USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1910-1912 > Part 31
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Registered No.
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
4 COLOR OR RACE
White
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
20
(Month)
(Day)
...
(Year)
7 AGE
If LESS than 1 day, ........ hrs.
41 yrs. mos.
. ds.
or ....... min. ?
8 OCCUPATION
(a)' Trade, profession, of
particular kind of work ...
(b) General nature of industry, business, or establishment in which employed ( or employer)
9 BIRTHPLACE
(State or country)
New Bedford Muss
10 NAME OF
FATHER
Wieland 22. Tracker
PARENTS
II BIRTHPLACE
OF FATHER
(State or country)
Florentin R.O.
12 MAIDEN NAME
OF MOTHER
Sarch. Whenthey
13 BIRTHPLACE
OF MOTHER
(State or country)
Info Tyron Geland
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
Geo. Fr. Reit
(Address)
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH ,
1 PLACE OF DEATH Wantto Hear .(No.
Margaret Jane Jucken
FULL NAME
cordow of frank. Piele
[If married or divorced woman or widow give maiden name, also name of husband.] , @RESIDENCE 15 Fuldtunion 8h Wunschut
16 DATE OF DEATH
may
191. 1. (Address)
6 DATE OF BIRTH
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, Hlousework, or At home, and children, not gain- fully employed, as At school or At home. Care should be taken to report specifically the occupations of persons engaged in domestic service for wages, as Servant, Cook, Housemaid, etc. If the occupation has been changed or given up on account of the DISEASE CAUSING DEATH, state occupation at beginning of illness. If retired from business, that fact may be indicated thus: Farmer (retired, 6 yrs.). For persons who have no occupation whatever, write None.
Statement of cause of death. - Name, first, the DISEASE CAUSING DEATH (the primary affection with respect to time and causation), 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 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 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 strcet, 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
(No. 2 Ferrare are 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
- -
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
Vidonc
6 DATE OF BIRTH
2
14
(Month)
(Day)
, 1822 17
(Year)
7 AGE
If LESS than I day, ... .. hrs.
79 yrs. 2 mos. 22 ds.
Or ....... min. ?
8 OCCUPATION
(a) Trade, profession, or particular kind of work
(b) General nature of industry, business, or establishment in which employed ( or employer)
9 BIRTHPLACE
(State or country)
1) Fittor VWE.
10 NAME OF FATHER
11 BIRTHPLACE OF FATHER (State or country)
1 man
12 MAIDEN NAME OF MOTHER
Unknown
13 BIRTHPLACE OF MOTHER (State or country)
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
(Address)
Filed 191
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
May. 6
(Month)
(Day)
1941
(Year)
1 HEREBY CERTIFY that I attended deceased from
may 6
1917 , to
Quay 6
91
-
that I last saw her alive on
May 6 .
, 1916
and that death occurred, on the date stated above, at
8.00 PM
The CAUSE OF DEATH* was as follows :
angina Pectoris.
months. yrs.
(Duration) mos. ... ds. Semility - arterias luis
Contributory.
(SECONDARY)
yrs.
mos.
.(Duration).
..
.ds.
(Signed)
D. L. Ya chacon.
M.D.
may 1
.. 191 ...... (Address).
502 Shirley Af -
* 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
191
ADDRESS
20 UNDERTAKER
IC Skaggs
(City or town.)
2 FULL NAME
Cimice In. Emery-
[If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE 2
Gideon - 5.
PARENTS
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 quostion 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, Loeo- 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 tho business or industry, and therefore an additional line is provided for tho 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, stato 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 ( AUSING DEATH (tho primary affection with respect to time and causation), using always tho samo accepted term for the same disease. Examples: Cerebro-spinal fever (the only definite synonym is "Epidemic cerebro-spinal meningitis ") ; Diphtheria (avoid uso 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 ; Chronie 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," "Senilo," 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.
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
Marlborough (No Crane Meadow
St. ;.. .
Ward)
[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 -
male
white
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
Married
8 DATE OF BIRTH
(Month)
(Day)
(Year)
7 AGE
63 yrs. - mos. - ds
or ....... min. ?
8 OCCUPATION
(a) Trade, profession, or
particular kind of work
retired Builder
(b) General nature of industry, business, or establishment in which employed (or employer)
9 BIRTHPLACE
(State or country)
Nova Scotia
10 NAME OF
FATHER
Horatio Geldert
PARENTS
11 BIRTHPLACE OF FATHER (State or country)
Nova Scotia
12 MAIDEN NAME OF MOTHER unknown
1ª BIRTHPLACE OF MOTHER (State or country)
Nova Scotia
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
(Address)
16 Filed June 5, 191. 1 P. B. murphy
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
May. 7 1911 19! (Year)
(Month) (Day)
17
I HEREBY CERTIFY that I attended deceased from
May 7, 1.91,1191
If LESS than I day, „ hrs. that | last saw h alive on
.. , 191
and that death occurred, on the date stated above, at
m.
The CAUSE OF DEATH* was as follows :
Suffocation
.(Duration) .
.yrs. .
mos. ..
ds.
Contributory .... burning by forest fire (SECONDARY)
.(Duration) .
yrs.
mos.
ds.
(Signed)
E ....... G. Hoitt, Led. Exam.
. M.D.
May 7 , 191 1 (Address)
Marlborough
* 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
Hope cemetery
Boston
DATE OF BURIAL
May 11 . 191]
20 UNDERTAKER
J.Frank Child
ADDRESS
Marlborough
MARLBOROUGH (City or town.)
2 FULL NAME
Alden Geldert
[If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE Winthrop, Mass., 46 Tewksbury street
Registered No.
j
STANDARD CERTIFICATE OF DEATH. 0
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 Serrant, 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, 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- acmia " (merely symptomatic), " Atrophy," "Collapse," " Coma," "Convulsions," "Debility " ("Congenital," "Senilc," 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 duc 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.
PARENTS
11 BIRTHPLACE OF FATHER (State or country) Ulussia
12 MAIDEN NAME OF MOTHER Rachel charmes:
17 BIRTHPLACE OF MOTHER (State or country) 5) Rusial.
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant) ..
(Address)
96 Bruns wick A Pac.
Filed. 191
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
may
(Month)
11
(Day)
19! / (Year)
May 11
17
I HEREBY CERTIFY that
attended deceased from
Jan- 10
1911, to
, 1911.
11
1911
and that death occurred, on the date stated above, at.
m.
The CAUSE OF DEATH* was as follows : - Chronic Endocarditis. Chronic Diffuse nephritis
(Duration) 2 yrs. + Chronic Cholecystitis tyall Stina) .mos. ds.
Contributory
(SECONDARY)
(Duration) ..
3 yrst-
mos.
ds.
St.E. Brandon-
., M.D.
(Signed)
May 11 1911 (Address).
Ileentral Ayr
* If death followed injury or violence the certificate of death must be made out by the Medical Examiner. bareBouton
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 Sifereth Israel com, ieri. west Routere-
DATE OF BURIAL
May. 12.
, 191)
20 UNDERTAKER
ruest- Levine
ADDRESS 3 Baldwin El Boston
Ward)
[If death occurred in a hospital or institution, give its NAME instead of street and number.]
2 FULL NAME .. Jennie Fleisher. .. .
[If married or divorced woman or widow give maiden name, also name of husband.]
Vife of & M Fleischer
@RESIDENCE
25 Seaform
ar. wintiot. mass
Registered No.
PERSONAL AND STATISTICAL PARTICULARS
3 SEX Female
4 COLOR OR RACE
white
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word) Married
6 DATE OF BIRTH
(Month) (Day)
, 1
(Year)
7 AGE
58 yrs. mos. . ds.
or min. ?
8 OCCUPATION At Home
(a) Trade, profession, or
particular kind of work
(b) General nature of industry, business, or establishment in which employed ( or employer). At Home
9 BIRTHPLACE (State or country) Russia
10 NAME OF
FATHER
Jos. Levenson
non
If LESS than 1 day, hrs. that I last saw he . alive on.
Wintrop Mass
BOSTON (City or town.)
The Commonwealth of Massachusetts STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH Wintrop. Mass .. (No. 25 Seaform av. St. ;
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, statc 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 (" I'neumonia," 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 septicemia," " 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.
'FULL NAME. 3 SEX Male 6 DATE OF BIRTH 7 AGE 8 OCCUPATION PARENTS important. See instructions on back of certificate. 15 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 71
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH Worthof (No.
Charles. Edward / Bacon
[If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE
24 Casabella St Barcos
Registered No.
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
may
(Month )
16
(Day)
(Year)
17 I HEREBY CERTIFY that I attended deceased from
1911, to
may 16'
1911,
I day, ....
hrs.
that I last saw her alive on
May 16"
191]
and that death occurred, on the date stated above, at /0 9m.
or .....
min. ?
vs :
The CAUSE OF DEATH*
angina Pectoris
(Duration)
yrs.
3
mos.
ds.
Contributory
General antonio sclerosis
(SECONDARY)
(Duration)
mos. ds.
(Signed)
1
M.D.
may
18
191
/ .. (Address)
* If death followed injury or violence the certificate of death inust be made out by the Medical Examiner.
18 LENGTH OF RESIDENCE (FOR HOSPITALS, INSTITUTIONS, TRANSIENTS, OR RECENT RESIDENTS).
At place
of death ..
yrs.
mos.
6 ds.
In the
State
. yrs.
mos.
ds.
Where was disease contracted,
If not at place of death ?.
3.4 Spattilla St Boston
Former or
usual residence.
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