Town of Winthrop : Record of Deaths 1910-1912, Part 26

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 26


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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mos.


ds.


Filed .. 191.


WRITE PLAINLY, WITH UNFADING INK - THIS IS A PERMANENT RECORD.


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- kecpers 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 Printhrop Mars (No. 49 Lauramo in f. Russell.


Cottage avast ...


2FULL NAMEDauraman Ky. [If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE 49 Cottage Einz -


(City or town.)


Ward)


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


Registered No.


PERSONAL AND STATISTICAL PARTICULARS


3 SEX


4 COLOR OR RACE


5 SINGLE,


MARRIED,


WIDOWED,


OR DIVORCED


(Write the word)


6 DATE OF BIRTH


11


19


(Day)


, 1820


(Year)


7 AGE


If LESS than


1 day, .. . . hrs.


or min. ?


8 OCCUPATION


(a) Trade, profession, or


particular kind of work.


Builder.


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


9 BIRTHPLACE


(State or country)


Marlboro Mass.


10 NAME OF


FATHER


Otis Russell.


PARENTS


11 BIRTHPLACE OF FATHER (State or country} Marlboro.


12 MAIDEN NAME


OF MOTHER


Jovana Pic


1ª BIRTHPLACE OF MOTHER (State or country)


14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE


(Informant).


(Address)


16


Filed 191


REGISTRAR


MEDICAL CERTIFICATE OF DEATH


16 DATE OF DEATH


feb. 14


(Monthı)


(Day)


( Year)


17 I HEREBY CERTIFY that I attended deceased from


191


, to.


191


-


that | last saw h ......


alive on ..


, 191 1


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


m.


The CAUSE OF DEATH* was as follows :


Pneumonia nova


(Duration)


yrs. .


. mos. .


7


ds.


Contributory.


. (Duration)


yrs.


mos. ds.


(Signed) .


Albul B. Dorman


M.D.


Feb 16, 191 . (Address)


Printhoop Mars


* If death followed injury or violence the certificate of death must be made out by the Medical Examiner.


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


At place


of death.


yrs.


mos.


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 Marlboro


DATE OF BURIAL


2-17-1911


20 UNDERTAKER


It. C. Skaggs'


ADDRESS


Herthaof.


WRITE PLAINLY, WITH UNFADING INK -THIS IS A PERMANENT RECORD.


., 19 !!


(Month)


90 yrs.


2 mos.


26 ds.


(SECONDARY)


La grippe


tel. 14, 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 1 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- Coul 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: 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, 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 state? unless im- portant. Example: Measles (disease causing death), 29 ds .; Broncho-pneumonia (secondary), 10 ds. Never report mere symptoms or terminal conditions, such as " Asthenia," " An- aemia " (merely symptomatic), " Atrophy," "Collapse," "Coma," "Convulsions," "Debility " ("Congenital," "Senile," etc.), " Dropsy," " Exhaustion," " Heart failure," "Haemorrhage," " Inanition," "Marasmu-," " Old age," "Shock," "Uraemia," "Weakness," etc. when a definite disease can be ascertained as the cause. Always qualify all diseases resulting from childbirth or miscarriage, as "PUER- PERAL septicaemia," " PUERPERAL peritonitis," etc. State cause for which surgical operation was undertaken.


Cases for the Medical Examiners. - Under the provisions of chapter 24 of the Revised Laws deaths under the following conditions must be referred to the Medical Examiners:


1. Deaths following injury or violence, as Burns, Falls, Drowning, Gas Poisoning, Suicide, Homicide, etc.


2. Deaths supposedly caused by violence, as Criminal Abortion, Poisoning, Starvation, Suffocation, Ex- posure, etc.


3. Sudden deaths of persons not disabled by recognized disease, as A death upon the 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


Шитев M


(CITY OR TOWN.)


FULL NAME


.Registered No.


Place of 2


203 Shirley St Wencheok Mais


Death *


5


Death


19 ((


Residence


Widow of Owen gabbott


Age


.years.


.months.


4


days


STATISTICAL DETAILS


SEX


Female


COLOR


white


SINGLE, MARRIED,


WIDOWED, OR


DIVORCED


widow


MAIDEN NAME K


Harriet . W . Riley


HUSBAND'S NAME t


2


BIRTHPLACE$


Baldini me


NAME OF


FATHER


Stilman Riley


BIRTHPLACE


OF FATHER#


Baldini 2


MAIDEN NAME


OF MOTHER


Eliza ann. Stores


BIRTHPLACE


OF MOTHER +


Conway 21.1+


OCCUPATION


Dressmaker


INFORMANT §


Miss agness. as


Filed


19


Clerk


PLACE OF BURIAL OR REMOVAL U


hout Conway n.l+


DATE OF BURIAL


2/17


UNDERTAKER


C.R Bern


ADDRESS


PHYSICIAN'S CERTIFICATE


I HEREBY CERTIFY that I attended deceased during last illness, from Feb 11 19/


to. 7614 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 : General arteriosclerosis


.. (OURATION) ..


years


DAYS


Contributory :


.(OURATION).


3


DAYS


(Signed) ..


7615


1911


M.D.


(Address)


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


How long at Place of Death ? ... years .. .................... months. ...................... days


Where was disease contracted,


If not at place of death ?.


* 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.


south vsorion


FILL OUT WITH INK .- THIS IS A PERMANENT RECORD


ALL NAMES TO BE IN FULL


RETURN OF A DEATH Harriet. Wilson abbott


59


Date of


2/14


tel. 14, 1911


THE COMMONWEALTH OF MASSACHUSETTS


RETURN OF A DEATH


(CITY OR TOWN.)


FULL NAME


Gregory Hloro


.Registered No ..


Place of 2


34 Havittorie Corr


Date of l


2/17


19 LC


Death


S


4


.months.


.days


STATISTICAL DETAILS


SEX


COLOR


white


SINGLE, MARRIED,


WIDOWED, OR


DIVORCED


married


MAIDEN NAME !! HUSBAND'S NAME +


BIRTHPLACE# Plymout one


NAME OF


FATHER


Daniel Stone


BIRTHPLACE


OF FATHER$


Lincoln Mais


MAIDEN NAME


OF MOTHER


BIRTHPLACE


OF MOTHER #


Unity


One


OCCUPATION


Stationary Eugenia


INFORMANT § mi flore form ofdeceased


Filed


19


Clerk


PLACE OF BURIAL OR REMOVAL !!


DATE OF BURIAL


2/19


1911


UNDERTAKER GR Bennem


ADDRESS


PHYSICIAN'S CERTIFICATE


I HEREBY CERTIFY that I attended deceased during last illness, from 19 // to 70017 19/1 , 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 : Selenio Coronary arteries


.


(DURATION).


1


.. DAYS


Contributory :


General arteriosclerosis


indefinite


.(DURATION). . DAYS


31 Mutcall


M.D.


(Signed)


72619"


1941


(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 ?


* 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.


South vzorcon


FILL OUT WITH INK. - THIS IS A PERMANENT RECORD


ALL NAMES TO BE IN FULL


Death *


S


Residence 10 15


Age


> 3


.years.


Feb. 17, 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


important. See instructions on back of certificate.


The Commonwealth of Massachusetts


STANDARD CERTIFICATE OF DEATH


1 PLACE OF DEATH another of mars (No. 30 Semble Ane


Ellen A. Richardson


'FULL NAME


[If married or divorced woman or widow give maiden name, also name of husband.] aRESIDENCE 30 Double Ane


PERSONAL AND STATISTICAL PARTICULARS


1


MEDICAL CERTIFICATE OF DEATH


16 DATE OF DEATH


17


I HEREBY CERTIFY that I attended deceased from


7069


191.1 ...


Feb 17


1917


to


If LESS than


1 day .....


hrs.


that I last saw her alive on


Feb-15


191.1 ... ,


-


and that death occurred, on the date stated above, at 3 30 am The CAUSE OF DEATH* was as follows : Pneumonia


(Duration)


yrs.


mos.


9


ds.


Contributory


(SECONDARY)


(Duration)


yrs.


mos.


ds.


B1 Metcall


M.D.


(Signed)


7617, 191


(Address)


winshop mass.


* 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 mazz levenna dora


DATE OF BURIAL


Je2 19.


1911


20 UNDERTAKER


ADDRESS


Filed 191 ..


REGISTRAR


Registered No.


3 SEX


female


4 COLOR OR RACE


5 SINGLE,


massed


MARRIED,


WIDOWED,


·


OR DIVORCED (Write the word)


(Month)


(Day)


(Year)


6 DATE OF BIRTH


Ang 24 1845


(Month)


(Day)


1


(Year)


7 AGE


6.5 yrs. 5 mos mos. 20 ds.


or ....... min. ?


8 OCCUPATION


(a) Trade, profession, or


particular kind of work


at home


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


9 BIRTHPLACE


(State or country)


Portsmouth S. A.


10 NAME OF


FATHER


Ceren Bragolon


PARENTS


11 BIRTHPLACE OF FATHER (State or country)


12 MAIDEN NAME


OF MOTHER


Am, H. Waldron


12 BIRTHPLACE OF MOTHER (State or country)


Porknowth N. H


14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE


(Informant)


Author Neilson


(Address)


30 Purple Ane


(City or town.)


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


St. ;..


Ward)


legit F. Brown, 124 Dovedeo to St


1917


Tel. 17,1911


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 engincer, 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 luborer, 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, 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 (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 Alcoholismi, 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 Charles Blumberg


Registered No .. .. 1639


Place of Death


Boston


and Residence S


Date of Death


1911.


Age


31


.


years ..


.months.


6


.days.


STATISTICAL DETAILS.


SEX


COLOR


SINGLE, MARRIED, WID., DIV.


M


Maiden Name


Husband's Name


Birthplace


New York, N. Y.


Name of


Herman Blumberg


Father


Birthplace of Father


Russia


Maiden Name of Mother ...


Hannah Ratkowsky


Birthplace of Mother ..


Russia


Occupation Travelling salesman


Informant.


PHYSICIAN'S CERTIFICATE.


I HEREBY CERTIFY that I attended deceased during last illness,


from


1911, to


1911, 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:


ST


RAR'S


PATRIBU


,SIT DEL


CITY


Primary (Duration OFFICE


suicidal - during temporary


BOSTDNIA CONDITA ..


8 0 SREGI


MINE


N. MASS.


insanity


STO


Contributory : ( (Duration)


(Signed)


T Leary , Med .Ez.


M.D.


Feb. 17 1911


SPECIAL INFORMATION from Hospitals, Institutions, Transients, or Recent Residents.


Place of Burial or removal .. .


Brooklyn, J. Y. (Union Tield Cem)


Undertaker


L Jones & Con


Usual Residence


Winthrop (Millers Hotel)


Filed


Teb. 21


1911


A true copy.


Attest :


Registrar.


)


Carbolic acid poisoning -


TVITATI


18 80. NATA A


Feb.17


Hotel Essex


teb. 17,1111


CAUSE OF DEATH in plain terms, so that it may be properly classified. Exact statement of OCCUPATION is very N. B. - Every item of information should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state important. See instructions on back of certificate.


The Commonwealth of Massachusetts STANDARD CERTIFICATE OF DEATH


1 PLACE OF DEATH


Winthrop Mass


(No.


4 Pleasant-


St. ;...


Ward)


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


Ezargaret


· Gardner


Um B


Winthrop mass


Registered No.


PERSONAL AND STATISTICAL PARTICULARS


3 SEX


FI


4 COLOR OR RACE


5 SINGLE,


MARRIED,


WIDOWED,


OR DIVORCED


(Write the word)


16 DATE OF DEATH


Feliway


(Month)


199


(Dáy)


1911 (Year)


17 I HEREBY CERTIFY that I attended deceased from


191@ ..... , to


17


, 191/ .. .


that I last saw h


alive on


Fely


17


1916


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


The CAUSE OF DEATH* was as follows :


acute cardiac dilititions and


having congestion of kidneys.


@ tourdiant.


.yrs.


mos.


Contributory


arterio - salario


(SECONDARY)


Several (Duration)


.yrs. ..


mos. .


.ds.


(Signed)


Fely 18


191/ .. (Address)


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.


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


Feb. 19, 191


15 Filed .. 191. ....


REGISTRAR


MEDICAL CERTIFICATE OF DEATH


6 DATE OF BIRTH


(Month) (Day)


7 AGE


68 yrs.


mos. ds.


or ........ min. ?


8 OCCUPATION


(a)' Trade, profession, or


particular kind of work


CC2 /touru


(b) General nature of industry,


business, or establishment in


which employed (or employer)


9 BIRTHPLACE


(State or country)


tuciny Cape Breton


10 NAME OF


FATHER


PARENTS


11 BIRTHPLACE OF FATHER (Státe or country)


Filmen Cape Breton.


12 MAIDEN NAME


OF MOTHER


mary In Forgal


13 BIRTHPLACE OF MOTHER (State or country) Pinar Salu Briton


14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE


(Informant)


Man Yanderson


(Address)


14 Pleasant Iv


20 UNDERTAKER


An Dosthe Burke


ADDRESS


75 chambers 4


Bestin mass


WRITE PLAINLY, WITH UNFADING INK - THIS IS A PERMANENT RECORD.


Winthrop mar.


BOSTON (City or town.)


'FULL NAME


[If married or divorced woman or widow


give maiden name, also name of husband.]


@RESIDENCE


4 Pleasant St.


1


(Year)


If LESS than


day ......... hrs.


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.




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