Town of Winthrop : Record of Deaths 1913-1915, Part 48

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 48


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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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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