.
How long at Place of Death 7 .. 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.
1 State or country; also city, town or county, If known,
§ Name and address of person giving statistical details. Il Name of cemetery.
FILL OUT WITH INK. - THIS IS A PERMANENT RECORD
ALL NAMES TO BE IN FULL
RETURN OF A DEATH
Place of )
Daritual
mass
(DURATION).
2
.OAYS
23 mary station Branch1- 909
FILL OUT WITH INK. - THIS IS A PERMANENT RECORD ALL NAMES TO BE IN FULL
COMMONWEALTH OF MASSACHUSETTS
RETURN OF A DEATH
Stant rojo C -(CITY-OR -TOWN.)
FULL NAME
Jennie Ly Lord
.Registered No.
Place of l
Death *
S
Startup mass
Date of l
March 1"
.1909
Residence
223 9 iveren Street
Age
39
years.
3
months
7
.days
STATISTICAL DETAILS
SEX female
COLOR
White
SINGLE, MARRIED, WIDOWED, OR DIVORCED
MAIDEN NAME + Jennie W, Rabbine
HUSBAND'S NAME t
Vallet & ford
BIRTHPLACE $ Burlington &
NAME OF FATHER George L, Robbins
BIRTHPLACE
OF FATHER *
Selectoro NH,
MAIDEN NAME
OF MOTHER
LonnieL, nelson
BIRTHPLACE OF MOTHER $ Baldwin-VI
OCCUPATION Hansenje
INFORMANT § Husband and Sister
PHYSICIAN'S CERTIFICATE
I HEREBY CERTIFY that I attended deceased during last illness, from. Fale 2 8Ht 1909 to March 1 1909 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 : Apoplecus
. (DURATION).
1 1/2
DAYS
Contributory :
(Signed)
A. B. Forman
M.D.
1.190% (Address)
WwwThigh Mais
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
PLACE OF BURIAL OR REMOVAL !!
DATE OF BURIAL
190
ADDRESS
UNDERTAKER Dinner Cloud
* 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.
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