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