USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1916-1918 > Part 114
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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- toncum, etc., Carcinoma, Sarcoma, etc., of_
(name origin; "Cancer" is less definite; avoid use of "Tumor" for malignant neoplasmns); Measles; Whooping cough; Chronic valvular heart discase; Chronic interstitial nephritis, etc. The contributory (secondary or inter- current) affection need not be stated unless important. Example: Measles (discase causing death), 29 Gs .; Broncho- pneumonia (secondary), 10 ds. Never report mere symp- toms or terminal conditions, such as "Asthenia," "Col-
" Anemia" (merely symptomatic), " Atrophy,"
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 discase 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 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 caused by violence, as Criminal abortion, Poisoning, Starvation, Suffocation, Exposure, etc.
3. Sudden deaths of persons not disabled by recognized diseasc, 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.
CAUSE OF DEATH in plain terms, so that it may be properly classified. Exact statement of OCCUPATION is very N. B .- Every item of information should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should stato important. See Instructions on back of certificate.
15-'17-XXM.J The Gnuunmmwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH
Himthanh
(No 20 Belfour an
St. ;.... Ward)
................
antonio
Rogers
2FULL NAME
[If married or divorced woman or widow
give maiden name, also name of husband.]
@RESIDENCE
Imthap 20 Bellevard ane,
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
* SEX
mak
4 COLOR OR RACE
white
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
Indown
-
$ DATE OF BIRTH
(Month)
(Day)
1
(Year)
1 AGE
60
................. yrs.
.. mos.
ds.
or ........ min. ?
8 OCCUPATION
(a) Trade, profession, or
particular kind of work,
(b) General nature of industry,
business, or establishment in
which employed (or employer)
tumitura Made
9 BIRTHPLACE
(State or country)
Portugal
PARENTS
11 BIRTHPLACE
OF FATHER
(State or country)
Portugal
12 MAIDEN NAME
OF MOTHER
13 BIRTHPLACE
OF MOTHER
(State or conntry)
Portugal
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(informant)
Mamir & Cohru
(Address)
20 Bellaria au Thonthat
16 Filed
191
....
REGISTRAR
1$ DATE OF DEATH
August
2
(Month)
(Day)
1918
(Year)
17
I HEREBY CERTIFY that I attended deceased from
Julyet 3, 1919, to.
Levert 2
191
.......- 1 that I last saw him 1 alive on 1918 and that death occurred, on the date stated above, at 4pm
The CAUSE OF DEATH* was as follows :
bur inowa of the is
Did a surgical operation precede death ?
Date
.(Duration) .............. yrs. .............
mos. ......
ds.
Contributory
......
(SECONDARY)
(Signed)
leasestico
M.D
Aunt 2, 1917 (Address)
411 Hinaus
* If death followed injury or violence the certificate of death must be made out by the Medical Examiner.
18 LENGTH OF RESIDENCE (FOR HOSPITALS, INSTITUTIONS, TRANSIENTS, OR RECENT RESIDENTS).
In the
At place
of death
.... yrs. ............
mos.
ds.
State ............ yrs.
mos. ..........
ds .............
Where was disease contracted, If not at place of death ?.
Former or usual residence.
·19 PLACE OF BURIAL OR REMOVAL Nrw Calay
DATE OF BURIAL
Cus 4
......
191
20 UNDERTAKER
ADDRESS
2788 Those
BOSTON
(City or town.) [if death occurred In a hospita or institution, give its NAME Instead of street and number.J
Registered No.
If LESS than
1 day ......... hrs.
Fremitina Polisties
10 NAME OF
FATHER
John Ragas
(Duration)
.. mos.
......
.......... yrs.
ds.
-
6 €
6
STANDARD CERTIFICATE OF DEATH.
Statement of occupation. -- Precise statement of occu- pation 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, c. g., Farmer or Planter, Physician, Compositor, Architect, Loco- motive 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) Sales- man, (b) Groecry; (a) Forcman, (b) Automobile factory. The material 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 House- keepers who receive a definite salary), may be entered as Housewife, Housework, or At home, and children, not gain- fully employed, as At school or At home. Care should be taken to report specifically the occupations of persons engaged in domestic service for wages, as Servant, Cook, Housemaid, etc. If the occupation lias 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 indicated thus: Farmer (retired, 6 yrs.). For persons who have no occu- pation whatever, write None.
Statement of cause of death. - Name, first, the DIS- EASE CAUSING DEATHI (the primary affection with respect to time and causation), using always the same accepted term for the same discase. Examples: Cerebro-spinal fever (the only definite synonym is "Epidemie cerebro-spinal meningitis"); Diphtheria (avoid use of "Croup"); Typhoid fever (never re- port "Typhoid pricumonia"); Lobar pneumonia; Broncho- pneumonia ("Pneumonia," unqualified, is indefinite) ; Tuber-
culosis of lungs, meninges, peritonacum, etc., Carcinoma, Sar- coma, etc., of .. .. (name origin: "Cancer" is less definite; avoid use of "Tumor" for malignant neoplasms); Mcasles; Whooping cough; Chronic valvular heart discase; Chronic interstitial nephritis, etc. The contributory (second- ary or intercurrent) affection need not be stated unless im- portant. Example: Mcasles (cliscase causing death), 29 ds .; Broncho-pneumonia (secondary), 10 ds. Never report mere symptoms or terminal conditions, such as "Asthenia,"-"An- aemia" (merely symptomatic), "Atrophy," "Collapse," "Coma," "Convulsions," "Debility" ("Congenital," "Senile," ete.), "Dropsy," "Exhaustion," "Heart failure," "Haemorrhage," "Inanition," "Marasmus," "Old age," "Shock," "Uracmia," "Weakness," etc., when a definite discase can be ascertained as the cause. Always qualify all diseases resulting from childbirth or miscarriage, as "PUER- PERAL septieacmia," "PUERPERAL peritonitis," etc. State cause for which surgical operation was undertaken.
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. Deatlıs 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, Ex- posure, etc.
3. Sudden deathis 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.
R. 15. 1-'17 4100,000.
1
.
The Commonwealth of Massachusetts STANDARD CERTIFICATE OF DEATH
(City or town)
Township
Winthrop
No.1.2,
or Village.
or
St.,.
Ward
(If death occurred in a hospital or institution, give its NAME instead of street and number)
Robert B. Hastiness
St., ...
.. Ward.
(If non-resident give city or town and State)
days.
How long in U. S., if nf foreign birth ?
years
months
days
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH (month, day, and year) 8-7-
19/8
17 I HEREBY CERTIFY, That I attended deceased from 18, aug. 2, 1918.
that I last saw
heee alive on
Oct. 2., 118.
and that death occurred, on the date stated above, at
6 P
.m.
The CAUSE OF DEATH* was as follows
Chronic untertitel nephritis
(duration)
3
. yrs.
mos ....
ds.
CONTRIBUTORY
Cheval Drobny
.(duration)
PS.
.. 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 ?
Cliccal
What test confirmed diagnosis ?
Ml Para
(Signed).
5/3; 19/5 (Address)
Minutes of The
I.I.D.
* State the DISEASE CAUSING DEATH, or ip 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
Cleveland Chio
DATE OF BURIAL
8-5
1918
20 UNDERTAKER
W.C. Skaggs
ADDRESS
Winthrop
1 PLACE OF DEATH
County
Suffolk
City
2 FULL NAME
(a) Residence.
No 50 Floyd
(Usual place of abode)
Length of residence in city or town where death occurred
months
yeats
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
4 COLOR OR RACE
W
5a If married, widowed, or divorced
HUSBAND of
(or) WIFE of
6 DATE OF BIRTH (month, day, and year)
7 AGE
Ycars
Months
Days
54
8
25-
8 OCCUPATION OF DECEASED
(a) Trade, profession, or
particular kind of work
Retired
(b) General nature of industry,
business, or establishment in
which employed (or emplnycr)
(c) Name of employer
(State or country)
71.9.
PARENTS
14
Informant
nt Fames Hartner
(Address)
Sprmegheld Ut
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
19
IN. D. " WNIJE PLAINLT, WITH UNFADING INK - THIS IS A PERMANENT NECOND. Every fem of Information should be
9 BIRTHPLACE (city or town)
Schenectady
5 SINGLE, MARRIED, WIDOWED, OR
DIVORCED (write the word)
11-7-1863
If LESS than
1 day, ........ hrs.
ar ........ min.
10 NAME OF FATHER John wHastiness
11 BIRTHPLACE OF FATHER (city or town).
albany
(State or country) 1 M.St. 12 MAIDEN NAME OF MOTHER alla facts,
13 BIRTHPLACE OF MOTHER (city or town) chanceclan (State or country) on-cf.
REGISTRAR
State
mas
Registered No
(SECONDARY)
166
NO HLIM AINIVIA 3LIUM -EN
KLYUSLU UNIILU SIAILS SIANDARD CLKILLICALE UF DLAIII [Approved by U. S. Census and American Public Health Association]
Statement of occupation. - Precise statement of occupa- tion is very important, so that the relative healthfulness of various pursuits can be known. The question applies to each and every person, irrespective of age. For many occupations a single word or term on the first line will be sufficient, e. g., Farmer or Planter, Physician, Compos- itor, Architcet, Locomotive engineer, Civil engineer, Stationary fireman, etc. But in many cases, especially in industrial employments, it is necessary to know (a) the kind of work and also (b) the nature of the business or industry, and therefore an additional line is provided for the latter statement; it should be used only when needed. As examples: (a) Spinner, (b) Cotton mill; (a) Salesman, (b) Grocery; (a) Foreman, (b) Automobile factory. The ma- terial worked on may forin part of the second statement. Never return "Laborer," "Foreman," " Manager," "Dealer," etc., without inore precise specification, as Day laborer, Farm laborer, Laborer -Coal mine, etc. Woinen 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 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 DEATII (the primary affection with respect to tiine and causation), using always the same accepted term for the same discase. 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 .; Broncho- pneumonia (secondary), 10 ds. Never report merc 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- nus," "Old age," "Shock," "Uremia," "Weakness," etc., when a definite discase can be ascertained as the cause. Always qualify all diseases resulting from child- birth or miscarriage, as "PUERPERAL septicemia," "PUER- PERAL peritonitis," etc. State cause for which surgical operation was undertaken. For VIOLENT DEATHS STATE MEANS OF INJURY and qualify as ACCIDENTAL, SUICIDAL, or HOMICIDAL, or as probably such, if impossible to de- termine definitely. Examples: Accidental drowning; Struck by railway train - accident; Revolver wound of head - homicide; Poisoned by carbolic acid - probably suicide. The nature of the injury, as fracture of skull, and consequences (e. g., sepsis, tetanus) may be stated
under the head of "Contributory."
(Recommendations on statement of cause of death approved by Committee on Nomenclature of the American Medical Association.)
Casas for the Medical Examiners. - Under the provi- sions of chapter 24 of the Revised Laws deaths under the following conditions must be referred to the Medical Examiners:
1. Deaths following injury or violence, as Burns, Falls, Drowning, Gas poisoning, Suicide, Homicide, etc.
2. Deaths supposedly caused by violence, as Criminal abortion, Poisoning, Starvation, Suffocation, Exposure, etc.
3. Sudden deaths of persons not disabled by recognized disease, as A death upon the street, or one supposed to be due to Alcoholism, etc.
4. Deaths under circumstances unknown, as A person found dead, etc.
ADDITIONAL SPACE
FOR FURTHER STATEMENTS BY PHYSICIAN.
R 15. 1-'18. 100,000.
City 3 SEX male 7 AGE 63 particular kiod of work. PARENTS Informant TOTIL TLAILI, WITH UNCADING INA THIS IS A PERMANENT RECORD. Every riem of Information should be (c) Name of employer 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.
14 anna. R. Collman
(Address)
So Collage PK Roell
15 Filed , 19
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH (month, day, and year)
ango
1918
17
I HEREBY CERTIFY, That I attended deceased from
19/7, to.
any 5
1918
that I last saw h Am alive on
19.
218
and that death occurred, on the date stated above, at 12-15 m. The CAUSE OF DEATH* was as follows:
Hepatic Carlosés
(duration)
.yrs.
.mos. .
ds.
CONTRIBUTORY
hupendels
(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 ?
200
What test confirmed diagnosis ?
abdand Cercate
(Signed)
9 ~~ , 19 /8 (Address)
218 havi fr unttop
* 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
Wirdlaw Camely everett berg, ?
19
18
... ..
The Commonwealth of Massachusetts STANDARD CERTIFICATE OF DEATH
Winthrop (City or town)
.........
1 PLACE OF DEATH
County
AT Block
State
maso
Registered No.
or
.or Village
So Collage Park Road s
St.,
Ward
(If death occurred in a hospital or institution, give its NAME instead of strect and number)
2 FULL NAME
Imothy aney atwood
(a) Residence.
No ..
80 Collage RK Rd
St.,.
.Ward.
(Usual place of abode)
Length of residence io city or towo 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)
5a If married, widowed, or divorced
HUSBAND of
(or) WIFE of
6 DATE OF BIRTH (month, day, and ycar)
Ycars
Months
Days 18
If LESS thao 1 day, ........ lars. er ........ min.
8 OCCUPATION OF DECEASED
(a) Trade, profession, or
Trade
(b) Geoeraloature of indostry,
business, or establishment io
which employed (or employer)
Tailor
Wielfleck-
9 BIRTHPLACE (city or town)
mass
(State or country)
10 NAME OF FATHER
Eleger. H. Celwood
11 BIRTHPLACE OF FATHER (city or town)
Wellfleet
(State or country) maso
12 MAIDEN NAME OF MOTHER Lucan Freeman 13 BIRTHPLACE OF MOTHER (city or town) Wellfleet (State or country) man
M.D.
20 UNDERTAKER
ER Beno
ADDRESS
Winthrop
Township
Whentheok
No.
(If non-resident give city or town and State)
KLYISED UNITLD SIAILS 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, ete. But in many cases, especially in industrial employments, it is necessary to know (a) the kind of work and also (b) the nature of the business or industry, and therefore an additional line is provided for the latter statement; it should be used only when needed. As examples: (a) Spinner, (b) Cotton mill; (a) Salesman, (b) Grocery; (a) Foreman, (b) Automobile factory. The ma- terial worked on may forin part of the second statement. Never return "Laborer,"
"Foreman," "Manager," "Dealer," etc., without inore 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 terin 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_
(naine 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 .; Broneho- pneumonia (secondary), 10 ds. Never report mere symp- toms or terminal conditions, such as "Asthenia," "Col- "Anemia" (merely symptomatic), "Atrophy,"
lapse," "Comna," "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," 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, ete.
ADDITIONAL SPACE
FOR FURTHER STATEMENTS BY
PHYSICIAN.
R 15. 1-'18. 100,000.
COMMONWEALTH OF MASSACHUSETTS
RETURN OF A DEATH-1918.
CITY OF BOSTON
7964
Registered No.
Place of Death / and Residence
Boston
AUG.9
68
years
months days.
STATISTICAL DETAILS.
SEX.
COLOR.
SINGLE, MARRIED, WID., DIV.
M
W
M
Maiden Name
Husband's Name
IRELAND
Birthplace
Name of Father
THOMAS H.QUINN
Birthplace of Father IRELAND
Maiden Name of Mother
Birthplace of Mother
Occupation HOTEL R.R.NEWS CO.
Informant
PHYSICIAN'S CERTIFICATE.
1 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
R
Primary (Duration)
ICU
LOBIS
OFFICE
BOSTONIA CONDITAA.
JA. 1822.
SREOIMINE DONATA A
T
MASS.
1 Contributory: ( CEREBRAL HEMORRHAGE -6 MOS. (Duration)
(Signed) E.S.BISBEE M.D
1918
SPECIAL INFORMATION from Hospitals, Institutions, Transients, or Recent Residents.
Place of Burial or removal
FOREST HILLS
Undertaker
A.L.EASTMAN CO.
WINTHROP (36 FLOYD ST)
Usual Residence
AUG.12 1918.
Filed A true copy. Attest :
Registrar.
MICHAEL H.QUINN
FULL NAME
Date of Death
MAC LEOD HOSPT.
1918,
Age
SAT
CHR. NEPHRITIS -10 YRS
CITY
aug. 9, 1918
.
The Commmmwealth of Massachusetts STANDARD CERTIFICATE OF DEATH
Winthrop. BOSTON
(City or town)
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