USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1913-1915 > Part 54
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Emails
1
If LESS than
t day ......... hrs.
16 DATE OF DEATH
april
(Month)
(Day)
210/
1914
(Year)
10 NAME OF
FATHER
Unknown Verque
11 BIRTHPLACE
OF FATHER
(State or country)
Undaround
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 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, 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 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 , C'arcinoma, Sar- coma, etc., of ... (name origin: "Cancer" is less definite ; avoid use of " Tumor" for malignant neoplasms) ; Measles ; Whooping cough ; Chronic ralvular 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 strect, or onc supposed to be duc to Alcoholism, etc.
4. Deaths under circumstances unknown, as A person found dcad, 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
...
(No.
2. 2 Willow are
St. :.. .........
Ward)
[If death occurred in a hospital or institution, give its NAME instead of street and number.]
Registered No.
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
3 SEX
4 COLOR OR RACE
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
1841
(Day)
(Year)
7 AGE
If LESS than
I day, ....... hrs.
or min. ?
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)
(Duration)
yrs.
4
.mos.
ds.
Contributory
(SECONDARY)
(Duration)
yrs.
mos. ...........
ds.
(Signed)
31 Metcalf
M.D.
apr 22 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.
mos.
ds.
State ...
yrs.
In the
mos.
ds.
Where was disease contracted, If not at place of death 7.
Former or usual residence
19 PLACE OF BURIAL OR REMOVAL
DATE OF BURIAL
4/2]
191
20 UNDERTAKER
ADDRESS
Filed. 191
.....
REGISTRAR
16 DATE OF DEATH
(Month)
21
.. 191
4
(Day)
(Year)
17
I HEREBY CERTIFY that I attended deceased from
Dec
1913, to
19114.
that I last saw h 07 alive on
ajul 20°
1914
and that death occurred, on the date stated above, ats, 154m.
The CAUSE OF DEATH* was as follows :
Chronic Endocarditis
Intral Insufficiency
10 NAME OF
FATHER
Royal Penci
PARENTS
11 BIRTHPLACE
OF FATHER
(State or country)
Chebe-
12 MAIDEN NAME
OF MOTHER
13 BIRTHPLACE
OF MOTHER
(State or country)
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
13. J. Fly.(
(Address)
(City or town.)
adaline Learned Floyd
2 FULL NAME
[If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE 22 Wielovidare
11 ige of 13. Pappan. ett dje
6 DATE OF BIRTH
5 (Month)
yrs. 3 mos. L.) . .... ds.
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 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," "Dehility " ("Congenital," "Senile," etc.), "Dropsy,""Exhaustion," "Heart failure," " Haemorrhage," " Inanition," " Marasmus," " Old age," "Shock," "Uraemia," " Weakness," etc., when a definite disease can be ascertained as the cause. Always qualify all diseases resulting from childbirth or miscarriage, as " PUER- PERAL septicaemia," " PUERPERAL peritonitis," etc. State cause for which surgical operation was undertaken.
Cases for the Medical Examiners. - Under the provisions of chapter 24 of the Revised Laws deaths under the following conditions must be referred to the Medical Examiners:
1. Deaths following injury or violence, as Burns, Falls, Drowning, Gas Poisoning, Suicide, Homicide, etc.
2. Deaths supposedly caused by violence, as Criminal Abortion, Poisoning, Starvation, Suffocation, Ex- posure, etc.
3. Sudden deaths of persons not disabled by recognized disease, as A death upon the street, or one supposed to be due to Alcoholism, etc.
4. Deaths under circumstances unknown, as A person found dead, etc.
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
Man that Men toity or town.)
1 PLACE OF DEATH
Minctual
(No.
96
Muritlucas
St. :
X
Ward)
fif death occurred le a hospital or institution, give its NAME instead of street and number.]
Schuyler Breder andrews
2FULL NAME
[If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE
married
Registered No. 84
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
3 SEX
Male
4 COLOR OR RACE
Nlite
i SINGLE,
MARRIED,
marked
WIDOWED.
OR DIVORCED
(Write the word)
· DATE OF BIRTH november 18
(Month)
(Day)
(Year)
TAGE
If LESS than
I day ......... hrs.
65 yrs ...
.. yrs.
5
mos.
....
10
ds.
Of ......... min. ?
$ OCCUPATION
(a) Trade, profession, or
particular kind of work
auditor, retired
(b) General nature of industry. business, or establishment in which employed (or employer).
1848 11 I HEREBY CERTIFY that I attended deceased from
, 1909.
to
Olux 29, 1914.
that I last saw h cu alive on
afree 2 my, 1914.
and that death occurred, on the date stated above, at 115-Pm.
The CAUSE OF DEATH* was as follows :
Brancho Primera
...
(Duration)
8 yrs.
X
.. mos.
........
Contributory
Cerebral Chapliny
(SECONDARY)
.. (Duration).
5 yrs.
mos.
ds-
(Signed)
Chue 28 914 (Address)
.....
M.D.
* If death followed Injury or violence the certificate of death must be made ont by the Medical Examiner.
1 LENGTH OF RESIDENCE (FOR HOSPITALS, INSTITUTIONS, TRANSIENTS, OR RECENT RESIDENTS).
At place
of death ............ yrs.
mos.
ds.
State
.......... yra.
In the
mos.
.......
ds .............
Where was disease contracted, If not at place of death ?.
Former or usual residence
1º PLACE OF BURIAL OR REMOVAL Hanthor Mars
DATE OF BURIAL
30g
* UNDERTAKER Holla7 Hawer
ADDRESS
Filed 191
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.
PARENTS
11 BIRTHPLACE
OF FATHER
(State or country)
Union Me
12 MAIDEN NAME
OF MOTHER
Julia Bucher
18 BIRTHPLACE
OF MOTHER
(State or country)
Hudson h4
" THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE/
(informant)
Ble JK, Andrew 2
(Address)
REGISTRAR
10 DATE OF DEATH
april
19!
4
(Month)
(Day)
27
(Year)
9 BIRTHPLACE
(State or country)
Hooper Brighandler, 24
10 NAME OF
FATHER
George Riley andrews
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 agc. 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, ctc. 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 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 diseasc. Examples: Cerebro-spinal fever (the only definite synonym is "Epidemie 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, 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 (sccond- ary or intercurrent) affection need not be stated unless imn- portant. Example: Measles (discase 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," "Hacmorrhage," "Inanition," "Marasmus," "Old agc," "Shock," "Uraemia," "Weakness," ctc., when a definite disease can be ascertaincd 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.
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
' PLACE OF DEATH Winthanh (No ... 7 Beacon
St. :
Ward)
[If married or divorced woman or widow give maiden name, also name of losband.] @RESIDENCE 7 Beveon St Winthrop
Registered No.
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
1ª DATE OF DEATH
april
(Month)
28.
(Day)
191
(Year)
6 DATE OF BIRTH
gan
(Month)
3
18.5-3
(Day)
(Year)
7 AGE
If LESS than 1 day .......... hrs.
61
.yrs.
3
........ mos. ..........
24 de.
or ......... min. ?
8 OCCUPATION
(a)' Trade, profession, or
particular kind of work
Broker
(b) General nature of industry.
business, or establishment in
which employed (or employer).
9 BIRTHPLACE
(State or country)
London England
10 NAME OF
FATHER
Mark Samuel
11 BIRTHPLACE
OF FATHER
(State or country)
London Eng
12 MAIDEN NAME
OF MOTHER
Hannah abrahams
1ª BIRTHPLACE
OF MOTHER
(State or country)
London England
11 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
Leon Greensur
16 Filed 191
REGISTRAR
17
4
I HEREBY CERTIFY that I attended deceased from
Dea. 15.
1913
apr, 27, 1
to
191
that I last saw h leu alive on
Apr 27,19/14
and that death occurred, on the date stated above, at.
HP
m.
The CAUSE OF DEATH* was as follows :
Chronic Interstitial Nephritis
Indefinido
(Duration)
ds.
Contributorý
arturo -sclerose
(SECONDARY)"
Indefinite
.. (Duration)
.. yrs.
.........
............. ....
(Signed)
Irl Partir
M.D.
que. 28., 1914
(Address).
Winthrop
* 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. ............ da.
Stat ............ yr's. .......... mos.
........
Where was disease contracted,
ds.
..........
If not at place of death ?.
Former or
usual residence
19 PLACE OF BURIAL OR REMOVAL
Wedkan
DATE OF BURIAL
april 29.
191X
(Address)
234 chestnut St Chelsea Hand in Hand
" UNDERTAKER William@Carala
ADDRESS
317 Broadway
CHEPAS
1.06.
Winthrop
(City or town.) [If death occurred IR a hospital or institution, give ita NAME instead of street and number.]
2FULL NAME
morris Samuel -
3 SEX
male
4 COLOR OR RACE
white
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
married.
mos. ds
apr . 28
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 househoid 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- 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 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 disabied 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
(No. 40 Uulow
Bentley
2 FULL NAME
[If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE 40 Willow ane wanetant 200as
wife of W2 H. Gardner
Registered No.
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
female
4 COLOR OR RACE
vicente
26
(Month)
(Day)
7 AGE
If LESS than 1 day, ........ hrs.
38 . yrs. 6 mos. 26 ds.
Or ....... min. ?
8 OCCUPATION
(a) Trade, profession, or
particular kind of work
Home life
(b) General nature of industry,
business, or establishment
which employed (or employer)
· BIRTHPLACE
(State or country)
medfre
PARENTS
12 MAIDEN NAME
OF MOTHER
Carolina Bentley
18 BIRTHPLACE
OF MOTHER
(State or country)
England
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
( Address)
16
Filed 191 .......
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
(Month)
(Day)
(Year)
1856 17 I HEREBY CERTIFY that I attended deceased from (Year) Apr. 18, AM. 30, 191 1914 to
4 that I last saw her alive on the 30, 1914 and that death occurred, on the date stated above, at 7.45 m. The CAUSE OF DEATH* was as follows : Botan Pneu na
(Duration)
.... yrs.
mos.
11
.ds.
Contributory
Probably due to an embolus
(SECONDARY)
.(Duration) ...
... yrs. ...
mos.
(Signed)
Albert B. Domman
M.D.
May 3, 1914 (Address)
Winthrop Mass
* 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
1$ PLACE OF BURIAL OR REMOVAL
DATE OF BURIAL
5
191
4
20 UNDERTAKER
To. R. Bare
ADDRESS
(City or town.)
Ward)
[If death occurred in a hospital or institution, give its NAME instead of street and number.]
Marion
6 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
married
6 DATE OF BIRTH
90
1914
........
3/4 hours, .ds.
10 NAME OF
FATHER
Thomas Hodgson
11 BIRTHPLACE
OF FATHER
(State or country)
England
In the
ʼ
·
STANDARD CERTIFICATE OF DEATH.
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