Town of Winthrop : Record of Deaths 1913-1915, Part 7

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 7


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).


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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- neumonia (" Pneumonia," unqualified, is indefinite) ; Tuber-


culosis of lungs, meninges, peritonaeum, etc., Carcinoma, Sar- coma, etc., of .... . (name origin: "Cancer " is less definite ; avoid use of "Tumor" for malignant neoplasms) ; Measles ; Whooping cough ; Chronic valvular heart disease; Chronic interstitial nephritis, etc. The contributory (second- ary or intercurrent) affection need not be stated unless im- portant. Example: Measles (disease causing death), 29 ds .; Broncho-pneumonia (secondary), 10 ds. Never report mere symptoms or terminal conditions, such as " Asthenia," " An- aemia " (merely symptomatic), " Atrophy," "Collapse," "Coma," "Convulsions," "Debility " ("Congenital," "Senile," etc.), "Dropsy," "Exhaustion," "Heart failure," "Haemorrhage," " Inanition," " Marasmus," " Old age," "Shock," "Uraemia," "Weakness," etc., when a definite disease can be ascertained as the cause. Always qualify all diseases resulting from childbirth or miscarriage, as " PUER- PERAL septicaemia," " PUERPERAL peritonitis," etc. State cause for which surgical operation was undertaken. For VIOLENT DEATHS state MEANS OF INJURY and qualify as ACCIDENTAL, 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 - prob- ably 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 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 duc 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


The Commonwealth of Massachusetts STANDARD CERTIFICATE OF DEATH


1 PLACE OF DEATH Winthrop Mark (No. 20 Beacon St. ;..


(City or town.)


Ward)


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


PERSONAL AND STATISTICAL PARTICULARS


3 SEX


4 COLOR OR RACE


W.


5 SINGLE


MARRIED,


WIDOWED,


OR DIVORCED


(Write the word)


Widowed


6 DATE OF BIRTH


aug (Monthy)


9


,1818


(Day)


(Year)


If LESS than


[ day, ..


hrs.


or ...


min. ?


-


8 OCCUPATION


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


Retired Farmer.


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


9 BIRTHPLACE


(State or country)


Queensbury n.B.


10 NAME OF


FATHER


William Cliff


PARENTS


(State or country) Queensbury 7.03


12 MAIDEN NAME OF MOTHER Deborah Brown.


1ª BIRTHPLACE OF MOTHER (State or country)


Queensbury MB


14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE


(Informant)


2 8. Chill


(Address)


Filed. 191


REGISTRAR


16 DATE OF DEATH


(Month)


24 (Day)


., 19! 3


(Year)


1 HEREBY CERTIFY that I attended deceased from


del 15


1913 , to


Jul. 21


, 191.3,


that I last saw harinalive on.


726 21


, 191 3,


and that death occurred, on the date stated above, at .. /2 .. +$m.


The CAUSE OF DEATH* was as follows :.


Tobar prema


(Duration)


yrs.


mos.


7


ds.


Contributory.


(SECONDARY)


Ingranditio


(Duration) .


yrs.


mos. ..


ds.


(Signed)


Cheofmahony


..


M.D.


76.24, 1913 (Address).


355 Whentheob St


* 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.


yrs.


State


4


mos.


ds.


Where was disease contracted, If not at place of death ?.


Former or usual residence ...


1º PLACE OF BURIAL OR REMOVAL


DATE OF BURIAL


29 Pourden House Jersey Lo Queenebraun. B. Jely


1913


:0 UNDERTAKER


ADDRESS


Edwin Le Delay Cambridge


important. See instructions on back of certificate.


WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD.


William Cliff Jr 2 FULL NAME [If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE


29 Jordy House Terrace Som Registered Yole Mans


MEDICAL CERTIFICATE OF DEATH


7 AGE


94 6 yrs. mos. 15. ds.


11 BIRTHPLACE OF FATHER


Tel.24,1110


STANDARD CERTIFICATE OF DEATH.


Statement of occupation. - Precise statement of occupa- tion is very important, so that the relative healthfulness of various pursuits can be known. The question applies to each and every person, irrespective of age. For many occupations a single word or term on the first line will be sufficient, e. g., Farmer or Planter, Physician, Compositor, Architect, Loco- motive engineer, Civil engineer, Stationary fireman, etc. But in many cases, especially in industrial employments, it is necessary to know (a) the kind of work and also (b) the nature of the business or industry, and therefore an additional line is provided for the latter statement ; it should be used only when needed. As examples: (a) Spinner, (b) Cotton mill; (a) Sales- man, (b) Grocery ; (a) Foreman, (b) Automobile factory. The material worked on may form part of the second statement. Never return " Laborer," " Foreman," " Manager,""Dealer," etc., without more precise specification, as Day laborer, Farm laborer, Laborer- Coal mine, etc. Women at home, who are engaged in the duties of the household only (not paid House- keepers who receive a definite salary), may be entered as Housewife, Housework, or At home, and children, not gain- fully employed, as At school or At home. Care should be taken to report specifically the occupations of persons engaged in domestic service for wages, as Servant, Cook, Housemaid, etc. If the occupation has been changed or given up on account of the DISEASE CAUSING DEATH, state occupation at beginning of illness. If retired from business, that fact may be indicated thus: Farmer (retired, 6 yrs.). For persons who have 110 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 (tho only definite synonym is " Epidemic cerebro-spinal meningitis ") ; Diphtheria (avoid use of "Croup ") ; Typhoid fever (never re- port " Typhoid pneumonia ") ; Lobar pneumonia ; Broncho- pneumonia (" Pneumonia," unqualified, is indefinite) ; Tuber-


culosis of lungs, meninges, peritonaeum, etc., Carcinoma, Sar- coma, etc., of ..... .... (name origin: "Cancer" is less definite ; avoid use of "Tumor" for malignant neoplasms) ; Measles; Whooping cough; Chronic valvular heart disease; Chronic interstitial nephritis, etc. The contributory (second- ary or intercurrent) affection need not be stated unless im- portant. Example: Measles (disease causing death), 29 ds .; Broncho-pneumonia (secondary), 10 ds. Never report mere symptoms or terminal conditions, such as " Asthenia," " An- aemia " (merely symptomatic), "Atrophy," "Collapse," "Coma," " Convulsions," " Debility " ("Congenital," "Senile," etc.), "Dropsy," " Exhaustion," "Heart failure," "Haemorrhage," " Inanition," " Marasmus," " Old age," "Shock," "Uraemia," " Weakness," etc., when a definite disease can be ascertained as the cause. Always qualify all diseases resulting from childbirth or miscarriage, as "PUER- PERAL septicaemia," "PUERPERAL peritonitis," etc. State cause for which surgical operation was undertaken.


Cases for the Medical Examiners. - Under the provisions of chapter 24 of the Revised Laws deaths under the following conditions must be referred to the Medical Examiners :


1. Deaths following injury or violence, as Burns, Falls, Drowning, Gas Poisoning, Suicide, Homicide, etc.


2. Deaths supposedly caused by violence, as Criminal Abortion, Poisoning, Starvation, Suffocation, Ex- posure, etc.


3. Sudden deaths of persons not disabled by recognized disease, as A death upon the street, or one supposed to be due to Alcoholism, etc.


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


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


Booth Bay Mains


12 MAIDEN NAME OF MOTHER


Omma S. Rogan


13 BIRTHPLACE OF MOTHER (State or country)


Brooklyn NY.


"THE ABOVE IS TRUE TO THE BEST OF MYCKNOWLEDGE


(Informant) ...


George W. Banhfell


(Address)


109 Cricut Good


REGISTRAR


MEDICAL CERTIFICATE OF DEATH


16 DATE OF DEATH


(Month)


24


(Day)


1913


(Year)


I HEREBY CERTIFY that I attended deceased from


Dec. 21


, 1912, to


Feb 24


., 191.3.,


1 day, .... hrs. that | last saw ! alive on


Est 24.


, 1913.


and that death occurred, on the date stated above, at 07 p. m.


The CAUSE OF DEATH* was as follows :


Schetic Pneumonia


.(Duration) ...


... yrs.


mos.


20


ds.


Septic Endocarditis


Contributory


(SECONDARY)


(Duration) .


yrs.


2


mos.


ds.


(Signed)


frank Ofilland


M.D.


726 25, 1913 (Address) 15 Prinacela 8


* 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.


mos.


ds.


Where was disease contracted, If not at place of death ?.


usual residence.


109 Circuit Good Winthick


Former or


19 PLACE OF BURIAL OR REMOVAL


DATE OF BURIAL


Winthrop bem Winthropdich. 27# 1913


O UNDERTAKER Brown and Rolling


ADDRESS East Boston


BOSTON


(City or town.)


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


Wisley alphous Campbell 2 FULL NAME


[If married or divorced womap ør widow give maiden name, also name of husband.] ... @RESIDENCE 109 einenit Good Winthrop


Registered No.


PERSONAL AND STATISTICAL PARTICULARS


4 COLOR OR RACE Male Whits


5 SINGLE,


MARRIED


WIDOWED


ingles


( Write the word)


8 DATE OF BIRTH


July


29


.1895


17


(Month)


(Dấy)


(Year)


7 AGE


If LESS than


18


... yrs. ..


6


mos. .


26


ds.


or ....


min. ?


8 OCCUPATION


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


Scholar


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


9 BIRTHPLACE


(State or country)


East Boston


10 NAME OF George IV. Campbell


11 BIRTHPLACE OF FATHER (State or country)


WRITE PLAINLY, WITH UNFADING INK - THIS IS A PERMANENT RECORD.


The Commonwealth of Massachusetts


STANDARD CERTIFICATE OF DEATH


1,PLACE OF DEATH Winthrop (No. 109 Cucuit Road


St. ;..


Ward)


Filed 191


In the


Fel: 24 1913


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 oach 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 iu 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 bo 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 tho second statement. Never return "Laborer," "Foreman," " Manager," "Dealer," etc., without more precise specification, as Day laborer, Farm laborer, Laborer - Coal mine, etc. Women at homo, who are engaged iu 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 (AUSING DEATH (the primary affection with respect to time and causation), usiug 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 , Carcinoma, Sur- coma, etc., of .. . (name origin: "Cancer" is less definite ; avoid use of " Tumor" for malignant neoplasms) ; Measles ; Whooping cough; Chionie valvular heart disease ; Chronic interstitial nephritis, eto. 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," "Haemorrhago," " Inanition," " Marasmus," " Old age," "Shock," " Uraemia," " Weakuess," etc., when a definite disease can be ascertained as the cause. Always qualify all diseases resulting from childbirth or miscarriage, as " PUER- PERAL seplieaemia," " PUERPERAL peritonitis," etc. State cause for which surgical operation was undertaken.


Cases for the Medical Examiners. - Under the provisions of chapter 24 of the Revised Laws deaths under the following conditions must be referred to the Medical Examiners:


1. Deaths following injury or violence, as Burns, Falls, Drowning, Gas Poisoning, Suicide, Homicide, etc.


2. Deaths supposedly caused by violence, as Criminal Abortion, Poisoning, Starvation, Suffocation, Ex- posure, etc.


3. Sudden deaths of persons not disabled by recognized disease, as A death upon the street, or one supposed to be due to Alcoholism, etc.


4. Deaths under circumstances unkuown, as A person found dead, etc.


N. B .- Every item of information should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state CAUSE OF DEATH in plain terms, so that it may be properly classified. Exact statement of OCCUPATION is very


important. See instructions on back of certificate.


The Commonwealth of Massachusetts


STANDARD CERTIFICATE OF DEATH


1 PLACE OF DEATH Hinthrow (No. 3 Wikinson


Cucle


St. :.


Ward)


BOSTON (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


4 COLOR OR RACE


3 SINGLE,


MARRIED,


WIDOWED,


OR -DIVORCED


(Write the word)


6 DATE OF BIRTH


M bay


24'


(Month) (Day)


(Year)


7 AGE


If LESS than 1 day, . hrs.


yrs.


9


mos.


2 - ds.


or ....... min. ?


8 OCCUPATION


(a) Trade, profession, or


particular kind of work


-tác.


Manager


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


9 BIRTHPLACE


(State or country)


10 NAME OF FATHER John No.


PARENTS


11 BIRTHPLACE OF FATHER (State or country) Farristown inn.


12 MAIDEN NAME OF MOTHER Gertrude 26. Frinich


13 BIRTHPLACE OF MOTHER (State or country)


Philadelphia Pa.


14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE


(Informant)


(Address)


Winthrop


Filed ... .. 191 ..


REGISTRAR


MEDICAL CERTIFICATE OF DEATH


16 DATE OF DEATH


1915


17


1 HEREBY CERTIFY that I attended deceased from


Frb. 22


. 1913


to


Feb. 26 191.3, that I last saw his alive on tab. 26; 1913 and that death occurred, on the dato stated above, at ..... 04 .. m. The CAUSE OF DEATH* was as follows :


Tubricalos Peritonitis


att yrs. &


.. (Duration)


mos. ds.


Contributory


(SECONDARY)


(Duration)


.yrs. ..


mos. . ....


ds.


(Signed)


M.D.


fort. 26, 1913 (Address)


416 Mailbourg 1St


* 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 disease contracted, If not at place of death ?.


Former or usual residonce.


19 PLACE OF BURIAL OR REMOVAL Morristown Finn.


30 UNDERTAKER ES Brown + Jon


DATE OF BURIAL


tev. 28, 19/3.


ADDRESS


Puch David 2FULL NAME [If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE 3 Likunion Circle


Fremiles of


Registered No.


(Month)


(Day)


26, 193


(Year)


WRITE PLAINLY, WITH UNFADING INK - THIS IS A PERMANENT RECORD.


Tel. 26, 1913


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, Architeet, Loco- motive engineer, Civil engineer, Stationary fireman, etc. Bnt in many cases, especially in industrial employments, it is necessary to know (a) the kind of work and also (b) the nature of the business or industry, and therefore an additional line is provided for the latter statement; it should be used only when needed. As examples: (a) Spinner, (b) Cotton mill; (a) Sales- man, (b) Grocery ; (a) Foreman, (b) Automobile factory. The material worked on may form part of the second statement. Never return " Laborer," " Foreman," " Manager,""Dealer," etc., without more precise specification, as Day laborer, Farm laborer, Laborer - Coal mine, etc. Women at home, who are engaged in the duties of the household only (not paid House- keepers who receive a definite salary), may be entered as Housewife, Housework, or At home, and children, not gain- fully employed, as At school or At home. Care should be taken to report specifically the occupations of persons engaged in domestic service for wages, as Servant, Cook, Housemaid, etc. If the occupation has been changed or given np 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; Broneho- pneumonia (" Pneumonia," unqualified, is indcfinite) ; Tuber-


eulosis 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 ; Chronie 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 deatlı), 29 ds .; Broneho-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 septieaemia," "PUERPERAL peritonitis," etc. State canse for which surgical operation was undertaken.


Cases for the Medical Examiners. - Under the provisions of chapter 24 of the Revised Laws deaths under the following conditions must be referred to the Medical Examiners:


1. Deaths following injury or violence, as Burns, Falls, Drowning, Gas Poisoning, Suicide, Homicide, etc.


2. Deaths supposedly caused by violence, as Criminal Abortion, Poisoning, Starvation, Suffocation, Ex- posure, etc.


3. Sudden deaths of persons not disabled by recognized disease, as A death upon the street, or one supposed to be due to Alcoholism, etc.


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


COMMONWEALTH OF MASSACHUSETTS


RETURN OF A DEATH-1913.


CITY OF BOSTON.


FULL NAME


Annie F. Reardon


Registered No


1992


Place of Death )


Boston


Carney Hospt.


and Residence S


Date of Death


Feb. 26


1913.


Age.


years


4


months.


6


days ..


STATISTICAL DETAILS.


SEX


COLOR


SINGLE, MARRIED, WID., DIV.


F


Maiden Name


Sheridan


Augustus F.Reardon


SICUT PA


Primary (Duration )-


Surgical Shock


NICE:


Operation for Fibroid of Uterus


BOSTONIA


CONDITAA.


Name of


John P. Sheridan


Father


Birthplace of Father Ireland


Maiden Name


of Mother Mary J. Gray


Birthplace of Mother ..


Cambridge


Occupation at Home


Informant


Place of Burial Malden (Holy Cross)


or removal


Undertaker W. H. Thomas (Newton)


Usual Residence.


Winthrop, Winthrop Beach


Washington Chambers


Filed .


Mar. 3


1913.


A true copy.


Attest :


ErMSlenen


Registrar.


PHYSICIAN'S CERTIFICATE.


I HEREBY CERTIFY that I attended deceased during last illness,


from 1913, to .1913, 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:


GISTRAR


'S


Husband's Name


Watertown


Birthplace


ETVITATIS RF


BO'STO


1131. VI. BONATA D


and Salpingitis


N. MAS. S. Contributory : 2 Hysterectomy, Salpingectomy


(Duration)


2 ds.


(Signed)


Norman M. Scott


M.D.


Feb. 26


1913


.......


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


------- 1 1


CITY:RE


S. SIT


42


H.LIM


ANT


SIHI


IS A PERMANENT


JT RECORD


Feb. 26, 1913


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


Winthrop (No. 28 Marshall .St. :.. ....... Ward)


Kintinos (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


28 manner of panchoof


Registered No.


PERSONAL AND STATISTICAL PARTICULARS


MEDICAL CERTIFICATE OF DEATH


3 SEX


4 COLOR OR RACE


5 SINGLE,


MARRIED,


WIDOWED,


OR DIVORCED


(Write the word)


6 DATE OF BIRTH


Vina 10. 1840


(Month)


(Day)


1


(Year)


7 AGE


If LESS than


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


72


... yrs.


6


... mos.


ds.


........


min. ?


8 OCCUPATION


(a) Trade, profession, or


particular kind of work


Betired


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


9 BIRTHPLACE


(State or country)


Laminate Fraer.


10 NAME OF


FATHER


Politcom. syvrides


PARENTS


12 MAIDEN NAME


OF MOTHER


13 BIRTHPLACE OF MOTHER (State or country) Proton.


14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE


·


(Informant)


(Address)


Filed


191


REGISTRAR


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


20 UNDERTAKER


ADDRESS


17 I HEREBY CERTIFY that I attended deceased from may Fi 28, 193 . ,


1912,


to


that I last saw h alive on July 28, 1918 and that death occurred, on the date stated above, at/ 030 m. The CAUSE OF DEATH* was as follows :


Chr Myocarditis & auter Felerio


(Duration) ........ yrs. ............... .mos. ds.


Contributory.


(SECONDARY)


(Duration)


yrs.


mos. ... ds.


M.D.


(Signed)


Ich 1


,191 .......


( Address){


218 man12 Nantes


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




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