USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1910-1912 > Part 58
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of death
.. yrs
mos.
.... 3 .... ds.
40 In the 66
Stat ...... .. yrs ... mos. 20 ds ..... Where was disease contracted, 36 Belecome and runthat If not at place of death ?
Former or
usual residence
Same
IS PLACE OF BURIAL OR REMOVAL Mit Hohe Semaliny
DATE OF BURIAL
man 7th
1912
20 UNDERTAKER
Caha Ee Chester
ADDRESS.
Boston Mass
..... Ward)
BOSTON
[If death occurred in a hospital or institution, give its NAME instead of street and number.]
2 FULL NAME
(Month)
If LESS than I day, ........ hrs.
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, Locomotive 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) Salesman, (b) Grocery; (a) Foreman, (b) Automobile factory. The ma- terial 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 Housekeepers who receive a definite salary), may be entered as Housewife, Housework, or At home, and children, not gainfully 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 begin- ning 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 menin- gitis"); Diphtheria (avoid use of "Croup"); Typhoid fever (never report "Typhoid pneumonia"); Lobar pneumonia;
Broncho-pneumonia ("Pneumonia," unqualified, is indefi- nite); Tuberculosis of lungs, meninges, peritonacum, etc., Carcinoma, Sarcoma, 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 (secondary or intercurrent) affection need not be stated unless important. Example: Measles (disease causing deatlı), 29 ds .; Broncho-pneumonia (second- ary), 10 ds. Never report mere symptoms or terminal conditions, such as "Asthenia," "Anaemia" (merely symptomatic), "Atrophy," "Collapse," "Coma," "Con- vulsions," "Debility" ("Congenital," "Senile," etc.), "Dropsy," "Exhaustion," "Heart failure," "Haemor- rhage," "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 "PUERPERAL 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 fol- lowing conditions must be referred to the Medical Exam- iners :
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, Exposure, 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.
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 winther (No .... 119 Harmon St. ;...
Marietta. V. allen
2 FULL NAME,
[If married or divorced woman or widow
give maiden name, also name of husband.]
@RESIDENCE
Winthrop
Widow of Echan. 20.
Registered No.
PERSONAL AND STATISTICAL PARTICULARS
3 SEX female
4 COLOR OR RACE
White
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
Widow
6 DATE OF BIRTH
(Month)
(Day) (Year)
7 AGE
yrs. 6
mos. 8
.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)
9 BIRTHPLACE
(State or country)
Tafterville V+
PARENTS
12 MAIDEN NAME OF MOTHER Hannah Perkins
13 BIRTHPLACE OF MOTHER (State or country)
fleckbridge rt
" THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
Chas 2. 13 emmaen
(Address)
Filed 191 ..
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
march
8 2
(Month)
(Day)
. 191
(Year)
17
I HEREBY CERTIFY that I attended deceased from
190 5
, to
, 191.2.
If LESS than 1 day, . .. hrs. that I last saw h ...... .... alive on , 1912 or min. ? and that death occurred, on the date stated above, at//~0m. The CAUSE OF DEATH* was as follows :
Cheranno Valvulaseach Di sure
(Duration) 15 yrs. . mos. .
wds.
Cestino sclerosis
Contributory
(SECONDARY)
(Duration) .. -
-
mos. .
ds.
Johnson
M.D.
(Signed)
march 10
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
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
E. Barnard Connely
DATE OF BURIAL
3/11
. 1912
MO UNDERTAKER
ADDRESS
لـ
Ward)
(City or town.) [If death occurred in a hospital or institution, give its NAME instead of street and number.]
N. B. - Every item of information should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state
10 NAME OF
FATHER
Ease Vaughan
1) BIRTHPLACE OF FATHER (State or country) Stockbridge Vt
ch . 8 , 191 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 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 luborer, 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 Housewife, Housework, or At home, and children, not gaill- 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-
. eulosis of lungs, meninges, peritonaeum, etc., Carcinoma, Sur- 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 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.
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
I PLACE OF DEATH
(No. 109 Boudou
St. ;.. . .
Ward)
(City or town.) [If death occurred in a hospital or institution, give its NAME instead of street and number.]
2 FULL NAME Sarah M. Statt
{If married or divorced woman or widow give maiden name, also name of husband.]( @RESIDENCE 107 Broudacic St.
Willianof Fameo). Watt
Registered No.
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
4 COLOR OR RACE
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
Mariscal
6 DATE OF BIRTH
(Month)
(Day)
, 1882 17 (Year)
7 AGE
If LESS than I day,. . . hrs.
30
yrs. . „ mos. . ds.
or ... min. ?
8 OCCUPATION
(a) Trade, profession, or particular kind of work Let France
(b) General nature of industry, business, or establishment in which employed (or employer).
) BIRTHPLACE
(State or country)
Wales
10 NAME OF
FATHER
Hugh Williams
PARENTS
12 MAIDEN NAME OF MOTHER
7
mamy
Fores
13 BIRTHPLACE OF MOTHER (State or country) Wales
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
....
(Adras) wic Baudour of
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
march
(Month)
(Day)
. 191
(Year)
I HEREBY CERTIFY that I attended deceased from
1912, to
March 9, 191.
that | last saw h~
alive on
march 9
, 191 2,
and that death occurred, on the date stated above, at !- P m.
The CAUSE OF DEATH* was as follows :
Chronic Diffuse nephritis and
Diabilis Wellilis
yrs.
.. .. mos. .
-
ds.
Contributory.
(SECONDARY)
(Duration)
yrs.
mos. .
.ds.
(Signed)
march 12, 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.
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
3-12.1912
20 UNDERTAKER
ADDRESS
Filed .. 191.
,
M.D.
11 BIRTHPLACE OF FATHER (State or country)
-
In the
9
much . 9, 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: («) 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 lunys, 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 septicemia," " PUERPERAL peritonitis," etc. State canse 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 deuth 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
PLACE OF DEATH Winthrop mans (No. 12 Dougles David Q. Collins *FULL NAME
St. :.. Ward)
BOSTON (City or town.) [If death occurred in a hospital or institution, give its NAME instead of street and number.]
[If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE
12 Dougles
Registered No.
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
I COLOR OR RACE
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCE Male
(Write the word)
6 DATE OF BIRTH
(Month)
(Day)
1
(Year)
7 AGE
30 yrs. -
-
mos.
ds.
or ...
... min. ?
& OCCUPATION
(a) Trade, profession, or
particular kind of work
Bookkeeper
(b) General nature of industry,
business, or establishment in
which employed (or employer).
9 BIRTHPLACE
(State or country)
Boston
10 NAME OF
FATHER
Daniel D.
PARENTS
11 BIRTHPLACE OF FATHER (State or country)
Island
12 MAIDEN NAME OF MOTHER Sarah. Mª Greece.
13 BIRTHPLACE
OF MOTHER
(State or country)
Boston
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
Mother
(Address)
16
Filed 191.
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
March
9
(Month)
(Day)
1912
(Year)
17 I HEREBY CERTIFY that I attended deceased from march 9 , 1912, 1 Gracch 7, 1912.
that I last saw hamalive on
Insach 9
191.2.
and that death occurred, on the date stated above, at.
119 m.
The CAUSE OF DEATH* was as follows :
.(Duration)
.yrs.
mos.
ds.
Contributory (SECONDARY)
(Duration)
yrs.
mos.
ds.
(Signed)
Chas. 7. Touching ...
M.D.
march 1. 1912 (Address)
304 Ziletekst
* 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 placo
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 AX Jassfh w. R. mur
DATE OF BURIAL
Mar 12
1912-
ADDRESS
UNDERTAKER
C
....
.
If LESS than
day,
„.hrs.
mich . 9 .1912
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. Nevor 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 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 timo 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, ete., Carcinoma, Sar- coma, etc., of .. (name origin: "Cancer" is less definite; avoid use of "Tumor" for malignant neoplasmns) ; 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," "Haemorrhago," " Inanition," " Marasmus," " Old age," "Shock," " Uraemia," " Weakness," etc., when a definite disease can be aseertained as the cause. Always qualify all diseases resulting from childbirth or miscarriage, as "PUER- PERAL septicaemia," " PUERPERAL peritonitis," etc. State causo 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. ctc.
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
.(No ....
11. Perkins
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
Mute
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
6 DATE OF BIRTH
(Month) (Day)
1
(Year)
7 AGE
4.7
28
yrs. 4 mos. ds. or ....... min. ?
8 OCCUPATION
(a) Trade, profession, or
particular kind of work
Han Dessen
(b) General nature of industry, business, or establishment in which employed (or employer).
Owner of state
9 BIRTHPLACE
(State or country)
New York City
PARENTS
12 MAIDEN NAME
OF MOTHER
13 BIRTHPLACE
OF MOTHER
(State or country)
€
V
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant) ...
(Address)
14
Filed .. 191.
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
Mch
(Montlı)
9
(Day)
1912
(Year)
17
I HEREBY CERTIFY that I attended deceased from
nov. 30
1912
to
ruch. 9
If LESS than I day, ... . . hrs. that i last saw her alive on
Inch.8.
191.2.
and that death occurred, on the date stated above, at/ 200 m.
The CAUSE OF DEATH* was as follows :
Bare
none of Breast.
(Duration). 2 yrs. mos. . ds.
Contributory
asthma
(SECONDARY)
.( Duration)
1
yrs.
mos. ..
ds.
(Signed)
....
I. t. Porter
M.D.
.. .
Med.10
191 (Address).
Minutual maro.
* 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 REMOVAL
DATE OF BURIAL
3/1
1912
.
10 UNDERTAKER
ADDRESS
10 NAME OF FATHER James Rogers
11 BIRTHPLACE OF FATHER (State or country)
(City or town.)
Emily
Baker
2 FULL NAME
[If married or divorced woman or widow
give maiden name, also name of husband.]
@RESIDENCE
nuethrop
uch. 9, 1912
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