USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1916-1918 > Part 105
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tiendations 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 due to Alcoholism, etc.
4. Deaths under circumstances unknown, as A person found dead, etc.
ADDITIONAL SPACE
FOR FURTHER STATEMENTS BY PHYSICIAN.
R 15. 2-'18. 100,000.
2 FULL NAME 3 SEX 7 AGE Years 17 PARENTS 14 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. 15 N. B. - WRITE PLAINLY, WITH UNFADING INK -THIS IS A PERMANENT RECORD. Every item of information should be (h) Genera I nature of industry, business, or establishment in which employed (or employer) (c) Name of employer
The Commonwealth of Massachusetts STANDARD CERTIFICATE OF DEATH
(City or town)
1 PLACE OF DEATH
County
Township For winMo
State
Registered No .....
or Village
or
(If death occurred in a hospital or institution, give its NAME instead of street and number)
Elizabeth Kohel Littleton
(a) Residence. No.
(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
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) Jan 22-192
Months
Days
4
If LESS than I day, ........ hrs. or ........ min.
8 OCCUPATION OF DECEASED
(a) Trade, profession, or particular kind of work Schval
9 BIRTHPLACE (city or town).
(State or country)
10 NAME OF FATHER
11 BIRTHPLACE OF FATHER (city or town)
(State or country)
12 MAIDEN NAME OF MOTHERK
13 BIRTHPLACE OF MOTHER (city er Lowde
(State or country)
Informant Stephen Littleton
(Address) 4 arcuit Rd.
Filed ,19
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH (month, day, and year) May 2>
1918
17
I HEREBY CERTIFY, That I attended deceased from
april 25, 1918
thay 2)
,19/5
that I last saw hez alive on
May 27
1918
and that death occurred, on the date stated above, at 2.a. .m. The CAUSE OF DEATH* was as follows :
acuta endocarditis with insuf.
ficiency of the Mitral valve cause
by acute articular Rheumatism
(duration)
..... yr's ...
1
.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 ?
(Signe chodestino edcone
M.D.
5/28/1918 (Address) 419 Havevat Borton Illans
* State the DISEASE CAUSING DEATII, 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
Ilino Com. PT
DATE OF BURIAL UM15/29 19 /8.
20 UNDERTAKER
WEDADDRESS
City No.
St., Ward
St.,
Ward.
(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, Architeet, 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 necded. 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- catcd 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: Cerebrospinal fever (the only definite synonym is "Epidemic cerebrospinal menin- gitis"); Diphtheria (avoid use of "Croup"); Typhoid fever (never report "Typhoid pneumonia"); Lobar pneumonia; Bronchopneumonia ("Pneumonia," unquali- ficd, is indefinitc); 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; Chronic 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 syınp- toms or terminal conditions, such as "Asthenia," "Anemia" (merely 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," 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 earbolic 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.
carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state CAUSE OF DEATH in plain terms, so that it may be properly classifled. Exact statement of OCCUPATION is very important. See instructions on back
of certificate.
14
Informant Lousia V Hogan
(Add 325 WanttrosOK
15
Filed
........... , 19
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
3 SEX
male
4 COLOR OR RACE
White
5 SINGLE, MARRIED, WIDOWED, OR DIVORCED (write the word) Married.
5a If married, widowed, or divorced HUSBAND of (ot) WIFE of Lougia V. Hogyan
6 DATE OF BIRTH (month, day, and year)
1866
7 AGE Years
52
Months
Days
If LESS than 1 day, ........ hrs. or ........ min.
8 OCCUPATION OF DECEASED
(a) Trade, profession, or
particular kind of work
Taylor
(b) General nature of industry,
business, or establishment in
which employed (or employer).
(c) Name of employer
Inspector of Clothing
U. S. Government
9 BIRTHPLACE (city or town)
East Boston
(State or country)
mass
10 NAME OF FATHER Roger Hogan
PARENTS
11 BIRTHPLACE OF FATHER (eity or town). -
(State or country) Ireland
12 MAIDEN NAME OF MOTHER Ann Haley
13 BIRTHPLACE OF MOTHER (eity or town) .......
(State or country) Preland
* 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 Holy Cross, Walden, June 2 :10
20 UNDERTAKER ADDRESS M. r. Kellys 11 Meridian Sh
BOSTON (City or town)
1 PLACE OF DEATH
County
Suffolk
State
Massachusetts
Registered No.
Township
Winthrop
or Village.
or
City BOSTON
No. 325 ....
Winthrop St., Ward
(If death occurred in a hospital or institution, give its NAME instead of street and number)
2 FULL NAME
John Williams ogan
(a) Residence. No. 325 Winthrop
St.,
.Ward.
(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
16 DATE OF DEATH (month, day, and year) hwan 30 1918
17
I HEREBY CERTIFY, That I attended deceased from
., 19 ....
19
.....
that I last saw h mmm
alive on
.19
and that death occurred, on the date stated above, at
m. The CAUSE OF DEATH* was as follows : Cachal Hemmings
.(duration)
.......... yrs ................. mos ................ ds.
CONTRIBUTORY
Peterio accursio
(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 ?
(Signed)
Charles 7. mahner
M.D.
530, 1918 (Address) 3 56, Umthat it
FOR WHAT ?
0.
V
(If non-resident give eity or town and State)
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
[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 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, Compos- itor, Architeet, Locomotive cngincer, 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 statenient; it should be used only when needed. As examples: (a) Spinner, (b) Cotton mill; (a) Salesman, (b) Groecry; (a) Forcman, (b) Automobilc 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 houschold 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 domestie service for wages, as Servant, Cook, Housemaid, ctc. It the occupation has been changed or given up on account of the DISEASE CAUSING DEATII, 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. - Naine, 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 menin- gitis"); Diphtheria (avoid use of "Croup"); Typhoid fevcr (never report "Typhoid pneumonia"); Lobar pneumonia; Bronchopneumonia ("Pneumonia," unquali- fied, is indefinite); Tuberculosis of lungs, meningcs, peri- toneum, etc., Carcinoma, Sarcoma, etc., of __.
(name origin; "Cancer" is less definite; avoid use of "Tumor" for malignant neoplasms); Measles; Whooping cough; Chronic valvular hcart discasc; Chronic interstitial nephritis, etc. The contributory (secondary or inter- current) affection necd not be stated unless important. Example: Mcasles (disease causing death), 29 &s .; Broncho- pneumonia (secondary), 10 ds. Never report mere symp- toins or terminal conditions, such as "Asthenia," "Anemia" (merely 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 septiecmia," "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 suicidc. 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 Crimina. abortion, Poisoning, Starvation, Suffocation, Exposure, etc.
3. Sudden deaths of persons not disabled by recognized disease, 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.
ADDITIONAL SPACE
FOR FURTHER STATEMENTS BY
PHYSICIAN.
R 15. 2~'18. 100,000.
The Commonwealth of Massachusetts STANDARD CERTIFICATE OF DEATH
(City or town)
1 PLACE OF DEATH
County ..
Suffolk
State
Mass.
Registered No.
Township
.or Village
30 Waldemar Ave.
St.,
Ward
(If death occurred in a hospital or institution, give its NAME instead of street and number)
2 FULL NAME
"alter ..... E.Albertson
(a) Residence.
No.
3p Waldemar Ave.
St.,
.Ward.
(If non-resident give city or town and State)
Length of residence in city or town wbere death occurred
5
years
months
days.
How long in U. S., if of foreign birth ?
years
months
days
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
Male
4 COLOR OR RACE
White
5 SINGLE, MARRIED, WIDOWED, OR
DIVORCED (write the word)
Married
5a If married, widowed, or divorced
HUSBAND of
(or) WIFE of
Elsie Albertson
6 DATE OF BIRTH (month, day, and year)
June 9,1875
7 AGE
42
Ycars
Months
Days
If LESS than
1 day, ........ brs.
or ........ min.
8 OCCUPATION OF DECEASED
(a) Trade, profession, or
particular kind of work
Paint Salesman
(b) General nature of industry,
High St.Boston,
business, or establishment in
which employed (or employer)
(c) Name of employer
Wilhelm Dexter Co.
9 BIRTHPLACE (city or town) ...
Fast Boston, Mass.
(State or country)
10 NAME OF FATHER William H. Albertson
PARENTS
11 BIRTHPLACE OF FATHER (city or town)
E.Boston
(State or country)
Lass.
(Signed)
I.D.
6/3. 19/8 (Address)
Penne Muse 1
* State the DISEASE CAUSING DEATII, 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
6-4-18
19
ADDRESS
15 Filed ., 19
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH (month, day, and year) June 1 . 18 19
17
I HEREBY CERTIFY, That I attended deceased from
nov
20
1917.
18
19.
that I last saw hm
alive on
18.
and that death occurred, on the date stated above, at
5P
m.
The CAUSE OF DEATH* was as follows:
1
Crema Porsonny
(duration)
yrs.
....
... mos.
10 ds.
CONTRIBUTORY
Clure. Referentes.
.
(duration)
26
.. yrs ...
.. mos. ds.
18 /Where was disease contracted if not at place of death?
Did an operation precede death?
.... Date of.
Nov 1917
Was there an autopsy ?.
What test confirmed diagnosis?
12 MAIDEN NAME OF MOTHER Annie O.Casco 13 BIRTHPLACE OF MOTHER (city or town) Boston (State or country)
14 Mrs.Elsie Albertson
Informant
(Address)
30 Valdemar Ave inthron
Hale St. Cem. Beverly, Mass
20 UNDERTAKER
W.C. Skaggs
00
N. B. - WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD. Every item of information should be
carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state CAUSE OF DEATH in plain terms,
of certificate.
so that it may be properly classified. Exact statement of OCCUPATION is very important. See instructions on back
. or
City.
winthrop
No ..
(Usual place of abode)
11
21
[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 terin 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," ete., without more precise specification, as Day laborer, Farm laborer, Laborer - Coal mine, etc. Women at home, who are engaged in the duties of the houschold only (not paid Housekeepers who reccive 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, 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 eausation), using always the saine 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- fied, is indefinite); Tuberculosis of lungs, meninges, peri- toneum, 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; Chronic 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- toms or terminal conditions, such as "Asthenia," "Anemia" (mcrely symptomatic), "Atrophy," "Col-
," "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," etc. State cause for whichi 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
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, ctc.
3. Sudden deaths of persons not disabled by recognized disease, 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.
ADDITIONAL SPACE
FOR FURTHER STATEMENTS BY
PHYSICIAN.
R 15. 1-'18. 100,000.
The Commonwealth of Massachusetts STANDARD CERTIFICATE OF DEATH
Winthrop (City or town)
1 PLACE OF DEATH County
State
mass
Registered No ..
Township
Village
or
No.
St., Ward
(If death occurred in a hospital or institution, give its NAME instead of street and number)
2 FULL NAME
(a) Residence.
No.
IL REVENU
St.,
.Ward.
(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
Female White
5 SINGLE, MARRIED, WIDOWED, OR
DIVORCED .(write the word)
Vinale
5a If married, widowed, or divorced
HUSBAND of
(01) WIFE of
6 DATE OF BIRTH (month, day, and year)
7 AGE
Years
Months
In June 2
If LESS than I day, ..... hrs. pr ....... min.
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
Winthrop
9 BIRTHPLACE (city or town).
(State or country)
masa
10 NAME OF FATHER
PARENTS
11 BIRTHPLACE OF FATHER (city or town)
newkedfra What test confirmed diagnosis ?
(State or country)
maise
12 MAIDEN NAME OF MOTHER
Susan Christ, 1 6/2,1916 (Adress) 352 Pinchabest Lerdans
13 BIRTHPLACE OF MOTHER (city or town)
(State or country)
mass
14
Informant Oma Chinelother
(Address)
11 (ever St
15 Filed
19
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH (month, day, and year) June 2 196
17 I HEREBY CERTIFY, That I attended deceased from 2 19 ..
N , 19 .. 18.
that I last saw h ........____ alive on .19
2
and that death occurred, on the date stated above, at m. The CAUSE OF DEATH* was as follows : Premature
(duration)
.yrs ......
mos .....
. ds.
CONTRIBUTORY
(SECONDARY)
(duration)
yrs ....
18 Where was disease contracted
if not at place of death ?
Did an operation precede death ?
Date of
Was there an autopsy ?.
(Signed)
Charles 7. Mahoney
., M.I.D.
* 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
holy cross maiden
DATE OF BURIAL
6/3
19
20 UNDERTAKER them Cro Ci ally
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,
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