Town of Winthrop : Record of Deaths 1910-1912, Part 17

Author: Winthrop (Mass.)
Publication date: 1910
Publisher:
Number of Pages: 956


USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1910-1912 > Part 17


Note: The text from this book was generated using artificial intelligence so there may be some errors. The full pages can be found on Archive.org (link on the Part 1 page).


Part 1 | Part 2 | Part 3 | Part 4 | Part 5 | Part 6 | Part 7 | Part 8 | Part 9 | Part 10 | Part 11 | Part 12 | Part 13 | Part 14 | Part 15 | Part 16 | Part 17 | Part 18 | Part 19 | Part 20 | Part 21 | Part 22 | Part 23 | Part 24 | Part 25 | Part 26 | Part 27 | Part 28 | Part 29 | Part 30 | Part 31 | Part 32 | Part 33 | Part 34 | Part 35 | Part 36 | Part 37 | Part 38 | Part 39 | Part 40 | Part 41 | Part 42 | Part 43 | Part 44 | Part 45 | Part 46 | Part 47 | Part 48 | Part 49 | Part 50 | Part 51 | Part 52 | Part 53 | Part 54 | Part 55 | Part 56 | Part 57 | Part 58 | Part 59 | Part 60 | Part 61 | Part 62 | Part 63 | Part 64 | Part 65 | Part 66 | Part 67 | Part 68 | Part 69 | Part 70 | Part 71 | Part 72 | Part 73 | Part 74 | Part 75 | Part 76 | Part 77 | Part 78 | Part 79 | Part 80 | Part 81 | Part 82 | Part 83 | Part 84 | Part 85 | Part 86 | Part 87 | Part 88 | Part 89 | Part 90 | Part 91 | Part 92 | Part 93 | Part 94 | Part 95


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.




Need help finding more records? Try our genealogical records directory which has more than 1 million sources to help you more easily locate the available records.