USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1916-1918 > Part 120
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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 discase, 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
1 PLACE OF DEATH
County.
State
Registered No .....
Township
or Village ..
or
City
No ..
St.,
. Ward
(If death occurred in a hospital or institution, give its NAME instead of street and number)
2 FULL NAME Many Adele Howell
(a) Residence. No. 105 Shower are St., Ward.
(Usual place of abode)
(If non-resident give city 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
3 SEX female -
4 COLOR OR RACE
5 SINGLE, MARRIED, WIDOWED, OR DIVORCED (write the word) Suple
5a If married, widowed, or divorced HUSBAND of (or) WIFE of
6 DATE OF BIRTH (month, day, and year)
Sepet 14-
7 AGE
Years 16
Months 11
Days
28
· If LESS than 1 day, ........ hrs. or ........ min.
8 OCCUPATION OF DECEASED
(a) Trade, profession, or particular kind of work
School End
.....
(h) General nature of industry, business, or establishment in which employed (or employer)
(c) Name of employer
9 BIRTHPLACE (city or town) ..
(State or country)
10 NAME OF FATHER
PARENTS
11 BIRTHPLACE OFFATHER (eity or town). (State or country) Kesteak lowa
12 MAIDEN NAME OF MOTHER adele. C Vidde
13 BIRTHPLACE OF MOTHER (eity or town)
(State or country) Honolulu
14
Informant
@ R. Ben
(Address)
15
Filed .. , 19
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH (month, day, and year) Seft. 11
1918
17
I HEREBY CERTIFY, That I attended deceased from
Seft.
19/8
Self. 11
19.1.8.
that I last saw her alive on
Seft 11
1918
and that death occurred, on the date stated above, at
9 P.
. m.
The CAUSE OF DEATH* was as follows :
Lobar Pneumonia.
Rt. uffer. Lobe-
(duration)
yrs ..... . .
mos ..
8.
ds.
CONTRIBUTORY (SECONDARY)
(duration) ... yrs. .
.. mos ..
ds.
18 Where was disease contracted
if not at place of death ?
Did an operation precede death ?
Zwo. Date of.
Was there an autopsy ?. no.
What test confirmed diagnosis ?
Clinical Sugiro
(Signed)
Selman 5. Chase Is.C. ",
I.D.
Off.12.1918. (Address)
Int. Banks. Wanted har
* 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 Left/4/2018
20 UNDERTAKER
ADDRESS
... .
"I LAINLI; WITHI UNLADING INA - INIS 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, ....
James. F. House
of certificate.
=
(City or town)
REVISED UNITED STATES STANDARD CERTIFICATE OF 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 terin 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 form part of the second statement. Never return "Laborer,"
"Forcman," "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 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 cerebrospinal menin- gitis"); Diphtheria (avoid use of "Croup"); Typhoid ferer (never report "Typhoid pneumonia"); Lobar pneumonia; Bronchopneumonia ("Pneumonia," unquali- fied, is indefinite); 'Tuberculosis of lungs, meninges, peri- toneum, etc., Carcinoma, Sarcoma, cte., 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 syinp- toms or terminal conditions, such as "Asthenia," "Anemia" (merely 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 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 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 Examinors. - 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
WILLIAM B.WELTON
Registered No. 8926
Place of Death l and Residence
Boston
Date of Death
SEPT.II
1918,
Age 38
years
months days.
STATISTICAL DETAILS.
SEX.
COLOR.
SINGLE, MARRIED, WID., DIV.
M
W
M
Maiden Name
Husband's Name
Birthplace
BOSTON
Name of Father
JOHN F.WELTON
Birthplace of Father BOSTON
Maiden Name of Mother
ELEANOR BURKE
Birthplace of Mother
(Signed)
F .H.HUNT
M. D
SEPT . 1 11918
SPECIAL INFORMATION from Hospitals, Institutions, Transients, or Recent Residents.
IN HOSPT . I MO.+
Place of Burial or removal MALDEN (HOLY CROSS)
Undertaker
R.C. KIRBY
SEPT.16
Filed
1918.
A true copy.
Attest :
Ermslenen
Filed Dec. 18, 1918
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
PATRIBO
PULMONARY TUBERCULOSIS
CITY
BOSTONIA
TAT CONDITA A.
18 80.
DONATA A
ST
O
N. MASS.
Contributory : (Duration)
Occupation
LABORER
Informant
Primary (Duration) ESOFFICE SOBIS
A. 1822.
B SREGIMINE
Usual Residence
WINTHROP (25 NORTH AVE)
Registrar.
CONSUMPTIVES HOSPT .
-
Sept. 11, 1918
IST-92
CAUSE OF DEATH in plain terms, so that it may be properly classified. Exact statoment of OCCUPATION is very N. B .- Every item of information should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state important. Soe instructions on back of certificate.
1 PLACE OF DEATH
County
Post
Hospital
DEPARTMENT OF COMMERCE BUREAU OF THE CENSUS
STANDARD CERTIFICATE OF DEATH
Massachus Ello
State of
Registered No.
[If death occurred in
St .:
Ward)
a hospital or Institution, give Its NAME Instead of street and number.]
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
Septembre 12
(Month)
(Day)
191.8 ( Year)
17
I HEREBY CERTIFY, That I attended deceased from
Dept 7
1918
Dept 12
8
191.
that I last saw h&M alive on
Bent - 1-10 Por
8
to
191 ..
and that death occurred, on the date stated above, at 2 ... A. m.
The CAUSE OF DEATH * was as follows: .
Labas Queumana
right way
9 BIRTHPLACE
(State or country )
Clinton Mars .
10 NAME OF
FATHER
John
PARENTS
11 BIRTHPLACE
OF FATHER
(State or country)
Germany
12 MAIDEN NAME
OF MOTHER
augusta Hillner
13 BIRTHPLACE
OF MOTHER
(State or country)
germany
18 LENGTH OF RESIDENCE (FOR HOSPITALS, INSTITUTIONS, TRANSIENTS,
OR RECENT RESIDENTS)
At place
of death
yrs.
mos .:
5 ds.
.ds.
State
30
yrs.
In the
mos
14
ds.
Where was disease contracted, Franklin Union Boston mars if not at placo of death ?
Former or HElistas mas.
usual residence.
19 PLACE OF BURIAL OR REMOVAL
DATE OF BURIAL
2
191 ..
20 UNDERTAKER
ADDRESS
Flied
191.
REGISTRAR
-
(Informant)
(Address)
15
11-3184
4 COLOP. OR RACE
MARRIED.
WIDOWED,
OR DIVORCED
( Write the word)
5 SINGLE. MarxeEd
6 DATE OF BIRTH
august 29.
(Month)
(Day""
1888
(Year)
7 AGE
30
14
ds.
yrs. mos.
If LESS than
1 day, ____ hrs.
or ____. min. ?
8 OCCUPATION (a) Trade, profession, or particular kind of work
Soldier
(b) General nature of Industry,
business, or establishment in
which employed (or employer)
21. S.army
(Duration)
yrs.
mos ds.
Contributory
(SECONDARY)
(Duration) yrs.
mos .. ds.
(Signed)
Seht 12
191
(Address)
Fort Banks
M. D.
* State the DISEASE CAUSING DEATH, or, iu deaths from VIOLENT CAUSES, state (1) MEANS OF INJURY ; and (2) whether ACCIDENTAL, SUICIDAL, or HOMICIDAL.
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
Fort Bank2
Township
or
Village
Hunthrop
City
2 FULL NAME
Johnc
3 SEX
male White
~30
REVISED UNITLU STATES STANDARD CERTIFICATE OF DEATH [Approved by U. S. Census and American Public Ilealth Association]
Statement of occupation .- Precise statement of occupation 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, 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, 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, 0." .It home, and children, not gainfully employed, as At school or At home. Care should be taken to report spe- cifically the occupations of persons engaged in domestie service for wages, as Servant, Cook, Housemaid, 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 CAUS- ING DEATH (the primary affection with respect to time and eausation), 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," unqualified, is indefi- nite); Tuberculosis of lungs, meninges, peritonaeum, etc., Car- cinoma, Sarcoma, etc., of - (name origin; “Can- cer" is less definite; avoid use of " Tumor" for malignant ncoplasms); Measles ; Whooping cough; Chronic valvular Heart disease; Chronic interstitial nephritis, etc. The eon- tributory (secondary or intercurrent) affection need not be stated unless important. Example : Measles (disease eausing death), 29 ds .; Bronchopneumonia (secondary), 10 ds. Never report mere symptoms or terminal condi- tions, such as "Asthenia," "Anaemia" ( inerely symptom-
atic), "Atrophy," "Collapse," "Coma," "Convulsions," "Debility" ("Congenital," "Senile," etc.), "Dropsy," "Exhaustion," "Heart failure," "Haemorrhage," "Inani- tion," " Marasmus," "Old age," "Shock," "Uraemia," "Weakness," etc., when a definite disease ean be ascer- tained as the eause. Always qualify all diseases result- ing from childbirth or miscarriage, as "PUERPERAL septi- chaemia," "PUERPERAL peritonitis," ete. 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 determine 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. )
NOTE .- Individual offices may add to above list of undesirable terms and refuse to accept certificates containing them. Thus the form in use in New York City states: "Certificates will be returned for additional information wbich give any of the following diseases, without explanation, as the sole cause of death: Abortion, cellulitis, childbirth, convulsions, baemorrhage, gangrene, gastritis, erysipelas, meningitis, miscarriage, necrosis, peritonitis, phlebitis, pyaemia, septicbaemia, tetanus." But general adoption of tbe minimum list suggested will work vast improvement, and its scope can be extended at a later date.
11-3184
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH Huittrop (No 156, Washington Ave
St. : Ward)
Winthrop
(City or towy.) [if death occurred in a hospital or institution, give its NAME instead of street and number.]
ME Minnie Q. Wright
2 FULL NAME {If married or divorced woman or widow give maiden name, also name of husband.] @ RESIDENCE 156 Washington Ave Withurp
Wasson- Albert 6.
PERSONAL AND STATISTICAL PARTICULARS
3 SEX timale
4 COLOR OR RACE
White
$ SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED-
(Write the word)
6 DATE OF BIRTH
Nov 27
(Month)
(Dấy)
( Year)
7 AGE
If LESS than ! day, ....... hrs.
47
yrs.
9
mos ...
15
ds.
or ...... min. ?
S OCCUPATION
(a) Trade, profession, or
particular kind of work
Ar Home
(b) General nature of industry, business, or establishment in which employed (or employer)
9 BIRTHPLACE
(State or country)
Payton Mase
PARENTS
11 BIRTHPLACE OF FATHER (State or country)
Unknown
12 MAIDEN NAME
OF MOTHER
Unknown
13 BIRTHPLACE OF MOTHER (State or country)
Unknown
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
Alberto. Wright
(Address) 156 Washington Stre
15
Filed ., 191.
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
Sekh
(Month)
(Day)
12. .. 191. ( Year)
March
1
1
HEREBY CERTIFY that I attended deceased from
8
191
Lepr. 1298
to
that I last saw her alive on
Reph. 12.
1918
and that death occurred, on the date stated above, at
104/5%.
The CAUSE OF DEATH* was as follows :
Carcinoma of Sutesteurs
. (Duration)
2 yr(?)
mos.
ds.
Contributory
(SECONDARY)
(Duration )
.yrs.
mos.
ds.
(Signed)
Il Partes
M.D.
Lep. 13 .. 1918
(Address)
Winthrop
"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.
DATE OF BURIAL
19 PLACE OF BURIAL OR REMOVAL Woodlawn
20 UNDERTAKER
ADDRESS
İILVVIIV.
...
N. B. - Every item of information should be 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.
: 10 NAME OF
FATHER
George Wasson
1870
17
Registered No.
YANO ILIM WINIYT ALIUM MIN
Sept. 12, 1918
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, e. 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) Grocery; (a) Foreman, (b) Automobile factory. The material worked on may form part of the second statement. Never return "Laborer," "Foreman," "Manager," "Dealer," ete., without more precise specification, as Day laborer, Farm laborer, Laborer - Coal mine, etc. Women at home, who are engaged in the duties of the household only (not paid House- keepers who receive a definite salary), may be entered as Housewife, Housework, or At home, and children, not gan- fully employed, as At school or At home. Care should be taken to report specifically the oceupations 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 fact may be indicated thus: Farmer (retired, 6 yrs.). For persons who have no occu- pation whatever, write Nonc.
Statement of cause of death. - Name, first, the DIS- KASE CAUSING DEATHI (the primary affection with respect to time and cansation), using always the same accepted term for the same disease. Examples: Cerebro-spinal fever (the only definite synonym is "Epidemic ecrebro-spinal meningitis"); Diphtheria (avoid use of "Croup"); Typhoid fever (never re- port "Typhoid pneumonia"); 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 ncoplasms) ; Measles, Whooping cough, Chronic valvular heart disease, Chronic interstitial nephritis, etc. The contributory (second- ary or intereurrent) affection need not be stated unless in- portant. Example: Measles (d'seaso causing death), 29 ds .; Broncho-pneumonia (secondary), 10 ds. Never report mere symptoms or terminal conditions, such as "Asthenia," "An- aemia" (mercly symptomatic), "Atrophy," "Collapse," "Coma," "Convulsions," "Debility" ("Congenital," "Senile," etc.), "Dropsy," "Exhaustion," "Heart failure," "Haemorrhage," "Inanition," "Marasmus," "Old age," "Shock," "Uraemia," "Weakness," ete., when a definite disease can be ascertained as the cause. Always qualify all diseases resulting from childbirth or miscarriage, as "PUER- PERAL septicacmia," "PUERPERAL peritonitis," ete. 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. Deaths following injury or violence, as Burns, Falls, Drowning, Gas poisoning, Suicide, Homicide, etc.
2. Deaths supposedly caused by violence, as Criminal abortion, Poisoning, Starration, 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.
R. 15. 7-'17. 100,000
The Commonwealth of Massachusetts STANDARD CERTIFICATE OF DEATH
(City or town)
1 PLACE OF DEATH
County.
Suffolk
State
Marc
.Registered No.
or
St.
Ward
(If death occurred in a hospital or institution, give its NAME instead of street and number)
2 FULL NAME
Dice D. Bugan
(a) Residence.
No. 10 Orlando, antes
St.,
.Ward.
(Usual place of abode)
Length of residence in city or town where death occurred
10 years boots
days.
How long in U. S., if of foreign birth ?
years
(If non-resident give city or town and State)
months
days
PERSONAL AND STATISTICAL PARTICULARS
4 COLOR OR RACE
w
5 SINGLE, MARRIED, WIDOWED, OR
DIVORCED (write the word)
Married
5a If married, widowed, or divorced
HUSBAND of
(or) WIFE of
: John d. Briggs
6 DATE OF BIRTH (month, day, and year)
Months
Days
If LESS than 1 day, ........ hrs. pr ........ min.
8 OCCUPATION OF DECEASED
(a) Trade, profession, or
particular kind of work.
Housewife
9 BIRTHPLACE (city or town)
Woodstock
(State or country) Much
10 NAME OF FATHER brauchwastout
PARENTS
11 BIRTHPLACE OF FATHER (city or town)
(State or country)
12 MAIDEN NAME OF MOTHER
13 BIRTHPLACE OF MOTHER (city or town)
(State or country)
11
* 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
Woodstock Which
DATE OF BURIAL
9-16
19/8
ADDRESS
15 Filed
............ , 19
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH (month, day, and year) Cef.12. 10 /8
17
I HEREBY CERTIFY, That I attended deceased from
July 16
, to ...
19
18
Tiff, 12
19.18 ..
that I last saw her
alive on
11
1918.
and that death occurred, on the date stated above, at
110.
m.
The CAUSE OF DEATH* was as follows :
-Berateral Stewarthager
(duration)
yrs ...
mos ....
ds.
CONTRIBUTORY
artigoseleri-
SECONDARY des.
(duration)
18 Where was disease contracted
if not at place of death ?
Did an operation precede death?
no.
Date of.
Was there an autopsy ?
200.
What test confirmed diagnosis ?
Clinical
(Signed)
Tartar
I.I.D.
7/4, 19/18 (Address)
of certificate.
Township City 3 SEX 7 AGE Years ..... .... " VITI AVING INA -THIS IS A PERMANENT KECUKD. Every item of information should be (b) General nature of industry, business, or establishment in which employed (or employer) (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,
14 Solu S. Briggs
Informant
(Address)
No. 10,
or Village. Arlanda Cv3
20 UNDERTAKER
W.a. Skaggs Winther
yrs ....
.mos .. .
ds.
581
[Approved by U. S. Census and Amcrican Public Health Association]
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