Town of Winthrop : Record of Deaths 1910-1912, Part 19

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 19


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. - 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, 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: Mcasles (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.


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


BOSTON


(City or town.)


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


2 FULL NAME alice C. Foster


[If married or divorced woman or widow give maiden name, also name of husband.] alice C. Auvotre villa, (husband; George 8. Fosta) @RESIDENCE


Registered No.


PERSONAL AND STATISTICAL PARTICULARS


3 SEX


4 COLOR OR RACE when


5 SINGLE,


MARRIED,


WIDOWED,


OR DIVORCED


(Write the word)


mamed


6 DATE OF BIRTH


?


1


(Month)


(Day)


1862 (Year)


7 AGE


48


yrs.


mos. 3


ds.


or .... . min. ?


8 OCCUPATION


(a) Trade, profession, or


particular kind of work


Housewife


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


House work


9 BIRTHPLACE


(State or country)


Balón


10 NAME OF


FATHER


John Pusistevilla


PARENTS


11 BIRTHPLACE OF FATHER (State or country)


St. John New Foundland


12 MAIDEN NAME OF MOTHER many


2


13 BIRTHPLACE


OF MOTHER


(State or country)


new Found land


14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE


(Informant)


George 8, 4 oster


REGISTRAR


MEDICAL CERTIFICATE OF DEATH


16 DATE OF DEATH


november


28, 190


(Month)


(Day)


(Year)


17 I HEREBY CERTIFY that I attended deceased from 1908 , 191 to 1910 , 191. -


If LESS than


I day, ...


hrs.


that I last saw her alive on.


, 1910


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


2.30Pm.


The CAUSE OF DEATH* was as follows :


Heart Disease (Mutual Requisiti)


at least 3 years


(Duration)


yrs. .


mos.


...


ds.


Diabetes


Contributory ..


(SECONDARY)


at least 6 minutter


(Duration)


yis.


mos.


ds.


(Signed)


pr 29, 90 (Address).


35 6 mail bow for


* 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


yrs.


In the


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 Nov. 50, 10 491


(Address)


15 Trident av peintures Calvary Cometer:,


20 UNDERTAKER


Holm. Varen Yfm


ADDRESS


54. a Sheet,


1 PLACE OF DEATH


mutton mars (No. 15 Inclear Que Sti Ward)


N. B. - Every item of information should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state


Filed 191


M.D.


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 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 kungs, metetges, Veritonaeum, 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.


The Commonwealth of Massachusetts


STANDARD CERTIFICATE OF DEATH


1 PLACE OF DEATH Winthrop


(No. 10, Foodwe are St. ,. Ward)


2 FULL NAME


alive C. Fenster


[If married or divorced woman or widow


give maiden name, also name of husband.]


@RESIDENCE


15 Trident ave


Registered No.


PERSONAL AND STATISTICAL PARTICULARS


3 SEX


4 COLOR OR RACE


5 SINGLE,


MARRIED,


WIDOWED,


OR DIVORCED


(Write the word)


6 DATE OF BIRTH


(Month) (Day)


1


(Year)


7 AGE


If LESS than [ day, ........ hrs.


St 55 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)


14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE


(Informant).


(Address)


Filed .. 191 ..


REGISTRAR


MEDICAL CERTIFICATE OF DEATH


16 DATE OF DEATH


non


28, 190


(Month)


(Day)


(Year)


17 I HEREBY CERTIFY that I have investigated the death of the deceased.


The CAUSE OF DEATH* was as follows :


natural causes: heart disease -


(Duration) ...


yrs.


mos.


ds.


Contributory (SECONDARY)


.. (Duration)


mos. ds.


(Signed)


Senza Buyers Margrethe yrs. ..


M.D.


hm29, 1910 (Address) MEDICAL EXAMINER


* State the DISEASE CAUSING DEATH, or, in deaths from VIOLENT CAUSES, state (1) MEANS of INJURY; and (2) whether ACCIDENTAL, SUICIDAL or HOMICIDAL.


18 LENGTH OF RESIDENCE (FOR HOSPITALS, INSTITUTIONS, TRANSIENTS, OR RECENT RESIDENTS).


At place


of death


yrs.


mos.


ds.


State


.. yrs.


In the


.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


20 UNDERTAKER


ADDRESS


shootd be stated EXACTLY. PHYSICIANS should state rly classified. "Exact statement of OCCUPATION is very


CAUSE OF DEATH in plain terms, so that it may wu (


N. B. - Every item of information should be carefully sup. important. See instructions on back of certificate.


11 BIRTHPLACE OF FATHER (State or country)


2882 winthrop (City or toun.)


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


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 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 discase; 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. For VIOLENT DEATHS state MEANS OF INJURY and qualify as ACCIDENTAL, SUICIDAL, or HOMICIDAL, or as probably such, if impossible to determine definitely. Examples: Accidental drowning; Struck by railway train - accident ; Revolver wound of head-homicide ; Poisoned by carbolic acid - prob- ably suicide. The nature of the injury, as fracture of skull, and consequences (e. g., sepsis tetanus) may be stated under the head of " Contributory."


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


Warten of Has No ... 4 athenian Circle Visor 28 RAppo


2 FULL NAME Baby Harus


[If married or divoreed woman or widow


give maiden name, also name of husband.]


@RESIDENCE


Chica


Registered No.


PERSONAL AND STATISTICAL PARTICULARS


3 SEX Male


+ COLOR OR RACE


White


5 SINGLE,


MARRIED,


WIDOWED,


OR DIVORCED


(Write the word)


Single


6 DATE OF BIRTH


November 28 (Month)


(Day)


1910


.,


(Year)


7 AGE


If LESS than I day, J. hrs.


X yrs. mos.


ds.


or K min. ?


8 OCCUPATION (a) Trade, profession, or particular kind of work


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


' BIRTHPLACE


(State or country)


Wanthet Mins


10 NAME OF


FATHER


Echarles. L. Hansen


PARENTS


11 BIRTHPLACE OF FATHER


(State or country) Hannover U. H.


12 MAIDEN NAME OF MOTHER Clara. L. Haynes


13 BIRTHPLACE


OF MOTHER


(State or country)


Boston


14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE


(Informant)


(Address)


15


Filed . 191


REGISTRAR


MEDICAL CERTIFICATE OF DEATH


16 DATE OF DEATH


200


(Month)


(Day)


28, 19:0


(Year)


17


I HEREBY CERTIFY that I attended deceased from


1


nov 28


... . 1910


., to


, 1910,


that I last saw h.


LAMlalive on


nev 28


, 191 0,


and that death occurred, on the date stated above, at/030 0Pm.


The CAUSE OF DEATH* was as follows :


marasmus 5 horasion).


Contributory. (SECONDARY)


.. (Duration) .


yrs. .


mos.


....


ds.


(Signed)


191 .... (Address)


Elintop


* 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


, 1910


20 UNDERTAKER


ADDRESS


(City or town.)


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


I 1


yrs. .


mos. ..


ds.


., M.D.


now ..


ʼ


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, Łoco- 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 -4 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 10 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; Broneho- 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 statei unless im- portant. Example: Measles (disease causing death), 29 ds .; Broncho-pneumonia (secondary), 10 ds. Nevci 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 septicemia," " 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


RETURN OF )A DEATH


(CITY OR TOWNS


FULL NAME


Registered No.


Date of


Death S


Age 14


.. years.


8


months. /2 .days


STATISTICAL DETAILS


SEX


COLOR Mente


SINGLE, MARRIED, WIDOWED, OR DIVORCED


.


MAIDEN NAME +


HUSBAND'S NAME +


BIRTHPLACE #


NAME OF FATHER Forum Cafen 19cago Cm


BIRTHPLACE OF FATHER$


MAIDEN NAME OF MOTHER Della. H. 1 agem


BIRTHPLACE OF MOTHER $


OCCUPATION School 30m


INFORMANT §


John .C. 19 egy5 Cm


PHYSICIAN'S CERTIFICATE


to 19 I HEREBY CERTIFY that I attended deceased during last illness, from 19


..... , 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 :


.(DURATION) ... DAYS


Contributory :


.. (DURATION) ... DAYS


(Signed)


M.D.


19 (Address)


SPECIAL INFORMATION only for Hospitals, Institutions, Transients, or Recent Residents.


How long at Place of Death ? . years ..


. months. days


Where was disease contracted, If not at place of death ?


Filed


19


Clerk


PLACE OF BURIAL OR REMOVAL !!


DATE OF BURIAL


19 / 0


UNDERTAKER


ADDRESS


* 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 details, Il Name of cemetery.


1


ALL NAMES TO BE IN FULL


.......


Place of l


Death *


S


1970


Residence


N. B. - Every item of information should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS SHU:AG 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


Metcalf Hospital


St. Ward)


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


Registered No.


19422


PERSONAL AND STATISTICAL PARTICULARS


3 SEX


4 COLOR OR RACE


5 SINGLE,


MARRIED,


WIDOWED,


OR DIVORCED


(Write the word)


6 DATE OF BIRTH


(Month) (Day)


(Year)


7 AGE


If LESS than I day ......... hrs.


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)


14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE


(Informant)


(Address)


IS Filed , 191.


REGISTRAR


MEDICAL CERTIFICATE OF DEATH


un


29 (Dấy)


, 1960 (Year)


17


I HEREBY CERTIFY that I have investigated the death of the deceased.


The CAUSE OF DEATH* was as follows : Fracture of the skull with


associated harmontage, con- fusion, and oedema of brain, caused by jungeing d ds.


Contributory. a conflagration (SECONDARY) (Duration) yrs.


mos. ds.


(Signed)


Serge Burgers Dagrally.


M.D.


191℃ (Address).


MEDICAL EXAMINER


* State the DISEASE CAUSING DEATH, or, in deaths from VIOLENT CAUSES, state (1) MEANS of INJURY; and (2) whether ACCIDENTAL, SUICIDAL or HOMICIDAL.


18 LENGTH OF RESIDENCE (FOR HOSPITALS, INSTITUTIONS, TRANSIENTS, OR RECENT RESIDENTS).


In the


At place


of death,


.. yrs.


mos.


ds.


State


.. yrs.


.mos.


ds.


Where was disease contracted, If not at place of death ?.


Former or usual residence .


DATE OF BURIAL


19 PLACE OF BURIAL OR REMOVAL Winthrop, mass


....


191


20 UNDERTAKER


le. R. Bennison


ADDRESS


Winthrop Mess


2881 Winthrop (City or town.)


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


.C. Begge, Jr.


16 DATE OF DEATH


(Month)


14 yrs. mos. ds.


11 BIRTHPLACE OF FATHER (State or country)


Nov. 29, 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) Salcs- man, (b) Grocery; (a) Foreman, (b) Automobile factory. The Tutorial 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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