USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1910-1912 > Part 9
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).
Part 1 | Part 2 | Part 3 | Part 4 | Part 5 | Part 6 | Part 7 | Part 8 | Part 9 | Part 10 | Part 11 | Part 12 | Part 13 | Part 14 | Part 15 | Part 16 | Part 17 | Part 18 | Part 19 | Part 20 | Part 21 | Part 22 | Part 23 | Part 24 | Part 25 | Part 26 | Part 27 | Part 28 | Part 29 | Part 30 | Part 31 | Part 32 | Part 33 | Part 34 | Part 35 | Part 36 | Part 37 | Part 38 | Part 39 | Part 40 | Part 41 | Part 42 | Part 43 | Part 44 | Part 45 | Part 46 | Part 47 | Part 48 | Part 49 | Part 50 | Part 51 | Part 52 | Part 53 | Part 54 | Part 55 | Part 56 | Part 57 | Part 58 | Part 59 | Part 60 | Part 61 | Part 62 | Part 63 | Part 64 | Part 65 | Part 66 | Part 67 | Part 68 | Part 69 | Part 70 | Part 71 | Part 72 | Part 73 | Part 74 | Part 75 | Part 76 | Part 77 | Part 78 | Part 79 | Part 80 | Part 81 | Part 82 | Part 83 | Part 84 | Part 85 | Part 86 | Part 87 | Part 88 | Part 89 | Part 90 | Part 91 | Part 92 | Part 93 | Part 94 | Part 95
.. years.
×
.months ...
days
W Mars
STATISTICAL DETAILS
PHYSICIAN'S CERTIFICATE
I HEREBY CERTIFY that I attended deceased during last illness, from .. June 30 19/0 Analy 22? to 19/0 that to the best of my knowledge and belief death occurred on the date stated above, and that the CAUSE OF DEATH was as follows :
Primary :
apendicitis perforated
(DURATION). 24 DAYS
Contributory :
(DURATION ). .. DAY8
(Signed)
M.D.
Any 23
.19/0
(Address)
worthit has
SPECIAL INFORMATION only for Hospitais, Institutions, Translents, or Recent Residents.
How long at
20 dias
Piace of Death ?
months .. days
Where was disease contracted,
If not at place of death ?
Cust any hulp
Filed
.... 19
Cierk
* City or town, street and number, If any. If death occurs away from USUAL RESI- DENCE, give facts called for under "Speciai Information." If In a Hospital or Institution, give Its NAME Instead of street and number.
t In case of married or divorced woman, or widow.
# State or country; also city, town or county, If known.
§ Name and address of person giving statistical details. || Name of cemetery.
FILL OUT WITH INK. - THIS IS A PERMANENT RECORD
ALL NAMES TO BE IN FULL
COLOR
SINGLE, MARRIED, WIDOWED, OR DIVORCED Lungen
MAIDEN NAME +
HUSBAND'S NAME t
BIRTHPLACE #
Philadelphia Pa
NAME OF
FATHER
Jacob Schiff
BIRTHPLACE
OF FATHER#
Germany
MAIDEN NAME OF MOTHER kenney Olschein
BIRTHPLACE
OF MOTHER +
Germany
OCCUPATION
at home
INFORMANT §
Siste
PLACE OF BURIAL OR REMOVAL li
Phil - Pa
DATE OF BURIAL
July 25
1960
UNDERTAKER
ADDRESS
Date of ¿ July 2 2 Death
19/ 0
years
SEX
Female
July 22, 1910
THE COMMONWEALTH OF MASSACHUSETTS
Winthrop .
(CITY OR TOWN.)
FULL NAME
auchan Thomas Selman Clay
Registered No .. ....
Date of l
7/24
19 /0
Death S
Death *
S
Residence
20 Collage an
40
9
months.
2 4.
days
457 WashingHowIt Newtow Mass.
STATISTICAL DETAILS
SEX
Male
COLOR
White
SINGLE, MARRIED, WIDOWED, OR DIVORCED
Manuel
MAIDEN NAME Ť
HUSBAND'S NAME Ť
BIRTHPLACE # Nalafax U.S.
NAME OF
FATHER
Thomas Clay
BIRTHPLACE
OF FATHER#
England
MAIDEN NAME
OF MOTHER
Christyann Dunn
BIRTHPLACE
OF MOTHER #
England
OCCUPATION
Salesman
INFORMANT § wife
Filed
19
Clerk
PLACE OF BURIAL OR REMOVAL !!
DATE OF BURIAL
7/26
19/0
UNDERTAKER
ADDRESS
PHYSICIAN'S CERTIFICATE
I HEREBY CERTIFY that i attended deceased during last illness, from Lecker 0 1010 to fully 2x 1910 . that to the best of moy knowledge and belief death occurred on the date stated above, and that the CAUSE OF DEATH was as follows : Primary :
Contributory :
amentos
(DURATION).
. DAYS
(Signed)
M.D.
Recla 25 19/0 (Address) Nanetropp
SPECIAL INFORMATION only for Hospitals, Institutions, Transients, Recent Residents.
How long at
Place of Death ?
. years.
months. days
Where was disease contracted, if not at place of death ?
* City or town, street and number, If any. If death occurs away from USUAL RESI- DENCE, give facts called for under "Special Information." If In a Hospital or Institution, give Its NAME instead of street and number.
t In case of married or divorced woman, or widow.
# State or country; also city, town or county, if known.
§ Name and address of person giving statistical detalls, Il Name of cemetery.
ALL NAMES TO BE IN FULL
RETURN OF A DEATH
Place of l
20 Collage are winthrop
4 Age
.years.
(DURATION) ISCR DAYS
arthur 1. S. way July 24, 1910
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
Honora. haner
13 BIRTHPLACE
OF MOTHER
(State or country)
Tienes n. 4,
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
(Address)
159 Diewelt &Ha.,
16
Filed .. 191
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
(Month)
(Day)
19!
(Year)
1850 17 | HEREBY CERTIFY that I attended deceased from
191
to.
191.
If LESS than
I day, ..
„hrs.
that | last saw h
alive on
, 191
and that death occurred, on the date stated above, at.
m.
The CAUSE OF DEATH* was as follows :
(Duration).
yrs. .
mos. ...
ds.
Contributory
(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.
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
Clay 2. 1910
20 UNDERTAKER
ADDRESS
REGISTRAR
1
STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH Worcester Mars ( No .
July 30 1910
St. ;
Ward)
BOSTON (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
male
4 COLOR OR RACE
(Month)
(Day)
-
(Year)
7 AGE
54 yrs. mos. 29 ds.
or min. ?
8 OCCUPATION
(a) Trade, profession, or
particular kind of work
Mannen
Barton Theus
(b) General nature of industry,
business, or establishment in
which employed (or employer)
3 R.R.T.L.R.R.
9 BIRTHPLACE
(State or country)
10 NAME OF
FATHER
Thomas Scott
11 BIRTHPLACE
OF FATHER
(State or country)
George. Wales Scott
2 FULL NAME
[If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE 46 Seynne St Winchrote H1020
Registered No.
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
6 DATE OF BIRTH
20
3
The Commonwealth of Massachusetts
In the
-- XNI DNIOVANA
I V SI SIH.L - A PERMANENT RECORD
C
C July 30, 1910
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 linc is provided for the latter statement ; it should be used only when needed. As examples: (a) Spinner, (b) Cotton mill; (a) Salcs- man, (b) Grocery ; (a) Forcman, (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- Coul minc, etc. Women at home, who are engaged in the duties of the household only (not paid House- keepers who receive a definite salary), may be entered as Housewife, Housework, or At home, and children, not gain- fully 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 fevcr (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 state 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 " ("('ongenital," "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
1 PLACE OF DEATH
Worcester.
(No .. State 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
3 SEX
Male
4 COLOR OR RACE
W
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
Married
6 DATE OF BIRTH
1856
1
(Month)
(Day)
(Year)
7 AGE
54
-
yrs.
mos.
ds.
Or ......... min. ?
8 OCCUPATION
(a) Trade, profession, or
particular kind of work
Steamboat captain
Palot.
(b) General nature of industry.
business, or establishment in
which employed .(or employer):
9 BIRTHPLACE
(State or country)
Boothbay, Me.
10 NAME OF FATHER Thomas
PARENTS
11 BIRTHPLACE
OF FATHER
(State or country)
Nova Scotia
12 MAIDEN NAME
OF MOTHER
Hanora McNeil
12 BIRTHPLACE
OF MOTHER
(State or country)
Nova Scotia
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
Ray L Whitney
(Informant)
Worcester.
(Address).
Filed
191
REGISTRAR
MEDICAL: CERTIFICATE OF DEATH:
14 DATE OF DEATH
July ..... 29,
191.0
(Month)
(Day)
(Year)
17
I HEREBY CERTIFY that I attended deceased from
Nov 2,
1908
July 29,
0
to
191
im
July 29,
199
and that death occurred, on the date stated above,
11 Pm.
The CAUSE OF DEATH* was as follows :
General piralysis of the insane
3
(Duration)
. . yrs.
mos.
ds.
Contributory.
Exhaustion of general paral-
(SECONDASiS.
1
(Duration)
yrs.
mos.
ds.
R L
Whitney
M.D.
Jul 30.
0
2, 191
(Address)
Worcester.
* 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.
28
In the Unknown
ds.
State ........
.. yrs.
mos.
. ds ...
Where was disease contracted,
TInknown
If not at place of death ?.
Former or Winthrop.
usual residence.
19 PLACE OF BURIAL OR REMOVAL
Boston
DATE OF BURIAL
Aug 2,
0
191
AUX
20 UNDERTAKERS A Putnam
ADDRESS Cester.
important. See instructions on back of certificate.
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
(City or town.)
George W Scott
2 FULL NAME
[If married or divorced woman or widow
give maiden namo, also name of husband;]
@RESIDENCE
Winthrop.
If LESS than
I day, ....
. hrs.
that i: last saw h
alive on
(Signed)
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 lias 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. - Nanie, 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 septicemia," " PUERPERAL peritonitis," etc. State cause for which surgical operation was undertaken.
Cases for the Medical Examiners. - Under the provisions of chapter 24 of the Revised Laws deaths under the following conditions must be referred to the Medical Examiners:
1. " Deaths following injury or violence, as Burns, Falls, Drowning, Gas Poisoning, Suicide, Homicide, etc.
2. Deaths supposedly caused by violence, as Criminal Abortion, Poisoning, Starvation, Suffocation, Ex- posure, etc.
3. Sudden deaths of persons not disabled by recognized disease, as A death upon the street, or one supposed to be due to Alcoholism, etc.
4. Deaths under circumstances unknown, as A person found dead, etc.
ALL NAMES TO BE IN FULL
THE COMMONWEALTH OF MASSACHUSETTS
RETURN OF A DEATH
(CITY OR TOWN.)
FULL NAME
backermin . Phothe blouson
Registered No.
67
Place of ¿
Death *
5
390 Whichnow It Waiting
Residence
West Roxbury Man
Age 64
... years.
X
months -8 days
STATISTICAL DETAILS
SEX
temale
COLOR
White
SINGLE, MARRIED, WIDOWED, OR DIVORCED
MAIDEN NAME +
Jackson
HUSBAND'S NAME +
Ww a. Johnson
BIRTHPLACE #
Charlestown man
NAME OF
FATHER
Swo Perkins Jackson
BIRTHPLACE
OF FATHER $
MAIDEN NAME
OF MOTHER
E actuina Bran
BIRTHPLACE
OF MOTHER $
Barcon- mais
OCCUPATION
at-1 tours
INFORMANT §
Aero Mary E Mumor
390 Marchioh &m;
PLACE OF BURIAL OR REMOVAL II
Woodlawn Comelig Insect
DATE OF BURIAL
7/19
.. 19/ G
UNDERTAKER
BR Berman
ADDRESS
PHYSICIAN'S CERTIFICATE
I HEREBY CERTIFY that I attended deceased during last illness, from ... July 16. 9
to
vody/26 19 CV,
that to the best of my knowledge and belief death occurred on the
date stated above, and that the CAUSE OF DEATH was as follows :
Primary :
Intenstitul
Nephutis
(DURATION).
DAYS
Contributory :
Carcinoma
(DURATION)
. DAYS
(Signed)
M.D.
July 2] 19:1
(Address)
SPECIAL INFORMATION only for Hospitals, Institutions, Translents, or Recent Residents.
How long at
Place of Death ?
. years ..
................
. months.
...... days
Where was disease contracted,
If not at place of death ?.
Filed
19
Clerk
* City or town, street and number, If any. If death occurs away from USUAL RESI- DENCE, give facts called for under "Special Information." If In a Hospital or Institution, give Its NAME Instead of street and number.
t In case of marrled or divorced woman, or widow.
# State or country; also city, town or county, If known.
§ Name and address of person giving statistical detalls. Il Name of cemetery.
Date of ¿
7/26
1910
Death 1
July 26, 1910
THE COMMONWEALTH OF MASSACHUSETTS
RETURN OF A DEATH
(CITY OR TOWN.)
FULL NAME
annie Delves ambler
.Registered No.
68
Place of }
409 Shirley St Wuchart
Date of ¿
1/27
Death S
19/0
Death *
.
Residence
STATISTICAL DETAILS
SEX Female
COLOR
SINGLE, MARRIED, WIDOWED, OR DIVORCED
manuel
MAIDEN NAME $
Delves"annie"
HUSBAND'S NAME t
alfred. It. ambler
BIRTHPLACE #
England
NAME OF
FATHER
Samuel Delvis
BIRTHPLACE
OF FATHER#
England
MAIDEN NAME
OF MOTHER
Mariann Thorley
BIRTHPLACE
OF MOTHER #
England
OCCUPATION
A Home
INFORMANT §
Sanghte & Husband
PHYSICIAN'S CERTIFICATE
I HEREBY CERTIFY that I attended deceased during last illness, from ... Janey 26 1910 to. July 27 1910. that to the best of my knowledge and belief death occurred on the date stated above, and that the CAUSE OF DEATH was as follows :
Primary :
Chronic Brughto Diverse
several years.
.(DURATION)
........ DAYS
Contributory :
aceites
uncertaino
(DURATION).
DAYS
(Signed)
M.D.
July 2719/0 (Address)
SPECIAL INFORMATION only for Hospitals, Institutions, Transients, or Recent Residents.
How long at
Place of Death ?
.. years ...................... months.
days
Where was disease contracted,
If not at place of death ?
Filed
19
Clerk
* City or town, street and number, if any. If death occurs away from USUAL RESI- DENCE, give facts called for under "Special Information." If In a Hospital or Institution, give Its NAME Instead of street and number.
t In case of married or divorced woman, or widow. # State or country; also city, town or county, If known.
§ Name and address of person giving statistical details. Il Name of cemetery.
ALL NAMES TO BE IN FULL
PLACE OF BURIAL OR REMOVAL II
Marchiof Semely
DATE OF BURIAL
7/29
19/0
UNDERTAKER
6 R Benmen
ADDRESS
Wucher
man
Age.
47
.years.
.months.
10
.days
July 27, 1910.
THE COMMONWEALTH OF MASSACHUSETTS
RETURN OF A DEATH
(CITY OR TOWN.)
FULL NAME
Hamah Elizabeth Ilestora
Registered No.
69
Place of
Death *
5
Residence
1
11
11
Ag
11 years
.... . months.
U .. days
STATISTICAL DETAILS
SEX
COLOR
SINGLE, MARRIED, WIDOWED, OR- DIVORCED
Hawkins
MAIDEN NAME T
HUSBAND'S NAME t Harfleurw Huston
BIRTHPLACE #
NAME OF FATHER
BIRTHPLACE
OF FATHER#
SommerCitabine Conglands
MAIDEN NAME
OF MOTHER
BIRTHPLACE OF MOTHER # England
OCCUPATION
INFORMANT §
PHYSICIAN'S CERTIFICATE
I HEREBY CERTIFY that I attended deceased during last illness, from Quale 25 .19 to. July 29 19/0 that to the best of my knowledge and belief death occurred on the date stated above, and that the CAUSE OF DEATH was as follows : Primary : Enteritis,
(DURATION).
DAYS
Contributory :
(DURATION). .......... DAYS
(Signed)
M.D.
July 27 1900
(Address)
SPECIAL INFORMATION only for Hospitals, Institutions, Transients, or Recent Residents.
How long at Place of Death ? .. years.
months. days
Where was disease contracted, If not at place of death ?
Filed
.19
Clerk
* City or town, street and number, If any. If death occurs away from USUAL RESI- DENCE, give facts called for under "Special Information." If In a Hospital or Institution, give Its NAME Instead of street and number,
t In case of married or divorced woman, or widow.
# State or country; also city, town or county, If known.
§ Name and address of person giving statistical detalls. || Name of cemetery.
ALL NAMES TO BE IN FULL
PLACE OF BURIAL OR REMOVAL I!
DATE OF BURIAL July 3/ 19/0.
UNDERTAKER If. C. Skangu
ADDRESS Columbia 17
Date of ¿
.19/0,
Death 1
IT ---------
July 29, 1910
PARENTS 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. 16 N. B. - Every item of information should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state -
The Commonwealth of Massachusetts STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH Hinitrop Mar. (No. 290 Bowdoin
St. ;.
Ward)
'FULL NAME 0 Hice Whaley roble
[If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE In winter of Mass.
Oscar Yo.
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
4 COLOR OR RACE
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
widow
6 DATE OF BIRTH
Jan.
(Month)
(Day)
1828
(Year)
7 AGE
If LESS than 1 day ..... . . hrs ..
yrs. 7 mos. / ds. or ....... min. ?
8 OCCUPATION
(a)' Trade, profession, or
particular kind of work
to home.
(b) General nature of industry, business, or establishment in which employed ( or employer).
9 BIRTHPLACE
(State or country)
try) Pourich Conn
Conn.
10 NAME OF
FATHER
Fr haben.
11 BIRTHPLACE OF FATHER (State or country)
12 MAIDEN NAME OF MOTHER unnie (madon
13 BIRTHPLACE OF MOTHER (State or country)
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
-
(Informant)
Lowin Noble
(Address)
Hansturk
Filed 191
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
aug.
1910
(Month)
(Day)
(Year)
17
I HEREBY CERTIFY that I attended deceased from
Suela 25
1910, to.
Cinq 3, 1910,
that I Mast saw h
Me alive on
... 191. 0,
and that death occurred, on the date stated above, at .
. . m.
The CAUSE OF DEATH* was as follows :
Entero colitis
(Duration)
.yrs.
mos.
.ds.
Contributory
Oca aqu
(SECONDARY)
(Duration)
yrs.
mos. . . .. ds.
(Signed)
Trx. Parce)
M.D.
Tranche of hoar
1910 (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
DATE OF BURIAL
1910
20 UNDERTAKER
ADDRESS
brown
BOSTON
(City or town.)
[If death occurred in a hospital or institution, give its NAME instead of street and number.]
Registered No. 70
82
0
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- pneumonia ("Pneumonia," unqualified, is indefinite) ; Tuber-
Need help finding more records? Try our genealogical records directory which has more than 1 million sources to help you more easily locate the available records.