USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1916-1918 > Part 108
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Informant The Grave
(Address) 1 +4 Aring Rd With
Filed ,19
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH (month, day, and year) feche 229 1918.
17 I HEREBY CERTIFY, That I attended deceased from March 1 18
to .........
Scene 22- 1918.
that I last saw h
alive on
, 19.60 .
and that death occurred, on the date stated above, at
SP
m.
The CAUSE OF DEATH* was as follows :
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 ?
no . Date of
Was there an autopsy ?
What test confirmed diagnosis ?
ncf. Partes
(Signed)
I.I.D.
6/2/04/1918 (Address)
* 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 spaee.)
19 PLACE OF BURIAL, CREMATION, OR REMOVAL
Ihring vient iane
DATE OF BURIAL 1225199
20 UNDERTAKER
ADDRESS
×
=
State
Mass
(City or town)
Registered No ..
(Usual place of abode)
[Approved by U. S. Census and American Public Health Association]
Statement of occupation. - Precisc 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 Housewife, Housework, or At home, and children, not gainfully employed, as At school or At home. Care should be taken to report spc- cifically the occupations of persons engaged in domestic service for wages, as Servant, Cook, Housemaid, ctc. 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 .- Namc, 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- toneum, etc., Carcinoma, Sarcoma, etc., of.
(name origin; "Cancer" is less definite; avoid use of "Tumor" for malignant ncoplasms); Measles; Whooping cough; Chronie valvular heart discase; Chronie 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- 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 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 earbolie 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 Committec 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.
COMMONWEALTH OF MASSACHUSETTS
RETURN OF A DEATH-1918.
CITY OF BOSTON
FULL NAME
ABRAHAM COHEN
Registered No. 6571
Place of Death } and Residence
Boston
INFANTS HOSPT.
Date of Death
JUNE 22
1918, Age
years
months 25 days .
STATISTICAL DETAILS.
SEX.
COLOR.
SINGLE, MARRIED, WID., DIV.
M
W
S
Maiden Name
Husband's Name
Birthplace
WINTHROP
Name of Father
JACOB COHEN
Birthplace of Father RUSSIA
Maiden Name of Mother
ROSE LURINSKY
Birthplace of Mother RUSSIA
Occupation
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:
TRAR
R
PA TRIB's Primary Ix (Duration)
CITY
ROBISZ
TYTTA
BOSTONIA CONDITAA
PA A. 1822.
8 TISREGTMINE DONATA 1800.
5
or
N. MASS. Contributory : (Duration)
PYELITIS -- | MO.
HYMAN COHEN
(Signed) M.D
JUNE 22
1918
SPECIAL INFORMATION from Hospitals, Institutions, Transients, or Recent Residents.
Place of Burial
or removal
Undertaker
WOBURN (BETH JOSEPH)
J.STANETSKY
WINTHROP (252 SHIRLEY ST)
Usual Residence
Filed
A true copy.
Attest :
JUNE 25
ErMSlenen
1918.
Registrar.
CEREBRO-SPINAL MENINGITIS -! MO. (COLON BACILLUS INFECTION)
June 22,1918.
COMMONWEALTH OF MASSACHUSETTS
RETURN OF A DEATH-1918. HARRIETT MERRIAM WILBER
CITY OF BOSTON
6662
Registered No.
Place of Death / and Residence (
Boston
JUNE 22
62
1918, Age
years
months 4
days.
STATISTICAL DETAILS.
SEX.
COLOR.
SINGLE, MARRIED, WID., DIV.
F
W
M
Maiden Name
WOODS
Husband's Name
GEORGE W. WILBER
BILLERICA
Birthplace
Name of Father
ORESTES M.WOODS
Birthplace of Father
Maiden Name of Mother
SARAH M. BURROWS
Birthplace of Mother
CHELMSFORD
Occupation
AT HOME
Informant
PHYSICIAN'S CERTIFICATE.
I HEREBY CERTIFY that I attended deceased during last illness,
1918, from 1918, to 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'
R
PATRIBUS Primary $ (Duration)
CITY
BOSTONIA
CONDITAA
1830.
B
MINE DONATA A
S
MASS. Contributory: { (Duration)
CYSTITIS -- 21 DAYS
1.
(Signed)
H.M.POLLOCK M.D
JUNE 22 1918
SPECIAL INFORMATION from Hospitals, Institutions, Transients, or Recent Residents.
Place of Burial
or removal
MASS. CREMATORY
Undertaker S.M.BURROUGHS
WINTHROP(94 COTTAGE AVE)
Usual Residence
Filed
JUNE 29
1918.
A true copy.
Attest :
Registrar.
-
TRANSVERSE MYELITIS - I MO. II DY
OFFICE
1822
FULL NAME
MASS .HOMEO.HOSPT.
Date of Death
June 22, 1918.
(
COMMONWEALTH OF MASSACHUSETTS
RETURN OF A DEATH-1918.
CITY OF BOSTON
FULL NAME
CLARA MORRELO
Registered No. 6673
Place of Death { and Residence
Boston
Date of Death
JUNE 25
1918, Age 31
years 8
months 16
days.
STATISTICAL DETAILS.
SEX.
COLOR
SINGLE, MARRIED, WID., DIV.
F
W
MAR.
Maiden Name
NEWELL
Husband's Name
MICHELE MORRELO
Birthplace
CHELSEA
Name of Father
GEORGE NEWELL
Birthplace of Father
CHERBORN
Maiden Name of Mother
ELLEN
Birthplace of Mother
---
Occupation HOUSEWIFE
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'S
T PATRIBIR
primary! (Duration)
SICUT
OFFICE
3 YRS
CTVITAT
BOSTONIA
CONDITAA
A.1822
BOSTON
Contributory: (Duration)
(Signed) E.H.FERGUSON M.D
1918
SPECIAL INFORMATION from Hospitals, Institutions, Transients, or Recent Residents.
Place of Burial or removal
MALDEN (HOLY CROSS)
Undertaker
C.R.BENNISON
WINTHROP
Usual Residence
WINTHROP (110 BOWDOIN ST)
Filed
A true copy.
Attest :
JUNE 29
ErMSlenen
1918.
Registrar.
CITY RE
TUBERCULOSIS PULMONALIS
REGIMINE DONATA A. MASS. 160.
FREE HOME FOR CONSUMPTIVES
June 25,1918.
The Commonwealth of Massachusetts STANDARD CERTIFICATE OF DEATH
(City or town)
1 PLACE OF DEATH
County NUTCIK
State . a. C
setts
Registered No.
Township
or Village
or
City
nthro.
No.
Prescott
St., ..........
... Ward
(If death oeeurred in a hospital or Institution, give its NAME instead of street and number)
2 FULL NAME
Albert volley Beurs
St.,.
Ward.
(Usual place of abode)
Length of residence in city or town where death occurred
years
1
months
3
days.
How long in U. S., if of foreign hirth ?
years
months
days
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
ale
4 COLOR OR RACE
wait.
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) May 5 1045
7 AGE
Years
Months
73
1
Days 20
If LESS than
1 day, ........ hrs.
or ........ min.
8 OCCUPATION CF DECEASED
(a) Trade, profession, or
particular kind of work.
konl @ tote
(h) General nature of industry,
business, or establishment in
which employed (or employer)
(c) Name of employer
9 BIRTHPLACE (city or town)
Boston
(State or country)
chusetts
10 NAME OF FATHER
11 BIRTHPLACE OF FATHER (city or town) ... Dennis
(State or country)
asrachusetts
12 MAIDEN NAME OF MOTHER
13 BIRTHPLACE OF MOTHER (city or town) ..... roustor (State or country)
14
Informant
Paul
fears
(Address)
22 Prescott It Wintheok
15
Filed .. , 19
REGISTRAR
19 PLACE OF BURIAL, CREMATION, OR REMOVAL
Tras Cremation Society
DATE OF BURIAL
×
20 UNDERTAKER
I. E. Henderson & Coo
ADDRESS
Everest
18
that I last saw
alive on
19
and that death occurred, on the date stated above, at m.
The CAUSE OF DEATH* was as follows :
gunter infanterie, orique walton.
(duration)
yrs.
mos.
4
ds.
CONTRIBUTORY
(SECONDARY)
(duration) kukumars.
.... mos ...
ds.
18 Where was disease contracted
if not at place of death?
35 Phasaut IV.
Did an operation precede death ?
no
Date of
Was there an autopsy ?
no
What test confirmed, diagnosis ?
(Signed)
M.D. Pulpo- 1918 (Address) 2) howmand ant. * 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.)
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,
PARENTS
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH (month, day, and year) делу 2 1918
8
17
I HEREBY CERTIFY, That I attended deceased from
Anna 30
,19/8
to
19
(If non-resident give city or town and State)
(a) Residence.
No ..
ruscott
Statement of occupation. - Precise statement of oceupa- tion is very important, so that the relative healthfulness of various pursuits can be known. The question applies to caeli 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, Architeet, Locomotive engineer, Civil engineer, Stationary fireman, ete. But in many eascs, especially in industrial employments, it is necessary to know (a) the kind of work and also (h) 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) Groecry; (a) Foreman, (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 specifieation, as Day laborer, Farm laborer, Laborer - Coal mine, ete. 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 domestie 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 oeeupation at beginning of illness. If retired from business, that faet inay be indi- cated thus: Farmer (retired, 6 yrs.). For persons who liave no oceupation whatever, write None.
Statement of cause of death .- Name, first, the DISEASE CAUSING DEATH (the primary affeetion with respect to tiine and eausation), using always the same aeeepted 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; Bronehopneumonia ("Pneumonia," unquali- fied, is indefinite); Tuberculosis of lungs, meninges, peri- toneum, etc., 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, etc. The contributory (secondary or inter- current) affeetion need not be stated unless important. Example: Measles (disease eausing death), 29 ds .; Broncho- pneumonia (secondary), 10 ds. Never report mere symp- toms or terminal conditions, such as "Asthenia," "Col- "Anemia" (merely symptomatie), "Atrophy," lapse," "Coma," "Convulsions," "Debility" ("Con-
genital," "Senile," ete.), "Dropsy," "Exhaustion," "Heart failure," "Hemorrhage," "Inanition," "Maras- inus," "Old age," "Shock," "Uremia," "Weakness," etc., when a definite disease ean be aseertained as the cause. Always qualify all diseases resulting from ehild- birth or miscarriage, as "PUERPERAL septicemia," "PUER- P'ERAL 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 head - homicide; Poisoned by carbolic acid - probably suicide. The nature of the injury, as fracture of skull, and consequences (e. g., sepsis, te'anus) may be stated
on statement of eause of death approved by Con on Nomenelature 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 Medieal Examiners:
1. Deaths following injury or violenee, as Burns, Falls, Drowning, Gas poisoning, Suicide, Homicide, ete.
2. Deaths supposedly eaused by violenee, as Criminal abortion, Poisoning, Starvation, Suffocation, Exposure, ete.
3. Sudden deaths of persons not disabled by recognized disease, as A death upon the street, or one supposed to be due to Alcoholism, ete.
4. Deaths under eircumstanees unknown, as A person found dead, ete.
ADDITIONAL SPACE
FOR FURTHER STATEMENTS BY
PHYSICIAN.
R 15. 1-'18. 100,000.
The Commonwealth of Massachusetts
Town of Westfield, Mass
((ity or town)
1 PLACE OF DEATH
County
Hampden
State
Tase.
Registered No
Township
Westfield
City.
No.
,
or Village
State Sanatorium
St.,
.or
Ward
(If death occurred in a hospital or institution, give its NAME instead of street and number)
2 FULL NAME
Francis David Moriarty
(a) Residence.
No ..
41 Washington are . s.
.Ward.
Winthrop. mars.
(Usual place of abodc)
Leogth of resideoce io city or town where death occurred
years
months 5 days.
How loog in U. S., if of foreign birth ? yeark
months
days
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
male
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) July 30, 1902
7 AGE
Years
15
Montha
11
Days
5
If LESS than
1 day, ........ hrs.
or ........ min.
Pulmonary Tuberculosis
8 OCCUPATION OF DECEASED
(a) Trade, profession, or
particular kind of work.
School
(b) General nature of iodustry, business, or establishmeot in which employed (or employer) ....... (c) Name of employer
9 BIRTHPLACE (city or town)
newark
(State or country) Olio
10 NAME OF FATHER George W. Moriarty
11 BIRTHPLACE OF FATHER (city or town).
(State or country)
Comelaville
Pal.
12 MAIDEN NAME OF MOTHER Vanie allen
13 BIRTHPLACE OF MOTHER (city or town) Johnstown (State or country) Ohio
14 State Sanatorium
Informant
(Address)
Westfield. Mas
15
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH (month, day, and year) July 5. 1918
17
I HEREBY CERTIFY, That I attended deceased from
18
June 1
19.
July 5
, 19 18
to
that I last saw him
alive on
.....
July 5.
..... ,
19
18
and that death occurred, on the date stated above, at
8.75 G. m. The CAUSE OF DEATH* was as follows :
(duration)
.yrs ...
9
mos.
.........
.. ds.
CONTRIB
Pulmonary J. B.
(SECONDARY)
.(duration)
yrs.
.. mos.
ds.
18 Where was disease contracted
if not at place of death ?
Winthrop mass
Did an operation precede death ?
20
Date of!
-
Was there an autopsy ?
What test confirmed diagnosis ?
(Signed)
74.19 / & (Address)
Hubert P. Colton
M.D.
State Sanatorium
* 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
newark, Ohio
DATE OF BURIAL
19 -
20 UNDERTAKER
Sambon Journ Co.
ADDRESS
Westfield
maso.
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.
STANDARD CERTIFICATE OF DEATH
(If non-resident give city or town and State)
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 engincer, 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 linc is provided for the latter statement; it should be used only when necdcd. As examples: (a) Spinner, (b) Cotton mill; (a) Salesman, (b) Grocery; (a) Forcman, (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 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 spc- 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 illucss. 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 DEATH (the primary affection with respect to time and causation), using always the same accepted term for the same diseasc. Examples: Cercbrospinal 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- 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 (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- toms or terminal conditions, such as "Asthenia." "Anemia" (merely symptomatic), "Atrophy," "Col- lapse," "Coma," "Convulsions,"" "Dcbility" (“Con- genital," "Senile," etc.), "Dropsy," "Exhaustion," "Heart failure," "Hemorrhage," "Inanition," "Maras- Inus," "Old age," "Shock," "Uremia," "Weakness," etc., when a definite diseasc can be ascertained as the cause. Always qualify all discases 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 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
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, ctc.
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 strcet, 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.
COMMONWEALTH OF MASSACHUSETTS
RETURN OF A DEATH-1918.
CITY OF BOSTON
FULL NAME
RACHAEL MC P. EATON
(ADOPTED)
Registered No. · 7011
Place of Death and Residence 1
Boston
MASS .HOMEO .HOSPT .
Date of Death
1918,
Age
4 years 8
months 25
days.
STATISTICAL DETAILS.
SEX.
COLOR.
SINGLE, MARRIED, WID., DIV.
F
W
S
Maiden Name
Husband's Name
PATRICUS SPELADETY (Duration)
SEPTIC DIPHTHERIA - 8 DYS
Birthplace
- -P.E.I.
Name of Father
Birthplace of Father
Maiden Name of Mother
RACHAEL MC PHEARSON
Birthplace of Mother
- -P.E.I.
(Signed) S.A.CLEMENT M .D.
JULY 7 1918
SPECIAL INFORMATION from Hospitals, Institutions, Transients, or Recent Residents.
IN HOSPT .4 DAYS
Place of Burial or removal
WINTHROP. (WINTHROP CEM) Usual R. sidence
W. T. WHITE
WINTHROP (12 PARK AVE)
JULY II
1918.
Undertaker
REVERE
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'
CITY
OFFICE
TVY BOSTONIA CONDITAA.
0.1822
e 18 80. SREGIMINE DONAM D STON. MASS.
Contributory: { (Duration )
ACUTE TOXAEMIA
Occupation
Informant
Filed A true copy. Attest : ErMSlenen
Registrar.
JULY 7
July T. 1918.
-
The Commonwealth of Massachusetts STANDARD CERTIFICATE OF DEATH
( City or town )
1 PLACE OF DEATH,
County
SUITOIK
State
Mass.
Registered No.
Township WinterUN
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