USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1913-1915 > Part 57
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les. Date
(Duration)
......... yrs. ........
4
mos.
ds.
Contributory
(SECONDARY)
.(Duration)
....... yrs.
......
.mos.
ds
(Signed)
Edward ). Granger
M.D.
May 29, 1914 (Address)
Wintherp
* 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,
In the
Stato ..... yri. ............
mos.
.
Where was disease contracted, If not at place of death ?... Former or usual residence.
" PLACE OF BURIAL OR REMOVAL Holywood Cem
DATE OF BURIAL
May 29. 1914
DUNDERTAKER J.J. Lane
ADDRESS
Winthrop
BOSTON
(City or town.) [If death occurred in a hospital or institution, give its NAME Instead of street and number.]
-
Registered No.
(Day)
1914
TAGE 82 yre. 7 mos 200
10 NAME OF
FATHER
Jacob Bussen
STANDARD CERTIFICATE OF DEATH.
Statement of occupation. - Precise statement of occu- pation is very important, so that the relative healthfulness of various pursuits ean 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, Architect, Loco- motive cnyincer, 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) Forcman, (b) Auton:obile 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 minc, 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- CASE 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 "Epidemic cerebro-spinal meningitis"); Diphtheria (avoid use of "Croup"); Typhoid fever (never re- port "Typhoid pneumonia"); Lobar pneumonia; Broncho- pneumonia ("Pneumonia," unqualified, is indefinite) ; Tuber-
culosis of lungs, meninges, peritonacum, etc., Carcinoma, sar- coma, etc., of. ... (name origin: "Cancer" is less definite; avoid use of "Tumor" for malignant neoplasms) ; Mcasles; 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), 22 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," "Marasınus," "Old age," "Shock," "Uracmia," "Weakness," etc., when a definite disease can be ascertained as the cause. Always qualify all diseases resulting from childbirth or miscarriage, as "PUER- PERAL septicaemia," "PUERPERAL peritonitis," etc. State eause 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 discase, 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.
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 Commmuwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH Wichnot .(No. 22 adams St. ..... Ward)
(City or town.) fif death occurred im a hospital or institution, give ita NAME Instead of street and number.]
Edward Wier
2FULL NAME
[If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE
22 adams St Warchest
Registered No.
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH :
Month)
29, 1914
(Day)
(Yéar)
" DATE OF BIRTH
18 1943
(Month)
(Day)
(Year)
7 AGE
70
yrs.
8
mos.
.......
ds.
or ....... min. ?
B OCCUPATION
(a) Trade, profession, or
particular kind of work
(b) General nature of Industry.
business, or establishment in
which employed (or employer).
Reluct
9 BIRTHPLACE
(State or country)
Halafax 2. 5,
10 NAME OF
FATHER
-
11 BIRTHPLACE
OF FATHER
(State or country)
Halafax U.S.
(
12 MAIDEN NAME
OF MOTHER)
Marquet. Sarah Dufres
1ª BIRTHPLACE
OF MOTHER
(State or country)
Halafay U.S.
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
(Address)
Filed
191
REGISTRAR
18 DATE OF. DEATH
17
I HEREBY CERTIFY that I attended deceased from
may 6
1914, to
Imay 21, 1915
that i last saw h .... kata alive on
grand 29, 1914
and that death occurred, on the date stated above, at
6:45 m.
The CAUSE OF DEATH* was as follows :
Chemin Interstitial
nephritis myocarditis
.(Duration)
ds.
......
.yrs.
.............. mos. ...............
Contributory. (SECONDARY)
(Duration)
........ yr8.
............
mos.
........... ds.
(Signed)
C. 7. Mahoney
M.D.
2 31, 1914 (Address)
855 minctures
* 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 tha
At place
of death ............ yrs.
mos.
ds.
Stato
...... yra.
mos.
Where was disease contracted, If not at place of death ?..
Former or usual residence
1 PLACE OF BURIAL OR REMOVAL
DATE OF BURIAL
1914
" UNDERTAKER
en.3.
ADDRESS
3 SEX
Male
4 COLOR OR RACE
White
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
manuel
If LESS than
{ day ......... hrs.
PARENTS
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, e. g., Farmer or Planter, Physician, Compositor, Architect, Loco- molive 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) 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 laborcr, 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, Houscwork, 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 Scrvant, 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- DASE CAUSING DEATH (the primary affection with respect to time and causation), using always the same accepted term for the same discasc. Examples: Cerebro-spinal fever (the only definite synonym is "Epidemic cerebro-spinal meningitis"); Diphtheria (avoid use of "Croup"); Typhoid fever (never re- port "Typhoid pneumonia"); Lobar pneumonia; Broncho- pneumonia ("Pneumonia," unqualified, is indefinite) ; Tuber-
culosis of lungs, meninges, peritonacum, etc., C Curetnon
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: Mcasles (disease causing death), 29 ds .; Broncho-pneumonia (secondary), 10 ds. Never report mero 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 age," "Shock," "Uracmia," "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 duc 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
51
(No.
St. ;............... Ward)
[if death occurred In a hospital or institution, give its NAME Instead of street and number.]
Atéivait
'FULL NAME
[If married or divorced woman or widow
give maiden name, also name of husband.]
@RESIDENCE
45
Beacon
Registered No.
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
3 SEX
4 COLOR OR RACE
valente
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
1ª DATE OF DEATH
May
1914
(Month)
(Day)
(Year)
6 DATE OF BIRTH
(Month)
(Day)
(Year)
7 AGE flott Bonn
......... yrs. „mos .. .de.
min. ?
8 OCCUPATION
(a) Trade, profession, or
particular kind of work
(b) General nature of industry.
business, or establishment in
which employed (or employer)
(Prever ature)
? BIRTHPLACE
(State or country)
.. (Duration)
......... yrs.
..................
ds.
Contributory
(SECONDARY)
(Duration)
yTs. ......... mos. ds
M.D.
Serem ist 1011 (Address)
Muchrop
* 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.
Where was disease contracted, If not at place of death ?...
Former or usual residonce.
LA PLACE OF BURIAL OR REMOVAL
DATE OF BURIAL
6/3
1915
D UNDERTAKER
E. R. Pena
ADDRESS
Filed ., 191
REGISTRAR
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)
It Jolina 21. 13.
12 MAIDEN NAME
OF MOTHER
Ella Downey
18 BIRTHPLACE
OF MOTHER
(State or country)
new Bedford may
" THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
(Address)
If LESS than I day ......... hrs.
I HEREBY CERTIFY that i attended deceased from
May 28., 1914.
to
191
.........
that ! last saw h ........
alive on
191
.......
and that death occurred, on the date stated above, at
m.
The CAUSE OF DEATH* was as follows :
Still - bor
10 NAME OF
FATHER
Eso. F. Stewart
(Signed)
Dr.g. Partes
(City or town.)
STANDARD CERTIFICATE OF DEATH.
Statement of occupation. - Precise statement of occu- pation is very important, so that the relative healthifulness 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 thic first line will be sufficient, e. g., Farmer or Planter, Physician, Compositor, Architect, Loco- motive engineer, Civil engineer, Stationary fireman, cte. 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) 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), inay 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- DASE 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 "Epidemie cerebro-spinal meningitis"); Diphtheria (avoid use of "Croup"); Typhoid fever (never re- port "Typhoid pneumonia"); Lobar pneumonia; Broncho- pneumonia ("Pneumonia," unqualified, is indefinite) ; Tuber-
culosis of lungs, meninges, peritonacum, etc., Carcinoom offert, A
coma, ctc., of ... .... (name origin: "Cancer" is less definite; avoid use of "Tumor" for malignant neoplasms) ; Mcasles; 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 merc symptoms or terminal conditions, such as "Asthenia," "An- aenia" (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 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.
1
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH
Winthrop
(No
335
Winthrop
St. :.
Ward)
[If death occurred in a hospital or institution, give its NAME instead of street and number.]
2 FULL NAME
Annie Loretta Galvinwife of
[If married or divorced woman or widow give maiden name, also name of husband.] C. OConnell Fallin
@RESIDENCE
335 Hintlook St
Registered No.
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
4 COLOR OR RACE
Female Mit
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
Manrizal
· DATE OF BIRTH
Seht
22
(Month)
(Day)
(Year)
7 AGE
50
yrs.
8
mos.
....
12
ds.
or ........ min. ?
8 OCCUPATION
(a) Trade, profession, or
particular kind of work
Housewife
(b) General nature of industry.
business, or establishment in
which employed (or employer).
' BIRTHPLACE (State or country) Worcester frase
PARENTS
12 MAIDEN NAME
OF MOTHER
Marx malver
13 BIRTHPLACE
OF MOTHER
(State or country) teland
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
C. C'Carnielli Salvin
(Address) 9.95inclure.It
...
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
A. une
(Month)
3
. 1914
(Year)
(Day)
I HEREBY CERTIFY that I attended deceased from
1913 to
Sunt3, 194.
that I last saw
e alive on
June 3, 1914.
and that death occurred, on the date stated above, at
10 m.
The CAUSE OF DEATH* was as follows :
Lateral Schuss
(Duration)
....... ..... yrs.
. 1
mos.
ds.
Contributory
(SECONDARY)
(Signed)
(Duration)
fancy all elly
yışı
robs.
ds.
M.D.
Sunca, 1914 (Addres).
825 Withupp 51
" 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 dlsease contracted, If not at place of death ?.
Former or usual residence.
19 PLACE OF BURIAL OR REMOVAL Alfilma Warcerto
DATE OF BURIAL
1
circle ? 19/11
20 UNDERTAKER
Holm Jill Imaliy
ADDRESS
19 culantic de
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.
Vinci
(City or town.)
Filed. . 191
10 NAME OF
Michael Juin
II BIRTHPLACE OF FATHER (State or country) Ireland
....
If LESS than
[ day ......... hrs.
1863
17
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 bousebold 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 bave 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- pncumonia (" 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 neoplasme) ; 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," "Haemorrbage," "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 Examinors:
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
(No.
Hospital.
St. : .. Ward)
2 FULL NAME
Annie Mc Ewen
( Mc Kenzie)
[If married or divorced woman or widow give maiden name, also name of husband.] William H. Mc ..... Ewen
@RESIDENCE
32 Pearl Averue, Winthrop, Mass.
PERSONAL AND STATISTICAL PARTICULARS
I PLACE OF DEATH
"elrose
3 SEX
4 COLOR OR RACE
Femal.
White
6 DATE OF BIRTH
June 8, 1845
(Month)
7 AGE
69
.. yrs.
8 OCCUPATION
(a) Trade, profession, or
particular kind of work
At home
(b) General nature of industry,
business, or establishment in
which employed (or employer).
10 NAME OF
FATHER
11 BIRTHPLACE
OF FATHER
PARENTS
13 BIRTHPLACE
Scotland
OF MOTHER
(State or country)
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.
N. D. - Every Hem of Information should be carefully supplied. AGE should be stated CAACILI. FISICIANS Should state
(State or country)
Scotland.
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
Married
(Year)
If LESS than
0
mos.
1
ds.
or ....... min. ?
3 BIRTHPLACE
(State or country)
Pictou, Nova Scotia.
Donald Mc Konzie
12 MAIDEN NAME OF MOTHER Harriett Ross
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
William Henry Mc Ewen Jr.
(Informant)
(Address) 965 Franklin St. Melrose.
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
June 9, 1914.
191
(Year)
I HEREBY CERTIFY that I attended deceased from
June 5
4
June 9
4
191
to
191
191
1 P
m.
alive on
June 9,
4.
and that death occurred, on the date stated above, at
The CAUSE OF DEATH* was as follows : Acuto Miliary Tuberculosis.
10 days.
(Duration).
yrs.
mos. . ds.
Contributory
Oedema of Brain
(SECONDARY)
10 hours
(Duration)
. yrs.
mos.
ds.
(Signed)
Paul H. Provandie.
M.D.
June
10
4
$91
(Address)
Melrose, Mass.
* If death followed injury or violence the certificate of death must be made out by the Medical Examiner.
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