Town of Winthrop : Record of Deaths 1913-1915, Part 54

Author: Winthrop (Mass.)
Publication date: 1913
Publisher:
Number of Pages: 1094


USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1913-1915 > Part 54


Note: The text from this book was generated using artificial intelligence so there may be some errors. The full pages can be found on Archive.org (link on the Part 1 page).


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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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