USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1913-1915 > Part 78
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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 cercbro-spinal meningitis") ; Diphtheria (avoid use of "Croup") ; Typhoid fever (never ro- 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 septicemia," "PUERPERAL peritonitis," etc. State cause for which surgical operation was undertaken.
Cases for the Medical Examiners. - Under the provisions of chapter 24 of tho Revised Laws deaths under the following conditions must be referred to the Medical Examiners:
1. Doaths 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 important. See instructions on back of certificate.
The Commonwealth of Massachusetts STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH Huntwohl (No
1
1
St. :
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)
18
(Day)
1915
(Year)
I HEREBY CERTIFY that I attended deceased from
191
191.
, to
that I last saw h .....
alive on
191
and that death occurred, on the date stated above, at
m.
The CAUSE OF DEATH* was as follows :
stilllow
(Duration)
.....
.. yrs.
mos. ds.
Contributory (SECONDARY)
(Duration)
... yrs.
mos. ...
ds.
(Signed)
Charles 7 mahoney
M.D.
Jan 20
1915 (Address).
3.55 mmchlop
* 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 the
ds.
State
.yrs.
mos.
ds ..........
Where was disease contracted, If not at place of death ?.
Former or usual residence
1ª PLACE OF BURIAL OR REMOVAL
(Informant)
(Address)
34
16 Filed 191
REGISTRAR
.....
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
6 DATE OF BIRTH
Yan
20
1916
11
(Month)
(Day)
(Year)
7 AGE
If LESS than t 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)
BIRTHPLACE
(State or country)
10 NAME OF
FATHER
PARENTS
11 BIRTHPLACE OF FATHER (State or country)
12 MAIDEN NAME OF MOTHER Etter Vanzel
18 BIRTHPLACE OF MOTHER (State or country)
" THE ABOVEY'S TRUE TO THE BEST OF MY KNOWLEDGE
DATE OF BURIAL
Cin Q.Q 193
20 UNDERTAKER 5
ADDRESS
79
(City or town.)
2 FULL NAME
[If married or divorced woman or widow
give maiden name, also name of husband.]
@RESIDENCE
32
E
3 SEX thatE
4 COLOR OR RACE
1
Jan. 10 -
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 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; 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 childhirth 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.
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH
(No
494 Shirley
St. :
Ward)
[If death occurred in a hospital or institution, give its NAME instead of street and number.]
Registered No.
PERSONAL AND STATISTICAL PARTICULARS
3 SEX -
female
4 COLOR OR RACE
White
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
2vidon
6 DATE OF BIRTH
Oct -
(Month)
(Day)
5th 1849
(Year)
7 AGE
If LESS than
I day, ........ hrs ..
65 yrs. 3
... yrs.
mos.
11 ds.
.. min. ?
$ 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)
Burton mars
PARENTS
12 MAIDEN NAME
OF MOTHER
Cenna Tener
13 BIRTHPLACE
OF MOTHER
(State or country)
" THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
Y
(Informant)
Gertrude 7. Veinteband
(Address)
16
Filed 191
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
lan
(Month)
19.1915
(Day)
(Year)
17
I HEREBY CERTIFY that I attended deceased from
Och. x5.
19175
Jan . 14,
to
1913 ....
that I last saw her
alive on
Som 17 th 1915. and that death occurred, on the date stated above, at .m. The CAUSE OF DEATH* was as follows :
(Duretion)
.yrs.
mos.
ds.
arterio sclerose
Contributory
(SECONDARY)
Andel
.(Duration)
yrs.
mos.
Us.
(Signed)
Millique &. Portes
M.D.
Srce 19., 1913 (Address)
Drinetrop
* 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.
....... yr$
mos.
ds.
State
.yrs.
....
mos.
ds .............
Where was disease contracted, If not at place of death 7.
Former or usual residence.
17 PLACE OF BURIAL OR REMOVAL
Novellaun
maso
DATE OF BURIAL
Jan 2.2. 1915
* UNDERTAKER
ADDRESS
Windland 1
(City or town.)
....
Sarah.
Frances. Tay low
2 FULL NAME
[If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE
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.
2
10 NAME OF
FATHER
Shadrach. Kien
11 BIRTHPLACE
OF FATHER
(State or country)
In the
Jan. 11, 1/1
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 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; 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 .; 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.
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH
(No.
410 Breveelér ceve
St. :
Ward)
{if death occurred in a hospital or institution, give its NAME instead of street and number.]
2 FULL NAME
Chrubros.
arms.
Stiles
[If married or divorced woman or widow
give maiden name, also name of husband.]
@RESIDENCE
410 1 reweter ave wonetterof Man.
Registered No.
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
4 COLOR OR RACE
Mute
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
16 DATE OF DEATH
Jan
24
1915
(Month)
(Day)
(Year)
6 DATE OF BIRTH
30
1842
(Month)
(Day)
(Year)
7 AGE
73
.. yrs.
12
ros.
5
ds.
Or ....... min. ?
& OCCUPATION
(a) Trade, profession, or
particular kind of work
Releve C Machen. fr
(b) General nature of industry,
business, or establishment in
which employed (or employer).
138221. RIR
9 BIRTHPLACE
(State or country)
10 NAME OF
FATHER
azro.
Elites
11 BIRTHPLACE
OF FATHER
(State or country)
12 MAIDEN NAME
OF MOTHER
Hellen Wwilling
13 BIRTHPLACE
OF MOTHER
(State or country)
Perfume ville p.f
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(informant)
(Address)
Filed .. 191.
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
17
I HEREBY CERTIFY that I attended deceased from
19
. 1915, to.
24
1915.
that I last saw him alive on
24
191.3.,
and that death occurred, on the date stated above, a
9 1 m.
The CAUSE OF DEATH* was as follows :
Cereal hemorrhage.
(Duration)
.. yrs.
mos.
ds.
Contributory
artir seunosis
(SECONDARY)
(Duration)
.. yrs.
mos.
ds.
(Signed)
M.D.
... am 25
191 ...... (Address).
14.4
* 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 disease contracted,
if not at place of death ?.
Former or
usual residence
19 PLACE OF BURIAL OR REMOVAL
Keene 11.H
DATE OF BURIAL
1/27
1915
20 UNDERTAKER
ADDRESS
(City or town.)
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
If LESS than 1 day ......... hrs ..
Jan. at, 1
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 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 ; 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 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.
COMMONWEALTH OF MASSACHUSETTS
RETURN OF A DEATH-1915.
CITY OF BOSTON. 854
FULL NAME
Place of Death ¿
Boston
and Residence S
Date of Death
JAN.26
1915.
Age
60
years months
days.
STATISTICAL DETAILS.
SEX.
COLOR.
M
W
SINGLE, MARRIED, WID., DIV. WID.
Maiden Name
Husband's Name
Birthplace GERMANY
Name of Father
LOUIS KALMUS
Birthplace
of Father
GERMANY
Maiden Name
of Mother
BERTHA JACOBY
Birthplace of Mother
GERMANY
COLLECTOR
Occupation
Informant
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
IST
PATRICIA Primary ( Duration ) in IS. SIT DE
. IFICE
ITA
TONTITAA
ISREGIMI
STO
V. MASS
SUICIDAL DURING TEMPORARY
INSANITY
(Signed)
T. LEARY MED. EX.
M. D.
JAN. 261915
SPECIAL INFORMATION from Hospitals, Institutions, Transients, or Recent Residents.
Place of Burial or removal
Undertaker
FOREST HILLS
J. P.CLEARY & SON
Usual Residence
WINTHROP HDS.
Filed
FEB. 1
A true copy.
Attest:
Eumylenen 1915 .
Registrar.
ILL. GAS POISONING
E
BOSTONIA
T.1 0.1822.
DONATI A.
Contributory : {
(Duration)
O
OTTO KALMUS
Registered No.
767 WASHINGTON ST.
Jan 26, 1915
The Commonwealth of Massachusetts STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH Winthrop
(No.
34 Madison Avenues.
...... .. Ward)
" FULL NAME
Margaret- Mary Murphy
[If married or divorced woman or widow give maiden name, also name of husband.] aRESIDENCE 34 Madison Avenue
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
' COLOR OR RACE
Female White
5 SINGLE,
Single
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
16 DATE OF DEATH
Jan
(Month)
(Day)
(Year)
" DATE OF BIRTH
Han
18
908
(Month)
(Day)
...
(Year)
7 AGE
7 . -
mos.
13
ds.
or ........ min. ?
$ OCCUPATION
(a) Trade, profession, or
particular kind of work.
School
(b) General nature of industry, business, or establishment In which employed (or employer).
9 BIRTHPLACE
(State or country)
East Boston
PARENTS
12 MAIDEN NAME
OF MOTHER
Mary A, Aberly
18 BIRTHPLACE
OF MOTHER
(State or country)
Salem mass
" THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
Dennis J. Murphy
(Address)
34 Madison Avenue
Filed
191
REGISTRAR
17
I HEREBY CERTIFY that I attended deceased from
Jan 25"
1915, to
tam 3/2
1915
Stan 31
and that death occurred, on the date stated above, at
10m.
The CAUSE OF DEATH* was as follows : Dipirona Paralysis of heart
Did a surgical operation precede death? no
Date
i.
(Duration)
........ yrs.
mos.
3
ds.
Contributory
(SECONDARY)
(Duration)
„yrs.
mos.
ds.
(Signed)
(3) met calf
M.D.
um 315- 1915
(Address)
Waltherp
* 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.
In the
State ..
..........
.yrs.
mos. ds ............. Where was disease contracted, If not at place of death ?.
Former or usual residence.
1º PLACE OF BURIAL OR REMOVAL Holy Cross
DATE OF BURIAL
Jul 2
1915
UNDERTAKER
M. J. Kelly 11 Meridian Six
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.
N. B. - Every item of information should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state
Winthrop
BOSTON ..........
(City or town.) [If death occurred in a hospital or institution, give its NAME instead of street and number.]
Registered No.
= MEDICAL CERTIFICATE OF DEATH
31
, 1915
....
If LESS than
day»
... hrs.
that I last saw h.
5
alive on
1915,
..
10 NAME OF
FATHER
Dennis J. Murphy
11 BIRTHPLACE
OF FATHER
(State or country)
East Boston
Jan. 31, 1915 STANDARD CERTIFICATE OF DEATH.
Statement of occupation. ---- Preeise 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, 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 linc 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 laborcr, Farm laborer, Laborer - 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, cte. 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.
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