USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1913-1915 > Part 52
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Where was disease contracted, If mot at place of death ?. Former or usual residence
1º PLACE OF BURIAL OR REMOVAL Holyhead 6am.
DATE OF BURIAL
April 2.
191
4
"UNDERTAKER
this Dans
ADDRESS
120 AmisKY
1
2FULL NAME
PERSONAL AND STATISTICAL PARTICULARS
& SEX
4 COLOR OR RACE
5 SINGLE,
MARRIED, Married
WIDOWED,
OR DIVORCED
(Write the word)
· DATE OF BIRTH
1
(Month)
(Day)
(Year)
TAGE
58
If LESS than
i day ......... hra.
... yr.
mos.
de.
OF ......... min. ?
a OCCUPATION
Tailor
(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)
Doston Mass
10 NAME OF
FATHER
Michual Stranay
11 BIRTHPLACE
OF FATHER
(State or country)
Chraland
12 MAIDEN NAME
,
OF MOTHER
Mary OBrien
PARENTS
18 BIRTHPLACE
OF MOTHER
Iraland
(State or country)
1ª THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
Mrs. Williamy ST. France
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.
Filed.
N. B .- Every Item of Information should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state
.
(Address)
52 Chonatal Forte Que Hiver
191
REGISTRAR
STANDARD CERTIFICATE OF DEATH. L
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, Architcet, Loco- motive cngincer, 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 laborcr, 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 faet 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 discase. Examples: Cerebro-spinal fever (the only definite synonym is "Epidemie cerebro-spinal meningitis"); Diphtheria (avoid use of "Croup"); Typhoid fever (never re- port "Typhoid pneumonia"); Lobar pneumonia; Broncho- pneumonia ("Pneumonia," unqualified, is indefinite) ; Tuber-
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 (discase causing death), 29 ds .; Broncho-pneumonia (secondary), 10 ds. Never report mere symptoms or terminal conditions, such as "Asthenia," "An- acmia" (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. Stato 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 duc 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 .... ].
380. Thisday
St. :
................
.Ward)
BOSTON (City or town.) [If death occurred la a hospital or institution, give its NAME Instead of street and number.]
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
$ SEX
15
4 COLOR OR RACE
5 SINGLE
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
If idowad
$ DATE OF BIRTH
(Month)
(Day)
1
(Year)
TAGE
95
.yrs. ... mos. ......
of ......... min. ?
8 OCCUPATION
(a) Trade, profession, or
particular kind of work
Patirad
(b) General nature of industry.
business, or establishment In
which employed (or employer).
$ BIRTHPLACE
(State or country)
Ireland
10 NAME OF
FATHER
Patrick Casay
PARENTS
12 MAIDEN NAME
OF MOTHER
Channa Collin
1ª BIRTHPLACE
OF MOTHER
(State or country}
Creland
" THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
Nova Bowen
(Address) 380 Shirtand Winthrop
Filed
191
REGISTRAR
19
I HEREBY CERTIFY that I attended deceased from
apr 6th
11914, to
Upw. G.
191
that I last saw halle
alive on
6
and that death occurred, on the date stated above, at
2 00 m.
.m.
The CAUSE OF DEATH* was as follows :
Labas Pneumonia
(Duration)
3
Contributory.
(SECONDARY)
........
.(Duration)
yrs.
.............. mos.
.d&
(Signed)
D.H. Pantes
M.D.
Cfr 8 /19th (Address
--
* 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).
In the
At place
of death ........ yrs.
mos ._
de
State
.yrs.
mos.
Where was disease contracted, if moi at place of death ?. Former or usual residence
" PLACE OF BURIAL OR REMOVAL Old Calvary bem
DATE OF BURIAL
April8, 1914
· UNDERTAKER
APPRESE 6. Boston 120 Have LY
....
C. -
Johanna
"FULL NAME
Windows of Dennis ver Casas
[If married or divorced woman or widow
give maiden name, also name of husband.]
@RESIDENCE
380 Shirley 8 28 anthrop
Registered No.
1ª DATE OF DEATH
april
(Month)
6.48
(Day)
·
(Year)
1914
.yrs. ............... mos.
de.
11 BIRTHPLACE
OF FATHER
(State or country)
"Ireland
If LESS than
I day ......... hrs.
STANDARD CERTIFICATE OF DEATH.
Statement of occupation. - Precise statement of occu- pation is very important, so that the relative healthfulness of various pursuits can be known. The question applies to cach and every person, irrespective of age. For many occupations a single word or term on the first line will be sufficient, c. g., Farmer or Planter, Physician, Compositor, Architect, Loco- motive engineer, Civil engineer, Stationary fireman, 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," "Dcaler," 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 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 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) ; 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" (mcrely symptomatic), "Atrophy," "Collapsc," "Coma," "Convulsions," "Debility" ("Congenital," "Senile," etc.), "Dropsy," "Exhaustion," "Heart failure," "Hacınorrhage," "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 provi- sions of chapter 24 of the Revised Laws deaths under the fol- lowing conditions must be referred to the Medical Examiners:
1. Deatlıs following injury or violence, as Burns, Falls, Drowning, Gas poisoning, Suicide, Homicide, etc.
2. Deaths supposedly caused by violence, as Criminal abortion, Poisoning, Starvation, Suffocation, Ex- posure, etc.
3. Sudden deaths of persons not disabled by recognized discase, as A death upon the street, or one supposed to be due to Alcoholism, etc.
4. Deaths under circunstances unknown, as A person found dead, ctc.
important. See instructions on back of certificate. CAUSE OF DEATH in plain terms, so that it may be properly classified. Exact statement of OCCUPATION is very .... ........
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
IPLACE OF DEATH
Matcall Genital Winthrop St.
Ward)
(City or town.) Elf death occurred in a hospital or institution, give its NAME instead of street and number.1
2 FULL NAME
Annie
Anis Cousine vila of
[If married or divorced woman or widow give maiden name, also name of husband.] ...... Edward & Cousing
@RESIDENCE
25 Plummer Que
....
Registered No.
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
3 SEX
4 COLOR OR RACE
Female White
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
a) married
16 DATE OF DEATH
april
(Month)
6
191
4
(Day)
(Year)
& DATE OF BIRTH
(Month)
(Day)
, 1871
(Year)
7 AGE
If LESS than
I day ........ hrs.
Or ......... min. ?
8 OCCUPATION
(a) Trade, profession, or
particular kind of work
Av) Home
(b) General nature of Industry.
business, or establishment In
which employed (or employer).
9 BIRTHPLACE
(State or country}
Dublin, Ireland
PARENTS
12 MAIDEN NAME
OF MOTHER
Annie Catenvan
13 BIRTHPLACE
OF MOTHER
(State or country)
LeEland
" THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
Eduard & banana
(Address) 25 1 hummer MEL
REGISTRAR
17 I HEREBY CERTIFY that I attended deceased from qualche 28 4
, 191
to
april 6
1914
that I last saw ha alive on
april 6
199
and that death occurred, on the date stated above, at
10A.m.
The CAUSE OF DEATH* was as follows :
Chimes autenticial
.....
(Duration)
.......... yrs.
..............
.mos.
ds.
Contributory.
(SECONDARY)
(Duration)
... yrs.
mos. .............
ds.
(Signed)
Charles 7. Mahoney
.......
M.D.
aprile
1914 (Address)
885 Umablad St
* 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. .... If not at place of death ?.
Where was disease contracted,
Former or usual residence.
1 PLACE OF BURIAL OR REMOVAL
DATE OF BURIAL Chut 8. 1914
20 UNDERTAKER
ADDRESS
Filed 191
10 NAME OF
FATHER
Lohn Catemary
11 BIRTHPLACE
OF FATHER
(State or country)
England
43 yrs
3
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 cach and every person, irrespective of age. For many occupations a single word or term on the first line will be sufficient, c. g., Farmer or Planter, Physician, Compositor, Architect, Loco- motive engineer, Civil engineer, Stationary fireman, 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," ctc., 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 occu- pation whatever, write None.
Statement of cause of death. - Name, first, the DIS- EASE CAUSING DEATH (the primary affection with respect to time and causation), using always the same accepted term for the same disease. Examples: Cerebro-spinal fever (the only definite synonym is "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, ctc., 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 (discase causing death), 29 ds .; Broncho-pneumonia (secondary), 10 ds. Never report mcre symptoms or terminal conditions, such as "Asthenia," "An- aemia" (mcrely 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. Stato 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.
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. 44 Thore Denne
St. : Ward)
(City or town.) {If death occurred in a hospital or institution, give its NAME instead of street and number.]
Elza. Ellen. Farnham 2 FULL NAME
[If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE 44 Cet
Widowof George. C. Gamla Registered No. Shore Deve
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
3 SEX
4 COLOR OR RACE
which
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
Jordan
6 DATE OF BIRTH
mar
/2
1838
(Month)
(Day) (Year)
7 AGE
If LESS than [ day, ........ hrs.
76
yrs.
1
mos.
21
.ds.
or ........ min. ?
8 OCCUPATION
(a) Trade, profession, or
particular kind of work
Relevant.
(b) General nature of industry,
business, or establishment in
which employed (or employer)
9 BIRTHPLACE
(State or country)
mit Vernon me
PARENTS
12 MAIDEN NAME
OF MOTHER
Hannah. Han
1ª BIRTHPLACE
OF MOTHER
(State or country)
" THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
(Address)
Filed 191
....
....
REGISTRAR
16 DATE OF DEATH
april
(Month)
7 - 1914
(Day)
(Year)
17 I HEREBY CERTIFY that I attended deceased from March 21, 1914, to 1914
that I last saw her
alive on
apr. 7
191.56
and that death occurred, on the date stated above, at.
m.
The CAUSE OF DEATH* was as follows :
Cerebral Hemorrhage.
17
(Duration)
......... yrs.
mos. .
Contributory
(SECONDARY)
.(Duration)
yrs.
......
ds.
(Signed)
SHE. itragdon
,
M.D.
mos.
....
april 9, 1914 (Address) Ile entral An
/* 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 dealh ?.
Former or usual residence
19 PLACE OF BURIAL OR REMOVAL
DATE OF BURIAL
4 10
..
191
....
20 UNDERTAKER
ADDRESS .
ds. .
10 NAME OF
FATHER
Columbus , Ensku'
11 BIRTHPLACE
OF FATHER
(State or country)
1914
STANDARD CERTIFICATE OF DEATH.
Statement of occupation. - Precise statement of occupa- tion is very important, so that the relative healthfulness of various pursuits can be known. Tho question applies to 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- fuliy 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. Tho 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 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, 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.
important. See instructions on back of certificate. CAUSE OF DEATH in plain terms, so that it may be properly classified. Exact statement of OCCUPATION is very PARENTS
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH Winthrop .(No .. 18 Chester QUES.
John J Driscoll
2 FULL NAME
[If married or divorced woman or widow
give maiden name, also name of husband.]
@RESIDENCE
86hveter ane.
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
3 SEX
4 COLOR OR RACE
Male White
5 SINGLE,
MARRIED,
WIDOWED,
-OR DIVORCED
(Write the word)
16 DATE OF DEATH
april
(Month)
(Day) 9
1914
(Year)
I HEREBY CERTIFY that I attended deceased from L 191 4 t V ., 191 that I last saw halive on 6 1914 and that death occurred, on the date stated above, at 4Am. The CAUSE OF DEATH* was as follows :
(Duration)
... yrs.
mos.
ds.
Contributory
(SECONDARY)
(Duration)
... yrs.
mos.
ds.
(Signed)
0.7. mahoney
M.D.
april 1, 1914 (Address).
36-5 2medup SR
* 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
of death.
.yrs.
mos.
đs.
State
.. yrs.
mos.
ds.
Where was disease contracted, If not at place of death ?.
Former or usual residence
1º PLACE OF BURIAL OR REMOVAL
Holy Cross trinida
DATE OF BURIAL
Af ul 11. 1914
20 UNDERTAKER
Filed 191
. ....
REGISTRAR
Winthuch (City or town.) [If death occurred in a hospital or institution, give its NAME instead of street and number.]
Ward)
6 DATE OF BIRTH
, 1832
17
(Month)
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