USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1916-1918 > Part 107
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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- posure, 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. 1
4. Deathis under circumstances unknown, as A person found dead, etc.
R 16. 10-'17. 10,000.
City. 3 SEX 7 AGE Ycars 74 (State or country) PARENTS 14 (Address) 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. 15 N. B .- WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD. Every item of information should be (h) General nature of industry, business, or establishment in which employed (or employer) (c) Name of employer
The Commonwealth of Massachusetts STANDARD CERTIFICATE OF DEATH
Winthrop (City or town)
1 PLACE OF DEATH
County
ruffolk
Township
Winthrop
or Village.
or
St., Ward
(If death occurred in a hospital or institution, give its NAME instead of street and number)
2 FULL NAME
Mary &
Bussen
(a) Residence.
No 24 Temple Ave
(Usual place of abfode)
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
Female White
5 SINGLE, MARRIED, WIDOWED, OR
DIVORCED (write the word)
Widowed
5a If married, widowed, or divorced
HUSBAND of
(or) WIFE of
La. Bussen
6 DATE OF BIRTH (month, day, and year) Abril 1-1844
Months
Days
If LESS than 1 day, ........ hrs. or ........ min.
8 OCCUPATION OF DECEASED
(a) Trade, profession, or
particular kind of work
Ar bone
9 BIRTHPLACE (city or town)
Boston Masz
10 NAME OF FATHER Peter furlong
11 BIRTHPLACE OF FATHER (city or town)
(State or country)
Denmark
12 MAIDEN NAME OF MOTHER aun Deveraux
13 BIRTHPLACE OF MOTHER (city or town)
(State or country)
Ireland
MEDICAL CERTIFICATE OF DEATH
19 / &. 16 DATE OF DEATH (month, day, and year) 2017.12
17 I HEREBY CERTIFY, That I attended deceased from
19.00
15
May 12.
19 ......
to,4 ....
that I last saw halive on
1965.
and that death occurred, on the date stated above, at
m. The CAUSE OF DEATH* was as follows :
Cerebral Hemorokager
.(duration)
.yrs .....
mos .. ... ..
ds.
CONTRIBUTORY
(SECONDARY
Lady
(duration)
yrs. .
.. mos.
ds.
18 Where was disease contracted
if not at place of death?
Did an operation precede death ?
xd. Date of
Was there an autopsy ?
Cliccal.
What test confirmed diagnosis ?
(Signed)
O19 /&(Address)
Теперьоф Тал,
I.I.D.
* State the DISEASE CAUSING DEATH, or in deaths from VIOLENT CAUSES, state (I) 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 Holywood leamethy june 5 105
20 UNDERTAKER
E.G. Brown Kon"
ADDRESS Each Boston
1
Informant
Mr. George Bussey
Filed 19
REGISTRAR
State
.........
Registered No ..
No.
St.,
Ward.
(If non-resident give city or town and State)
2
[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, c. 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 ina- 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 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- 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; 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" (merely symptomatic), "Atrophy," "Col-
lapse," "Coma," "Convulsions,"""Debility" (“Con- genital," "Senile," cte.), "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," ctc. 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
Chelsea
(City or town)
1 PLACE OF DEATH
County
Suffolk
State
pass.
Registered No.
450
Township
or Village.
or
City
Chelsea
No.
Frost Hospital
St ...
.Ward
(If death occurred in a hospital or institution, give its NAME instead of street and number)
2 FULL NAME
Richard Thore s
(a) Residence. No.
121 Court Road
St.,
.Ward.
Wint hrop, lass.
(If non-resident give eity or town and State)
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
MEDICAL CERTIFICATE OF DEATH
3 SEX
Lu le
4 COLOR OR RACE
White
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)
Dec.15. 1840
7 AGE
Years
Months
Days
If LESS than 1 day, ........ hrs. or ....... min.
8 OCCUPATION OF DECEASED
(a) Trade, profession, or
particular kind of work
None
(b) General nature of industry,
business, or establishment in
which employed (or employer)
(c) Name of employer
9 BIRTHPLACE (city or town).
Nova Scotia
(State or country)
10 NAME OF FATHER
John Thomas
11 BIRTHPLACE OF FATHER (city or town)
(State or country)
Nova Scotia
12 MAIDEN NAME OF MOTHER Unknown
13 BIRTHPLACE OF MOTHER (eity or town)
(State or country)
Nova Scotia
14
Informant
Hr.I. O .Thoras
(Address) winthrop, 1288.
15 Filed une 19. 1918.
REGISTRAR
(duration)
yrs.
mos ..
ds.
CONTRIBUTORY
icute Retention Prostatitis
(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) .... Doran.
6/ 1191 &Address)
69( Proadi V
M.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 Lass. Cremator
DATE OF BURIAL June 21 ,38
20 UNDERTAKER 5.3.Waterman & Sons
ADDRESS
Roxbury
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.
74
--
16 DATE OF DEATH (month, day, and year)
June 19
1918
17
I HEREBY CERTIFY, That I attended deceased from
June 12
1918, to
June 19
191.8
that I last saw h
alive on
June 18
1918
and that death occurred, on the date stated above, at
5.70
2 .m.
The CAUSE OF DEATH* was as follows :
Uremia
PARENTS
(Usual place of abode)
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 inany cases, especially in industrial cinployments, 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 inay 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 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 lave 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 ouly definite synonym is "Epidemie cerebrospinal inenin- 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- toneum, etc., Carcinoma, Sarcoma, etc., of ...
(name origin; "Cancer" is less definite; avoid use of "Tumor" for malignant neoplasms); Mcasles; Whooping cough; Chronic valvular heart disease; Chronic interstitial nephritis, etc. The contributory (secondary or inter- current) affection need not be stated unless important. Example: Mcasles (discase causing death), 29 ds .; Broncho- pneumonia (secondary), 10 ds. Never report mere symp- toms or terininal conditions, such as "Asthenia." "Ancmia" (inercly 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 discases resulting from child- birth or iniscarriage, as "PUERPERAL septicemia," "PUER- PERAL peritonitis," ctc. 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 dc- 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 (c. g., sepsis, tetanus) may be stated
on statement of cause of death approved by Committee on Nomenclature of the American Medical Association.)
Cases for the Medical Examiners. - Under tlie 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. 10,000.
COMMONWEALTH OF MASSACHUSETTS
RETURN OF A DEATH-1918.
CITY OF BOSTON
FULL NAME
WILLIAM B. FLOYD
Registered No. 6515
Place of Death l and Residence
Boston
BOSTON HARBOR (LONG ISLAND)
82
1918, Åge
years months days.
STATISTICAL DETAILS.
SEX.
COLOR.
SINGLE, MARRIED, WID., DIV.
M
3
3
Maiden Name
Husband's Name
WINTHROP
Birthplace
Name of Father
THOMAS FLOYD
Birthplace of Father
-
Contributory : (Duration ) -
Maiden Name of Mother
- --
Birthplace of Mother
Occupation SEA CAPT. (RETIRED)
Informant
PHYSICIAN'S CERTIFICATE.
I HEREBY CERTIFY that I attended deceased during last illness, from 1918, to
1918, 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:
STRAR
T PATRIBUS ..
Primary ( Duration
SOBIS A
OFFICE
BOSTDNIA
VIT
CONDITA A.
SREGIMINE DONATA A 16 80.
T
ON. MASS.
(Signed)
G.B.MAGRATH MED.EX.
M.D
JUNE 20 1918
SPECIAL INFORMATION from Hospitals, Institutions, Transients, or Recent Residents.
1
Place of Burial
or removal
WINTHROP (WINTHROP CEM)
W.C. SKAGGS
Undertaker
WINTHROP
WINTHROP ( PLEASANT ST)
Usual Residence
JUNE 24
Filed A true copy. Attest :
1918.
Registrar.
DROWNING-UNDER CIRCUMSTANCES UNKNOWN
CITY
C.
Date of Death JUNE 19
June 19, 1918.
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
Mintloh .......
(City or town)
1 PLACE OF DEATH
County ..
Vultolle
Township
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.
45 demon
St.,.
.Ward.
(Usual place of abode)
Length of residence in city or town where death occorred
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
(01) WIFE of Annie F Stanton
6 DATE OF BIRTH (month, day, and year)
1859
7 AGE
Ycars
Months
Days
If LESS than 1 day, ........ hrs. or ........ min.
8 OCCUPATION OF DECEASED
(a) Trade, profession, or
particular kind of work
master Jeamster
(b) General nature of industry, bosiness, or establishment in which employed (or employer) (c) Name of employer
9 BIRTHPLACE (city or town)
Boston
(State or country)
mass
10 NAME OF FATHER Patrick
PARENTS
12 MAIDEN NAME OF MOTHER margaret, Corcoran
13 BIRTHPLACE OF MOTHER (city of town)
(State or country)
14 (annie) Inato. B
Informant
(Address)
1.5Nouvion St
15
Filed , 19
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH (month, day, and year) trong 2 0
19
17 I HEREBY CERTIFY, That I attended deceased from r
1968
1 19 .......
that I last saw ho alive on
f= == 15
19
and that death occurred, on the date stated above, at fr m. The CAUSE OF DEATH* was as follows :
2
intero
(duration)
. yrs .....
... mos ..
ds.
CONTRIBUTORY
Comme En bocadito
(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 ? 1
What test confirmed diagnosis ?
(Signed).
€
M.I.D.
1 2, 19 8 (Address) 36
* 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
Stoly lever maldau
DATE OF BURIAL June 23 19/ 5
-
ADDRESS
20 UNDERTAKER
John F.B. maley
so that it may be properly classified. Exact statement of OCCUPATION is very important. See instructions on back
of certificate.
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,
State
Registered "NO .......
or Village
or
City William Edward malone
(If non-resident give city or town and State)
59
11 BIRTHPLACE OF FATHER (city or town).
(State or country)
Ireland
Ireland
1
[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 ean be known. The question applies to each and every person, irrespective of age. For inany occupations a single word or terin 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 needed. As examples: (a) Spinner, (b) Cotton mill; (a) Salesman, (b) Grocery; (a) Forcman, (b) Automobile factory. The ina- 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 minc, 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 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- 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; Chronic interstitial nephritis, etc. The contributory (secondary or inter- current) affection need not be stated unless important. Example: Measles (disease causing death), 29 ds .; Broneho- pneumonia (secondary), 10 ds. Never report mere symp- 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 carbolic acid - probably suicide. The nature of the injury, as fracture of skull, and consequences (e. g., sepsis, tetanus) may be stated
(Recommendations under the head of "Contributory." on statement of eause of death approved by Committee on Nomenclature of the American Medical Association.)
Casas for the Medicai 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 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.
County City 3 SEX timale 7 AGE (a) Trade, profession, or particular kind of work (State or country) PARENTS 14 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. 15 N. B .- WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD. Every item of information should be 81
The Commonwealth of Massachusetts STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH
Township Winthrop
or Village or
No.
St., Ward
(If death occurred in a hospital or institution, give its NAME instead of street and number)
2 FULL NAME Harriet J. Remington
. (a) Residence. No. 144 Young Rd
t.,
.Ward.
(If non-resident give eity or town and Statc)
Length of resideoce in city or town where death occorred
mooths
days.
How long io U. S., if of foreigo birth ?
years
months
days
PERSONAL AND STATISTICAL PARTICULARS
4 COLOR OR RACE White
5 SINGLE, MARRIED, WIDOWED, OR
DIVORCED (write the word)
dos e.l
5a If married, widowed, or divorced HUSBAND of (or) WIFE of
6 DATE OF BIRTH (month, day, and year)
July 0-1836
Years
Months
11
1
If LESS than 1 day, ........ hrs. or ........ min.
8 OCCUPATION OF DECEASED
(h) Geoeraloature of iodostry, business, or establishment io which employed (or employer) (c) Name of employer
9 BIRTHPLACE (city or town)
Hartford Clown
10 NAME OF FATHER Ireithe Garrett
11 BIRTHPLACE OF FATHER (city or town)
(State or country) E minafield lass 12 MAIDEN NAME OF MOTHER Ludia Gorreto
13 BIRTHPLACE OF MOTHER (city or town)1 .. (State or country) Inringfield Mase
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