USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1910-1912 > Part 17
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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 strect, or one supposed to be due to Alcoholism, etc.
4. Deaths under circumstances unknown, as A person found dead, etc.
COMMONWEALTH OF MASSACHUSETTS.
RETURN OF A DEATH-1910.
CITY OF BOSTON.
FULL NAME
William B Fisher
Registered No.
9479
Place of Death ¿
Boston
State Hospt.
and Residence
Date of Death
Oct.25
1910.
Age
years
months.
19
days.
STATISTICAL DETAILS.
SEX
COLOR
M
IV
SINGLE, MARRIED, WID., DIV. M
Maiden Name
Husband's Name
Birthplace Wheeling, W. Va.
Name of Ben jamin Fisher
Father.
Birthplace of Father
Maiden Name
Eltazera Bailey
of Mother
Birthplace of Mother
Occupation None
Informant
.......
PHYSICIAN'S CERTIFICATE.
I HEREBY CERTIFY that I attended deceased during last illness,
from 1910, to .1910, 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:
IST ATRIBE
RAR'S
SIT
General paresis-1 yr +
:Primary (Duration) BIS
AFICE
TVTTA
BOSTONIA CONDITAAL
A.1822
BOSTON
. MAS.S.
Contributory : 2 (Duration)
(Signed).
E C Noble
.M.D.
Oct. 25
1910
.....
SPECIAL INFORMATION from Hospitals, Institutions, Transier.ts, or Recent Residents.
or removal.
Wheeling, W . Va.
Usual Residence.
Winthrop
Oct. 27
Filed
1910.
A true copy. Attest :
Registrar.
....
ISREGIMINE
DONATA A.
............
Place of Burial
Undertaker
J S Waterman & Sons
59
4
CIT
THE COMMONWEALTH OF MASSACHUSETTS
RETURN OF A DEATH
FULL NAME
George Di Maley
Place of l
79 Atlantic St Vanthrow
Death *
S
Residence
79 Atlantic It
Age
years.
5
.months. 24 .days
STATISTICAL DETAILS
SEX male
COLOR
White
SINGLE, MARRIED, WIDOWED, OR DIVORCED
Single
MAIDEN NAME +
HUSBAND'S NAME +
BIRTHPLACE $ Wintwok Mass
NAME OF FATHER
John F. I'Maley
BIRTHPLACE OF FATHER$
Portsmouth ket
MAIDEN NAME OF MOTHER Ellen Shelly
BIRTHPLACE OF MOTHER $ Boston mass
OCCUPATION
INFORMANT S
John FI Imaley
79 Atlantic St.
PLACE OF BURIAL OR REMOVAL II Holy Cross
DATE OF BURIAL
10/29
1910
UNDERTAKER
ADDRESS
frederick nagratt East Borton
PHYSICIAN'S CERTIFICATE
I HEREBY CERTIFY that I attended deceased during last illness, from Ccr. 10 ... 1910 to Geek 27 1920. 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 : Tubercular Meningitis
(DURATION).
17
DAYS
Contributory :
Primaria
(DURATION)
8
DAYS
(Signed)
Edward J. Granger
M.D.
6.4.27 1910 (Address)
304 0 million In
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
..... .... 19
Clerk
* City or town, street and number, If any. If death occurs away from USUAL RESI- DENCE, glve 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.
# State or country; also city, town or county, If known.
§ Name and address of person glving statistical detalls.
|| Name of cemetery.
ALL NAMES TO BE IN FULL
Wintluck (CITY OR TOWN.)
Registered No.
Date of l
Oct 27
19/0
Death
- Deange of Oct. 27, 1910.
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
I PLACE OF DEATH
Foungo Jatil (No. .. .....
St: ;
Ward)
teity or towy.) [If death occurred in a hospital or institution, give its NAME instead of street and number.]
Registered No.
PERSONAL AND STATISTICAL PARTICULARS
3 SEX Fem
4 COLOR OR RACE
White
(Month)
(Day)
(Year)
7 AGE
If LESS than
day, .. .... hrs.
47 yrs. /1. mos.
13 ds.
or ....... min. ?
8 OCCUPATION
(a) Trade, profession, or
particular kind of work ....
at Home
(b) General nature of industry, business, or establishment in which employed ( or employer)
9 BIRTHPLACE
(State or country)
madicon bias
10 NAME OF
FATHER
alfred a. Nuller
PARENTS
11 BIRTHPLACE ( OF FATHER (State or country) London En.".
12 MAIDEN NAME OF MOTHER
13 BIRTHPLACE OF MOTHER (State or country)
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
(Address)
16
Filed 191
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
Nov.
5th
(Month)
(Day)
, 1910
(Year)
17
I HEREBY CERTIFY that I attended deceased from
191
, to
191
that | last saw h .....
alive on. .
, 191
and that death occurred, on the date stated above, at 10 am.
The CAUSE OF DEATH* was as follows :
Tubercular Tumar of fulvio
Operation at Carne, Hospital, at-
lowed by further development
8 te direche
.(Duration)
yrs. .
mos. ...
ds.
Contributory.
(SECONDARY)
.. (Duration)
yrs.
mos. ...
... ds.
(Signed) .
Albert 13 Domman
. ,
M.D.
Mr. Gt, 1910. (Address)
Wirthof Mars.
* 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
3 - , 19kč
,
ADDRESS
20 UNDERTAKER
HE Sharan
2 FULL NAME
martha Jean traiduell
[If married or divorced woman or widow give maiden name, also name of husband!} @RESIDENCE facendo frites
John Galdurch
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
6 DATE OF BIRTH
21
1863
nov. 5, 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 needed. As examples: (a) Spinner, (b) Cotton mill; (a) Sales- man, (b) Grocery ; (a) Foreman, (b) Automobile factory. Th 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 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 "Croup") ; Typhoid fever (never re- port " Typhoid pneumonia ") ; Lobar pneumonia; Broncho- pneumonia (" Pneumonia," unqualified, is indefinite) ; Tuber-
culosis of lungs, meninges, peritoneum, 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 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," "Marasmu-," "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 strect, 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 Charlesmate Hospital
Cambridge (City or town.)
1 PLACE OF DEATH
Cambridge
(No
350 Charles River Rd.
St. :
Ward)
[If death occurred in a hospital or institution, give its NAME instead of street and number.]
FULL NAME
James Donerty
[If married or divorced woman or widow
give maiden name, also name of husband.]
@RESIDENCE
27 Ocean Spray Ave. , Winthrop
Registered No. 1600
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
3 SEX M
+ COLOR OR RACE
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
16 DATE OF DEATH
Nov. 6,1910
(Month)
(Day)
191
(Year)
6 DATE OF BIRTH
(Month)
(Day)
(Year)
7 AGE
5.4 . yrs. 0 . mos. 0 ds
Or ........ min. ?
8 OCCUPATION
(a)' Trade, profession, or
particular kind of work
Liquor Dealer
(b) General nature of industry,
business, or establishment in
which employed (or employer)
3 BIRTHPLACE
(State or country)
Ireland
10 NAME OF
FATHER
Patrick Doherty
PARENTS
11 BIRTHPLACE OF FATHER (State or country)
Ireland
12 MAIDEN NAME OF MOTHER Margaret Devlin,
13 BIRTHPLACE
OF MOTHER
(State or country)
Ireland
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
Cornelius Doherty
(Address)
Winthrop, Mas9.
>
17
I HEREBY CERTIFY that I attended deceased from
191.
, to
191
If LESS than I day. hrs. that ! last saw h alive on 191
and that death occurred, on the dato stated above, at
m.
The CAUSE OF DEATH* was as follows :
Pneumonia
(Duration) ..
.yrs.
mos.
6
ds.
Contributory
(SECONDARY)
.(Duration)
.yrs.
mos.
ds.
(Signed)
M.D.
191
(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 Holy Cross, Malden.
DATE OF BURIAL
NOV . 7, 1910
191
Filed .. Nov. 8,29.10.
20 UNDERTAKER
Felix F. Talbot,
AREfestown.
Gril City Chef REGISTRAR
1
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 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 sam 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, peritoneum, 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 deatlı), 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
(No. 1H. ExentosPR
St. ;..
(City or town.)
Ward)
[If death occurred in a hospital or institution, give its NAME instead of street and number.]
Registered No.
PERSONAL AND STATISTICAL PARTICULARS
Widonad
6 25
.
(Year)
If LESS than
1 day, ..
.. hrs.
or
min. ?
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
Filed 191
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
november
(Month)
10th (Day)
, 1910.
(Year)
1835
nov. 10th
17
I HEREBY CERTIFY that I attended deceased from
nova 6 th
1910, to
, 1910,
that I last saw hele alive on
nor.9th
. . , 1910
and that death occurred, on the date stated above, at .. m.
The CAUSE OF DEATH* was as follows :
Bronchitis
(Duration) yrs.
mos.
10
ds.
Contributory
Metral Hlenori
(SECONDARY)
(Duration) yrs.
mos. ..
ds.
(Signed)
Dr.l. Porta
, M.D.
7201.10
C191 A. (Address)
Winthrop Years
* 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
11-12. 1910
ADDRESS
20 UNDERTAKER
1
H. Chaque
1 PLACE OF DEATH 2 FULL NAME. [If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE 3 SEX 4 COLOR OR RACE 5 SINGLE, MARRIED, WIDOWED, OR DIVORCED (Write the word) Inale White 6 DATE OF BIRTH (Month) (Day) 7 AGE 8 OCCUPATION 1 (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) Marietta, Chico 10 NAME OF FATHER 1 - 11 BIRTHPLACE OF FATHER (State or country) 12 MAIDEN NAME OF MOTHER PARENTS 13 BIRTHPLACE OF MOTHER (State or country) (Informant). important. See instructions on back of certificate. (Address) 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 75 yrs. Af mos. 15 ds.
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: («) 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 are engaged in the duties of the honsehold 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, peritondeum, 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 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," "Haemorrhagc," " Inanition," "Marasmn :," " 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.
PARENTS
11 BIRTHPLACE
OF FATHER
(State or country)
Nulcham Mas
12 MAIDEN NAME
OF MOTHER
Connie Victoria ScoXX
13 BIRTHPLACE
OF MOTHER
(State or country)
Boston mais
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
Hereat al ford.
(Address)
33 houg no Se limitant
14
Filed.
191
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
17
I HEREBY CERTIFY that I attended deceased from
190%, to
No. 11
., 1919 ...
that I last saw her alive on
Nr.
, 191 0 ..
and that death occurred, on the date stated above, at.
7 ( .m.
The CAUSE OF DEATH* was as follows :
Caramamma
.
of the intestines
(Duration) .
1
.yrs.
mos.
-
ds.
Contributory ..
(SECONDARY)
an
(Duration)
1
yrs. mos.
-
ds.
(Signed)
Rim 12
191 0
.(Address)
60 Sugar
an
* 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
1919
ADDRESS
20 UNDERTAKER
Chas R Berman
1
(City or town.) [If death occurred in a hospital or institution, give its NAME instead of street and number.]
Registered No.
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
4 COLOR OR PACE
white
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
1
6 DATE OF BIRTH
200
1
(Month)
(Day)
. 1892
(Year)
7 AGE
18 %
yrs.
X
mos.
/ O.ds.
If LESS than
1 day,
. . hrs.
.... min. ?
8 OCCUPATION
(a)' Trade, profession, or
particular kind of work ..
at Home
(b) General nature of industry,
business, or establishment in
which employed (or employer)
4
9 BIRTHPLACE
(State or country)
J' Boston Muss
10 NAME OF
FATHER
Hubert, M. Ford
The Commonwealth of Massachusetts STANDARD CERTIFICATE OF DEATH 1 PLACE OF DEATH Winterof Mass (No. 33 Douglas ST St. :
'FULL NAME
Hellen.
Estelle, J'ord
[If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE 33 Douglas AL
Ward)
11
(Month)
(Day)
191 0
(Year)
now. 11,1910
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 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 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.
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