USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1913-1915 > Part 62
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).
Part 1 | Part 2 | Part 3 | Part 4 | Part 5 | Part 6 | Part 7 | Part 8 | Part 9 | Part 10 | Part 11 | Part 12 | Part 13 | Part 14 | Part 15 | Part 16 | Part 17 | Part 18 | Part 19 | Part 20 | Part 21 | Part 22 | Part 23 | Part 24 | Part 25 | Part 26 | Part 27 | Part 28 | Part 29 | Part 30 | Part 31 | Part 32 | Part 33 | Part 34 | Part 35 | Part 36 | Part 37 | Part 38 | Part 39 | Part 40 | Part 41 | Part 42 | Part 43 | Part 44 | Part 45 | Part 46 | Part 47 | Part 48 | Part 49 | Part 50 | Part 51 | Part 52 | Part 53 | Part 54 | Part 55 | Part 56 | Part 57 | Part 58 | Part 59 | Part 60 | Part 61 | Part 62 | Part 63 | Part 64 | Part 65 | Part 66 | Part 67 | Part 68 | Part 69 | Part 70 | Part 71 | Part 72 | Part 73 | Part 74 | Part 75 | Part 76 | Part 77 | Part 78 | Part 79 | Part 80 | Part 81 | Part 82 | Part 83 | Part 84 | Part 85 | Part 86 | Part 87 | Part 88 | Part 89 | Part 90 | Part 91 | Part 92 | Part 93 | Part 94 | Part 95 | Part 96 | Part 97 | Part 98 | Part 99 | Part 100 | Part 101 | Part 102 | Part 103 | Part 104 | Part 105 | Part 106 | Part 107 | Part 108 | Part 109 | Part 110 | Part 111 | Part 112 | Part 113 | Part 114 | Part 115 | Part 116 | Part 117 | Part 118 | Part 119 | Part 120 | Part 121
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.
CITY OF BOSTON.
FULL NAME JOHN G. BRAYMAN
Registered No.
7115
Place of Death l
Boston
LONG ISLAND HOS PT.
and Residence S
Date of Death
AUG. I
1914. Age 85
years
months days.
STATISTICAL DETAILS.
SEX.
COLOR.
SINGLE, MARRIED, WID., DIV.
M
Maiden Name
GIS
RAR'S
IT PATRIBES, S
Primary (Duration)
CITY
FICE
ARTERIOSCLEROSIS
BOSTONIA
Name of Father
BRAYMAN
B
OSTO
N. MASS.
Contributory . } ( Duration) 1
Maiden Name of Mother
-
Birthplace of Mother
PRINTER
Occupation
Informant
Place of Burial or removal
MT. HOPE
Usual Residence
WINTHROP (3 STURGIS ST. )
Filed
AUG. 4 1914.
A true copy.
Attest :
EumSeinen
Registrar.
O
Undertaker
K. T . GOOD
PHYSICIAN'S CERTIFICATE.
I HEREBY CERTIFY that I attended deceased during last illness,
from 1914, 1914, to 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 :
Husband's Name
R
SICUT P
R. I.
Birthplace
CIVITATISR
CONJITAA.
G MINE DONATA A.
(Signed)
C. G. RICHARDS
M.D.
AUG. I 1914
SPECIAL INFORMATION from Hospitals, Institutions, Transients, or Recen! Residents.
A. 1822
Birthplace of Father
CHR. MYOCARDITIS
0 1 1914
1
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
Chelsea
Mass ..
(No.
Frost Hospt.
.......
St. : ...... Ward)
CHELSEA (City or town.)
[If death occurred in a hospital or institution, give its NAME instead of street and number.]
2 FULL NAME
Edward Perry Kenney
[If married or divorced woman or widow
give maiden name, also name of husband.]
@RESIDENCE
35 Corel Ave., Winthrop. ass,
PERSONAL AND STATISTICAL PARTICULARS
: SEX
' COLOR OR RACE
6 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
Marr.
16 DATE OF DEATH
............
Augr
(Month)
2
, 191.4
(Day)
(Year)
6 DATE OF BIRTH
(Month)
(Day)
7 AGE
50 yrs. 3
mos.
11. ds.
„min. ?
$ OCCUPATION
(a) Trade, profession, or
particular kind of work
Teamster
(b) General nature of industry.
business, or establishment
which employed (or employer).
9 BIRTHPLACE
(State or country)
Portland, Me.
(Duration)
......... yrs.
mos.
1
ds.
Contributory.
(SECONDARY)
(Duration)
....... yrs. ..
......... mos.
ds.
(Signed)
F. J. Powers
M.D.
Ang. ......
3.
.. 1914 (Address).
22] Shurtleff
* If death followed injury or violence the certificate of death ninst be made ont 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.
-
19 PLACE OF BURIAL OR REMOVAL Winthrop Com.
DATE OF BURIAL
Aug . 5 ., 191
(Address)
35 Coral Ave.
Filed Aug. 3, 1914-
REGISTRAR
* UNDERTAKER Charles R. Bennison
ADDRESS
Winthrop
10 NAME OF
FATHER
Perry Kenney
PARENTS
11 BIRTHPLACE
OF FATHER
(State or conntry)
England
12 MAIDEN NAME
OF MOTHER
Louisa Sherlock
11 BIRTHPLACE
OF MOTHER
(State or country)
Eng lend
16 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
Wary C. Kenney
Registered No.
514
MEDICAL CERTIFICATE OF DEATH
M
22
1864
17
I HEREBY CERTIFY that I attended deceased from
(Year)
Aug ..
2 ............. , 191.4 ... , to
191-
-
........
If LESS than
I day ......... hrs.
that I last saw h ...........
alive on
191
and that death occurred, on the date stated above, at ....
-
m.
The CAUSE OF DEATH* was as follows : Cerebral ..... Hemorrhage
In the
4 hrs.
Rug. ʼ
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, e. g., Farmer or Planter, Physician, Compositor, Architcet, 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 linc 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 dutics 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 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: Mcasles (disease causing death), 29 ds .; Broncho-pneumonia (secondary), 10 ds. Never report merc symptoms or te minal 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," "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 duc to Alcoholism, etc.
4. Deaths under circumstances unknown, as A person found dead, ctc.
NORTH
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
1 PLACE/OF DEATH Winthrop (No 90 Birch Road
St. ;
Ward)
REVERE (City or town.) [If death occurred in a hospital or institution, give its NAME. instead of street and number.]
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
Male
+ COLOR OR RACE
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
Fugle
6 DATE OF BIRTH
13
1914
17
(Month)
(Day)
(Year)
7 AGE Still Bom
If LESS than I day ..... hrs.
yrs.
mos. ds.
or min. ?
8 OCCUPATION
(a)' Trade, profession, or
particular kind of work
7
(b) General nature of industry,
business, or establishment in
which employed (or employer).
9 BIRTHPLACE
(State or country)
"Winthrop, il ass.
PARENTS
11 BIRTHPLACE OF FATHER (State or country) Гурасиел Л.С.
12 MAIDEN NAME OF MOTHER Olace Eher Morin
13 BIRTHPLACE OF MOTHER (State or country) Boston
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
lehar L. Lakeland
(Address)
Winsthhah
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
(Month)
(Day)
, 19101.
(Year)
I HEREBY CERTIFY that I attended deceased from
, 1914 .. , to
., 19192.,
that I last saw h
alive on
191
and that death occurred, on the date stated above, at
m.
The CAUSE OF DEATH* was as follows :
(Duration)
yrs.
...
mos.
ds.
Contributory
(SECONDARY)
(Duration)
.yrs.
mos. .
ds
(Signed)
..... , 191
(Address)
* If death followed Injury or vlolenee the certificate of death must be made out by the Medical Examiner.
16 LENGTH OF RESIDENCE (FOR HOSPITALS, INSTITUTIONS, TRANSIENTS, OR RECENT RESIDENTS).
At place
of death
yrs,
mos.
ds.
State
In the
yrs.
mos.
ds ...
Where was disease contracted, If not at place of death ?
Former or usual residence.
19 PLACE OF BURIAL OR REMOVAL
DATE OF BURIAL
usg 8. 191h
20 UNDERTAKER
ADDRESS
Temin
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.
Baby.
Copeland
'FULL NAME [If married or divorced woman or widow give maiden name, also name of husband. @RESIDENCE 90 /Bunch
Good Whetherof
Registered No.
Filed 191
10 NAME OF
FATHER
Chas & Copeland
..
, M.D.
ang
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 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 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, peritoneum, etc., Careinoma, Sar- roma, 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 in- portant. Example : Measles (disease causing death), 29 ds .; Broncho-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 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 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.
11 BIRTHPLACE OF FATHER (State or country)
12 MAIDEN NAME OF MOTHER
13 BIRTHPLACE OF MOTHER (State or country)
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant).
(Address)
14
Filed. , 191
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH ang 21 (Day)
(Month)
191. (Year)
17 I HEREBY CERTIFY that I have investigated the death of the deceased.
The CAUSE OF DEATH* was as follows : natural Causes; Presumably heart disease and antino Schuur. (Surdicion durantea )
mos. ds.
Contributory. (SECONDARY)
(Duration) ... yrs.
.. mos. ds.
(Signed)
Jerzy Bugen Magath,
M.D.
guy 21 . (Address) MEDICAL EXAMINER
* State the DISEASE CAUSING DEATII, or, in deaths from VIOLENT CAUSES, state (1) MEANS of INJURY; and (2) whether ACCIDENTAL, SUICIDAL or HOMICIDAL.
18 LENGTH OF RESIDENCE (FOR HOSPITALS, INSTITUTIONS, TRANSIENTS, OR RECENT RESIDENTS).
At place
of death.
yrs.
.. mos.
.....
ds.
State .. .
.. yrs. ....
. . mos. .
...
Where was disease contracted, If not at place of death ?.
Former or usual residence ..
19 PLACE OF BURIAL OR REMOVAL
DATE OF BURIAL
191.
20 UNDERTAKER
ADDRESS
.
STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH Winthrop (No. Revere
( Jourshad)
2 FULL NAME ..
Patrick & Carry
[If married or divorced woman or widow give maiden name, also name of husband.]s @RESIDENCE 391 Shirts St
Registered No.
PERSONAL AND STATISTICAL PARTICULARS
+ COLOR OR RACE
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
1850
6 DATE OF BIRTH
6
(Month)
(Day)
(Year)
If LESS than I day, . hrs.
63 yr. ...
7 mos. 25 ds.
or min. ?
(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) toland.
3 SEX 7 AGE 8 OCCUPATION PARENTS WHITE PLAINLY, WITH UNFADING INA THIS IS A PERMANENT NEUUND. 1 10 NAME OF FATHER
The Commonwealth of Massachusetts
6287 Winthing (City or tow
St. ....... . Ward)
[If death occurred in a hospital or institution, give its NAME instead of street and number.]
In the
ds ....
ang 21/11/4
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, 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," ete., 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 oceu- 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 synonyni 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, peritoneum, 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 nced 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," ete. State cause for which surgical operation was undertaken. For VIOLENT DEATHS state MEANS OF INJURY and qualify as ACCI- DENTAL, SUICIDAL, Or HOMICIDAL, or as probably such, if impossible to determine definitely. Examples: Accidental drowning; Struck by railway train - accident; Revolver wound of head - homicide; Poisoned by carbolic acid -- probably suicide. The nature of the injury, as fracture of skull, and consequences (e. g., sepsis tetanus) may be stated under the head of "Contributory."
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. Deathis 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.
3 SEX 4 COLOR OR RACE 5 SINGLE, MARRIED, WIDOWED, OR DIVORCED (Write the word) 6 DATE OF BIRTH 10 (Month) (Day) 7 AGE 73 10 yrs. .mos. 6 ds. 8 OCCUPATION (a) Trade; profession, or particular kind of work Retired (b) General nature of industry, business, or establishment in which employed (or employer) 10 NAME OF FATHER 11 BIRTHPLACE OF FATHER (State or country) I? MAIDEN NAME OF MOTHER PARENTS WATTE FLAINET, WITH UNTADING INA THIS IS A PERMANENT NEUUND. 9 BIRTHPLACE (State or country) bankin mue
Lunaud M Fil
du. me
leallein l.ray
1ª BIRTHPLACE OF MOTHER (State or country)
" THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
Bensin P dish
( Address)
25 marchell Il
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
1
22
(Month)
(Day)
191 (Year)
I HEREBY CERTIFY that I have investigated the
death of the deceased.
The CAUSE OF DEATH* was as follows ?
Fractured humerus (2 weeks) accidental fall.
(Duration)
yrşı
mos. ds.
Contributory (SECONDARY)
.mos. ds.
(Signed)
M.D.
191 ... (Address)
MEDICAL EXAMINER
* State the DISEASE CAUSING DEATH, or, in deaths from VIOLENT CAUSE. state (1) MEANS of INJURY; and (2) whether ACCIDENTAL, SUICIDAL or HOMICIDAL.
.8 LENGTH OF RESIDENCE (FOR HOSPITALS, INSTITUTIONS, TRANSIENTS, OF RECENT RESIDENTS).
At place
of death. ..
yrs.
mos.
ds.
State
In the
yrs. ..
mos.
ds ..
Where was disease contracted, If not at place of death ?
Former or usual residence
19 PLACE OF BURIAL OR REMOVAL
DATE OF BURIAL
Glenwerd born Quy 25- 191 !!
UNDERTAKER
MODRESS
296 mocidin Sl
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH theofe (No. 2v- Marshall,
St. ; luttuop ,
Ward)
Derty P. Fish
2 FULL NAME
[If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE 20 marshall H
PERSONAL AND STATISTICAL PARTICULARS
15-
(Year)
If LESS than I day, hrs.
or ...
... min. ?
Fi -d 191
(City or town.)
[If death occurred in a hospital or institution, give its NAME instead of street and number.]
Registered No.
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 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 laborcr, 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 eausation), 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," unqualificd, is indefinitc); Tuber
Need help finding more records? Try our genealogical records directory which has more than 1 million sources to help you more easily locate the available records.