USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1907-1909 > Part 23
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Hilerant for Dangles
Debility.
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.
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.
State disease cau
COMMONWEALTH OF MASSACHUSETTS
Winthrop
(CITY OR TOWN.)
FULL NAME
Darclay Prixa.
Place of ì Death *
64 Share Dami Winstrol Maso.
Death
Residen
66 Sac amore It Sowewill. Age
62
.years months. ... days
STATISTICAL DETAILS
SEX
Male
COLOR
While
SINGLE, MARRIED, WIDOWED, OR DIVORCED manuel
MAIDEN NAME t HUSBAND'S NAME t
BIRTHPLACE #
Fredentilor n.B.
NAME OF
FATHER
Samuel
BIRTHPLACE
OF FATHER$
Keswick M.B.
MAIDEN NAME
OF MOTHER
Ruch Cliff
BIRTHPLACE OF MOTHER # Queenalowangle 9.13.
OCCUPATION
INFORMANT §
note
PLACE OF BURIAL OR REMOVAL !!
DATE OF BURIAL
1909
UNDERTAKER le R Berna
ADDRESS·
PHYSICIAN'S CERTIFICATE
1 HEREBY CERTIFY that I attended deceased during last Illness, from May 15 1907 to You 23
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 :
Contributory :
(DURATION). ... DAY8
(Signed)
M.D.
2× 190$ (Address)
SPECIAL INFORMATION only for Hospitals, Institutions, Translents, 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
Fredenche low-
n. B.
* 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.
RETURN OF A DEATH
Registered No.
Date of ¿ June 28 .190 9
(DURATION). .DAYS
69 alfred F, Kaker June 23, 1909
COMMONWEALTH OF MASSACHUSETTS
RETURN OF A DEATH
FULL NAME
Martin Reiss
Place of }
Death
S
Shirley
St. Detlivet
Residence
3) Joy St, Somerville
Age
28
.. years.
.months.
.... .days
STATISTICAL DETAILS
SEX
m
COLOR
10
SINGLE, MARRIED,
WIDOWED, OR
DIVORCED
manuel
MAIDEN NAME t HUSBAND'S NAME +
BIRTHPLACE#
NAME OF
FATHER
Lowgrane Rees
BIRTHPLACE
OF FATHER
Sucede
MAIDEN NAME
OF MOTHER
BIRTHPLACE
OF MOTHER+
OCCUPATION
-
INFORMANT § Wife
PHYSICIAN'S CERTIFICATE
I HEREBY CERTIFY that I attended deceased during fast illness, from .. 190 ...... to:
490 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 :
Electrical Shock,
accidental
(DURATION). DAY8
Contributory :
(DURATION) . DAY8
(Signed)
Senza Burgers Manch
.M.D.
190 ... (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 II
Woodlawn Connecting)
190.2
ADDRESS
UNDERTAKER
CRBecause
DATE OF BURIAL
* 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 clty, town or county, If known.
§ Name and address of person giving statistical detalls. Il Name of cemetery.
ALL NAMES TO BE IN FULL
14
Winthrop (CITY OR TOWN.)
.Registered No.
Date of ¿ June 25 Death 1 1.1909
70 Martin Reiss June 25, 1909
[1.'09-37-XXXM.]
Permit No.
RETURN OF DEATH. BOSTON, MASS.
Date of Death, .... June 26, 1909.
19
.
Name in full, Ann Eulalie Burk
Calbeck
William.R.
(If married or divorced woman give maiden name, also name of husband.)
Sex, .Female Color, White
(White, Biack, Mixed, Chinese, Condition, Widow
(Single, Married, Widowcd or
Indian, etc.)
Divorced.)
Age, .. 8.8 ....... Years, .9. Months, II .Days. Occupation, .........
Residence, *... East Boston, Mass:
Ward, ...... 0.ne.
Place of Death, 369 Winthrop Street, Winthrop, Mass:
(State year, month and day.)
Place of Birth,.
Magdalene Islands.
Date of Birth, Sept. 15, 1820
Name and Birthplace ? of Father,
Philip F. Calbeck Unknown .. P .......... I.
Maiden Name and 1 Mary ... ANN ... Burk Unknown .P.E. I.
Birthplace of Mother,
Place of Interment,
Woodlawn Cemetery, Everett
* If an institution, state how long an inmate and previous residence. E. Q. Brown Undertaker.
PHYSICIAN'S CERTIFICATE OF THE CAUSE OF DEATH.
Name and Age
Boston,
June 29"
19 09.
of Deceased, ann Endie Burk
Age,88 years. 1
I hereby certify that I attended deceased from.
1907
19
June 26 09
19 6 9, that I last saw her - alive on the 726 day of. 1909.
that died on the 26
day of. 1909, about. 11 pm .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, Uralma nephritis
Disease
Contributing cause, aldase
Chief Cause, one year
Duration
Contributing cause,. 3mil caly
M. D.
PHYSICIANS BEFORE STATING CAUSE OF DEATH ARE REQUESTED TO SEE THE OTHER SIDE OF THIS BLANK. Y
21
,
3
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."
Asphyxla. 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 polsoning. 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.
Dentitlon.
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 .?
General 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.
Inanition.
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? If
inability to take food, state cause.
Infantile asthenia. See " Asthenia." The term "infantile" adds no precis 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
tuberculosis, syphilis, or cholera infantum? St
fully, as this return in itself is practically worthless
compilation.
Meningitis.
Was it epidemic cerebro-spinal meningitis? If so, w
exactly in this form Did it follow scarlet fever, pr
monia, or some acute infection? If so, name the
mary disease. Was it traumatic? If so, state
nature of the violence which caused the meningi
Was it tuberculous meningitis?
Nephritis.
Was it'acute or chronic?
If acute, occurring in the cou
of some disease, name the disease causing death.
Old age.
This is not a satisfactory return.
The influence of ag
shown by the statement of age in years, months,
days. To this the statement of "old age" as a caus
death adds nothing of value.
Name the disease
which the old person succumbed.
Peritonitis. What was the cause of the peritonitis? "Idiopathic p tonitis" should be rarely returned. Was it puerp - or traumatic? In the latter case, state mode of inju
Pernicious anemia.
If any definite cause can be assigned for the anemia
should be reported. Anemia due to tuberculosis, sy
ilis, etc., should be returned under the primary dise
Pneumonia. Specify definitely whether broncho-pneumonia or lob pneumonia. If sequel to influenza, state that fact
Pyemia. What caused the pyemia? Was it puerperal or tr matic? If traumatic, state nature of accident caus injury.
Senile asthenia. See "Old age" and "Asthenia." death.
Give disease caus
Senile atrophy. See "Old age" and "Atrophy." death.
State disease caus
Senile decay.
See "Old age." State disease causing death.
Senile decline.
See "Old age." Name the disease, if any, that caused
decline.
Senile marasmus.
See "Old age" and "Marasmus." Name disease caus
death.
Shock. What caused the shock? If from injury, state natur accident. If from surgical operation, state disease injury requiring the operation.
Surgical operation.
Surgical shock.
Always state the disease or injury requiring operat Unless the operation was improper or unskilfully ] formed, it should not be given as the primary caus death.
Teething. Name the disease affecting the teething child. See "I tition."
Toxemia.
Was this acute or chronic poisoning due to some exte: agent? Was it auto-intoxication, due to poisons Į erated in the body by disease? If so, state the ni of the disease.
Tuberculosis. State organ affected. Do not fail to state as pulmor tuberculosis if lungs were affected.
Tumor. Was it a cancer? Whether a cancer or tumor, do not to specify organ or part of body affected.
Typhoid condition.
Avoid this term as it is likely to be mistaken for typl
fever.
Typhoid pneumonla.
Was the primary disease typhoid fever or pneumonia ?
Typho-malarial fever.
Was it typhoid fever? Was it malarial fever? A 1 ture of these diseases rarely occurs, the great majo of cases of so-called "typho-malarial fever "/being n ing more nor less than typhoid fever.
State name of disease causing imperfect nutrition. Did it
follow some disease? If so, give name of disease.
COMMONWEALTH OF MASSACHUSETTS
RETURN OF A DEATH
Winthrop (CITY OR TOWM)
FULL NAME
EmmaL. hhuscall
Place of l
Death *
4 Shore Drive Winthrop
Date of ¿
Death 5
July 4 7
.months. days
STATISTICAL DETAILS
SEX
COLOR
SINGLE, MARRIED, WIDOWED, OR DIVORCED
MAIDEN NAME +
Emma & Loving
HUSBAND'S NAME t
BIRTHPLACE ៛ Manuce
Bastian
NAME OF
FATHER
Benjamine
BIRTHPLACE
OF FATHER #
Bastian
MAIDEN NAME
OF MOTHER
margaret Hughes
BIRTHPLACE
OF MOTHER #
Boston
OCCUPATION
none
INFORMANT §
PLACE OF BURIAL OR REMOVAL II
DATE OF BURIAL
St. Mario W.Quincy
July 6 .. 190 9
UNDERTAKER J.J. Lane
ADDRESS
120 Havre St. EV8.
PHYSICIAN'S CERTIFICATE
| HEREBY CERTIFY that I attended deceased during last illness, from. 9 to feely f. 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 : Cancer of Breast
(DURATION) DAY8
Contributory :
(DURATION) DAY8
(Signed)
M.D.
lucky 4 1909 (Address)
SPECIAL INFORMATION only for Hospitals, Institutions, Translents, 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. # State or country ; also city, town or county, If known.
§ Name and address of person giving statistical detailse li Name of cemetery.
years .. ...
Registered No.
190
0
Residence
4 5 horas Die Winthe de Age 49
July 4 - 09
[1-'09-37-XXXM.]
Permit No.
RETURN OF DEATH.
Winthrop BOSTON, MASS.
Date of Death,
July y" 19 09
Name in full, abbie Orva me
LEod
(If married or divorced woman give maiden name, also name of husband.)
Sex, Otemale Color, thrite
(White, Black, Mixed, Chinese, Indian, etc.) Condition, Single
(Single, Married, Widowed or Divorced.)
Age, 24 Years, 9 Months, ~Days. Occupation, 1
Residence, *. De Bogie maine
Ward,
Place of Death, 84 Jaun Bar avenue= Winthrop mars
Place of Birth, New Brunswick Date of Birth,
(State year month and day.)
Name and Birthplace of Father,
John Irving Megood- Ten Brunswick
Maiden Name and Office oforder= Springfield new Brunsnok Birthplace of Mother,
Place of Interment,
@hanbury pearl, mass
* If an institution, state how long an inmate and previous residence. Summer Cloud Undertaker.
PHYSICIAN'S CERTIFICATE OF THE CAUSE OF DEATH.
Boston, July
19.09
Name and Age?
Age, 24 years. - 9mos
I hereby certify that I attended deceased from Jueces 10 1909, to lucy 7. 109. 19 , that I last saw her alive on the.
day of .. 1909,
that the died on the.
day of .... 1909, about 9 .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,
Disease
Contributing cause,
Duration
Chief Cause, Uncertain
...
Contributing cause, If. Parter M. D.
PHYSICIANS BEFORE STATING CAUSE OF DEATH ARE REQUESTED TO SEE THE OTHER SIDE OF THIS BLANK.
21
- of Deceased, abbie Inva mcleod
LIST OF INDEFINITE TERMS WHICH SHOULD BE AVOIDED IN GIVING CAUSES OF DEATH.
Acute gastritls. ..
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 .?
General 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.
Tuberculosis. State organ affected. Do not fail to state as pulmon tuberculosis if lungs were affected.
Hypostatic congestion.
Name the disease causing the passive or hypostatic con- gestion.
State name of disease causing imperfect nutrition. Did it follow some disease? If so, give name of disease.
I nanition. 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? If inability to take food, state cause.
Infantlle asthenla. See " Asthenia." The term "infantile" adds no precis 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
tuberculosis, syphilis, or cholera infantum? St
fully, as this return in itself is practically worthless
compilation.
Meningitis.
Was it epidemic cerebro-spinal meningitis? If so, wi
exactly in this form. Did it follow scarlet fever, pn
monia, or some acute infection? If so, name the
mary disease. Was it traumatic? If so, state
nature of the violence which caused the meningi
Was it tuberculous meningitis ?
Nephritis. Was it acute or chronic? If acute, occurring in the cou of some disease, name the disease causing death.
Old age. This is not a satisfactory return. The influence of age shown by the statement of age in years, months, a days. To this the statement of "old age" as a cause death adds nothing of value. Name the disease which the old person succumbed.
Peritonitis. What was the cause of the peritonitis? "Idiopathic pe tonitis" should be rarely returned. Was it puerpe
or traumatic? In the latter case, state mode of inju
Pernicious anemia. If any definite cause can be assigned for the anemia, should be reported. Anemia due to tuberculosis, sy ilis, etc., should be returned under the primary disea
Pneumonia. Specify definitely whether broncho-pneumonia or lob pneumonia. If sequel to influenza, state that fact.
Pyemia. What caused the pyemia? Was it puerperal or trs matic ? If traumatic, state nature of accident causi injury.
Senile asthenia. See "Old age" and "Asthenia." Give disease causi
death.
Senile atrophy. See "Old age" and "Atrophy." death.
State disease causi
Senile decay.
See " Old age." State disease causing death.
Senile decline.
See "Old age." Name the disease, if any, that caused
decline.
Senile marasmus. See "Old age" and "Marasmus." Name disease causi death.
Shock. What caused the shock? If from injury, state nature accident. If from surgical operation, state disease injury requiring the operation.
Surgical
operation.
Surgical shock.
Always state the disease or injury requiring operati Unless the operation was improper or unskilfully p formed, it should not be given as the primary cause death.
Teething. Name the disease affecting the teething child. See "D. tition."
Toxemia. Was this acute or chronic poisoning due to some exter: agent ? Was it auto-intoxication, due to poisons g erated in the body by disease? If so, state the na of the disease.
Tumor. Was it a cancer? Whether a cancer or tumor, do not to specify organ or part of body affected.
Typhoid condition. Avoid this term as it is likely to be mistaken for typh fever.
Typhoid pneumonia.
Was the primary disease typhoid fever or pneumonia ?
Typho=malarial fever.
Was it typhoid fever ? Was it malarial fever? An ture of these diseases rarely occurs, the great major of cases of so-called "typho-malarial fever" being no ing more nor less than typhoid fever.
Imperfect nutrition.
ALL NAMES TO BE IN FULL
COMMONWEALTH OF MASSACHUSETTS
RETURN OF A DEATH
FULL NAME
William
& Richardson
Place of | Z
64 Perfect are
Death . S
Residence
Age
2)
.. years
.months.
days
STATISTICAL DETAILS
SEX
m
COLOR
w.
SINGLE, MARRIED, WIDOWED, OR DIVORCED
MAIDEN NAME Ť
HUSBAND'S NAME t
BIRTHPLACE# Franken: mais
NAME OF FATHER fremont M. Richardson
BIRTHPLACE
OF FATHER#
Hartwich me
MAIDEN NAME
OF MOTHER
H. Cela Echó
BIRTHPLACE
OF MOTHER#
Hollington Mars
OCCUPATION
cenk
INFORMANT § alfred Harmy Com
PHYSICIAN'S CERTIFICATE
I HEREBY CERTIFY that I attended deceased during last illness, from feely 11. .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 :
Quebral Hemorrhage
.(DURATION)
DAYS
Contributory :
.(DURATION) DAYS
(Signed)
M. D.
lucky 11 190g (Address)
Sparethrow
SPECIAL INFORMATION only for Hospitals, Institutions, Translents, 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 Français mais
UNDERTAKER
ADDRESS
DATE OF BURIAL May 14 190 ....
* 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 marrled or divorced woman, or widow. # State or country ; also city, town or county, If known.
§ Name and address of person glving statistical detalls. Il Name of cemetery.
(CITY OR TOWN.)
Registered No ...
Date of ¿
Death S
July 11th
1909
74 Hilliance F. Richardson July 11-09
[1.'09-37-XXXM.]
Permit No.
RETURN OF DEATH.
Winthrop
BOSTON, MASS.
Date of Death,
July 11' 19.09.
Name in full,
Benjamin B. Voar
(If married or divorced woman give maiden name, also name of husband.)
Sex, Female Color, White Condition, Divorced
(Single, Married, Widowed or
Divorced.)
Age, 33 Years, 10 Months, 1 Days. Occupation,
(White, Black, Mixed, Chinese,
Indian, etc.)
Hotel Proprietrese
Residence, *.
Stanthing Mask
Hard, .....
Place of Death,.
11y Houthal, Shore Drive
Place of Birth,
East Borto Date of Birth,
(State year, month and day.)
Name and Birthplace ! of Father,
Charles Of Crocker-New london Conn
Maiden Name and Eliza M.While= tora Service
Birthplace of Mother,
Place of Interment,
Homing Cemetery melasa
* If an institution, state how long an inmate and previous residence. Summer loyd Undertaker.
PHYSICIAN'S CERTIFICATE OF THE CAUSE OF DEATH.
Name and Age ?
of Deceased, Haelen Ih Pour Age,. 33 years.
I hereby certify that I attended deceased from July 8, 1909, to.
Jordy 11.
19 , that I last saw
alive on the 11/ day of fely ( 1909, that The died on the 11. day of. July 1907, about 6 o'clock
H.M. T. P.M., and that, to the best of my knowledge and Velief, the cause of. Le death was as follows : Chief cause, Uraerna
Disease Contributing cause, acuto Maria
Chief Cause,
Duration Contributing cause, 3 . doyu.
M. D.
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