USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1913-1915 > Part 27
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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 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.
56
pharant
St. ;
........ .. ....
.Ward)
(City or town.) [If death occurred in a hospital or institution, give its NAME instead of street and number.]
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
& SEX
4 COLOR OR RACE
w
§ SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
Undouad
6 DATE OF BIRTH
(Month)
(Day)
1846
(Year)
7 AGE
If LESS than
I day ......... hrs.
67
„.yrs.
3 ms.
6 de.
or ......... min. ?
& OCCUPATION
(a) Trade, profession, or
particular kind of work
at home
(b) General nature of industry.
business, or establishment in
which employed (or employer).
9 BIRTHPLACE
(State or country)
Newton - mars
PARENTS
12 MAIDEN NAME
OF MOTHER
Mary G. Varney
13 BIRTHPLACE
OF MOTHER
(State or country)
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant) ...
Hamon Foule
(Address)
5% Sleaccent
REGISTRAR
17
I HEREBY CERTIFY that I attended deceased from
191
3, to.
1913.
that I last saw her
alive on
20
1915.
and that death occurred, on the date stated above, at,
9309m.
The CAUSE OF DEATH* was as follows :
Carcinoma 1 Vulva 8 Grossas
(Duration)
1 yrs.
.........
mos.
ds.
Contributory
(SECONDARY)
(Duratien)
.... yrs.
mos.
ds.
(Signed)
jamed calf
M.D.
une4 22, 19/3 (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).
In the
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.
IS PLACE OF BURIAL OR REMOVAL In .
Prize levoue Sem Grafton Mar
DATE OF BURIAL
8-23-
1913
-
ADDRESS
Filed 131
16 DATE OF DEATH
auf
2/
(Month)
(Day)
1913
(Year)
2 FULL NAME
Clara
4. Knight
Baker -Buy. W. Knight
[If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE 96 pleasant Stilwinther
Registered No.
20 UNDERTAKER
W.C. Skaggs
10 NAME OF
FATHER
Joseph W Baker,
11 BIRTHPLACE
OF FATHER
(State or country)
STANDARD CERTIFICATE OF DEATH.
Statement of occupation. - Precise statement of occupa- tion is very important, so that the relative healthfulness of various pursuits can be known. The question applies to each and every person, irrespective of age. For many occupations a single word or term on the first line will be sufficient, e. g., Farmer or Planter, Physician, Compositor, Architect, Loco- motive engineer, Civil engineer, Stationary fireman, etc. But in many cases, especially in industrial employments, it is necessary to know (a) the kind of work and also (b) the nature of the business or industry, and therefore an additional line is provided for the latter statement; it should be used only when needed. As examples: (a) Spinner, (b) Cotton mill; (a) Sales- man, (b) Grocery ; (a) Foreman, (b) Automobile factory. The material worked on may form part of the second statement. Never return "Laborer," "Foreman," " Manager," "Dealer," etc., without more preciso 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 Nonc.
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 usc of "Croup ") ; Typhoid fever (never re- port " Typhoid pneumonia ") ; Lobar pneumonia ; Broncho- pneumonia (" Pneumonia," unqualified, is indefinite) ; Tuber-
culosis of lungs, meninges, peritonaeum, etc , Carcinoma, Sar- coma, etc., of .... (name origin: "Cancer" is less definite; avoid use of "Tumor " for malignant neoplasms) ; Measles; Whooping cough; Chronic valvular heart disease; Chronic interstitial nephritis, etc. The contributory (second- ary or intercurrent) affection need not be stated unless im- portant. Example: Measles (disease causing death), 29 ds .; Broncho-pneumonia (secondary), 10 ds. Never report mere symptoms or terminal conditions, such as " Asthenia," " An- aemia " (merely symptomatic), " Atrophy," "Collapse," " Coma," " Convulsions," "Debility " ("Congenital," "Senile," etc.), "Dropsy,""Exhaustion," "Heart failure," "Haemorrhage," "Inanition," " Marasmus," " Old age," "Shock," "Uraemia," " Weakness," etc., when a definite disease can be ascertained as the cause. Always qualify all diseases resulting from childbirth or miscarriage, as "PUER- PERAL septicaemia," " PUERPERAL peritonitis," etc. State cause for which surgical operation was undertaken.
Cases for the Medical Examiners. - Under the provisions of chapter 24 of the Revised Laws deaths under the following conditions must be referred to the Medical Examiners:
1. Deaths following injury or violence, as Burns, Falls, Drowning, Gas Poisoning, Suicide, Homicide, etc.
2. Deaths supposedly caused by violence, as Criminal Abortion, Poisoning, Starvation, Suffocation, Ex- posure, etc.
3. Sudden deaths of persons not disabled by recognized disease, as A death upon the street, or one supposed to be due to Alcoholism, etc.
4. Deaths under circumstances unknown, as A person found dead, etc.
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH Metcalf Hittar W Muchrot fl
(City or town.)
[If death occurred in a hospital or institution, give its NAME instead of street and number.]
2 FULL NAME
[If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE Cleveland Ohio
Registered No.
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
3 SEX
4 COLOR OR RACE
White
5 SINGLE,
MARRIED,
WIDOWED,
Married
OR DIVORCED
(Write the word)
6 DATE OF BIRTH
Dec
(Month)
(Day)
7 AGE
59
yrs. 8 mos. . 19 ds.
8 OCCUPATION (a) Trade, profession, or particular kind of work
(b) General nature of industry, business, or establishment in which employed (or employer)
9 BIRTHPLACE
(State or country)
turillay Olivo
.
10 NAME OF
FATHER
Robert Holly day
JI BIRTHPLACE OF FATHER (State or country)
12 MAIDEN NAME OF MOTHER Lydia Patterson
13 BIRTHPLACE OF MOTHER (State of Bellfountain Otici
" THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
(Address)
Filed 191
REGISTRAR
16 DATE OF DEATH
ang
(Month)
(Year)
I HEREBY CERTIFY that I attended deceased from
23
191.3 .. , to
If LESS than
! day, ...
hrs.
that I last saw hun alive on ..
any 2 3 , 1913,
and that death occurred, on the date stated above, at .9 55 pm.
or ....... min. ?
The CAUSE OF DEATH* was as follows :
)y phone Fewer
Perforation
(Duration)
yrs. ...
mos. .. 2,
ds.
Contributory (SECONDARY)
(Duration) yış.
mos. ..
ds.
(Signed)
~1
Ly 25. 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.
12 ds.
State
ds.
Where was disease contracted,
If not at place of death ?....
usual residence ..
Former or
65 Summit any windhoff
19 PLACE OF BURIAL OR REMOVAL
DATE OF BURIAL
Washington D. C Cing 2 8, 191
3
20 UNDERTAKER
ADDRESS
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.
John Wilson Holly day
St. :.. Ward)
24, 193
(Day)
1
17
1.853
(Year)
PARENTS
In the
yrs.
20 mos.
., M.D.
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 ('AUSING 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 cercbro-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, peritonaeun, 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," "Scnile," 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
metcalf Hospital
(No.
St. :
Ward)
(City or town.) [If death occurred in a hospital or institution, give its NAME instead of street and number.]
2 FULL NAME
George a. West
[If married or divorced woman or widow
give maiden name, also name of husband.]
@RESIDENCE 123 Buchanan Sf
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
3 SEX
male
4 COLOR OR RACE
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
manuel
6 DATE OF BIRTH
prie
(Month)
20
854
17
(Year)
7 AGE
If LESS than I day, ........ hrs.
59 yrs.
mos.
ds.
or ...
.. min. ?
3 OCCUPATION
(a) Trade, profession, or
particular kind of work
Laborer
(b) General nature of industry,
business, or establishment in
which employed (or employer).
9 BIRTHPLACE
(State or country)
England
PARENTS
11 BIRTHPLACE
OF FATHER
(State or country)
England
12 MAIDEN NAME
OF MOTHER
Rachael Thornton
:ª BIRTHPLACE
OF MOTHER
(State or conntry)
England
" THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
men Wear
(Address)
123 Buchman Sr
Filed 19 .........
REGISTRAR ....
16 DATE OF DEATH
Left
2ª
1913
(Month)
(Day)
(Year)
I HEREBY CERTIFY that I attended deceased from
amy , 0'
1913.
to
Sift for
1913
that I last saw h.
alive on
Saft 12
93
and that death occurred, on the date stated above, at.
12
m.
The CAUSE OF DEATH* was as follows :
My phone
7wer
(Duration)
......
.yrs.
mos.
22
ds.
Contributory
(SECONDARY)
.(Duration)
yss.
mos. ds.
(Signed)
31 Mulcall
M.D.
191 .-
3
(Address)
....
* If death followed injury or violence the certificate of death must be made out by the Medical Examiner.
IS LENGTH OF RESIDENCE (FOR HOSPITALS, INSTITUTIONS, TRANSIENTS, OR RECENT RESIDENTS).
At place
of death.
yrs.
mos.
20 ds.
In the
State.
... yrs.
......
... mos.
ds .............
Where was disease contracted,
If not at place of death ?.
123 Buchman st Wanting's
Former or
usual residence
12 B Buchen
Waitup !
1º PLACE OF BURIAL OR REMOVAL
DATE OF BURIAL
2m
Nordlacan leaveby Med Sept 3 1913
20 UNDERTAKER
ADDRESS E. G. Brown Ron Tuss Boston
10 NAME OF
FATHER
Thomas
BOSTON
Registered No.
(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, irrespectivo 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 homo, 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.
COMMONWEALTH OF MASSACHUSETTS
RETURN OF A DEATH-1913.
CITY OF BOSTON.
FULL NAME JENNINGS
Registered No .....
8147
Place of Death Boston
44.WINTHROP ST (HOSPT)
and Residence S
Date of Death
SEPT . 5
1913. Age
years
months 3 days
STATISTICAL DETAILS.
SEX
COLOR
SINGLE, MARRIED, WID., DIV.
M
SIN.
Maiden Name .......
Husband's Name
.....
CITY :REC
Birthplace .. BOSTON
Name of Father C.H.A.R.L.E.S . H . JENNINGS.
Birthplace of Father E. N.G.L.AND
Maiden Name
of Mother CO.R.A .. . U.N.I.O.N.
Birthplace of Mother
Occupation
Informant.
Place of Burial or removal .. MT.HOPE
Undertaker 4 ... S .. W.A.TE.B.MAN ..... SONS
PHYSICIAN'S CERTIFICATE.
I HEREBY CERTIFY that I attended deceased during last illness,
1913,
from 1913, 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'
Primary DIFFICULT LABOR- MITRAL RE- (Duration)
IFICE
0.1 219
^'DONAT .5
N
Contributory · 3 (Duration) 1
(Signed)
..... O .. . BA.R.T.LE.I.T. ............ M.D.
1913
SPECIAL INFORMATION from Hospitals, Institutions, Transients, or Recen! Residents.
Usual Residence
WINTHROP
Filed
SE.P.T .... 8 . 1913.
A true copy. Attest :
Registrar.
1
G.U.R.G.I.T.A.I.I.G.N.
.
MASS
TO
Sept. 5, 1913
COMMONWEALTH OF MASSACHUSETTS
RETURN OF A DEATH-1913.
CITY OF BOSTON.
FULL NAME
ROSIE BUTEYM
Registered No .. .
8173
Place of Death Boston
CARNEY HOSPT
and Residence S
Date of Death
SEPT.5
1913.
Age
1 9
years
months
.... days.
STATISTICAL DETAILS.
SEX
COLOR
SINGLE, MARRIED, WID., DIV.
FEM.
WHITE
SIV.
Maiden Name
Husband's Name
Birthplace
POLAND
Name of Father CHARLES BUTEYM 0 8 BØSTO
Birthplace
of Father ...
POLAND
Maiden Name
of Mother.
REGINA KRECZUHONA
Birthplace of Mother
POLAND
Occupation HOUSEWORK
Informant
PHYSICIAN'S CERTIFICATE.
I HEREBY CERTIFY that I attended deceased during last illness,
from
913, 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 : RAR'S
Primary (Duration-)
POST-PARTUM HEM. FOL. PREMATURE
OFFICE:
BIRTH OF FOETUS - I DAY
ATA A.1 2
J. MAS.S.
Contributory · ¿ TOXAEMIA AND (Duration)
NEPHRITIS
(Signed)
WALTER RYDER
M.D.
SEPT. 5 1913
SPECIAL INFORMATION from Hospitals, Institutions, Transients, or Recent Residents.
Place of Burial
or removal
MT . BENEDICT
Undertaker
W. J. CASSIDY
Usual Residence
WINTHROP (36 CUTLER ST)
Filed.
SEPT . IO
1913.
A true copy.
Attest:
Registrar.
: CITY : REG
ICU., VAI
C
ETVITATIS REV
BIFF HTRãO A 16 MAUTJR
sehr.
1
1
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
11 BIRTHPLACE OF FATHER (State or country) Unknown
12 MAIDEN NAME OF MOTHER Phoebe Dunham
1ª BIRTHPLACE OF MOTHER (state or country ) unknown
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant).
George . Freeman
( Address)
131 Grover are stuthree
-
F .d 191
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
Sept.
9. 1913
(Year)
(Month
(Dấy)
17 I HEREBY CERTIFY that I have investigated the
death of the deceased.
If LESS than
1 day, ..
hrs.
The CAUSE OF DEATH* was as follows :
natural Causes!
min. ?
Character indefinite
be cardio
disease
or havesont
(Spontaneoora) dy itxa Brno
ds.
Contributory
(SECONDARY)
(Duration)
yrs. ...
mos. ds.
Junge Burgers magaly.
M.D.
Sist 903
3. 1PKT 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, OF RECENT RESIDENTS).
At place
of death
yrs.
m.os.
ds.
State.
In the
yrs. ..
mos. .
ds.
Where was disease contracted, if not at place of death ?.
Former or usual residence.
19 PLACE OF BURIAL, OR WELLSY Chewy DATE OF BURIAL coveration Fioreet Hellocely Sept. 12 1913
"O UNDERTAKER
ADDRESS
Vefrancis Mi Hilson Lowerville
5975 Winthrop (City or town.) Elf death occurred in a hospital or institution, give its NAME instead of street and number.]
2 FULL NAME
Imars
[If married or divorced woman of widow give maiden name, also name of Husband.] @RESIDENCE menalle . mars
quest- George Poireauxan
Registered No.
PERSONAL AND STATISTICAL PARTICULARS
3 SEX Randle
4 COLOR OR RACE
White
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
Married
· DATE OF BIRTH
July (Month)
(Day)'
1 1846 (Year)
7 AGE
67 yrs. 2 mos.
mos. 8 ds.
(a) Trade, profession, or particular kind of work Housewife
(b) General nature of industry, business, or establishment in which employed (or employer)
9 BIRTHPLACE (State or country) Newark st. C.
10 NAME OF
FATHER
Aaron quest
8 OCCUPATION
(
The Commonwealth of Massachusetts STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH
(No. 130
are St. Ward)
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 occupations a single word or term on the first line will be sufficient, c. g., Farmer or Plunter, Physician, Compositor, Architcet, 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, Laborcr - 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. Carc 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 occu- pation whatever, write None.
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