USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1913-1915 > Part 48
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9 BIRTHPLACE
(State or country)
17 Quizen SL
10 NAME OF
FATHER
Williani P. Polleras
PARENTS
11 BIRTHPLACE
OF FATHER
(State or country)
13 Mars
12 MAIDEN NAME
OF MOTHER
Hazel. & Parall
18 BIRTHPLACE
OF MOTHER
(State or country)
13 wolkiges h. y.
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
Malúmi 1º Pillerin
(Address)
Filed.
191
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
-
(Month)
(Day)
17 I HEREBY CERTIFY that I attended deceased from March 7, 1914, to March 8 1914
hrs. that I last saw ha alive on March 8, .. 1914. and that death occurred, on the date stated above, at 4 1Pm. The CAUSE OF DEATH* was as follows :
Premature Durch
(Duration) ...
.yrs. ..
mos.
how
Contributory (SECONDARY)
(Duration)
.yrs.
.ds.
mos.
(Signed)
March 9
1914 (Address)
Wennthe Mask.
* 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.
18 PLACE OF BURIAL OR REMOVAL
DATE OF BURIAL
11. 19156
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.
or town.)
Pallerson
-
2 FULL NAME
[If married or divorced woman or widow
give maiden name, also name of husband.]
@RESIDENCE
17 Culler DL
Registered No.
16 DATE OF DEATH
March
8
1914
(Year)
yrs. mos. ds.
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 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, peritonacum, 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
John Stewart
2 FULL NAME
[If married or divorced woman or widow
give maiden name, also name of husband.]
@RESIDENCE
(No.
26. Enfield
St. ; .Ward)
(City or town.) [If death occurred in a hospital or institution, give its NAME instead of street and number.]
Registered No.
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
' COLOR OR RACE
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
Windowsg
6 DATE OF BIRTH
3 (Month)
9
18307
(Day)
(Year)
7 AGE
If LESS than I day ......... hrs.
83 yrs. 11 mos. 19 das.
Or ........ min. ?
& OCCUPATION
(a) Trade, profession, or
particular kind of work.
Sea Capitania
(b) General nature of industry, business, or establishment which employed (or employer)
$ BIRTHPLACE
(State or country)
Scotland
PARENTS
11 BIRTHPLACE
OF FATHER
(State or country)
Scotland
12 MAIDEN NAME
OF MOTHER
18 BIRTHPLACE
OF MOTHER
(State or country)
Scotland
"THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informan
(Address)
3.6 Enfuld Rs-
Filed.
191
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
3
8
(Month)
(Day)
1914 (Year)
I HEREBY CERTIFY that I attended deceased from
het 8
1914
1914
to
that I last saw him
alive on
191
4
and that death occurred, on the date stated above, at
m.
The CAUSE OF DEATH* was as follows :
(Duration)
.yrs. ......
mos.
8
ds.
Contributory
(SECONDARY)
yrs. (Duration) (3)mel call
mos.
......
ds.
(Signed)
M.D.
161
..... (Address)
horas
* If death followed injury or violence the certificate of death must be made out by the Medical Examiner.
15 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
1ª PLACE OF BURIAL OR REMOVAL
DATE OF BURIAL
3-10
191.42
30 UNDERTAKER WC. Skaggs
ADDRESS
Weedlook
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.
General carbonio Velenosi
.
10 NAME OF
FATHER
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 home, who are engaged in the duties of the household only (not paid Ilouse- keepers who receive a definite salary), may be entered as Ilousewife, 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 havo no occupation whatever, write None.
Statement of cause of death .- Name, first, the DISEASE ('AUSING DEATH (the primary affection with respect to time and causation), using always the same accepted term for the same disease. Examples: C'erebro-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- paoumonia (" 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 ; Chronie 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," "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 provisions of chapter 24 of the Revised Laws deaths under the following conditions must be referred to the Medical Examinors:
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
(No. Ist Bundes
St. ;.
Ward)
[If death occurred in a hospital or institution, give its NAME instead of street and number.]
Registered No.
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
4 COLOR OR RACE
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
Manual
(Year)
7 AGE 37 yrs. 1)
If LESS than ! day ......... hrs.
Ss.
or ........ min. ?
(a) Trade, profession, or
particular kind of work
U.S. A.e.
(b) General nature of industry,
business, or establishment in
which employed (or employer).
U.S. army
10 NAME OF
FATHER
Romance. La Clave
12 MAIDEN NAME
OF MOTHER
Julia. La Clara
13 BIRTHPLACE
OF MOTHER
(State or country)
Canada
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
Laurence La Clase
(Address)
Parkway R. 9.
REGISTRAR -
16 DATE OF DEATH
(Month)
(Year)
17
I HEREBY CERTIFY that I attended deceased from
For 20
1914
March 8
to
191
that I last saw h alive on
March 8
161
and that death occurred, on the date stated above, at
5 25 Pm.
The CAUSE OF DEATH* was as follows :
1
(Duration)
yrs.
mos.
16
ds.
Contributory.
(SECONDARY)
yrs. ..
und 19
mos.
ds.
(Signed)
M.D.
14.49. 94
(Address).
Fast Marcher, 'Max.
* 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
Paraje
R.2.
DATE OF BURIAL
3/10
,
19111
20 UNDERTAKER
en. 13.
ADDRESS
Filed 191
(City or town.)
Joseph. La
U.S. R. Clase
[If married or divorced woman or widow
give maiden name, also name of husband.]
@RESIDENCE
2 FULL NAME
3 SEX
6 OCCUPATION
· BIRTHPLACE
(State or country)
11 BIRTHPLACE
OF FATHER
CAUSE OF DEATH in plain terms, so that it may be properly classified. Exact statement of OCCUPATION is very
PARENTS
important. See instructions on back of certificate.
1&
N. B. - Every item of information should be carefuly supplied. AGE should be stated EXACTLY. PHYSICIANS should state
(State or country)
.... ....
(Day)
1914
6 DATE OF BIRTH
X
(Month)
(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 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, peritonacum, 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. .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.
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH
Winthrop
45Herman
Anna Frances Imalone
St. :
: FULL NAME
[If married or divorced woman or widow
give maiden name, also name of husband.]
aRESIDENCE 45 Harmon It
Windwok (City or town.)
Ward)
[If death occurred in a hospital or institution, give its NAME instead of street and number.]
Registered No.
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
4 COLOR OR RACE
Hemale White
5 SINGLE,
MARRIED, --
WIDOWED,
OR DIVORCED
(Write the word)
a Single
6 DATE OF BIRTH
(Month)
12
0,1888
17
I HEREBY CERTIFY that I attended deceased from
(Day)
(Year)
1910
191.
., to
mck 14'
1914
that I last saw h M alive on
mah 14
If LESS than
I day ......... hrs.
1914.
and that death occurred, on the date stated above, at
10 45 mam
7 AGE
25
yrs.
7
mos.
2
....
ds.
or ...
min. ?
8 OCCUPATION
(a) Trade, profession, or
particular kind of work
At Home
(b) General nature of industry.
business, or establishment in
which employed (or employer).
BIRTHPLACE
(State or country)
Överett mase
masa.
PARENTS
12 MAIDEN NAME
Annie Stanton
Canton
11 BIRTHPLACE
OF MOTHER
(State or country)
Boston Mass.
" THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
William @ malone.
( Add
45 Herman It
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
Arch
14 1
1914
(Month)
(Day)
(Year)
The CAUSE OF DEATH* was as follows :
Hida Kms
(Duration)
.. yrs.
mos.
ds.
Contributory
(SECONDARY)
.(Duration)
..... yrs.
mos.
ds.
(Signed)
Mek 15. 1914 (Address)
Winthrop
* If death followed injury or violence the certificate of deafu 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 6
usual residence.
19 PLACE OF BURIAL OR REMOVAL Holy Leves Malden
DATE OF BURIAL
/11av17. 194
20 UNDERTAKER
alm J. Q makey
ADDRESS
19 Atlantic St
Filed 191
....
William@malone
11 BIRTHPLACE OF FATHER (State or country)
Doston Frase
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, Laborcr- Coal mine, etc. Women at home, who are + engaged in the duties of the household only (not paid Hlousc- 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 Examinors:
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 Metinel Hospital, (No. St. ;...... .Ward)
(City or town.)
[If death occurred in a hospital or institution, give its NAME instead of street and number.]
Farnsworth) Pametin Bulk
2 FULL NAME
[If married or divorced woman or widow
give maiden name, also name of husband.]
@RESIDENCE
34 Trident are
wrechnet
Registered No.
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
3 SEX
Male
COLOR OR RACE
white
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
Sanger
6 DATE OF BIRTH
mais
16
(Month)
(Day)
1914
(Year)
7 AGE
3
X
.yrs.
×6
mos.
1914
2 or ....... min. ?
If LESS than I day ... hrs. that I last saw bleu) alive on Mah 16., 194 and that death occurred, on the date stated above, at .. 49cm. The CAUSE OF DEATH* was as follows : Trem ature
(Duration)
yrs.
mos.
.ds.
Contributory.
(SECONDARY)
(Duration)
.. . yrs. ...
mos.
ds.
(Signed)
N.R. Cañto
M.D.
meh 11.
191 4 (Address)
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