Town of Winthrop : Record of Deaths 1913-1915, Part 19

Author: Winthrop (Mass.)
Publication date: 1913
Publisher:
Number of Pages: 1094


USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1913-1915 > Part 19


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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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 Criminol Abortion, Poisoning, Storvotion, 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


82 Human Sto. Winthrop Maso


(City or town.)


[If death occurred in a hospital or institution, give its NAME instead of street and number.]


PERSONAL AND STATISTICAL PARTICULARS


8 SEX


4 COLOR OR RACE


5 SINGLE,


MARRIED,


WIDOWED,


OR DIVORCED


(Write the word)


mances


6 DATE OF BIRTH


7


(Month)


(Day)


28


1845


., (Year)


7 AGE


If LESS than


( day ......... hrs.


68


.. yrs.


10 mos ..


9 d8.


„min. ?


8 OCCUPATION


(a) Trade, profession, or


particular kind of work


Retired


(b) General nature of industry,


business, or establishment in


which employed ( or employer)


? BIRTHPLACE


(State or country)


Weston Juano


10 NAME OF


FATHER


Eli E. Bene


PARENTS


12 MAIDEN NAME


OF MOTHER


Eliza Veman


13 BIRTHPLACE OF MOTHER (State or country) Boston.


14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE


(Informant)


New John X. Beaux


(Address)


82 Herman St.


Filed


191


REGISTRAR


MEDICAL CERTIFICATE OF DEATH


16 DATE OF DEATH


(Month)


71, 1913


(Day)


(Year)


17


I HEREBY CERTIFY that I attended deceased from


1911


191



.... , to


1913


that I last saw ha.


alive on


1


71


1913


and that death occurred, on the dato stated above, at


7.30/m


The CAUSE OF DEATH* was as follows :


Chromic Interolbal repletos


.(Duration)


2


.yrs.


................ mos. ................ ds.


Contributory


(SECONDARY)


.(Duration)


.yrs.


.........


........


mos. ............


„ds.


(Signed)


31Delcall


M.D.


1913


(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.


1º PLACE OF BURIAL OR REMOVAL Winthrops.com


DATE OF BURIAL


6/1, 1913


20 UNDERTAKER


W.C. Shagan


ADDRESS


Winthrop


Ward)


John f. Benis


$FULL NAME


Manned


[If married of divorced woman or widow give maiden name, also name of husband.] @RESIDENCE 82 Hermon St. Wintherh


Registered No.


11 BIRTHPLACE


OF FATHER


(State or country)


HEstonmais.


In the


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.


N. B .- Every item of information should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state CAUSE OF DEATH in plain terms, so that it may be properly classified. Exact statement of OCCUPATION is very


important. See instructions on back of certificate.


The Commonwealth of Massachusetts STANDARD CERTIFICATE OF DEATH


1 PLACE OF DEATH


(No. 305


Wmittags


St. ;.


........


Ward)


5199 Winthrop (City or town.) U [If death occurred in a hospital or institution, give its NAME instead of street and number.]


2 FULL NAME


mary


G. W. Lemand


[If married or divorced woman or widow


give maiden name, also name of husband.]


@RESIDENCE


300 Multis ST., withip-


Registered No.


PERSONAL AND STATISTICAL PARTICULARS


8 SEX


4 COLOR OR RACE


5 SINGLE,


MARRIED,


WIDOWED,


OR DIVORCED


(Write the word)


Widowed


6 DATE OF BIRTH


12 (Month)


2.9


183KG


(Year)'


7 AGE


If LESS than 1 day, ........ hrs.


75 yrs.


6 mos ..


mos.


10 ds.


or ........ min. ?


8 OCCUPATION


(a) Trade, profession, or


particular kind of work


athome


(b) General nature of industry, business, or establishment in which employed (or employer)


9 BIRTHPLACE


(State or country)


10 NAME OF L.E. Ihiteles.


PARENTS


12 MAIDEN NAME OF MOTHER Mary & Robinson


1ª BIRTHPLACE OF MOTHER (State or country) 21-4-


14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE


(Informant)


Edivination and


(Address)


305 With012SK


Filed ., 191


REGISTRAR


MEDICAL CERTIFICATE OF DEATH


16 DATE OF DEATH


(Month)


(Day)


8, 19/3


(Year)


I HEREBY CERTIFY that I have investigated the death of the deceased.


The CAUSE OF DEATH* was as follows :


natural Causes.


Harmonhar.


Spontanen. ythe Brain (apoplexy)


(Duration)


yrs.


mos.


ds.


Contributivo mundial attendant


(SECONDARY)


(Duration)


yrs.


mos. ds.


M.D.


1.45pm MEDICAL EXAMINER


* State the DISEASE CAUSING DEATH, or, in deaths from VIOLENT CAUSES, state (1) MEANS of INJURY; and (2) whether ACCIDENTAL, SUICIDAL Or HOMICIDAL.


18 LENGTH OF RESIDENCE (FOR HOSPITALS, INSTITUTIONS, TRANSIENTS, OR


RECENT RESIDENTS).


At place


of death


.. yr$.


mos.


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


DATE OF BURIAL


Layfayette Ind 6-12- 1913


* UNDERTAKER


W.C. Skaggs


ADDRESS


(Signed) .


9 , 1913 (Address).


11 BIRTHPLACE OF FATHER (State or country)


(Day)


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, ospecially 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 nceded. As examples: (a) Spinner, (3) 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. For VIOLENT DEATHS state MEANS OF INJURY and qualify as ACCIDENTAL, SUICIDAL, Or HOMICIDAL, or as probably such, if impossible to determine definitely. "Examples: Accidental drowning; Struck by railway train - accident ; Revolver wound of head - homicide ; Poisoned by carbolic acid - prob- ably suicide. The nature of the injury, as fracture of skull, and consequences (e. g., sepsis tetanus) may be stated under the head of "Contributory."


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.


COMMONWEALTH OF MASSACHUSETTS


RETURN OF A DEATH-1913. JOHN WELTON


CITY OF BOSTON.


FULL NAME


Registered No. 5631


Place of Death } Boston


CHILDRENS HOSPT.


and Residence S


JUNE 10


1913.


Age


6


years


3


months 8 days.


STATISTICAL DETAILS.


SEX


COLOR


SINGLE, MARRIED, WID., DIV.


S.I.N.


Maiden Name


..... ...


GIST


RAR'S


Husband's Name


BOSTON


Birthplace


Name of


WILLIAM WELTON


Father


Birthplace


BOSTON


of Father.


Maiden Name


ANNA G. LEAHEY


of Mother


Birthplace of Mother.


BOSTON


Occupation


Informant


......


Place of Burial


MALDEN (HOLY CROSS)


or removal


Undertaker P.J.MC ARDLE


PHYSICIAN'S CERTIFICATE.


I HEREBY CERTIFY that I attended deceased during last illness,


from 1913, to 1913, 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 :


PATRILIS, SIT DA { Primary (Duration) AFFICE


SPINA BIFIDA


SICU


CITY


.


TIVITATISR


CONDITAA.


D. 182


TISREGIMINE E. DONATI A. 1330.


BOŚTO


N. MASS Contributory · 3 POST-OPR.SHOCK - 8 DYS


(Duration)


(Signed)


H. J . FITZSIMMONS


M.D.


JUNE ... 10 1913


SPECIAL INFORMATION from Hospitals, Institutions, Transients, or Recen! Residents.


Usual Residence


WINTHROP (34 PICO AVE)


Filed JUNE13 1913.


A true copy. Attest : Simslenen


Registrar.


Date of Death


1


T


I


(


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


Withnot


(No.


53 Prospech are


Ward)


[If death occurred in e hospital or institution, give its NAME instead of street and number.]


Julia Lincoln Flood


2 FULL NAME


[If married or divorced woman or widow give maiden name also name of husband.] @RESIDENCE


wife of LuckE. H. Flood


Registered No.


PERSONAL AND STATISTICAL PARTICULARS


3 SEX


female


4 COLOR OR RACE


5 SINGLE,


MARRIED,


WIDOWED,


OR DIVORCED


(Write the word)


marcel


a DATE OF BIRTH


5


(Month)


(Day)


(Year)


7 AGE


61 yra.


yra.


11


mos.


a


......


ds.


or ........ min. ?


a OCCUPATION


(·) Trade, profession, or


particular kind of work


al Home


(b) General neture of industry, business, or establishment which employed (or employer).


· BIRTHPLACE


(State or country)


Pownell Vt


PARENTS


11 BIRTHPLACE


OF FATHER


(State or country)


Paulet V+


12 MAIDEN NAME


OF MOTHER


13 BIRTHPLACE


OF MOTHER


(State or country)


Paulel VA


14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE


(Informant)


(Address)


REGISTRAR


MEDICAL CERTIFICATE OF DEATH


17


I HEREBY CERTIFY that I attended deceased from


June 3, 1913, to June 10,


1913


...... . that I last saw her alive on 1913 June 10, ........ and that death occurred, on the date stated above, at / 30/.m. The CAUSE OF DEATH* was as follows :


Lobar Pneumonia


(Duration)


- yrs ..


mos.


ds.


Contributory.


Paralysis of the Intestines


(SECONDARY)


(Duration)


yrs. mos.


2


ds.


(Signed)


Albert B. Norman


M.D.


June 11,


1913 ... (Address),


Wenthon 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 plece


mos.


In the


ds .............


of death.


.. yrs.


mos.


ds.


State


yrs.


Where was disease contracted, If not at place of death ?.


Former or usual residence.


12 PLACE OF BURIAL OR REMOVAL


DATE OF BURIAL


June 12


....


3


191


.......


20 UNDERTAKER


ADDRESS


Filed 191


-


16 DATE OF DEATH


time


10


1913


(Month)


(Day)


(Year)


....


10 NAME OF


FATHER


Luther Lincoln


...


If LESS than


1 day ......... hrs.


(City or town.)


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 Ilousc- kcepers 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, 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 deatbs 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 strect, or one supposed to be due to Alcoholism, etc.


4. Deaths under circumstances unknown, as A person found dead, etc.


Registrar.


I certify that this is a true copy of the certificate received for record. Attest,


Medical Certificate of Death State of Conn.


1. Full name of deceased ADA PEARL KELLEY


2. Primary cause of death Ruptured Heart


3. Duration days


4. Secondary or contributory Fractured Ribs


5. Duration


days


Remarks


R. R. Accident - Passenger


I hereby Certify that Iattended the deceased-in h -........ tast illness, and that the cause of death was as above stated.


Signature


Geroge Sherrill, Med. Ex.


Dated


June 13,


19.13 .


Address


Stamford, Conn.


Undertaker's Certificate Personal and Statistical


1. Full name of deceased Ada Pearl Kelley


2. Place of death-Town Stamford No. Railroad


Street


Ward


3. Number of families in house


Winthrop


4. Residence at time of death Boston, Mass. Town State or Country


5. Occupation Housekeeper


6. Condition (state whether single, married, divorced or widowed) ... Married


7. If wife or widow, give name of husband Edward .J. Kelley


8. Date of death-year 1913 , month June


day 12


9. Date of birth-year 1884


month


Feby.


, day


8


10. Age 29 years, 4 months, 4 days


11. Sex Female


12. Color White


13. Birthplace-Town Chicago


State or Country


Illinois


14. Father's name in full Charles Frahm


15. Father's birthplace-Town


State or Country


16. Mother's maiden name


17. Mother's birthplace-Town State or Country


18. Place of burial Chicago, Ill.


Cemetery


19. Name of informant Edward J. Kelley


Address .


Boston, Mass.


20. Was body embalmed Yes If so name Thomas ... A. Brennan


License No. 74


of embalmer


Signature of Undertaker [or Person in charge].


Lyman Hoyt's Son & Co. Address Stamford, Conn.


Wm - Waterbury


Capacny in which he signs


This Certificate received for record on the ....... 13 day of June 19 13.


Chas. H. Martin, SuRegistrar.


Place of Burial Chicago, Cemetery.


Ill.


June 12. 1913 ara Pearl Kelley


This copy of Certificate received for record at


this .. day of 19


Registrar.


THIS 13 A FERMARERI RECURB. -


The Commonwealth of Massachusetts STANDARD CERTIFICATE OF DEATH


I PLACE OF DEATH Winthrop (No. 23


St. :. Ward)


6226 Winthrop (City or town.) [If death occurred in a hospital or institution, give its NAME instead of street and number.]


2 FULL NAME Rudolph &. Schlicken [If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE 23 Linkstay ST. - Wullnap


PERSONAL AND STATISTICAL PARTICULARS


MEDICAL CERTIFICATE OF DEATH


16 DATE OF DEATH


18


19113


....


(Month)


(Day)


(Year)


& DATE OF BIRTH


1871 T


(Day) (Year)


7 AGE


If LESS than I day ......... hrs.


42 .yrs. mos. ds. or ........ min. ?


8 OCCUPATION


(a) Trade, profession, or


particular kind of work


Officción husband


maken


(b) General nature of industry, business, or establishment in which employed (or employer)


Orice 8 Managem


(Duration)


.yrs.


......


.. mos.


ds.


Contributetome dead )


(SECONDARY)


(Duration) .yrs.


mos. ds.


(Signed)


M.D.


AS, 1915 (Address)


12P


MEDICAL EXAMINER


* State the DISEASE CAUSING DEATH, or, in deaths from VIOLENT CAUSES, state (1) MEANS of INJURY; and (2) whether ACCIDENTAL, SUICIDAL or IIOMICIDAL.


18 LENGTH OF RESIDENCE (FOR HOSPITALS, INSTITUTIONS, TRANSIENTS, OR


: RECENT RESIDENTS).


At place


ds.


State


.yrs.


of death.


yrs.


mos.


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


femme 21, 1913


20 UNDERTAKER


ADDRESS Wurlit


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


1ª BIRTHPLACE OF MOTHER (State or country )


C


14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE


(Informant)


C.R. Person


1


(Address)


Filed. 191.


REGISTRAR


natural Causes:


Probables Cardio- renal disease -


9 BIRTHPLACE


(State or country)


Germany (Berlini)


10 NAME OF


FATHER


11 BIRTHPLACE OF FATHER (State or country) ン


9


Marcel


Registered No.


3 SEX


male


4 COLOR OR RACE


White


5 SINGLE,


MARRIED,


WIDOWED,


OR DIVORCED


(Write the word)


(Month)


17 I HEREBY CERTIFY that I have investigated the death of the deceased. The CAUSE OF DEATH* was as follows :




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