USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1913-1915 > Part 55
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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, 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.
COMMONWEALTH OF MASSACHUSETTS
RETURN OF A DEATH-1914. HELEN M WILCOX
CITY OF BOSTON. 4427
FULL NAME
Registered No.
NEW ENG.DEACONESS HOSPT.
Place of Death and Residence
Boston
MAY 3
1
years 8
months
days.
STATISTICAL DETAILS.
SEX.
COLOR.
SINGLE, MARRIED, WID., DIV.
F
SIN
from 1914, to
1914, that to the best of my knowledge and belief death occurred, on the date stated above, and that the CAUSE OF DEATH was as follows :
Maiden Name
EGISTRAR
IT PATRIBLE
Primary ( Duration)
-
SHOCK FOL. OPR.DECOMPRESSION
Husband's Name
SICUT
OFFICE
ON BRAIN (CRANIOTOMY) 1 DAY
BOSTO. IA
Name of Father
ROGER M. H. WILCOX
RE TMI
Birthplace of Father
PORTLAND. ME.
BIRTH INJURY OF BRAIN
1
Maiden Name of Mother
LEONTINE RICHARDSON
Birthplace of Mother
BROOKLINE
DE WITT WILCOX
M.D.
1914
SPECIAL INFORMATION from Hospitals, Institutions, Transients, or Recen! Residents.
Place of Burial or removal
WINTHROP (WINTHROP CEM)
WINTHROP ( 112 WASHINGTON AV)
Usual Residence
Filed
MAY 6 1914.
Undertaker
C. R. BENNISON
WINTHROP
A true copy. Attest :
ErMSlenen
Registrar.
Informant
PHYSICIAN'S CERTIFICATE.
I HEREBY CERTIFY that I attended deceased during last illness,
CITY RE
WINTHROP
Birthplace
CONCITAA.
1 11.
STO
FE DONATA A . MASS. Contributory : { (Duration)
(Signed)
Occupation
Date of Death
1914.
Age
-
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
wachnot
(No.
melcol Noshote
Ward)
(City or town.) [If death occurred in a hospital or institution, give its NAME instead of street and number.]
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH,
3 SEX
Male
4 COLOR OR RACE
white
5 SINGLE,
MARRIED,
Single
WIDOWED,
OR DIVORCED
(Write the word)
S DATE OF BIRTH
may
8
1:14
17
(Month)
(Day)
(Year)
7 AGE
If LESS than
1 day, ........ hrs.
ds.
or ....... min. ?
& OCCUPATION
(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)
Wowchinh Mars
10 NAME OF
FATHER
Handell. G. Hodgkin
PARENTS
11 BIRTHPLACE
OF FATHER
(State or country)
Rockland me
12 MAIDEN NAME
OF MOTHER
weide. 2. Walker
13 BIRTHPLACE
OF MOTHER
(State or country,
Hvert Warren Mais
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
W. a. Hodylemi
(Address) 15 Court. Park Pool
REGISTRAR
IS DATE OF DEATH
I HEREBY CERTIFY that I attended deceased from
, 1914, to
may 11
1914
that I last saw him alive on
may 11"
, 1914
and that death occurred, on the date stated above, at
11 pm.
The CAUSE OF DEATH* was as follows :
Premature (7 mois.)
.(Duration)
.. yrs.
mos.
2
ds.
Contributory
(SECONDARY)
(Duration)
.. yrs.
mos.
ds.
(Signed)
31 Metcalf
M.D.
may 12
191
4 .... (Address) withfp
* If death followed injury or violence the certificate of death must be made out by the Medical Examiner.
.8 LENGTH OF RESIDENCE (FOR HOSPITALS, INSTITUTIONS, TRANSIENTS, OR RECENT RESIDENTS).
At place
of death.
. yrs.
. mos.
In the
ds
State
yrs.
mos.
2
ds.
Where was disease contracted,
If not at place of death ?.
Former or
usual residence
19 PLACE OF BURIAL OR REMOVAL
DATE OF BURIAL
5/14
..
191 4
........
20 UNDERTAKER
ADDRESS
Filed 191.
Albert Walker Hodgkins
2 FULL NAME
[If married or divorced woman or widow
give maiden name, also name of husband.]
@RESIDENCE
15 Court Road Winters
Registered No.
(Month)
11
. 1914
(Year)
(Day)
yrs.
mos.
3
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, 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.
1 SEX PARENTS Important. See Instructions on back of certificate. 16 Filed 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 ...
The Conmmmwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
BOSTON ....
1 PLACE OF DEATH
18 Juin 88
(No.
Winthrop
St. :
Ward)
Soplica R. Dowell
2FULL NAME
[If married or divorced woman or widow
give maiden name, also name of husband.]
@RESIDENCE
18drift
Kunales Plumas Dowell
Registered No.
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
4 COLOR OR RACE
SINGLE.
-MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
6 DATE OF BIRTH
(Month)
(Day)
1
(Year)
or ......... min. ?
8 OCCUPATION
(a) Trade, profession, or
particular kind of work
Hinsleeper
(b) General nature of Industry.
business, or establishment in
which employed (or employer).
Did a surgical operation precede death
/Pate
(Duration)
yr8.
mcs.
1
da
Contributory.
arterio- salerada
(SECONDARY)
Sendetente
.. (Duration)
...... yrs. ..............
mos.
.......
.. ds.
(Signed)
Il. Porto
M.D.
thay
(Address).
Winetrop
* If death followed injury or violence the certificate of death must be made ont by the Medical Examiner.
10 LENGTH OF RESIDENCE (FOR HOSPITALS, INSTITUTIONS, TRANSIENTS, OR RECENT RESIDENTS).
At place
of death ........... yrs.
mos. ....
de.
State
In the
Where was disease contracted, If mot at place of death ?.
Former or
usual residence.
" PLACE OF BURIAL OR REMOYAL udgobernaten May 18 1914
DATE OF BURIAL
" UNDERTAKER W.Shewas
4081 ADDRESS Baradway To Boston
191
REGISTRAR
U DATE OF DEATH
May
15€
(Month)
(Day)
1915 (Year)
I HEREBY CERTIFY that I attended deceased from
may 7th
to
Mage Ich
19
that last saw her
alive on.
may/ 14st
1912
and that death occurred, on the date stated above, at
6Pm.
The CAUSE OF DEATH* was as follows :
Bronchitis (Capillary )
9 BIRTHPLACE
(State or country)
Cheland
10 NAME OF
FATHER
ThomasKnowles
1) BIRTHPLACE
OF FATHER
(State or country}
ireland
12 MAIDEN NAME
OF MOTHER
Sophia Hunles
13 BIRTHPLACE
OF MOTHER
(State or country)
Ireland
14 THE ABOVE IS TRUE, TO THE BEST OF MY KNOWLEDGE
(Informant).
John Daunt
(Address)
(City or town.) [If death occurred le a hospital or institution, give its NAME instead of street and number.]
" AGE 8/
If LESS than
! day ......... hrs.
yra. mos.
STANDARD CERTIFICATE OF DEATH.
Statement of occupation. - Precise statement of occu- pation is very important, so that the relative healthfulness of various pursuits can be known. The question applies to each and every person, irrespective of age. For many occupations a single word or term on the first line will be sufficient, c. 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 linc is provided for the latter statement; it should be used only when needed. As examples: (a) Spinner, (b) Cotton mill; (a) Salcs- man, (b) Grocery; (a) Forcman, (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- LASE CAUSING DEATH (the primary affection with respect to time and causation), using always the same accepted term for the same discase. Examples: Cercbro-spinal fcvcr (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 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," "Collapsc," "Coma," "Convulsions," "Debility" ("Congenital," "Senile," etc.), "Dropsy," "Exhaustion," "Heart failure," "Hacmorrhage," "Inanition," "Marasmus," "Old age," "Shock," "Uraemia," "Weakness," etc., when a definite discase can be ascertained as the cause. Always qualify all discases resulting from childbirth or miscarriage, as "PUER- PERAL scpticaemia," "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, ctc.
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
Wintaraf
(No.
480
Winthrop
St. :
Ward)
BOSTON (City or town.) [If death occurred in a hospital or institution, give its NAME instead
Man . Atclick han Gary
2 FULL NAME
[If married or divorced women or widew.
give maiden name, also name of huob md.]
ARESIDENCE 480 Cordial 21
James
Registered No.
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
' COLOR OR RACE
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
" DATE OF BIRTH
(Month)
(Day)
1
(Year)
7 AGE 38
If LESS than
I day ........ hrs.
yrs.
mos.
ds.
or ......... min. ?
& OCCUPATION
ar x time
(b) General nature of Industry, business, or establishment in which employed (or employer).
9 BIRTHPLACE
(State or country)
Cash Pacto
10 NAME OF
FATHER
Jannes Sheary
PARENTS
11 BIRTHPLACE OF FATHER (State or country) Ireland
12 MAIDEN NAME
OF MOTHER
18 BIRTHPLACE OF MOTHER (State or country) Ireland
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
Thisland
(Address)
REGISTRAR
17
I HEREBY CERTIFY that I attended deceased from
1914, to
Zwany 17
1914
that I lase saw h __ alive on
auf 17
191%,
and that death occurred, on the date stated above, at
m.
The CAUSE OF DEATH* was as follows :
Pula
(Duration)
.yrs.
.........
mos.
ds.
Contributory. (SECONDARY)
.(Duration) .... yrs. ....... .............. .. mos. ds.
(Signed)
M.D.
.. 1914 (Address)
365 Zuckert
* 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.
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 Stoly Jaestou
DATE OF BURIAL May 20. 1914 ...........
20 UNDERTAMER
ADDRESS
Filed 191
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
(Month)
(Day)
17
..... 1914
(Year)
(a) Trade, profession, or
particular kind of work
0
In the
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," "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 Nonc.
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 discase. 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," "Marasınus," "Old age," ""Shock," "Uracmia," "Weakness," etc., when a definito disease can be ascertained as the cause. Always qualify all diseases resulting from childbirth or miscarriage, as "PUER- PERAL septicaemia," "PUERPERAL peritonitis," ctc. State cause for which surgical operation was undertaken.
Cases for the Medical Examiners. - Under the provi- sions of chapter 24 of the Revised Laws deaths under the fol- lowing conditions must be referred to the Medical Examiners:
1. Deaths following injury or violence, as Burns, Falls, Drowning, Gas poisoning, Suicide, Homicide, etc.
2. Deaths supposedly caused by violence, as Criminal abortion, Poisoning, Starvation, Suffocation, Ex- posure, etc.
3. Sudden deaths of persons not disabled by recognized disease, as A death upon the street, or one supposed to be due to Alcoholism, etc.
4. Deaths under circumstances unknown, as A person found dead, etc.
N. B. - Every item of information should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state CAUSE OF DEATH in plain terms, so that it may be properly classified. Exact statement of OCCUPATION is very
important. See instructions on back of certificate.
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH Wuiltrop (No. 42 Harbour View ...........
le
St. : Ward)
6047 Winthrop (City or town.) [If death occurred in a hospital or institution, give its NAME instead of street and number.]
2 FULL NAME
William 9 Mmman
[If married or divorced woman or widow
give maiden name, also name of husband.]
@RESIDENCE
42 mountain are -france the
Registered No.
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
3 SEX
Mall
4 COLOR OR RACE
White
· SINGLE,
MARRIED.
WIDOWED,
OR DIVORCED
(Write the word)
manuel
6 DATE OF BIRTH
(Month)
(Day)
1
(Year)
7 AGE
If LESS than
I day, ........ hrs.
45 .yrs. mos. . . ds.
or ....... min. ?
8 OCCUPATION
(a) Trade, profession, or
particular kind of work ..
Saluman
(b) General nature of industry,
business, or establishment in
which employed (or employer)
Real Estate
9 BIRTHPLACE
(State or country)
Somersworth N.H.
Contributory
(SECONDARY)
(Duration)
yrs.
... mos. ds.
(Signed)
Lenge Burgas Magsaltos
.,
M.D.
(Mass8, 19:4 (Address)
14:35 am MEDICAL EXAMINER
* State the DISEASE CAUSING DEATH, or, in deaths from VIOLENT CAUSES, state (1) MEANS of INJURY; and (2) whether ACCIDENTAL, SUICIDAL or HOMICIDAL.
.8 LENGTH OF RESIDENCE (FOR HOSPITALS, INSTITUTIONS, TRANSIENTS, OR RECENT RESIDENTS).
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