USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1916-1918 > Part 100
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lapse," "Coma," "Convulsions," "Debility" (“Con-
genital," "Senile," etc.), "Dropsy," "Exhaustion," "Heart failure," "Hemorrhage," "Inanition," "Maras- mus," "Old age," "Shock," "Uremia," "Weakness," ete., when a definite disease can be ascertained as the cause. Always qualify all diseases resulting from child- birth or miscarriage, as "PUERPERAL septicemia," "PUER- PERAL peritonitis," ete. State eause for which surgical operation was undertaken. For VIOLENT DEATHS STATE MEANS OF INJURY and qualify as ACCIDENTAL, SUICIDAL, or HOMICIDAL, or as probably sueh, if impossible to de- termine definitely. Examples: Accidental drowning; Struck by railway train - accident; Revolver wound of hcad - homicide; Poisoned by carbolic acid - probably suicide. The nature of the injury, as fracture of skull, and consequences (c. g., sepsis, tetanus) may be stated
under the head of "Contributory." (Recommendations on statement of cause of death approved by Committee on Nomenclature of the American Medical Association.)
Cases for the Medical Examiners. - Under the provi- sions 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, cte.
2. Deaths supposedly eaused by violenee, as Criminal abortion, Poisoning, Starvation, Suffocation, Exposure, etc.
3. Sudden deaths of persons not disabled by recognized disease, as A death upon the strcet, or one supposed to be due to Alcoholism, ete.
4. Deaths under eircumstances unknown, as A person found dead, etc.
ADDITIONAL SPACE
FOR FURTHER STATEMENTS BY
PHYSICIAN.
R 15. 2-'18. 100,000.
The Commonwealth of Massachusetts STANDARD CERTIFICATE OF DEATH
Cambridge (Clty or town)
1 PLACE OF DEATH 1
County.
Township
.or Village ..
or
City Carsludge
No ..
Italy Short Hospital
St.
„Ward
(If death occurred in a hospital or institution, give its NAME instead of street and number)
2 FULL NAME Mary a. Deriving
(a) Residence. No. 5300irident ave
(Usual place of abode) Length of residence in city or town where death occurred
years
months
days. How long in U. S., if of foreign birth ? years
months
days
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
4 COLOR OR RACE
5 SINGLE, MARRIED, WIDOWED, OR
DIVORCED (write the word)
5a If married, widowed, or divorced
HUSBAND of
(or) WIFE of
6 DATE OF BIRTH (month, day, and year)
7 AGE
Years 75
Months
Days
0
0
8 OCCUPATION OF DECEASED Domestic
(a) Trade, profession, or particular kind of work
(Retired )
(b) General nature of industry, business, or establishment in which employed (or employer) (c) Name of employer
9 BIRTHPLACE (city or town)
Dr. Edina. Sold.
(State or country)
10 NAME OF FATHER
John
11 BIRTHPLACE OF FATHER (city or town)
(State or country) Ireland
12 MAIDEN NAME OF MOTHER Margaret Dono- , 19 (Address) 4/15/18
13 BIRTHPLACE OF MOTHER (city of town) var (State or country)
14
Informant (Address)
15 4123 Filed ... . . 19/8
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
18
17
I HEREBY CERTIFY, That I attended deceased from
4/1
18
to
19
4/15
19
18
that I last saw h ....
alive on
,19
...
and that death occurred, on the date stated above, at ..........
m. The CAUSE OF DEATH* was as follows :
If LESS than 1 day, ........ hrs. or ....... min. Diabetes Mellitus
(duration)
.yrs ................. mos .................
~ ds.
CONTRIBUTORY (SECONDARY)
(duration) ............... yrs ................. mos ................ ds.
18 Where was disease contracted
if not at place of death ?
Did an operation precede death ?
Date of ...
Was there an autopsy ?.
What test confirmed (diagnosis ? Daniel Mc Tillot
(Signed
M.D.
Camb
* State the DISEASE CAUSING DEATH, or in deaths from VIOLENT CAUSES, state (1) MEANS AND NATURE OF INJURY, and (2) whether ACCIDENTAL, SUICIDAL, or HOMICIDAL. (See reverse side for additional space.)
19 PLACE OF BURIAL, CREMATION, OR REMOVAL Beverly, mars)
DATE OF BURIAL
4/16
19
18
20 UNDERTAKER
Jak. F . Mullew
ADDRESS
Camb.
N. B .- WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD. Every item of information should be so that it may be properly classified. Exact statement of OCCUPATION Is very important. See instructions on back carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state CAUSE OF DEATH in plain terms,
PARENTS
of certificate.
.......
State mass.
Registered No. 701
Winthrop
Ward.
...
(If non-resident give city or town and State)
16 DATE OF DEATH (month, day, and year) 4/15 19
=
{Approved by U. S. Census and American Public Health Association]
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, Compos- itor, Architect, Locomotive 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) Salesman, (b) Grocery; (a) Foreman, (b) Automobile factory. The ma- terial 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 Housekeepers who receive a definite salary), may be entered as Houscwifc, Housework, or At home, and children, not gainfully employed, as At school or At home. Care should be taken to report spe- cifically 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 indi- cated thus: Farmer (retired, 6 yrs.). For persons who have no occupation whatever, write Nonc.
Statement of cause of death .- Name, first, the DISEASE CAUSING DEATII (the primary affection with respect to time and causation), using always the same accepted term for the same disease. Examples: Cerebrospinal fever (the only definite synonym is "Epidemie cerebrospinal menin- gitis"); Diphtheria (avoid use of "Croup"); Typhoid fever (never report "Typhoid pneumonia"); Lobar pneumonia; Bronchopneumonia ("Pneumonia," unquali- ficd, is indefinite); Tuberculosis of lungs, meninges, peri- toncum, etc., Carcinoma, Sarcoma, etc., of.
(name origin; "Cancer" is less definite; avoid use of "Tuinor" for malignant ncoplasms); Measles; Whooping cough; Chronic valvular heart discasc; Chronic interstitial nephritis, etc. The contributory (sccondary or inter- current) affection need not be stated unless important. Example: Measles (disease causing death), 29 ds .; Broncho- pneumonia (secondary), 10 ds. Never report mere symp- tonis or terminal conditions, such as "Asthenia," "Anemia" (mnerely symptomatic), "Atrophy," "Col- lapse," "Coma," "Convulsions,"" " "Debility" (“Con-
genital," "Senile," etc.), "Dropsy," "Exhaustion," "Heart failure," "Hemorrhage," "Inanition," "Maras- mus," "Old age," "Shock," "Uremia," "Weakness," etc., when a definite disease can be ascertained as the cause. Always qualify all diseases resulting from child- birth or miscarriage, as "PUERPERAL septicemia," "PUER- PERAL peritonitis," ete. State cause for which surgical operation was undertaken. For VIOLENT DEATHS STATE MEANS OF INJURY and qualify as ACCIDENTAL, SUICIDAL, or HOMICIDAL, or as probably such, if impossible to de- termine definitely. Examples: Accidental drowning; Struck by railway train - accident; Revolver wound of hcad - 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." (Recommendations on statement of cause of death approved by Committee on Nomenclature of the American Medical Association.)
Cases for the Medical Examiners. - Under the provi- sions 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, Exposure, 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.
ADDITIONAL SPACE
FOR FURTHER STATEMENTS BY PHYSICIAN.
R 15. 1-'18.
10,000.
The Commonwealth of Massachusetts STANDARD CERTIFICATE OF DEATH
Somerville
(City or town)
1 PLACE OF DEATH
County Middlesex
State Massachusetts
Registered No.384
Township
or Village.
or
City.
......
Somerville
No
Somerville Contagious St., Ward
(If death occurred in a hospital or institution, give its NAME instead of street and number)
2 FULL NAME
Elmore Robertson
St., ... Ward. Winthron, Mass.
(a) Residence. No. 36 Marshall
(Usual place of abode)
Length of residence in city or town wbere death occurred
years
months
days.
How long in U. S., if of foreign birth ?
years
months
days
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
3 SEX
Female
4 COLOR OR RACE
White
5 SINGLE, MARRIED, WIDOWED, OR
DIVORCED (write the word)
Single
5a If married, widowed, or divorced
HUSBAND of
(or ) WIFE of
-
6 DATE OF BIRTH (month, day, and year)
April 2, 1895
7 AGE Years
Months
Days
13
If LESS than 1 day, ........ hrs. or ........ min.
8 OCCUPATION OF DECEASED
(a) Trade, profession, or
particular kind of work
Nurse
(b) General nature of iodustry, business, or establishment in which employed (or employer) (c) Name of employer
9 BIRTHPLACE (city or town). (State or country) Lockport, N. S.
10 NAME OF FATHER Charles Robertson
PARENTS
11 BIRTHPLACE OF FATHER (city or town)
(State or country) P. E. I.
12 MAIDEN NAME OF MOTHER Elmore Decker
13 BIRTHPLACE OF MOTHER (city or town) (State or country) Black Point, I. S.
14
Staniny Robertson,
Informant
43 Medhill Avo.
(Address) Winthrop
Lass EM. Cool
15
Filed.
Apr. 16, 19 78Frederic
REGISTRAR
19 PLACE OF BURIAL, CREMATION, OR REMOVAL Lockport, N. S.
DATE OF BURIAL Apr. 16 19 18
20 UNDERTAKER D. Fudge & Son,
ADDRESS
omnorville
Mass.
N. B. - WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD. Every item of information should be so that it may be properly classified. Exact statement of OCCUPATION is very important. See instructions on back carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state CAUSE OF DEATH in plain terms,
of certificate.
16 DATE OF DEATH (month, day, and year) April 15, 19 18
., 19. Anr. 15. 18 17 I HEREBY CERTIFY, That I attended deceased from Feb. 15, 191.8 to
that I last saw her ... alive on Apr. 14, .19 18
and that death occurred, on the date stated above, at 4.45 A.
The CAUSE OF DEATH* was as follows :
Pulmonary tuberculosis
(duration)
.. yrs .............. mos ............ ds.
CONTRIBUTORY
(SECONDARY)
(duration) ............ yrs ................. mos ..... ds.
18 Where was disease contracted
if not at place of death ?
Did an operation precede death ? Date of.
Was there an autopsy ?
Wbat test confirmed diagnosis ?
(Signed).
C. Clarke Torle,
M.D.
715, 1918(Address) 24 Prospect Hill Ave. , Som.
* State the DISEASE CAUSING DEATH, or in deaths from VIOLENT CAUSES, state (1) MEANS AND NATURE OF INJURY, and (2) whether ACCIDENTAL, SUICIDAL, or HOMICIDAL. (See reverse side for additional space.)
=
23
(If non-resident give city or town and State)
Hospital
[Approved by U. S. Census and American Public Health Association]
Statement of occupation. -- Preise statement of occupa- tion is very important, so that the relative healthfulness of various pursuits ean 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, Compos- itor, Architect, Locomotive engineer, Civil engineer, Stationary fircman, ete. 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) Salesman, (b) Grocery; (a) Foreman, (b) Automobile factory. The ma- terial worked on may form part of the second statement. Never return "Laborer," "Foreman," "Manager," "Dealer," ete., without more precise specifieation, as Day laborer, Farm laborcr, Laborer - Coal mine, etc. Women at home, who are engaged in the duties of the household only (not paid Housekeepers who receive a definite salary), may be entered as Housewife, Housework, or At home, and children, not gainfully employed, as At school or At home. Care should be taken to report spe- eifically the occupations of persons engaged in domestic service for wages, as Servant, Cook, Housemaid, ete. 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 faet may be indi- eated thus: Farmer (retired, 6 yrs.). For persons who have no oceupation whatever, write None.
Statement of cause of death. - Name, first, the DISEASE CAUSING DEATH (the primary affection with respect to time and eausation), using always the same accepted term for the same disease. Examples: Cerebrospinal fever (the only definite synonym is "Epidemie cerebrospinal inenin- gitis"); Diphtheria (avoid use of "Croup"); Typhoul fevcr (never report "Typhoid pneumonia"); Lobar pneumonia; Bronchopneumonia ("Pneumonia," unquali- fied, is indefinite); Tuberculosis of lungs, meninges, peri- toneum, ete., Carcinoma, Sarcoma, ete., of _.
(name origin; "Caneer" is less definite; avoid use of "Tumor" for malignant neoplasms); Measles; Whooping cough; Chronic valvular heart disease; Chronic interstitial nephritis, ete. The contributory (secondary or inter- current) affection need not be stated unless important. Example: Measles (discase eausing death), 29 ds .; Broncho- pneumonia (secondary), 10 ds. Never report mere symp- toms or terminal conditions, such as "Asthenia,"
"Anemia" (merely symptomatie), "Atrophy," "Col- lapse," "Coma," "Convulsions,"" "Debility" ("Con-
genital," "Senile," ete.), "Dropsy," "Exhaustion," "Heart failure," "Hemorrhage," "Inanition," "Maras- inus," "Old age," "Shoek," "Uremia," "Weakness," etc., when a definite disease ean be ascertained as the cause. Always qualify all diseases resulting from ehild- birth or miscarriage, as "PUERPERAL septicemia," "PUER- PERAL peritonitis," etc. State eause for which surgical operation was undertaken. For VIOLENT DEATHS STATE MEANS OF INJURY and qualify as ACCIDENTAL, SUICIDAL, or HOMICIDAL, or as probably such, if impossible to de- termine 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." (Recommendations on statement of cause of death approved by Committee on Nomenclature of the American Medical Association.)
Cases for the Medical Examiners. - Under the provi- sions 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 eaused by violence, as Criminal abortion, Poisoning, Starvation, Suffocation, Exposure, 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 eircumstanees unknown, as A person found dead, ete.
ADDITIONAL SPACE
FOR FURTHER STATEMENTS BY
PHYSICIAN.
R 15. 1-'18. 10,000.
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
WINThrop
(City or town)
1 PLACE OF DEATH
County.
Township
or Village
New Worldher Holal Stingus
St., .Ward
(If death occurred in a hospital or institution, give its NAME instead of street and number)
2 FULL NAME
Roxana Chapman
(a) Residence.
No.
(Usual place of abode)
Length of residence in city or town wbere death occurred
years
months
days.
How Inng in U. S., if of foreign birtb ?
years
months
days
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
female
4 COLOR OR RACE
white
5 SINGLE, MARRIED, WIDOWED, OR
DIVORCED (write the word)
mans
5a If mawiod, widowed os divor to
HUSBAND Of
(or) WIFE of
Wife of Melvin
A Chapman
6 DATE OF BIRTH (month, day, and year)
Left : 1839
7 AGE
Years 18
Months
7
Days
16
8 OCCUPATION OF DECEASED
(a) Trade, profession, or particular kind of work
(b) General nature of industry, business, or establishment in which employed (or employer) (c) Name of employer
9 BIRTHPLACE (city or town)
Cavendish
(State or country)
10 NAME OF FATHER Elijah Bemis
PARENTS
11 BIRTHPLACE OF FATHER (city or town)
(State or country)
12 MAIDEN NAME OF MOTHER Linken
13 BIRTHPLACE OF MOTHER (city or town) ..
(State or country)
14
Informant San Delini Chafinna IR
(Address)
15
Filed. , 19 ! 8.
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH (month, day, and year) abril 17
1915
17 I HEREBY CERTIFY, That I attended deceased from april 8 1918 aprilis 19. to
that I last saw ha alive on
1928.
and that death occurred, on the date stated above, at A m. The CAUSE OF DEATH* was as follows :
If LESS than 1 day, ........ hrs. or ........ min. Cerebral vacombase
(duration)
yrs.
mos ....
ds.
CONTRIBUTORY
interior recensies
(SECONDARY)
(duration)
......
... yrs.
.......
mos.
ds.
18 Where was disease contracted if not at place of death ?
Did an operation precede death ? Date of.
Was there an autopsy ?
0
What test confirmed diagnosis ?
(Signed
Charles 7. mationen
M.D.
/2, 1918 (Address) 8 13, walker, it.
* State the DISEASE CAUSING DEATH, or in deaths from VIOLENT CAUSES, state (1) MEANS AND NATURE OF INJURY, and (2) whether ACCIDENTAL, SUICIDAL, or HOMICIDAL. (See reverse side for additional space.)
19 PLACE OF BURIAL, CREMATION, OR REMOVAL
DATE OF BURIAL
4/19
1960
20 UNDERTAKER
ADDRESS
of certificate.
N. B .- WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD. Every item of information should be so that it may be properly classified. Exact statement of OCCUPATION is very important. See instructions on back carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state CAUSE OF DEATH in plain terms,
City ...........
No ..
State
Mars
Registered No ...
or
(If non-resident give city or town and State)
[Approved by U. S. Census and American Public Health Association]
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, Compos- itor, Architcet, Locomotive 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) Salesman, (b) Grocery; (a) Foreman, (b) Automobile factory. The ma- terial 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 Housekeepers who receive a definite salary), may be entered as Housewife, Housework, or At home, and children, not gainfully employed, as At school or At home. Care should be taken to report spe- cifically 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 indi- cated 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 discasc. Examples: Cerebrospinal fever (the only definite synonym is "Epidemic cerebrospinal inenin- gitis"); Diphtheria (avoid use of "Croup"); Typhoid fever (never report "Typhoid pneumonia"); Lobar pneumonia; Bronchopneumonia ("Pneumonia," unquali- fied, is indefinite); Tuberculosis of lungs, meninges, peri- toncum, etc., Carcinoma, Sarcoma, etc., of _.
(name origin; "Cancer" is less definite; avoid use of "Tumor" for malignant neoplasms); Measles; Whooping cough; Chronic valvular heart disease; Chronie interstitial nephritis, etc. The contributory (secondary or inter- current) affection need not be stated unless important. Example: Measles (disease causing death), 29 ds .; Broncho- pneumonia (secondary), 10 ds. Never report mere symp- toins or terininal conditions, such as "Asthenia," "Anemia" (increly symptomatic), "Atrophy," "Col- lapse," "Comna," "Convulsions,"" "Debility" (“Con- genital," "Senile," etc.), "Dropsy," "Exhaustion," "Heart failure," "Hemorrhage," "Inanition," "Maras- inus," "Old age," "Shock," "Uremia," "Weakness," etc., when a definite disease can be ascertained as the cause. Always qualify all diseases resulting from child- birth or miscarriage, as "PUERPERAL septicemia," "PUER- PERAL peritonitis," etc. State cause for which surgical operation was undertaken. For VIOLENT DEATHS STATE MEANS OF INJURY and qualify as ACCIDENTAL, SUICIDAL, or HOMICIDAL, or as probably such, if impossible to de- termine 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." (Recommendations on statement of cause of death approved by Committee on Nomenclature of the American Medical Association.)
Casas for the Medical Examiners. - Under the provi- sions 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, Exposure, 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.
ADDITIONAL SPACE FOR FURTHER STATEMENTS BY
PHYSICIAN.
R 15. 1-'18. 100,000.
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH
County.
Whatfolk
Township
City
or Village. No. 11 almont St Wuccles
Ward
(If death occurred in a hospital or institution, give its NAME instead of street and number)
2 FULL NAME
Bemjimai Lencoen Macherosos
(a) Residence.
No.
11 almont St
St.,
.Ward.
(If non-resident give city or town and State)
mooths days
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
male
4 COLOR OR RACE
5 SINGLE, MARRIED, WIDOWED, OR
DIVORCED (write the word)
5a If married, widowed, or divorced
HUSBAND of
(or) WIFE of
6 DATE OF BIRTH (month, day, and year) July 29-1917
7 AGE
Years
Months
Days
X8 21
If LESS than I day, ........ hrs. or ........ min.
8 OCCUPATION OF DECEASED
(a) Trade, profession, or particular kind of work ..
(b) General nature of indostry. business, or establishment in which employed (or employer) (c) Name of employer
9 BIRTHPLACE (city or town) (State or country) mans
10 NAME OF FATHER James. I.
PARENTS
11 BIRTHPLACE OF FATHER (city or town)
(State or country)
12 MAIDEN NAME OF MOTHER Care. E. Milliteen
13 BIRTHPLACE OF MOTHER (eity or town) (State or country)
14
Informant Jaime, . E. Mathewian
(Address)
# 11 allenbe Sa
15 Filed
............. ., 19
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH (month, day, and year) Cfr. 18 19 18
17
I HEREBY CERTIFY, That I attended deceased from
ajan.
1
4
1918
isr. 18
19 .. 1.x .
to.
that I last saw h ...
alive on
18
1918.
and that death occurred, on the date stated above, at
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