USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1913-1915 > Part 77
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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, ete.
2. Deaths supposedly caused by violence, as Criminal abortion, Poisoning, Starvation, Suffocation, Ex- posurc, 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.
1. 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)
Unknown
"iz MAIDEN NAME
OF MOTHER
Phere Every
18 BIRTHPLACE
OF MOTHER
(State or country)
HI THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
John alexander
(Address) 25-3- Plesanta Ventral
chun
....
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
-
(Month)
1
(Day)
11
1915-
(Year)
I HEREBY CERTIFY that, I attended deceased from
Oct 4
·
1915, to
law 11
191.5.
that I last saw her alive on. Jan 11 1915 and that death occurred, on the date stated above, at.2 ........ a.m.
The CAUSE OF DEATH* was as follows :
neuruathen
anemia
Did a surgical operation precede death ?
Date
(Duration).
8
.yrs. .....
Contributory.
Cente nephritis 5
(SECONDARY)
urema
(Signad)
Groft Funch
M.D.
Jan 13
„, 1915 (Address)
255 Pleasant 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).
At place
of death.
yrs.
... mos.
In tha
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
Cambridge Cometeram/4195
20 UNDERTAKER
Filed 191
The Commonwealth of Massachusetts STANDARD CERTIFICATE OF DEATH
BOSTON
1 PLACE OF DEATH
Winthrop Iran (No. 25.5- Plesant
.St. ;. ........ .Ward)
(City or town.) [If death occurred in a hospital or institution, give its NAME instead of straet and number.]
Hannah F. alexander 2 FULL NAME
[If married or divorced woman or widow give maiden name, also name of husband.], @RESIDENCE
John alexa
Registered No.
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
4 COLOR OR RACE
Female While
Tenalk
· DATE OF BIRTH
184 /7
(Month) (Day)
(Year)
? AGE
69
If LESS than
1 day ......... hrs.
.yrs. mos. ...............
ds.
or ........ min. ?
$ OCCUPATION
(a) Trade, profession, or
particular kind of work
Housewife
(b) Ganeral natura of industry, business, or establishment in which employad (or employer).
9 BIRTHPLACE
(State or country)
Wellfleet man,
mass,
10 NAME OF
FATHER
Richard Stubber
-
-mos ..
.ds.
.(Duration)
2 weeks
„ds.
ADDRESS
296 Mendian
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
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 terin 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 laborcr, Laborer - Coal mine, etc. Women at home, who are engaged in the duties of the household only (not paid House- kecpers 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 neoplasmns) ; Mcasles; 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 (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," "Exl.austion," "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 septicemia," "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 eaused by violence, as Criminal abortion, Poisoning, Starvation, Suffocation, Ex- posurc, 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.
The Commonwealth of Massachusetts STANDARD CERTIFICATE OF DEATH
St. :
.... .Ward)
(City or town.) [If death occurred in a hospital or institution, give its NAME instead of street and number.]
2 FULL NAME
Generic Weston Munday
[If married or divorced woman or widow give maiden name, also name of husband.] Wife of 1000 Forrest Mundury
@RESIDENCE
2 Washington Terrace svenchart thars
PERSONAL AND STATISTICAL PARTICULARS
4 COLOR OR RACE
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
manuel
29
1865
(Month)
(Day)
(Year)
If LESS than
I day ......... hrs.
5
mos.
ds.
or ......... min. ?
(b) General nature of industry,
business, or establishment in
which employed (or employer)
-
.(Duration)
yrs. .......... mos. 14 ds.
Contributory
(SECONDARY)
(Signed)
(31 Metall
.(Quration) yrs.
mos.
......... ds.
.,
M.D.
Ci 191.5 .. (Address).
If death followed injury or violence the certificate of dohth must be made out by the Medical Examiner.
18 LENGTH OF RESIDENCE (FOR HOSPITALS, INSTITUTIONS, TRANSIENTS, OR In the RECENT RESIDENTS). At place
of death .......
yrs.
mos. .
ds.
State ........
.. yrs.
mos.
ds .............
Where was disease contracted, If not at place of death ?.
Former or usual residence.
19 PLACE OF BURIAL OR REMOVAL
DATE OF BURIAL
1/14
191.5
....
20 UNDERTAKER
ADDRESS
16 Filed ., 191
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
Jan
(Month)
(Day)
11, 19/5
(Year)
17
I HEREBY CERTIFY that I attended deceased from
>
1911, to
Jan 11
1915,
....
that I last saw hy alive on
....
112
1915
and that death occurred, on the fate stated above, at.
7pm.
The CAUSE OF DEATH* was as follows :
Lobar Pneumonia
Registered No.
I PLACE OF DEATH
$ SEX
' DATE OF BIRTH
7 AGE
& OCCUPATION
(a) Trade, profession, or
particular kind of work ...
9 BIRTHPLACE
(State or country)
10 NAME OF
FATHER
11 BIRTHPLACE
OF FATHER
(State or country)
PARENTS
13 BIRTHPLACE
OF MOTHER
(State or country)
(Informant)
CAUSE OF DEATH in plain terms, so that it may be properly classified. Exact statement of OCCUPATION is very
(Address)
important. See instructions on back of certificate.
N. B. - Every item of information should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state
49
.. yra.
12 MAIDEN NAME
OF MOTHER
Lydia Com Sanalsom
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
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, 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 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 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 .; Broneho-pneumonia (secondary), 10 ds. Never report mere symptoms or te minal conditions, such as "Asthenia," "An- aemia" (merely symptomatic), "Atrophy," "Collapse," "Coma," "Convulsions," "Debility" ("Congenital," "Senile," etc.), "Dropsy," "Exhaustion," "IIcart failure," "Hacmorrhage," "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 septieaemia," "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-1915.
CITY OF BOSTON.
Registered No. 362
MASS. GEN.HOSPT.
1915.
Age
39
years
7
21
months
days.
STATISTICAL DETAILS.
SEX.
COLOR.
SINGLE, MARRIED, WID., DIV.
F
W
MAR.
Maiden Name
O BRIEN
Husband's Name
EDWARD GAFFNEY
FALL RIVER
Birthplace
Name of Father
MICHAEL O BRIEN
Birthplace of Father
IRELAND
Contributory : { AC. CARDIAC INSUFFICIENCY -
(Duration)
15 MIN.
(Signed)
H. W. HERSEY
M.D.
1915
SPECIAL INFORMATION from Hospitals, Institutions, Transients, or Recen? Residents.
Place of Burial or removal ST. JOSEPHS
Undertaker
J.F. O MALEY
PHYSICIAN'S CERTIFICATE.
I HEREBY CERTIFY that I attended deceased during last illness,
from 1915, to that to the best of my knowledge and belief death occurred, on the date stated above, and that the CAUSE OF DEATH was as follows :
1915,
S
RAR'S
R
T PATRIEUS, SIT DE .If Primary ( Duration2
OFFICE
CTVYTAT
BOSTONIA
CONDITA&
TIS REGIMI
BOSTO
N. MASS
Maiden Name of Mother
SARAH MAC DONALD
Birthplace IRELAND
of Mother
AT HOME
Occupation
Informant
Usual Residence
WINTHROP ( 35 OCEAN AV)
Filed
A true copy.
Attest :
JAN. 15
ErMSlenen
1915.
Registrar.
FULL NAME
MARY E GAFFNEY
Place of Death and Residence S
Boston
Date of Death
JAN. 12
CITY
SICUT
PYO PNEUMOTHORAX (RT) 10 DYS
A. 1822
NE DONATA A
Jan. 12, 1915
COMMONWEALTH OF MASSACHUSETTS
RETURN OF A DEATH-1915.
CITY OF BOSTON.
ISABELLE KILROY
FULL NAME
Place of Death
Boston
and Residence
Date of Death
JAN. 13
1915.
Age
years
months
14
days.
STATISTICAL DETAILS.
SEX.
COLOR.
SINGLE, MARRIED, WID., DIV.
F
W
SIN.
Maiden Name
Husband's Name
Birthplace
BOSTON
Name of Father
-
Birthplace of Father
Maiden Name of Mother
CATHERINE KILROY
Birthplace of Mother IRELAND
Occupation
Informant
Place of Burial or removal
ST. JOSEPHS
Undertaker E.L. BEAN
QUINCY
PHYSICIAN'S CERTIFICATE.
I HEREBY CERTIFY that I attended deceased during last illness,
1915, from 1915, to that to the best of my knowledge and belief death occurred, on the date stated above, and that the CAUSE OF DEATH was as follows : RAR'S
EGIST UT PATRIAS, SIT DE
Primary: ( Duration)
FICE
CIVITA
BOSTONIA
15 DYS +
TORTITAAL ISRECIMINE DONATA A STO 1330. . MASS
Contributory : (Duration)
(Signed)
M.D.
1915
SPECIAL INFORMATION from Hospitals, Institutions, Transients, or Recent Residents.
WINTHROP
Usual Residence
Filed
JAN.27 1915.
A true copy.
Attost :
Eumylenen
Registrar.
O
Registered No. 659
ST. MARYS HOSPT.
CITY RE
FAILURE TO ASSIMILATE FOOD
R. W. HASTINGS
Jan. 13, 1915
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. hear (No 428 Revere St. : Ward)
Martin Houlihan
2 FULL NAME [If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE Int Banko, Winthrop
Registered No.
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
3 SEX
4 COLOR OR RACE
W
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
6 DATE OF BIRTH
(Month) (Day)
7 AGE
If LESS than
[ day ......... hrs.
or ..
min. ?
& OCCUPATION
(a) Trade, profession, or particular kind of work. Valdres-
(b) General nature of industry, business, or establishment in which employed (or employer)
9 BIRTHPLACE
(State or country)
Leland
10 NAME OF
FATHER
Wm Houlihan
PARENTS
11 BIRTHPLACE OF FATHER (State or conntry) Juland
12 MAIDEN NAME OF MOTHER
Jaharos le ulteriano
18 BIRTHPLACE OF MOTHER (State or country)
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant) .
W & Skaggs
(Address)
REGISTRAR
16 DATE OF DEATH
Jan.
1.3 (Day)
1910 (Year)
17 I HEREBY CERTIFY that I have investigated the death of the deceased.
The CAUSE OF DEATH* was as follows : Oedema of the Brain and Exhaustion presumably
Consemment
The overdue
of alcohol and expome
.. (Duration) ...
yrs.
...
Contributory Found dead)
(SECONDARY)
.(Duration)
yrs. ..
mos. .ds.
(Signed)
Burgers Magnets
M.D.
(Address).
MEDICAL EXAMINER
* State the DISEASE CAUSING DEATII, or, in deaths from VIOLENT CAUSES, state (1) MEANS of INJURY; and (2) whether ACCIDENTAL, SUICIDAL Or HOMICIDAL.
8 LENGTH OF RESIDENCE (FOR HOSPITALS, INSTITUTIONS, TRANSIENTS, OR RECENT RESIDENTS).
In the
At place
of death
yrs.
mos.
ds.
State
yrs. ..
mos.
ds ...
Where was disease contracted, If not at place of death ? ..
Former or usual residence
19 PLACE OF BURIAL OR REMOVAL
DATE OF BURIAL Holy Cross Ceece 1-15, 1912
O UNDERTAKER U.C. Strays
ADDRESS
Fied , 21
6559
(City or town.) {If death occurred in a hospital or institution, give its NAME instead of street and number.]
(Month)
!
(Year)
Cat. 3. 5 yrs.
mos.
ds.
mos. .
ds.
Jan. 10,171. STANDARD CERTIFICATE OF DEATH.
Statement of occupation. - Precise statement of occu- pation is very important, so that the relative healthfulness of various pursuits can be known. The question applies to each and every person, irrespective of age. For many occupations a single word or term on the first line will be sufficient, e. g., Farmer or Planter, Physician, Compositor, Architect, Loco- motive engineer, Civil engineer, Stationary fireman, ctc. But in many cases, especially in industrial employments, it is necessary to know (a) the kind of work and also (b) the nature of the business or industry, and therefore an additional line is provided for the latter statement; it should be used only when necded. 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 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) ; Mcasles; Whooping cough; Chronie 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 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 street, or one supposed to be due to Alcoholism, etc.
4. Deaths under circumstances unknown, as A person found dead, ctc.
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 Withsolo (No .... 64 Temple aves.
Ward)
[If death occurred in a hospital or institution, give its NAME instead of street and number.]
Registered No.
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
(Month)
(Day)
(Year)
17 I HEREBY CERTIFY that I attended deceased from
, 1915, to
Jan 14
1915
that I last saw her alive on Jan 14
191.3,
and that death occurred, on the date stated above, at.
m.
The CAUSE OF DEATH* was as follows :
(Duration)
.. yrs.
mos.
ds.
Contributory
(SECONDARY)
(Duration).
6yrs.
U
mos.
0
(Signed)
Tu 15, 1915 (Address) 290 Benamm HG. Book
* 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 plece
of death.
yrs.
mos.
In the
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
Marblehead
O UNDERTAKER
George E. Titois
ADDRESS
25 Washington St.
marblehead, Mass.
3 SEX
Female
4 COLOR OR RACE
White
5 SINGLE,
MARRIED
WIDOWED,
OR DIVORCED
(Write the wordt)
Single
6 DATE OF BIRTH
January
(Month)
14
(Day)
(Year)
7 AGE
If LESS than
1 day, 0 hrs.
C .yrs. 0 mos. 0 ds. or Q min. ?
8 OCCUPATION (a) Trade, profession, or particular kind of work
(b) General nature of industry, business, or establishment in which employed (or employer).
' BIRTHPLACE
(State or country)
Winthrop
Massachusetts
10 NAME OF
FATHER
Fred W. nichols
11 BIRTHPLACE
OF FATHER
Marblehead
(State or country)
Massachusetts
12 MAIDEN NAME
OF MOTHER
Marion E. Gauntlett
12 BIRTHPLACE
OF MOTHER
(State or country)
Boston
Massachusetts
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
Mrs. R.d. nichols
(Address) 123 Quincy ave. Winthrop, Mass.
Filed ....: 121
REGISTRAR
(City or town.)
2 FULL NAME
Child on Fred D. Tuchola
[If married or divorced woman or widow, give maiden name, also name of husband.] @RESIDENCE
1 1
, 191y
1915
PARENTS
191
C
STANDARD CERTIFICATE OF DEATH.
r
1
< 5
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 naturo 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 Hlousc- 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, otc. 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.
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