USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1916-1918 > Part 123
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Statement of cause of death .- Name, first, the DISEASE CAUSING DEATH (the primary affection with respect to tiine 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.
(naine origin; "Cancer" is less definite; avoid use of "Tumor" for malignant neoplasms); Mcaslcs; Whooping cough; Chronic valvular heart discase; Chronic interstitial ncphritis, etc. The contributory (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- 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," 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; Poisoncd 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 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. 20,000.
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
(City or town)
County
Middlesex
State
Mass.
Registered No ...
City
Winthrop
No.
8H-Rear Park Ave
Ward
(If death occurred in a hospital or institution, give its NAME Instead of street and number)
2 FULL NAME
Strand &.
Ross
(a) Residence.
No. 42 Highland Que &,
Length of residence in city or towo where death occurred
years
months
days.
How loog in U. S., if of foreign birth ?
years
months
days
PERSONAL AND STATISTICAL PARTICULARS
5 SINGLE, MARRIED, WIDOWED, OR
DIVORCED (write the word)
6 DATE OF BIRTH (month, day, and year) Feb. 10.1863
Days
If LESS thao
1 day, ........ brs.
or ........ min.
Contractor
9 BIRTHPLACE (city or town)
Portland
10 NAME OF FATHER Lahm Pass
11 BIRTHPLACE OF FATHER (city or town).
Portland
(State or conntry)
Miami
12 MAIDEN NAME OF MOTHER Luella Moody
13 BIRTHPLACE OF MOTHER (city or town).
(State or country)
maine
Portlande
14 Mu Lizzie Ross
(Address)
Hr Highland Ave Somerville
Filed .. , 19
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH (month, day, and year) Sept. 18, 19/8
17
I HEREBY CERTIFY, That I attended deceased from
Sept. 14
1918
Sept. 18.
,1918
.. , to ..
that I last saw him alive on
Sept. 17
., 1918
and that death occurred, on the date stated above, at 4.400 m.
The CAUSE OF DEATH* was as follows :
Spanish Influenza&
Pneumonia Catarrhal
bronchial
(duration)
?
CONTRIBUTORY
(SECONDARY)
(duration)
.yrs ... . ........ mos ...
ds.
18 Where was disease contracted
if not at place of death ?
Doing business in Boston
Did an operation precede death ?.
.Date of.
Was there an autopsy ?
What test confirmed diagnosis ?
Dr. E. A. Locke
(Signed)
all haupt Carsielf Boston
., M.D.
19
(Address)
28 hoigh Landow. Somerset
-
* 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 I Wyoming Com., melrose.
20 UNDERTAKER
W. T. Till
DATE OF BURIAL Jefs 2019/8
ADDRESS
Veneville
15 N. B .- WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD. Every item of information should be (b) Geoeral nature of industry, business, or establishment in which employed (or employer) (c) Name of employer
1 PLACE OF DEATH
Township
(Usual place of abode)
3 SEX
Mar
4 COLOR OR RACE
White
5a If married, widowed, or divorced
HUSBAND of
(or) WIFE of
7 AGE
Years
55
Months
7
8 OCCUPATION OF DECEASED
(a) Trade, profession, or
particular kind of work
PARENTS
Informant
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
(State or country)
Maine
of certificate.
or Village.
or
.Ward. 3.
Somerville
(If non-resident give city or town and State)
yrs ..
.. mos ..
.. ds.
[Approved by U. S. Census and American Public Health Association]
Statement of occupation. -- Precise statement of occupa- tion is very muportant, so that the relative healthfulness of various pursuits can be known. The question applies to cach 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 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 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 domestie service for wages, as Servant, Cook, Housemaid, etc. It 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 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 samne discase. Examples: Cerebrospinal fever (the only definite synonym is "Epidemie 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, 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 necd not be stated unless important. Example: Measles (disease causing death), 29 &s .; Broncho- pneumonia (secondary), 10 ds. Never report mere symp- toms or terminal conditions, such as "Asthenia," " Ancmia" (merely symptomatic), "Atrophy," "Col- lapse," "Coma," ""Convulsions," "Debility" ("Con-
genital," "Senile," etc.), "Dropsy," "Exhaustion," "Heart failure," "Hemorrhage," "Inanition," "Maras- inus," "Old age," "Shock," "Uremia," "Weakness," etc., when a definite disease can be ascertained as the cause. Always qualify all 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 - nomicide; Poisoned by carbolic acid - probably suicide. The nature of the injury, as fracture of skull, and consequences (e. g., sepsis, tetanus) may be stated
A
INI WRITE
under the head of "Contributory." (Recommendations on statement of cause of death approved by Cominittee 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 liseasc, 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 SP
FOR FURTHER STATEMENTS BY PHYSICIAN.
R 15. 1-'18. 100,000.
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 classifled. Exact statement of OCCUPATION is very
important. See Instructions on back of certificate.
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH
(No. 10)
Vina avz.
St. :
Ward)
.....
Victor N. Helecon
2 FULL NAME
[If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE 10 Vine ave. Kuiethiop
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
4 COLOR OR RACE
& SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
Single
16 DATE OF DEATH
Sept.
18. 1918
(Day)
(Year)
DATE OF BIRTH
6
(Month)
9
188$ 17 (Year)
(Day)
7 AGE
If LESS than
! day ........ hrs.
32 yrs.
.......
3
.mos.
90s
or ........ min. ?
& OCCUPATION
(a) Trade, profession, or
particular kind of work
Juveler
(b) General nature of industry, business, or establishment which employed (or employer)
9 BIRTHPLACE
(State or country)
E. Boston
PARENTS
12 MAIDEN NAME
OF MOTHER
Jennie S. Carloon
13 BIRTHPLACE OF MOTHER (State or country) Sevaden.
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
Service S. Carlson
(Address) 10 Veic avz.
16
Filed 191 .....
REGISTRAR
that I last saw h
IM alive on
Salt, 17. 1918
and that death occurred, on the date stated above, at .... A.m.
The CAUSE OF DEATH* was as follows :
Latar Pneumonia
(Duration)
................ yrs.
mos.
4
ds.
Contributory.
Influenza
(SECONDARY)
.. (Duration)
mos.
......
4
.ds.
(Signed)
E. E. Bowen
M.D.
Sugar 19. 1918 (Address)
Ease Borta
* 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 Winthrop Cent.
DATE OF BURIAL
9-21
1918
20 UNDERTAKER
I. e. Ska
acon
ADDRESS
Withrole
(City or town.) [If death occurred in a hospital or institution, give its NAME instead of street and number.]
.......... Registered No.
MEDICAL CERTIFICATE OF DEATH
(Month)
I HEREBY CERTIFY that I attended deceased from Sept. 10, 1918, to
Setet 18, 1918
10 NAME OF
FATHER
Sven nelsson
11 BIRTHPLACE
OF FATHER
(State or country)
Swarden
Sept. 18, 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 caclı 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) Forcman, (b) Automobile factory. The material worked on may form part of the second statement. Never return "Laborer," "Foreman," "Manager," "Dealer," ctc., 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 wlio 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 Scrvant, Cook, Housemaid, ete. 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 None.
Statement of cause of death. - Name, first, the DIS- EASE CAUSING DEATH (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 "Epidemic cerebro-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, peritonaeum, etc., Carcinoma, Sar- coma, etc., of .... .... (name origin: "Cancer" is less definite; avoid usc of "Tumor" for malignant ncoplasms) ; 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: Measles (disease causing death), 29 ds .; Broncho-pneumonia (secondary), 10 ds. Never report mere symptoms or terminal conditions, such as "Asthenia," "An- acmia" (mcrely symptomatic), "Atrophy," "Collapse," "Coma," "Convulsions," "Debility" ("Congenital," "Senile," etc.), "Dropsy," "Exhaustion," "Heart failure," "Haemorrhage," "Inanition," "Marasmus," "Old age," "Shock," "Uraemia," "Weakness," etc., when a definite disease can be ascertained as the cause. Always qualify all diseases resulting from childbirth or miscarriage, as "PUER- PERAL septicaemia," "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. Deaths following injury or violence, as Burns, Falls, Drowning, Gas poisoning, Suicide, Homicide, etc.
2. Deaths supposedly caused by violence, as Criminal abortion, Poisoning, Starvation, Suffocation, Ex- posure, etc.
3. Sudden deaths of persons not disabled by recognized disease, as A death upon the street, or one supposed to be due to Alcoholism, etc.
4. Deaths under circumstances unknown, as A person found dead, ctc.
Jun HLIM
1 PLACE OF DEATH
County
Post Strafital
DEPARTMENT OF COMMERCE BUREAU OF THE CENSUS
STANDARD CERTIFICATE OF DEATH
State of
massachusetts
Registered No.
St .;
Ward)
[If death occurred in a hospital or Institution; give 'ts NAME Instead of street and number.]
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
male
4 COLOR OR RACE
White
5 SINGLE,
MARRIED,
WIDOWED.
OR DIVORCED
( Write the word)
Single
6 DATE OF BIRTH
1894
(Day)
(Year)
7 AGE
If LESS than
1 day, ____ hrs.
or ____. min. ?
8 OCCUPATION
(a) Trade, profession, or
particular kind of work
mos.
ds.
Soldier
(b) General nature of Industry,
business, or establishment in
which employed (or employer)
US army
9 BIRTHPLACE
(State or country )
Darker to This
PARENTS
11 BIRTHPLACE
OF FATHER
(State or country}
montgomery les Ohio
12 MAIDEN NAME
OF MOTHER
Sarah Bale,
rah
13 BIRTHPLACE
OF MOTHER
(State or country)
Darker the Ohio
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
Call , Vody / eva's
(Address: Port
15
Flied 191
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
September 19
(Month)
(Day)
1918. (Year)
17
I HEREBY CERTIFY, That I attended deceased from
Seff, 12
1918 __ , to
Saft. 19
191.2,
that I last saw h Lus. alive on
Seft 19
1918,
and that death occurred, on the date stated above,
1239.m.
The CAUSE OF DEATH* was as follows:
Labar Pneumonia
.
Right middle. Labe
(Duration)
yrs.
mos.
ds.
Contributory.
Influenza,
(SECONDARY)
2. (Duration)
yrs.
mos.
5
ds.
(Signed)
Vilman & Chase
M. D.
Seff 20
1918.
(Address)
Inf. Bauer. Mars
* State the DISEASE CAUSING DEATH, or, in deaths from VIOLENT CAUSES, state (1) MEANS OF INJURY ; and (2) whether ACCIDENTAL, SUICIDAL, or HOMICIDAL.
18 LENGTH OF RESIDENCE (FOR HOSPITALS, INSTITUTIONS, TRANSIENTS, OR RECENT RESIDENTS)
At place
In the
of death
- yrs.
mos.
_ds. State
yrs.
mos.
7.
ds.
Where was disease contracted,
If not at place of death ?
Hospital
Former or
usual residence.
Hospital.
ACE OF BURIAL OR REMOVAL
DATE OF BURIAL
Self-23
191
20 UNDERTAKER )
ADDRESS
11-3181
important. See instructions on back of cortificato. N. B .- Every item of information should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should stato CAUSE OF DEATH in plain terms, so that it may be properly classified. Exact statement of OCCUPATION is very
Fort Bank
Township
or
Hunthrop
Village
or
City
mass
(No.
2 FULL NAME
Harvey Oda
1
2
10 NAME OF
Henry Oda
FATHER
(Month)
REVISED UNITED STATES STANDARD CERTIFICATE OF DEATH
[Approved by U. S. Census and American Public Health Association]
Statement of occupation .- Precise statement of occupation 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 fireman, ctc. 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 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 dutics of the household only (not paid Housekeepers who receive a definite salary), may be entered as Housewife, Housework, 0" 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 CAUS- ING 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," unqualified, is indefi- nitc); Tuberculosis of lungs, meninges, peritonaeum, etc., Car- cinoma, Sarcoma, etc., of (name origin; “Can- cer" is less definite; avoid usc of " Tumor" for malignant neoplasms); Measles; Whooping cough; Chronic valvular heart disease; Chronic interstitial nephritis, etc. The con- tributory (secondary or intercurrent) affection need not be stated unless important. Example : Measles (disease causing death), 29 ds .; Bronchopneumonia (secondary), 10 ds. Never report mere symptoms or terminal condi- tions, such as "Asthenia," "Anaemia" ( merely 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 can be ascer- tained as the cause. Always qualify all diseases result- ing from childbirth or miscarriage, as "PUERPERAL septi- chaemia," "PUERPERAL 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 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 which give any of the following discases, without explanation, as the sole cause of death: Abortion, cellulitis, childbirth, convulsions: haemorrhage, gangrene, gastritis, erysipelas, meningitis, miscarriage, necrosis, peritonitis, phlebitis, pyacmia, scptichaemia, tetanus." But general adoption of the 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
BOSTON (City or town)
1 PLACE OF DEATH
County
Suffolk
State.
Massachusetts ...... Registered No.
Township
Winthrop.
or Village
or
City ............
No.
36 Temple Ave.
St.,
.Ward
(If death occurred in a hospital or institution, give its NAME instead of street and number)
2 FULL NAME
George M.Stevens.
(a) Residence.
No
36 Temple Ave.
St., ...
......
.. Ward.
(If non-resident give city or town and State)
Langtb nf residence in city or town where death occurred
years
months
days.
How Inng in U. S .. if of foreign birth ?
years
months
days
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
male
4 COLOR OR RACE
white
5 SINGLE, MARRIED, WIDOWED, OR
married.
5a If married, widowed, or diyproed
HUSBAND of
(or) WIFE of
Feb 2 1875.
6 DATE OF BIRTH (month, day, and year)
7 AGE
Years
43
Months
6
Days
17
If LESS than
1 day, ........ hrs.
ar ........ min.
8 OCCUPATION OF DECEASED
(a) Trade, profession, or
particular kind of work.
Contractor.
(b) General nature of industry, business, nr establishment in which employed (nr employer) (c) Name of emplayer
9 BIRTHPLACE (city or town Westboro Mass (State or country)
·
10 NAME OF FATHER
William H. Stevebs
PARENTS
11 BIRTHPLACE OF FATHERNEWBury Mass (State or country)
12 MAIDEN NAME OF MOTHAnnie L. Burne.
13 BIRTHPLACE OF MOTHERSU em Mass.
(State or country)
14 Mrs.Stevens.
Informant (Address)
15
Filed
...... , 19
REGISTRAR
16 DATE OF DEATH (month, day, and yea
Lepo. 19.
19/8
17
I HEREBY CERTIFY, That I attended deceased from
Seoh, 13.
19.
, to ..
wph. 19
19.1.8 ...
that I last saw hlasu alive on
Delph, 18.
, 1918.
and that death occurred, on the date stated above, at
3-450.
P.m.
The CAUSE OF DEATH* was as follows:
Broacho- precemonica
.(duration)
.yrs ........
.mos ..
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