USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1910-1912 > Part 73
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which employed (or employer)
9 BIRTHPLACE
(State or country)
Boston
10 NAME OF
FATHER
Bazaras Levy
11 BIRTHPLACE OF FATHER (State or country)
Switzerland
Hlad
12 MAIDEN NAME OF MOTHER Chinahth Jacob
1ª BIRTHPLACE OF MOTHER (State or country)
Leandra Eng
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
Mr. Brwin Degroot
(Address)
46 Dolphin Cur Backing
Filed.
191. ....
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
July 20,
191.1.
(Month)
(Day)
(Year)
17 I HEREBY CERTIFY that I attended deceased from 191 ..... , to 191
that I last saw h.
alive on
191
and that death occurred, on the dato stated above, at.
m.
The CAUSE OF DEATH* was as follows :
Certificate
attached
(Duration)
yrs.
mos.
ds.
Contributorya
(SECONDARY)
(Duration)
.yrs.
mos.
ds.
(Signed)
, M.D.
191
(Address)
* If death followed injury or violence the certificate of death must be made out by the Medical Examiner.
16 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.
"PLACE OF BURIAL OR REMOVAL
DATE OF BURIAL
Handin Hand Dadhan July 22
1912
O UNDERTAKER
W=C Carafa
ADDRESS
Chalisa
Winthrop BOSTON .....
Ward)
(City or town.) [If death occurred in a hospital or institution, give its NAME instead of street and number.]
PARENTS
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 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, 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-
.D.P.
culosis of lungs, meninges, peritoneum, etc., 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 .; Broncho-pneumonia (secondary), 10 ds. Never report mere symptoms or terminal conditions, such as " Asthenia," " An- aemia " (mcrely 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. Doaths 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.
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 Metcalf Hospital (No .. Anthrop
2 FULL NAME. Sarah
DEgroot
[If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE 46 Dolphin Give Brachmont
Registered No.
PERSONAL AND STATISTICAL PARTICULARS
3 SEX Famehr
4 COLOR OR RACE
white
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
6 DATE OF BIRTH
(Month) (Day)
(Year)
7 AGE
If LESS than
I day, . . hrs.
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)
2 BIRTHPLACE
(State or country)
Boston
PARENTS
12 MAIDEN NAME
OF MOTHER
13 BIRTHPLACE OF MOTHER (State or country)
" THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
(Address)
Filed 191.
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
July
20
(Month)
(Day)
1
, 1912
(Year)
17
I HEREBY CERTIFY that I attended deceased from
July
16
191.2 to
, 191.2,
20
that I last saw h
alive on
. , 191.2_,
and that death occurred, on the date stated above, at.
66 m.
The CAUSE OF DEATH* was as follows :
aceite obstruction of small
intestine () huambosil)
.. (Duration) .
yrs. .
mos.
6
ds.
Contributory ..
(SECONDARY)
(Duration) yrs.
mos. .
ds.
(Signed)
... M.D.
July 20
1912 (Address)
WIf 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.
3 ds.
In the
State
yrs.
mos.
ds
Where was disease contracted,
If not at place of death ?
Beachment
Former or
usual residence
Rivera
mass
19 PLACE OF BURIAL OR REMOVAL
DATE OF BURIAL
Hand in Hand Ardhan July 22, 1912
20 UNDERTAKER
Wm 6 Carala
ADDRESS
317 Broadway
(City or town.)
St. Ward)
[If death occurred in a hospital or institution, give its NAME instead of street and number.]
40 .. yrs .. mos. ds.
10 NAME OF
FATHER
11 BIRTHPLACE OF FATHER (State or country)
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 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 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- 1 pneumonia (" Pneumonia," unqualified, is indefinite) ; Tuber-
culosis of lungs, meninges, peritoneum, etc., Carcinoma, Sar- coma, etc., of .. ... (name origin: "Cancer" is less definite ; avoid use of "Tumor" for malignant neoplasms) ; Measles ; Whooping cough ; Chronic valvular heart disease ; Chronic interstitial nephritis, etc. The contributory (second- ary or intercurrent) affection need not be stated unless im- portant. Example : Measles (disease causing death), 29 ds .; Broncho-pneumonia (secondary), 10 ds. Never report mere symptoms or terminal conditions, such as " Asthenia," " An- aemia " (merely symptomatic), "Atrophy," "Collapse," "Coma," "Convulsions," "Debility " ("Congenital," "Senile," etc.), "Dropsy," " Exhaustion," "Heart failure," "Haemorrhage," " Inanition," " Marasmus," " Old age," "Shock," "Uraemia," " Weakness," etc., when a definite disease can be ascertained as the cause. Always qualify all diseases resulting from childbirth or miscarriage, as " PUER- PERAL septicaemia," " PUERPERAL peritonitis," etc. State cause for which surgical operation was undertaken.
Cases for the Medical Examiners. - Under the provisions of chapter 24 of the Revised Laws deaths under the following conditions must be referred to the Medical Examiners:
1. Deaths following injury or violence, as Burns, Falls, Drowning, Gas Poisoning, Suicide, Homicide, etc.
2. Deaths supposedly caused by violence, as Criminal Abortion, Poisoning, Starvation, Suffocation, Ex- posure, etc.
3. Sudden deaths of persons not disabled by recognized disease, as A death upon the street, or one supposed to be due to Alcoholism, etc.
4. Deaths under circumstances unknown, as A person found dead, etc.
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
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH Writtento Man .. (No ... 15.3 Wochenk St. ;... Ward)
Georgia & Belchen 2 FULL NAME [If married or divorced woman ox widow give maiden name, also name of husband.] . @RESIDENCE 153 Waneleet Sec
(City or town.)
Elf death occurred in a hospital or institution, give its NAME instead of street and number.]
Registered No.
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
female
4 COLOR OR RACE
white
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
Feijão
6 DATE OF BIRTH
12
month)
(Day)
(Year)
17 AGE
12
2
16
ds.
yrs. mos.
6 OCCUPATION
(a) Trade, profession, or
particular kind of work
at School
(b) General nature of industry, business, or establishment in which employed (or employer)
2 BIRTHPLACE
(State or country)
10 NAME OF FATHER Danie
PARENTS
11 BIRTHPLACE OF FATHER (State or country) Warchest
12 MAIDEN NAME OF MOTHER Mina allem
13 BIRTHPLACE OF MOTHER (State or country)
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
OR Bene
(Address)
Wenchen't was
Filed. 191
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
(Day)
July 21 5
1912
( Year)
I HEREBY CERTIFY that I attended deceased from
July 8.
, 1912, to
July 21et, 1912
If LESS than
| day. ..
hrs.
that I last saw her alive on
July 21th, 1912
and that death occurred, on the date stated above, at 2 409.
or ....
min. ?
The CAUSE OF DEATH* was as follows :
acute articular Rheumatism
complicated with Pericarditis
* Endocarditis
(Duration)
yrs.
ds.
.mos.
Contributory ..
Pericarditis Endocarditis
· (SECONDARY)
(Duration)
yrs,
mos.
21 ds.
(Signed)
Horace $
Soule
M.D.
.
July 239.
11912 (Addres) 180 Withinp Str
/* 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 July 22- 19/h
20 UNDERTAKER
ADDRESS
WRITE PLAINLY, WITH UNFADING INK - THIS IS A PERMANENT RECORD.
important. See instructions on back of certificate.
1904
17
C
July 21, 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 luborer, 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, peritonueum, 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 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
1 PLACE OF DEATH Hunethiop (No Hr grashingtoneste
(City or town.)
[If death occurred in a hospital or institution, give its NAME Instead of street and number.]
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
3 SEX
4 COLOR OR RACE
W
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
Quarries
B DATE OF BIRTH
(Month)
(Day)
(Year)
7 AGE
79 yrs.
10
mos.
20 de.
If LESS than
{ day ......... hrs.
„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)
marie
(Duration)
... yrs.
mos.
ds.
Contributory
Diabetes Mellitus
(SECONDARY)
(Duration jecal yrs
mos.
ds.
(Signed)
24, 22, 191 2 (Address)
...
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.
In the
mos.
ds.
State ........... yrs.
mos.
...... .ds .............
Where was disease contracted, If not at place of death ?.
Former or usual residence.
1º PLACE OF BURIAL OR REMOVAL
DATE OF BURIAL
7-24, 1912
ADDRESS
Filed 191
REGISTRAR
18 DATE OF DEATH
I HEREBY CERTIFY that I attended deceased from
July 1)
1912
truly 2,4
., to
1912
that I last saw ht2
alive on
2.9
1912,
and that death occurred, on the dato stated above, at 330 pm.
The CAUSE OF DEATH* was as follows :
angina
Pectras
General arterio sclerosis
1
10 NAME OF
FATHER
Seth gryman
PARENTS
11 BIRTHPLACE
OF FATHER
(State or country)
marie
١
-
12 MAIDEN NAME
OF MOTHER
1ª BIRTHPLACE
OF MOTHER
(State or country)
Maine
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
Q.S. Bartlett
(Address)
267 Boudou SP
TO UNDERTAKER
W.C. Staygo
Ward)
Caroline . Barthth
FULL NAME
Hyman Jozias
[If married or divorced woman or widow give maiden name, also name of busband.] @RESIDENCE Hr Washington Der. Winthrop
Registered No.
(Month)
2,00
1912
....
(Day)
(Year)
17
31
July 21, 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- 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," " 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.
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
MONSON, MASS, (City or town.)
1 PLACE OF DEATH
Noutra ellers
.
.(No.
Epelapolic Hospital St.
....... ... Ward)
[If death occurred in a hospital or institution, give its NAME instead of street and number.]
Registered No.
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
$ SEX
4 COLOR OR RACE
Funde colunte
5 SINGLE,
MARRIED,
WIDOWED,
Jury Ce
OR DIVORCED
(Write the word)
6 DATE OF BIRTH
(Month)
(Day)
(Year)
7 AGE
If LESS than day „hrs.
.yrs. ... mos. ds.
or ......... min. ?
$ 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
Fredrick C. Clark
11 BIRTHPLACE
OF FATHER
(State or country)
Dover llama
12 MAIDEN NAME
OF MOTHER
Estalla Osborne
IS BIRTHPLACE
OF MOTHER
(State or country)
Jokeroff-ellare
" THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
ellorgan B Hodatum
(Address)
Palener 16 00
Filed Jely 24. 191
REGISTRAR
16 DATE OF DEATH
20
2
(Month)
(Day)
(Year)
1890 17 I HEREBY CERTIFY that/I attended deceased from
N 1912 ....... ,
to
1912
that I last saw h.
Ev alive on
1912
and that death occurred, on the date stated above, at.
44Pm
The CAUSE OF DEATH* was as follows : Pulmonary Edema
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