USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1910-1912 > Part 56
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11ch
1912.
(Year)
17
I HEREBY CERTIFY that I attended deceased from
Feb. yet
, 191.2 , to
Jeb. 11th
, 1912
66
yrs.
10
mos.
15 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)
91.18.
10 NAME OF
FATHER
John Brown
PARENTS
11 BIRTHPLACE OF FATHER (State or country) 7.13.
12 MAIDEN NAME OF MOTHER Graham
13 BIRTHPLACE OF MOTHER (State or country) n. B.
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant) .4
A.C. Deluxor
(Address) MG Itintheof 85
(City or town.)
20 UNDERTAKER
IKC Shayan
mos. .
ds.
(Duration)
yrs.
Cedente.
mos. ..
2
.ds.
Tel. 11, 1917
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, Broneho- pneumonia (" Pneumonia," unqualified, is indefinite) ; Tuber-
calosis 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," " 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 septicemia," " 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.
The Commonwealth of Massachusetts STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH 1
(No. 210 Shore Prin
St. ;..... 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
male
4 COLOR OR RACE
volute
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
manik
6 DATE OF BIRTH
22
(Month)
(Day)
(Year)
7 AGE
7.4
yrs.
mos.
22
ds.
8 OCCUPATION
(a) Trade, profession, or
particular kind of work
(b) General nature of industry,
business, or establishment in
which employed (or employer).
2
9 BIRTHPLACE (State or country)
Lancaster - Hace.
10 NAME OF
FATHER
Trong E. V. Williams
PARENTS
11 BIRTHPLACE OF FATHER (Stifte or country)
12 MAIDEN NAME OF MOTHER Frabain Burnham
13 BIRTHPLACE OF MOTHER (State or country)
Kennebunkport me
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
(Address)
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH Jelenmay 14,192 Fel Month) 74 0 2. 191 (ar)
1 HEREBY CERTIFY that I attended deceased from
Jeb 1st
1909.
to
Jake, 14.1912
,
If LESS than
I day,
hrs.
that I last saw humalive on
Dieb, 14 A, 1912
and that death occurred, on the date stated above, at 6 G.
or
min. ?
. m.
The CAUSE OF DEATH* was as follows :
arteriosclerosis
mos. . about Mee years .(Duration) .. yrs. ..
Contributory.
(SECONDARY)
.(Duration)
yrs.
mos.
ds.
(Signed)
Ein. Wsta
M.D.
Fel 15, 1912 (Addres).
* If death followed injury or violence the Certificate out by the Medical Examiner.
18 LENGTH OF RESIDENCE (FOR HOSPITALS, INSTITUTIONS, TRANSIENTS, OR RECENT RESIDENTS).
At place
of death ...
yrs.
mos.
ds.
in the
State.
yrs.
..
mos.
ds ..... ...
Where was disease contracted, If not at place of death ?..
Former or usual residence ....
19 PLACE OF BURIAL OR REMOVAL Carole Canceling
DATE OF BURIAL
2/18
.
1912
20 UNDERTAKER
6.72. (Barnen
ADDRESS
.
Filed .. 191.
Wechat (City or town.)
George
Forrest Williams
2 FULL NAME {If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE 2 10 Shove Dumi
1838
17
STANDARD CERTIFICATE OF DEATH.
Statement of occupation. - Preciso statement of occupa- tion is very important, so that tho relative healthfulness of various pursuits can be known. The question applies to each and overy person, irrespective of age. For many occupations a singlo 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, ctc. But in many cases, especially in industrial employments, it is necessary to know (a) the kind of work and also (b) the naturo 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 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: Cercbro-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- come, etc., of ... . ... (name origin : "Cancer " is less definite ; avoid use of " Tumor" for malignant neoplasms) ; Mcasles ; Whooping cough ; Chronic valvular heart disease; Chronic interstitial nephritis, etc. The contributory (second- ary or intercurrent) affection need not be stated unless int- portant. Examplo: 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 septicaemiu," " 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
I PLACE OF DEATH
wanche- (No .... 14 format IL
St. ;.... .... 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
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
Funga
6 DATE OF BIRTH och
2 0
1900
17
(Month)
(Day)
(Year)
7 AGE
3
yrs.
mos. .
10
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)
10 NAME OF
FATHER
Wacção. 15.
PARENTS
Il BIRTHPLACE OF FATHER (State or country)
Px Solin 21. 03
12 MAIDEN NAME OF MOTHER Agnes. Inc Only
13 BIRTHPLACE OF MOTHER (State or country)
Li Men -11/3.
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
(Address)
16
Filed 191.
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
tch
(Month)
15
(Day)
1912
( Year)
I HEREBY CERTIFY that I attended deceased from
7 ch
13
1912 to
1912. ميلا
If LESS than I day, . .. hrs. that I last saw he alive on 15, 1912, and that death occurred, on the date stated above, at 10 am. The CAUSE OF DEATH* was as follows :
(Duration) .
yrs. . .... .. mos. . ds.
Contributory. (SECONDARY) -
.(Duration) ..
yrs.
mos. .. ds.
(Signed)
76 17. 1912 (Address)
263 Winthours St. ., 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
12 PLACE OF BURIAL OR REMOVAL
DATE OF BURIAL
2/17
.
191.
20 UNDERTAKER
ADDRESS
(City or town.)
Walter. Edward HIS tam 2 FULL NAME [If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE
14 JoursL &K
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.
.
Feb. 15, 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 kuown. The question applies to each and every person, irrespective of age. For many occupations a single word or term on the first liue 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 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 tiule and causation), using always the same accepted term for the same disease. Examples: Cerebro-spinal fever (the only defiuite 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 .; 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," 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 septieaemia," " 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 1 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 Fidelia Holland
13 BIRTHPLACE OF MOTHER (State or country) alstrad ]1.x)
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
Willard M. Bacon-
(Address)
Filed .. 191 ..
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
Felly
22 191.
(Month)
(Day)
(Year)
(Year) May to July 22 192,
If LESS than I day, hrs. that | last saw h -.. alive on Fely
21, 1912 and that death occurred, on the date stated above, at 6 950my The CAUSE OF DEATH* was as follows :
Sanabona of Sim
allaQuations 2 /yes.
mos. .
ds.
Contributory .. (SECONDARY)
(Duration) .. yrs.
mos. .
ds.
(Signed)
Fely 22, 1912.
( Addres)
* 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
DATE OF BURIAL
Fely, 211. 1912
20 UNDERTAKER
ADDRESS
(City or town.) {If death occurred in a hospital or institution, give its NAME instead of street and number.]
Electa Bacon 2 FULL NAME
[If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE 6H Summerset Gata
Sanders James Bacon
Registered No.
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
4 COLOR OR RACE
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
Undowned
6 DATE OF BIRTH
6 (Month)
7
.1836
1.
(Day)
7 AGE
7.5 yrs.
yrs. . .
8 mos.
15 ds.
... 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)
Charleston ?1.1.
10 NAME OF
FATHER
Joseph Succedere
1} BIRTHPLACE OF FATHER (State or country)
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH Winthrop. -
(No. 64. Summersdoor
Ward)
I HEREBY CERTIFY that I attended deceased from
..
M.D.
tel. 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, 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- 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, Laborcr- 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 be entered as Housewife, Housework, or At home, and children, not gain- fully employcd, 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, 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, Homieide, etc.
2. Deaths supposedly caused by violence, as Criminal Abortion, Poisoning, Starvation, Suffocation, Ex- posure, etc.
3. Sudden deathis 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. 20 Belcher
St. ;..
Ward)
[If death occurred in a hospital or institution, give its NAME instead of street and number.]
Registered No.
PERSONAL AND STATISTICAL PARTICULARS
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
married
1858
(Year)
or
min. ?
9 BIRTHPLACE
(State or country)
Prince Edwarder Island
Envy Coffin
Cinco Oduards Sland
Thargarst Handrakan
60
Mince duardex bland
11 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
Amelia A Welcher
(Address)
72 Atlantic SU Winthrop
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
Free .
(Month)
2%
(Dáy)
(Year)
17
I HEREBY CERTIFY that I attended deceased from
Feb. 18
1912
Heh. 24
1912
.... ,
If LESS than
1 day
hrs.
that I last saw herce alive on
Ach. 22d
1912
and that death occurred, on the date stated above, at.
210 m.
The CAUSE OF DEATH* was as follows :
Dabar Precumoria
(Duration)
.... yrs.
mos.
5
ds.
Contributory.
Pulmonary Order
(SECONDARY)
.(Duration)
yrs.
. mos.
.ds.
(Signed)
NR. Porter
M.D.
Fur. 24/1912 (Address)
* If death followed injury or violence the certificate of death must be made out hy 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 Holy Cross DEmentor
DATE OF BURIAL
El 25. 192
CO UNDERTAKER
fach J. & Finlay
ADDRESS
79 Atlantic St.
3 SEX 4 COLOR OR, RACE Okhito 6 DATE OF BIRTH May 7 (Month) (Day) 7 AGE 8 OCCUPATION (a) Trade, profession, or particular kind of work Carpenter (b) General naturo of industry, business, or establishment in which employed (or employer). 10 NAME OF FATHER amee Henry 11 BIRTHPLACE OF FATHER/ (State or country) 12 MAIDEN NAME OF MØTHER PARENTS 1ª BIRTHPLACE OF MOTHER (State or country) important. See instructions on back of certificate. Filed 191 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 53 .yrs. 9 mos. 16 ds.
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