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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