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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