Town of Winthrop : Record of Deaths 1910-1912, Part 18

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 18


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).


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Statement of cause of death. - Naine, 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," " All- 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 Winthrop (No. 68 Bates avenue


St. ;.


Ward)


Winthrop (City or town.) [If death occurred in a hospital or institution, give its NAME instead of street and number.]


*FULL NAME. Catherine a, Lill


[If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE 68 Bates anche Winthrop


Wife of George m.


nee Jacke


Registered No.


PERSONAL AND STATISTICAL PARTICULARS


MEDICAL CERTIFICATE OF DEATH


3 SEX


4 COLOR OR RACE


W


5 SINGLE,


MARRIED,


WIDOWED,


OR DIVORCED


(Write the word)


married


6 DATE OF BIRTH


(Month)


(Day)


7 AGE


49 yrs.


mos. .


ds.


8 OCCUPATION


(a) Trade, profession, or particular kind of work Housewife


(b) General nature of industry, business, or establishment in which employed (or employer).


9 BIRTHPLACE


(State or country)


West Newton Mass!


PARENTS


12 MAIDEN NAME OF MOTHER


widget Clark


13 BIRTHPLACE OF MOTHER (State or country) 2 rueand


14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE


(Informant)


John W. will


(Address)


44 rates are


18 Filed 191.


REGISTRAR


17


1 HEREBY CERTIFY that I attended deceased from


1


(Year)


July


15


,1910, to Mar. 14


1910,


If LESS than


I day .....


hrs.


that I last saw haus alive on


nov. 14


, 191.0 ,


and that death occurred, on the date stated above, at 2-10/m.


or ....... min. ?


The CAUSE OF DEATH* was as follows :


Epicheliana of arvi Utri


Uren tain-


(Duration)


yrs.


mos. ds.


Contributory


Cardiac


(SECONDARY)


(Duration)


yrs.


2


(Signed)


N.J. Porter


M.D.


...


/200 16. 1910 (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


DATE OF BURIAL


mary Haitham mas.


,


1910


20 UNDERTAKER


mas: iune


ADDRESS East Postar


(Day)


14


1910


(Year)


16 DATE OF DEATH


non.


(Month)


mos. ! ds.


10 NAME OF


FATHER


Michael Jaffe


11 BIRTHPLACE OF FATHER (State or country) Ireland


Nov. 14, 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.


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 ferer (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 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, Fulls, 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.


1


COMMONWEALTH OF MASSACHUSETTS.


RETURN OF A DEATH-1910.


CITY OF BOSTON.


FULL NAME


Florence A Crossman


Registered No.


10223


Place of Death


Boston


N. E. Deaconess Hospt.


and Residence S


Date of Death.


Nov.20


1910.


Age


54


years


11


months.


9


days.


STATISTICAL DETAILS.


SEX


COLOR


SINGLE, MARRIED, WID., DIV. M


F


Maiden Name


Pollard


ST


RAR'S


Ac. Intestinal paralysis, fol


Husband's Name


Albert P Crossman


Rockland


CITY


Birthplace


.


Name of


Isaac Pollard


Father


Birthplace


of Father


Ipswich


Contributory : ! (Duration)


Maiden Name


of Mother.


Lydia ... Stetson


Birthplace


of Mother


Rockland


Occupation


Housewife


No.v.21 1910-


......... .


SPECIAL INFORMATION from Hospitals, Institutions, Transier.ts, or Recent Residents:


In hospital 8 days


Usual Residence.


Winthrop( 5 Hillside st)


Filed


Nov.25


1910.


A true copy.


Attest : ErMSlenen


Registrar.


Place of Burial


or removal


Cambridge "Camb . Cem"


Undertaker


L Jones & Son


PHYSICIAN'S CERTIFICATE.


I HEREBY CERTIFY that I attended deceased during last illness,


1910,


from 1910, to 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:


PATRIBU


SITD Primary (Duration) FICE;


abdominal hysterectomy, for


ZBOSTONIA CONDITA AD. 1 /0.1822;


1130.


BONATA D


MASS. malignant ... disease


.....


(Signed)


G W Kaan


........ .M.D.


Informant


TISREGDEN


BOSTON


S MALNER


The Commonwealth of Massachusetts STANDARD CERTIFICATE OF DEATH


1 PLACE OF DEATH


(No. Metcalf


Shild & Dlvomfuld


BOSTON


(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 RACE


5 SINGLE,


MARRIED,


WIDOWED,


OR DIVORCED


(Write the word)


Jungle


6 DATE OF BIRTH


(Month)


(Day)


1 (Year)


7 AGE


If LESS than 1 day, .... hrs.


.yrs.


mos.


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)


10 NAME OF FATHER


PARENTS


12 MAIDEN NAME OF MOTHER/


13 BIRTHPLACE OF MOTHER (State or country)


Breton Highlands


14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE


(Informant)


(Address)


18 Filed. 191.


REGISTRAR


MEDICAL CERTIFICATE OF DEATH


16 DATE OF DEATH Aw 229 (Month)


90


191


(Day)


(Year)


17 I HEREBY CERTIFY that I attended deceased from Ihm 22, 1910, to INN 202 .191


0


-


that I last saw her alive on , 191 3mpi and that death occurred, on the date stated above, at The CAUSE OF DEATH* was as follows : madental to Birth Still born


(Duration)


yrs.


mos. ds.


Contributory


(SECONDARY)


(Duration) 31 Pulat


yrs.


mos. .


.ds.


(Signed)


IN24.


1


1910 .. (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


DATE OF BURIAL


1915


ADDRESS


20 UNDERTAKER


(


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.


11 BIRTHPLACE OF FATHER (State or country)


6.


M.D.


,


'FULL NAME [If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE


Ward)


nov . 22, 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, Laborcr- 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 (rctired, 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 fcrer (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 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.


'FULL NAME 3 SEX 16 DATE OF BIRTH 7 AGE 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) Toulon 10 NAME OF FATHER PARENTS 13 BIRTHPLACE OF MOTHER (State or conntry) (Informant) important. See instructions on back of certificate. (Address) 15 Filed. 191 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 2.5 yrs.


The Commonwealth of Massachusetts STANDARD CERTIFICATE OF DEATH


BOSTON


(City or town.)


[If death occurred in a hospital or institution, give its NAME instead of street and number.]


PERSONAL AND STATISTICAL PARTICULARS


4 COLOR OR RACE


5 SINGLE,


MARRIED,


WIDOWED,


OR DIVORCED


(Write the word)


-


auq.


q', 1885


(Month)


(Day)


(Year)


If LESS than


I day,


. hrs.


3


mos.


13


ds


Or ....... min. ?


mans


Grablands


11 BIRTHPLACE OF FATHER (State or country) Boston


12 MAIDEN NAME OF MOTHER danmale J. Thuntleff


Roxbury mais.


14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE


REGISTRAR (


MEDICAL CERTIFICATE OF DEATH


16 DATE OF DEATH


Nov 229


(Month)


(Day)


, 1910


(Year)


17


HEREBY CERTIFY that I attended deceased from


Av 279


1910


, to.


... 1910.


that I last saw hoz alive on


Nov 229


., 1910.,


and that death occurred, on the date stated above, at


6/m.


The CAUSE OF DEATH* was as follows :


.


(Duration)


yrs.


....


mos.


1


ds.


Contributory


(SECONDARY)


(Duration) y's


mos.


.ds.


(Signed)


331 5 mil cal


W24. 190.


( Address )


Comtrip


.,


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.


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 1


DATE OF BURIAL


1910.


.


ADDRESS,


20 UNDERTAKER C


Ward)


1


Louise bloomperle.


[If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE 155 Nordride woh Nuntroop mart.


Partidos - IL. Stanley


Registered No.


1 PLACE OF DEATH Hinitrof mais (No


Metall Idos. St. ;.


No0. 22, 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 ou 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 ouly 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 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. - 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 ferer (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, peritonacum, 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 (sccondary), 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 onc 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


I PLACE OF DEATH


(No.


39 Hermon


St. :


Ward)


'FULL NAME.


Bridget Maria McCallion


on- Howald undow of Daniel T. M Callcon


[If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE nul Helter It & Boston


PERSONAL AND STATISTICAL PARTICULARS


3 SEX Of fr


4 COLOR OR RACE


5 SINGLE,


MARRIED,


WIDOWED,


OR DIVORCED


(Write the word)


6 DATE OF BIRTH


(Month) (Day)


(Year)


7 AGE


65 yrs.


mos.


ds


or .min. ?


8 OCCUPATION


(a)' Trade, profession, or


particular kind of work


House wife


(b) General nature of industry, business, or establishment in which employed ( or employer).


9 BIRTHPLACE


(State or country)


Ireland


PARENTS


11 BIRTHPLACE


OF FATHER


(State or country)


Ireland


12 MAIDEN NAME


OF MOTHER


Mary Cafull


1ª BIRTHPLACE OF MOTHER (State or country) Ireland


14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE


(Informant)


mrs L. M Hennessy


(Address)


210A elites It. En.


16 Filed 191.


REGISTRAR


MEDICAL CERTIFICATE OF DEATH


16 DATE OF DEATH


22"


(Month)


(Day)


,1910


(Year)


I HEREBY CERTIFY that I attended deceased from


IV~ 214


1910


to


... 1910,


If LESS than


1 day, ..


hrs.


that I last saw h M alive on


21 Nov


., 191 0 ,


and that death occurred, on the date stated above, at 2 4m.


The CAUSE OF DEATH* was as follows :


aproflex up.


(Duration)


yrs.


mos.


2


ds.


Contributory


(SECONDARY)


(Duration) mos. ds. YES Biomedical , M.D.


(Signed) .


IN 22"


1910) .... (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


DATE OF BURIAL


Holy Cross Malden no , 24.1916


ADDRESS


.


20 UNDERTAKER


Thor y Lane


Withrofa (City or town.)


[If death occurred in a hospital or institution, give its NAME instead of street and number.]


Registered No.


10 NAME OF


FATHER


John


Non 00.22, 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 aro engaged in the duties of the household only (not paid House- keepers who receive a definite salary), may be entered as Ilousewife, 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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