USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1913-1915 > Part 40
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).
Part 1 | Part 2 | Part 3 | Part 4 | Part 5 | Part 6 | Part 7 | Part 8 | Part 9 | Part 10 | Part 11 | Part 12 | Part 13 | Part 14 | Part 15 | Part 16 | Part 17 | Part 18 | Part 19 | Part 20 | Part 21 | Part 22 | Part 23 | Part 24 | Part 25 | Part 26 | Part 27 | Part 28 | Part 29 | Part 30 | Part 31 | Part 32 | Part 33 | Part 34 | Part 35 | Part 36 | Part 37 | Part 38 | Part 39 | Part 40 | Part 41 | Part 42 | Part 43 | Part 44 | Part 45 | Part 46 | Part 47 | Part 48 | Part 49 | Part 50 | Part 51 | Part 52 | Part 53 | Part 54 | Part 55 | Part 56 | Part 57 | Part 58 | Part 59 | Part 60 | Part 61 | Part 62 | Part 63 | Part 64 | Part 65 | Part 66 | Part 67 | Part 68 | Part 69 | Part 70 | Part 71 | Part 72 | Part 73 | Part 74 | Part 75 | Part 76 | Part 77 | Part 78 | Part 79 | Part 80 | Part 81 | Part 82 | Part 83 | Part 84 | Part 85 | Part 86 | Part 87 | Part 88 | Part 89 | Part 90 | Part 91 | Part 92 | Part 93 | Part 94 | Part 95 | Part 96 | Part 97 | Part 98 | Part 99 | Part 100 | Part 101 | Part 102 | Part 103 | Part 104 | Part 105 | Part 106 | Part 107 | Part 108 | Part 109 | Part 110 | Part 111 | Part 112 | Part 113 | Part 114 | Part 115 | Part 116 | Part 117 | Part 118 | Part 119 | Part 120 | Part 121
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.
8. 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
derpy REVERE.
RETURN OF A DEATH
(CITY OR TOWN.)
FULL NAME
Menu H. Kurtis
.Registered No.
2
Place of Revere, 66 Crescente fre.
Death * 5
Residence
Winthrop, 435 Withrof Px,
Age
1
.. years.
11
28
.. months
days
STATISTICAL DETAILS
COLOR
SINGLE, MARRIED,
SEX
Male White
DIVORCED
Single
MAIDEN NAME +
HUSBAND'S NAME +
BIRTHPLACE # Boston, Meaza
NAME OF
FATHER
Unknown
BIRTHPLACE
OF FATHER+
MAIDEN NAME
OF MOTHER
Sophi Kurlia
BIRTHPLACE OF MOTHER $ Poland, Russia
OCCUPATION
INFORMANT §
R. R. Benson
Winthrop, Meuse.
PLACE OF BURIAL OR REMOVAL II
Winthrop, Meass.
DATE OF BURIAL
Jan. 5, 1914.
UNDERTAKER de R. Bennison
ADDRESS Winthrop, Means
PHYSICIAN'S CERTIFICATE
I HEREBY CERTIFY that I attended deceased during last illness, from Dec. 28 1903 to Jan, 2, 19/14, 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 :
Primary
(le de ma of lunge + Brain
(BURATION).
. DAY8
Contributory :
Congenital Syphilis
2 years (DURATION)
.. DAY8
Brannmid A. Auchens .M.D. ¿Signed)\ Jan 3, 1964 Address avere 687 Withnon Ave
SPECIAL INFORMATION only for Hospitals, Institutions, Transients, or Recent Residents.
How long at
Place of Death ?
years.
....
.. months ..
days
Where was disease contracted,
If not at place of death ?.
Filed Jan. 10,1964@Shareof
Clerk'
* City or town, street and number, If any. If death occurs away from USUAL RESI- DENCE, glve facts called for under "Speclal Information." If In a Hospital or Institution, give Its NAME Instead of street and number.
t In case of married or divorced woman, or widow. * State or country j aiso city, town or county, If known.
§ Name and address of person giving statistical details. Il Name of cemetery.
Date of January 8 20 914
Death
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH
Withiops
(No. 303 Maria
St. ;..
„Ward)
(City or town.)
[If death occurred in a hospital or institution, give its NAME instead of street and number.]
2 FULL NAME
Hubert D. Hlige
[If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE
Registered No.
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
3 SEX
' COLOR OR RACE
W
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
Single
$ DATE OF BIRTH
12 (Month)
5-
9/2
(Day)
(Year)
7 AGE
If LESS than
I day ........ hrs that I last saw h unalive on
1914. and that death occurred, on the date stated above, at 6 cm. The CAUSE OF DEATH* was as follows :
acute Intestinal auto-
intera tofammia
Contributory
(SECONDARY)
X
(Duration)
yrs.
.. mos.
3 ds.
(Duration)
yrs.
mos. ds.
(Signed)
Grill & Salvatore, M.D.
Sony 5, 1914 (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.
......
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
1-7
......
19KL
(Address)
30/3 Main Strenethat Willnot com
20 UNDERTAKER
W.C: Skaggs
ADDRESS
Willnot
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)
DEBoston Mary
12 MAIDEN NAME
OF MOTHER
Laura Daleman.
18 BIRTHPLACE
OF MOTHER
(State or country}
Lockport I-S.
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
Buy. 4. Filee.
Filed 191
REGISTRAR
16 DATE OF DEATH
(Month)
(Day) 5~ ,19156 (Year) .....
17 I HEREBY CERTIFY that I attended deceased from Domy 4, 1914, to Sau 5, 1914
.ds.
Or ......... min. ?
& 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
FATHER
Benj. J. Flyge-
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 cach 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 Planter, Physician, Compositor, Architect, Loco- motive engineer, Civil engineer, Stationary fireman, ctc. 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) Groecry; (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 gaill- 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 occu- pation whatever, write None.
Statement of cause of death. - Name, first, the DIS- EASE CAUSING DEATH (the primary affection with respect to time and causation), using always the same accepted term for the same disease. Examples: Cerebro-spinal fever (the only definite synonym is "Epidemie cerebro-spinal meningitis"); Diphtheria (avoid use of "Croup"); Typhoid fever (never re- port "Typhoid pneumonia"); Lobar pneumonia; Broncho- pneumonia ("Pneumonia," unqualified, is indefinitc); Tuber-
coma, etc., of ... .... (name origin: "Cancer" is less definite; avoid use of "Tumor" for malignant neoplasms); Mcasles; Whooping cough; Chronic valvular heart disease; Chronic interstitial nephritis, ctc. The contributory (second- ary or intercurrent) affection need not be stated unless im- portant. Example: Mcasles (discase causing death), 29 ds .; Broncho-pneumonia (secondary), 10 ds. Never report merc symptoms or terminal conditions, such as "Asthenia," "An- acmia" (merely symptomatic), "Atrophy," "Collapse," "Coma," "Convulsions," "Debility" ("Congenital," "Senile," ctc.), "Dropsy," "Exhaustion," "Heart failure," "Haemorrhage," "Inanition," "Marasmus," "Old age," "Shock," "Uraemia," "Weakness," etc., when a definite discase can be ascertained as the cause. Always qualify all discases resulting from childbirth or miscarriage, as "PUER- PERAL septicaemia," "PUERPERAL peritonitis," ctc. State cause for which surgical operation was undertaken.
Cases for the Medical Examiners. - Under the provi- sions of chapter 24 of the Revised Laws deaths under the fol- lowing conditions must be referred to the Medical Examiners:
1. Deaths following injury or violence, as Burns, Falls, Drowning, Gas poisoning, Suicide, Homicide, etc.
2. Deaths supposedly caused by violence, as Criminal abortion, Poisoning, Starvation, Suffocation, Ex- posure, etc.
3. Sudden deaths of persons not disabled by recognized discase, 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
Municherp
(No. 102
Pleasant
St. : .... . Ward)
BOSTON
(City or town.) [If death occurred in a hospital or institution, give its NAME instead of street and number.]
2 FULL NAME
Adelaide Loveland
[If married or divorced woman or widow give maiden name, also name of husband.] Brandon aRESIDENCE 102 Pleasant 81 EB.
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
3 SEX
Female
4 COLOR OR RACE
White
$ SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word,
Divorced
16 DATE OF DEATH
Jan
(Month)
5.
,1914
(Year)
(Day)
6 DATE OF BIRTH
Dee
(Month)
21
(Day)
(Year)
7 AGE
73 yrs.
- -
mos. 15 ds.
or ........ min. ?
* OCCUPATION
(a) Trade, profession, or
particular kind of work
ar / forme
(b) General nature of industry, business, or establishment in which employed (or employer)
9 BIRTHPLACE
(State or country)
Boston Mass
PARENTS
11 BIRTHPLACE
OF FATHER
(State or country)
york Me
12 MAIDEN NAME
OF MOTHER
Mary Painted
13 BIRTHPLACE
OF MOTHER
(State or country)
york Me.
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
nice Stella Parker
(Address)
102 Pleasant
REGISTRAR
17
840
amy 3º
1913
a
If LESS than
day,
.... hrs.
that I last saw h 2
alive on
when 31st
1913
and that death occurred, on the date stated above, at 5 50 g m.
The CAUSE OF DEATH* was as follows :
mitral Regurgitation
Chronic Indicarcitin
(Duration)
.yrs.
6
mos.
ds.
Contributory
(SECONDARY)
(Duration)4 ..
„yrs.
mos.
ds.
(Signed)
M.D.
1914
(Address)
Writhing
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.
In the
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
DATE OF BURIAL
2 Pm
Winthrop Gerneles Dan 7, 1914
20 UNDERTAKER
ADDRESS E.G. Brown Han Eass Boston
Filed .. 191 ...
...
I HEREBY CERTIFY that I attended deceased from 1
to
19184
·
Registered No.
10 NAME OF
HER Henry Bragdo
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. Tho question applies to eachlı 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, ctc. But in many cases, especially iu industrial employments, it is necessary to know (a) the kind of work and also (b) the nature of the business or industry, and therefore an additional line is provided for the latter statement ; it should be used only when needed. As examples: (a) Spinner, (b) Cotton mill; (a) Sales- man, (b) Grocery ; (a) Forcman, (b) Automobilefactory. 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 minc, 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 takea to report specifically the occupations of persons engaged in domestic service for wages, as Servant, Cook, Ilousemaid, 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 deatlı), 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
Winthrop
(No.
441
Winner
St. :. .......... Ward)
Eli Rour
" FULL NAME [If married or divorced woman or widow give maiden name, also name of husband.] aRESIDENCE 441 Winnilook at. Werde com
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
(Month)
T
1914
(Year)
(Day)
· DATE OF BIRTH
16
85%
(Year)
7 AGE
If LESS than
I day ......... hrs.
56 yrs. 6 mos. 2º ds.
or ....... .min. ?
B OCCUPATION
(a) Trade, profession, or
particular kind of work
(b) General nature of Industry, business, or establishment in which employed (or employer).
17 I HEREBY CERTIFY that I attended deceased from Jan 4 191.54, to 1914 .... that I last saw ha alive on .... 1914. and that death occurred, on the date stated above, at 69 m. The CAUSE OF DEATH* was as follows : Falar Pneumonia
.(Duration) ...... yrs. ..
....... mos. 7 ds.
Contributory
(SECONDARY)
(Duration) yrs.
......
............
(Signed)
Charles7. mahoney
...... , M.D.
fra 7, 1914 (Address) 355 hmetly Sp
.....
( 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.
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
1-7- 194
* UNDERTAKER
WO Façon
ADDRESS
wiellager
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)
New Foundland
12 MAIDEN NAME
OF MOTHER
C
-
13 BIRTHPLACE OF MOTHER (State or country)
" THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
(Address) Left Withop Se
Filed
191
.....
REGISTRAR
(City or town.)
[if death occurred in a hospital or institutico, give its NAME instead of street and number.j
Registered No.
3 SEX
4 COLOR OR RACE
W
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
mamed
6 (Month)
(Day)
9 BIRTHPLACE
(State or country)
10 NAME OF
FATHER
700
Thomas Kowe-
.. mos. ds.
.......
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 cach 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, 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 laborcr, Farm laborer, Laborer - Coal mine, ete. 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, Houscwork, 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 domestie 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.
Statement of cause of death. - Name, first, the DIS- EASE CAUSING DEATH (the primary affcetion 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 "Epidemie cerebro-spinal meningitis"); Diphtheria (avoid use of "Croup"); Typhoid fever (never re- port "Typhoid pneumonia"); Lobar pneumonia; Broncho- pneumonia ("Pneumonia," unqualified, is indefinite) ; Tuber-
coma, etc., of. (name origin: "Cancer" is less definite; avoid use of "Tumor" for malignant ncoplasms); 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 eausing 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," "Hacmorrhage," "Inanition," "Marasmus," "Old age," "Shock," "Uracmia," "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 provi- sions of chapter 24 of the Revised Laws deaths under the fol- lowing conditions must be referred to the Medical Examiners:
1. Deaths following injury or violence, as Burns, Falls, Drowning, Gas poisoning, Suicide, Homicide, etc.
2. Deaths supposedly 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 Commmuralth of Massachusetts STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH
( No.
4
St. ; ...... Ward)
Manon Ruber infrey.
2 FULL NAME
6
6
[If married or divorced woman or widow
give maiden name, also name of husband.]
@RESIDENCE
4 vaganione eva litros
Registered No.
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
4 COLOR OR RACE
w
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
V
$ DATE OF BIRTH
7 31
(Month)
(Day)
(Year)
7 AGE
If LESS than
I day ......... hrs.#
... yrs.
5 mos.
6
ds.
Or ......... min. ?
& 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)
Winthrop
PARENTS
12 MAIDEN NAME
OF MOTHER
Ruby Beauce
18 BIRTHPLACE
OF MOTHER
(State or country)
NewHaven-
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
(Address)
Filed
191
....
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
913
17
I HEREBY CERTIFY that I attended deceased from
how. 5ch
1912 to
1914
that ! last saw b/2/
alive on
1914
and that death occurred, on the date stated above, at.
1.0
m.
The CAUSE OF DEATH* was as follows :
......
(Duration)
O
.yrs.
mos.
ds.
Contributory.
(SECONDARY)
.. (Duration)
.yrs.
.. mos.
ds.
(Signed)
7
191 (Address)
Winstrol Mes
M.D.
* 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 ............
In the
Where was disease contracted, If not at place of death ?
Former or usuai residence.
19 PLACE OF BURIAL OR REMOVAL
DATE OF BURIAL
1-4- 194
20 UNDERTAKER
ADDRESS
(City or town.)
[If death occurred in a hospital or institution, give its NAME instead of street and number.]
7. 1914
(Month)
(Day)
(Year)
.........
10 NAME OF
FATHER
11 BIRTHPLACE
OF FATHER
(State or country)
....... ,
STANDARD GERTIFICATE 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, e. g., Farmer or Planter, Physician, Compositor, Architect, Loco- motive engineer, Civil engineer, Stationary fircman, cte. 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) Forcman, (b) Automobile factory. The material worked on may form part of the second statement. Never return "Laborer," "Foreman," "Manager," "Dealer," ete., without more precise specification, as Day laborcr, Farm laborcr, Laborcr - Coal mine, etc. Women at home, who are engaged in the duties of the household only (not paid Housc- 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 Scrvant, 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 (retircd, 6 yrs.). For persons who have no occu- pation whatever, write None.
Statement of cause of death. - Name, first, the DIS- EASE CAUSING DEATH (the primary affection with respect to time and causation), using always the same accepted term for the same disease. Examples: Ccrebro-spinal fever (the only definite synonym is "Epidemie cerebro-spinal meningitis"); Diphtheria (avoid use of "Croup"); Typhoid fever (never re- port "Typhoid pneumonia"); Lobar pneumonia; Broncho- pneumonia ("Pneumonia," unqualified, is indefinite) ; Tuber-
Need help finding more records? Try our genealogical records directory which has more than 1 million sources to help you more easily locate the available records.