Town of Winthrop : Record of Deaths 1910-1912, Part 55

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 55


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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In the


At place


of death.


yrs.


mos.


ds.


State.


.yrs.


mos.


ds.


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


Former or usual residence ....


19 PLACE OF BURIAL OR REMOVAL


athol Maso


20 UNDERTAKER


Levis Jours Som


DATE OF BURIAL


jan 3,


1912


ADDRESS


50 Lag


ege to


Filed , 191.


3929


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


10 NAME OF


FATHER


William F. Haake.


11 BIRTHPLACE


OF FATHER


(State or country)


Germany


Jan. 29 11/2


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 ou the first line will be sufficient, e. g., Farmer or Planter, Physician, Compositor, Architect, Loco- motive engineer, Civil engineer, Stationary fircman, 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 Housc- 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 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 nced 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 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 ·Winchof Maso (No. III Highland any


St. ;...


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


Harriet Elizabet Nartshow


2 FULL NAME


[If married or divorced woman or widow


give maiden name, also name of husband.]


@RESIDENCE


Winthrop


Engine, H1 Suchand- Reed.


Registered No.


PERSONAL AND STATISTICAL PARTICULARS


3 SEX


4 COLOR OR RACE


5 SINGLE,


MARRIED,


WIDOWED,


OR DIVORCED


(Write the word)


Meczuer (


6 DATE OF BIRTH


Oct


22


1843


17


(Month)


(Day)


(Year)


17 AGE


If LESS than


I day .... .


hrs.


68 yrs ..


3


mos.


/ O.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 eountry)


Salzburg Mars


10 NAME OF


FATHER


Isaac


Read


PARENTS


I' BIRTHPLACE


OF FATHER


(State or country)


12 MAIDEN NAME


OF MOTHER


13 BIRTHPLACE


OF MOTHER


(State or country)


14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE


(Informant)


(Address)


3 LU alimenta 5% 18ce/05


REGISTRAR


MEDICAL CERTIFICATE OF DEATH


16 DATE OF DEATH


January 31


(Month) 0


(Day)


, 1912


(Year)


I HEREBY CERTIFY that I attended deceased from January 25, 1912, to January 31, 1912, that I last saw her alive on January 31 ., 191.2, and that death occurred, on the date stated above, at Turam. The CAUSE OF DEATH* was as follows :


Lobar Pneumonia of Right lung.


(Chromie myo carditis.)


(Duration). yrs. - mos ..


7


ds.


Contributory


(SECONDARY)


acute Dilatation of heart.


(Duration) ....


yrs. . - mos. . 070 ds.


(Signed)


Letitia Douglasadams


M.D.


February 1, 1912 (Address)


199 Cliff ave, Winthrop.


* 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


In the


of death ...


yrs.


mos.


ds.


State


yrs. .


mos.


ds.


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


Former or usual residence


19 PLACE OF BURIAL OR REMOVAL


DATE OF BURIAL


Feb2


191 2


0 UNDERTAKER


ADDRESS


Filed .. 191


(City or town.)


Jan. 31, 1912


STANDARD CERTIFICATE OF DEATH.


Statement of occupation. - Precise statement of occupa- tion is very important, so that the relative healthifulness 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 engincer, 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 Serrant, 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, peritonaeum, etc., Carcinoma, Sur- 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.


2


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


(No.


5 mitte


asus


-


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


6 SINGLE,


MARRIED,


WIDOWED,


OR DIVORCED


(Write the word)


Widerved


6 DATE OF BIRTH


(Month)


(Day)


1


(Year)


7 AGE


87 yes yrs. mos. ds.


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).


2 BIRTHPLACE


(State or country)


Ruland


PARENTS


12 MAIDEN NAME OF MOTHER


13 BIRTHPLACE OF MOTHER (State or country)


14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE


(Informant)


Cara Le Cullinane


(Address)


5 mgitt ave


16


Filed. . 191.


REGISTRAR


MEDICAL CERTIFICATE OF DEATH


16 DATE OF DEATH


Jahrany on


(Month)


3


(Day)


1912


(Year)


17 I HEREBY CERTIFY that I attended deceased from


Sept


1911, to


73h


1912


If LESS than


| day,.


... hrs.


that I last saw hoh alive on


Ich


3


1912.


and that death occurred, on the date stated above, at


4P


.. m. The CAUSE OF DEATH* was as follows :


Samle arterio Sclerose


(Duration) ..


2 yrs.


mos.


ds.


Contributory. (SECONDARY)


(Duration)


mos.


ds.


(Signed)


un ell


M.D.


1912 (Address) 263 Winkler


-


* 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 REMOVETrialde Holy Cres Cen


DATE OF BURIAL


Hello 1912


20 UNDERTAKER


Reaturet mitchell.


ADDRESS 323 Bundenlille Chemin mais


:


Written BOSTON (City or town.)


2 FULL NAME


Ellen Mer Callinane


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


Charles = malrency


or ....... min. ?


10 NAME OF


FATHER


Daniel


11 BIRTHPLACE OF FATHER (State or country) Ireland


STANDARD CERTIFICATE OF DEATH.


Statement of occupation. - Precise statement of occupa- tion is very important, so that the relative hoalthfulnoss 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 engincer, 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 aro engaged in the duties of the household only (not paid Ilouse- kecpers who receive a definite salary), may be entered as Hlousewife, 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 (tho 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, peritonacum, etc , Carcinoma, Sar- coma, etc., of ... . (name origin: "Cancer" is less dofinite ; 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 in- portant. Example: Measles (disease causing death), 29 ds .; Broncho;pneumonia (secondary), 10 ds. Never report mere symptoms or terminal conditions, such as " Asthenia," " An- acmia " (merely symptomatic), " Atrophy," "Collapse," "Coma," "Convulsions," "Debility " ("Congenital," "Senile," etc.), " Dropsy," " Exhaustion," "Heart failure," "Hacmorrhage," " 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.


The Commonwealth of Massachusetts STANDARD CERTIFICATE OF DEATH


1 PLACE OF DEATH Winthrop


(No. 225


St. ;.


Ward)


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


PERSONAL AND STATISTICAL PARTICULARS


3 SEX


4 COLOR OR RACE


6 SINGLE,


MARRIED,


WIDOWED,


OR DIVORCED


(Write the word)


a DATE OF BIRTH ~Mar. (Month)


7 AGE


If LESS than


I day ........


hrs.


7/ yrs . 15 mos.


19 ds.


or


......


min. ?


8 OCCUPATION


(a) Trade, profession, or


particular kind of work


to home.


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


9 BIRTHPLACE


(State or country)


ar) outpost 2


10 NAME OF


Jonathan Pendleton


PARENTS


12 MAIDEN NAME OF MOTHER 8


,2 sinkwater


1ª BIRTHPLACE OF MOTHER (State or country) Pancolmille ME.


14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE


(Informant)


(Address) 225 Whasane 100


16


Filed. ... 191.


REGISTRAR


MEDICAL CERTIFICATE OF DEATH


16 DATE OF DEATH


Felly


(Month)


7


yDay)


1912


(Year)


Felyy


I HEREBY CERTIFY that I attended deceased from


Fely 5


191.L., to


.. , 1912.


that I last saw halive on


Fly 6


., 191 2. and that death occurred, on the date stated above, at./ __ 2m. The CAUSE OF DEATH* was as follows :


Chronic Valvula Heart Disease


(Duration) . 10 .yrs. .. mos. ds. Bronchial aselena


Contributory


(SECONDARY)


.(Duration) . ....... yrs.


-


-


mos.


4


„ds.


M.D.


(Signed)


Fely


8


191 Z .. (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).


In the


At place


of death


yrs.


.. mos.


ds.


State ...


... yrs.


...


mos. .


ds.


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


Former or usual residence.


19 PLACE OF BURIAL OR REMOVAL DATE OF BURIAL Ministerof Brand. Feb. 10, 1912


20 UNDERTAKER


ADDRESS


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.


'FULL NAME


francesca


Pendleton-Chas. L.


[If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE 215 Pleasant Le. Wanietrots


Winetiros


Registered No.


19'


(Đay)


,


(Year)


BIRTHPLACE OF FATHER (State or country) try) Toutefort mc.


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 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," " All- 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.


1


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


' PLACE OF DEATH


(No. 179.


St. ;.....


Ward)


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


2 FULL NAME ... frances of Simpson


[If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE 179 Iquetrots St, Lle


Window of this Simpson


Registered No.


PERSONAL AND STATISTICAL PARTICULARS


3 SEX Fr


COLOR OR RACE


W


5 SINGLE,


MARRIED,


WIDOWED,


OR DIVORCED


(Write the word)


Undouzel


6 DATE OF BIRTH


-2


(Month)


(Day)


(Ýear)


7 AGE


If LESS than


1 day,.


hrs.


that I last saw her alive on.


Feb. 11th


, 1912, and that death occurred, on the date stated above, at .. 7/ m. The CAUSE OF DEATH* was as follows :


Labar Pneumonia


Contributory .... .


Pulmonary


(SECONDARY)


(Duration)


yrs.


(Signed)


William t. Porter


..


M.D.


Hab. 13.


1912 (Address).


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


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


At place


of death


yrs. .


mos.


In the


ds.


State


yrs.


mos.


ds ... .


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


Former or usual residence


19 PLACE OF BURIAL OR REMOVAL Woodlawn an


DATE OF BURIAL


3 - 4 . 1912


ADDRESS


Filed. 191


REGISTRAR


MEDICAL CERTIFICATE OF DEATH


16 DATE OF DEATH


Fred.


(Month)


(Day)




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