USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1913-1915 > Part 53
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(Day)
(Year)
7 AGE
If LESS than
1 day, ........ hrs.
81
yrs.
4
mos.
ds.
or ....... min. ?
8 OCCUPATION
(a) Trade, profession, or
particular kind of work
Retired
(b) General nature of industry, business, or establishment in which employed (or employer).
· BIRTHPLACE
(State or country)
Augusta Inc.
10 NAME OF
FATHER
Everial Driscoll
11 BIRTHPLACE
OF FATHER
(State or conntry)
Ireland
12 MAIDEN NAME
OF MOTHER
1ª BIRTHPLACE
OF MOTHER
(State or country)
Maland
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
William H. Welding
(Address)
Registered No.
ADDRESS
79. Atlar de el
In the
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 use of "Croup") ; Typhoid fever (never ro- port " Typhoid pneumonia ") ; Lobar pneumonia ; Broncho- pneumonia ("Pneumonia," unqualified, is indefinite) ; Tuber-
culosis of lungs, meninges, peritoneum, etc., Carcinoma, Sar- coma, etc., of ... . (name origin: "Cancer" is less definite ; avoid use of " Tumor" for malignant neoplasmc) ; 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
2 FULL NAME Coldred Eine Thie
{If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE 35 Washington Que, winthrop
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
¿ SEX
Vale chite
4 COLOR OR RACE
5 SINGLE,
MARRIED,
Widowed
WIDOWED,
OR DIVORCED
(Write the word)
6 DATE OF BIRTH
Clu-4
(Month)
23
, 15/c 17
(Year)
(Day)
7 AGE
49
yrs.
7 mos.
19 ds.
& OCCUPATION
(e) Trede, profession, or
particuler kind of work
Machinist
(b) Generel nature of industry,
business, or establishment in
which employed (or employer).
9 BIRTHPLACE
(State or country)
East Born
4
PARENTS
12 MAIDEN NAME
OF MOTHER
1ª BIRTHPLACE
OF MOTHER
(State or country)
of retail
11 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
(Address)
love field Manel
Filed
., 191
REGISTRAR
16 DATE OF DEATH
(Month)
(Day)
11.1911
(Year)
I HEREBY CERTIFY that I attended deceased from
1913
to
191
11.
If LESS than
day ,
. hrs.
that I last saw hernalive on
191
... min. ?
and that death occurred, on the date stated above, at.
6 1/5/m.
Em.
The CAUSE OF DEATH* was as follows :
Pulmonares Tuberculose.
(Duration)
2 Yrs.
yrs.
8
mos.
11
ds.
Contributory
(SECONDARY)
(Duration)
. yrs.
mos.
ds.
(Signed)
Heures & bhuduring.
M.D.
(1 10-2 11 19H (Address).
C'estfield Ma
0
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.
11
mos.
13 ds.
In the
State 49 yrs. 7 mos. // ds.
Where was disease contracted,
If not at place of death ?.
ta 1 cartón
Former or
usual residence.
centtrap mais
19 PLACE OF BURJAL OR REMOVAL
111-11.
6€ ml
DATE OF BURIAL
1,2e 1c/ 19/11
ADDRESS
20 UNDERTAKER
L'mbran diese (0)
WESTFIELD, MASS. (City or town.)
( est e fic ( Word)
{If deeth occurred in a hospitel or institution, give its NAME insteed of street and number.]
10 NAME OF
FATHER
11 BIRTHPLACE OF FATHER (State or country) Ireland
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 in Instry, 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 "Cronp") ; 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 loss 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 ini- portant. Example : Measles (disease causing death), 29 ds .; Broncho-pneumonia (secondary), 10 ds. Nover 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 cansed 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
Winthropi
(No.
258
Court Road
St. ;
........
Ward)
Thinthroh BOSTAY ....
(City or town.) [If death occurred in a hospital or institution, give its NAME instead of street and number.]
Cohn Hamilton Forsy the
2FULL NAME
[If married or divorced woman or widow
give maiden name, also name of husband.]
@RESIDENCE
Thuchup 258 Court Road.
Registered No.
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
3 SEX
male
4 COLOR OR RACE
white
6 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
married.
1
(Day)
(Year)
7 AGE
If LESS than
1 day .......... hrs.
72
.yrs.
1
mos.
5
ds.
Or ......... min. ?
8 OCCUPATION
(a) Trade, profession, or
particuler kind of work
Manufacturer
(b) General nature of industry,
business, or establishment in
which employed (or employer)
Cerebral Hammaralage
(Duretion)
X
.yrs.
Y
mos.
5
.ds.
Contributory
arterio seleveres
(SECONDARY)
Semnal (Duration)
X mos.
X
ds.
(Signed)
M.D.
Christy, 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).
At place
of death.
.. yrs.
In the
......
.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 Forest Hills.
DATE OF BURIAL
17
19162
" UNDERTAKER
ADDRESS
Filed 191
REGISTRAR
18 DATE OF DEATH
april
(Month)
14
1914
....
(Day)
(Year)
17
I HEREBY CERTIFY that I attended deceased from
· Cetvel 9
... 1914, to Cafree 14, 194
that I last saw her alive on
Cabral 14.
1914
and that death occurred, on the dato stated above, at 3 00 m.
The CAUSE OF DEATH* was as follows :
9 BIRTHPLACE
(State or country)
Brockline Mass
PARENTS
10 NAME OF
FATHER
William
11 BIRTHPLACE
OF FATHER
(State or country)
Scotland.
12 MAIDEN NAME
OF MOTHER
Jane Bennett
13 BIRTHPLACE
OF MOTHER
(State or country)
England.
"THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
(Address)
N. B. "Every item of information should be carefuly supplied. AGE should be stated EAAGILT. PHYSICIANS should state
6 DATE OF BIRTH
Mar 9 1842.
(Month)
.....
STANDARD CERTIFICATE OF DEATH.
Statement of occupation. - Precise statement of occupa- tion is very important, so that the relativo 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.
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.
4 Dagarcouleur.
1
St. : Ward)
(City or town.)
[If death occurred in a hospital or institution, give its NAME instead of street and number.]
'FULL NAME
Lucretia ): Became.
[If married or divorced woman or widow give maiden name, also name of husband.] Hinsdale Leo. W. Peau. @RESIDENCE A Sayamor tur Winthrop
Registered No.
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
3 SEX
4 COLOR OR RACE
w-
5 SINGLE, LO
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
idound
6 DATE OF BIRTH
(Month)
(Day)
(Year)
7 AGE
69
.yrs.
mos. ...................
da.
2 ......... min. 7
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)
PARENTS
12 MAIDEN NAME
OF MOTHER
1
Charity Vanalinslunce
18 BIRTHPLACE
OF MOTHER
(State or country)
n'y.
" THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informan
Muss. B.C. curry-
(Address)
A Sadamente leur.
REGISTRAR
Indefinite .....
(Duration) .......... yrs ................ mos ..
da.
Contributory
Interstitial nephritis
....
(SECONDARY)
L'indeferiti
(Duration)
mos.
.ds.
... yrs.
(Signed)
M.D.
apr. 16. 1014 (Address)
Tinchipp Mark,
If death followed injury or violence the certificate of death must be made out by the Medical Examiner.
1ª LENGTH OF RESIDENCE (FOR HOSPITALS, INSTITUTIONS, TRANSIENTS, OR RECENT RESIDENTS).
At place
of death ............ yrs.
mos.
In the
da
State ............ yTs.
---...
.........
d ..............
.. mos.
Where was disease contracted, If not at place of death ?.
Former or usual residence
19 PLACE OF BURIAL OR REMOVAL
DATE OF BURIAL
4
1%
.......
191L/
20 UNDERTAKER
W.C. Skaggs
ADDRESS
Flied 191
10 DATE OF DEATH
4 -
15- 1914
(Ycar)
(Month)
(Day)
1845 17
If LESS than
j day, ........ hrs.
I HEREBY CERTIFY that I attended deceased from
Selah. 15th
1913
apr. 9.
to
1914
that I last saw her
alive on
/apr. 9
1984
and that death occurred, on the date stated above, at.
3Pm
m.
The CAUSE OF DEATH* was as follows :
Valor Lar Heart Disease
10 NAME OF
FATHER
Peter B. Hinsdale.
11 BIRTHPLACE
OF FATHER
(State or country)
Unknown-
STANDARD CERTIFICATE OF DEATH.
Statement of occupation. - Prceise 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, e. g., Farmer or Planter, Physician, Compositor, Architcet, 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 cxamples: (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 homc. 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- BASE 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
S of tantys, ne
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- acmia" (merely symptomatic), "Atrophy," "Collapse," "Coma," "Convulsions," "Debility" ("Congenital," "Senile," etc.), "Dropsy," "Exhaustion," "Heart failure," "Hacmorrhage," "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 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.
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH Winthrop (No. 26 argent St. : .......... Ward)
Winthrop
(City or town.) [If death occurred in a hospital or institution, give its NAME instead of street and number.]
2 FULL NAME
Sarah Jane
Young.
[If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE
Virgie
- James & Young
Registered No.
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
3 SEX
temale
4 COLOR OR RACE
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
Widowed
6 DATE OF BIRTH
July
(Month)
(Day)
12
1832
(Year)
7 AGE
81
... yrs. 9 mos. 9 ds.
or ........ min. ?
$ OCCUPATION
(a) Trade, profession, or
particular kind of work
Af Stomer
(b) General nature of industry,
business, or establishment in
which employed (or employer) ..
9 BIRTHPLACE
(State or country)
John
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)
Mr. Fr & Young
(Address)
26 Sargent de
REGISTRAR
....
17
I HEREBY CERTIFY that I attended deceased from
to
apr. 210h
1914
abril 18th
.....
that I last saw h Az alive on
apr. 20.
, 1914.
and that death occurred, on the date stated above, at.
8.a.m.
The CAUSE OF DEATH* was as follows :
Cerebral Hemorrhage
(Duration)
.yrs.
mos.
ds.
Contributory.
artères-sclerpaio
(SECONDARY) /
tadel
.(Duration)
.yrs.
mos ..
ds.
Irl. Partie
M.D.
(Signed),
apr 21h 1914 (Address)
Winchaos
* 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 Forest Hills Cemetery
DATE OF BURIAL HoPm April 23, 1914
L
30 UNDERTAKER
& & Brown ton
ADDRESS
East Boston
Filed 191
N. B. - Every Item of Information should be careruny supplied. AGE should be stated ERAGILT. 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.
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