Town of Winthrop : Record of Deaths 1913-1915, Part 49

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 49


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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Heatherof


* 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


3


3/2


0


191


.....


20 UNDERTAKER


ADDRESS


Filed 191 ..


REGISTRAR


16 DATE OF DEATH


(Month)


(Day)


16


19152


(Year)


17 I HEREBY CERTIFY that I attended deceased from


191.


ta


4 Mah, 16. 1914


8 OCCUPATION


(a) Trade, profession, or


particular kind of work


(b) General nature of industry,


business, or establishment


in


which employed (or employer).


' BIRTHPLACE


(State or country)


10 NAME OF


FATHER


Rexford. C


PARENTS


11 BIRTHPLACE


OF FATHER


(State or country)


Franklin to call


U.H.


12 MAIDEN NAME


OF MOTHER


Paddie May Blake


18 BIRTHPLACE


OF MOTHER


(State or country)


Gilvington n. H.


14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE


(Informant)


(Address)


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, 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.


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


(No


270 Shirley DO. S.


Winthrop BOSTON


(City or town.)


[If death occurred in a hospital or institution, give its NAME instead of street and number.]


2 FULL NAME


Margaret Chan Maloney


[If married or divorced wowfan or widow give maiden name, also name of husband.] @RESIDENCE 270 Shirley It. Winthrop


Registered No.


PERSONAL AND STATISTICAL PARTICULARS


3 SEX


Female White


4 COLOR OR RACE


5 SINGLE,


MARRIED,


WIDOWED,


OR DIVORCED


(Write the word)


Married


' DATE OF BIRTH


aug


(Month)


(Day)


1


(Year)


7 AGE 50


yrs.


7


mos.


ds.


Or ....... min. 3


& OCCUPATION


(a) Trade, profession, or


particular kind of work


House wife


(b) General nature of industry,


business, or establishment in


which employed (or employer).


9 BIRTHPLACE


(State or country)


Boston


PARENTS


12 MAIDEN NAME


Elizabeth MCormick


13 BIRTHPLACE OF MOTHER (State or country) Ireland


14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE


(Informant) Joseph & Maloney


(Address)


REGISTRAR


17 I HEREBY CERTIFY that I attended deceased from Que // 1914. to


191


4


that I last saw her


alive on


191


manche 16 4 and that death occurred, on the date stated above, at 3H m. The CAUSE OF DEATH* was as follows : Artisvia


(Duration) .............. yrs.


2


mos.


· ds.


Houghins surance


Contributory.


(SECONDARY)


(Duration)


ds.


(Signed)


3/11


191% (Address)


* If death followed injury or violence the certificate of de:lib tuist bemque 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 Holy Cross. Malden.


DATE OF BURIAL


March 19, 191


4


10 UNDERTAKER


ADDRESS


Edward J. Dando 123 Maverick It.En


....


Filed 191


MEDICAL CERTIFICATE OF DEATH


16 DATE OF DEATH


March 17


191


4 ......


(Month)


(Day)


( Year)


Margareta. Grady


Ward)


Joseph of


ZM.D.


10 NAME OF


FATHER


Patrick Grady


11 BIRTHPLACE


OF FATHER


(State or country)


Ireland


If LESS than


I day. ....... hrs.


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," " Forcman," " Manager," "Dealer," etc., without more precise specification, as Day laborer, Farm laborer, Laborer- Coal mine, ctc. 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 np 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 , C'arcinoma, Sar- 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, 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 septicacmia," "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 le 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 Commomuralth of Massachusetts


STANDARD CERTIFICATE OF DEATH


1 PLACE OF DEATH


(No.


16


Cora


St. :


Ward)


(City or town.) Elf death occurred la a hospital or institution, give its NAME Instead of street and number.]


Registered No.


PERSONAL AND STATISTICAL PARTICULARS


MEDICAL CERTIFICATE OF DEATH


$ SEX


4 COLOR OR RACE


W


5 SINGLE,


MARRIED.


WIDOWED.


OR DIVORCED


(Write the word)


Vinyle


6 DATE OF BIRTH


4


(Month)


21


(Day)


1848


(Year)


7 AGE


If LESS than


1 day ......... hrs.


7.3 yrs. 10


... yrs.


18 da


da.


mos. ....


of ......... min. ?


8 OCCUPATION


(a) Trade, profession, or


particular kind of work


Computer


(b) General nature of industry,


business, or establishment


in


which employed (or employer).


9 BIRTHPLACE


(State or country)


N.E.J.


10 NAME OF


FATHER


Dave Douglas


-


11 BIRTHPLACE


OF FATHER


(State or country)


P.E.J.


12 MAIDEN NAME


OF MOTHER


Mande Clack-


13 BIRTHPLACE


OF MOTHER


(State or country)


(P.E.).


14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE


(Informant)


Leo. Nowytal


(Address)


1b


Filed 191


REGISTRAR


18 DATE OF DEATH


3 -


(Month)


(Day)


19


1914


(Year)


I HEREBY CERTIFY that I attended deceased from mck 11


1914


to


Ich 19'


191.4


that I last saw him


alive on


much 1 9'


1914


and that death occurred, on the date stated above, at


9409m.


The CAUSE OF DEATH* was as follows :


mitral requigitation


Chronic Indicarditis


.(Duration)


........... yrs. ................ mos.


14 da.


Contributory.


(SECONDARY)


(Duration)


yrs.


.........


.. mos.


........


ds.


31 melcall


M.D.


(Signed)


meh 20, 1914


(Address).


Winthrop


* If death followed injury or violence the certificate of death must be made out by tho Medical Examiner.


18 LENGTH OF RESIDENCE (FOR HOSPITALS, INSTITUTIONS, TRANSIENTS, OR RECENT RESIDENTS).


Åt place


In the


of death ........


.. yrs.


mos. ....


......


State ...... y.3.


.. 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


3-21, 1914


30 UNDERTAKER


1cstaggo


ADDRESS


e


PARENTS


William F. Douglas.


2FULL NAME


[If married or divorced woman or widow


give maiden name, also name of husband.]


@RESIDENCE


Wincheops


STANDARD CERTIFICATE OF DEATH,


٢ 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 fireman, etc. But in many cases, especially in industrial employinents, 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 which needed. As examples: (a) Spinner, (b) Cotton mill; (a) Salcs- man, (b) Grocery; (a) Foreman, (b) Automobile factory. The material worked on may form part of the second statement. Never return "Laborer," "Foreman," "Manager," "Dcaler," etc., without more precise specification, as Day laborer, 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. 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 (retircd, 6 yrs.). For persons who have no occu- pation whatever, write None.


Statement of cause of death. - Name, first, the DIS- CASE 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) ; Tubcr-


coma, etc., of ... ....... .... (name origin: "Cancer" is less definite; avoid use of "Tumor" for malignant neoplasms); Mcasles; Whooping cough; Chronic valvular heart discase; 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," "IIeart 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 scpticacmia," "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 onc supposed to be due to Alcoholism, etc.


4. Deaths under circumstances unknown, as A person found dead, etc.


1


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.


203 River (2


real St .;


Ward)


(City or town.) fif death occurred In a hospital or institution. give its NAME Instead of street and number.]


Registered No.


PERSONAL AND STATISTICAL PARTICULARS


1 SEX


4 COLOR OR RACE


5 SINGLE,


MARRIED,


WIDOWED,


OR DIVORCED


(Write the word)


Vicious x


· DATE OF BIRTH


4


(Month)


20


(Day)


1846 17


(Year)


7 AGE


If LESS than s day, ........ hrs.


$ OCCUPATION


(a) Trsde, profession, or


particular kind of work


7


(b) General nature of Industry, business, or establishment which employed (or employer).


9 BIRTHPLACE


(State or country)


7


10 NAME OF


FATHER


11 BIRTHPLACE


OF FATHER


(State or country)


12 MAIDEN NAME


OF MOTHER


18 BIRTHPLACE


OF MOTHER


(State or country)


" THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE


(Informant)


шения жилечения


(Address)


203 Huur2 Roky


16


Filed 191


REGISTRAR


MEDICAL CERTIFICATE OF DEATH


L' DATE OF DEATH


3.


20


1914


(Month)


(Day)


(Year)


I HEREBY CERTIFY that I attended deceased from


19


At, to Mich. 20.


1911/


that I last saw her


alive on


mah


20


191L.


and that death occurred, on the date stated above, at


1.P


m.


The CAUSE OF DEATH* was as follows :


arteriosclerosis


...... (Duration) .. ............ yrs. ........... ................ ds. ... mos.


Contributory.


aortic Valoul or replace


(SECON


la del


(Duration)


.... yrs.


Parte


(Signed)


M.D.


That, 20: 1914. (Address)


Winthrop Mais


* If death followed injury or violence the certificate of death must be made ont by the Medical Examiner.


18 LENGTH OF RESIDENCE (FOR HOSPITALS, INSTITUTIONS, TRANSIENTS, OR RECENT RESIDENTS).


At place


In the


of death .......


yrs.


........ mos.


ds.


Steta .......... yra.


mos.


ds ...........


Where was disease contracted,


if not at place of death ?..


Former or usual residence.


1 PLACE OF BURIAL OR REMOVAL Kenton While


DATE OF BURIAL


3-24.1914


20 UNDERTAKER


I. C. Fragy 2


1


ADDRESS


FULL NAME


Eliza W. Devia


[If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE 203 RiverRd.


N. B. - Every item of Information should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state


67 yra. 4


or ......... min. ?


PARENTS


mos. ds.


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, e. g., Farmer or Planter, Physician, Compositor, Architect, Loco- motive cngincer, Civil engineer, Stationary fireman, etc. But in many eascs, 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) Salcs- 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," 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 Housc- keepers who reccive 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 domestic service for wages, as Servant, Cook, Housemaid, ctc. 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. - Namc, first, the DIS- LASE CAUSING DEATH (the primary affection with respect to time and causation), using always the same accepted term for the same diseasc. 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 tungs, meninges, pol tronacannes


coma, etc., of. .... (name origin: "Cancer" is less definite; avoid use of "Tumor" for malignant neoplasms) ; Mcasles; Whooping cough; Chronic valvular hcart discasc; 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," "Wcakness," etc., when a definite discase 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 Commonwealth of Massachusetts


STANDARD CERTIFICATE OF DEATH


1 PLACE OF DEATH


Wencherok (No.


19 devis ave


St. :


Ward)


(City or town.) [If death occurred in a hospital or institution, give its NAME instead of street and number.]


Crofton. 11. Mc Leod


2 FULL NAME


[If married or divorced woman or widow


give maiden name, also name of husband.]


@RESIDENCE


19 Leas We Wanthet


Registered No.


PERSONAL AND STATISTICAL PARTICULARS


3 SEX


4 COLOR OR RACE


6 SINGLE,


MARRIED,


WIDOWED,


OR DIVORCED


(Write the word)


6 DATE OF BIRTH


any


(Month)


(Day)


18


18.71


(Year)


7 AGE


If LESS than


I day, ........ hrs.


yrs.


V


mos.


4 de


ds.


or ........ min. ?


$ OCCUPATION


(a) Trade, profession, or


particular kind of work


Lawyer


(b) General nature of industry,


business, or establishment in


which employed (or employer).


9 BIRTHPLACE


(State or country)


Chicopee Mars


PARENTS


11 BIRTHPLACE


OF FATHER


(State or country) So Buste glas U.S.


12 MAIDEN NAME


OF MOTHER


agree. S. Swans lang


13 BIRTHPLACE


OF MOTHER


(State or country)


Shelloma 41,5


14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE


(Informant)


G/l 2-2


(Address)


REGISTRAR


MEDICAL CERTIFICATE OF DEATH


16 DATE OF DEATH


March


(Month)


22


(Day)


191


(Year)


17 I HEREBY CERTIFY that I attended deceased from Mach 21, 1914, to Mack 22 194 that I last saw h come alive on March 2 2, 19 ... 4 and that death occurred, on the date stated above, at. 145 am.


The CAUSE OF DEATH* was as follows : Valvula Heart Disease




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