Town of Winthrop : Record of Deaths 1913-1915, Part 27

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 27


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 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



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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