USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1913-1915 > Part 97
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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, etc.
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 strect, or one supposed to be due to Alcoholism, etc.
4. Deathis under circumstances unknown, as A person found dcad, 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)
Ireland.
12 MAIDEN NAME OF MOTHER Tachel Jualy
13 BIRTHPLACE OF MOTHER (State or country) Ireland
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant) /
(Address)
Filed. . 191.
REGISTRAR
16 DATE OF DEATH
may
(Month)
(DẠY)
HEREBY CERTIFY that I have investigated the death of the deceased.
The CAUSE OF DEATH* was as follows : natural Causes. 8 resumal heart disease (cormay Selevous? acute dilatation?)
[ Found decried invented
ds.
Contributory. (SECONDARY)
(Duration) .. yrs.
mos. ds.
(Signed)
Jury Burgers Magneth
M.D.
Many G. 195 (Addre
MEDICAL EXAMINER
* State the DISEASE CAUSING DEATH, or, in deaths from VIOLENT CAUSES, state (1) MEANS of INJURY; aud (2) whether ACCIDENTAL, SUICIDAL or IlOMICIDAL.
18 LENGTH OF RESIDENCE (FOR HOSPITALS, INSTITUTIONS, TRANSIENTS, OR RECENT RESIDENTS).
At place
of death.
yrs.
mos.
ds.
State
.yrs.
mos.
ds.
Where was disease contracted, If not at place of death ?. ..
Former or usual residence.
19 PLACE OF BURIAL OR REMOVAL
Holy Cross Com
20 UNDERTAKER W.C. Skarg0
6895 winthrop (City or town.)
[if death occurred in a hospital or institution, give its NAME instead of street and number.]
2 FULL NAME John (Patrick Edward) Hurley [If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE 2 Limerick Park, multiop
Registered No.
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
COLOR OR RACE
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
a
6 DATE OF BIRTH
(Month)
(Day)
186 (Year)
7 AGE
If LESS than 1 day, ....... hrs.
50 .... yrs.
mos.
ds.
or .min. ?
8 OCCUPATION
(a) Trade, profession, or particular kind of work Soldier U.S. army-
(b) General nature of industry, business, or establishment In which employed (or employer).
9 BIRTHPLACE
(State or country)
Ireland
10 NAME OF FATHER
Thos. Sturly.
In the
DATE OF BURIAL
5-//
. 1913~
ADDRESS
WRITE PLAINLY, WITH UNFADING INK - THIS IS A PERMANENT RECORD.
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH wruller go (No. 2 ., Limerick PK St. , Ward)
MEDICAL CERTIFICATE OF DEATH
9, 1915 (Year)
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, etc. But in inany 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 cxamples: (a) Spinner, (b) Cotton mill; (o) 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 causatiou), 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 neoplasmns) ; Measles; Whooping cough; Chronic valvular heart disease; Chronic interstitial nephritis, ctc. 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 septicacmia," "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."
A
Cases for the Medical Examiners. - Under the provi- sions of eliapter 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 onc supposed to be duc to Alcoholism, ctc.
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
I] BIRTHPLACE
OF FATHER
(State or country)
Nova Scotia
12 MAIDEN NAME
OF MOTHER
.
Elizabeth Chali.
1ª BIRTHPLACE
OF MOTHER
(State or country)
giove Sentia
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informent)
Gracie nickerson
(Address)
Filed
191
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
3 SEX
' COLOR OR RACE
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED Luce
(Write the word)
1
$ DATE OF BIRTH
9
(Month)
15
(Day)
.... (Year)
7 AGE
If LESS than
i day ......... hrs.
67 yrs. ....... 8 mos.
or ........ min. ?
· OCCUPATION
Retired Computer
(b) Generst nature of Industry,
business, or establishment
In
which employed (or employer).
my Manico
(Duration)
............. yrs.
.........
mos.
ds.
Contributory
(SECONDARY)
(Duration).
„yrs.
.......
.. mos. ................ ds.
(Signed)
C. 7. Mahoney
M.D.
may . 2.
1915 (Address)
35 5 Uma
* 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.
Stete ............ yrs. ............ mos.
..........
ds .............
in the
Where was disease contracted,
If not at place of death ?.
Former or
usual residence
1º PLACE OF BURIAL OR REMOVAL Winthrop, Cerca.
DATE OF BURIAL
5-13
1915
20 UNDERTAKER
ghC. Skaggs.
ADDRESS
Wirethunder ,
(City or town.) [if death occurred in a hospital or institution, give its NAME instead of street and number.]
............
1 PLACE OF DEATH
(No. 286 Winthrop St. ............... .Ward)
2 FULL NAME
Curtis a. Nickerson.
[If married or divorced woman or widow
give maiden name, also name of husband.]
RESIDENCE 186 Winthrop Str Winthrop Masa.
.... Registered No.
PERSONAL AND STATISTICAL PARTICULARS
16 DATE OF DEATH
(Month)
10
, 1915
(Day)
(Year)
1827
17
I HEREBY CERTIFY that I attended deceased from
april 18
191.5 ... , to
1915.
that I last saw him alive on
191.35
and that death occurred, on the date stated above, at ...
........... m.
The CAUSE OF DEATH* was as follows :
(a) Trade, profession, or
perticular kind of work
· BIRTHPLACE
(State or country)
Novascotia
10 NAME OF
FATHER
almen Mickelson
Nova Scotia
....
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
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) 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 Nonc.
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 usc 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 bo 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" (mcrely symptomatic), "Atrophy," "Collapse," "Coma," "Convulsions," "Debility" ("Congenital," "Senile," etc.), "Dropsy," "Exhaustion," "Heart failure," "Haemorrhage," "Inanition," "Marasmus," "Old age," "Shock," "Uraemia," "Weakness," etc., when a definite disease can be ascertained as the cause. Always qualify all diseases resulting from childbirth or miscarriage, as "PUER- PERAL septicaemia," "PUERPERAL peritonitis," etc. State cause for which surgical operation was undertaken.
Cases for the Medical Examiners. - Under the 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.
2 FULL NAME. 3 SEX 7 AGE 73 W.C. ( From, Cul: & OCCUPATION (a) Trade, profession, or particular kind of work PARENTS 13 BIRTHPLACE OF MOTHER (State or country} 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 CAUSE OF DEATH in plain terms, so that it may be properly classified. Exact statement of OCCUPATION is very (b) General nature of industry. business, or establishment in which employed (or employer)
The Commonwealth of Massachusetts STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH
Withrob.
(No.
66
argent
St. :
Ward)
(City or town.) [If death occurred in a hospital or institution, give its NAME instead of street and number.]
Jessie
[If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENGE 66 Margens AV.
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
4 COLOR OR RACE
Female white
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
Widow
6 DATE OF BIRTH
Amaro, 84%.
(Months
(Day)
(Year)
yrs.
11 mos
mos.
2
.ds.
or ....... min. ?
9 BIRTHPLACE
(State or country)
Scotland
-
10 NAME OF
FATHER
Beny Davidson
11 BIRTHPLACE
OF FATHER
(State or country)
Scotland
12 MAIDEN NAME
OF MOTHER
Jessie Bridge forte
Scotland
" THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
Zigo Bain,
(Address)
66 ParquetSi,
Filed 191.
....
REGISTRAR
16 DATE OF DEATH
May
I HEREBY CERTIFY that I attended deceased from
March ich
May 12ch
1915
1915
to
If LESS than I day, .. ..... hrs. that | last saw! Malive on
May 12 th
, 19115
and that death occurred, on the date stated above, at
1110
.m.
The CAUSE OF DEATH* was as follows :
Chronic Chem ateru
(Duration)
2
yrs.
mos.
ds.
Contributory
artureo scherou
(SECONDARY)
Indefinite
(Duration).
... yrs.
.. mos .. ds.
M.D.
* 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).
ALplace
of death.
.. yrs.
mos.
ds.
State
yrs.
...
mos.
ds.
Where was disease contracted, If not at place of death ?.
Former or Usual residence ..
1º PLACE OF BURIAL OR REMOVAL Woodlawn
DATE OF BURIAL
May 1515.
20 UNDERTAKER
ADDRESS
Whichrop
Bari
Davidsow- Hola
Registered No.
(Month)
(Day)
.... . 1915 (Year)
(Signed)
May 13., 1915 (Address)
In the
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: 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,""Exhaustion," "Heart failure," "Haemorrhage," " Inanition," " Marasmus," " Old age," "Shock," "Uraemia," " Weakness," etc., when a definite disease can be ascertained as the cause. Always qualify all diseases resulting from childbirth or miscarriage, as " PUER- PERAL septicaemia," " PUERPERAL peritonitis," etc. State cause for which surgical operation was undertaken.
. Cases for the Medical Examiners. - Under the provisions -. of chapter 24 of the Revised Laws deaths under the following conditions must be referred to the Medical Examiners:
1. Deaths following injury or violence, as Burns, Falls, Drowning, Gas Poisoning, Suicide, Homicide, etc.
2. Deaths supposedly caused by violence, as Criminal Abortion, Poisoning, Starvation, Suffocation, Ex- posure, etc.
3. Sudden deaths of persons not disabled by recognized disease, as A death upon the street, or one supposed to be due to Alcoholism, etc.
4. Deaths under circumstances unknown, as A person found dead, etc.
COMMONWEALTH OF MASSACHUSETTS
RETURN OF A DEATH-1915.
CITY OF BOSTON.
FULL NAME
ELMER CHICKERING
Registered No. 4928
Place of Death ¿
Boston
and Residence
Date of Death
MAY 14
1915.
Age
58
years
2
months
26
days.
STATISTICAL DETAILS.
SEX
COLOR.
SINGLE, MARRIED, WID., DIV.
M
W
MAR.
Maiden Name
Husband's Name
Birthplace
BRANDON. VT.
Name of Father
WILLIAM CHICKERINGSTO
Birthplace of Father
Maiden Name of Mother
MARY
Birthplace of Mother
Occupation PHOTOGRAPHER
Informant
Place of Burial or removal
MT. HOPE
Undertaker
J. S. WATERMAN & SONS
PHYSICIAN'S CERTIFICATE.
I HEREBY CERTIFY that I attended deceased during last illness,
from
1915, to
1915, 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
GIST T PATRATHIS, SIT DA
RE
SICUT
Primary: ( Duration ))
DIABETES - 2 YRS +
CITY
BOSTONIA
CORTITAA
1430.
TE DONATAN
N. MASS
Contributory · (Duration)
(Signed)
W. A. MAC INTYRE
M.D.
MAY 14 1915 SPECIAL INFORMATION from Hospitals, Institutions, Transients, or Recen? Residents.
Usual Residence
WINTHROP
Filed
MAY 18 1915.
A true copy.
Attest :
ErMSlenen
Registrar.
2.1822.
ISREOIMIN
PSYCHOPATHIC HOSPT.
may 14 , 1915
G
COMMONWEALTH OF MASSACHUSETTS
RETURN OF A DEATH-1915.
CITY OF BOSTON.
FULL NAME
FRANCIS DAVIS
Registered No.
4900
MASS . HOMEO . HOSPT.
Place of Death l and Residence S
Boston
Date of Death
1915.
Age
years
months
17
days.
STATISTICAL DETAILS.
SEX
COLOR.
SINGLE, MARRIED, WID., DIV.
M
W
SIN.
Maiden Name
EGIST PATRIKIS, SIT DA RE
SICUT
Primary: (Duration).
DIPHTHERIA
Birthplace
WINTHROP
Name of
Father
AUGUSTUS S. DAVIS TISREGIM!
F DONATA A.
Birthplace
of Father
CAMDEN . N. J.
Contributory : (Duration)
-
Birthplace
of Mother
BOSTON
Occupation
NONE
MAY 15 1915 SPECIAL INFORMATION from Hospitals, Institutions, Transients, or Recent Residents.
IN HOSPT. 14 DYS
Place of Burial
or removal
MALDEN ( HOLY CROSS )
Undertaker G.M. ALLEN
Usual Residence
WINTHROP ( 98 OCEAN VIEW ST)
Filed
MAY 18
1915.
A true copy.
Attest :
Eumylenen
Registrar.
M. D.
Informant
PHYSICIAN'S CERTIFICATE.
I HEREBY CERTIFY that I attended deceased during last illness,
from
1915, to
1915, 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
Husband's Name
CITY
R. CFICE
LAL BOSTONIA
TONTITA AA
1130.
V. MASS
Maiden Name
of Mother
EMMA FERNEKEE
E- R. LEWIS
(Signed)
8
8
MAY 14
many 14/1915
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
(No.
36 Worth Que
St ..
.. Ward)
George G. Biocone
2 FULL NAME
[If married or divorced woman or widow
give maiden name, also name of husband.]
ARESIDENCE 36 harth ave. Waethiop, Mais
.... Registered No.
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
¿ SEX
4 COLOR OR RACE
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
marked
$ DATE OF BIRTH
4
(Month)
(Day)
6
., 1848 17
(Year)
1 AGE
If LESS than
[ day ......... hrs.
69
.yra.
...... mos.
ds.
Or ......... min. ?
· OCCUPATION
(a) Trade, profession, or
particular kind of work
Retired
(b) General neture of industry,
business, or establishment in
which employed (or employer)
$ BIRTHPLACE
(State or country)
Theat newbury Mars.
PARENTS
11 BIRTHPLACE
OF FATHER
(State or country)
new Harup.
12 MAIDEN NAME
OF MOTHER
George
18 BIRTHPLACE
OF MOTHER
(State or country)
wishing mais.
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
(Address)
36 Forth arz
REGISTRAR
.........
I HEREBY CERTIFY that I attended deceased from
hov 23
1914, to
many 14
2 ...
that I last saw him alive on
may 14
, 1915
and that death occurred, on the date stated above, at /1.50 Am.
The CAUSE OF DEATH* was as follows :
of Livro
0
(Duration)
1 yik. ..
1
„mos.
da.
Contributory
(SECONDARY)
.(Duretion)
.......... yrs. .....
........ mos. ............
ds.
.......
M.D.
(Signed)
04.1915 (Address) 145 1 inthanh EP
* 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
da.
Stato ............ yra.
mos.
Where was disease contracted, If not at place of death ?...
Former or usual residence.
D PLACE OF BURIAL OR REMOVAL
DATE OF BURIAL
1-16-1917.
D UNDERTAKER
H. C. Skaggs
ADDRESS
Winthrop
191.5 ....
(Month)
(Day)
(Year)
16 DATE OF DEATH
May 14
(City or town.) [if death occurred in a hospital or institution, give its NAME instead of street and number.]
Filed . 191
....
10 NAME OF
FATHER
trancio Biocone
,
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 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) 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- 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.
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