USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1910-1912 > Part 28
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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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