Town of Winthrop : Record of Deaths 1910-1912, Part 54

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 54


Note: The text from this book was generated using artificial intelligence so there may be some errors. The full pages can be found on Archive.org (link on the Part 1 page).


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Plamonary


Ordena


(SECONDARY)


(Duration) .


yrs.


mos.


ds.


(Signed)


De Porter


...


M.D.


Winthrop Mars


23, 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. ...


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


Pine Grove com, Keine


DATE OF BURIAL


1-25. 191.2


ADDRESS


50 UNDERTAKER


9h. C. Skaggs


(City or town.)


Jennie a. South


2 FULL NAME [ If married or dixgreed woman or widow give maiden navng, also name of husband.] @RESIDENCE


Filed ... ., 191


10 NAME OF FATHER Warren G. Hatch.


11 BIRTHPLACE OF FATHER (State or country)


Jan. 22


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, Architcet, 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- mun, (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 Hlousewife, Ilousework, 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, Hlousemaid, 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," etc. State cause for which surgical operation was undertaken.


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


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


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


3. Sudden deaths of persons not disabled by recognized disease, as A death upon the street, or one supposed to be due to Alcoholism, etc.


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


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 PARENTS


:


The Commonwealth of Massachusetts


STANDARD CERTIFICATE OF DEATH


1 PLACE OF DEATH


Metcalf Hospital (No Wanthet Sheet


Ward)


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


2 FULL NAME


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


wife of Robert Ferguson- Hall Registered No.


PERSONAL AND STATISTICAL PARTICULARS


3 SEX


female


4 COLOR OR RACE


5 SINGLE,


MARRIED,


WIDOWED,


OR DIVORCED


(Write the word)


marie's


6 DATE OF BIRTH


1883


(Month)


(Day) (Year)


7 AGE


29 yrs.


mos. X. 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)


Stewartin Scotland


10 NAME OF


FATHER


Thomas Hall


11 BIRTHPLACE OF FATHER (State or country) Stewarton S'collant


12 MAIDEN NAME


OF MOTHER


Grizel Curie


13 BIRTHPLACE OF MOTHER (State or country) England


14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE


(Informant)


Rolnik. ferguson


(Address)


76 Finesont 8%


REGISTRAR


MEDICAL CERTIFICATE OF DEATH


16 DATE OF DEATH


Jana


2%, 1912


(Month)


(Day)


(Year)


17


I HEREBY CERTIFY that | attended deceased from


Jan 20°


1912, to


Jan 22, 1912.


If LESS than


I day,.


hrs.


that last saw her. alive on


Jan 22, 191.2


and that death occurred, on the date stated above, at 8 am.


The CAUSE OF DEATH* was as follows :


Puesparal Eclampsia


(Duration)


yrs. ..


mos.


2


ds.


Contributory ..


(Duration) 31 Met call-


yrs.


mos. ..


.. ds.


Jan 24. 1912 (Address)


A


Whythrop hours


..


* 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.


2


ds.


in the


State.


yrs. / Q


ds.


Where was disease contracted,


If not at place of death ?


76 Fremont ST Womshop


usual residence


Former or


76 Fremont St Winthrop mass


19 PLACE OF BURIAL OR REMOVAL Scotland


DATE OF BURIAL


.


1912


20 UNDERTAKER


ADDRESS


Filed 191


(SECONDARY) Delivery


(Signed)


M.D.


Enphernia. ferguson


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, Architeet, 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 ('AUSING 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 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 disabled by recognized disease, as A death upon the street, or one supposed to be due to Alcoholism, etc.


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


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


important. See instructions on back of certificate.


A


12 MAIDEN NAME OF MOTHER


13 BIRTHPLACE OF MOTHER (State or country)


14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE


(Informant)


-ather


1


(Address)


Filed


.- , 191


REGISTRAR


17


I HEREBY CERTIFY that I attended deceased from


1


(Year)


Jaw


191.2 ... , to


faw 22.


1912


that I last saw hun alive on


7


1912


and that death occurred, on the dato stated above, at ] A.m.


The CAUSE OF DEATH* was as follows :


Aculi Clicatation of heart


Pneumonia


articulation


(Duration) .


~ yrs.


-_ ms ...


7


ds.


Contributory


(SECONDARY)


William VI Framper


(Duration)yrs ...


mos.


2


ds.


(Signed)


Jour 23, 192


66 Pong SLIB


If death followed injury or violence the certificato of death must bo 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


DATE OF BURIAL


X216 24/1912


20 UNDERTAKER


ADDRESS


.


3 SEX


4 COLOR OR RACE


5 SINGLE,


MARRIED,


WIDOWED,


OR DIVORCED


(Write the word)


Single


6 DATE OF BIRTH


(Month)


(Day)


7 AGE


If LESS than


1 day ......... hrs.


V yrs.


mos.


16


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).


) BIRTHPLACE


(State or country)


10 NAME OF


FATHER


PARENTS


The Commonwealth of Massachusetts


1 STANDARD CERTIFICATE OF DEATH


1 PLACE OF DEATH


...


Viscotu


St. :


Ward)


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


Du Machen


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


Registered No.


PERSONAL AND STATISTICAL PARTICULARS


MEDICAL CERTIFICATE OF DEATH


16 DATE OF DEATH


Low


(Month)


22


1912.


(Day)


(Year)


u a


M.D.


11 BIRTHPLACE OF FATHER (State or country)


1


3


BOSTON (City or town.)


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, 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) 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 needod. As examples: (a) Spinner, (b) Cotton mill; (a) Sales- man, (b) Grocery ; (a) Foreman, (b) Automobile factory. The material worked on may form part of the second statement. Never return " Laborer," " Foreman," " Manager," " Dealer," etc., without more precise specification, as Day laborer, Farm laborer, Laborer - Coal mine, etc. Women at home, who are engaged in the duties of the household only (not paid Ilouse- keepers who receive a definite salary), may be entered as 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, 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 uso 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 neod not bo 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. Deatlıs 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 strcet, 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


12 MAIDEN NAME


OF MOTHER


Georgice Fibras


18 BIRTHPLACE


OF MOTHER


(State or country)


14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE


(Informant)


Altanasio Papkiax


(Address)


40 Trident ave


5


Filed


191


REGISTRAR


MEDICAL CERTIFICATE OF DEATH


3 SEX


4 COLOR OR RACE


w


5 SINGLE,


MARRIED,


WIDOWED,


OR DIVORCED


( Write the word)


Single


16 DATE OF DEATH


Jau


·


22


1912


(Month)


(Day)


(Year)


6 DATE OF BIRTH


·


22


(Month)


(Day)


1712


(Year)


7 AGE


If LESS than


[ day, ..


1


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)


9 BIRTHPLACE


(State or country)


Withroth


grass.


Contributory


Historia


(SECONDARY)


.(Duration)


.. yrs.


mos.


.ds.


(Signed)


Dello S. Jackson


M.D.


Jan . 22, 19/2 (Address)


366 CommonwealthCu


* If death followed injury or violence the certificate Bieten Thanade


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 St. This poston


DATE OF BURIAL


June 25


1912


.....


20 UNDERTAKER


( 2


2


Winthrop


BOSTON (City or town.)


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


Plakias


2FULL NAME


[If married or divorced woman or widow


give maiden name, also name of husband.]


@RESIDENCE


40 Trident are winthrop


Registered No.


PERSONAL AND STATISTICAL PARTICULARS


The Commonwealth of Massachusetts


1 PLACE OF DEATH


STANDARD CERTIFICATE OF DEATH w withof (No. 40 Trident ave ST.


ADDRESS


120


LA.


& Boston


17


I HEREBY CERTIFY that I attended deceased from


Jan . 22


1912 .. , to


Sau. 22


, 1912


What I last saw how alive on ...


Jan. 22


1912


and that death occurred, on the date stated above, at//. - 4.m.


The CAUSE OF DEATH* was as follows :


Prolapsed Nurbilical Cord


(Duration)


yrs.


mos.


ds.


10 NAME OF


FATHER


Athanasior Plakas


11 BIRTHPLACE


OF FATHER


(State or country)


Greece


Jan . 22, 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, Architeet, 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 cercbro-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- comna, otc., of .. .. (namo origin : "Cancer" is less definite ; avoid use of " Tumor" for malignant neoplasms) ; Measles; Whooping cough; Chronie 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 .; Broneho-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," otc.), " Dropsy," "Exhaustion," "Heart failure," "Haemorrhage," " Inanition," " Marasmus," " Old age," "Shock," " Uraemia," "Weakness," etc., when a definite disease can be ascertained as the causo. Always qualify all diseases resulting from childbirth or miscarriage, as " PUER- PERAL septieaenia," " 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 violonce, as Burns, Falls, Drowning, Gas Poisoning, Suicide, Homicide, etc.


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


3. Sudden deaths of persons not disabled by recognized disease, as A death upon the street, or one supposed to be due to Alcoholism, etc.


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


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


The Commonwealth of Massachusetts


STANDARD CERTIFICATE OF DEATH


1 PLACE OF DEATH Winthrop


(Nohero Wruttrop Hotel St. Ward)


William J. Haake 2 FULL NAME. [If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE


Hyde Park - 17 Safford Si,


Registered No.


PERSONAL AND STATISTICAL PARTICULARS


3 SEX


Thale


4 COLOR OR RACE


White.


5 SINGLE,


MARRIED,


WIDOWED,


OR DIVORCED


(Write the word)


Suizle


6 DATE OF BIRTH


6


Sept 6.1867


(Month)


(Day)


(Year)


7 AGE


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


44 .. yrs. 4 mos.


24 ds.


or ..


min. ?


8 OCCUPATION


(a) Trade, profession,


particular kind of work


Traveling Salesman,


(b) General nature of industry,


business, or establishment in


which employed (or employer)


(Borto thevos)


9 BIRTHPLACE


(State or country)


Williamsburg. Mas


PARENTS


12 MAIDEN NAME


OF MOTHER


Devia Schroder.


13 BIRTHPLACE


OF MOTHER


(State or country)


Germany


14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE


Henry C. Wache


(Informant)


(Address) 11 Orchard So necofin Mars


REGISTRAR


MEDICAL CERTIFICATE OF DEATH


(Day)


16 DATE OF DEATH


Jan.


28


(ionth)


-


1912


(Year)


17


I HEREBY CERTIFY that I have investigated the


death of the deceased.


The CAUSE OF DEATH* was as follows :


Poisoning by paraldehyde,


Circunità


ndes in deter


minate. not homicidal


ds.


Contributory (SECONDARY)


(Duration) ...


... yrs.


.. mos.


ds.


(Signed)


M.D.


Jan.29


1912 (Address)


MEDICAL EXAMINER


* State the DISEASE CAUSING DEATH, or, in deaths from VIOLENT CAUSES, state (1) MEANS of INJURY; and (2) Whether ACCIDENTAL, SUICIDAL or HOMICIDAL.


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




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