USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1907-1909 > Part 24
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PHYSICIANS BEFORE STATING CAUSE OF DEATH ARE REQUESTED TO SEE THE OTHER SIDE OF THIS BLANK.
21
19.09.
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. ?
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 pulmo tuberculosis if lungs were affected.
Tumor. Was it a cancer? Whether a cancer or tumor, do no to specify organ or part of body affected.
Typhoid condition. Avoid this term as it is likely to be mistaken for typ fever.
Typhoid pneumonia.
Was the primary disease typhoid fever or pneumonia :
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 prec 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 du tuberculosis, syphilis, or cholera infantum? S fully, as this return in itself is practically worthles compilation.
Meningitis. Was it epidemic cerebro-spinal meningitis? If so, exactly in this form. Did it follow scarlet fever, p monia, or some acute infection? If so, name the mary disease. Was it traumatic? If so, state nature of the violence which caused the menin Was it tuberculous meningitis?
Nephritis. Was it acute or chronic ? If acute, occurring in the co of some disease, name the disease causing death.
Old age. This is not a satisfactory return. The influence of a shown by the statement of age in years, months, days. To this the statement of "old age" as a cau death adds nothing of value. Name the diseas which the old person succumbed.
Peritonitis. What was the cause of the peritonitis? "Idiopathic tonitis" should be rarely returned. Was it puer or traumatic? In the latter case, state mode of inj
Pernicious anemia. If any definite cause can be assigned for the anemi should be reported. Anemia due to tuberculosis, s. ilis, etc., should be returned under the primary dise
Pneumonia. Specify definitely whether broncho-pneumonia or lo pneumonia. If sequel to influenza, state that fac
Pyemia. What caused the pyemia? Was it puerperal or t matic? If traumatic, state nature of accident cau injury.
Senile asthenia. See "Old age" and "Asthenia." Give disease cau
death.
Senile atrophy. See "Old age" and "Atrophy." death.
State disease cau
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 cau
death.
Shock. What caused the shock? If from injury, state natu accident. If from surgical operation, state diseas 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 cau death.
Teething. Name the disease affecting the teething child. See "1 tition."
Toxemia. Was this acute or chronic poisoning due to some exte agent ? Was it auto-intoxication, due to poisons erated in the body by disease? If so, state the n of the disease.
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.
Typho-malarial fever.
Was it typhoid fever? Was it malarial fever? A ture of these diseases rarely occurs, the great maj of cases of so-called "typho-malarial fever" being I ing more nor less than typhoid fever.
COMMONWEALTH OF MASSACHUSETTS
RETURN OF A DEATH Stedt One
(CITY OR TOWN.)
FULL NAME
Place of )
Death *
29 Come are Within Rate of
fruits 13
190 9
Residence
> Murdock Park Brighton kom
Age
Stick four months.
.. years ..
.. days
STATISTICAL DETAILS
SEX
Marc
COLOR
SINGLE, MARRIED, WIDOWED, OR DIVORCED
MAIDEN NAME + HUSBAND'S NAME t
BIRTHPLACE #
1
29 Coral are Wunchet
NAME OF
FATHER
Micheal Brennan
BIRTHPLACE
OF FATHER#
Framingham Mais
MAIDEN NAME
OF MOTHER
alice Games
BIRTHPLACE
OF MOTHER #
OCCUPATION
Civil Engineers
INFORMANT $
PHYSICIAN'S CERTIFICATE
I HEREBY CERTIFY that I attended deceased during last illness, from. July 13 . 190$ ...
July 13 190.7 .... , that to the best of my knowledge and belief death occurred on the date stated above, and that the CAUSE OF DEATH was as follows :
Primary :
still born
.(DURATION). .......
.DAYS
Contributory :
(DURATION)
DAY8
(Signed)
31 Met calf
M.D.
fry 16.
.190 .... (Address).
SPECIAL INFORMATION only for Hospitals, Institutions, Transients, or Recent Residents.
How long at Piace 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.
UNDERTAKER
OR Perman.
DATE OF BURIAL
PLACE OF BURIAL OR REMOVAL !!
July 19th 1909
190 ...
ADDRESS
§ Namo and address of person giving statistical detalls. Il Name of cemetery.
ALL NAMES TO BE IN FULL
Registered No ...
76 Вчемнам
COMMONWEALTH OF MASSACHUSETTS
RETURN OF A DEATH
FULL NAME
Howard. J. Thomson
Place of l
Death *
5
41 Emerson
Goal
Date of ¿ July 13
,1909
Residence
Age
.. years.
×
.months.
27
.days
STATISTICAL DETAILS
SEX Male
COLOR
White
SINGLE, MARRIED, WIDOWED, OB DIVORCED
Manuel
MAIDEN NAME + HUSBAND'S NAME t
BIRTHPLACE #
Lynn mass
NAME OF
FATHER
Robert. W.
BIRTHPLACE
OF FATHER$
MAIDEN NAME
OF MOTHER
BIRTHPLACE OF MOTHER + Effic Watson Thompson
OCCUPATION
Bank cluck
PHYSICIAN'S CERTIFICATE
I HEREBY CERTIFY that I attended deceased during last illness, from. July 13 190 .. 9 ... to July 13 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 :
Mitral Regungitation
(DURATION)
19 yrs
1 DAYS
Contributory :
... (DURATION).
........... DAY8
(Signed) ..
1
Bethel colf
M.D.
13 90
.. 1909 (Address).
134 hours ST worthy
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
* Clty 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 Institutlon, glve Its NAME Instead of street and number.
t In case of married or divorced woman, or widow. State or country ; also city, town or county, If known,
§ Name and address of person giving statistical details. [] Name of cemetery.
UNDERTAKER
CR Bemun
ADDRESS
INFORMANT S Jacher Robert. W. 411 B. way Lagun Man
PLACE OF BURIAL OR REMOVAL !!
DATE OF BURIAL
7/15
Death
22
Ктериор (CITY OR TOWNS
Registered No.
77 Howard J. Thompson July 1 3 - 09
[1-'09-37-XXXM.]
Permit No.
RETURN OF DEATH.
Winthrop
BOSTON, MASS.
Date of Death,
July 14" 19.09
Name in full,
Othank Edward Die
(If married or divorced woman give maiden name, also name of husband.)
Sex, Male Color, White Condition, Married
(White, Black, Mixed, Chinese,
Indian, etc.)
actor
(Single, Married, Widowed or
Divorced.)
Age, 53 Years, ~Months, ~Days. Occupation,
Residence,*
Boston Mass
Ward,.
Place of Death,
95, Shirley Steel
Place of Birth,
Hartford Como Date of Birth,
(State year, month and day.)
Name and Birthplace ?
of Father,
Edwin Bill=Scotland= Come
Maiden Name and Birthplace of Mother, Lydia Downing = Unknown
Place of Interment,
* If an institution, state how long an inmate and previous residence. Summer Lloyd
Undertaker.
PHYSICIAN'S CERTIFICATE OF THE CAUSE OF DEATH.
Printenofo Booton July 19 09
Name and Age ?
of Deceased, Taux E. Jiel
I hereby certify that I attended deceased from.
Age, 33 years. 19 , to
,
19 , that I last saw 1 alive on the. day of 19
that he died on the. 14
day of
190 }, about.
6
.. o'clock
A.M., or P.M.f., and that, to the best of my knowledge and belief, the cause of. death was as follows :
Disease 3 Chief cause, Acateles
Contributing cause,
Pulmonary Ordering
Chief Cause,. Indefinida
Duration
Contributing cause, 6 hrs.
If. low M. D.
PHYSICIANS BEFORE STATING CAUSE OF DEATH ARE REQUESTED TO SEE THE OTHER SIDE OF THIS BLANK.
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 ?
Asthenla. 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.
Hypostatic congestion.
Name the disease causing the passive or hypostatic con- gestion.
Imperfect nutrition.
State name of disease causing imperfect nutrition. follow some disease? If so, give name of disease.
Did it
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 asthenla. See "Asthenia." The term "infantile" adds no precisio 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 t tuberculosis, syphilis, or cholera infantum? Stat fully, as this return in itself is practically worthless fo compilation.
Meningitis. Was it epidemic cerebro-spinal meningitis? If so, writ exactly in this form. Did it follow scarlet fever, pneu monia, or some acute infection? If so, name the pr mary disease. Was it traumatic? If so, state th nature of the violence which caused the meningiti Was it tuberculous meningitis?
Nephritis. Was it acute or chronic ? If acute, occurring in the cours 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, an days. To this the statement of "old age" as a cause o death adds nothing of value. Name the disease t which the old person succumbed.
Peritonitis. What was the cause of the peritonitis? "Idiopathic per tonitis" should be rarely returned. Was it puerpers or traumatic? In the latter case, state mode of injury
Pernicious anemia. If any definite cause can be assigned for the anemia, should be reported. Anemia due to tuberculosis, syph ilis, etc., should be returned under the primary disease
Pneumonia. Specify definitely whether broncho-pneumonia or loba pneumonia. If sequel to influenza, state that fact,>
Pyemia. What caused the pyemia? Was it puerperal or trhu matic? If traumatic, state nature of accident causin injury.
Senile asthenia. See "Old age" and "Asthenia." death. O
Senile atrophy. See "Old age" and "Atrophy." death.
State disease caus-6
Senile decay.
See "Old age." State disease causing death.
Senile decline.
See "Old age."
Name the disease, if any, that caused th
decline.
Senile marasmus.
See "Old age" and " Marasmus."
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 fai 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.
Typho-malarial fever.
Was the primary disease typhoid fever or pneumonia ?
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.
Name disease causing
Give disease causho
COMMONWEALTH OF MASSACHUSETTS
RETURN OF' A DEATH
Wiechel (CITY OR TOWN.)
FULL NAME Ban Willia
Place of ) 66 Sumysier are Death * S
Residence
Age
days
STATISTICAL DETAILS
SEX
Male
COLOR
Muito
SINGLE, MARRIED, WIDOWED, OR
DIVORCED
MAIDEN NAME +
HUSBAND'S NAME t
BIRTHPLACE #
66 tummysente ore
NAME OF FATHER Chas. Williams
BIRTHPLACE OF FATHER# St. George agoues.
MAIDEN NAME OF MOTHER Mary J. Compa
BIRTHPLACE OF MOTHER #
ABoston
OCCUPATION
INFORMANT §
1
PLACE OF BURIAL OR REMOVAL !!
Nunctunt
UNDERTAKER
DATE OF BURIAL 7/19 1909
ADDRESS Wortht
PHYSICIAN'S CERTIFICATE
I HEREBY CERTIFY that I attended deceased during last illness, from. July 17 1909 to nul 1) .190 ... that to the best of my knowledge and belief death occurred on the date stated above, and that the CAUSE OF DEATH was as follows :
Primary : Still Born Incidental to Birth
(DURATION). .DAYS
Contributory :
Bondiail
(DURATION). DAYS
(Signed)
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
* 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. [{ Name of cemetery,
ALL NAMES TO BE IN FULL
Date of ¿ Death S
Registered No. Holy 17 1909
salliance Jonly 17-09
COMMONWEALTH OF MASSACHUSETTS
RETURN OF A DEATH
(CITY OR TOWN.)
FULL NAME
Henry Francis cahill
Registered No.
Date of
July 17, 1909
.190
Death
Residence
"9 Seafcam Ave., Winthrop, Mass . Age
26
-
.months.
.days
STATISTICAL DETAILS
SEX
Male
COLOR
White
SINGLE, MARRIED,
WIDOWED, OR
DIVORCED
Married
MAIDEN NAME + HUSBAND'S NAME t
BIRTHPLACE + South Boston, Mass.
NAME OF
FATHER
Henry Thomas Francis Cahill
BIRTHPLACE
OF FATHER$
Blackburn, Englan 1
MAIDEN NAME
OF MOTHER
Sarah Foley
BIRTHPLACE
OF MOTHER$
Norfolk, Virginia
OCCUPATION
Treakman
INFORMANT §
Catherine Alice Cahill,
"y Senfoam Ave., Winthrop, dass.
PLACE OF BURIAL OR REMOVAL I
Winthrop reach, wass.
DATE OF BURIAL July 18, 1909
UNDERTAKER
ADDRESS
has. H. Ficharison Co. Techinster
PHYSICIAN'S CERTIFICATE
vieved body of
1 HEREBY CERTIFY that I attended deceased during last
- illness, from.
7%, 1909-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 :
Probable fracture of skull
in railroad accident
(DURATION).
DAYS
Contributory :
(DURATION)
.DAYS
(Signed)
A. H. Pierce, Age't Med. ExM.D.
Tu] 17, 190(Address).
Leominster
Tasr.
SPECIAL INFORMATION only for Hospitais, 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
July 17,
1900
3.S. Gibson
ass'y Joun Clerk
* 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 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.
ALL NAMES TO BE IN FULL
Leominster
Place of
Leominster, Mass.
Death * S
.. years.
Henry Francis Cahill July 17-09
FILL OUT WITH INK. - THIS IS A PERMANENT RECORD ALL NAMES TO BE IN FULL
COMMONWEALTH OF MASSACHUSETTS
City
RETURN OF A DEATH
FULL NAME.A ...
Anthony
IiDonald
Registered No .... p
* Place of Death ..
Hruthrop
Cambridge
Death
Name of Hospital or Institution, if any 435 Hauttrop 27
Place of
Residence
No.
Street
City or Town
STATISTICAL DETAILS
Sex mats hita Color !
Single, Marriot, Widowed or Divorced
Maiden Name
If a married or divorced woman or widow
JOVIS
VIS
Husband's Full Name
HFERES
Birthplace City or Town and State or Country Maisthrop, Mais
TABRISA!
Birthplace of Father
Aty or Town and State or Country Cape Breton, et, ,
Maiden Name of Mother Masgant Wir Krall
Birthplace of Mother City or Town and Mate or Country Lidl000
Occupation
Informant's Name (Person giving statistical details)
Place of Burial or Removal Maldau, Mass
Cemetery
Undertaker's Name Frank I Malouad ss, Thythialf.
PHYSICIAN'S CERTIFICATE
I HEREBY CERTIFY that I attended deceased during last
illness, from ...
16
Jury 19 09
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 : ( If a soldier or sailor who served in the war of the rebellion both the primary and contributory causes of death must be given.)
Primary :
3
Hasbro Saturitos
4 days
(Duration )
Contributory :
....
(Duration )
(Signed)
M. D.
(Address)
* How long at
Place of Death ?
Years ............
Months.
......
Days
Usual Residence
SPECIAL INFORMATION from Hospitals, Institutions, Transients, or Recent Residents.
Received at office of
Board of Health
190
No. of Burial
Permtt
Form I
Clerk of Board of Health
TAUES MON LANUCOUNCIL 90
Date of
pily 199
190
9
Age
2
Years
Months
Days
GRA, OHRA
Full Name of Father REGMINE
80 anthony msDowald- July 19-09
The office of Board of Health will be open for the granting of permits for burial as follows: Saturdays, 8 a. m. till I p. m .; Sundays and Holidays, 12 m. till I p. m .; Other Days from 8 a. m. till 4 p. m.
BE VERY CAREFUL TO FILL ALL BLANKS IN INK
De
rn
ge ar
f
C
[1-'09-37-XXXM.]
Permit No.
RETURN OF DEATH. Hintup BOSTON, MASS.
Date of Death, ..... July 19 1909.
19
Name in full, Carolia M. Harriott
Martyn
John
(If married or divorced woman give maiden name, also name of husband.)
Sex, Female Color, White Condition, Widow
(White, Black, Mixed, Chinese, Indian, etc.)
(Single, Married, Widowcd or Divorced.)
Age, 62 Years, 9 Months, 6. Days. Occupation,
Residence, *.... 288 Court Road, Winthrop. ...... Ward,
Place of Death, ... 288 .... Court .... Road, .... Winthrop.
Place of Birth, ..... England
Date of Birth, Oct. 13. 1846
Name and Birthplace ? William H. Martyn- - England
of Father,
Maiden Name and Mary A. Wymond- England
Birthplace of Mother,
Place of Interment, Forest Hills Cemetery.
* If an institution, state how long an inmate and previous residence. E.Q. Brown, Undertaker.
PHYSICIAN'S CERTIFICATE OF THE CAUSE OF DEATH.
Boston,
20 19.0.2
Name and Age ? Carolina Mr. 76 anniott Age,. 62 years.
of Deceased,
I hereby certify that I attended deceased from ... Sikl- 1908, to July 17
1909, that Ilast saw
alive on the. 17 day of .. 1909
130
that
8 hr
.died on the.
19
day of.
1909, about .......
-
o'clock
A.M., or P.M., and that, to the best of my knowledge and belief, the cause of death was as follows : Chief cause, Cancer y Sutesting
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