Town of Winthrop : Record of Deaths 1910-1912, Part 28

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 28


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


2. Deaths supposedly caused by violeuce, 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 Han theoh (No.


STANDARD CERTIFICATE OF DEATH metcalls Hospital st. :


(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


16 DATE OF DEATH


march.


27


191 7


(Month)


(Day)


(Year)


1: I HEREBY CERTIFY that I attended deceased from March 26 1911 to


March 27, 191. that I last saw hamvalive on. march 27, 191.1. and that death occurred, on the date stated above, at .... 3 A. m. The CAUSE OF DEATH* was as follows : appendicitis


(Duration) .


yrs.


...


mos.


2


ds.


Contributory


Several Peritonitis


(SECONDARY)


30 horas mos. ds.


.(Duration) .


D.S. Jackson


yrs. ..


M.D.


March 27 1911 (Address)


562 Shirley 29.


* 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


ds.


State


yrs. .


In the


mos.


ds ....


of death ...


. yrs.


mos.


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


Former or usual residence.


19 PLACE OF BURIAL OR REMOVAL


Everett Mark


DATE OF BURIAL


march 27.


191/


:0 UNDERTAKER


J.E Hendesmeter


ADDRESS


Erett max


PERSONAL AND STATISTICAL PARTICULARS


Lugar


3 SEX


male


4 COLOR OR RACE


white


5 SINGLE,


MARRIED,


WIDOWED,


OR DIVORCED


(Write the word)


6 DATE OF BIRTH


Decercher 29


(Month)


1889


(Day)


(Year)


7 AGE


If LESS than


day, . .... hrs.


21 yrs. 3


mos. .


29


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)


2 BIRTHPLACE


(State or country)


Everett mask


II BIRTHPLACE


OF FATHER


(State or country)


Summary


PARENTS


WHITE PLANET, WITH UNADING IN THIS IS A TEAMANLAT DEVOND.


10 NAME OF


FATHER


Ferdinand Fredit your Signed)


12 MAIDEN NAME OF MOTHER Emang Claves


13 BIRTHPLACE OF MOTHER (State or country)


Lawrence max


14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE


(Informant)


Ferdinand H. young


(Address)


Central Ave Everett


Filed .... 191.


..... REGISTRAR


Ward)


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


Edward Ferdinand Going


Central Ave Event Marx


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 enginecr, 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 mil !; (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 minc, 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, peritoneum, etc , Carcinoma, Sur- eoma, 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 violenco, 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


Weichert ......


, RETURN OF A DEATH


(CITY OR TOWN.)


FULL NAME


Eunice Catherine Ramsey


Registered No ...


Date of ¿


april1


1911


Death


3


months.


22


days


STATISTICAL DETAILS


SEX


female


COLOR


mente


SINGLE, MARRIED, WIDOWED, OR DIVORCED


Large.


MAIDEN NAME +


HUSBAND'S NAME +


BIRTHPLACE #


Morton n. B


NAME OF


FATHER


John. T. Ramsey


BIRTHPLACE


OF FATHER$


Jyne Valley . 5. 4.


MAIDEN NAME


OF MOTHER


Evn. Baglole


BIRTHPLACE


OF MOTHER #


Tyne Valley P.S. J ..


OCCUPATION


at home


INFORMANT § Parents


Filed


19


Clerk


PLACE OF BURIAL OR REMOVAL I


DATE OF BURIAL


4/3


19 / /


UNDERTAKER


CR Benson


ADDRESS


Wouldn't


PHYSICIAN'S CERTIFICATE


.19// to .. I HEREBY CERTIFY that I attended deceased during last illness, from Auch it april 14 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 :


Tuberculosis ? Lung


(DURATION)


6 mois


.. DAYS


Contributory :


.. (DURATION) .OAYS


(Signed)


M.D.


19/ / (Address)


winthrop


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 detalls, Il Name of cemetery.


FILL OUT WITH INK. - THIS IS A PERMANENT RECORD


ALL NAMES TO BE IN FULL


Place of )


6 Parcial SL


Death *


5


Residence


.. Age


16


.. years


1


april 1, 1911


0


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


(No. 788. 1 ou ut Prad


St. ;. .


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


16.


6 DATE OF BIRTH


May


(Month)


7 AGE


42 yrs.


yrs.


8 OCCUPATION


Juveler


(a)' Trade, profession, or


particular kind of work


(b) General nature of industry,


business, or establishment in


which employed (or employer).


10 NAME OF


FATHER


William


PARENTS


WRITE PLAINLT, WITH ONFADING INK - InIS TO A PERMANENT SECOND.


9 BIRTHPLACE


(State or country)


Gare Doctin


5 SINGLE,


MARRIED,


WIDOWED,


OR DIVORCED


(Write the word)


Harreid


1860 17


(Day)


(Year)


If LESS than


I day, .....


„hrs.


10


mos.


22 ds.


or


.. min. ?


fare.


11 BIRTHPLACE OF FATHER (State or country) Brgland


12 MAIDEN NAME OF MOTHER Emma J. Martign


13 BIRTHPLACE OF MOTHER (State or country)


14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE


(Informant)


(Address)


288 Janne Road.


REGISTRAR


MEDICAL CERTIFICATE OF DEATH


16 DATE OF DEATH Apie 1


(Month)


(Day)


191./ (Year)


I HEREBY CERTIFY that I attended deceased from


Nov. 14


1910


.


that I last saw halive on


., 191/


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


The CAUSE OF DEATH* was as follows :


Chemin Desquamative Nellatis.


ds.


mos. .


ds


all of willu (Duration) .


yrs.


(Signed)


Frank Hf Villa-


M.D.


In. 3


191. { (Address)


15 primentan St-


* 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 residonce.


19 PLACE OF BURIAL OR REMOVAL DATE OF BURIAL


mais.


1 Jan. of 1911.


20 UNDERTAKER


1


ADDRESS


6. Barton


(City or town.)


'FULL NAME


Millicine


Fechala


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


10


Filed. .. 191


of unknown


(Duration) {


general deterinne schirares,


mos.


Contributory Enlargement of Live.


(SECONDARY)


Diluted Heard-


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," " 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 operatiou 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.


1


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 Man (No. 70 Triton


(City or town.)


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


Salina Eva Hyman 2 FULL NAME


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


@RESIDENCE


Registered No.


PERSONAL AND STATISTICAL PARTICULARS


3 SEX Female


4 COLOR OR RACE White


6 DATE OF BIRTH


11- (Month)


2%


(Day)


(Year)


7 AGE


If LESS than I day, .. hrs.


53 yrs. yrs. 4 mos. 8 ds


... min. ?


8 OCCUPATION


(a) Trade, profession, or particular kind of work House wife


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


9 BIRTHPLACE


(State or country)


guntherp. Maso.


| 10 NAME OF


FATHER


Havre Belcher.


PARENTS


11 BIRTHPLACE OF FATHER (State or country) grintheok, Marv.


12 MAIDEN NAME OF MOTHER Bertha Fardie


13 BIRTHPLACE OF MOTHER (State or country) Chatinur Mari.


14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE


(Informant)


(Address)


REGISTRAR


MEDICAL CERTIFICATE OF DEATH


16 DATE OF DEATH


I HEREBY CERTIFY that I attended deceased from


march 30, 1911


., to


april


4 , 1911 ..


that | last saw h_Oralive on


april 3


, 1917 ,


and that death occurred, on the date stated above, at.3 A. m.


The CAUSE OF DEATH* was as follows :


(Duration)


years.


mos. ..


ds.


Contributory Probable verine carcina


(SECONDARY)


months


(Duration)


yrs.


mos. .. ds.


(Signed)


D. J. Jackson


. ,


M.D.


april 5, 1911


(Address) ..


562 Shirley So.


* 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


1916


ADDRESS


20 UNDERTAKER


It. C. Skaygo.


Filed . 191


5-SINGLE, MARRIED WIDOWED, OR DIVORCED (Write the word)


18537 17


(Month)


(Day) 4


1911 (Year)


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) Forcman, (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 _It home. Care should be taken to report specifically the occupations of persons engaged in domestic service for wages, as Servant, Cook, Housemaid, etc. If the occupation has been changed or given up on account of the DISEASE CAUSING DEATH, state occupation at beginning of illness. If retired from business, that fact may be indicated thus: Farmer (retired, 6 yrs.). For persons who have no occupation whatever, write Nonc.


.


Statement of cause of death. - Name, first, the DISEASE CAUSING DEATH (the primary affection with respect to time and causation), using always the same accepted term for the same disease. Examples: ('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 neoplasmns) ; Mcasles; 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, Ilomicide, 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 duc to Alcoholism, etc.


4. Deaths under circumstances unknown, as A person found dead, etc.


COMMONWEALTH OF MASSACHUSETTS


RETURN OF A DEATH


(CITY OR TOWN.)


FULL NAME


Andwick 3. Day.


.Registered No.


Place of l


19 Chuter Av. Winthrop


Death *


S


Residence


19 (Juster Avec Hunter) Age


68 ... years.


... months. ......... days


STATISTICAL DETAILS


SEX


COLOR


SINGLE, MARRIED, WIDOWED, OR DIVORCED


Meadowver


MAIDEN NAME Ť HUSBAND'S NAME t


BIRTHPLACE#


NAME OF FATHER 1) iltrain


BIRTHPLACE OF FATHER# 11 refere cresce


1/2.


MAIDEN NAME OF MOTHER (Pennetta Horse


BIRTHPLACE OF MOTHER # Toutand ME.


OCCUPATION


Retired Druggut


INFORMANT §


PLACE OF BURIAL OR REMOVALI Fordlaun


.1 DATE OF BURIAL


UNDERTAKER


ADDRESS


PHYSICIAN'S CERTIFICATE


| HEREBY CERTIFY that I attended deceased, during last illness, from. mich 5 199 1 .... to april 6 1991 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 : Carcinoma of liver & Stomach


6 mio


(DURATION)


DAYS


Contributory :


(DURATION) ........ DAYS


(Signed)


(31 Mal call


M. D.


april ? 1911 (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


190


Clerk


* 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 detalls. Il Name of cemetery.


FILL OUT WITH INK. - THIS IS A PERMANENT RECORD


ALL NAMES TO BE IN FULL


Winthrop


Date of l


Ups. 6 1911.


... 190


Death S


april 6, 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.


PARENTS


12 MAIDEN NAME OF MOTHER


1


1


13 BIRTHPLACE OF MOTHER (State or country)


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)


10


(Day)


, 1912 (Year)


17


I HEREBY CERTIFY that I attended deceased from


cfr.5


1911, to 9/2.9


.. , 191 / .,


hrs. that I last saw h alive on


Spk. 9.10 P.M., 1911.


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


The CAUSE OF DEATH* was as follows :


mos.


6


ds.


Contributory ..


(SECONDARY)


(Duration) yrs. . mos. .ds.


(Signed)


Can, ,., 191, (Address).


* If death followed injury or violenee 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.


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


ADDRESS


20 UNDERTAKER Gordon DA. Brown


Past Boston


BOSTON (City or town.)


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


Registered No.


PERSONAL AND STATISTICAL PARTICULARS


3 SEX


4 COLOR OR RACE


White


a SINGLE


MARRIED,


WIDOWED,


OR DIVORCED


(Write the word)


Single


6 DATE OF BIRTH


unknown


(Month)


(Day)


7 AGE


If LESS than I day, . . ..


53.


.yrs.


mos.


ds.


or ....... min. ?


8 OCCUPATION


Engliem


(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


r


The Commonwealth of Massachusetts


STANDARD CERTIFICATE OF DEATH


1 PLACE OF DEATH 1 tre Danke .(No. Winthrop 7'Lacc 2


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


...


St. ; Ward)


(Duration)


Age of Pateira,


yrs.


.


., M.D.


11 BIRTHPLACE OF FATHER (State or eountry) 16. 1


n Rumin


In the


1


(Year)


STANDARD CERTIFICATE OF DEATH.




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