Town of Winthrop : Record of Deaths 1913-1915, Part 97

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 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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