USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1913-1915 > Part 58
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16 LENGTH OF RESIDENCE (FOR HOSPITALS, INSTITUTIONS, TRANSIENTS, OR RECENT RESIDENTS).
At place
of death ...
. yrs. .
mos.
5
In the
ds.
State ..
.. . yrs.
....
mos.
ds ...... ....
Where was disease contracted,
if not at place of death ?
Unknown
Former or
usual residence.
32 Pearl Av. Winthrop. Mass.
1º PLACE OF BURIAL OR REMOVAL Burlington, Mass.
DATE OF BURIAL
June 11
191
191
Filed. June 11 1014. We Waren andAlbert J. Walton, REGISTRAR
ADDRESS
Melrose, Mass
(City or town.)
[If death occurred in a hospital or institution, give its NAME instead of street and number.]
Registered No.
(Month)
(Day)
(Day)
day ........
hrs.
that I last saw h.
er
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 engincer, 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 hne 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 minc, etc. Women at home, who are engaged in the duties of the household only (not pald 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 lunys, 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 onc supposed to be duc to Alcoholism, etc.
4. Deaths under circumstances unknown, as A person found dead, etc.
. ......
.
CAUSE OF DEATH In plain terms, so that It may be properly classified. Exact statement of OCCUPATION is very important. See instructions on back of certificate.
The Commonwealth of Massachusetts
STANDARD, CERTIFICATE OF DEATH
1 PLACE OF DEATH
Chelsea, Mass
(No
Frost Hospital
St. ;.............. Ward)
CHELSEA (City or town.) [If death occurred in a hospital or institution, give its NAME instead of street and number.]
? FULL NAME
Mary E. Staples
[If married or divorced woman or widow give maiden name, also name of husband.]
Wife of Wm. Staples
@RESIDENCE
21 George St. Winthrop. Mass
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
* SEX
4 COLOR OR RACE
F.
· DATE OF BIRTH
-
(Month)
(Day) (Year)
PAGE
If LESS than
[ day ......... hrs.
6.1 .yrs.
- mos.
- ds.
or ........ min. ?
& OCCUPATION
(a) Trade, profession, or
particular kind of work
At .... Home
(b) General nature of Industry.
business, or establishment in
which employed (or employer) ...
9 BIRTHPLACE
(State or country)
East Boston
Contributory.
(SECONDARY)
(Duration)
............. yrs. .
............... mos.
de.
-
(Signed)
Edward J. Grainger
M.D.
June 7
...... 1914 (Address)
Winthrop .. .... Mass
....
3
* If death followed injury or violence the certificate of death must be made out by the Medical Examiner.
18 LENGTH OF RESIDENCE (FOR HOSPITALS, INSTITUTIONS, TRANSIENTS, OR RECENT RESIDENTS).
In the
At place
of death
...... yrs. .......
.mos.
-
ds.
State ............ yra. ....
-
da ...........
Where was disease contracted, If not at place of death ?. Former or usual residence
19 PLACE OF BURIAL OR REMOVAL Winthrop, Mass
DATE OF BURIAL
June 8,
4
191
Filed June 7. 191.4
REGISTRAR
16 DATE OF DEATH
June
6
191.4.
(Month)
(Day)
(Year)
17 I HEREBY CERTIFY that I attended deceased from June 4 191 4.
to
June
6
191 4
....
that I last saw h
alive on
June
6
191 4 and that death occurred, on the date stated above, at m. The CAUSE OF DEATH* was as follows : Chronic ..... Interstitial .... Nephritis
(Duration)S.e.V ... yrs. -mos ... ds.
10 NAME OF
FATHER
Michael H. Shute
PARENTS
11 BIRTHPLACE
OF FATHER
(State or country)
Portsmouth, N. H.
12 MAIDEN NAME
OF MOTHER
Sarah A. Mason
18 BIRTHPLACE
OF MOTHER
(State or country)
Manchester . N. H.
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
C. R. Bennison
(Address)
20 UNDERTAKER
C. R.
Bennison
ADDRESS
Winthrop
Registered No.7385
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word Married
185.3
STANDARD CERTIFICATE OF DEATH.
Statement of occupation. - Precise statement of oecu- 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, 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 wlien 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 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, peritonacum, etc., Carcinoma, Sar- coma, etc., of. ... (name origin: "Cancer" is Icss 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 necd 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 symptomnatic), "Atrophy," "Collapse," "Coma," "Convulsions," "Debility" ("Congenital," "Senile," etc.), "Dropsy," "Exl.austion," "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.
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
Shand Theman
.............. Ward)
(City or town.) fif death occurred in a hospital or institution, give its NAME insteed of street and number.]
John P. Gallagher "FULL NAME
[If married or divorced woman or widow give malden name, also name of husband.] @RESIDENCE
112 Byron & East Buty
Registered No.
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
4 COLOR OR RACE
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
Mano.
6 DATE OF BIRTH
(Month)
(Day)
1
(Year)
7 AGE
If LESS than
I day ......... hrs.
46
.yrs. ... mos. ds.
Of ......... min. ?
8 OCCUPATION
(a)' Trade, profession, or
particular kind of work
Merchant
(b) Genaral nature of industry,
business, or establishment in
which employed (or employef) ...
· BIRTHPLACE
(State or country)
Galia Maine
PARENTS
11 BIRTHPLACE
OF FATHER
(State or country)
Irland
12 MAIDEN NAME
OF MOTHER
Cenne Scanlon
13 BIRTHPLACE
OF MOTHER
(State or country]
Jeland
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
Wife
(Address)
112 Byron LA
14
Filed 191.
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
June
10
4
(Month)
(Day)
191
(Year)
17
I HEREBY CERTIFY that I attended deceased from
april 7, 1913,
to
June 10, 1914
that I last saw him alive on
June
9
1914
and that death occurred, on the date stated above, at 9 Am.
The CAUSE OF DEATH* was as follows :
Chronic Interstitial Nephritis
.............
(Duration)
1 yrs. 2
..... mos. ............ .ds.
Contributory
(SECONDARY)
(Duration)
.. yrs.
mos. „ds.
(Signed)
Edmund Fr. Morau
.....
M.D.
Dune10, 1914 (Address).
641 Bennington St, E.B
* 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 plece
In the
of death ............ yrs. ....... mos. .......... ds.
Stato ........... yrs.
........... mos.
ds .............
Where was disease contracted, if not at place of death ?...
Former cr usual residonce.
" PLACE OF BURIAL OR REMOVAL
DATE OF BURIAL
7me 12, 1914
» UNDERTAKER
ADDRESS
BOSTON .......
10 NAME OF
FATHER
John
101914
STANDARD CERTIFICATE OF DEATH.
Statement of occupation. - Precise statement of occupa- tion is very important, so that the rolative 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 cngincer, Stationary fireman, etc. But in many cases, especially in industrial employments, it is necessary to know (a) the kind of work and also (b) the nature of the business or industry, and therefore an additional line is provided for the latter statement; it should be used only when needed. As cxamples: (a) Spinner, (b) Cotton mill; (a) Sales- man, (b) Grocery ; (a) 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 minc, etc. Women at home, who are engaged in the duties of the household only (not pald 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, stato 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 "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, 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 cansing death), 29 ds .; Broneho-pneumonia (secondary), 10 ds. Never report mere symptoms or terminal conditions, such as " Asthenia," " All- 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 bo ascertained as the cause. Always qualify all diseases resulting from childbirth or miscarriage, as " PUER- PERAL septicemia," " PUERPERAL peritonitis," etc. State cause for which surgical operation was undertaken.
Cases for the Medical Examiners. - Under the provisions of chapter 24 of the Revised Laws deaths under the following conditions must be referred to the Medical Examiners:
1. Deaths following injury or violence, as Burns, Falls, Drowning, Gas Poisoning, Suicide, Homicide, etc.
2. Deaths supposedly 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, otc.
4. Deaths under circumstances unknown, as A person found dead, etc.
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH
winchnot
(No.
35 Somnen avist.
Ward)
(City or town.) [If death occurred in a hospital or institution, give its NAME Instead of street and number.]
2FULL NAME
Emma. C. Freeman
[If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE
willen of Melville. Fruman Registered No.
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
3 SEX
4 COLOR OR RACE
White
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
1ª DATE OF DEATH
June
11
19114
(Month)
(Day)
(Year)
6 DATE OF BIRTH
(Month)
(Day)
1
(Year)
7 AGE
63
.yrs.
mos. de.
......
If LESS than
1 day ......... hrs.
Of ......... min. ?
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) ..
9 BIRTHPLACE
(State or country)
Welfleck Man
10 NAME OF
FATHER
Clement Higgins
11 BIRTHPLACE
OF FATHER
(State or country)
Welfleck May
12 MAIDEN NAME
OF MOTHER
Forces . L. Collins
18 BIRTHPLACE
OF MOTHER
(State or country)
Timo mas
"THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
(Address)
Filed
191
அவை
REGISTRAR
17
I HEREBY CERTIFY that i attended deceased from
to
1913
191
june 11
191 %
that I last saw hly alive on
June 16
1914.
and that death occurred, on the date stated above, at& ~ am.
The CAUSE OF DEATH* was as follows :
Diabetes
Roma.
1
:
(Duration).
2 yrs.
ayrs.
............. mos. ds.
Contributory (SECONDARY)
.. (Duration) .yrs.
.. mos. ds
31mal call
M.D.
...........
1914 (Address)
Winthrop
/* If death followed injury or violence the certificate of death must be made out by the Medical Examiner.
In the
18 LENGTH OF RESIDENCE (FOR HOSPITALS, INSTITUTIONS, TRANSIENTS, OR
RECENT RESIDENTS).
At place
of death ............ yrs.
„,mos.
ds.
State ............ yra.
Where was disease contracted, If not at place of death ?. Former or usual residence
1º PLACE OF BURIAL OR REMOVAL Welfreck mars
DATE OF BURIAL
6/14
· UNDERTAKER
ADDRESS
important. See instructions on back of certificate. N. B. - Every item of information should be carefully supplied. AGE should be stated EARGILT. PHYSICIANS should state CAUSE OF DEATH in plain terms, so that it may be properly classified. Exact statement of OCCUPATION is very PARENTS
(Signed)
tm 11
STANDARD CERTIFICATE OF DEATH,
Statement of occupation. - Precise statement of oceu- 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- 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) 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 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 oceu- 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, perfortuny, euv
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 discases resulting from childbirth or miscarriage, as "PUER- PERAL septicacmia," "PUERPERAL peritonitis," etc. State cause for which surgical operation was undertaken.
Cases for the Medical Examiners. - Under the provi- sions of chapter 24 of the Revised Laws deaths under the fol- lowing conditions must be referred to the Medical Examiners:
1. Deaths following injury or violence, as Burns, Falls, Drowning, Gas poisoning, Suicide, Homicide, etc.
2. Deaths supposedly caused by violence, as Criminal abortion, Poisoning, Starvation, Suffocation, Ex- posure, etc.
3. Sudden deaths of persons not disabled by recognized disease, as A death upon the street, or one supposed to be due to Alcoholism, etc.
4. Deaths under circumstances unknown, as A person found dead, etc.
The Commmuwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
! PLACE OF DEATH
wruchurt
(No.
John, &, O' Gara
*FULL NAME
[If married or divorced wømdf or widow
give maiden name, also name of husband.]
@RESIDENCE
97
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
3 SEX
male
4 COLOR OR RACE
white
6 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
Single
1ª DATE OF DEATH
que
12
191 4
(Month)
(Day)
(Yéar)
$ DATE OF BIRTH
(Month)
(Day)
1
(Year)
7 AGE
45
yrs. mos .. ds.
or ......... min. ?
8 OCCUPATION
(a) Trade, profession, or
particular kind of work
Fireman Met Seven .
(b) General nature of industry,
business, or establishment in
which employed (or employer)
9 BIRTHPLACE
(State or country)
10 NAME OF
FATHER
Martin & Gara
PARENTS
12 MAIDEN NAME
OF MOTHER
Hanora, Fully
18 BIRTHPLACE
OF MOTHER
(State or country)
feeland
"THE ABOVE IS TRUE TO THE BESTOF MY KNOWLEDGE
(Informant)
(Address)
FI :. J
19]
REGISTRAR
18 LENGTH OF RESIDENCE (FOR HOSPITALS, INSTITUTIONS, TRANSIENTS, OR RECENT RESIDENTS).
In the
At place
of death ..........
.yrs.
6
mos.
de.
State ............ y.a.
............. fr.03.
ds ....
Where was disease contracted, 9) Thore Drie
If not at place of death ?.....
usual residonce.
Former or
92 There Have Lockthe
1 PLACE OF BURIAL OR REMOVAL
Holly have
DATE OF BURIAL
1915
D UNDERTAKER
9. Gallavan
ADDRESS
So Borlow
de.
Contributory.
amputation (operation)
(SECONDARY)
(Duration)
............ yrs.
mos.
4hs
(Signed)
31Met call
M.D.
my 12
1914 (Address)
Wattrop
* If death followed Injury or violence the certificate of death must bo made out by the Medical Examiner.
of left ankle
OInfection three fort
,(Duratofi)
............. yrs.
......
mos.
6
11 BIRTHPLACE
OF FATHER
(State or country)
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.
Ward)
(City or town.) [If death occurred In a hospital or institution, giva. its NAME instead of street and number.]
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