Town of Winthrop : Record of Deaths 1910-1912, Part 52

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 52


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or removal ..


DORCHESTER


J. C. GILLIS


Undertaker


MEDFORD


Usual Residence.


WINTHROP


JAN. I


Filed ..


1911


A true copy .


Attest :


Registrar.


=


1830.


DONATA A


B SREOMMIN


CIVITATIS


BOSTONIA CONDITAA.


TA A. 1822


MULTIPLE INJURIES. CRUSH CHEST.


MARY LEE


Registered No ..


Dec. 27, 1912


0


important. See instructions on back of certificate. 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


Winthrop (No. 24, underbile .St. ;.. ...... Ward)


2 FULL NAME 2. Jones


[If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE 24 Underhill St., Winthrop.


Registered No.


PERSONAL AND STATISTICAL PARTICULARS


MEDICAL CERTIFICATE OF DEATH


16 DATE OF DEATH


Dees 28, 19/1 (Year)


(Month)


(Day)


17 I HEREBY CERTIFY that I have investigated the death of the deceased.


The CAUSE OF DEATH* was as follows :


natural Causes.


probably dialetto -


(Suddivischeats.)


mos. .


ds.


Contributory


(SECONDARY)


(Duration)


yrs. .


.mos. ds.


(Signed)


Senza Burgers Mangiato,


M.D.


Sheer 29


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 OF 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 Salary Lean Holum


DATE OF BURIAL Dec 3, 191/


20 UNDERTAKER"


ADDRESS


9 Pial st Camb,


3 SEX


m


4 COLOR OR RACE


5 SINGLE,


MARRIED,


WIDOWED,


OR DIVORCED


(Write the word)


6 DATE OF BIRTH 1854 (Month)


(Day)


(Year)


7 AGE


If LESS than 1 day, ........ hrs.


.. yrs. mos.


ds. or ....... min. ?


8 OCCUPATION


(a) Trade, profession, or


particular kind of work


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


Department Store


? BIRTHPLACE


(State or country)


Seland


IO NAME OF


FATHER


James Jones


PARENTS


12 MAIDEN NAME OF MØTHER


lathering learn


13 BIRTHPLACE OF MOTHER (State or country) Salland


" THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE


(Informant)


Lathering : 1162


(Address)


8, Janaist. hamb.


Filed .. , 191


REGISTRAR


3829 Winthrop. (City or town.)


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


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


11 BIRTHPLACE OF FATHER (State or country) Jeland


lelerk


Dec. 2 1911


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 minc, 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 Ilousewife, 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, 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, peritonaeum, etc., Carcinoma, Sar- coma, etc., of .. (name origin: "Cancer" is less definite ; avoid use of " Tumor" for malignant neoplasms) ; Measles; Whooping cough; Chronic valvular heart discase ; Chronic interstitial nephritis, etc. The contributory (second- ary or intercurrent) affection need not be stated unless im- portant. Example: Measles (disease causing death), 29 ds .; Broncho-pneumonia (secondary), 10 ds. Never report mere symptoms or terminal conditions, such as " Astheuia," " 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 bo 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.


3 SEX 4 COLOR OR RACE Aluta Female 6 DATE OF BIRTH (Month) 7 AGE 8 OCCUPATION (b) General nature of industry, business, or establishment in which employed (or employer). 9 BIRTHPLACE (State or country) Ireland 10 NAME OF FATHER 12 MAIDEN NAME OF MOTHER PARENTS important. See instructions on back of certificate. Filed 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 62 yrs. mos.


The Commonwealth of Massachusetts


STANDARD CERTIFICATE OF DEATH


1 PLACE OF DEATH Winthrop No. 29 Bay ViewCho St. ;.. . . mary Ellen Steward Moran. 2 FULL NAME [If married or divorced woman or widow give maiden name, also name of husband.] may E. Cocovan Widow of Colon moran. @RESIDENCE 29 Bour Vair cure


Ward)


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


Registered No.


PERSONAL AND STATISTICAL PARTICULARS


5 SINGLE,


MARRIED,


WIDOWED,


OR DIVORCED


(Write the word)


-


(Day)


(Year)


(a) Trade, profession, or


particular kind of work


Av Stame


John Cacaran


11 BIRTHPLACE OF FATHER (State or country) Ireland


lenoun


1ª BIRTHPLACE OF MOTHER (State or country) Seland


11 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE


(Informant)


HElana a Steward


(Address)


29 Bay View ave


REGISTRAR


MEDICAL CERTIFICATE OF DEATH


16 DATE OF DEATH


DEC .


31


(Month)


(Day)


(Year)


I HEREBY CERTIFY that I attended deceased from


to.


May


1914


DEC. 31 91.


if LESS than 1 day, hrs. that I last saw her alive on or min. ? DEC. 30 ., 191.1, and that death occurred, on the date stated above, at ... ...... m. The CAUSE OF DEATH* was as follows :


Carcinoma al Stomach


.(Duration) . . . .... yrs. ..


6


mos.


ds.


Contributory


Greenmoro


(SECONDARY)


.(Duration) .


yrs. ...


. mos.


3


ds


(Signed)


Edward). granger


M.D.


Jau1/12 1912 (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).


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.


1º PLACE OF BURIAL OR REMOVAL Stoly Cross LEnetEry


DATE OF BURIAL


Jan 2, 192


CO UNDERTAKER


John FICO: male !!


ADDRESS


19 atlantic 1


19/11


1849


17


ds.


191


.


Dec. 31.


1


STANDARD CERTIFICATE OF DEATH.


Statement of occupation. - Preciso 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, irrespectivo 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, ctc. 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 preciso specification, as Day laborer, Farm taborer, Laborer - Coal mine, etc. Women at home, who are engaged in tho duties of the household only (not paid Ilouse- keepers who receive a definite salary), may be entered as Ilousewife, 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 porsons 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, 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 er intercurrent) affection nced not bo stated unless im- portant. Example: Measles (disease causing death), 29 ds .; Broncho-pneumonia (sccondary), 10 ds. Never report mere symptoms or terminal conditions, such as " Asthenia," " An- aemia " (merely symptomatic), " Atrophy," "Collapse," "Coma," " Convulsions," "Debility " ("Congenital," "Scnile," etc.), "Dropsy," " Exhaustion," " Heart failure," "Haemorrhago," " Inanition," "Marasmus," " Old age," "Shock," " Uraemia," " Weakness," etc., when a definite diseaso can be ascertained as the cause. Always qualify all discases resulting from childbirth or miscarriage, as " PUER- PERAL septicacmia," " PUERPERAL peritonitis," etc. State cause for which surgical operation was undertaken.


Cases for the Medical Examiners. - Under the provisions of chapter 24 of tho 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 net 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.


COMMONWEALTH OF MASSACHUSETTS


RETURN OF A DEATH-1912.


CITY OF BOSTON.


FULL NAME


EDWARD JACKSON


Registered No.


74


CHILDRENS HOSPT.


Place of Death ¿


Boston


and Residence S


Date of Death


JAN.4


1912.


Age


years months ... .. ........... .. days.


STATISTICAL DETAILS.


SEX


COLOR


SINGLE, MARRIED, WID., DIV.


M


W


S


from


1912, to ...


.. 1912, 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 :


STRAR


IBU


PAZ


Primary: 1


BRONCHO-PNEUMONIA - 5 MOS


Husband's Name


BOSTON


CITY


BOSTONIA


Name of


HENRY M. JACKSON


CONDITA


Father.


CIMINE


MASS.


Contributory : ( (Duration)


Maiden Name


of Mother


BOSTON


Birthplace


of Mother


NONE


Occupation


Informant.


Place of Burial


MALDEN (HOLY CROSS )


or removal


E.G. TOBIN


JAN.8


Undertaker.


Filed


1912.


A true copy.


Attest :


ErMSlenen


Registrar.


Fin(Duration) ) SOBIS


OFFICE


YONATA A


BOSTON


BOSTON


16 31


Birthplace


of Father


HELENA G MACGINNISS


(Signed)


W.S.PARKER


.M.D.


1912 ...........


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


Usual Residence


WINTHROP (35 SEAFOAM AVE)


5


PHYSICIAN'S CERTIFICATE.


I HEREBY CERTIFY that I attended deceased during last illness,


Maiden Name


Birthplace


Jan. 4, 1912


.


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


important. See instructions on back of certificate.


The Commonwealth of Massachusetts


1 PLACE OF DEATH


STANDARD CERTIFICATE OF DEATH 16 Millions


mischung


(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


male


4 COLOR OR RACE


White


5 SINGLE,


MARRIED,


WIDOWED,


OR DIVORCED


(Write the word)


married


6 DATE OF BIRTH


(Month)


(Day)


1861


(Year)


7 AGE


50


.yrs.


mos.


5


ds.


or ....... min. ?


8 OCCUPATION


(a) Trade, profession, or


particular kind of work


Salesnous


(b) General nature of industry,


business, or establishment in


which employed (or employer)


Thousprow + Fearit


norton, men


9 BIRTHPLACE


(State or country)


Boston, mais


PARENTS


12 MAIDEN NAME


OF MOTHER


Elizabeth &. Taylor


13 BIRTHPLACE OF MOTHER (State or country) West Yarmouth man


11 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE


(Informan


Whitman 6 & smith


(Address)


16 Hillour que.


REGISTRAR


17


I HEREBY CERTIFY that I attended deceased from


Jan. 10h


, 1910


to


1912


qu. vit


that I last saw hace alive on


1912


and that death occurred, on the date stated above, at


6 a. m.


The CAUSE OF DEATH* was as follows :


Carcinoma of throck


.. (Duration)


2


.yrs.


mos.


6


ds.


Contributory


(SECONDARY)


(Duration)


yrs. ..


. mos. ds.


(Signed)


M.D.


Jan, 85. 1912 (Address)


Montiert, mans


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


18 LENGTH OF RESIDENCE (FOR HOSPITALS, INSTITUTIONS, TRANSIENTS, OR RECENT RESIDENTS).


At place


of death


yrs.


mos.


In the


ds.


State


yrs.


mos.


ds ..


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


Former or usual residence.


19 PLACE OF BURIAL OR REMOVAL


DATE OF BURIAL


0


191 2


10 UNDERTAKER


CR Berman


ADDRESS


Filed 191


16 DATE OF DEATH


I am


6 th


(Month)


(Day)


1912


(Year)


If LESS than


I day, . hrs.


15 m


10 NAME OF


FATHER


Whitman B. Smith


11 BIRTHPLACE OF FATHER (State or country) no Bellingham Maks


2 FULL NAME {If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE 16 willow are


STANDARD CERTIFICATE OF DEATH. ʻ


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 agc. For many occupations a singlo word or term on the first line will be sufficient, o. 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) tho kind of work and also (b) the nature of the business or industry, and thereforo an additional line is provided for tho latter statement ; it should be used only when needed. As examples: (a) Spinner, (b) Cotton mill; (a) Sales- man, (b) Grocery ; (a) Forcman, (b) Automobile factory. The material worked on may form part of tho sccond statement. Never return " Laborer," " Foreman," " Manager," "Dealer," etc., without moro precise specification, as Day laborer, Farm taborer, Laborer- Coal mine, etc. Women at home, who are engaged in the duties of the household only (not paid House- 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, writo 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: C'erebro-spinal fever (the only definite synonym is "Epidemic cerebro-spinal meningitis") ; Diphtheria (avoid use of "Croup ") ; Typhoid fever (never re- port " Typhoid pneumonia ") ; Lobur pneumonia; Broncho- pneumonia (" Pneumonia," nnqualified, is indefinite) ; Tuber-


culosis of lungs, meninges, peritonaeum, etc., C'arcinoma, Sur- coma, etc., of .. .. (name origin: "Cancor" is less definite; avoid use of " Tumor" for malignant neoplasms) ; Measles; Whooping cough ; Chronic valvular heart disease ; Chronic interstitial nephritis, etc. The contribntory (second- ary or intercurrent) affection need not be stated unless im- portant. Example : Measles (disease cansing 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," "Hacmorrhage," "Inanition," " Marasmns," " Old age," "Shock," " Uraenia," " Weakness," etc., when a definite disease can be ascertaincd as the cause. Always qualify all diseases resulting from childbirth or miscarriage, as " PUER- PERAL septicemia," " PUERPERAL peritonitis," ctc. State canse 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.


COMMONWEALTH OF MASSACHUSETTS


RETURN OF A DEATH-1912.


CITY OF BOSTON. 133


FULL NAME


JULIA GLENISTER


..........


Registered No.


CARNEY HOSPT.


Place of Death ¿ Boston


and Residence S


Date of Death


JAN.6


2


1912.


Age


years


10


months. ............. .days.


STATISTICAL DETAILS.


SEX


COLOR


FEM. W


SINGLE, MARRIED, WID., DIV. SIN.


Maiden Name


Husband's Name


WINTHROP


Birthplace


Name of


JOHN GLENISTER


Father


Birthplace of Father


BOSTON


Maiden Name ALICE J MITCHELL


of Mother


CINCINNATI . OHIO


Birthplace of Mother.


Occupation


Informant.


Place of Burial


WINTHROP (WINTHROP CEMD


or removal.


C.R. BENNISON


Undertaker


WINTHROP


PHYSICIAN'S CERTIFICATE.


I HEREBY CERTIFY that I attended deceased during last illness,


from 1912, to 1912, 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 :


STA


AR


DOUBLE LOBAR PNEUMONIA -


IT Primary : (Duration) SUBIS.


OFFICE


1 MO. 7 DA7S


BOSTONIA TAT CONDITA A


. 1822.


EVİMINE.


MASS: Contributory : 2 (Duration)


J. J.MC CARTY M. D.


(Signed)


JAN.6


1912


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


Usual Residence


WINTHROP


JAN. 9


1912.


Filed.


A true copy.


Attest :


ErMSlenen


Registrar.


PATRIBU


CITY


BOSTON


1631


DONATA D.


IL HROT!


Jan . 6 . 1912


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


important. See instructions on back of certificate.


The Commonwealth of Massachusetts


STANDARD CERTIFICATE OF DEATH


I PLACE OF DEATH winthrop


(No. 175 Count Road St. : .Ward)


Barnes


[If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE 178 Court Road Warchef man


Registered No.


PERSONAL AND STATISTICAL PARTICULARS


3 SEX


Mule


4 COLOR OR RACE


White


5 SINGLE,


MARRIED,


WIDOWED,


OR DIVORCE6 Marcail


(Write the word)


6 DATE OF BIRTH


may


24


Month)


(Day)


1863


(Year)


7 AGE


If LESS than


1 day,


hrs.


Or ........ min. ?


8 OCCUPATION


(a) Trade, profession, or


particular kind of work,


Machenmit & Ingenere


(b) General nature of industry,


business, or establishment in


which employed (or employer).


Hatunas Agence


9 BIRTHPLACE


(State or country)


Barnsville n.B.


10 NAME OF


FATHER


Geo. Barnes


PARENTS.


11 BIRTHPLACE


OF FATHER


(State or country)


Burnsville h. B


12 MAIDEN NAME


OF MOTHER


Eliz abelle Jame


Tave the Donald


13 BIRTHPLACE


OF MOTHER


(State or country)


Belli Asle


31.15


14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE


(Informant)


Chud Bemun.


(Address)


Filed 191.


REGISTRAR


MEDICAL CERTIFICATE OF DEATH


(Month)


(Day))


6. 1912


(Year)


17 I HEREBY CERTIFY that I have investigated the death of the deceased.


The CAUSE OF DEATH* was as follows :


natural Causes! acute dilatation


the heart probably Segment me coucherme mos. ds.


(SECOND (anddewien) direct)


mos.


...


.ds.


(Signed) Serge Burgers Magnet, ... M.D.


6.992


MEDICAL EXAMINER


* State the DISEASE CAUSING DEATHI, 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.


mos. .


ds ...


Where was disease contracted,


If not at place of death ?.


Former or usual residence


19 PLACE OF BURIAL OR REMOVAL It John n. 13 ,


DATE OF BURIAL


Jan 9, 1918


20 UNDERTAKER


ADDRESS


3848


(City or town.


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


Victor W


2 FULL NAME


48 yrs. 7


mos.


9


ds.


16 DATE OF DEATH


In the


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, irrospective 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- kcepers 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.




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