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).
Part 1 | Part 2 | Part 3 | Part 4 | Part 5 | Part 6 | Part 7 | Part 8 | Part 9 | Part 10 | Part 11 | Part 12 | Part 13 | Part 14 | Part 15 | Part 16 | Part 17 | Part 18 | Part 19 | Part 20 | Part 21 | Part 22 | Part 23 | Part 24 | Part 25 | Part 26 | Part 27 | Part 28 | Part 29 | Part 30 | Part 31 | Part 32 | Part 33 | Part 34 | Part 35 | Part 36 | Part 37 | Part 38 | Part 39 | Part 40 | Part 41 | Part 42 | Part 43 | Part 44 | Part 45 | Part 46 | Part 47 | Part 48 | Part 49 | Part 50 | Part 51 | Part 52 | Part 53 | Part 54 | Part 55 | Part 56 | Part 57 | Part 58 | Part 59 | Part 60 | Part 61 | Part 62 | Part 63 | Part 64 | Part 65 | Part 66 | Part 67 | Part 68 | Part 69 | Part 70 | Part 71 | Part 72 | Part 73 | Part 74 | Part 75 | Part 76 | Part 77 | Part 78 | Part 79 | Part 80 | Part 81 | Part 82 | Part 83 | Part 84 | Part 85 | Part 86 | Part 87 | Part 88 | Part 89 | Part 90 | Part 91 | Part 92 | Part 93 | Part 94 | Part 95
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.
Need help finding more records? Try our genealogical records directory which has more than 1 million sources to help you more easily locate the available records.