Town of Winthrop : Record of Deaths 1910-1912, Part 33

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 33


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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The Commonwealth of Massachusetts


STANDARD CERTIFICATE OF DEATH


1 PLACE OF DEATH Winthrop (No. 18 Jaun Bar Crest;


-


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


18 Faun Bar and Winthrop


Registered No.


PERSONAL AND STATISTICAL PARTICULARS


3 SEX m


4 COLOR OR RACE


5 SINGLE,


MARRIED,


WIDOWED,


OR DIVORCED


(Write the word)


Windwed


6 DATE OF BIRTH


april


(Month)


(Day)


(Year)


7 AGE


If LESS than | day,. .. hrs.


60 yrs. . mos. .. ds


or ...... min. ?


8 OCCUPATION


(a)' Trede, profession, or


particular kind of work ..


Retired


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


Carpenter & Bul der


9 BIRTHPLACE


(State or country)


St Holm n.B.


PARENTS


11 BIRTHPLACE OF FATHER (State or country) Ireland


12 MAIDEN NAME OF MOTHER


Bridget Spain


13 BIRTHPLACE


OF MOTHER


(State or country)


Ireland


14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE


(Informant)


mrs. C. a. Lenleines


(Address)


160 Somhar


sets ave. Winthrop


REGISTRAR


MEDICAL CERTIFICATE OF DEATH


16 DATE OF DEATH


May


29


(Month)


(Day)


1911


(Year)


17 I HEREBY CERTIFY that I attended deceased from


191.


, to


191


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 : fred while attending playarian was away - Cancer of REctura-


(Duration)


.yrs.


mos. ds.


Contributory. (SECONDARY)


(Duration)


yrs.


mos. .ds.


(Signed)


We willicup Board of Health.


Edward J. granger


* 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 New Calvary


DATE OF BURIAL


June 1


. 1911


VADDRESS


20 UNDERTAKER


J. J. Lame ly Hallo Lane 1120 Have 28.


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


important. See instructions on back of certificate.


Winthrop BOSTON


(City or town.)


Ward)


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


Filed .. 191.


10 NAME OF


FATHER


Thomas Cusede


191 ...


( Address).


M.D.


STANDARD CERTIFICATE OF DEATH.


Statement of occupation. - Precise statement of ocenpa- tion is very important, so that the relative healthfulness of varions pursnits 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. Bnt, 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- fnlly 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: Mcasles (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," "Uraenia," " 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.


1


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


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) England


12 MAIDEN NAME OF MOTHER


Margaret Hardwell


1ª BIRTHPLACE OF MOTHER (State or country)


England


14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE


(Informant)


(Address)


34 River Rd Winthrop Mass


REGISTRAR


MEDICAL CERTIFICATE OF DEATH


16 DATE OF DEATH


6


3


(Month)


(Day)


19! /


(Year)


I HEREBY CERTIFY that I attended deceased from


dift


1910


May


3


1911.


that I last saw hey. alive on


fine


1


, 191 } ,


and that death occurred, on the date stated above, at .... ! / f, m.


The CAUSE OF DEATH* was as follows :


Perniciono anaemia


Duration


indefinite.


(Duration)


yrs. ..


mos.


ds.


Contributory


gradual exhaustion with


final pulmonary ordena of oneor two days


Le DKnowlow


..


(Signed)


M.D.


June 4


1911. (Address)


544 Warren 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 residence.


19 PLACE OF BURIAL OR REMOVAL


Forrestdale


Mulden, Muss,


20 UNDERTAKER Fred W young


Ward)


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


2 FULL NAME


Martha Harol Gould


[If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE 34 River Road. Winthrop Muss.


PERSONAL AND STATISTICAL PARTICULARS


3 SEX


Female


4 COLOR OR RACE


White


5 SINGLE,


MARRIED,


Married


WIDOWED,


OR DIVORCED


(Write the word)


6 DATE OF BIRTH


3


18


1862


17


(Month)


(Day)


(Year)


7 AGE


If LESS than I day, .. .. hrs.


44


yrs.


2


mos.


10 ds.


or .....


min. ?


8 OCCUPATION


(a) Trade, profession, or


particular kind of work.


Housewife


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


Housework


9 BIRTHPLACE


(State or country)


England


10 NAME OF


FATHER


Jacob Harrop


duration


DATE OF BURIAL


June 6. 1917


ADDRESS


Lynn-Mars_


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


The Commonwealth of Massachusetts STANDARD CERTIFICATE OF DEATH


1 PLACE OF DEATH Winthrop, Muss. (No. 34 River Road


(City or town.)


&t. ;...


Registered No.


1538


Filed 191


STANDARD CERTIFICATE OF DEATH.


Statement of occupation. - Precise statement of occupa- tion is very important, so that the relative healthfulness of various pursuits can be known. The question applies to each and every person, irrespective of age. For many occupations a single word or term on the first line will be sufficient, e. g., Farmer or Planter, Physician, Compositor, Architect, Loco- motive engineer, Civil engineer, Stationary fireman, etc. But in many cases, especially in industrial employments, it is necessary to know (a) the kind of work and also (b) the nature of the business or industry, and therefore an additional line is provided for the latter statement; it should be used only when needed. As examples: (a) Spinner, (b) Cotton mill; (a) Sales- man, (b) Grocery ; (a) Foreman, (b) Automobile factory. The material worked on may form part of the second statement. Never return "Laborer," "Foreman," " Manager,""Dealer," etc., without more precise specification, as Day laborer, Farm laborer, Laborer - Coal mine, etc. Women at home, who are engaged in the duties of the household only (not paid House- keepers who receive a definite salary), may be entered as Housewife, Housework, or At home, and children, not gain- fully employed, as At school or At home. Care should be taken to report specifically the occupations of persons engaged in domestic service for wages, as Servant, Cook, Housemaid, etc. If the occupation has been changed or given up on account of the DISEASE CAUSING DEATH, state occupation at beginning of illness. If retired from business, that fact may be indicated thus: Farmer (retired, 6 yrs.). For persons who have no occupation whatever, write None.


Statement of cause of death. - Name, first, the DISEASE CAUSING DEATH (the primary affection with respect to time and causation), using always the same accepted term for the same disease. Examples: Cerebro-spinal fever (the., only definite synonym is " Epidemic cerebro-spinal meningitis") ; Diphtheria (avoid use of " Croup ") ; Typhoid fever (never re- port " Typhoid pneumonia ") ; Lobar pneumonia ; Broncho- 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.


--


.


The Commonwealth of Massachusetts


STANDARD CERTIFICATE OF DEATH


1 PLACE OF DEATH


(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


5 SINGLE,


MARRIED,


WIDOWED,


OR DIVORCED


(Write the word)


widow


& DATE OF BIRTH


10


(Month)


(Day)


1842


(Year)


7 AGE 68


yrs.


mos.


30


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)


Barton Maso


PARENTS


11 BIRTHPLACE OF FATHER (State or country) Canamin Me


12 MAIDEN NAME


OF MOTHER


Nancy Dockam


13 BIRTHPLACE OF MOTHER (State or country)


mersicht mr


14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE


(Informant)


le RBennem


(Address)


Wencheet nias


16


Filed 191


REGISTRAR


MEDICAL CERTIFICATE OF DEATH


16 DATE OF DEATH


1


17


I HEREBY CERTIFY that I attended deceased from


may 20


191


... 1911.


If LESS than I day, hrs. that I last saw h My alive on.


, 191 } , and that death occurred, on the date stated above, at. 104 Sam The CAUSE OF DEATH* was as follows : General Cartesio acbasis intral Insufficiency


(Duration) .


2 yrs.


mos.


ds.


Contributory


..


(Duration)


2


yes .


mos. .


ds.


(Signed)


n


Inie 10


191|


... (Address)


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


In the


18 LENGTH OF RESIDENCE (FOR HOSPITALS, INSTITUTIONS, TRANSIENTS, OR


RECENT RESIDENTS).


At place


of death


.yrs.


mos.


14. ds.


State


.... .. yrs.


mos.


16


ds.


Where was disease contracted,


if not at place of death ?...


usual residonce ..


Former or


Philadelphia


Pa.


19 PLACE OF BURIAL OR REMOVAL Reaching Ecurity


DATE OF BURIAL


191 ª


20 UNDERTAKER


ADDRESS


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


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.


.(No.


adelaide Susan de favor


'FULL NAME


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


Widow of John. S. LE Favor


St. ; Ward)


(Month)


97


(Day)


191.1. (Year)


to


10 NAME OF


FATHER


John Burrill


(SECONDARY)


Cerebral itamarching


(31 ) metcal)


M.D.


STANDARD CERTIFICATE OF DEATH.


1


Statement of occupation. - Precise statement of occupa- tion is very important, so that the relative healthfulness of various pursuits can be known. The question applies to each and every person, irrespective of age. For many occupations a single word or term on the first line will be sufficient, e. g., Farmer or Planter, Physician, Compositor, Architect, Loco- motive engineer, Civil engineer, Stationary fireman, etc. But in many cases, especially in industrial employments, it is necessary to know (a) the kind of work and also (b) the nature of the business or industry, and therefore an additional line is provided for the latter statement ; it should be used only when needed. As examples: (a) Spinner, (b) Cotton mill; (a) Sales- man, (b) Grocery ; (a) Foreman, (b) Automobile factory. The material worked on may form part of the second statement. Never return "Laborer," "Foreman," " Manager," "Dealer," etc., without more precise specification, as Day laborer, Farm laborer, Laborer - Coal mine, etc. Women at home, who are engaged in the duties of the household only (not paid House- keepers who receive a definite salary), may be entered as Housewife, Housework, or At home, and children, not gain- fully employed, as At school or At home. Care should be taken to report specifically the occupations of persons engaged in domestic service for wages, as Servant, Cook, Housemaid, etc. If the occupation has been changed or given up on account of the DISEASE CAUSING DEATH, state occupation at beginning of illness. If retired from business, that fact may be indicated thus: Farmer (retired, 6 yrs.). For persons who have no occupation whatever, write None.


Statement of cause of death. - Name, first, the DISEASE CAUSING DEATH (the primary affection with respect to time and causation), using always the same accepted term for the same disease. Examples: Cerebro-spinal fever (the only definite synonym is "Epidemic cerebro-spinal meningitis") ; Diphtheria (avoid use of "Croup") ; Typhoid fever (never re- port " Typhoid pneumonia ") ; Lobar pneumonia ; Broneho- 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 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 strcet, or one supposed to be due to Alcoholism, etc.


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


COMMONWEALTH OF MASSACHUSETTS.


RETURN OF A DEATH-1911.


CITY OF BOSTON.


FULL NAME


Thomas J Darlow


Registered No ....


5610


Place of Death }


Boston


Childrens Hospt.


and Residence S


Date of Death


Jun. 11


1911.


Age


3


years


5


months


12


days.


STATISTICAL DETAILS.


SEX


COLOR


SINGLE, MARRIED, WID., DIV.


S


Maiden Name


ST


RAR'S


Husband's Name


Birthplace Winthrop


Name of


Father


John A Darlow BO


ISR 1830.


DONATA A


MASS.


Birthplace


England


of Father


Maiden Name of Mother .. . Fannie E Real


Birthplace of Mother.


Cambridge


Occupation


Informant ...


Place of Burial or removal .....


Cambridge"Camb. Cem" W C Skaggs


Undertaker


Winthrop


Usual Residence


Winthrop (17 Tewksbury st)


Jun. 15


Filed.


.1911


A true copy.


Attest :


ErMSlenen


Registrar.


MARGIN RESERVED FOR BINDING.


PHYSICIAN'S CERTIFICATE.


I HEREBY CERTIFY that I attended deceased during last illness,


1911, from 1911, to that to the best of my knowledge and belief death occurred on the date stated above, and that the CAUSE OF DEATH was as follows:


ATRIBU


SIT DE Primary ( Dura Han)


Tubercular meningitis -


CITY


FICE


15 days


VIT


BOSTORIA" CONDITAAD. 18


UNE


TON


Contributory : 2 (Duration)


(Signed)


17.P.Lucas


M. D.


.. 1911


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


June 11, 1911


1


THE COMMONWEALTH OF MASSACHUSETTS


RETURN OF A DEATH


..


(CITY OR TOWN.)


FULL NAME


Caroline. Gertrude Higham


.Registered No ..


Place of )


94 Bellevue Cvr


Death *


S


Residence


Age


58


years.


4


.months.


10


.days


STATISTICAL DETAILS


SEX female


COLOR


Miete


SINGLE, MARRIED, WIDOWED, OR DIVORCED


mannen


MAIDEN NAME +


Williams


HUSBAND'S NAME +


Daniel Higham


BIRTHPLACE #


Baston- Mars


NAME OF


FATHER


Marlborough. Williams


BIRTHPLACE


OF FATHER+


Burton mais


MAIDEN NAME


OF MOTHER


Allary Ella- Farrar


BIRTHPLACE


OF MOTHER #


anton mais


OCCUPATION at Home


INFORMANT §


PLACE OF BURIAL OR REMOVAL I


.


DATE OF BURIAL 4


19 '/


UNDERTAKER


ADDRESS


PHYSICIAN'S CERTIFICATE


I HEREBY CERTIFY that I attended deceased during last illness, from June 1908 to true 13 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 :


Locomotor ataxia


(DURATION)


3 Mm.


1 DAYS


Contributory :


.(DURATION).


......... DAYS


(Signed).


.M.D.


June 14191


(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


19


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 details. Il Name of cemetery.


FILL OUT WITH INK .- THIS IS A PERMANENT RECORD ALL NAMES TO BE IN FULL


Date of free 13 Death


19/1


June 13, 1911


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


The Commonwealth of Massachusetts


STANDARD CERTIFICATE OF DEATH


1 PLACE OF DEATH


(No .... 15


1 1. 03 St. .... Ward)


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


2 FULL NAME


[If married or divorced woman or widow


give maiden name, also name of husband.]


@RESIDENCE


+75. 15 +1


PERSONAL AND STATISTICAL PARTICULARS


3 SEX


4 COLOR OR RACE


Feira !'chu?


5 SINGLE,


MARRIED,


WIDOWED,


OR DIVORCED


(Write the word)


Singly


6 DATE OF BIRTH


1


15-


(Month)


(Day)


(Year)


7 AGE


If LESS than


I day,.


.. hrs.


.yrs.


mos.


10 ds.


or ....... min, ?


8 OCCUPATION


(a) Trade, profession, or


particular kind of work


1571C


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


9 BIRTHPLACE


(State or country)


10 NAME OF


FATHER


-


PARENTS


11 BIRTHPLACE OF FATHER (State or country} Mail.


12 MAIDEN NAME OF MOTHER


~


13 BIRTHPLACE OF MOTHER (State or country) Tansau


1: THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE


(Informant) ..


Traite Killer.


(Address) * Inthe


16


Filed ... ... 191


REGISTRAR


MEDICAL CERTIFICATE OF DEATH


16 DATE OF DEATH


(Month) June 15, (Day)


1911.


(Year)


17 I HEREBY CERTIFY that I attended deceased from June 5, 1911, to .. June 15, 1911, that I last saw her alive on June 151, 1911. and that death occurred, on the date stated above, at m. The CAUSE OF DEATH* was as follows :


Premature bitte


.. (Duration) .


.. yrs. ..


. mos. ..


ds.


Contributory


(SECONDARY)


.(Duration) .


yrs.


mos.


...


ds.


(Signed)


Albert B. Gorman


M.D.


June 151, 1911. (Address)


Withook 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.


In the


. yrs. ..


mos.


ds.


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


Former or usual residence.


19 PLACE OF BURIAL OR REMOVAL


DATE OF BURIAL


6-15


1911.


:0 UNDERTAKER


ADDRESS


4


e


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


important. See instructions on back of certificate.


Registered No.


,


19/1


...


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 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: («) 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 receivo 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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