USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1910-1912 > Part 54
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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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