Town of Winthrop : Record of Deaths 1913-1915, Part 77

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 77


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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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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