Town of Winthrop : Record of Deaths 1910-1912, Part 73

Author: Winthrop (Mass.)
Publication date: 1910
Publisher:
Number of Pages: 956


USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1910-1912 > Part 73


Note: The text from this book was generated using artificial intelligence so there may be some errors. The full pages can be found on Archive.org (link on the Part 1 page).


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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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