USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1916-1918 > Part 131
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(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 eausing death), 29 ds .; Broncho- pneumonia (secondary), 10 ds. Never report mere syınp- toins or terminal conditions, such as "Asthenia," "Anemia" (merely symptomatie), "Atrophy," "Col-
lapse," "Coma," "Convulsions,"""Debility" ("Con-
genital," "Senile," ete.), "Dropsy," "Exhaustion," "Heart failure," "Hemorrhage," "Inanition," "Maras- nus," "Old age," "Shoek," "Uremia," "Weakness," ete., when a definite discase ean be aseertained as the cause. Always qualify all diseases resulting from ehild- birth or miscarriage, as "PUERPERAL septicemia," "PUER- PERAL peritonitis," ete. State eause for which surgical operation was undertaken. For VIOLENT DEATHS STATE MEANS OF INJURY and qualify as ACCIDENTAL, SUICIDAL, or HOMICIDAL, or as probably sueh, if impossible to de- termine definitely. Examples: Accidental drowning; Struck by railway train - accident; Revolver wound of head - homicide; Poisoned by carbolic acid - probably suicide. The nature of the injury, as fracture of skull, and consequences (e. g., sepsis, tetanus) may be stated
under the head of "Contributory." (Recommendations on statement of cause of death approved by Committee on Noinenelature 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, ete.
3. Sudden deaths of persons not disabled by recognized disease, as A death upon the street, or one supposed to be due to Alcoholism, 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
(City or town)
1 PLACE OF DEATH
County.
Hampden
State
Mass.
Registered No.
Township
or Village
or
(If death occurred in a hospital or institution, give its NAME instead of street and number)
2 FULL NAME
Thomas A. Maloney
Private
(a) Residence.
No.
(Usual place of abode)
355 winthrop
St.,
Ward.
Boston, Mass.
(If non-resident give city or town and State)
Length of residence in city or town where death occurred
years
months 6
days.
How long in U. S., if of foreign birth ?
years
months
days
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
M
4 COLOR OR RACE
W
5 SINGLE, MARRIED, WIDOWED, OR DIYORCED (write the word) Married
5a If married, widowed, or divorced
HUSBAND of
(or) WIFE of
Margaret McGaugh
6 DATE OF BIRTH (month, day, and year)
Jan 22, 1887
7 AGE
Years
31
Months
8
Days 5
If LESS than I day, ........ hrs. or ....... min.
8 OCCUPATION OF DECEASED
(a) Trade, profession, or
particular kind of work
Soldier
(b) General nature of industry,
business, or establishment in
which employed (or employer)
(c) Name of employer
U. S. Army
(duration)
. yrs .....
mos.
6
ds .
CONTRIBUTORY
La Grippe
(SECONDARY)
(duration)
.... yrs ....
.mos.
ds.
18 Where was disease contracted
if not at place of death ?
Did an operation precede death?
no
Was there an autopsy ?.
no
What test confirmed diagnosis ?
-
(Şigned)
William C. Leary
M.D.
last19
(Address)
630 Main
* 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, Mass.
DATE OF BURIAL
Sept 29 19 18
15 Oct 8
Filed
19 18
Filed Dee. 18, 1918
REGISTRAR
N. B .- WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD. Every item of information should be so that It may be properly classified. Exact statement of OCCUPATION is very important. See instructions on back carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state CAUSE OF DEATH in plain terms,
of certificate.
14
Informant
Margaret .... Maloney
(Address)
Boston, Mass.
PARENTS
11 BIRTHPLACE OF FATHER (city or town).
(State or country)
Ireland
12 MAIDEN NAME OF MOTHER
Margaret Pender
Boston
13 BIRTHPLACE OF MOTHER (city or town)
(State or country)
Mass .
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH (month, day, and year) Sept 27
19 18
17
I HEREBY CERTIFY, That I attended deceased from
Sept 21
19
18
Sept 26
18
19
im
Sept 26
18
that I last saw h
alive on
19
and that death occurred, on the date stated above, at
m.
The CAUSE OF DEATH* was as follows : Broncho-pneumonia
9 BIRTHPLACE (city or town).
East Boston
(State or country)
Mass .
10 NAME OF FATHER
Thomas Maloney
Date of.
City
Springfield
No.
Mercy Hospital
St .....
2
Ward
20 UNDERTAKER
W. A. Sweeney
ADDRESS
179 chestnut
St
REVISED UNITED STATES STANDARD CERTIFICATE OF DEATH [Approved by U. S. Census and American Public Health Association]
Statement of occupation. - Precise statcinent of occupa- tion is very important, so that the relative healthfulness of various pursuits ean be known. The question applies to cach 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, 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 laborcr, 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, Houscmaid, 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 indi- eated 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 eausation), using always the same accepted term for the saine disease. Examples: Cercbrospinal fever (the only definite synonym is "Epidemic cerebrospinal menin- gitis"); Diphtheria (avoid use of "Croup"); Typhoid fever (never report "Typhoid pneumonia"); Lobar pneumonia; Bronchopneumonia ("Pneumonia," unquali- fied, is indefinite); Tuberculosis of lungs, meninges, peri- toneum, etc., Carcinoma, Sarcoma, etc., of_
(namne origin; "Cancer" is less definite; avoid use of "Tumor" for malignant neoplasms); Mcasles; 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 symp- toins 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," ete., when a definite disease 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 (e. g., scpsis, 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, Ilomicide, ctc.
2. Deaths supposedly caused by violence, as Criminal abortion, Poisoning, Starvation, Suffocation, Exposure,
etc.
3. Sudden deaths of persons not disabled by recognized disease, as A death upon the street, or one supposed to be due to Alcoholism, etc.
4. Deaths under circumstances unknown, as A person found dead, etc. 4
ADDITIONAL SPACE
FOR FURTHER STATEMENTS BY
PHYSICIAN.
R 15. 1-'18. 20,000.
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.
BOSTON
No.
St., Ward
(If death occurred in a hospital or institution, give its NAME instead of street and number)
2 FULL NAME
Mariam
Norton
(a) Residence.
No.
202 St. Paul St.
St., ............
... Ward.
Brooklyn, Ma
(Usual place of abode)
Length of residence in city or town where death occurred
years
3 months
days.
How long in U. S., if of foreign birth ?
years
months
days
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
4 COLOR OR RACE
femara. white
5 SINGLE, MARRIED, WIDOWED, OR
DIVORCED (write the word)
widowed
Sa If married, widowed, or divorced
HUSBAND of
(or) WIFE of
Jacob Norton
6 DATE OF BIRTH (month, day, and year)
Se1. 21.1828
7 AGE Years 90
Months
Days
7
If LESS than
1 day, ........ hrs.
or ....... min.
8 OCCUPATION OF DECEASED
(a) Trade, profession, or particular kind of work
(b) General nature of industry, business, or establishment in which employed (or employer) (c) Name of employer
9 BIRTHPLACE (city or town).
London England
(State or country)
10 NAME OF FATHER
11 BIRTHPLACE OF FATHER (eity or town) ..
London
(State or country) Eng.
12 MAIDEN NAME OF MOTHER
13 BIRTHPLACE OF MOTHER (city or town)
London Ing
(State or country)
14 Geo W. Norton
Informant
(Address)
202 St. Paul St. Brooklyn
15
Filed
.. , 19
REGISTRAR
16 DATE OF DEATH (month, day, and year) Refah. 2.8. 19 /8 .
17 HEREBY CERTIFY, That I attended deceased from aug. 14
to ...
Sept. 28
, 1918
that I last saw h
er
alive on
Sept. 28.
8-451. .m. The CAUSE OF DEATH* was as follows:
Organic Search Desease
.. (duration) A .... + yrs.
mos.
. ds.
CONTRIBUTORY
(SECONDARY)
(duration)
......
yrs ..
mos .....
18 Where was disease contracted
if not at place of death ?
Did an operation precede death ?
Date of.
Was there an autopsy ?
no.
FOR WHAT ?
clerical
What test confirmed diagnosis ?
Millican . Paraos
(Signed)
1/30, 19/8 (Adress)
Wartet opp, Mars.
M.D.
* 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
Wakefield
DATE OF BURIAL
C
19
20 UNDERTAKER
AL. Eastman Co.
ADDRESS
828 WIRaco
N. B. - WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD. 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.
PARENTS
Samuels
To
. ds.
, 19.
15
and that death occurred, on the date stated above, at
MEDICAL CERTIFICATE OF DEATH
(If non-resident give city or town and State)
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 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," 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- eifically 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- eated 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 usc 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 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- mus," "Old age," "Shock," "Uremia," "Weakness," etc., when a definite disease ean be ascertained as the cause. Always qualify all diseases resulting from ehild- 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 dc- 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 eircumstances unknown, as A person found dead, etc.
ADDITIONAL SPACE
FOR FURTHER STATEMENTS
BY
PHYSICIAN.
R 15. 2-'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 classified. Exact statement of OCCUPATION is very important. See instructions on back of certificate.
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
I PLACE OF DEATH Winthrop mass No. 94 Verrace ave
St. ; Ward)
2 FULL NAME
Sarah &. Montgomery
[If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE 94 Terrace Tvr. Muthion
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
4 COLOR OR RACE
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
Jingle
6 DATE OF BIRTH
11 (Month)
25 (Day)
(Year)
7 AGE
If LESS than. 1 day, ........ hrs./
32 yrs. 10 mos. ds.
or ........ min. ?
8 OCCUPATION
(a) Trade, profession, or
particular kind of work
BookKuper
(b) General nature of industry, business, or establishment in which employed (or employer).
9 BIRTHPLACE (State or country) Belfast Ireland
10 NAME OF
FATHER
James Montgomery
PARENTS
11 BIRTHPLACE OF FATHER (State or country) "Belfast Freland
12 MAIDEN NAME OF MOTHER Susannah Boyce,
13 BIRTHPLACE OF MOTHER (State or country) Belfast Grelaud
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
(Address)
16
Filed 191
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH Geht 28
(Month)
(Day)
1918
(Year)
I HEREBY CERTIFY that I have investigated the death of the deceased.
The CAUSE OF DEATH* was as follows :
Influenza pneumonia (broncho)
(Duration)
.yrs.
mos. .. ds.
Contributory
(SECONDARY)
(Duration)
yrs
mos. .ds.
1
(Signed)
Oct 1
1918 (Address).
M.D.
MEDICAL EXAMINER
* 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).
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 Istlopeset 10-2-198
20 UNDERTAKER
ADDRESS
(City or town.)
[If death occurred in a hospital or institution, give its NAME instead of street and number.]
Registered No.
NISHYW
ONIONIA HO-
Sept. 28, 1918.
STANDARD CERTIFICATE OF DEATH.
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, 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," 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 Ilouse- 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 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 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: 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 use of "Tumor " for malignant neoplasms) ; Measles .; Whooping cough; Chronic valvular heart disease; 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- aemia " (merely 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. 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 - prob- ably suicide. The nature of the injury, as fracture of skull, and consequences (e. g., sepsis tetanus) may be stated under the head of " Contributory."
Cases for the Medical Examiners. - Under the provisions 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, Ex- posure, etc.
3. Sudden deaths of persons not disabled by recognized disease, as A death upon the strect, or one supposed to be due to Alcoholism, etc.
4. Deaths under circumstances unknown, as A person found dead, etc.
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
BOSTON (City or town)
1 PLACE OF DEATH
County
Suffolk
State
Massachusetts
Registered No.
Township
City
BOSTON
No.
58 Beacon IL Duitse, on Ward
(If death occurred in a hospital or institution, give its NAME instead of street and number)
2 FULL NAME
(If in the Army or Navy of the United States giye rank organization, etc.)
(a) Residence./
No.
58 Beauno Thin stre Ward.
(Usual place of abode )
Length of residence in city or towo where death occurred
years
months
days.
How fong io U. S., if of foreign birth ?
years
months
days
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
272
4 COLOR OR RACE
71
5 SINGLE, MARRIED, WIDOWED, OR
DIVORCED (write the word)
fazla
5a If married, widowed, or divorced
HUSBAND of
(or) WIFE of
marya
6 DATE OF BIRTH (month, day, and/year)
7 AGE
27
Years
Months
Days
If LESS thao
1 day, ........ hrs.
or ....... min.
8 OCCUPATION OF DECEASED
(a) Trade, profession, or
particular kind of work
Conductive
(b) Geoeral oature of industry,
business, or establishmeot in
which employed (or employer)
(c) Name of employer
B.Q.B.T .L. P.R
9 BIRTHPLACE (city or town)
(State or country)
10 NAME OF FATHER Laurence J
PARENTS
11 BIRTHPLACE OF FATHER (city or town)
(State or country)
€ Batore
12 MAIDEN NAME OF MOTHER
Sigoed).
Celler Teppichese 2021. (Address) I tement81.
13 BIRTHPLACE OF MOTHER (city or town)
(State or country)
E13ator
16 DATE OF DEATH (month, day, and year) Sepia 9 19
17
I HEREBY CERTIFY, That I attended deceased from
Fyrt 19
19.6
29
19.6 ..
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