USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1910-1912 > Part 57
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Francis Coffin
2 FULL NAME
[If married or divorced woman or widow
give maiden name, also name of husband.]
@RESIDENCE
20 Belcher It Winthrop
Winthrop (City or town.)
Tel. 24, 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 ou 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 tho 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 bo ontered as Ilousewife, Housework, or At home, and childreu, not gain- fully employed, as At school or At home. Care should be taken to report specifically tho 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 indicatod thus: Farmer (retired, 6 yrs.). For persons who have no occupation whatever, write None.
Statement of cause of death. - Name, first, the DISEASE CAUSING DEATH (the primary affection with respect to time and causation), using always the same accepted term for the same disease. Examples: Cerebro-spinal fever (the only definite synonym is "Epidemic cerebro-spinal meningitis") ; Diphtheria (avoid use of "Croup ") ; Typhoid fever (never rc- port " Typhoid pneumonia ") ; Lobar pneumonia ; Broncho- pneumonia (" Pneumonia," unqualified, is indefinite) ; Tuber-
culosis of lungs, meninges, 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 causc. 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.
PARENTS
12 MAIDEN NAME
OF MOTHER
Jane Grow.
1ª BIRTHPLACE OF MOTHER (State or country)
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
tico Elduin 2, 8 millones
(Address)
49 cottage 415.
16
Filed .. 191
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
(Month)
26. 1912
(Day)
(Year)
I HEREBY CERTIFY that I attended deceased from
Ich. 24
1912 , to
Fich. 26
. 1912:
that I last saw her alive on
, 1912 .
and that death occurred, on the date stated above, at
The CAUSE OF DEATH* was as follows :
Route nephritis (Operations
(Duration)
yrs.
mos. .
ds.
Contributory.
Epitelioma of Cervix
(SECONDARY)
.(Duration)
yrs.
mos. . .. ds.
(Signed)
Brilliant Porte.
, M.D.
Manchuof, Maso
H+ h. T.C. 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.
4
In the
ds.
State Serene
yrs.
mos.
ds ...
Where was disease contracted,
If not at place of death ?
49 Courage ave
Former or
usual residence
49 Collage ave.
19 PLACE OF BURIAL OR REMOVAL
DATE OF BURIAL
Ich. 1. 1912
:0 UNDERTAKER
INC. Skaggs
lealt 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
OFF
4 COLOR OR RACE
20
5 SINGLE,
MARRIED,PAC
WIDOWED
OR DIVORCED
(Write the word)
Married
6 DATE OF BIRTH
3 (Month)
21
1/85
17
(Day)
(Year)
7 AGE
If LESS than I day, hrs.
55 . yrs. . . 11 mos. 3 ds.
or
min. ?
8 OCCUPATION
(a) Trade, profession, or
particular kind of work
al France
(b) General nature of industry. business, or establishment in which employed (or employer).
9 BIRTHPLACE
(State or country)
n.8-
10 NAME OF
FATHER
leo book
11 BIRTHPLACE OF FATHER (State or country)
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH
(No.
Minnie a Smallinaw
2 FULL NAME [If married or divorced woman or widow. give maiden name, also name of husband.] @RESIDENCE He Collater2.
a Cook-(b) Edwin & Smallruan.
Registered No.
ADDRESS
Mintfructe-
STANDARD CERTIFICATE OF DEATH.
Statement of occupation. - Precise statement of occupa- tion is very important, so that the relative healthfulness of various pursuits cau 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 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 ouly 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 ('AUSING 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-
Dmalleman
culosis of lungs, meninges, peritoneum, etc., Carcinoma, Sar- come, 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 iutercurrent) affection necd not be stated unless im- portant. Example : Measles (disease causing death), 29 ds .; Broncho-pneumonia (secondary), 10 ds. Never report mere symptoms or terminal conditions, such as " Asthenia," " An- aemia " (merely symptomatic), "Atrophy," "Collapse," "Coma," "Convulsions," "Debility " ("Congenital," "Senile," etc.), " Dropsy," " Exhaustion," "Heart failure," "Haemorrhage," " Inanition," " Marasmus," " Old age," "Shock," " Uraemia," " Weakness," etc., when a definite disease can be ascertained as the cause. Always qualify all diseases resulting from childbirth or miscarriage, as " PUER- PERAL septicaemia," " PUERPERAL peritonitis," ctc. State cause for which surgical operation was undertaken.
Cases for the Medical Examiners. - Under the provisions of chapter 24 of the Revised Laws deaths under the following conditions must be referred to the Medical Examiners:
1. Deaths following injury or violence, as Burns, Falls, Drowning, Gas Poisoning, Suicide, Homicide, etc.
2. Deaths supposedly caused by violence, as Criminal Abortion, Poisoning, Starvation, Suffocation, Ex- posure, etc.
3. Sudden deaths of persons not disabled by recognized disease, as A death upon the street, or one supposed to be due to Alcoholism, etc.
4. Deaths under circumstances unknown, as A person found dead, etc.
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. 614
Shilling
St. ;
Ward)
4008 Winthrop (City or town.) [If death occurred in e hospital or institution, give its NAME instead of street and number.]
Registered No.
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
male
4 COLOR OR RACE
White
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
Manual
6 DATE OF BIRTH
July
(Month)
3
(Day)
1842
(Year)
7 AGE
If LESS than
I day, ..
hrs.
6964 yrs. 7
mos.
22
ds.
or ....... min. ?
8 OCCUPATION (a) Trade, profession, or particular kind of work
General manager
(b) General nature of industry, business, or establishment in which employed (or employer)
Tooth Bunch Company
BIRTHPLACE
(State or country)
Hudson 21. 4
10 NAME OF
FATHER
Gro. C. Hubbel
PARENTS
11 BIRTHPLACE OF FATHER (State or country) Hudson n.1.
12 MAIDEN NAME
OF MOTHER
ann Punkham
13 BIRTHPLACE OF MOTHER (State or country)
Hudson n.4
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
Edgar. E. Habbel &
(Address)
Ford ., 191
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
(Month)
(Dag)
17
I HEREBY CERTIFY that I have investigated the death of the deceased.
The CAUSE OF DEATH* was as follows : natural Causes. Heart disease, probably Cromary Selerais
(Sund devorador ators)
mos.
ds.
Contributory.
(SECONDARY)
(Duration)
... yrs.
mos.
ds.
(Signed)
Feng Burgers Magrath
M.D.
(Address).
MEDICAL EXAMINER
* State the DISEASE CAUSING DEATHI, 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).
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 Wirklich Toul
DATE OF BURIAL
3/3
....
...
1912
DO UNDERTAKER
ADDRESS
2 FULL NAME
[If married or divorced woman or widow
give maiden name, also name of husband.]
@RESIDENCE
614 Shirley Street
-
16 DATE OF DEATH
29, 1912
(Year)
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 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 winetwoh Mais .. (No .... 115 Lowning Road 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)
martin
6 DATE OF BIRTH
>
1872
17
(Month)
(Day)
.
(Year)
7 AGE
If LESS than 1 day, ... . hrs.
40 .yrs.
X
mos.
27
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)
Le que. Bunun
9 BIRTHPLACE
(State or country)
Long Island U.4
PARENTS
12 MAIDEN NAME
amelia Pattilbon
13 BIRTHPLACE
OF MOTHER
(State or country)
n. 1. ay-
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
Char R Berman
(Address)
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
32
1912
(Month)
(Day)
(Year)
1
HEREBY CERTIFY that I attended deceased from
Jan. 26.
, 1912, to
Mich 32
1912
that I last saw hamalive on
...
191.3
and that death occurred, on the date stated above, at ....... m.
The CAUSE OF DEATH* was as follows :
Duodenal clar
(Duration) ..
1
.mos. /3
ds.
yrs. ..
-
Contributory
Septic pneumonia
(SECONDARY)
(Duration) ...
yrs. .
mos. .
.ds.
(Signed)
Jeg Partir
M.D.
...
1912 (Address).
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
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 .
12 PLACE OF BURIAL OR REMOVAL BeroHelyen 2. 4
DATE OF BURIAL
9/6
1912
.
10 UNDERTAKER
ADDRESS
Wucht
Filed. 191.
16 DATE OF DEATH
Mich.
Charles Frederick Moon
2 FULL NAME
[If married or divorced woman or widow
give maiden name, also name of husband.]
@RESIDENCE
115 Rowing Road
(City or town.)
10 NAME OF
FATHER
Cehas. a. more
11 BIRTHPLACE
OF FATHER
(State or country)
Long Island
STANDARD CERTIFICATE OF DEATH.
Statement of occupation. - Precise statement of occupa- tion is very important, so that the relative hcalthfulness 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., C'areinoma, Sar- coma, ctc., 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 Alcoholismi, etc.
4. Deaths under circumstances unknown, as A person found dead, etc.
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. 14 N. B .- Every item of information should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should stato CAUSE PARENTS
STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH Winthrop mass
(No.
......
.......... ... Metcalf Hospital St .;
arthur Jackson
[If married or divorced woman or widow give maiden name, also name of husband.] * * RESIDENCE 36 Bellevue ave Whiteof Mass
Registered No.
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
SEX
male
' COLOR OR RACE
white
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
married
18 DATE OF DEATH march 5
191.2
(Month)
(Day)
(Year)
"DATE OF BIRTH
Oct- 14 1877- (Day) (Year)
7 AGE
40
.yrs. 4 mos. 20
ds.
or ........ min .?
·OCCUPATION
(a) Trade, profession, or
particular kind of work
Dentist
(b) General nature of industry. business. or establishment in which employed (or employer)
· BIRTHPLACE
(State or country)
Boston mass
10 NAME OF
FATHER
Joseph Jackson
11 BIRTHPLACE
OF FATHER
(State or country)
Burnham me
12 MAIDEN NAME
OF MOTHER
Clara Shute
18 BIRTHPLACE
OF MOTHER
(State or country)
Toharlest me
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant).
Nero arthur Jackson - Widow
(Address)
36 Bellone avec Witteof Boston
Filed
.........
191.
REGISTRAR
17 I HEREBY CERTIFY that I attended deceased from
Feb 21
1912to march 5 1912 that I last saw him alive on march 5 1912 ........ and that death occurred, on the date stated above, at&/sam The CAUSE OF DEATH* was as follows:
acute Gunquemano appendinão
13 days (Duration) ... yrs.
13
mos. .ds.
Contributory
Taxauna
(SECONDARY) George Of French, M. D. (Duration) .. mos. 4 ds.
(Signed)
march 5
191.2. (Address)
300 Pleasant St. 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 True calf targeted
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