USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1910-1912 > Part 13
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culosis of lungs, meninges, peritonacum, etc., C'arcinoma, Sar- coma, etc., of .. ..... (name origin : "Cancer" is less definite; avoid use of "Tumor" for malignant neoplasms) ; Measles ; Whooping cough; Chronic valvular heart disease; Chronic interstitial nephritis, etc. The contributory (second- ary or intercurrent) affection need not be stated unless im- portant. Example: Measles (disease causing death), 29 ds .; Broncho-pneumonia (secondary), 10 ds. Never report mere symptoms or terminal conditions, such as " Asthenia," " An- aemia " (merely symptomatic), " Atrophy," "Collapse," "Coma," "Convulsions," "Debility " ("Congenital," "Senile," etc.), "Dropsy," "Exhaustion," "Heart failure," "Haemorrhage," " Inanition," " Marasmus," " Old age," "Shock," "Uraemia," "Weakness," etc., when a definite disease can be ascertained as the cause. Always qualify all diseases resulting from childbirth or miscarriage, as "PUER- PERAL septicaemia," " PUERPERAL peritonitis," etc. State cause for which surgical operation was undertaken.
Cases for the Medical Examiners. - Under the provisions of chapter 24 of the Revised Laws deaths under the following conditions must be referred to the Medical Examiners:
1. Deaths following injury or violence, as Burns, Falls, Drowning, Gas Poisoning, Suicide, Homicide, etc.
2. Deaths supposedly caused by violence, as Criminal Abortion, Poisoning, Starvation, Suffocation, Ex- posure, etc.
3. Sudden deaths of persons not disabled by recognized disease, as A death upon the street, or one supposed to be due to Alcoholism, etc.
4. Deaths under circumstances unknown, as A person found dead, etc.
N. B. - Every item of information should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state CAUSE OF DEATH in plain terms, so that it may be properly classified. Exact statement of OCCUPATION is very
important. See instructions on back of certificate.
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH Wencherok Muss (No .. 24 Winchrol St. ;
(City or town.)
Ward)
[If death occurred in a hospital or institution, give its NAME instead of street and number.]
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
4 COLOR OR RACE
white
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
6 DATE OF BIRTH
21
(Month)
(Day)
,1901
(Year)
7 AGE
3
yrs.
mos.
3
ds.
or
min. ?
8 OCCUPATION
(a)' Trade, profession, or particular kind of work
(b) General nature of industry, business, or establishment in which employed (or employer)
9 BIRTHPLACE
(State or country)
Hastings are duIterson
10 NAME OF
FATHER
Fred Killow Wells
PARENTS
12 MAIDEN NAME OF MOTHER Margenede Jane Lowqq
13 BIRTHPLACE
OF MOTHER
(State or country)
Mormenek England
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
(Address)
159 WeicheL St911cars
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
Left
2 4
191 0
(Month)
(Day)
(Year)
17
I HEREBY CERTIFY that I attended deceased from
Dep. 20
1910, to
Sep. 24
. 19110.
that I last saw her
alive on
1910.
and that death occurred, on the date stated above, at
8a. m.
The CAUSE OF DEATH* was as follows :
Cyclic Vomiting
(Duration)
yrs.
mos.
ds.
Contributory
(SECONDARY)
-
Voxarmia
. (Duration)
yrs.
mos.
4.
.ds.
(Signed)
M.D.
Sep. 26. 1916
(Address)
Minitrope, mais,
* If death followed injury or violence the certificate of death must be made out by the Medical Examiner.
18 LENGTH OF RESIDENCE (FOR HOSPITALS, INSTITUTIONS, TRANSIENTS, OR RECENT RESIDENTS).
At place
of death
yrs.
mos.
In the
ds.
State ...
.yrs.
mos. .
ds.
Where was disease contracted, if not at place of death ?.
Former or usual residence.
19 PLACE OF BURIAL OR REMOVAL
DATE OF BURIAL
Jeff 26
1910
20 UNDERTAKER
ADDRESS
Filed 191
1
Hundred Jellow Wells
FULL NAME [If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE 24 Werechurch Street
Registered No.
If LESS than 1 day, hrs.
11 BIRTHPLACE
OF FATHER
(State or country)
Richmond Sle
STANDARD CERTIFICATE OF DEATH.
Statement of occupation. - Precise statement of occupa- tion is very important, so that the relative healthfulness of various pursuits can be known. The question applies to each and every person, irrespective of age. For many occupations a single word or term on the first line will be sufficient, e. g., Farmer or Planter, Physician, Compositor, Architect, Loco- motive engineer, Civil engineer, Stationary fireman, etc. But in many cases, especially in industrial employments, it is necessary to know (a) the kind of work and also (b) the nature of the business or industry, and therefore an additional line is provided for the latter statement ; it should be used only when needed. As examples: (a) Spinner, (b) Cotton mill; (a) Sales- man, (b) Grocery ; (a) Foreman, (b) Automobile factory. The material worked on may form part of the second statement. Never return "Laborer," " Foreman," " Manager," "Dealer," etc., without more precise specification, as Day laborer, Farm laborer, Laborer - Coal minc, etc. Women at home, who are engaged in the duties of the household only (not paid House- keepers who receive a definite salary), may be entered as Housewife, Housework, or At home, and children, not gain- fully employed, as At school or At home. Care should be taken to report specifically the occupations of persons engaged in domestic service for wages, as Servant, Cook, Housemaid, etc. If the occupation has been changed or given up on account of the DISEASE CAUSING DEATH, state occupation at beginning of illness. If retired from business, that fact may be indicated thus: Farmer (retired, 6 yrs.). For persons who have no occupation whatever, write Nonc.
Statement of cause of death. - Namc, first, the DISEASE CAUSING DEATH (the primary affection with respect to time and causation), using always the same accepted term for the same disease. Examples: Cerebro-spinal fever (the only definite synonym is "Epidemic cerebro-spinal meningitis ") ; Diphtheria (avoid use of "Croup ") ; Typhoid fever (never re- port " Typhoid pneumonia ") ; Lobar pneumonia; Broncho- pneumonia (" Pneumonia," unqualified, is indefinite) ; Tuber-
culosis of lungs, meninges, peritonaeum, etc., Carcinoma, Sar- eoma, etc., of .. . (name origin: "Cancer" is less definite ; avoid use of "Tumor" for malignant neoplasms) ; Measles; Whooping cough ; Chronic valvular heart disease; Chronic interstitial nephritis, etc. The contributory (second- ary or intercurrent) affection need not be stated unless im- portant. Example: Measles (disease causing death), 29 ds .; Broncho-pneumonia (secondary), 10 ds. Never report mere symptoms or terminal conditions, such as " Asthenia," " An- aemia " (merely symptomatic), " Atrophy," "Collapse," "Coma," "Convulsions," "Debility" ("Congenital," "Senile," etc.), "Dropsy," "Exhaustion," "Heart failure," "Haemorrhage," " Inanition," " Marasmus," "Old age," "Shock," "Uraemia," " Weakness," etc., when a definite disease can be ascertained as the cause. Always qualify all diseases resulting from childbirth or miscarriage, as " PUER- PERAL septicaemia," " PUERPERAL peritonitis," etc. State cause for which surgical operation was undertaken.
Cases for the Medical Examiners. - Under the provisions of chapter 24 of the Revised Laws deaths under the following conditions must be referred to the Medical Examiners :
1. Deaths following injury or violence, as Burns, Falls, Drowning, Gas Poisoning, Suicide, Homicide, etc.
2. Deaths supposedly caused by violence, as Criminal Abortion, Poisoning, Starvation, Suffocation, Ex- posure, etc.
3. Sudden deaths of persons not disabled by recognized disease, as A death upon the street, or one supposed to be due to Alcoholism, etc.
4. Deaths under circumstances unknown, as A person found dead, etc.
THE COMMONWEALTH OF MASSACHUSETTS
Winthrop
(CITY OR TOWN.)
FULL NAME
Catherine Hohe
Registered No.
Place of l
Winthrop 34 Tico KANE
Death *
S
Residence
34 Dico Ave
Age
... year
15
months. 13 .days
STATISTICAL DETAILS
COLOR
SEX Female White
SINGLE, MARRIED, WIDOWED, OR DIVORCED
MAIDEN NAME +
HUSBAND'S NAME t
BIRTHPLACE İ Boston Mass.
Walter Surplus Hohe
BIRTHPLACE OF FATHERY Cumberland Pel
MAIDEN NAME OF MOTHER Catherine Connolly.
BIRTHPLACE OF MOTHER $ Lynn Massy
OCCUPATION
INFORMANTS
Hatten & Hope
34 Dico LAVE.
PHYSICIAN'S CERTIFICATE
I HEREBY CERTIFY that i attended deceased during last illness, from Sent- 22 19 to Sent 26 /910, 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 : Endocarditis
Contributory :
Prenne
(DURATION). DAYS
(DURATION) 4 DAYS
(Signed) Hungryfall M.D.
Sup 26 191 (Address) 263
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
19
Clerk
PLACE OF BURIAL OR REMOVAL !?
St mary Lynn 9/28
19/0
John F. O maley 79 Atlantic st
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 city, town or county, if known.
§ Name and address of person giving statistical detalls. || Name of cemetery.
FILL OUT WITH INK. - THIS IS A PERMANENT RECORD
ALL NAMES TO BE IN FULL
RETURN
/OF A DEATH
Date of l
Seht 26
19/0
Death
Sept. 26, 1910
3 SEX Female 6 DATE OF BIRTH 7 AGE 56 Est PARENTS important. See instructions on back of certificate. 16 N. B. - Every item of information should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state CAUSE OF DEATH in plain terms, so that it may be properly classified. Exact statement of OCCUPATION is very (b) General nature of industry, business, or establishment in which employed (or employer)
The Commonwealth of Massachusetts STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH Metcalf Hospital ...
St. ;
Ward)
[If death occurred in a hospital or institution, give its NAME instead of street and number.]
FULL NAME Hamit Shellhouse
[If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE 21 Marion Street, Casi Boston
Registered No.
PERSONAL AND STATISTICAL PARTICULARS
4 COLOR OR RACE
White
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
Vidoro
-
(Month) (Day)
(Year)
If LESS than
day,
.hrs.
that | last saw hr
alive
191 ,
and that death occurred, on the date stated above, at 6.500 m.
The CAUSE OF DEATH* was as follows : multiple injuries, including
Skull (base, portable) molto ulting showration card lyon, Contributory accidental fall from (SECONDARY) .(Duration) yrs. a light
(Signed)
, M.D.
Sept30, 1918 (Address).
* If death followed injury or violence the certificate of death must be made out by the Medical Examiner.
18 LENGTH OF RESIDENCE (FOR HOSPITALS, INSTITUTIONS, TRANSIENTS, OR RECENT RESIDENTS).
At place
of death
yrs.
mos.
In the
ds.
State
.yrs
mos.
ds.
....
Where was disease contracted, if not at place of death ?...
Former or usual residence
19 PLACE OF BURIAL OR REMOVAL Woodlawn
DATE OF BURIAL
Det 32 1910
20 UNDERTAKER
nc. g. Kelly
ADDRESS
19 11 verick f.
Filed ... 191.
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
(Month)
(Day)
30, 1910
(Year)
17 I HEREBY CERTIFY that I attended deceased from
191
to
& OCCUPATION
(a) Trade, profession, or
particular kind of work
Home
-
9 BIRTHPLACE
(State or country)
Halifax n.f.
10 NAME OF
FATHER
Henry R. Bird
11 BIRTHPLACE OF FATHER (State or country) Unknown
12 MAIDEN NAME
OF MOTHER
Margaret 6, Unknown
13 BIRTHPLACE
OF MOTHER
(State or country)
Unknown
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informan
Hattie M. Stearns
(Address)
21 Marion St. 6. Barto
yrs. mos. ds.
or ..... min. ?
Harriet Bird Henry hellhouse
2791
(City or town.)
mos. . ds.
Sept. 30, 1910.
STANDARD CERTIFICATE OF DEATH.
Statement of occupation. - Precise statement of occupa- tion is very important, so that the relative healthfulness of various pursuits can be known. The question applies to each and every person, irrespective of age. For many occupations a single word or term on the first line will be sufficient, e. g., Farmer or Planter, Physician, Compositor, Architect, Loco- motive engineer, Civil engineer, Stationary fireman, etc. But in many cases, especially in industrial employments, it is necessary to know (a) the kind of work and also (b) the nature of the business or industry, and therefore an additional line is provided for the latter statement ; it should be used only when neoded. As examples: (a) Spinner, (b) Cotton mill; (a) Sales- man, (b) Grocery ; (a) Foreman, (b) Automobile factory. The material worked on may form part of the second statement. Never return " Laborer," " Foreman," " Manager," "Dealer," etc., without more precise specification, as Day laborer, Farm laborer, Laborer- Coal mine, etc. Women at home, who aro engaged in the duties of the household only (not paid House- keepers who receive a definite salary), may be entered as Housewife, Housework, or At home, and children, not gain- fully employed, as At school or At home. Care should be taken to report specifically the occupations of persons engaged in domestic service for wages, as Servant, Cook, Housemaid, etc. If the occupation has been changed or given up on account of the DISEASE CAUSING DEATH, state occupation at beginning of illness. If retired from business, that fact may be indicated thus: Farmer (retired, 6 yrs.). For persons who have no occupation whatever, write None.
Statement of cause of death. - Name, first, the DISEASE CAUSING DEATH (the primary affection with respect to time and causation), using always the same accepted term for the same disease. Examples: Cerebro-spinal fever (the only definite synonym is "Epidemic cerebro-spinal meningitis ") ; Diphtheria (avoid use of "Croup ") ; Typhoid fever (never re- port " Typhoid pneumonia ") ; Lobar pneumonia ; Broncho- pneumonia ("Pneumonia," unqualified, is indefinite) ; Tuber-
culosis of lungs, meninges, peritonaeum, etc., Carcinoma, Sar- coma, etc., of .. (name origin: "Cancer" is less definite; avoid use of " Tumor" for malignant neoplasms) ; Measles ; Whooping cough ; Chronic valvular heart disease; Chronic interstitial nephritis, etc. The contributory (second- ary or intercurrent) affection need not be stated unless im- portant. Example: Measles (disease causing death), 29 ds .; Broncho-pneumonia (secondary), 10 ds. Never report mere symptoms or terminal conditions, such as " Asthenia," " An- aemia " (merely symptomatic), " Atrophy," "Collapse," "Coma," "Convulsions," "Debility" ("Congenital," "Senile," etc.), "Dropsy," "Exhaustion," "Heart failure," "Haemorrhage," " Inanition," " Marasmus," " Old ago," "Shock," "Uraemia," "Weakness," etc., when a definite disease can be ascertained as the cause. Always qualify all diseases-resulting from childbirth or miscarriage, as "PUER- PERAL septicaemia," " PUERPERAL peritonitis," etc. State _cause for which surgical operation was undertaken.
Cases for the Medical Examiners. - Under the provisions of chapter 24 of the Revised Laws deaths under the following conditions must be referred to the Medical Examiners:
1. Deaths following injury or violence, as Burns, Falls, Drowning, Gas Poisoning, Suicide, Homicide, etc.
2. Deaths supposedly caused by violence, as Criminal Abortion, Poisoning, Starvation, Suffocation, Ex- posure, etc.
3. Sudden deaths of persons not disabled by recognized disease, as A death upon the street, or one supposed to be due to Alcoholism, etc.
4. Deaths under circumstances unknown, as A person found dead, etc.
Commonwealth 0 Massachusetts
UNITED STATES OF AMERICA.
Certificate of Death
FROM THE RECORDS OF DEATHS IN THE TOWN OF
Winthrop
MASSACHUSETTS, U. S A.
1. Date of Death,
October 1 1910
Thomas J. Lavery
(Maiden Name,
3. Sex, and whether Single, Married, or Widowed, -
male
Widowed
white
4. Color,
5. Age, 77 Years Months Days
6. Disease or Cause of Death Broncho t monia following fall
7. Residence,
8. Occupation,
9. Place of Death,
Winthrop
10. Place of Birth,
11. Name of Father,
matthew
pane Elleat
(Maiden Name)
13. Birthplace of Father, -
14. Birthplace of Mother, -
15.
Place of Interment, -
-
Inst. Benedict Rox
Entalie can't. Churchill depose and say,
that I hold the office of Town Clerk of the Town of
Winthrop
County of Suffolk and Commonwealth of Massachusetts; that the records of Births. Marriages and Deaths in said Town are in my custody, and that the above is a a true extract from the Records of Deaths in said Town, as certified by me.
WITNESS my hand and the Seal of said Town, on the
eighth,
day of February 1911.
Enlahe Churchill canet. Toun Clerk.
Quer
$29.2
40 Elmwood
Retired
Landart Boslow Mass.
12. Name of Mother, -
Ireland
Ireland
2. Name,
dair .
1 93
1
nl
וה
Commonwealth of Massachusetts. Suffolk Sel. Winthrop Freh. 20, 191.
1
Then personally affeared be for any, Preston Churchelf Town Clerk, Thomas Macht Hurackhand made oath that of the place of birth of Thomas J. Javery, was Joslow and Not Freland anall that all other information in the within return is Correct
Preston B, Churchill, Join Clerk,
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH Monthsof .. (No .. 40 Elemnordara; Ward)
Thomas & Javery 2 FULL NAME
{If married or divorced woman or widow give maiden name, also name of husband ] @RESIDENCE 40 Ehmerved äve.
PERSONAL AND STATISTICAL PARTICULARS
3 SEX Male
4 COLOR OR RACE
While
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
Midlerne
6 DATE OF BIRTH
Sept.
27
18歳
(Year)
(Month)
(Day)
7 AGE
If LESS than I day, .. . .. hrs.
yrs.
mos.
ds.
min.
& OCCUPATION
(a) Trade, profession, or
particular kind of work
Betina of 10 yrs.
General nature of industry, ness, or establishment in ich employed (or employer).
"IPTHPLACE
r or country)
Ireland
PARENTS
11 BIRTHPLACE
OF FATHER
(State or country)
Ireland
12 MAIDEN NAME
OF MOTHER
Jane Elliot
13 BIRTHPLACE OF MOTHER (State or country) trebamal.
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
Thomas Machen
(Address)
40 Ellermanel One,
16
Filed. 191
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
Odlaten
(Month )
(Day)
19 ! O
(Year)
I HEREBY CERTIFY that I attended deceased from
Seft 28
1910 , to
, 1910
-
that I last saw h umalive on
Oct 1
, 1910.
and that death occurred, on the date stated above, at 1.30m.
The CAUSE OF DEATH* was as follows :
Bracciolo pneumonia following fall
yrs. .
mos. 12 ds.
Traumation pour tall
.(Duration)
Contributory
SECONDARY)
down stairs
(Duration)
yrs.
mos.
12 ds.
M.D.
* If death followed injury or violence the certificate of death must be made out by the Medical Examiner.
18
LENGTH OF RESIDENCE (FOR HOSPITALS, INSTITUTIONS, TRANSIENTS, OR RECENT RESIDENTS).
At place
of death.
yrs. ..
mos.
ds.
State
In the
yrs. ..
mos.
ds.
Where was disease contracted, If not at place of death ?.
Former or usual residence.
19 PLACE OF BURIAL OR REMOVAL
DATE OF BURIAL
MX Bericht Roy lect 3, 1910
20 UNDERTAKER
David Aleurton
ADDRESS
0
·
(City or town.)
{If death occurred in a hospital or institution, give its NAME instead of street and number.]
Registered No.
17
1910.
(Address).
important. See instru
10 NAME OF
FATHER
Mathew Lavery
,
(Signed)
Oct, Y, 1910
STANDARD CERTIFICATE OF DEATH.
-
Statement of occupation. - Precise statement of occupa- tion is very important, so that the relative healthfulness of various pursuits can be known. The question applies to each and every person, irrespective of age. For many occupations a single word or term on the first line will be sufficient, e. g., Farmer or Planter, Physician, Compositor, Architect, Loco- motive engineer, Civil engineer, Stationary fireman, etc. Bnt in many cases, especially in industrial employments, it is necessary to know (a) the kind of work and also (b) the nature of the business or industry, and therefore an additional line is provided for the latter statement; it should be used only when needed. As examples: (a) Spinner, (b) Cotton mill; (a) Sales- man, (b) Grocery ; (a) Foreman, (b) Automobile factory. The material worked on may form part of the second statement. Never return " Laborer," " Foreman," " Manager," "Dealer," etc., without more precise specification, as Day laborer, Farm laborer, Laborer- Coul mine, etc. Women at home, who are engaged in the duties of the household only (not paid House- keepers who receive a definite salary), may be entered as Housewife, Housework, or At home, and children, not gain- fully employed, as At school or At home. Care should be taken to report specifically the occupations of persons engaged in domestic service for wages, as Servant, Cook, Housemaid, etc. If the occupation has been changed or given up on account of the DISEASE CAUSING DEATH, state occupation at beginning of illness. If retired from business, that fact may be indicated thus: Farmer (retired, 6 yrs.). For persons who have no occupation whatever, write None.
Statement of cause of death. - Name, first, the DISEASE CAUSING DEATH (the primary affection with respect to time and causation), using always the same accepted term for the same disease. Examples: Cerebro-spinal fever (the only definite synonym is "Epidemic cerebro-spinal meningitis ") ; Diphtheria (avoid use of " Cronp") ; Typhoid fever (never re- port " Typhoid pneumonia ") ; Lobar pneumonia; Broncho- pneumonia (" Pneumonia," unqualified, is indefinite) ; Tuber-
culosis of lungs, meninges, peritonaeum, etc., Carcinoma, Sur- coma, etc., of ... (name origin: "Cancer" is less definite ; avoid use of "Tumor" for malignant neoplasms) ; Measles; Whooping cough ; Chronic valrular heart disease; Chronic interstitial nephritis, etc. The contributory (second- ary or intercurrent) affection need not be state ?? unless im- portant. Example: Measles (disease causing death), 29 ds .; Broncho-pneumonia (secondary), 10 ds. Never report mere symptoms or terminal conditions, such as " Asthenia," " An- aemia " (merely symptomatic), " Atrophy," " Collapse," "Coma," "Convulsions," "Debility " ("Congenital," "Senile," etc.), "Dropsy," "Exhaustion," " Heart failure," "Haemorrhage," " Inanition," " Marasmus," " Old age," "Shock," "Uraemia," "Weakness," etc. when a definite disease can be ascertained as the cause. Always qualify all diseases resulting from childbirth or miscarriage, as "PUER- PERAL septicaemia," " PUERPERAL peritonitis," etc. State cause for which surgical operation was undertaken.
Cases for the Medical Examiners. - Under the provisions of chapter 24 of the Revised Laws deaths under the following conditions must be referred to the Medical Examiners :
1. Deaths following injury or violence, as Burns, Falls, Drowning, Gas Poisoning, Suicide, Homicide, etc.
2. Deaths supposedly caused by violence, as Criminal Abortion, Poisoning, Starvation, Suffocation, Ex- posure, etc.
3. Sudden deaths of persons not disabled by recognized disease, as A death upon the street, or one supposed to be due to Alcoholism, etc.
4. Deaths under circumstances unknown, as A person found dead, etc.
The Commonwealth of Massachusetts STANDARD CERTIFICATE OF DEATH
I PLACE OF DEATH
Lynn
(No.
Union Hospital.
St. ;...... Ward)
{If death occurred in a hospital or institution, give its NAME instead of street and number.]
2 FULL NAME
Hannah Griffiths
[If married or divorced woman or widow give maiden name, also name of husband.] Heaton - Thomas.
@RESIDENCE
320 Bowdoin st, Winthrop
Registered No.1 067
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
3 SEX
F
4 COLOR OR RACE
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
M
6 DATE OF BIRTH
Sort. 21, 1850.
(Month)
(Day)
(Year)
7 AGE
If LESS than
I day,.
hrs.
that | last saw h
alive on
, 191.
.. ,
and that death occurred, on the date stated above, at
m.
The CAUSE OF DEATH* was as follows :
Parenchymatous nephritis
(Duration)
yrs.
mos.
.ds.
Contributory.
Acute dilatation of heart
(SECONDARY)
(Duration)
yrs.
...
.mos.
ds.
(Signed)
I. H Chicoinc
M.D.
191
( Address)
Lynn
* If death followed injury or violence the certificate of death must be made out by the Medical Examiner.
18 LENGTH OF RESIDENCE (FOR HOSPITALS, INSTITUTIONS, TRANSIENTS, OR RECENT RESIDENTS).
At place
of death
yrs.
In the
mos.
ds.
State
yrs.
mos.
ds ...
Where was disease contracted, If not at place of death ?.
Former or usual residence.
19 PLACE OF BURIAL OR REMOVAL
DATE OF BURIAL
191
Winthrop, lass.
20 UNDERTAKER
C. R. Benneson
ADDRESS
Winthrop
important. See instructions on back of certificate.
PARENTS
11 BIRTHPLACE
OF FATHER
(State or country}
Manchester, Eng.
12 MAIDEN NAME
OF MOTHER
Unknown
13 BIRTHPLACE
OF MOTHER
(State or country)
=
"THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
Thomas Griffiths
(Address)
- Winthrop Made
15 Filed ...
1911
REGISTRAR
16 DATE OF DEATH
Oct. 3, 1910
(Month)
(Day)
191
(Year)
17
0
I HEREBY CERTIFY that I attended deceased from
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