USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1916-1918 > Part 10
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1 PLACE OF DEATH .
(No
414 Runner
St. :
Ward)
(Day)
1916
.... .
....
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 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 nceded. 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," "Forcınan," "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 employcd, 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 ANDIOFISE 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 diseasc. Examples: Cerebro-spinal fcver (the only definite synonym is "Epidemie cerebro-spinal meningitis"); Diphtheria (avoid use of "Croup"); Typhoid fever (never re- port "Typhoid pneumonia"); Lobar pneumonia; Broncho- pneumonia ("Pneumonia," unqualificd, 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) ; Measlcs; Whooping cough; Chronic valvular heart discase; Chronic interstitial nephritis, etc. The contributory (second- ary or intercurrent) affection nced not be stated unless im- portant. Example: Mcaslcs (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,". "Hacmorrhage," "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 scpticaemia," "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 onc supposed to be duc to Alcoholism, etc. -
4. Deaths under circunstances 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)
Scotland
12 MAIDEN NAME
OF MOTHER
M. Ann Paxton
13 BIRTHPLACE
OF MOTHER
(State or country)
Scotland
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant) (Address)
16 Filed Apr. 5,1916 Jaseph , Attwell
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
3 SEX
M
COLOR OR RACE
W
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
M
" DATE OF BIRTH
December 16, 1858
(Month)
(Day)
(Year)
? AGE
If LESS than 1 day .......... hrs.
or ......... min. ?
8 OCCUPATION
(a) Trade, profession, or
particular kind of work
Book keeper
(b) General nature of industry, business, or establishment in which employed (or employer).
9 BIRTHPLACE
(State or country)
Scotland
Contributory.
(SECONDARY)
.(Duration)
... yrs. ................ mos. ....
ds.
(Signed)
p. C. Devlin
M.D.
191.
..... (Address)
Lynn
* 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
In the
of death
.yrs.
mos. ...........
ds.
State
.. yrs.
........
.. ds.
...
Where was disease contracted,
If not at place of death ?.
Former or usual residence.
19 PLACE OF BURIAL OR REMOVAL Winthrop, Mass.
DATE OF BURIAL
Mar. 18,
6
191
.......
20 UNDERTAKER Chas. Bennison
ADDRESS winthrop
CITY OF LYNN
(City or town.) [If death occurred in a hospital or institution, give its NAME Instead of street and number.]
2FULL NAME
David White
[If married or divorced woman or widow
give maiden name, also name of husband.]
@RESIDENCE
Winthrop, Mass.
Registered No.
357
PERSONAL AND STATISTICAL PARTICULARS
The Commonwealth of Massachusetts STANDARD CERTIFICATE OF DEATH
I PLACE OF DEATH
Lynn (No ........... .Lynn Tubercular .... Sana ........ St. ;
.......... Ward)
....
16 DATE OF DEATH
March 13,1916.
(Month)
(Day)
191
(Year)
17
I HEREBY CERTIFY that I attended deceased from
Feb. 5,
........... . 191 ... 6, tolkar
-
191 ... 6.,
that / last saw h.
... alive on.
13
191.6.,
and that death occurred, on the date stated above, at.
Tp
m.
The CAUSE OF DEATH* was as follows :
pulmonary tuberculosis
(Duration)
... yrs.
...........
.. mos.
ds.
....
10 NAME OF
FATHER
F. James
1
.....
WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD.
19
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, Architcet, 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 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) Forcman, (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 aro engaged in the duties of the household only (not paid House- keepers wlio 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, tho DIS- EASE CAUSING DEATH (the primary affection with respect to time and causation), using always tlie same accepted terin for the same disease. Examples: Cerebro-spinal fever (the only definito synonym is "Epidemie 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 ncoplasms); Measles; Whooping cough; Chronic valvular heart discase; 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-pncumonia (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," "Hacmorrhage," "Inanition," "Marasmus," "Old agc," "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 scpticaemia," "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 dcad, etc.
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH
Wirilbut
(No ....
Metcalf Harhilal
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
4 COLOR OR RACE
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
Willow
$ DATE OF BIRTH
aug
9
6ST
(Month) (Day)
(Year)
7 AGE
50
mos. ds.
or ....... 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)
Westport me
10 NAME OF
FATHER
Clark Acruett
11 BIRTHPLACE
OF FATHER
(State or country)
Westhard me.
12 MAIDEN NAME
OF MOTHER
alline Lemett
13 BIRTHPLACE
OF MOTHER
(State or country)
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
(Address)
16
Filed
191
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
17
1 HEREBY CERTIFY that I attended deceased from
rick 13
1915
2.1. 16
to
1916
that I last saw h G alive on
...
mk 16
198
and that death occurred, on the date stated above, at.
1.10/m.
The CAUSE OF DEATH* was as follows : Caranoma
General Porchomatis
Sablonton Mercatinis
.. (Duration)
Contributory
(SECONDARY)
mos.
2
ds.
(Duration)
Ben / Mulare
M.D.
(Signed)
Jul 16
191
....
(Address)
.......
* 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 ?.
6 Waldemar al
Former or
usual residence.
4 wouldunes we
19 PLACE OF BURIAL OR REMOVAL Eng Pleasant the
DATE OF BURIAL
3,10
.,
191.47
20 UNDERTAKER
CH Frauence
ADDRESS
Chelsea
WRITE PLAINLY, WITH UNFADING INK -THIS IS A PERMANENT RECORD.
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
(City or town.)
2 FULL NAME
1 Pellingill
...... .... [If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE 4 Waldam
(Month)
16
., 1916
(Day) ., (Year)
If LESS than
I day ......... hrs.
C
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, Laborcr - 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 gaill- 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 wlio 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 tinic 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 ncoplasms); 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 (discase causing death), 29 ds .; Broncho-pneumonia (secondary), 10 ds. Never report mere symptoms or terminal conditions, such as "Astlienia," "An- acmia" (merely symptomatic), "Atrophy," "Collapse," "Coma," "Convulsions," "Debility" ("Congenital," "Senile," etc.), "Dropsy," "Exhaustion," "Heart failure," "Haemorrhage," "Inanition," "Marasınus," "Old age," "Shock," "Uraemia," "Weakness," ctc., when a definite disease can be ascertaincd 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.
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.
CAUSE OF DEATH in plain terms, so that it may be properly classified. Exact statement of OCCUPATION is very N. B. - Every item of information should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state important. See instructions on back of certificate.
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
' PLACE OF DEATH
(No.
Ho Waldemailist.
Ward)
(City or own.) [If death occurred in a hospital or institution, give its NAME instead of street and number.]
. ...
[If married or divorced woman or widow
give maiden name, algo name of husband.j.
@RESIDENCE
Winthrop, Mars. Ho Waldemar av.
.... Registered No.
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
¿ SEX
4 COLOR OR RACE
w
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
Single
16 DATE OF DEATH
March
(Day)
(Month)
17. 1916.
(Year)
' DATE OF BIRTH
7
18
..
(Month)
(Day)
190,
(Year)
7 AGE
If LESS than
1 day ......... hrs.
„yrs.
7
mos.
29
ds
„min. ?
& OCCUPATION
(a) Trade, profession, or
particular kind of work.
(b) General nature of industry,
business, or establishment in
which employed (or employer).
17 I HEREBY CERTIFY that I attended deceased from March 11h 196 to March 17, 1916. that | last saw h.C ...... alive on mah. 16. 1916 and that death occurred, on the date stated above, at / a.m. The CAUSE OF DEATH* was as follows :
acute Malignant Endocardite
.(Duration)
„.yrs. ..
.mos. 1 de.
Contributory.
Sharon
(SECONDARY)
(Duration)
...... yrs.
............
mos.
10
.ds.
(Signed)
nel. Porter
M.D.
Mal. 18.1916 (Address)
Winetad, Mais.
* 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 ............ yra.
........... mos.
In the
.......
Where was disease contracted, If not at place of death ?...
Former or usual residence.
19 PLACE OF BURIAL OR REMOVAL quethrop Gut,
DATE OF BURIAL
3-18-1916
............
20 UNDERTAKER W.C. Skaggs
ADDRESS
Wirthofu
PARENTS
10 NAME OF
FATHER
Horace Richardson
11 BIRTHPLACE
OF FATHER
(State or country)
St. Martins Quebec
12 MAIDEN NAME
OF MOTHER
18 BIRTHPLACE
OF MOTHER
(State or country)
Hyde Park. Jurajo
" THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
Horace Richardson
(Address) HOWWaldemar Ceviz
16
Filed 191
REGISTRAR ..... ......
9 BIRTHPLACE
(State or country)
Taunton, mais
WRITE PLAINLY, WITH UNFADING INK - THIS IS A PERMANENT RECORD.
Pauline B. Richardson
? FULL NAME
171916
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 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 homc, 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 DEATII (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- acmia" (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 ascertaincd 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 discase, as A death upon the street, or onc supposed to be due to Alcoholism, etc.
4. Deaths under circumstances unknown, as A person found dead, etc.
WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD.
....... 3 SEX H 7 AGE PARENTS important. See instructions on back of certificate. 16 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 ....
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH
Winthrop
(No.
3%, Beacon
St. :
(City or town.)
[If death occurred in a hospital or institution, give its NAME instead of street and number.]
2 FULL NAME
Ella 4. Because Bearse
[If married or divorced woman or widow give maiden name, also name of husband.] ... Thor Ti Bracke (Hurley)
@RESIDENCE
Registered No.
PERSONAL AND STATISTICAL PARTICULARS
1 COLOR OR RACE
w
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
· DATE OF BIRTH
11-3-17711853,816
(Month)
(Day)
(Year)
If LESS than
I day ........ hrs.
60 yrs yrs.
....... 4 mos. ds.
Or ........ min. ?
& OCCUPATION
(a) Trade, profession, or
particular kind of work
(b) General nature of industry,
business, or establishment
which employed (or employer).
9 BIRTHPLACE
(State or country)
E. Boston
10 NAME OF
FATHER
Espara Hundar
11 BIRTHPLACE
OF FATHER
(State or country)
Calias Ing.
12 MAIDEN NAME
OF MOTHER
Sarah IN, Lowin
13 BIRTHPLACE
OF MOTHER
(State or country)
Calias Ing-
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
Anight Beauce
(Address)
5'7 Seacon St. hunthe Hoodlaconce 3-23-1916
Filed 191
......
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
mah
(Month)
2/.1916.
(Day)
(Year)
I HEREBY CERTIFY that I attended deceased from
non, 1ch.
191
to
March 21. 1916.
that I last saw her alive on
Mar, 21., 1916.
and that death occurred, on the date stated above, at.
5P. m.
m.
1
.....
The CAUSE OF DEATH* was as follows :
Diabetes Mellitus
(Duration)
3
yrs.
mos.
......
ds.
arteriosclerosis
Contributory
(SECONDARY)
(Duration)
.yrs.
mos.
ds.
(Signed).
M.J. Para
M.D.
mak. vz
191 .... (Address)
* 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).
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