USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1910-1912 > Part 4
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3 whose
(DURATION).
Contributory :
X
(DURATION) ... DAYS
M.D.
(Signed)
Rue /4 1960
(Address)
SPECIAL INFORMATION only for Hospitals, Institutions, Transients, or Recent Residents.
Former or Usual Residence
How long at
Place of Death ?
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. t State or country ; also city, town or county, If known.
$ Name and address of person giving statistical details. Il Name of cemetery.
ALL NAMES TO BE IN FULL
28 Februar a Beach may 1 3-1910
COMMONWEALTH OF MASSACHUSETTS
Welcherof (CITY OR TOWN.)
RETURN OF A DEATH
FULL NAME
Many Sinclair Tewksbury
Registered No.
Date of
March 15th
1960
Death
1
2
months ..
11
.days
STATISTICAL DETAILS
SEX
COLOR
1.
SINGLE, MARRIED,
WIDOWED, OR
DIVORCED
widow
MAIDEN NAME +
Mary. Sinclair Smith
HUSBAND'S NA
E Martina Granville
Tentesting
BIRTHPLACE # Bastón mass
NAME OF
FATHER
Horace Bear
BIRTHPLACE
OF FATHER $
New Hampshire
MAIDEN NAME
OF MOTHER
achsah. Holl- Smith
BIRTHPLACE
OF MOTHER $
New Hampshire
OCCUPATION Retired
INFORMANT §
Daughter
-
PLACE OF BURIAL OR REMOVAL !!
DATE OF BURIAL
1960
UNDERTAKER & R. Bennison
ADDRESS
PHYSICIAN'S CERTIFICATE
I HEREBY CERTIFY that I attended deceased during last iliness, from 1 190.6 ... to Mah. 15 1900 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 :
Cardiac Dropsy
(DURATION) 3 2000.
DAYS
Contributory :
Mitral Stenosis
(DURATION).
DAYS
(Signed)
M.D.
...
SPECIAL INFORMATION only for Hospitais, 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, glve 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
Place of l
9
altantic Street
Death *
S
Residence
Age
63
.. years ..
Inch. / 1900 (Address).
29 mary Suetain Tewksbury man 15 -igio
THE COMMONWEALTH OF MASSACHUSETTS
RETURN OF A DEATH
(CITY OR TOWN.)
FULL NAME Marylaubt Buce
Death *
Residence
Age
51
... years.
4 .months.
.days
STATISTICAL DETAILS
SEX
FEM
COLOR
SINGLE, MARRIED, WIDOWED, OR DIVORCED
MAIDEN NAME + HUSBAND'S NAME t
BIRTHPLACE #
Ellamonth MS
NAME OF
FATHER
Charles & Hackell
BIRTHPLACE OF FATHER#
MAIDEN NAME
OF MOTHER
Mary It Black
BIRTHPLACE
OF MOTHER#
Ellsworth ME
OCCUPATION Housewife
INFORMANT §
Edward N Buss
PLACE OF BURIAL OR REMOVAL ! fui ra Hyde Park Mari
DATE OF BURIAL Man 19. 95 0
UNDERTAKER Oliver N ferralla Wake field ADDRESS
PHYSICIAN'S CERTIFICATE
I HEREBY CERTIFY that I attended deceased during last illness, from 1914 to Melilla 1980, 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 : Mitine Regurgitate
Contributory :
Dilatation og hurt
8 min
(DURATION) ... . DAYS
, W.KI.M.D.
(Signed) ..
Mehra
.1910
(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.
ALL NAMES TO BE IN FULL
Place of Venithned Than 133 Washington 260
Registered No. Mar 17 19/0
.. (DURATION).
.DAYS
30 many labb Buck mek 17-1960
31 h
--- -
COMMONWEALTH OF MASSACHUSETTS
f
RETURN OF A DEATH
(CITY OR TOWN.)
FULL NAME
Frederick Temple Seof
.Registered No.
Place of l
Death * )
Metaal Hospital
Date of ¿
Mar 15
1960
Death
Residence
15
Age
1
.years.
months. 22. .days
STATISTICAL DETAILS
SEX
COLOR
20.
SINGLE, MARRIED, WIDOWED, OR DIVORCED
MAIDEN NAME +
HUSBAND'S NAME t
BIRTHPLACE # Somerville Mas
NAME OF
FATHER
Frederick Temple Scott.
BIRTHPLACE OF FATHER$ Salafox U.S.
OF MOTHER Newark England
antescelen want.
OF MOTHER $
Eliza Person
OCCUPATION
INFORMANT § -fachen
PHYSICIAN'S CERTIFICATE
tc I HEREBY CERTIFY that I attended deceased during last illness, from nº16 196. Mich 19' 190, 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 :
acute. Cappillan
(DURATION).
DAYS
Contributory :
(DURATION). ........... DAY8
.M.D.
(Signed)
Ih 19 190
.(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
PLACE OF BURIAL OR REMOVAL II
DATE OF BURIAL
Olav 20
1960
UNDERTAKER
€ 12. Benimsoia.
ADDRESS
·
* 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.
ALL NAMES TO BE IN FULL
31 Frederick amples Seatt .- mich 11-1410
.
1630$
INCORPORA
COMMONWEALTH OF MASSACHUSETTS
RETURN OF A DEATH
Registered No.
Date of Death Mar. 21, 1910
Place of
Death
125 Monument Street Medford
NAME OF HOSPITAL OR INSTITUTION, IF ANY
NO.
STREET
Place of
Residence.
51 Winthrop Street, Winthrop, Mass.
NO. STREET
CITY OR TOWN
Age ..
48 .. years ..
3
months
6
days
STATISTICAL DETAILS
SEX
COLOR
SINGLE, MARRIED
WIDOWED, OR
DIVORCED
I HEREBY CERTIFY that I attended deceased during last
illness from
March ... 18,
19 10,
to .......... March 21,
19 10. 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
Alcoholism
Duration
Many ... y.r.s ..
Contributory C rdiac Asthenia
Duration
Many ... we.cks. ..
(Signed)
James .... S ..... Kennedy.
M D.
(Address) Medford
Date Mar. 219 10
SPECIAL INFORMATION only for Hospitals, Institutions, Transients, or Recent Residents.
Where was Disease Contracted? Withroo
How long at Place of Death ? Days
Recorded
Mar. . 22,. 19
10 A. R. Reed
Clerk of Board of Health
UNDERTAKER'S NAME
ADDRESS JJoh .. .. E. Maulor
Filed
34 Lincoln St., Somerville Mars. Fr. 26,
19
Allatón A. Joyce
NO.
STREET
PHYSICIAN'S CERTIFICATE
Male MAIDEN NAME
White
widowed .....
HUSBAND'S FULL NAME
BIRTHPLACE AND DATE OF BIRTH
Portsmouth, N. H. Dec. 15, 1861
NAME OF FATHER George ... W ..... Sanborn
BIRTHPLACE OF FATHER Portsmouth, N. H.
MAIDEN NAME OF MOTHER Kate ... Andrews
BIRTHPLACE OF MOTHER
Lowell, Mass.
OCCUPATION
Clerk
FULL NAME OF INFORMANT
Adelphus .... Leavitt
OFFICIAL TITLE
ADDRESS
Medford
PLACE OF BURIAL
Cemetery
City or Town
Fair View, Dedham Mais.
City Clerk
ALL NAMES TO BE IN FULL
CITY OF MEDFORD
FULL NAME WARREN SAMUEL SANBORN
COMMONWEALTH OF MASSACHUSETTS
RETURN OF A DEATH (CITY OR TOWN.)
FULL NAME
Lydia. Walden Lunch
Registered No.
......
Place of l
Death *
41 Cutler fr
Residence
Age
... years.
1
.months.
.days
STATISTICAL DETAILS
·
SEX-
Female
COLOR
SINGLE, MARRIED, WIDOWED, OR DIVORCED
cordon
MAIDEN NAME +
Lydia. w. 5 off.
HUSBAND'S NAME Ť
Williami H. Lynch
BIRTHPLACE #
Bustol R.J.
NAME OF
FATHER
Sylvanus. Goff
BIRTHPLACE
OF FATHER#
Rehoboth R.P.
MAIDEN NAME
OF MOTHER
arm. Davis Gray
BIRTHPLACE
OF MOTHER #
Bristol R.V.
OCCUPATION
INFORMANT §
dangbeen -
PHYSICIAN'S CERTIFICATE
I HEREBY CERTIFY that I attended deceased during last illness, from Sehr. 17 1906 .. to Heh. 21 1950, 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 : Bronchitis
(DURATION).
×3
DAYS
Contributory :
· Senile atrophy
(DURATION) .. DAYS
(Signed)
M.D.
Puch. 221
1900 (Address)
Winthrop
1
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
PLACE OF BURIAL OR REMOVAL II
Providers R.C.
DATE OF BURIAL
3/23
1960
UNDERTAKER
C. R Bensó
ADDRESS
.
* 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. li Name of cemetery.
ALL NAMES TO BE IN FULL
Date of l
march 21
Death
83
22
32 mydia stalden Lynch mah 21 - 1/10
COMMONWEALTH OF MASSACHUSETTS
RETURN OF A DEATH
FULL NAME Coduran (
3. Уиванов
.Registered No.
Place of Death
30 8 Doudou St. Winthrop
Maru.
Date of Death
March 24-19'0-
Age
58 years
............._ months 12 days
STATISTICAL DETAILS
SEX
COLOR
white
SINGLE, MARRIED, WIDOWED, OR DIVORCED
MAIDEN NAME Ť
HUSBAND'S NAME +
BIRTHPLACE #
NAME OF FATHER John Vreeland
BIRTHPLACE OF FATHER# Staten Island 414-
MAIDEN NAME OF MOTHER Elizabeth Littlefield.
BIRTHPLACE
OF MOTHER #
OCCUPATION Insurance
INFORMANT §
PHYSICIAN'S CERTIFICATE
I HEREBY CERTIFY that I attended deceased during last illness, from, w20 190 .9 ... to March 23 1900. 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 :
Clivenina Paren lesmatins
Suplintos
....... (DURATION). -... DAY8 Urgencia
Contributory :
1 ( DURATION). 10 . DAYS
(Signed).
Hallan Het Land
M.D.
3/24
1900 ... (Address)
SPECIAL INFORMATION only for Hospitals, institutions, Transients, or Recent Residents.
Former or Usual Residence
How long at
Place of Death ?
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 details. Name of cemetery.
ALL NAMES TO BE IN FULL
PLACE OF BURIAL OR REMOVAL II
fut unou
DATE OF BURIAL Fuck 261000
ADDRESS
UNDERTAKER It. C. Skaqql
33 Edward a Vreeland much 24-1990
COMMONWEALTH OF MASSACHUSETTS
Munchrol (CITY OR TOWN.)
RETURN OF A DEATH Statt B
FULL NAME
Baby Juin
Registered No.
Date of l
mar 25
1980
Death *
S
Residence
I ocean view LL
Age
×
. years ..
X
.months.
2
.days
STATISTICAL DETAILS
SEX
Female
COLOR
-
white
SINGLE, MARRIED, WIDOWED, OR DIVORCED
MAIDEN NAME t HUSBAND'S NAME +
-
BIRTHPLACE #
wencheof mars
NAME OF
FATHER
James . King
BIRTHPLACE
OF FATHER$
Windsor n. S.
MAIDEN NAME
OF MOTHER
Clara. Talbott
BIRTHPLACE
OF MOTHER #
Foxobow man
OCCUPATION
INFORMANT §
factur
- James King
PHYSICIAN'S CERTIFICATE
.to I HEREBY CERTIFY that I attended deceased during last illness, from Nh 23 190 Much 25 .. 196. .. , 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 :
Premature
(DURATION)
2
.. DAY8
Contributory :
( DURATION) ....... ..... DAY8
(Signed).
M.D.
Juk 28
.190 ..
.. (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 "Speclal information." if in a Hospital or Institution, give Its NAME Instead of street and number.
t In case of marrled 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.
:
PLACE OF BURIAL OR REMOVAL !!
DATE OF BURIAL
3/200
196.9
UNDERTAKER
ADDRESS
ALL NAMES TO BE IN FULL
Place of l
Metall Hospital
Death 1
34
.
Breley.
Durch 25: 1910
COMMONWEALTH OF MASSACHUSETTS
RETURN OF A DEATH
(CITY OR TOWN.)
FULL NAME
Samma. Almina adams
.Registered No.
....
Place of l
Death *
S
Residence
15 Thorton Park Wurstel
66
.years.
3
9
.months.
.days
STATISTICAL DETAILS
SEX7
Terreca
COLOR
white
SINGLE, MARRIED, WIDOWED, OR DIVORCED
manuel
MAIDEN NAME: Emma. Elmin Cishley
HUSBAND'S NAME Ť
Celas. S. a doma
BIRTHPLACE #
NAME OF
FATHER
James . Maryum ashley
BIRTHPLACE
OF FATHER$
Sandy Hill 11. 4.
MAIDEN NAME
OF MOTHER
Emma. Elimina Ballum
BIRTHPLACE
OF MOTHER #
OCCUPATION
INFORMANT §
Filed
190
Clerk
PLACE OF BURIAL OR REMOVAL II
Winthings cometing
DATE OF BURIAL
3/28£
1960
ADDRESS
.
PHYSICIAN'S CERTIFICATE
I HEREBY CERTIFY that | attended deceased during last illness, from Mch 1 9 190 to
Ich 26 ıgo .. 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 :
Menun vitis from mastordite
(DURATION).
Contributory :
acute nephritis
(DURATION).
3
DAYS
(Signed)
Mek 28 19%.
(Address)
M.D.
SPECIAL INFORMATION only for Hospitais, 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 details. I{ Name of cemetery.
ALL NAMES TO BE IN FULL
UNDERTAKER C. K. Benim.
Date of l
Mar 26
1960
Death
3.5 nech 26-1910
COMMONWEALTH OF MASSACHUSETTS
RETURN OF A DEATH
FULL NAME
France Myrick nichukon
„Registered No.
Place of Death *
72 Pleasant st Gut/role
Date of Death.
March 28, 1910.
Age
76 years
months .days
STATISTICAL DETAILS
SEX
COLOR
10
SINGLE,MARRIED, WIDOWED, OR- DIVORCED
MAIDEN NAME +
martha w. Norton
HUSBAND'S NAME + Anam B. Muchason
BIRTHPLACE #
NAME OF FATHER ihn Horton
BIRTHPLACE OF FATHER# Easthai, Maso
MAIDEN NAME
OF MOTHER
Enrabeth Gould
BIRTHPLACE
OF MOTHER #
Easthan Dicawo
OCCUPATION
INFORMANT §
PHYSICIAN'S CERTIFICATE
I HEREBY CERTIFY that I attended deceased during last illness, from mar 1 war 28 1920, 1900 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 : Primary : Curvature à S'ème
V
(DURATION).
.DAYS
Contributory :
Senility
.(DURATION) . DAYS
(Signed)
Howrace & Soul
M.D.
mar 28
19 .(Address)
( Waltrop.
SPECIAL INFORMATION only for Hospitals, Institutions, Transients, or Recent Residents.
Former or
Usual Residence
How long at
Place of Death ?
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. | Name of cemetery.
PLACE OF BURIAL OR REMOVAL 11
DATE OF BURIAL
Provincetown Mand Mch 3.
1900
UNDERTAKER I.T.C. Skaggs
ADDRESS
2 Hismon st
ALL NAMES TO BE IN FULL
36 martha myrick nickerson mich 28 - 1910
COMMONWEALTH OF MASSACHUSETTS
RETURN OF A DEATH
(CITY OR TOWN.)
FULL NAME
R. L. Jeddie Douglas
Registered No.
37
Place of )
8- Lincolunit
Death *
..
Residence
8H Lincoln St. Winthrop
Age
60
... years
1 month
days
STATISTICAL DETAILS
SEX
Male
COLOR
White
SINGLE, MARRIED, WIDOWED, OR DIVORCED
MAIDEN NAME Ť HUSBAND'S NAME t
BIRTHPLACE #
Sunce Edward Island-
NAME OF
FATHER
So Douglas
BIRTHPLACE
OF FATHER$
Driver Edward Island
MAIDEN NAME
OF MOTHER
ane Coffin.
BIRTHPLACE
OF MOTHER+
Prince Edward Island)
OCCUPATION Mate Jender -
INFORMANT §
PHYSICIAN'S CERTIFICATE
HEREBY CERTIFY that I attended deceased during last
iliness, from
Jeb 15℃
19ØD .... to
1994,
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 :
bances of the Moneuch
That all, y mutter
. (DURATION). DAYS
Contributory :
(DURATION)
OAYS
(Signed)
6B.T. Campbell)
M.D.
tel.
1900 .... (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
PLACE OF BURIAL OR REMOVAL!
DATE OF BURIAL
UNDERTAKER
It.C. Shawar-
kasal-
ADDRESS
Columbia
Square
* 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. H Name of cemetery.
FILL OUT WITH INK. - THIS IS A PERMANENT RECORD
ALL NAMES TO BE IN FULL
Date of ¿
april 3.
19,00
Death
37 R.J geddie Douglas april 3, 1910
THE COMMONWEALTH OF MASSACHUSETTS
RETURN OF A DEATH
stoughton
(CITY OR TOWN.)
25
FULL NAME
James Freeman Drake Mason
Registered No.
Date of ¿
Apr. 3
10
Death
1
10
16
.months.
.days
STATISTICAL DETAILS
SEX
M
COLOR
W
SINGLE, MARRIED,
WIDOWED, OR
DIVORCED
W
MAIDEN NAME Ť
HUSBAND'S NAME +
BIRTHPLACE + Swansea
NAME OF
FATHER
George Mason
BIRTHPLACE
OF FATHER$
Swansea
MAIDEN NAME
OF MOTHER
Sarah E. Davis
BIRTHPLACE
OF MOTHER $
Rehoboth
OCCUPATION
Pattern maker
INFORMANT §
Mrs. H. D. M. Crane,
Stoughton
Daughter.
PLACE OF BURIAL OR REMOVAL II
Mt. Pleasant Cem.
Taunton
DATE OF BURIAL
Apr. 4, 10
UNDERTAKER
Lowe, mith & Powers
ADDRESS
Stoughton
PHYSICIAN'S CERTIFICATE
viewed
I HEREBY CERTIFY that | Xtended deceased during fast
Yillness FAX on Apr. 4 1.
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 :
Concussion of Brain
(DURATION) DAYS
Contributory :
Abscess of Brain
(DURATION). DAYS
(Signed)
W. O. Faxon, Medical Examiner
5 Norfolk isM.D.
Apr. 4
(Address)
Stoughton.
SPECIAL INFORMATION only for Hospitals, Institutions, Transients, or Recent Residents.
How long at
Place of Death ?
years.
4
months.
days
Where was disease contracted
Had a fall #211 Fountain
if not at place of death ?
S.t.,
Providence,
March 3.
191
Filed
May 6
.1910, Leo. OWentworth
Clerk
* Clty or town, street and number, if any. If death occurs away from USUAL RESI- DENCE, give facts called for under "Speclai 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. || Name of cemetery.
FILL OUT WITH INK. - THIS IS A PERMANENT RECORD
ALL NAMES TO BE IN FULL
Place of l
Stoughton
Death *
5
19
Residence
Winthrop
Age
76
.. years.
COMMONWEALTH OF MASSACHUSETTS
RETURN OF A DEATH
FULL NAME
Margarets Lane Douglas
Registered No.
38
Place of Death *
16 to bice Stuffit hol Ma22!
Date of Death ..
april y
Age
6 8 years
7 months
5 days
STATISTICAL DETAILS
SEX
COLOR
Female 2khite
SINGLE, MARRIED, WIDOWED, OR DIVORCED
MAIDEN NAME Ť HUSBAND'S NAME +
BIRTHPLACE #
Int Stuart
Prince Edward Island
NAME OF
FATHER
David Douglas.
BIRTHPLACE OF FATHER$ Vince edwards Island
MAIDEN NAME
OF MOTHER
Marguerite Dr. Clark.
BIRTHPLACE
OF MOTHER +
Clarkestorie.
Prince Edicalcoli
OCCUPATION throne.
INFORMANT §
PHYSICIAN'S CERTIFICATE
.to | HEREBY CERTIFY that I attended deceased during last illness, from april 64 190 190 .. ... 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 : Diabetes ( mellitus
(DURATION)
2.
DAYS
Contributory :
... (DURATION)
.. DAYS
(Signed)
(3) milch)
M.D.
april 8 190
.(Address)
SPECIAL INFORMATION only for Hospitals, Institutions, Transients, or Recent Residents.
Former or
Usual Residence
How long at
Place of Death ?
.Days
Where was disease contracted, If not at place of death ?.
Filed
190.
Cierk
* 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, glve 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 detalis. Il Name of cemetery.
ALL NAMES TO BE IN FULL
PLACE OF BURIAL. OR REMOVALH
Hinttop Cem
-
DATE OF BURIAL 3-10-
19,00
UNDERTAKER H Co. f Kaque.
ADDRESS
38 Margaret Jane Douglas april 8, 1910
THE COMMONWEALTH OF MASSACHUSETTS
RETURN OF A DEATH Lottie Lillian Merrill
(CITY OR TOWN.)
FULL NAME
Place of l
#19 Revere Slut
Date of l
4/9
19/0
Death 1
.
Residence
/1
"
Age
10
.years.
.months
9
days
STATISTICAL DETAILS
SEX
temala
COLOR
white
SINGLE, MARRIED, WIDOWED, OR DIVORCED
Single
MAIDEN NAME +
HUSBAND'S NAME +
BIRTHPLACE #
NAME OF
FATHER
Walter. 2.
BIRTHPLACE
OF FATHER#
Lewiston me
MAIDEN NAME
OF MOTHER
Mary Timer
BIRTHPLACE
OF MOTHER $
Lewiston me
OCCUPATION
School Sink
INFORMANT §
Machen Matter. I.
PLACE OF BURIAL OR REMOVALII
DATE OF BURIAL
4/12
19 ( 0
UNDERTAKER
ADDRESS Wucher
PHYSICIAN'S CERTIFICATE
I HEREBY CERTIFY that I attended deceased during last illness, from Maril 121 2 1910 to abril 95 1910, 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 : Pericarditis
tribiful
(DURATION).
DAYS
Contributory :
Rheumatien
(DURATION) ..
doubtful
(Signed)
Horace Soule
M.D.
19
(Address).
U
Winthrop Mass
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.
ALL NAMES TO . BE IN FULL
Registered No.
39
Death *
5
39 Lottie Lillian Merrill april 9, 1910
COMMONWEALTH OF MASSACHUSETTS.
RETURN OF A DEATH-1910.
CITY OF BOSTON.
3571
Registered No.
Mass. Gen . Hos pt .
Place of Death ¿
Boston
and Residence S
35
2
10
Date of Death
Apr. 11
1910.
Age
years
months
days.
STATISTICAL DETAILS.
SEX
COLOR
SINGLE, MARRIED, WID., DIV.
F
Maiden Name
Smith
GIST
PATRIBUS
SIT TRE Primary : (Duration)
FICE:
struction, fol : Salpingectomy
Name of
William R Smith
Father
Birthplace
England
of Father
Maiden Name
Clara E Thretcher
of Mother
Birthplace
England
of Mother
(Signed)
.................
C ... R.Lot.calf
.M.D.
.1910
SPECIAL INFORMATION from Hospitals, Institutions, Transients, or Recent Residents. Admitted to hospital for. 21 , 1910
Usual Residence
Winthrop(147 Main st)
Filed
Apr. 14
1910.
A true copy.
Attest :
ErMSlenen
Registrar.
Place of Burial
It Hope
or removal.
Undertaker
Smith & Poal:
PHYSICIAN'S CERTIFICATE.
I HEREBY CERTIFY that I attended deceased during last illness,
.1910,
from 1910, 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:
AR'S
Gen. Peritonitis, Intestinal ob-
Birthplace
England
CITY
BOSTONTA A. 1822
NYTTAT
CONDITAND.
123D.
DONATA A
and appendectomy - 11 dys
ISREGOSEINE
BOSTON
. MASS. Contributory : 2 (Duration)
Occupation
Housewife
Informant
Husband's Name
Paul Draeger
I
FULL NAME
Agnes C Draeger
THE COMMONWEALTH OF MASSACHUSETTS
RETURN OF A DEATH
(CITY OR TOWN.)
FULL NAME
Place of l
Death *
3
329 marchio IL
Residence
Age
80
.years.
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