USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1913-1915 > Part 7
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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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