USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1913-1915 > Part 72
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Nancy Llevar- LEE
2 FULL NAME
[If married or divorced woman or widow
give maiden name, also name of husband.]
@RESIDENCE
94
Wider 1 James LEE
Registered No.
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
4 COLOR OR RACE
mute
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
$ DATE OF BIRTH
14 1821
(Month)
(Day)
(Year)
7 AGE
If LESS than
1 day ......... hrs ..
83
yrs.
6
mos.
ds.
or
min. ?
$ OCCUPATION
(a) Trade, profession, or
01
particular kind of work
(b) General nature of industry,
business, or establishment
In
which employed (or employer).
9 BIRTHPLACE
(State or country)
10 NAME OF
FATHER
fm Llawant
PARENTS
12 MAIDEN NAME
OF MOTHER
Julia Low
1ª BIRTHPLACE
OF MOTHER
(State or country)
Celarleston-20
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
(Address)
Filed 191
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
17
I HEREBY CERTIFY that I attended deceased from
2pr 19
1914, to
ho 13
1914
that I last saw he alive on
19114
and that death occurred, on the date stated above, at ..
2.30 A.m.
The CAUSE OF DEATH* was as follows :
arten Feluosi
.(Duration)
..... yrs.
mos. ds.
Contributory ..
Ch. hyrcondition
(SECONDAO
.(Duration)
.yrs.
mos. ds.
(Signed)
Im14
1914
(Address) ..
215 mann nach
* 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 desth.
.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
DATE OF BURIAL
200115
191
20 UNDERTAKER
ADDRESS
(Month)
13
1914
(Year)
(Day)
M.D.
11 BIRTHPLACE
OF FATHER
(State or country)
(City or town.)
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 fircman, 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 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 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, 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 hcart discasc; 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," ctc., 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.
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
11 BIRTHPLACE OF FATHER (State or country) New York City
12 MAIDEN NAME
OF MOTHER
Arne A.xKelly
13 BIRTHPLACE OF MOTHER (State or country)
" THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
Daniel In Relation
(Address)
79 Highland ave
1 6
Filed
191 0
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
3 SEX
Female
4 COLOR OR RACE
White
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
Siglo
5 DATE OF BIRTH
Nov.
19
1914
17
(Month)
(Day)
(Yearf
7 AGE
If LESS than 1 day ......... hrs.
yrs. mos. ds.
Or ........ min. ?
B OCCUPATION
(a) Trade, profession, or
particular kind of work
(b) General nature of industry, business, or establishment In which employed (or employer) ..
Premature,
yrs.
mos.
ds.
qualfurentina
Contributory
(SLCONDARY)
P
(Duration)
... yrs. .........
mos.
ds.
(Signed)
Y Suzovni
M.D.
2ecet9, 19 ...
4 (Address)
Revere
* If death followed injury or violence the certificate of death must he made out by the Medical Examiner.
18 LENGTH OF RESIDENCE (FOR HOSPITALS, INSTITUTIONS, TRANSIENTS, OR RECENT RESIDENTS).
At place
of death
.......
In the
. yrs .
mos.
ds.
State ............ yra.
mos.
ds .............
Where was disease contracted,
If not at place of death ?
Former or usual residence
19 PLACE OF BURIAL OR REMOVAL St. Michaele Cemetery
DATE OF BURIAL
Nov19, 1914
ADDRESS
4
.....
(Month)
(Day)
191.
(Year)
I HEREBY CERTIFY that I attended deceased from
220019
1914 to.
2019
1915
that I last saw h
antve on
Zur 19
191.46.
and that death occurred, on the date stated above, at ..
ir laying
m.
The CAUSE OF DEATH* was as follows :
9 BIRTHPLACE
(State or country)
(y) Winthrop mass
10 NAME OF
FATHER
Daniel In xKelehrer
The Commonwealth of Massachusetts STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH
Winthrop
(No.
metcalf Hospital
St. ;. ....... .Ward)
Winthrop (City or town, [If death occurred in a hospital or institution, give its NAME instead of street and number.]
Stillborn Malcher
2 FULL NAME
{If married or divorced woman or widow
give maiden name, also name of husband,!
@RESIDENCE
79 Highland are
Registered No.
PERSONAL AND STATISTICAL PARTICULARS
16 DATE OF DEATH
200 19
3 UNDERTAKER
John t. O. maley
STANDARD CERTIFICATE OF DEATH.
Statement of occupation. - Precise statement of occu- pation is very important, so that the relative healthfulness of various pursuits ean 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, cte. 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 domestie 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 discase. Examples: Cerebro-spinal fever (the only definite synonym is "Epidemic cerebro-spinal meningitis"): Diphtheria (avoid use of "Croup"); Typhoid fever (never ro- port "Typhoid pneumonia"); Lobar pneumonia; Broncho- pneumonia ("Pneumonia," unqualificd, 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 disease; Chronic interstitial nephritis, etc. The contributory (sceond- ary or intercurrent) affection need not be stated unless im- portant. Example: Measles (disease causing death), 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 septicaemia," "PUERPERAL peritonitis," ete. 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 STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH Winthrop ....
(No.31
ITde Bienes) Dorman. 2 FULL NAME [If married or divorced woman or widow give maiden name, also name of húsband.] @RESIDENCE (3, 2%22).
SE ..
Ward)
Winthrop (City or town.) [If death occurred in a hospital or institution, give its NAME instead of street and number.]
Registered No.
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
4 COLOR OR RACE
Man DATE OF DEATH
6 DATE OF BIRTH
PV
(Month)
(Day)
(Year)
1
7 AGE
If LESS than | day, . . hrs.
5-7 yrs ..
mos. 14 ds.
or ....... min. ?
3 OCCUPATION
(a) Trade, profession, or particular kind of work
L'Ergiciani
(b) General nature of industry, business, or establishment in which employed (or employer)
@ BIRTHPLACE
(State or country)
10 NAME OF
FATHER
11 BIRTHPLACE OF FATHER (State or country)
12 MAIDEN NAME OF MOTHER
1ª BIRTHPLACE
OF MOTHER
(State or country)
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informent) ..
(Address)
16
Filed ... 191
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
Nos
2 2 20
(Month)
(Day)
1914 (Year)
HEREBY CERTIFY that I attended deceased from July 1914 to Não 22. , 1914 ...
that I last saw him alive on 1800 20" 1914, and that death occurred, on the date stated above, at. /30 Am.
The CAUSE OF DEATH* was as follows : Cerebral Harmon Mange
(Duration)
yrs ...
mos.
7
ds.
Contributory. (SECONDARY)
(Duration) . yrs.
mos. ..
ds.
(Signed)
-
2.10 metcalf
0
, M.D.
Winthrop
.
* 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
In the
yrs.
mos.
ds.
Where was dlsease contracted, If not at place of death ?
Former or usual residence
19 PLACE OF BURIAL OR REMOVAL
DATE OF BURIAL
30 UNDERTAKER
.
191 .. ... (Address)
I Maiali
PARENTS
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
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 Ilouse- 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 (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, peritonaeum, etc., Carcinoma, Sur- 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 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- 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 septicemia," " PUERPERAL peritonitis," etc. State cause for which surgical operation was undertaken.
Cases for the Medical Examiners. - Under the provisions of chapter 24 of the Revised Laws deaths under the following conditions must be referred to the Medical Examiners :
1. Deaths following injury or violence, as Burns, Falls, Drowning, Gas Poisoning, Suicide, Homicide, etc.
2. Deaths supposedly caused by violence, as Criminal Abortion, Poisoning, Starvation, Suffocation, Ex- posure, etc.
3. Sudden deaths of persons not disabled by recognized disease, as A death upon the street, or one supposed to be due to Alcoholism, 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 STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH
-
(No
M
M
2 FULL NAME
[If married or divorced woman or widow
give maiden name, also name of husband.]
@RESIDENCE
361 Shirley St Wucelui Registered Ng.
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
4 COLOR OR RACE
White
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
Linja.
· DATE OF BIRTH
20026 - 1914
(Month)
(Day)
(Year)
7 AGE
If LESS than
[ day ......... hrs.
.yrs.
mos.
ds.
or ........ min. ?
8 OCCUPATION
(a) Trade, profession, or
particular kind of work
(b) General nature of industry,
business, or establishment in
which employed (or employer).
9 BIRTHPLACE
(State or country)
PARENTS
11 BIRTHPLACE
OF FATHER
(State or country)
England
12 MAIDEN NAME
OF MOTHER
Clara Hezaberto Ranson
1ª BIRTHPLACE
OF MOTHER
(State or country)
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informan
(Address)
1. Filed -, 191
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
15 DATE OF DEATH
(Month)
26.
(Day)
1914
(Year)
17 I HEREBY CERTIFY that I attended deceased from non. 26 19/7 to
191
that I last saw h/
alive on
19145
and that death occurred, on the date stated above, at
m.
The CAUSE OF DEATH* was as follows :
Premature birch
(Duration)
....... yrs. ..............
.. mos.
ds.
Contributory
(SECONDARY)
(Duration)
........... yrs. ...........
.mos.
............
ds.
(Signed)
30
M.D.
non 28, 1914 (Address)
Minthush Mars
* 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.
1
ds.
State ............ yra.
......
In the
mos.
/ d
Where was disease contracted,
If not at place of death ?..
Former or
usual residence
361 Shirley At. Denstud
1º PLACE OF BURIAL OR REMOVAL
DATE OF BURIAL
Nr .3
1918
ADDRESS
* UNDERTAKER
le R Bac
St. ;..
.......... Ward)
(City or iown.)
[If death occurred in a hospital or institution, give its NAME instead of street and number.]
10 NAME OF
FATHER
ER Frederick. W. X'sES,
1
,
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) 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, Laborcr - Coal mine, etc. Women at home, who are engaged in the duties of the household only (not paid Housc- 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 mere symptoms or te. minal 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," "Uracmia," "Weakness," etc., when a definite disease can be ascertained as the cause. Always qualify all diseases resulting from childbirth or miscarriage, as "PUER- PERAL septicacmia," "PUERPERAL peritonitis," ctc. 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
STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH
(No.
491 Pleasant
St. :
......
Ward)
(City or town.) [If death occurred in a hospital or institution, give its NAME instead of street and number.]
Peter Mainfontes Mac gowan
2 FULL NAME
[If married or divorced woman or widow
give maiden name, also name of husband.]
@RESIDENCE
391 Pleasant It
Registered No.
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
3 SEX
Male
' COLOR OR RACE
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
Warned
16 DATE OF DEATH
Zoomben 27. 1914
(Month)
(Day)
(Year)
6 DATE OF BIRTH
18
1846
(Month)
(Day)
(Year)
7 AGE
68
9
mos.
2
ds.
or ........ min. ?
8 OCCUPATION
(a) Trade, profession, or
particular kind of work
Recent
The CAUSE OF DEATH* was as follows :
Double Sabor Pneumonia
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