Town of Winthrop : Record of Deaths 1913-1915, Part 68

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


USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1913-1915 > Part 68


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culosis of lungs, meninges, peritonaeum, etc., Carcinoma, Dar- 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 (discase causing death), 29 ds .; Broncho-pneumonia (secondary), 10 ds. Never report mcrc symptoms or terminal conditions, such as "Asthenia," "An- aemia" (mercly symptomatic), "Atrophy," "Collapse," "Coma," "Convulsions," "Debility" ("Congenital," "Senile," etc.), "Dropsy," "Exhaustion," "Heart failure," "Haemorrhage," "Inanition," "Marasmus," "Old age," "Shock," "Uracmia," "Weakness," etc., when a definite discase 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.


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


1 PLACE OF DEATH


STANDARD CERTIFICATE OF DEATH Winthrop (No Metcalf Hospital)


Ward)


(City or town.) [If death occurred in a hospital or institution, give its NAME instead of street and number.f


Registered No.


PERSONAL AND STATISTICAL PARTICULARS


8 SEX


Homale White


4 COLOR OR RACE


5 SINGLE,


MARRIED,


WIDOWED,


OR DIVORCED


(Write the word)


Midou


& DATE OF BIRTH


(Month) (Day)


5


(Year)


7 AGE


59


yrs. mos. ds.


Or ......... min. ?


8 OCCUPATION


(a) Trade, profession, or


particular kind of work


At Some


(b) General nature of Industry. business, or establishment in which employed (or employef)


9 BIRTHPLACE


(State or country)


Ireland


PARENTS


11 BIRTHPLACE OF FATHER (State or country) Ireland


12 MAIDEN NAME OF MOTHER Unknown


18 BIRTHPLACE OF MOTHER (State or country) Ireland.


"THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE


(Informant)


Timothis mahana


(Address)


Filed __: 191


REGISTRAR


MEDICAL CERTIFICATE OF DEATH


16 DATE OF DEATH


October


(Month)


(Day)


170


1914 (Year)


17


I HEREBY CERTIFY that I attended deceased from


Oct 14th


1914.


to.


Oct 17th


1914,


that I last saw her


alive on


191


Oct 17


4


and that death occurred, on the date stated above, at


m.


1


The CAUSE OF DEATH* was as follows :


Broncho Pneumonia from


Bronchoeclases


(Duration)


.......


.yrs.


4


........


mos.


ds.


Contributory ...


Bronchokclain


(SECONDARY)


Several


(Duration)


.. yrs.


mos. ds.


(Signed)


Horace & Joule


M.D.


Oct 17, 1914 (Address)


180 Waltherof St Walton


* 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


In the


of death .....


... yrs.


mos.


ds.


State ............ yrs.


...........


Where was disease contracted,


mos.


ds ......


....


if not at place of death ?.


Former or usual residence.


19 PLACE OF BURIAL OR REMOVAL It touchlies. Com


DATE OF BURIAL


Oct 19, 1914


20 UNDERTAKER


John F. O Maley


ADDRESS


77 Atlanticsd


2 FULL NAME


Hanora Mi Carthy widow


[If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE 441 Wantthat 26


of Dennis Mccarthy


10 NAME OF


FATHER


Unknown


If LESS than


day,


„hrs.


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, Architeet, Loco- motive engineer, Civil engineer, Stationary fireman, etc. But in many cases, especially in industrial employments, it is necessary to know (a) the kind of work and also (b) the nature of the business or industry, and therefore an additional line is provided for the latter statement; it should be used only when needed. As examples: (a) Spinner, (b) Cotton mill; (a) Sales- man, (b) Grocery; (a) Foreman, (b) Automobile factory. The material worked on may form part of the second statement. Never return "Laborer," "Foreman," "Manager," "Dealer," etc., without more precise specification, as Day laborer, Farm laborer, Laborer - Coal mine, ctc. Women at home, who are engaged in the duties of the household only (not paid House- keepers who receive a definite salary), may be entered as Housewife, Housework, or At home, and children, not gain- fully employed, as At school or At home. Care should be taken to report specifically the occupations of persons engaged in domestic service for wages, as Servant, Cook, Housemaid, etc. If the occupation has been changed or given up on account of the DISEASE CAUSING DEATH, state occupation at beginning of illness. If retired from business, that fact may be indicated thus: Farmer (retired, 6 yrs.). For persons who have no occu- pation whatever, write None.


Statement of cause of death. - Namc, first, the DIS- EASE CAUSING DEATH (the primary affection with respect to time and causation), using always the same accepted term for the same diseasc. Examples: Cerebro-spinal fever (the only definite synonym is "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, Sa coma, cte., of .... (name origin: "Cancer" is less definite; avoid usc of "Tumor" for malignant neoplasms) ; Measles; Whooping cough; Chronic valvular heart discase; Chronic interstitial nephritis, etc. The contributory (second- ary or intercurrent) affection need not be stated unless im- portant. Example: Measles (disease causing death), 29 ds .; Broncho-pneumonia (secondary), 10 ds. Never report merc symptoms or terminal conditions, such as "Asthenia," "An- aemia" (mcrely symptomatie), "Atrophy," "Collapse," "Coma," "Convulsions," "Debility" ("Congenital," "Senile," etc.), "Dropsy," "Exhaustion," "Heart failure," "Hemorrhage," "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.


COMMONWEALTH OF MASSACHUSETTS


RETURN OF A DEATH-1914.


CITY OF BOSTON. 94.26


FULL NAME


Place of Death l and Residence S


Boston


Date of Death


1914.


Åge


73


years


2


months 17


days.


STATISTICAL DETAILS.


SEX.


COLOR.


SINGLE, MARRIED, WID., DIV.


F


W


WID.


Maiden Name


Husband's Name


NEW YORK. N. Y.


Birthplace


Name of Father


JOHN BLAKE


Birthplace


NEW YORK. N.Y.


of Father


Maiden Name of Mother


ELLEN BROWN


Birthplace of Mother


NEW YORK. N.Y.


Occupation


AT HOME


Informant


PHYSICIAN'S CERTIFICATE.


I HEREBY CERTIFY that I attended deceased during last illness,


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 :


EGIST


RAR'S


T PATRIGIS


Primary ( Duration)


FFICE


CTVTT


BOSTDNIA


CONSITAA.


B ISREGIMINE DONATA A 1181.


STO


Contributory : Į


CERE. HEMORRHAGE - 3 MOS.


(Duration)


F. A. MACKENZIE


M.D.


(Signed)


Ост. 18 1914 SPECIAL INFORMATION from Hospitals, Institutions, Transients, or Recent Residents.


WINTHROP ( 143 PLEASANT ST.)


Usual Residence


Filed


OCT. 21


1914.


A true copy.


Attest :


EumSeinen


Registrar.


O


FOREST HILLS


Place of Burial or removal


Undertaker


R.& E.F. GLEASON


CITY R


SIT DE


CHR. NEPHRITIS - 2 YRS


A.113


N. MASS.


LOUISA BLOUNT


Registered No.


GORDON HOME


ост . 18


BLAKE


AMBROSE A BLOUNT


Oct 18, 1914


CAUSE OF DEATH in plain terms, so that it may be properly classified. Exact statement of OCCUPATION is very N. B. - Every item of information should be carefully supplied. AGE should be stated EX. IL molANS should state important. See instructions on back of certificate.


1 PLACE OF DEATH


The Commonwealth of Massachusetts STANDARD CERTIFICATE OF DEATH (No. 96 Winthrop St. :.. ......


Winthrop.


.Ward)


(City or town.) [If death occurred in a hospital or institution, give its NAME instead of street and number.]


2 FULL NAME


[If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE


96 inthron St Ninthrok


Registered No.


PERSONAL AND STATISTICAL PARTICULARS


MEDICAL CERTIFICATE OF DEATH


16 DATE OF DEATH Oct 25, 1914 (Month) (Day) (Year)


1 HEREBY CERTIFY that I have investigated the death of the deceased.


The CAUSE OF DEATH* was as follows :


Fracture of the Skull and the Right Trist sustained On accidentally falling from appletied


Contributory apples. -


(SECONDARY)


{Duration) yrs.


mos. ds.


(Signed)


SpearsRichardson


M.D.


Det:26. 1914 (Address) associate MEDICAL EXAMINER Suffolk


* State the DISEASE CAUSING DEATH, or, in deaths frony VIOLENT CAUNES, 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.


In the


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


191


0 UNDERTAKER


ADDRESS


Fied . 191


REGISTRAR


5 SINGLE,


MARRIED,


WIDOWED


OR DIVORCED


(Write the word)


6 DATE OF BIRTH


(Month)


(Day)


6 1868 17 (Year)


7 AGE


If LESS than 1 day, .... hrs.


45 yrs. 4


.yrs ..


mos.


17


ds.


or ......


min. ?


8 OCCUPATION


·Principal High School


(a) Trade, profession, o particular kind of work


(b) General nature of industry, business, or establishment in which employed (or employer).


9 BIRTHPLACE


(State or country)


garbow more


10 NAME OF


FATHER


Charles Osborne


PARENTS


11 BIRTHPLACE OF FATHER (State or country)


gerbow more


12 MAIDEN NAME OF MOTHER Janou ) Holmer


13 BIRTHPLACE OF MOTHER (State or country) Profton muss


14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE


(Informant).


(Address)


Ervine Davey Offame


3 SEX


male


4 COLOR OR RACE


Mlute


A


WRITE PLAINLY, WITH UNFADING INK - THIS IS


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," 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- kccpers 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


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: Mcasles (discase causing death), 29 ds .; Broncho-pneumonia (secondary), 10 ds. Never report mere symptoms or terminal conditions, such as "Asthenia," "An- aemia" (merely symptomatic), "Atrophy," "Collapse," "Coma," "Convulsions," "Debility" ("Congenital," "Senile," ctc.), "Dropsy," "Exhaustion," "Heart failure," "Haemorrhage," "Inanition," "Marasmus," "Old agc," "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. 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 strect, or one supposed to be due to Alcoholism, etc.


4. Deaths under circumstances unknown, as A person found dcad, etc.


Wald state


ATION is very


PHYSIA:


= ============


CAUSE OF DEATH in plain terms, so that it may be proper ..


N. B. - Every item of Information should be carefully supplied. Pus important. See Instructions on back of certificate.


The Commonwealth of Massachusetts


STANDARD CERTIFICATE OF DEATH


1 PLACE OF DEATH


Residence


(No.


96 Winthrop


St. :


Ward)


Mintha. (City or town.) [If death occurred in a hospital or institution, give ita NAME Instead of street and number.]


Registered No.


PERSONAL AND STATISTICAL PARTICULARS


MEDICAL CERTIFICATE OF DEATH


M DATE OF DEATH


(Month)


(Day)


191


(Year)


$ DATE OF BIRTH


6


1869 11


(Month)


(Day)


(Year)


" AGE


45


........ yrs ...........


.mos.


ds.


or ......... min. ?


8 OCCUPATION


(a) Trade, profession, or


particular kind of work


Sin of High School


(b) General nature of industry,


business, or establishment in


which employed (or employer).


9 BIRTHPLACE


(State or country)


Sonham Maine


10 NAME OF


FATHER


Charles Osborne


PARENTS


11 BIRTHPLACE


OF FATHER


(State or country}


Gorham Ollami


12 MAIDEN NAME


OF MOTHER


Sarah& Holmer


13 BIRTHPLACE OF MOTHER (State or country)


Grafton Caso


1' THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE


(Informant)


Other E. D. Osborne


(Address)


96 Win thought Centrach


Filed 191


REGISTRAR


(Duration)


.... yra.


.............. mos.


.........


ds.


Contributory


(SECONDARY)


(Duration)


........ yrs.


..........


mos.


ds.


(Signed)


M.D.


191 ........


(Address).


* If death followed injury or violence the certificate of death must be made out by the Medical Examiner.


18 LENGTH OF RESIDENCE (FOR HOSPITALS, INSTITUTIONS, TRANSIENTS, OR


RECENT RESIDENTS).


At place


in the


of death ....


... yrs.


.... mos. .........


de.


State ..


... mos.


............ ds ............


Where was disease contracted,


If not at place of death ?.


Former or


usual residence.


1 PLACE OF BURIAL OR REMOVAL Wanthoch Class


DATE OF BURIAL


Det2791


" UNDERTAKER


Kelley T Hawa


ADDRESS


Manchester


.


3 SEX


4 COLOR OR RACE


White


5 SINGLE,


MARRIED,


WIDOWED,


OR DIVORCED


(Write the word)


If LESS than


I day ......... hrs.


I HEREBY CERTIFY that I attended deceased from


191.


to


191


...... --


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 :


Evine Dewey Osborne


2FULL NAME


[If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE Winthrop


7


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) Salcs- 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- 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 "Epidemic cerebro-spinal meningitis"); Diphtheria (avoid use of "Croup"); Typhoid fever (never re- port "Typhoid pncuinonia"); 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 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 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 discase can be ascertained as the cause. Always qualify all diseases 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.


COMMONWEALTH OF MASSACHUSETTS


RETURN OF A DEATH-1914.


CITY OF BOSTON.


EUNICE BARRY


FULL NAME


Place of Death ¿ and Residence S


Boston


ост. 25


1914.


Age


94


years


months days.


STATISTICAL DETAILS.


SEX.


COLOR.


SINGLE, MARRIED, WID., DIV.


F


W


WID.


Maiden Name


Husband's Name


WILLIAM BARRY


Birthplace


- N.S


Name of Father


Birthplace of Father


Maiden Name of Mother


Birthplace of Mother


Occupation NONE


Informant


PHYSICIAN'S CERTIFICATE.


I HEREBY CERTIFY that I attended deceased during last illness,


from 1914, to that to the best of my knowledge and belief death occurred, on the 1914, date stated above, and that the CAUSE OF DEATH was as follows :


RAR'S


RE


T PATRIEL


Primary ( Duration)


BRONCHO-PNEUMONIA - 21 DYS+


FFICE


BOSTONIA


CONCITA A


SREGE


ST


N. MASS.


ARTER IO-SCLEROSIS


Contributory : ?


(Duration)


(Signed)


ISIDOR PERLSTEIN M. D.


1914


SPECIAL INFORMATION from Hospitals, Institutions, Transients, or Recent Residents.


Usual Residence


WINTHROP ( 148 BARTLETT


ROAD'


OCT.29


1914


Filed


A true copy . Attest :


ErMSlenen


Registrar.


O


MASS. CREMATORY


W. H. GRAHAM


Undertaker


G


S. SITD


CITY


SICUT


D. 1822


12$1.


DONATA D.


Piace of Burial or removal


Registered No. 9600


Date of Death


BOSTON STATE HOSPT.


Oct. 25, 1914


FORT!


COMMONWEALTH OF MASSACHUSETTS


derpy REVERE.


RETURN OF A DEATH


(CITY OR TOWN.)


AVERE 18


FULL NAME


Man tha K. Hammond


Registered No.


252


Place of )


Death * Revere, 1/2 Kimball Ave


Death S


Date of ¿


Cet. 25, 1984.


-


months. 24 .days


STATISTICAL DETAILS


SEX Hemale


COLOR


White


SONOLE, MARRIED, WIDOWED, OTT DIVORCED


Widow


MAIDEN NAME Ť


Nearthe Kempton


HUSBAND'S NAME +


Andrew Hammond


BIRTHPLACE # Wild N.J


NAME OF


FATHER


Joseph Kemplow


BIRTHPLACE


OF FATHER+


Nova Scotia


MAIDEN NAME


OF MOTHER


Mary Hammond


BIRTHPLACE


OF MOTHER +


Nova Scotia


OCCUPATION


Housekeeper


INFORMANT §


Nen Kempton (Brother )


PLACE OF BURIAL OR REMOVAL !!


Winthrop, Meas


UNDERTAKER


Anthony Santos


DATE OF BURIAL


Cax. 28


ADDRESS Pevere, Means.


PHYSICIAN'S CERTIFICATE


1 HEREBY CERTIFY that I attended deceased during last illness, from . 19


.4to Qx.25,191 4 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 : Primary : Angina Pectoris


.(DURATION)


. DAY 8


Contributory :


(DURATION)


.. DAY8


(Signed)


M.D.


Oct.27 1964 (Address)


SPECIAL INFORMATION only for Hospitals, Institutions, Transients,


or Recent Residents.


How long at


Place of Death ?


.. years


months


.. days


Where was disease contracted,


if not at place of death ?.


Filed Nov. 7, 1964 Albert ). Buon Tours Clerk


* City or town, street and number, If any. If death occurs away from USUAL RESI. DENCE, give facts called for under "Special Information." If In a Hospital or Institution, give Its NAME Instead of street and number,


t In case of married or divorced woman, or widow.


# State or country ; also city, town or county, If known.


§ Name and address of person giving statistical details. || Name of cometery.


ALL NAMES TO BE IN FULL


178 4


Residence


Winstwok 106 Washington Ave


64


... years.


The Commonwealth of Massachusetts


STANDARD CERTIFICATE OF DEATH


I PLACE OF DEATH


.


(No.


27 pleasant PK RS.


Ward)


(City or town.)


[If death occurred la a hospital or institution, give its NAME instead of street and number.]




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