USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1910-1912 > Part 25
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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: C'erebro-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 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 childbirthi 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.
important. See instructions on back of certificate. 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
The Commonwealth of Massachusetts STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH Winthrop (No. 30 Bellevue Ave. St. ;... ... Ward)
John J. Call am
2 FULL NAME [If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE 30 Bellevue Ave Winthrop
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
4 COLOR OR RACE
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
( Write the word)
Single
male White
6 DATE OF BIRTH
(Month) (Day)
(Year)
7 AGE
66 yrs. mos. ds.
or ....... min. ?
8 OCCUPATION
(a) Trade, profession, or
particular kind of work
Engi
(b) General nature of industry, business, or establishment in which employed (or employer)
Stationary
9 BIRTHPLACE
(State or country)
Schenectady n.y.
10 NAME OF
FATHER
John
11 BIRTHPLACE OF FATHER (State or country)
Ireland
12 MAIDEN NAME OF MOTHER
Murph
13 BIRTHPLACE OF MOTHER (State or country)
Undan
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
George Parsons
(Address)
30 Bellevue Ave
Filed 191
REGISTRAR
16 DATE OF DEATH
I HEREBY CERTIFY that I attended deceased from
, 1911
-
anuary 15, 1911, to
Feb. 7
If LESS than
I day,
hrs.
that I last saw hun alive on.
Feb. 7
191 / ,
and that death occurred, on the date stated above, at ..
43 pm.
The CAUSE OF DEATH* was as follows :
Carcinoma of Stomaco
(Duration)
yrs. .
4
mos.
ds.
Contributory. (SECONDARY)
(Duration)
yrs. .
mos. ds.
(Signed)
Edward . Grainger
Sel. 9
1911 . (Address)
304 Wattnap Sr.
* 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
In the
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 Feb. 10, 1911
20 UNDERTAKER Thos, Je hane
120 Havre St, 2,
WRITE PLAINLY, WITH UNFADING INK - THIS IS A PERMANENT RECORD.
Winthrop
BOSTON (City or town.)
[If death occurred in a hospital or institution, give its NAME instead of street and number.]
Registered No.
MEDICAL CERTIFICATE OF DEATH
7
(Month)
(Day)
. 191.1 (Year)
.
PARENTS
M.D.
ADDRESS
tel. 7, 1911
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- pnemnonia (" 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.
COMMONWEALTH OF MASSACHUSETTS.
RETURN OF A DEATH-1911.
CITY OF BOSTON.
FULL NAME Esther Ricker
Registered No ...
1357
Place of Death ¿ and Residence S
Boston
Infants Hospt.
Date of Death
1911.
Age
.
years
months
17
days.
STATISTICAL DETAILS.
PHYSICIAN'S CERTIFICATE.
SEX
COLOR
SINGLE, MARRIED, WID., DIV.
H
S
Maiden Name
Husband's Name
CITY.
Primary ( Duration
OFFICE
Name of William E. Ricker
Father
Birthplace of Father
Cambridge
Contributory : (
Spina Bifida
(Duration)
Maiden Name
Ethel Pinkham
of Mother
Birthplace of Mother ..
Dorchester
(Signed)
J R Torbert
M. D.
Occupation
Ilone
.. 1911
SPECIAL INFORMATION from Hospitals, Institutions, Transients, or Recent Residents.
Place of Burial or removal .
Winthrop"Winthrop Cem"
Usual Residence
Winthrop(24 Atlantic st)
Filed Feb.15 1911
Undertaker
1 C Skaggs
Winthrop
A true copy.
Attest :
Registrar.
DNIGNIS NON CHAUNCEY NIONYW
I HEREBY CERTIFY that I attended deceased during last illness,
1911,
from 1911, 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:
RAR'S ST ATRIBU SIT DEI Meningitis fol.Opr. for
Birthplace Winthrop
CONDITA.A.
TISREJIMINE BUNATA A. BOSTON
. MASS.
Informant
Feb.10
Feb. 10, 1911
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
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH Winding
1
(No Shirley ST., hea yacht Club Ward)
2 FULL NAME Lemuel G. Owen [If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE 32 Stanford 20, Boston
Dvd 8
22192 Registered No.
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
(Month)
10
(Day)
191.
(Year)
I HEREBY CERTIFY that I have investigated the death of the deceased.
If LESS than 1 day ....... hrs. The CAUSE OF DEATH* was as follows :
Electric Shock, accidental.
181
(Duration)
.. yrs.
.. mos.
ds.
Contributory (SECONDARY)
(Duration)
.yrs.
.mos. ds.
(Signed)
Serge Burgers Magrath
...
M.D.
Tel. 11
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
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
2
Salem Mass. Heb. 13
191 /
20 UNDERTAKER
ADDRESS
L. Blake 14 Portland. St.
important. See instructions on back of certificate.
King's bounty.
Prince Edwards Island
Unnie Walker
13 BIRTHPLACE OF MOTHER (State or country)
Kinga Security
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
angus X. Oliven
(Address)
8 albian St. Salen Mass
Filed. , 191 ..
REGISTRAR
3060 Winthrop (City or town.)
[If death occurred in a hospital or institution, give its NAME instead of street and number.]
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
4 COLOR OR RACE
Single
Male White
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
16 DATE OF BIRTH
Unlessown
(Month)
(Day)
7 AGE
25 yrs.
or ....... min. ?
×
mos.
X
ds.
8 OCCUPATION
Line man M. E. T. +T. Co
(a) Trade, profession, or
particular kind of work
(b) General nature of industry,
Telephone Wires
business, or establishment in
which employed (or employer)
10 NAME OF
FATHER
John Owen
11 BIRTHPLACE
OF FATHER
(State or country)
12 MAIDEN NAME
OF MOTHER
PARENTS
WhTTE FLAIRLT, WTTTT ONTADING INR TIIIS TO A TENMANLITT HLVUND,
9 BIRTHPLACE
(State or country)
King's bounty
Prince Edwarda leland
1886
(Year)
17
At place
of death.
.yrs. ...
„mos.
ds.
State
yrs.
Feb. 10, 1911
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, peritonaeun?, 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 nced 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 " (mcrcly 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
I PLACE OF DEATH
Medical Hospital
(No. Wantheit St
$FULL NAME
Thomas
[If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE Revere
finger
8/ worthnot Registered No.
PERSONAL AND STATISTICAL PARTICULARS
4 COLOR OR RACE
White
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
Singer
Dec
20
(Month)
(Day)
(Year)
If LESS than I day ..... .. hrs.
43
yrs.
1.
mos.
2 ds.
or ....... min. ?
8 OCCUPATION
(a)' Trade, profession, or
particular kind of work
Carpenter-
10 NAME OF
FATHER
thomas to lyt
12 MAIDEN NAME
OF MOTHER
Mary, It. Peric
13 BIRTHPLACE
OF MOTHER
(State or country)
no Chelica mas
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
This Floyd
(Address)
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
(Month)
(Day)
11, 191
(Year)
1867 17 I HEREBY CERTIFY that I attended deceased from 1
Tep 6'
1911., to ..
7-5-11
... , 191 / .,
that I last saw him
alive on
72011
, 191 / .,
and that death occurred, on the date stated above, at.
6.30cm
The CAUSE OF DEATH* was as follows :
Pneumonia
(Duration) .
.yrs.
mos.
ds.
Contributory
(SECONDARY)
(Duration) BiRutay
yrs.
mos. .
ds.
(Signed)
M.D.
7/6/3
191
. ( Address)
Which Means
* 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.
4
ds.
State
In the
.yrs. . mos,
ds.
Where was disease contracted,.
If not at place of death ?
Revery It worthy was
Former or
usual residence.
Revery st Wacht hos
19 PLACE OF BURIAL OR REMOVAL Wundert Comigo
DATE OF BURIAL
72.14, 191.
20 UNDERTAKER
ADDRESS
Within
warchest (City or town.) [If death occurred in a hospital or institution, give its NAME instead of street and number.]
Floyd
St. ;
Ward)
3 SEX Male 6 DATE OF BIRTH 7 AGE 9 BIRTHPLACE (State or country) 11 BIRTHPLACE OF FATHER (State or country) PARENTS WRITE PLAINET, WITH ONFADING INK - THIS IS A PERMANENT RECORD. (b) General nature of industry. business, or establishment in which employed (or employer)
Filed. - 191.
. .
11,1911
tel.
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, 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.
important. See instructions on back of certificate. 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
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH
Walterof War (No. >0 Pleurant
St. ;. .
Ward)
(City or town.) [If death occurred in a hospital or institution, give its NAME instead of street and number.]
FULL NAME
Lucinda Ann atwood
[If married or divorced woman or widow
give maiden name, also name of husband.]
Wedon of aller arrivare
@RESIDENCE
70 Pleasant St Wraithnot
1
Registered No.
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
female
4 COLOR OR RACE
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
wicon
6 DATE OF BIRTH
(Month)
(Day)
-
(Year)
7 AGE
yrs.
.. mos.
1
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).
at home
9 BIRTHPLACE
(State or country)
"Truro Maso
PARENTS
11 BIRTHPLACE
OF FATHER
(State or country)
Euro Mass
12 MAIDEN NAME
OF MOTHER
Racheck Lombard
13 BIRTHPLACE
OF MOTHER
(State or country)
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
archer. H. aleout
(Address)
70 Pleasant ft
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
February XX
(Month)
(Day)
11th
- 191/ (Year)
1829
17
I HEREBY CERTIFY that I attended deceased from
Jany
1910
to
Fely
11
.. , 191 [ .
If LESS than
1 day. . . ..
hrs.
that I last saw h alive on
Fely
10
. , 1910 ,
and that death occurred, on the date stated above, at/25Cm.
The CAUSE OF DEATH* was as follows :
arterio. 8 derasis
Contributary.
(SECONDARY)
(Duration) .
WE alsow
yrs.
., M.D.
(Signed) .
Foly 13
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 Manchot Ceny
DATE OF BURIAL
2/14
,
191/
....
20 UNDERTAKER
ADDRESS
Wucheng
yrs.
mos.
..
as.
10 NAME OF
FATHER
allen Rick
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