USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1910-1912 > Part 20
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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 fever (the only definite synonym is "Epidemic cerebro-spinal meningitis") ; Diphtheria (avoid use of " Croup") ; Typhoid fever (never re- port " Typhoid pneumonia ") ; Lobar pneumonia ; Broncho- pneumonia (" Pneumonia," unqualified, is indefinite) ; Tuber-
culosis of lungs, meninges, peritonaeum, etc., Carcinoma, Sar- coma, etc., of ........ ....... (name origin: " Cancer" is less definite ; avoid use of " Tumor" for malignant neoplasms) ; Measles ; Whooping cough; Chronic valvular heart disease; Chronic interstitial nephritis, etc. The contributory (second- ary or intercurrent) affection need not be stated unless im- portant. Example: Measles (disease causing death), 29 ds .; Broncho-pneumonia (secondary), 10 ds. Never report mere symptoms or terminal conditions, such as " Asthenia," " An- aemia " (merely symptomatic), " Atrophy," "Collapse," " Coma," " Convulsions," "Debility " ("Congenital," "Senile," etc.), " Dropsy," " Exhaustion," "Heart failure," "Haemorrhage," " Inanition," " Marasmus," " Old 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- ubly 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.
COMMONWEALTH OF MASSACHUSETTS.
RETURN OF A DEATH-1910.
CITY OF BOSTON.
FULL NAME
Caroline M Smallhoff
......
Registered No.
10551
Place of Death ¿
Boston
Boston State Hospt.
and Residence S
Date of Death
Dec. 1
1910.
Ag
68
4
months.
25
.days.
STATISTICAL DETAILS.
SEX
F
COLOR
W
SINGLE, MARRIED, WID., DIV. M
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
T PATRIBU
SITD
: Primacy (Duration)
Involution Melanchia - 4 mos.
FFICE
A.182
DONATA A
. MAS. S.
Contributory : 3
Broncho-Pneumonia - 3 dys
(Duration)
Maiden Name
Caroline A Wells
of Mother.
of Mother Boston
Occupation Housewife
Dec.1 1910
.........
SPECIAL INFORMATION from Hospitals, Institutions, Transier.ts, or Recent Residents. In hospital 16 days
Place of Burial
Dorchester(Codman Ground )
Usual Residence
Winthrop(63 Buchanan st)
or removal.
Undertaker J P Cleary
Filed
Dec.5
1910
A true copy.
Attest :
EumSeinen
Registrar.
....
Birthplace
(Signed)
S E Vosburgh
..... .. M.D.
Informant
PHYSICIAN'S CERTIFICATE.
Maiden Name
Morgan
Husband's Name
Jacob Smallhoff
Boston
Birthplace
Name of
Father ..
James H Morgan
REGISSEN
BOSTON
Birthplace
Eastport, Me.
of Father.
AR'S
CITY:
BOSTONIA CONDITAA.
years
4 ٠
COMMONWEALTH OF MASSACHUSETTS.
RETURN OF A DEATH-1910.
CITY OF BOSTON.
FULL NAME
James R Dunn
Registered No.
10757
Place of Death ¿
Boston
City Hospt.
and Residence S
Date of Death
Dec.6
.1910.
Age
26
. years .
4
months.
25
.days.
STATISTICAL DETAILS.
SEX
COLOR
SINGLE, MARRIED, WID., DIV.
W
S
Maiden Name
Husband's Name
Birthplace Lockport, N.S.
Name of
Father Simon G Dunn
Birthplace of Father.
Maiden Name
Lydia Dixon
of Mother
===-- IT S
Occupation
Physician
Informant
Contributory : 2 (Duration)
(Signed)
A J White
M.D.
Dec.7 1910
SPECIAL INFORMATION from Hospitals, Institutions, Transients, or Recent Residents.
Place of Burial
or removal.
Winthrop"Winthrop Cem
1 C Skaggs
Undertaker
Winthrop
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:
T
RAR'S
PATRIBUTE
SITA
Pneumonia - 5 dys
Primary: (Duration) BIS
FFICE:
BOSTONTA TIVIT
CONDITA MA
TISREGISSINE DONATA D. BO.STO 1830.
MASS.
Usual Residence.
Winthrop(45 Cottage aye)
Dec.10
1910.
Filed
A true copy.
Attest :
Registrar.
CITY
Birthplace of Mother
MOTPOE
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH Nightin a: (No. 25. Perkunna St. ;.. Ward)
Gilliam Me Laughlin 'FULL NAME [If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE 25 Telkens TI.
Winthrop
(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 an
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 I day, ... hrs.
yrs. mos.
ds.
or min. ?
8 OCCUPATION
(a)' Trade, profession, or
particular kind of work
Stevecore
(b) General nature of industry, business, or establishment in which employed (or employer).
9 BIRTHPLACE
(State or country)
1
PARENTS
12 MAIDEN NAME OF MOTHER
1
13 BIRTHPLACE OF MOTHER (State or country)
Brefand
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
(Month)
(Day) ., ( Year)
17
I HEREBY CERTIFY that I attended deceased from
DEe
69%
1912, to
,
that | last saw h .... alive on 1., 1916. and that death occurred, on the date stated above, at. 9-15m. The CAUSE OF DEATH* was as follows :
Dencertain (Duration)
yrs.
mos. ds.
Contributory (SECONDARY)
(Duration)
yrs.
mos. .
.ds.
(Signed)
. M.D.
Dea.10/ 19/0 (Address)
MiniTrope
* 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 r
DATE OF BURIAL .5. 1912.
20 UNDERTAKER
ADDRESS 2
-
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.
10 NAME OF
FATHER
tatrici
11 BIRTHPLACE OF FATHER (State or country)
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 necded. 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 disease ; Chronic interstitial nephritis, etc. The contributory (second- ary or intercurrent) affection need not be stated unless im- portant. Example: Measles (disease causing death), 29 ds .; Broncho-pneumonia (secondary), 10 ds. Never report mere symptoms or terminal conditions, such as " Asthenia," " An- aemia " (merely symptomatic), " Atrophy," " Collapse," "Coma," " Convulsions," "Debility " ("Congenital," "Senile," etc.), "Dropsy," "Exhaustion," "Heart failure," "Haemorrhage," " Inanition," " Marasmus," " Old age," "Shock," " Uraemia," "Weakness," etc., when a definite disease can be ascertained as the cause. Always qualify all diseases resulting from childbirth or miscarriage, as " PUER- PERAL septicaemia," " PUERPERAL peritonitis," etc. State cause for which surgical operation was undertaken.
Cases for the Medical Examiners. - Under the provisions of chapter 24 of the Revised Laws deaths under the following conditions must be referred to the Medical Examiners:
1. Deaths following injury or violence, as Burns, Falls, Drowning, Gas Poisoning, Suicide, Homicide, etc.
2. Deaths supposedly caused by violence, as Criminal Abortion, Poisoning, Starvation, Suffocation, Ex- posure, etc.
3. Sudden deaths of persons not disabled by recognized disease, as A death upon the street, or one supposed to be due to Alcoholism, etc.
4. Deaths under circumstances unknown, as A person found dead, etc.
N. B. - Every item of information should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state CAUSE OF DEATH in plain terms, so that it may be properly classified. Exact statement of OCCUPATION is very
important. See instructions on back of certificate.
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH
Winthrop
(No.
7 . Temple Not
St. ;
Ward)
[If death occurred in a hospital or institution, give its NAME instead of street and number.]
Registered No.
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
3 SEX
Male
4 COLOR OR RACE
While
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
Widower
6 DATE OF BIRTH
March
(Month)
(Day )
1839
(Year)
7 AGE
71
yrs.
2
mos.
28
ds
(a)' Trade, profession, or
particular kind of work ...
Broken
(b) General nature of industry,
business, or establishment in
which employed (or employer)
9 BIRTHPLACE
(State or country)
Boston Mass
PARENTS
(State or country)
Proton dass
12 MAIDEN NAME
OF MOTHER
Mary B, Parker Sam,
1ª BIRTHPLACE
OF MOTHER
(State or country)
Pepperell Mars
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
Clark Parku
(Address)
> Comple ave
REGISTRAR
16 DATE OF DEATH
Dec
(Month)
12
....... 1910
(Day)
(Year)
17
I HEREBY CERTIFY that I attended deceased from
Decr 8
191 0, to
Dec. 12 1910
If LESS than
1 day, .
hrs.
that I last saw hAM alive on
12 th Dec., 1910.
and that death occurred, on the date stated above, at 9.40 m.
or .....
. min. ?
The CAUSE OF DEATH* was as follows :
Lobar Pneumonia
(Duration)
yrs.
mos.
1/2 ds
ds.
Contributory.
Chronic Gastritis
SECONDARY)
Malignant !? )
(Duration)
2 yrs.
mos. .
.ds.
(Signed) ..
I. E. Brandon
M.D.
Dec. 13
1910 ..
(Address).
Ilentral Aux E 13.
* 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 usul residence.
19 PLACE OF BURIAL OR REMOVAL Gerest Abil
DATE OF BURIAL
Dec 16 . 1910
.....
20 UNDERTAKER
AL Eastman Co
ADDRESS
251 Cremant LE
BOSTON (City or town.)
Benjamin W Parker
'FULL NAME. enjamin
[If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE 7 Temples ave
Filed. 191.
10 NAME OF
FATHER
Nathaniel Parker
11 BIRTHPLACE
OF FATHER
Marris
OCCUPATION
alec. 12, 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 Ilouse- keepers who receive a definite salary), may be entered as Housewife, Housework, or At home, and children, not gain- fully employed, as At school or At home. Care should be taken to report specifically the occupations of persons engaged in domestic service for wages, as Servant, Cook, Housemaid, etc. If the occupation has been changed or given up on account of the DISEASE CAUSING DEATH, state occupation at beginning of illness. If retired from business, that fact may be indicated thus: Farmer (retired, 6 yrs.). For persons who have no occupation whatever, write None.
Statement of cause of death. - Name, first, the DISEASE CAUSING DEATH (the primary affection with respect to time and causation), using always the same accepted term for the same disease. Examples: Cerebro-spinal fever (the only definite synonym is "Epidemic cerebro-spinal meningitis") ; Diphtheria (avoid use of "Croup") ; Typhoid fever (never re- port " Typhoid pneumonia ") ; Lobar pneumonia; Broncho- pneumonia ("Pneumonia," unqualified, is indefinite) ; Tuber-
culosis of lungs, meninges, peritonaeum, etc., Carcinoma, Sar- coma, etc., of. . (name origin : "Cancer" is less definite ; avoid use of " Tumor" for malignant neoplasms) ; Measles; Whooping cough ; Chronic valvular heart disease; Chronic interstitial nephritis, etc. The contributory (second- ary or intercurrent) affection need not be stated unless im- portant. Example: 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.
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
1 PLACE OF DEATH
STANDARD CERTIFICATE OF DEATH Wucherplass (No. 335 Wineherfst St. ;
Ward)
[If death occurred in a hospital or institution, give its NAME instead of street and number.]
2 FULL NAME Kenneth, Belcher
[If married or divorced woman or widow
give maiden name, also name of husband.]
@RESIDENCE
Registered No.
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
3 SEX
Mule
4 COLOR OR RACE
white
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
6 DATE OF BIRTH
lec 10
(Month)
(Day)
.,
(Year)
7 AGE
If LESS than I day. .. .. hrs.
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
alphonso. W. Belcher
PARENTS
12 MAIDEN NAME
OF MOTHER
Mary. L'dich, Inoses
13 BIRTHPLACE OF MOTHER (State or country)
14 THE ABOVE IS TRUE, TO THE BEST OF MY KNOWLEDGE
(Informant)
Aiphones L.V. Selche
(Address)
x
335 Winthrop St. Trustmy
REGISTRAR
16 DATE OF DEATH
December
(Month)
(Day)
14
., 19 !... 0
(Year)
17
I HEREBY CERTIFY that I attended deceased from
10
1910
/4
., to.
, 191º,
that I last saw him alive on
Dm 14
, 1910
and that death occurred, on the date stated above, at/.30 Pm.
The CAUSE OF DEATH* was as follows :
Haemophilia neonatorum
(Duration)
yrs. .
×
mos.
4
ds.
Contributory ... (SECONDARY)
mos.
yrs.
ds.
(Duration)
DEplusan
M.D.
(Signed)
Su 15
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 placo
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 ..
PLACE OF BURIAL OR REMOVAL winthrop Cence.
DATE OF BURIAL
De 15, 1910
20 UNDERTAKER
Chas P. Bennison
ADDRESS
winthrop
15 Filed 191
11 BIRTHPLACE OF FATHER (State or country) Wwwchinh mars
1910
yrs.
mos.
(City or town.y
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 kuown. 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, Hlousework, 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), usiug 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, Sur- coma, etc., of ........ .. (uame origin: "Cancer" is less definite ; avoid use of " Tumor" for malignaut 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, 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.
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH metcalf Hospital (No ... Within St St. ;
Wantingto
(City or town.)
Ward)
[If death occurred in a hospital or institution, give its NAME instead of street and number.]
'FULL NAME Jusannan. albertu 1 ay lor
[If married or divorced woman or widow give maiden name, also name of husband.] . @RESIDENCE 34 nevada Slices Wurscht Than
Sausannan Ultrale Parker Wife of Oscars M. Taylor Registered No.
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
temale
7 AGE
62
8 OCCUPATION
(a)' Trade, profession, or
particular kind of work.
PARENTS
13 BIRTHPLACE
OF MOTHER
(State or country)
(Informant)
important. See instructions on back of certificate.
(Address)
18
N. B. - Every item of information should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state
CAUSE OF DEATH in plain terms, so that it may be properly classified. Exact statement of OCCUPATION is very
(b) General nature of industry,
business, or establishment in
which employed (or employer)
4 COLOR OR RACE
White
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
mannen
6 DATE OF BIRTH
cipria
12
(Month)
(Day)
1848
(Year)
or
min. ?
at home
9 BIRTHPLACE
(State or country)
Wylesford, Kungs County.
nova Scotia
10 NAME OF
FATHER
Church Parker
11 BIRTHPLACE
OF FATHER
(State or country)
nova Scotia
12 MAIDEN NAME
OF MOTHER
Lichen Parrish
Luva Scola-
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
Filed.
.... . 191.
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