USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1913-1915 > Part 101
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RULE 2. The transportation of bodies dead of smallpox, plague, Asiatic cholera, typhus fever, diphtheria (membranous croup, diphtheritic sore throat), scarlet fever, (scarlet rash, scarlatina), shall be permitted only under the following conditions :
The body shall be thoroughly embalmed with an approved disinfectant fluid, all orifices shall be closed with absorbent cotton, the body shall be washed with the disinfectant fluid, enveloped in a sheet saturated with the same, and placed at once in the coffin or casket which shall be immediately closed, and the coffin or casket or the outside case containing the same shall be metal, or metal lined, and hermetically and permanently sealed.
RULE 3 The transportation of bodies dead of any disease other than those mentioned in Rule 2 shall be permitted under the following conditions :
(a) When the destination can be reached within twenty four i.ours after death, the coffin or casket shall be encased in a strong outer box made of good sound lumber not less than seven-eighths of an inch thick, all joints must be tongued and grooved, top put on with cleats and cross pieces, all put securely together, and be tightly closed with white lead, asphalt varnish, or paraffin paint, and a rubber gasket placed on the upper edge between the lid and box.
(b) When the destination cannot be reached within twenty-four hours after death, the body shall be thoroughly embalmed and the coffin or casket placed in an outside case constructed as provided in paragraph (a).
RULE 4. No disinterred body dead from any disease or cause shall be transported by common carrier unless approved by the health authorities having jurisdiction at the place of disinterment, and transit permit and transit label shall be required as provided in Rule I.
The disinterment and transportation of bodies dead of diseases mentioned in Rule 2 shall not be allowed except by special permis- sion of the health authorities at both the place of disinterment and the point of destination.
All disinterred remains shall be enclosed in metal or metal lined boxes and hermetically sealed, provided that bodies in a receiving vault when prepared by licensed embalmers, shall not be regarded as disinterred bodies until after the expiration of 30 days.
RULE 5. The outside case may be omitted in all instances when the coffin or casket is transported in hearse or undertaker's wagon.
RULE 6. Every outside case shall bear at least four handles and when over 5 feet 6 inches in length, shall bear six handles.
RULE 7. The term "approved disinfectant fluid" as used in these rules means an embalming fluid that has been submitted to a bacteriological test and approved by the Board of Embalming Examiners of the State of New York, or a fluid that contains not less than 5 per cent. of formaldehyde gas ; the term "embalming " as employed in these rules shall require the injection by licensed embalmers of not less than 10 per cent. of the body weight, injected arterially in addition to cavity injection, and 12 hours sball elapse between the time of embalming and the shipment of the body. A 5 per cent. solution of carbolic acid, a I-500 solution of corrosive sublimate or 14 per cent. of a 40 per cent. solution of formaldehyde are approved as disinfectants for external washing of bodies when required by these rules. Other prepared disinfectants of equal germicidal action may also be used.
PROMULGATED BY STATE COMMISSIONER OF HEALTH, DECEMBER 30, 1913
The Commonwealth of Massachusetts STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH Melrose
.(No ....
2 Lakecroft Court,
St. :
Ward)
[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
White
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED Married
(Write the word)
16 DATE OF DEATH
June 19, 1915.
(Month)
(Day)
191
(Year)
6 DATE OF BIRTH
June 11, 1853
(Month)
(Day)
(Year)
7 AGE
6.2 ...... yrs. 0 mos. 8 ds. Or ....... min; ?
& OCCUPATION
(a) Trade, profession, or
Real estate
particular kind of work
(b) General nature of industry, business, or establishment in which employed (or employer)
Retired 2 years CHARLES WN1629
· MAL EY
(Duration)
.. yrs.
mos. ds.
Contributory J. (SECONDARY). 1
IS 0 19.07
(Duration)
.yrs.
mos.
ds.
Roscoe D. Perley, M.E.
M.D.
19. 191.
15 Address )
Melrose, Mass,
* 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.
7
In the
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
Woodlawn Cemetery Everett Mass
DATE OF BURIAL
June 21
195
(Address)
Winthrop Mass
Filed Jun. .... 21101. 15.
REGISTRAR
17
I HEREBY CERTIFY that I attended deceased from
191
., to
191
If LESS than
I day,
hrs.
that I last saw h
alive on
191
and that death occurred, on the date stated above, at m. The CAUSE OF DEATH* was as follows :
F. EL
PLORT 21628.
9 BIRTHPLACE
(State or country)
Boston, Mass
NORTHEND 6
10 NAME OF FATHER Peter D. Meston-
INCOR
PPCRA
op
PARENTS
11 BIRTHPLACE OF FATHER (State or country) Boston, Mass.
>
12 MAIDEN NAME
OF MOTHER
Sarah F. Whorf
13 BIRTHPLACE
OF MOTHER
(State or country)
Boston, Mass.
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
Catherine A. Meston
20 UNDERTAKER Albert J. Walton,
ADDRESS
Melrose, Mass
important. See instructions on back of certificate.
(City or town.)
2 FULL NAME
Lyman S. Meston
[If married or divorced woman or widow
give maiden name, also name of husband.]
@RESIDENCE
#203 Woodside Avenue, Winthrop Nass
Registered No.
Male
CITY. OF.
ROSS frebral embolism
June 19, 1915
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, peritonacum, 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.
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 (No. 86 Bartlett Ga St. : Ward)
Ella Q Hodgleis.
2 FULL NAME
[If married or divorced woman or widow
give maiden name, also name of husband.]
aRESIDENCE 86BartlettRac.
Registered No.
PERSONAL AND STATISTICAL PARTICULARS
3 SEX ternale
4 COLOR OR RACE
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
Niciowca
6 DATE OF BIRTH
2
(Month)
(Day)
(Year)
7 AGE
If LESS than
| day ......... hrs.
65 yrs. 10
mos.
18
.. ds.
or ....... min. ?
8 OCCUFATION
(a) Trade, profession, or
particular kind of work
(b) General nature of industry,
business, or establishment in
which employed (or employer)
' BIRTHPLACE
(State or country)
TY) Vantueket-Maze.
10 NAME OF
FATHER
Freeman Parker.
PARENTS
1) BIRTHPLACE
OF FATHER
(State or conntry
Barnstable March
12 MAIDEN NAME
OF MOTHER
Elizabeth-Hay.
18 BIRTHPLACE
OF MOTHER
(State or conntry)
Nantucket Muss.
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informer.t)
thank Godglass
(Address)
16
Filed 191
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
(Month)
20
1910-
(Day)
(Year)
I HEREBY CERTIFY that I attended deceased from
1919
to.
Samal 20
1910-
that I last saw bed
alive on
home 19
1910-
and that death occurred, on the date stated above, at -300 m.
The CAUSE OF DEATH* was as follows :
Cerebral appley.
(Duration)
.... yrs.
mos.
ds.
Contributory
(SECONDARY)
(Duration) 0-
Willard@oy
M.D.
mos.
ds.
(Signed)
,1910 -(Addr
sénat Broten
* 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 placa
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 Worklawn Cemetery June 22, 1915
DATE OF BURIAL
2 /
* UNDERTAKER
ADDRESS
E. G. Brown Hon East Boston.
N. B. - Every item of information should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state
Winthropo
(City or town.) [If death occurred in a hospital or institution, give its NAME instead of street and number.]
Cartero- Belerpara
3
C
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. - Namo, 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 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, Exe posure, etc.
3. Sudden deaths of persons not disabled by recognized disease, as A death upon the strcet, or one supposed to be due to Alcoholism, etc.
4. Deaths under circumstances unknown, as A person found dead, etc.
COMMONWEALTH OF MASSACHUSETTS
RETURN OF A DEATH-1915.
CITY OF BOSTON.
FULL NAME JOSEPH H. POOR
Registered No. 6212
Place of Death }
Boston
and Residence S
Date of Death
JUNE 26
1915. Age 5
years
months 23 days.
STATISTICAL DETAILS.
PHYSICIAN'S CERTIFICATE.
SEX
COLOR.
SINGLE, MARRIED, WID., DIV.
M
W
SIN.
Maiden Name
GIST T PATRIES. SIT DE
SICUT
Primary ( Duration)
FRAC.SKULL - ASSOCIATED
INTRA-CRANIAL INJURY
B SIDNIA TOHLEITA .
TA A. 1822.
MASS
Contributory: MOTOR VEHICLE ACCIDENT (Duration)
(Signed)
G. B. MAGRATH MED. EX.
M.D.
JUNE 26
1915
SPECIAL INFORMATION from Hospitals, Institutions, Transients, or Recent Residents.
Place of Burial or removal
WINTHROP ( WINTHROP CEM) Usual
Residence WINTHROP ( 18 HERMON ST)
Filed
JUNE 30
1915.
A true copy. Attest : Eumylenen
Registrar.
E
Husband's Name
Birthplace
BOSTON
Name of Father
JOSEPH H. POOR JR.
Birthplace of Father BOSTON
Maiden Name of Mother
ELIZABETH A. TAYLOR
Birthplace of Mother
-- N . S.
Occupation
Informant
I HEREBY CERTIFY that I attended deceased during last illness,
1915,
from 1915, to 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 : RAR'S
CITY
A. SFICE
CIVIT TISR
TISREGI'41
O
Undertaker W. C. SKAGGS
WINTHROP
MASS.GENERAL HOSPT.
٢
CAUSE OF DEATH in plain terms, so that it may be properly classified. Exact statement of OCCUPATION is very important. See instructions on back of certificate.
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH
Winthrop
(No ..
20
Present AT
St. :.
Ward)
manuel
[If married or divorced Avoman or widow give maiden name, also name of husband.] @RESIDENCE 73 Window At Rat
(Butler)
William
76
Registered No.
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
3 SEX
Temale
' COLOR OR RACE
Black
6SINGLE,
MARRIED,
married
WIDOWED,
OR DIVORCED
(Laike the word)
'DATE OF BIRTH July
(Monthy
(Day)
1851
(Year)
7 AGE
If LESS than
I day ......... hrs.
64
.. yrs.
mos.
ds.
min. ?
8 OCCUPATION
(a) Trade, profession, or
particular kind of work
Home
(b) General nature of industry, business, or establishment in which employed (or employer).
9 BIRTHPLACE
(State or country)
Portland Ine
10 NAME OF
FATHER
William Butler
11 BIRTHPLACE
OF FATHER
(State or country)
Portland me
12 MAIDEN NAME
OF MOTHER
Abigail Jones
13 BIRTHPLACE
OF MOTHER
(State or country)
Berück Byl
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
6 B manuel
son
(Address)
73 Windowst Rov
REGISTRAR
16 DATE OF DEATH
17
I HEREBY CERTIFY that [ attended deceased from
4. 1915
July 4, 199
to
that I last saw h-> alive on
...
and that death occurred, on the date stated above, at
m. The CAUSE OF DEATH* was as follows :
Did a surgical operation precede death ? - Date
(Duration)
yrs. ....
... mos.
....... ds.
Contributory.
(SECONDARY)
....... ....
.(Duration)
yrs.
mos.
ds.
(Signed)
plany all Elly
M.D.
July 6, 1915 (Address) 325 Withus DT
· If death followed injury or violence the certificate of death must be made ont 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
Portland me
DATE OF BURIAL
July 8. 1996
20 UNDERTAKER
ADDRESS
A S Waterman & How Boston
N. B .- Every item of information should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state
Winthrop
(City or town.) [If death occurred in a hospital or institution, give its NAME instead of street and number.]
2 FULL NAME
Jemett
PARENTS
Filed 191
1915
(Month)
(Day)
(Year)
STANDARD CERTIFICATE OF DEATH.
Statement of occupation. - Precise statement of occu- pation 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 oceupations a single word or term on the first line will be sufficient, e. g., Farmer or Planter, Physicion, Compositor, Architect, Loco- motive engincer, Civil engineer, Stationory firemon, etc. But in many eases, 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) Forcman, (b) Automobile factory. The material worked on may form part of the sceond 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 oceupation 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 occu- pation whatever, write None.
Statement of cause of death. - Name, first, the DIS- EASE 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 intereurrent) affection need not be stated unless im- portant. Example: Measles (disease eausing death), 29 ds .; Broncho-pneumonia (secondary), 10 ds. Never report mere symptoms or terminal conditions, such as "Asthenia," "An- acmia" (merely symptomatic), "Atrophy," "Collapse," "Coma," "Convulsions," "Debility" ("Congenital," "Senile," etc.), "Dropsy," "Exhaustion," "Heart failure," "Haemorrhage," "Inanition," "Marasmus," "Old age," "Shock," "Uraemia," "Weakness," ete., when a definite disease ean be ascertained as the eause. Always qualify all diseases resulting from childbirth or miscarriage, as "PUER- PERAL septicaemia," "PUERPERAL peritonitis," ctc. State eause for which surgical operation was undertaken.
Cases for the Medical Examiners. - Under the provi- sions of chapter 24 of the Revised Laws deaths under the fol- lowing 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 eaused 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 deod, etc.
CAUSE OF DEATH in plain terms, so that it may be properly classified. Exact statement of OCCUPATION is very N. B. - Every item of Information should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state important. See Instructions on back of certificate.
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH
Winthrop
(No.
211 Disturb
St. : . Ward)
(City or town.) [If death occurred in a hospital or institution, giva its NAME Instead of street and number.]
PERSONAL AND STATISTICAL PARTICULARS
' COLOR OR RACE
While
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
undowed
' DATE OF BIRTH March (Month)
11, 1847
(Day)
(Year)
If LESS than
I day ........ hrs.
68 yrs.
... yrs.
3
... mos.
26 de.
or ........ min. ?
* OCCUPATION
(a) Trade, profession, or
particular kind of work
housewife
· BIRTHPLACE
(State or country)
Stalifax M. S.
10 NAME OF
FATHER
Robert Fenerty
Halifax 91.8
12 MAIDEN NAME
OF MOTHER
iones Lauson
1ª BIRTHPLACE
OF MOTHER
(State or country)
Italifax, n.S.
"THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
William E. Oatual
(Address)
21 South Sixth 2 .- Mur Bedford
16 Filed ., 191
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
July 6
(Month)
(Day)
191
(Year)
17
I HEREBY CERTIFY that I attended deceased from
1914, to
Feb 28
July 6
1915 ..
that I last saw her alive on
Ogum 30
1915.
....... and that death occurred, on the date stated above, att A.m. The CAUSE OF DEATH* was as follows :
Chronic interstitial
nephritis
.(Duration) .
1
yrs. 4 mos.
ds.
Contributory
Ungemia
(SECONDARY)
Increasing for tout-
(Duration) 2yrs
2
mos.
...........
ds.
(Signed)
Forest Leavitt
....................
M.D.
July 6, 1915 (Address).
sculptor.
.....
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