Town of Winthrop : Record of Deaths 1910-1912, Part 53

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 53


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Statement of cause of death. - Name, first, the DISEASE CAUSING DEATH (the primary affection with respect to time and causation), using always the same accepted term for the same disease. Examples: Cerebro-spinal fever (the only definite synonym is "Epidemic cerebro-spinal meningitis") ; Diphtheria (avoid use of "Croup") ; Typhoid fever (never re- port " Typhoid pneumonia ") ; Lobar pneumonia ; Broncho- pneumonia (" Pneumonia," unqualified, is indefinite) ; Tuber-


culosis of lungs, meninges, peritonaeum, etc., Carcinoma, Sar- coma, etc., of. .... . (name origin: "Cancer" is less definite ; avoid use of " Tumor " for malignant neoplasms) ; Measles ; Whooping cough; Chronic valvular heart disease ; Chronic interstitial nephritis, etc. The contributory (second- ary or intercurrent) affection need not be stated unless im- portant. Example: Measles (disease causing death), 29 ds .; Broncho-pneumonia (secondary), 10 ds. Never report mere symptoms or terminal conditions, such as " Asthenia," " An- aemia " (merely symptomatic), " Atrophy," " Collapse," " Coma," "Convulsions," "Debility " ("Congenital," "Senile," etc.), "Dropsy," "Exhaustion," "Heart failure," "Haemorrhage," "Inanition," "Marasmus," " Old age," "Shock," "Uraemia," " Weakness," etc., when a definite disease can be ascertained as the cause. Always qualify all diseases resulting from childbirth or miscarriage, as " PUER- PERAL septicaemia," " PUERPERAL peritonitis," etc. State cause for which surgical operation was undertaken. 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 y be due to Alcoholism, etc.


4. Deaths under circumstances unknown, as A person found dead, etc ..


ª 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


1 PLACE OF DEATH


It inthat


(No. 316 Theavant


.St .;


Ward)


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


2FULL NAME


Rosalie


975 Carthy


[If married or divorced woman or widow


give maiden name, also name of husband.]


@RESIDENCE


316 Pleasant St.


Registered No.


PERSONAL AND STATISTICAL PARTICULARS


MEDICAL CERTIFICATE OF DEATH


3 SEX


Female.


4 COLOR OR RACE


White.


5 SINGLE,


MARRIED,


WIDOWED,


OR DIVORCED


(Write the word)


Single


1906


T


(Year)


7 AGE


5


yrs.


11


mos.


8


ds.


.... min. ?


8 OCCUPATION


(a) Trade, profession, or


particular kind of work


Home.


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


9 BIRTHPLACE


(State or country)


Winthrop, Mas ..


PARENTS


11 BIRTHPLACE


OF FATHER


(State or country)


Gast Boston, Mass ..


12 MAIDEN NAME


OF MOTHER


Julia A. Fulham


13 BIRTHPLACE


OF MOTHER


(State or country)


Boston, Dass ..


14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE


(Informant)


Joseph 4. Ins Carthy


(Address


316 Pleasant St. Hinthook


Filed.


__. 191


REGISTRAR


(Duration)


yrs.


.mos.


cf ds.


Contributory.


51


(SECONDARY)


J


(Duration)


2 yrs.


mos. ds.


(Signed)


C


1


C


M.D.


1912 (Address).


85


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


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


At place


of death


yrs.


mos.


ds.


State .........


yrs.


In the


mos.


ds .............


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


Former or usual residence.


19 PLACE OF BURIAL OR REMOVAL Holy Cross, Malden,


DATE OF BURIAL


San 9th 1912.


20 UNDERTAKER


9h. J. Kelly


CADDRESS


1.9 maverick Sq.


16 DATE OF DEATH


(Month)


(Day)


191


(Year)


6 DATE OF BIRTH


Summary


(Month)


29Th


17 I HEREBY CERTIFY that I attended deceased from


191.1 ... , to ... 191.


that I last saw h .... alive on 191 __ and that death occurred, on the date stated above, at 10-w/m. The CAUSE OF DEATH* was as follows : -


10 NAME OF


FATHER


Joseph 4. In Carthy.


If LESS than I day ......... hrs.


(Day)


BOSTON (City or town.)


far 1. 6, 1912


STANDARD CERTIFICATE OF DEATH.


Statement of occupation. - Precise statement of occupa- tion is very important, so that the relative healthfulness of various pursuits can be known. The question applies to each and every person, irrespective of age. For many occupations a single word or term on the first line will be sufficient, e. g., Farmer or Planter, Physician, Compositor, Architect, Loco- motive engineer, Civil engineer, Stationary fireman, etc. But in many cases, especially in industrial employments, it is necessary to know (a) the kind of work and also (b) the nature of the business or industry, and therefore an additional line is provided for the latter statement ; it should be used only when needed. As examples: (a) Spinner, (b) Cotton mill; (a) Sales- man, (b) Grocery ; (a) Foreman, (b) Automobile factory. The material worked on may form part of the second statement. Never return "Laborer," " Foreman," " Manager,"" Dealer," etc., without more precise specification, as Day laborer, Farm laborer, Laborer - Coal mine, etc. Women at home, who are engaged in the duties of the household only (not paid House- keepers who receive a definite salary), may be entered as Housewife, Housework, or At home, and children, not gain- fully employed, as At school or At home. Care should be taken to report specifically the occupations of persons engaged in domestic service for wages, as Servant, Cook, Housemaid, etc. If the occupation has been changed or given up on account of the DISEASE CAUSING DEATH, state occupation at beginning of illness. If retired from business, that fact may be indicated thus: Farmer (retired, 6 yrs.). For persons who have no occupation whatever, write None.


Statement of cause of death. - Name, first, the DISEASE CAUSING DEATH (the primary affection with respect to time and causation), using always the same accepted term for the same disease. Examples: Cerebro-spinal fever (the only definite synonym is " Epidemic cerebro-spinal meningitis") ; Diphtheria (avoid use of "Croup ") ; Typhoid fever (never rc- 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 im- portant. Example: Measles (disease causing death), 29 ds .; Broncho-pneumonia (secondary), 10 ds. Never report mere symptoms or terminal conditions, such as " Asthenia," " An- aemia " (merely symptomatic), " Atrophy," "Collapse," "Coma," " Convulsions," "Debility " ("Congenital," "Senile," etc.), " Dropsy,""Exhaustion," "Heart failure," "Haemorrhage," " Inanition," "Marasmus," " Old age," "Shock," " Uraemia," " Weakness," etc., when a definite disease can be ascertained as the cause. Always qualify all diseases resulting from childbirth or miscarriage, as " PUER- PERAL septicaemia," " PUERPERAL peritonitis," etc. State cause for which surgical operation was undertaken.


Cases for the Medical Examiners. - Under the provisions of chapter 24 of the Revised Laws deaths under the following conditions must be referred to the Medical Examiners :


1. Deaths following injury or violence, as Burns, Falls, Drowning, Gas Poisoning, Suicide, Homicide, etc.


2. Deaths supposedly caused by violence, as Criminal Abortion, Poisoning, Starvation, Suffocation, Ex- posure, etc.


3. Sudden deaths of persons not disahled 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. See instructions on back of certificate.


PARENTS


11 BIRTHPLACE


OF FATHER


(State or country)


Deer elle me


12 MAIDEN NAME


OF MOTHER


Can Wentworth


3 BIRTHPLACE OF MOTHER (State or country


Buckshot me


14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE


(Informant)


Walter George


(Address)


REGISTRAR


MEDICAL CERTIFICATE OF DEATH


-


1912


(Day)


(Year)


:7


I HEREBY CERTIFY that I attended deceased from


Jan


1


1912, to


Jan 7, 1912,


If LESS than 1 day, ...... hrs. that I last saw h alive on 6 , 1912. or ...... min. ? and that death occurred, on the date stated above, at ... 8 P.m. The CAUSE OF DEATH* was as follows :


(Duration) 2


.. yrs. ...


.. mos.


ds.


Contributory .... (SECONDARY)


.. (Duration) yrs. ₹ mos. ~ ds.


(Signed)


M.D.


263


Asi-


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


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


At place


of death


. yrs.


mos.


ds.


State.


In the


.. . yrs. .


mos.


ds .. .


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


Former or usual residence.


19 PLACE OF BURIAL OR REMOVAL


DATE OF BURIAL Jan 9# 19 2


DO UNDERTAKER


ADDRESS


Filed 131


The Commonwealth of Massachusetts


STANDARD CERTIFICATE OF DEATH


1 PLACE OF DEATH Wanthet Ma (No. 38 Juin Street .St.


Winchof


(City or town.)


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


Mary Elizabeth Nickerson


2 FULL NAME


[If married or divorced woman ør widow


give maiden name, also nameof husband.]


@RESIDENCE


38 from street


Widow Wallace Nickerson - Colby


Registered No.


PERSONAL AND STATISTICAL PARTICULARS


3 SEX


-


4 COLOR OR RACE


Arte


5 SINGLE,


MARRIED,


WIDOWED,


OR DIVORCED


(Write the word)


Widow


6 DATE OF BIRTH


(Month) (Day)


(Year)


7 AGE


75


1


mos.


ds.


7


.. yrs.


8 OCCUPATION


(a) Trade, profession, or


particular kind of work


at home


(b) General nature of industry,


business, or establishment in


which employed ( or employer).


9 BIRTHPLACE


(State or country)


Bucksport me


10 NAME OF


FATHER


Charles Colby


Sale


Ward)


.


16 DATE OF DEATH


yan


(Month)


8


STANDARD CERTIFICATE OF DEATH.


Statement of occupation. - Precise statement of occupa- tion is very important, so that the relative healthfulness of various pursuits can bo known. The question applies to each and every person, irrespective of age. For many occupations a single word or tern 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 bo 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 (AUSING DEATH (the primary affection with respect to time and causation), using always the same accepted term for the same disease. Exampics: 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 ") ; Lobar pneumonia ; Broncho- pneumonia (" Pneumonia," unqualified, is indefinite) ; Tuber-


culosis of lungs, meninges, peritonaeum, etc., Carcinoma, Sar- eoma, 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," "Senilc," etc.), "Dropsy," " Exhaustion," "Heart failure," "Haemorrhage," " Inanition," "Marasmus," " Old age," "Shock," "Uraemia," " Weakness," etc., when a definite disease can be ascertained as the causc. Always qualify all discases resulting from childbirth or miscarriage, as " PUER- PERAL septicaemia," " PUERPERAL peritonitis," etc. State cause for which surgical operation was undertaken.


Cases for the Medical Examiners. - Under the provisions of chapter 24 of the Revised Laws deaths under the following conditions must be referred to the Medical Examiners :


1. Deaths following injury or violence, as Burns, Falls, Drowning, Gas Poisoning, Suicide, Homicide, etc.


2. Deaths supposedly caused by violence, as Criminal Abortion, Poisoning, Starvation, Suffocation, Ex- posure, etc.


3. Sudden deaths of persons not disabled by recognized disease, as A death upon the street, or onc 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. See instructions on back of certificate.


The Commonwealth of Massachusetts


STANDARD CERTIFICATE OF DEATH


1 PLACE OF DEATH


Ituithof


(No. 150 Washington Com


(City or town.)


Ward)


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


PERSONAL AND STATISTICAL PARTICULARS


3 SEX


COLOR OR RACE


5 SINGLE,


MARRIED,


WIDOWED,


OR DIVORCED


(Write the word)


Undauss


7 AGE


66 yrs.


6 mos.


19 05.


or .....


min. ?


8 OCCUPATION


(a) Trade, profession, or


particular kind of work


at home


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


° BIRTHPLACE (State or country)


10 NAME OF FATHER


Garon Wing


PARENTS


12 MAIDEN NAME OF MOTHER


13 BIRTHPLACE OF MOTHER (State or country) maine.


14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE


(Informant) ...


(Address)


150 Washington Que


16


Filed. 191.


REGISTRAR


MEDICAL CERTIFICATE OF DEATH


16 DATE OF DEATH


Jany


Month )


12


(Day)


192


(Year)


I HEREBY CERTIFY that I attended deceased from


grue


, 191/ ., to


Daug 12, 191.2,


If LESS than


day,


hrs.


that I last saw halive on.


,1912,


and that death occurred, on the date stated above, at/ ... @ m.


The CAUSE OF DEATH* was as follows :


Cerebral apraplay


(Duration)


yrs.


mos.


ds.


Contributory.


arteriosclerosis


Secual (Duration)


yrs.


X mos. ds.


(Signed)


gary 12, 191.2 (Address)


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.


ds.


State


In the


yrs.


mos.


ds ....


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


Former or usual residence


19 PLACE OF BURIAL OR REMOVAL Baugen Vir.


DATE OF BURIAL


1-16


...


1912-


ADDRESS


20 UNDERTAKER H. C. Skaggs


Registered No.


6 DATE OF BIRTH


17


(Month)


(Day)


, 1972 (Year)


11 BIRTHPLACE OF FATHER (State or country)


Collin N. Storia 2 FULL NAME [If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE 150 Washington ave.


Jan. 12,1912


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, 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- 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, 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," "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," 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.


COMMONWEALTH OF MASSACHUSETTS


RETURN OF A DEATH-1912.


CITY OF BOSTON. 462


FULL NAME


Registered No.


B CH RELIEF


Place of Death Boston and Residence


JAN. 15


46


3


28


Date of Death


1912


Age


.. years


months


days.


STATISTICAL DETAILS.


SEX


COLOR


M


W


SINGLE, MARRIED, WID., DIV. MAR.


Maiden Name


Husband's Name


BOSTON


Birthplace


Name of CHARLES F. SCHWARRCONDITA.D.


Father ..


BOSTON


Birthplace


of Father


GERMANY


Maiden Name LENA HORSFELD


of Mother


SWITZERLAND


Birthplace of Mother.


CONFIDENTAL CLERK


Occupation


Informant


MARSHFIELD HILLS


Place of Burial or removal


A. L.EASTMAN & CO.


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 :


NATURAL CAUSES-ANEURISM OF


PAT


AR TA US. ST Primary: { Duration)


OFFICE


AORTA-RUPT. INTO RT.PLEURAL


CAVITY - HEMORRHAGE


IS REGIMINE DONATA A. MASS. 13 30 Contributory : 2 (Duration)


( SUDDEN DEATH)


(Signed)


G.B.MAGRATH.MED.EX.


.M.D.


JAN.16


1912


....


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


WINTHROP


Usual Residence


JAN.18


Filed


1912.


A true copy.


Attest :


ErMSlenen


Registrar.


112


ROSTONIA


A. 1022.


Undertaker


HENRY F. SCHWAAR


Jan. 15, 1912


L


COMMONWEALTH OF MASSACHUSETTS


RETURN OF A DEATH-1912.


CITY OF BOSTON. 548


FULL NAME


LIZZETTA HAYES


Registered No.


Place of Death }


Boston


MASS. GEN. HOSPT.


and Residence S


Date of Death


JAN.18


1912


Age


60


years


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


STATISTICAL DETAILS.


SEX


COLOR


F W


SINGLE, MARRIED, WID., DIV. WID


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


PATRIBUS.


AR Primary: {Duration)


ARTERIO-SCLEROSIS -


1


HYPERTROPHY & DILA.OF HEART


Birthplace


Name of


PHILLIP ROOS


Father


Birthplace


ENGLAND


of Father


Maiden Name of Mother


Birthplace of Mother


(Signed)


N. L. LANGNECKER


M.D.


JAN.18 1912


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


IN HOSPT. 2 DYS


Place of Burial


or removal


WINTHROP (WINTHROP CEM


Undertaker


W.E.SKAGGS


WINTHROP


Usual Residence


WINTHROP


Filed


JAN.20


1912.


A true copy.


Attest :


Eumylenen


Registrar.


OFFICE


CTVTT BOSTONIA ITA CONDITAA


A. 1822.


YEARS


1834


REGIMINE HONNTA A


BOSTON


MASS. Contributory : ( (Duration)


Occupation


AT HOME


Informant ........


PHYSICIAN'S CERTIFICATE.


Maiden Name


ROOS


Husband's Name


FRED HAYES


CITY


Jan. 18, 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 Huthrop (No10


4


1


Ward)


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


Registered No.


PERSONAL AND STATISTICAL PARTICULARS


3 SEX


4 COLOR OR RACE


w.


S SINGLE,


MARRIED,


WIDOWED,


OR DIVORCED


(Write the word)


Undauch


6 DATE OF BIRTH


7 (Month)


14 (Day)


1865 4-17


,


(Year)


7 AGE


46


yrs.


6


mos.


8 ds


or ....... min. ?


8 OCCUPATION


(a) Trade, profession, or


particular kind of work


at home.


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


9 BIRTHPLACE (State or country) new york.


PARENTS


Marie.


12 MAIDEN NAME


OF MOTHER


Bution


13 BIRTHPLACE OF MOTHER (State or country) 91.7.


14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE


(Informant) (Address)


REGISTRAR


MEDICAL CERTIFICATE OF DEATH


16 DATE OF DEATH


(Month)


22, 1912 (Day) (Year)


I HEREBY CERTIFY that I attended deceased from


1912


Jan. 222, 19/2


If LESS than I day, hrs. that I last saw her alive on face. 222, 1912. and that death occurred, on the date stated above, at . m. The CAUSE OF DEATH* was as follows :


Cerebral Termos


.(Duration) 2 yrs .. mos. ds.


Contributory.




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