USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1916-1918 > Part 112
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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 DEATHIS 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 (c. g., sepsis, tetanus) may be stated
under the head of "Contributory."
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. 1-'18. 100,000.
1
The Commonwealth of Massachusetts BOSTON
STANDARD CERTIFICATE OF DEATH
(City or town)
1 PLACE OF DEATH
Suffolk
State
Massachusetts
Registered No ..
Township
Winthrop
BOSTON
or Village. 440 Pleasant Street
St ....
Ward
(If death occurred in a hospital or Institution, give its NAME instead of street and number)
Arthur H. Wolcott. 440 Pleasant Street Ward.
(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
mooths
days
PERSONAL AND STATISTICAL PARTICULARS
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
Julia Wolcott.
6 DATE OF BIRTH (month, day, and elt, June 21 1849.
Years
69
Months
1
Days
1
If LESS than
1 day, ........ hrs.
.
or ........ min.
Diabetes mellitus
8 OCCUPATION OF DECEASED
(a) Trade, profession, or
Brush Manuf.
(b) Geoeral nature of industry, business, or establishment io which employed (or employer) (c) Name of employer
(duration)
yrs ..
... mos ....
ds.
CONTRIBUTORY
(SECONDARY)
.(duration)
... yrs .....
.......... mos ..
ds.
9 BIRTHPLACE (city or tow
So. Windsor Conn
18 Where was disease contracted
if not at place of death?
Did an operation precede death ? FOR WHAT >Date of.
Was there an autopsy ?.
Laboratory
What test confirmed diagnosis ?
(Signed)
H.W. Dinsel
M.D.
7/23, 19/8 (Address) 535 Beacon St, Boston
* 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 spaee.)
3 BIRTHPLACE OF
(State or country)
HIgganun Conn
14
T.G. Wolcott.
Informant
Wonthrop Mass.
(Address)
15
Filed
, 19
REGISTRAR
19 PLACE OF BURIAL, CREMATION, OR REMOVAL
Winthrop Cem
DATE OF BURIAL
July &4
19
20 UNDERTAKER
estatermantsaus
ADDRESS
Bastan
County.
City
................
2 FULL NAME
3 SEX
male
7 AGE
particular kind of work
PARENTS
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
(State or country)
10 NAME OF F
Nelson Wolcott.
11 BIRTHPLACE OF FOULEMindsor Conn (State or country)
12 MAIDEN NAME Sarah Kelsey
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH (month, day, and July 22 1918
19
17
I HEREBY CERTIFY, That I attended deceased from
April 7
19/8
.. , to.
July 22nd
19.2.8
that I last saw her alive on
Sale 22
1918.
and that death occurred, on the date stated above, at
3.30 P
.m.
The CAUSE OF DEATH* was as follows :
(If non-resident give city or town and State)
or
No
Winthrop ..
REVISED UNITED STATES STANDARD CERTIFICATE OF DEATHI [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 inay form part of the sceond statement. Never return "Laborer," "Forcınan," "Manager," "Dealer," etc., without more precise specification, as Day laborer, Farm laborer, Laborer -Coal mine, etc. Women at home, who are engaged in the duties of the household only (not paid 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 thẻ 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 "Epidemie cerebrospinal menin- gitis"); Diphtheria (avoid use of "Croup"); Typhoid fcver (never report "Typhoid pneumonia"); Lobar pneumonia; Bronchopneumonia ("Pneumonia," unquali- fied, is indefinite); Tuberculosis of lungs, meninges, peri- toneum, etc., Carcinoma, Sarcoma, etc., of_
(naine origin; "Cancer" is less definite; avoid use of "Tumor" for malignant neoplasms); Mcaslcs; Whooping cough; Chronic valvular heart disease; Chronic interstitial nephritis, etc. The contributory (sceondary or inter- current) affection need not be stated unless inportant. Example: Measles (disease causing death), 29 ds .; Broncho- pneumonia (secondary), 10 ds. Never report mere symnp- toins 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- 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- terinine 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, cte.
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.
The Commonwealth of Massachusetts
Rutt and (City or town)
1 PLACE OF DEATH
County.
Nureester
State.
Mass.
Registered No.
Township
Rutt and
City
No.
.or Village ....
Maple Lodge Sanatoriana
or
.St.
.Ward
(If death occurred in a hospital oginstitution, give its NAME instead of street and number)
2 FULL NAME
George alphonse Letellier
(a) Residence.
No ..
28
Jefferson
.St.,
.Ward.
(Usual place of abode)
80
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
white
5 SINGLE, MARRIED, WIDOWED, OR
DIVORCED (write the word)
Married
5a If married, widowed, or divorced
HUSBAND of
(or) WIFE of
Edith M. Letellier
6 DATE OF BIRTH (month, day, and year)
7 AGE
Years
38
Months
5
Days
10
If LESS than
1 day ......... hrs.
or ........ min.
8 OCCUPATION OF DECEASED
(a) Trade, profession, or
Pharmacist
(b) General nature of industry,
basiness, or establishment in
which employed (or employer)
(c) Name of employer
Proprietor
9 BIRTHPLACE (city or town)
(State or country)
Canada
10 NAME OF FATHER
Dr. a. Letellier
11 BIRTHPLACE OF FATHER (cify or town)
(State or country)
Canada
12 MAIDEN NAME OF MOTHER Wilhelmina Syliar
13 BIRTHPLACE OF MOTHER (city of town)
(State or country)
Canada
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH (month, day, and year)
July 22
19 /8
17
I HEREBY CERTIFY, That I attended deceased from
June 18
1918, to July 22
1918
that I last saw
hannalive on
July 22
1918.
and that death occurred, on the date stated above, at
6:158.
m.
The CAUSE OF DEATH* was as follows ;
abscess of the lens
(duration)
yrs mos
mos. -- ds.
CONTRIBUTORY
Pulmonary tuberculosis
(SECONDARY)
(duration)
.. yrs.
mos.
ds.
18 Where was disease contracted
if not at place of death ?
Wrathof mass
Did an operation precede death ?
no, Date of
Was there an autopsy ?.
no.
What test confirmed diagnosis ?
none
(Signed)
George n. Lapham
, B.I.D.
7/22. 1918 (Address)
Rutland mass.
* 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
Winthrop
DATE OF BURIAL 19
20 UNDERTAKER
B. E. Prescott
ADDRESS
Puttand
3 SEX Male 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 particular kind of work
of certificate.
Informant
Edith M. Letellier
(Address) 28 Jefferson st. Wanntrop
15 Filed July 2 2, 2918 Rain In St auff EGISTRAR
STANDARD CERTIFICATE OF DEATH
....
(If non-resident give city or town and State)
REVISED UNITED STATES STANDARD CLKISFILATE 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 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, 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 thercfore 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,"
"Forcman," "Manager," "Dcaler," ctc., without more precise specification, 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 domnestie 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 discase. Examples: Cerebrospinal fever (the only definite synonym is "Epidemic eerebrospinal 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 eontributory (secondary or inter- current) affection need not be stated unless important. Example: Mcasles (disease causing death), 29 ds .; Broncho- pneumonia (secondary), 10 ds. Never report mere symp- toms or terminal conditions, such as "Asthenia," " Ancmia" (merely symptomatic), "Atrophy," "Col-
lapsc," "Coma," "Convulsions," "Debility" ("Con-
genital," "Senile," etc.), "Dropsy," "Exhaustion," "Heart failure," "Hemorrhage," "Inanition," "Maras- mus," "Old age," "Shock," "Uremia," "Weakness," etc., when a definite discase ean 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 suclı, 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 (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, 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 circumstances unknown, as A person found dead, etc.
ADDITIONAL SPACE
FOR FURTHER STATEMENTS BY
PHYSICIAN.
A
R 15. 1-'18. 20,000.
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
(City or town)
1 PLACE OF DEATH
County
Suffolk
State
Wars
Registered No ...
Township
City Winthrop
or Village
or
No. 90 Him
St.,
Ward
(If death occurred in a hospital or institution, give its NAME instead of street and number)
2 FULL NAME
Frederick Wilkins
(a) Residence.
No. 90 Fremont
.St.,
Ward.
(Usual place of abode)
Length of residence in city or town where death occurred
20 years
months
days.
How long in U. S., if of foreign birth ?
years
months
days
PERSONAL AND STATISTICAL PARTICULARS
4 COLOR OR RACE
w
5 SINGLE, MARRIED, WIDOWED, OR
DIVORCED (write the word)
Widowed
5a If married, widowed, or divorced
HUSBAND of
(or) WIFE of
The late threelove Filledtwee
6 DATE OF BIRTH (month, day, and year) 6-3-7833
Years
Months
If LESS than
85
1
Days
19
1 day, ........ hrs. or ........ min.
8 OCCUPATION OF DECEASED
(a) Trade, profession, or
particular kind of work ...
Of Retired Lechera
(b) General nature of industry, business, or establishment in which employed (or employer) (c) Name of employer
9 BIRTHPLACE (city or town)
Hillsboron. N.
10 NAME OF FATHER Ira Wilkins
11 BIRTHPLACE OF FATHER (city or town)
(State or country)
12 MAIDEN NAME OF MOTHER
Dorcas Flink
13 BIRTHPLACE OF MOTHER (city or town)
(State or country)
Informant
Lillie Hilfiger
(Address) 90 Finement 3×
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH (month, day, and year)
22 July
1918
17 I HEREBY CERTIFY, That I attended deceased from 17 July 18, 22 Delas 18 19
that I last saw h the alive on
22 July
, 19 18.
and that death occurred, on the date stated above, at 11.15h.
.m.
The CAUSE OF DEATH* was as follows :
,
SEvile Provocardites
(du
many
mos ....
.ds.
CONTRIBUTOR
facture
og lip
,
(SECONDARY)
(duration)
.. yrs ...
.. mos.
5
ds.
18 Where was disease contracted
if not at place of death ?
Did an operation precede death ?
.Date of.
Was there an autopsy ?
run
Veckan What test confirmed diagnosis ?
glenncal
(Signed)
Durch zBateman
29/24-1918 (Address)
Freteall Porttal.
* 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
Vuethrop Cut
.
DATE OF BURIAL
7-25/2018
ADDRESS
20 UNDERTAKER
M.C. Skaggs
............. , 19
3 SEX 7 AGE 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 Filed. N. B. - WRITE PLAINLY, WITH UNFADING INK - THIS IS A PERMANENT RECORD. Every item of information should be (State or country)
(If non-resident give city or town and State)
LI.D.
.. yrs.
REVISED UNITED STATES 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 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 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- eifieally the occupations of persons engaged in domestie 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 faet 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 "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; Chronie 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," " Ancinia" (merely symptomatie), "Atrophy," "Col- 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 ean 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.)
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. 1-'18. 100,000.
The Commonwealth of Massachusetts
1 PLACE OF DEATH Deles County.
State
Amaca.
Registered No.
or Village.
or
St.,
Ward
(If death occurred in a hospital or institution, give its NAME instead of street and number )
Anis Soechline Horas
Morav.
(If in the Army or Nawy of the United States, give rank, organization, etc.)
(a) Residence.
No. 2876Main St.
St.,
Ward.
(Usual place of abody
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
3 SEX-
Formale Miuto
4 COLOR OR RACE
5 SINGLE, MARRIED, WIDOWED, OR
DIVORCED (write the word)
married
5a If married, widowed, or divorced HUSBAND of (or) WIFE of michael & Foran.
6 DATE OF BIRTH (month, day, and year)
Years
Months
Days
If LESS than I day, ........ hrs. or ........ min.
8 OCCUPATION OF DECEASED
(a) Trade, profession, or
At Stone.
9 BIRTHPLACE (city or town)
(State or country)
Ausfoundland
10 NAME OF FATHER Stilliam
11 BIRTHPLACE OF FATHER (city or town) (State or country) Serland
12 MAIDEN NAME OF MOTHER
margaret Haley.
13 BIRTHPLACE OF MOTHER (city or town) (State or country)
14 Practical Horan
(Address)
2876main St.
15 Filed. ,19
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH (month, day, and year) July 24 1918
17 I HEREBY CERTIFY, That"I attended deceased from May 18 July 240 ... to
that I last saw her
alive on
11
23d , 1918
4 a. m.
and that death occurred, on the date stated above, at
The CAUSE OF DEATH* was as follows : Hy prostatic Solar fremarcia
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