USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1913-1915 > Part 50
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wich acute cardiac Detilation
(Duration)
1
... yrs.
X
mos.
X
ds.
Contributory.
Sclerosis Certivary
(SECONDARY)
(Duration)
1
... yrs.
X
mos.
X
ds.
(Signed)
Orville E, labiusen
M.D.
Manz 4. 1914 (Address)
* If death followed injury or violence the certificate of death must be made out by the Medical Examiner.
16 LENGTH OF RESIDENCE (FOR HOSPITALS, INSTITUTIONS, TRANSIENTS, OR RECENT RESIDENTS).
At place
of death
yrs.
mos.
ds.
State
In the
yrs.
mos.
ds.
Where was disease contracted, If not at place of death ?.
Former or usual residence ...
19 PLACE OF BURIAL OR REMOVAL
DATE OF BURIAL
3/24.
1914
DO UNDERTAKER
ADDRESS
Filed. 191
4
10 NAME OF
FATHER
Robert. R. Me Leal
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 ro- 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 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 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.
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
# 6 Pintia €
(No.
Joseph. E. Fabry
2 FULL NAME
[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
16 DATE OF DEATH
26
4
(Month)
(Day)
191
(Year)
6 DATE OF BIRTH
(Month)
(Day)
1877
(Year)
7 AGE
37
yrs.
70s. 23
Nos ..
ds.
or ........ min. ?
8 OCCUPATION
a (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)
10 NAME OF
FATHER
PARENTS
12 MAIDEN NAME
OF MOTHER
13 BIRTHPLACE
OF MOTHER
(State or country)
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
Ce Resteranno
(Address)
REGISTRAR
17
I HEREBY CERTIFY that I attended deceased from march 24, 1914, to Locale 26, 191 4 ... that I last saw halive on Zemarch 26, 1914. and that death occurred, on the date stated above, at 10 m. The CAUSE OF DEATH* was as follows : Chimic Endocarditis
(Duration)
. . .. yrs.
mos.
ds.
Contributory
ante pericarditis
(SECONDARY)
(Duration)
....
..... yrs. ..... ...... mos.
ds.
(Signed)
Chao. 7. makon
355 mmlett Sp
.. ,
M.D.
Lunch 26 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).
In the
At place
of death ............ yrs.
.. mos.
ds.
State
yrs.
mos.
ds.
Where was disease contracted, If not at place of death ?.
Former or usual residence.
19 PLACE OF BURIAL OR REMOVAL
DATE OF BURIAL
-3/20 1914
20 UNDERTAKER
ADDRESS
4
Filed 191.
N. B. - Every item of information should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state
(City or town.)
St. : .... Ward)
[If death occurred in a hospital or institution, give its NAME instead of street and number.]
3 SEX
Hace
4 COLOR OR RACE
Cortrel
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
Marzenad
If LESS than
1 day, ........ hrs.
11 BIRTHPLACE OF FATHER (State or country)
STANDARD CERTIFICATE OF DEATH.
Statement of occupation. - Precise statement of occupa- tion is very important, so that the relative healthfulness of various pursuits can be known. The question applies to each and every person, irrespective of age. For many occupations a single word or term on the first line will be sufficient, e. g., Farmer or Planter, Physician, Compositor, Architect, Loco- motive engineer, Civil engineer, Stationary fireman, etc. But in many cases, especially in industrial employments, it is necessary to know (a) the kind of work and also (b) the nature of the business or industry, and therefore an additional line is provided for the latter statement ; it should be used only when needed. As examples: (a) Spinner, (b) Cotton mill; (a) Sales- man, (b) Grocery ; (a) Foreman, (b) Automobile factory. The material worked on may form part of the second statement. Never return "Laborer," "Foreman," " Manager," "Dealer," etc., without more precise specification, as Day laborer, Farm laborer, Laborer - Coal mine, etc. Women at home, who are engaged in the duties of the household only (not paid Ilouse- keepers who receive a definite salary), may be entered as Housewife, Housework, or At home, and children, not gain- fully employed, as At school or At home. Care should be taken to report specifically the occupations of persons engaged in domestic service for wages, as Servant, Cook, Housemaid, etc. If the occupation has been changed or given up on account of the DISEASE 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 usc of "Croup") ; Typhoid fever (never re- port " Typhoid pneumonia ") ; Lobar pneumonia ; Broncho- pneumonia ("Pneumonia," unqualified, is indefinite) ; Tuber-
culosis of lungs, meninges, peritonaeum, etc., Carcinoma, Sar- coma, etc., of. (name origin: "Cancer" is less definite ; avoid use of " Tumor" for malignant neoplasms) ; Measles ; Whooping cough; Chronic valvular heart disease; Chronic interstitial nephritis, etc. The contributory (second- ary or intercurrent) affection need not be stated unless im- portant. Example: Measles (disease causing death), 29 ds .; Broncho-pneumonia (secondary), 10 ds. Never report mere symptoms or terminal conditions, such as " Asthenia," " An- aemia " (merely symptomatic), " Atrophy," " Collapse," "Coma," "Convulsions," "Debility " ("Congenital," "Senile," etc.), "Dropsy," "Exhaustion," "Heart failure," "Haemorrhage," " Inanition," " Marasmus," " Old age," "Shock," "Uraemia," " Weakness," etc., when a definite disease can be ascertained as the cause. Always qualify all diseases resulting from childbirth or miscarriage, as "PUER- PERAL septicaemia," " PUERPERAL peritonitis," etc. State cause for which surgical operation was undertaken.
Cases for the Medical Examiners. - Under the provisions of chapter 24 of the Revised Laws deaths under the following conditions must be referred to the Medical Examiners:
1. Deaths following injury or violence, as Burns, Falls, Drowning, Gas Poisoning, Suicide, Homicide, etc.
2. Deaths supposedly caused by violence, as Criminal Abortion, Poisoning, Starvation, Suffocation, Ex- posure, etc.
3. Sudden deaths of persons not disabled by recognized disease, as A death upon the street, or one supposed to be due to Alcoholism, etc.
4. Deaths under circumstances unknown, as A person found dead, etc.
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
Apenthiop Mart NG. 35 Lea Loan Chasse
Hertha
BOSTON
(City or town.) [lf death occurred Im a hospital or institution, give its NAME Instead of street and number.]
*FULL NAME Baby Kelley
[If married or divorced woman or widew give maiden name, also name of husbandej
20
a RESIDENCE 35 La Frambu
Registered No.
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
3 SEX
Male
4 COLOR OR RACE
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
Mª DATE OF DEATH
March
(Month)
26
(Day)
. 191
(Year)
· DATE OF BIRTH
86
(Month)
(Day)
(Year)
7 AGE
yrs. mos. de.
If LESS than 1 day, ........ ........ hrs. that I last saw-h. alive on 191 Or ......... min .. ? and that death occurred, on the date stated above, at. 2 am. The CAUSE OF DEATH* was as follows :
Still born
......
Did a surgical operation precede death ? yes
Date New2 6/4
(Duration) ................. yr .. ........... ... mos. ds.
Contributory. (SECONDARY)
.........
(Duration)
...... yrs.
.......
.mos. ............ da.
(Signed)
M.D.
Bran 26, 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).
In the
At place
of death .......... yrs.
..... mos. ............
ds.
Stato ....... com. yri. . tobe
www .. mos.
....... de ...........
Where was disease contracted, If not at place of death ?.... Former or usual residence
1º PLACE CF BURIAL OR REMOVAL
DATE OF BURIAL
Mar 27
1915
RUNDERTAKER
ADDRESS
191
REGISTRAR
I HEREBY CERTIFY that I attended deceased from
June 26
1914
to
June 26
191
8 OCCUPATION
(a) Trade, profession, or
particular kind of work
(b) General nature of industry, business, or establishment in which employed (or employer).
9 BIRTHPLACE
(State or country)
10 NAME OF
FATHER
Lakul Kelley
PARENTS
11 BIRTHPLACE OF FATHER (State or country) /Gostar Mais
12 MAIDEN NAME
OF MOTHER
Louin Savyer
18 BIRTHPLACE OF MOTHER (State or country)
Bastion Mass
" THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant) SolunTellen
Filed
Z
4
.....
--.
Ward)
STANDARD CERTIFICATE OF DEATH.
Statement of occupation. - Precise statement of occu- pation is very important, so that the relative healthfulness of various pursuits can be known. The question applies to each and every person, irrespective of age. For many occupations a single word or term on the first line will be sufficient, 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 linc 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 employcd, 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- 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 cercbro-spinal meningitis"); Diphtheria (avoid use of "Croup"); Typhoid fever (never re- port "Typhoid pneumonia"); Lobar pneumonia; Broncho- pneumonia ("Pneumonia," unqualified, is indefinite) ; Tuber-
culosis of tungs, meninges, pertionalam, tvo., coma, etc., of ... (name origin: "Cancer" is less definite; avoid use of "Tumor" for malignant neoplasms) ; Measles; Whooping cough; Chronie valvular heart disease; Chronie 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 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
Writeof Mass (No
4
Sea Forum Ovest.
.Ward)
BOSTON (City or town.) [If death occurred in a hospital or institution, give its NAME instead of street and number.]
Mary Ellen Bagley
2 FULL NAME
[If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE
.
Mc Seauf- Peter Bagley
4 Sea Foam ave Winttuch Register No.
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
3 SEX
Female
4 COLOR OR RACE
Wlit
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
Widow
6 DATE OF BIRTH
(Month)
(Day)
(Year)
7 AGE
71
... yrs.
mos. ds.
or ....... min. ?
8 OCCUPATION
(a) Trade, profession, or
particular kind of work ...
None
(b) General nature of industry, business, or establishment in which employed (or employer)
? BIRTHPLACE
(State or country)
Ireland
10 NAME OF FATHER
Frauque MLeau
PARENTS
11 BIRTHPLACE
OF FATHER
(State or country)
Juland
12 MAIDEN NAME
OF MOTHER
Sarah
13 BIRTHPLACE
OF MOTHER
(State or country)
Ireland
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
annie Bagley
(Address)
14
Filed 121
REGISTRAR
16 DATE OF DEATH
much
26
(Day)
, 1914
(Year)
17
I HEREBY CERTIFY that I attended deceased from
1912
., 191
. ,
to
1914.
that I last saw
alive on
Mak 20, 1914
and that death occurred, on the date stated above, at.
2pm.
The CAUSE OF DEATH* was as follows :
1st March 1912 2nd Much 1914
.(Duration)
2 yrs.
mos.
ds.
Contributory
(SECONDARY)
(Duration)
yrs.
mos.
ds.
-
M.D.
(Signed)
(nh 2), 191X
,
(Address)
without
* 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. ..
Where was disease contracted, if not at place of death ?.
Former or usual residence
19 PLACE OF BURIAL OR REMOVAL
4 Sea Food Waittuck St Patricks Sowell
Masa
:0 UNDERTAKER Peter Savage
ADDRESS Lowell Mann
DATE OF BURIAL
Mar 28.
4
191
In the
Jouer
(Month)
if LESS than
I day, ....... hrs.
1
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 necdcd. 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 dutics 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_it home. Care should be taken to report specifically the occupations of persons engaged in domestic service fer 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 bo indicated thus: Farmer (retired, 6 yrs.). For persons who have no occupation whatever, write None.
Statement of cause of death. - Namc, 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 definito 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, peritoneum, etc., Carcinoma, Sur- 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," ".Seaile," etc.), " Dropsy," " Exhaustion," "Heart failure," "Haemorrhage," " Inanition," "Marasmus," " Old ago," "Shock," "Uraemia," "Weakness," etc., when a definite disease can bo ascertained as the cause. Always qualify all diseases resulting from childbirth or miscarriage, as " PUER- PERAL septicemia," " 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, ctc.
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.
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 outrough .(No. Cacasset ...
St. :
Ward)
rough (City or towp [If death occurred in a hospital or institution, give its NAME instead of street and number.]
FlorenceJ. Power 'FULL NAME
[If married or diyorced woman or widow give maiden name, also name of husband.] @RESIDENCE
Registered No. 2,
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
4 COLOR OR RACE
female Whit.
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
18 DATE OF DEATH
TH Telua
26. 1914.
.....
(Month)
(Day)
(Year)
6 DATE OF BIRTH
Cinq
(Monthy
7 1 1873
(Day)
(Year)
" AGE
40
..... yrs. 6 ... mos. 19/0%.
or ........ min. ?
& OCCUPATION
(a)' Trade, profession, or
particular kind of work
Clark
(b) General nature of Industry.
business, or establishment in
which employed (or employer).
9 BIRTHPLACE
(State or country)
.(Duration)
ds.
Contributory
(SECONDARY)
........
(Duration)
y's. .............
... mos.
......... ds.
(Signed)
Francis Q. Qnaqq
M.D.
tel-26
. 1914 (Address).
* If death followed injury or violence the certificate of death thust be made out by the Medical Examiner.
18 LENGTH OF RESIDENCE (FOR HOSPITALS, INSTITUTIONS, TRANSIENTS, OR RECENT RESIDENTS).
In the
At place
of death ........
.... yrs.
mos.
.ds.
Stato ............ yrs.
........
ds .............
Where was disease contracted, If not at place of death ?. Former or usual residence.
1º PLACE OF BURIAL OR REMOVAL
DATE OF BURIAL
727ar1.
1914
(Address)
14 Filed ich 13. 1914 George/T. Celles
REGISTRAR
17 I HEREBY CERTIFY that I attended deceased from
191
to
191
-
that I last saw h.
alive on
-
191
and that death occurred, on the date stated above, at
m.
The CAUSE OF DEATH* was as follows :
Maibrad accident
Probably Suicidal
PARENTS
U BIRTHPLACE
OF FATHER
(State or country)
Jackvill 3.13
12 MAIDEN NAME
OF MOTHER
- Standard
iveau
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