USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1910-1912 > Part 44
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11 BIRTHPLACE
OF FATHER
(State or country)
new york
12 MAIDEN NAME
OF MOTHER
Alice E. Sibbons
13 BIRTHPLACE
OF MOTHER
(State or country)
Boston inas'
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
T. J. Sullivan
(Address)
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
Cet.
(Month)
(Day)
17, 1911.
(Year)
17
I HEREBY CERTIFY that I attended deceased from Oct. 15, 1911, to. Det. 17 ., 1911, that I last saw her alive on Oct. 17. , 191/ .... and that death occurred, on the date stated above, at 4 5. .. m. The CAUSE OF DEATH* was as follows :
Burchnal Hemorrhage
. (Duration)
.yrs.
mos.
2
ds.
Contributory
Ustorio
(SECONDARY)
(Duration)
yrs. .
mos. .
ds.
(Signed)
TVR. Parker
Och. 18
1911. (Address)
* 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).
In the
At place
of death.
yrs.
mos.
2 ds.
State
.... yrs.
...... . mos.
ds .... ........
Where was disease contracted,
If not at place of death ?
Unknown
Former or
usual residence.
37 Dolphin Dou; Minthach
19 PLACE OF BURIAL OR REMOVAL
DATE OF BURIAL
Old Dorchester
191 1
20 UNDERTAKER
I.f. Sullivan
ADDRESS
628.4th St. South
,
M.D.
Filed 191
N. B. - Every item of information should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state
BOSTON (City or town.)
[If death occurred in a hospital or institution, give its NAME instead of street and number.]
6 DATE OF BIRTH
April 4 1876
(Month)
(Day)
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 employmeuts, it is necessary to know (a) the kiud 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 ou 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 gaiu- 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, Ilousemaid, 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 in- portaut. 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," " Weakuess," etc., when a definite disease can be ascertained as the cause. Always qualify all diseases resulting from childbirthi 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 unkuown, as A person found dead, etc.
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH Winthrop .(No. 22 Wave Way Que
St. : Ward)
Vous Than Kathryn Reinhart 2 FULL NAME
[If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE
Ross.
22 Wave Way que
alfred
Registered No.
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
3 SEX
4 COLOR OR RACE
Female White
6 DATE OF BIRTH
6
3
1854
(Year)
(Month) (Day)
7 AGE
If LESS than 1 day, ........ hrs.
57 yrs. 4 mos. 17 ds.
or ...... min. ?
$ OCCUPATION
(a) Trade, profession, or particular kind of work Housewife
(b) General nature of industry, business, or establishment in which employed (or employer)
(Duration) ...
.yrs.
.mos.
ds.
Contributory
(SECONDARY)
(Duration)
mos.
ds.
(Signed)
Det 21
191/
(Address).
MEDICAL EXAMINER
* State the DISEASE CAUSING DEATH, or, in deaths from VIOLENT CAUSES, state (1) MEANS of INJURY; and (2) whether ACCIDENTAL, SUICIDAL or HOMICIDAL.
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
DATE OF BURIAL
.
10-23, 1911 ..
ADDRESS
Filed
,191
REGISTRAR
17
I HEREBY CERTIFY that I have investigated the death of the deceased.
The CAUSE OF DEATH* was as follows :
Cerebral harmonhage
9 BIRTHPLACE (State or country)
10 NAME OF
FATHER
les. Row
PARENTS
11 BIRTHPLACE OF FATHER (State or country)
12 MAIDEN NAME OF MOTHER Mary Smith
13 BIRTHPLACE OF MOTHER (State or country)
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
(Address)
1%
& UNDERTAKER the Klagar
(City or town.) [If death occurred in a hospital or institution, give its NAME instead of street and number.]
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.
§ SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
Mar
16 DATE OF DEATH Oct 20 (Month) (Day)
1911 (Year)
M.D.
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 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, 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) ; Mcasles ; 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. For VIOLENT DEATHS state MEANS OF INJURY and qualify as ACCIDENTAL, SUICIDAL, Or HOMICIDAL, or as probably such, if impossible to determine definitely. Examples: Accidental drowning; Struck by railway train - accident ; Revolver wound of head - homicide ; Poisoned by carbolic acid - prob- ably suicide. The nature of the injury, as fracture of skull, and consequences (e. g., sepsis tetanus) may be stated under the head of " Contributory."
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. Sce instructions on back of certificate.
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH Ninhtrop (No. 146 Cliff an
Daniel It. Barney
St. ;.... ... Ward)
(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
MEDICAL CERTIFICATE OF DEATH
3 SEX
Mali
4 COLOR ØR RACE
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
Manai
850
6 DATE OF BIRTH
Dia
5-
(Month)
(Day)
(Year)
7 AGE
60,
yrs.
10
mos.
17 ds
or ..... „min.
8 OCCUPATION
(a) Trade, profession, or particular kind of work. Rittied
(b) General nature of industry, business, or establishment in which employed (or employer)
Salesman THang
9 BIRTHPLACE (State or country) Boston Mami
10 NAME OF
FATHER
Samuel P. Barry
11 BIRTHPLACE OF FATHER (State or country)
Boston Man
12 MAIDEN NAME OF MOTHER Mam a bunch
1ª BIRTHPLACE OF MOTHER (State or country)
Mass
11 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
Adelaida alarm
(Address)
Filed 191 ..
REGISTRAR
16 DATE OF DEATH
cew 22"
(Month)
(Day) 1911 (Year)
June
., 191.1
to
oct 22nd, 1911.
If LESS than 1 day, . hrs. that I last saw him alive on Oct 2 2 nd, 1911. and that death occurred, on the date stated above, at /185 3 The CAUSE OF DEATH* was as follows : General arteriosclerosis Cerebral Harmorrhage
(Duration)
1
.yrs.
mos.
ds.
Contributory (SECONDARY)
.(Duration)
yrs,
mos.
ds.
Bij hetcall
(Signed)
oct : 3", 1911
(Address).
winthrop
...
M.D.
* 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 No. Andom .
DATE OF BURIAL
ist 25. 1911
20 UNDERTAKER
MW. Weby Ddon. Lamance Man
2 FULL NAME [If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE
PARENTS
I HEREBY CERTIFY that | attended deceased from
.
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, uot gaiu- 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 giveu up ou 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 syuonym 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) ; T'uber-
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," " Au- aemia " (merely symptomatic), " Atrophy," " Collapse," " Coma," "Couvulsious," "Debility " ("Congenital," "Senile," etc.), "Dropsy," " Exhaustion," "Heart failure," "Haemorrhage," " Inanitiou," " Marasmus," " Old age," "Shock," " Uraemia," "Weakuess," 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," ctc. 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 Walterof Mars (No. 171 Hlene Drive St. ;.... Ward)
(City or town.) [If death occurred in a hospital or institution, give its NAME instead of street and number.]
'FULL NAME almunia Sheriff suckerman {If married or divorced woman or widow give maiden name, also name of husband.] widow of Samuel Cary Tuckerman @RESIDENCE Registered No. 171 Shore Drive winther
PERSONAL AND STATISTICAL PARTICULARS
4 COLOR OR RACE
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
16 DATE OF DEATH
oct
25
(Month)
(Day)
1911
(Year)
6 DATE OF BIRTH
Jan
(Month)
4
(Day)
1840
(Year)
or
min. ?
(b) General nature of industry,
business, or establishment in
which employed (or employer)
none
9 BIRTHPLACE
(State or country)
ry) Cambridge mais
10 NAME OF
FATHER
John Langdon Sheriff
1
11 BIRTHPLACE OF FATHER (State or country) Excla- 22 H.
12 MAIDEN NAME
OF MOTHER
Elena Maria Fellows
muss
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
le R. Benim.
Filed.
- 191 .. ...
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
17
I HEREBY CERTIFY that I attended deceased from
1909
191
to
Octobre 25, 191.
If LESS than
1 day, ..
.. hrs.
that I last saw her alive on
oct. 24
, 191.1. ...
and that death occurred, on the date stated above, at
8 amm.
The CAUSE OF DEATH* was as follows :
General muscular atrophy
(Duration) .
3
.yrs.
mos.
ds.
Contributory
(SECONDARY)
...
mos.
ds.
(Signed)
(Duration)
3.call
.yrs. .
M.D.
191
(Address)
winthrop
* 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.
1 PLACE OF BURIAL OR REMOVAL Forest Hills Gernely
DATE OF BURIAL
Oct 27, 1911
20 UNDERTAKER
ADDRESS
3 SEX
female
7 AGE
8 OCCUPATION
(a)' Trade, profession, or
particular kind of work
PARENTS
13 BIRTHPLACE
OF MOTHER
(State or conntry)
important. See instructions on back of certificate.
(Address)
16
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
70
9
mos.
21
ds.
yrs.
home
1
STANDARD CERTIFICATE OF DEATH.
Statement of occupation. - Precise statement of occupa- tiou is very important, so that the relative healthfulness of various pursuits cau be known. The questiou 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: (c) 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 returu " Laborer," "Foreman," " Manager," "Dealer," etc., without more precise specification, as Day laborer, Farm luborer, 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 Hlousewife, 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 pneumouia ") ; 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- aemia " (merely symptomatic), " Atrophy," "Collapse," "Coma," "Convulsions," "Debility" ("Congenital," "Senile," etc.), "Dropsy," "Exhaustion," "Heart failure," "Haemorrhage," " Inanition," "Marasmus," "Old age," "Shock," " Uraeuria," "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 uuder 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.
RI NOV
PT.
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
PLACE OF DEATH OfThester
(No
4 Center
St. :
Ward)
Dlou center (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
MEDICAL CERTIFICATE OF DEATH
3 SEX
Inale
6 DATE OF BIRTH
aug. 22
(Month)
(Day)
(Year)
7 AGE
54
.. . yrs.
2
mos.
4 ds.
or ........ min. ?
8 OCCUPATION
(a)' Trade, profession, or
particular kind of work.
Salesman
(b) General nature of industry,
business, or establishment in
which employed ( or emptoyer)
' BIRTHPLACE
(State or country}
Liverpool England
10 NAME OF
FATHER
Caleb Bold
11 BIRTHPLACE
OF FATHER
(State or eountry)
England
12 MAIDEN NAME
OF MOTHER
Elizabeth
13 BIRTHPLACE
OF MOTHER
(State or country)
England
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
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