USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1916-1918 > Part 143
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Statement of cause of death .- Name, first, the DISEASE CAUSING DEATII (the primary affeetion 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"); Typhoul fever (never report "Typhoid pneumonia"); Lobar pneumonia; Bronchopneumonia ("Pneumonia," unquali- fied, is indefinite); Tuberculosis of lungs, meninges, peri- toneum, etc., Carcinoma, Sarcoma, etc., of.
(name origin; "Cancer" is less definite; avoid use of "Tumor" for inalignant neoplasms); 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 (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," "Comna," "Convulsions,"" "Debility" (“Con-
genital," "Senile," etc.), "Dropsy," "Exhaustion," "Heart failure," "Hemorrhage," e." "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 child- birth or iniscarriage, 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; 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 eause of deatlı approved by Committee on Nomenclature of the American Medical Association.)
Cases for the Medical Examiners. - Under the provi- sions of chapter 24 of the Revised Laws deaths under the following conditions must be referred to the Medical Examiners:
1. Deaths following injury or violence, as Burns, Falls Drowning, Gas poisoning, Suicide, Homicide, etc.
2. Deaths supposedly caused by violence, as Criminal abortion, Poisoning, Starvation, Suffocation, Exposure, etc.
3. Sudden deaths of persons not disabled by recognized disease, as A death upon the street, or one supposed to be due to Alcoholism, etc.
4. Deaths under circumstances unknown, as A person found dead, etc.
ADDITIONAL SPACE FOR FURTIIER STATEMENTS BY
PHYSICIAN.
R 303. 6-'18. 50,000.
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 (Bland: Henneazul.
Informant
(Address)
15
Filed Nov. 21.2018
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH (month, day, and year) Nov. 800 1918
17
I HEREBY CERTIFY, That I attended deceased from
1918, to
son 8
1918
that I last saw h gh
alive on
1918.
and that death occurred, on the date stated above, at 3.15 A . m. The CAUSE OF DEATH* was as follows : Chronic Valveckan Heart Disease
The secretform not determinable ats whatis fattended her. (duration) yrs ... mos .. ds. CONTRIBUTORY Uicute Medipertains causing ....
(SECONDADY)
(duration)
about 20 hours
.. moon.
18 Where
disease con
if not at place of death?
at hen Residence .
Did an operation precede death? no Date of ...
Was there an autopsy ?
no
What test confirmed diagnosis ?
(Signed).
11.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 spacc.)
19 PLACE, OF BURIAL, CREMATION, OR REMOVAL
DATE OF BURIAL
19%
ADDRESS
20 UNDERTAKER
J. C. maley
(City or town)
1 PLACE OF DEATH/
County.
Township
or Village.
95 Beach Road
.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, give ranh, organization, etc.)
(a) Residence.
No. 95 Beach Road Wachwrap
.St.,
.. Ward.
(If non-resident give city or town and State)
(Usual place of abode)
Length of residence in city or town where death occurred
years
months
days.
How loog in U. S., if of foreign birth ?
years
months
days
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
Shemale Muita
5 SINGLE. MARRIED, WIDOWED, OR (dyp' he word)
5a If married, widowed, or divorced
HUSBAND of
(or) WIFE of
6 DATE OF BIRTH (month, day, and year)
1843
7 AGE 75
Years
Months
Days
If LESS than
1 ray, ........ hrs.
or ........ min.
8 OCCUPATION OF DECEASED
(a) Trade. profession, or
particular kind of work
AtHome.
(b) General nature of industry, business, or establishment in which employed (or employer) (c) Name of employer
preland.
9 BIRTHPLACE (city or town).
(State or country)
10 NAME OF FATHER
PARENTS
11 BIRTHPLACE OF FATHER (city or town) (State or country)
12 MAIDEN NAME OF MOTHER margaret Bygg 119, 1918 (Address) 202 86ok Drive Grillet
13 BIRTHPLACE OF MOTHER (city er town). (State or country) Irland.
The Commonwealth of Massachusetts STANDARD CERTIFICATE OF DEATH
State
Omare
Registered No.
.or
No
City Ellen Beatrice Galvin
4 COLOR OR RACE
REVISED UNITED STATES STANDARD CERTIFICATE OF DEATH [Approved by U. S. Census and American Public Health Association]
Statement of occupation. - Precise statement of occupa- tion is very important, so that the relative healthfulness of various pursuits can be known. The question applies to each and every person, irrespective of age. For many occupations a single word or term on the first line will be sufficient, e. g., Farmer or Planter, Physician, Compos- itor, 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) Salcsman, (b) Grocery; (a) Forcman, (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 entcred as Housewife, Housework, or At home, and children, not gainfully employed, as At school or At homc. 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 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 same diseasc. 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; Bronchopncumonia ("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); Mcasles; Whooping cough; Chronic valvular heart discase; Chronic interstitial nephritis, etc. The contributory (secondary or inter- current) affection need not be stated unless important. Example: Mcasles (disease causing death), 29 ds .; Broncho- pncumonia (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," "Urcmia," "Weakness," ete., 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 head - 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, ete.
3. Sudden deaths of persons not disabled by recognized disease, as A dcath upon the street, or one supposed to be due to Alcoholism, etc.
4. Deaths under circumstances unknown, as A person found dcad, etc.
ADDITIONAL SPACE
FOR FURTHER STATEMENTS BY PHYSICIAN.
1
R 15. 1-'18. 100,000.
The Commonwealth of Massachusetts STANDARD CERTIFICATE OF DEATH
Winthrop BOSTON (City or town)
1 PLACE OF DEATH
County
Suffolk
State Massachusetts Registered No ..
Township
Winthrop
or Village.
or
City
ROSTON
No.
1 Coral Que
St., ........
.Ward
(If death occurred in a hospital or institution, give its NAME Instead of street and number )
2 FULL NAME
Fannie Susman
(If in the Army or Sovy of the Unitdi Staves, gife rank, organization, etc.)
St.,
.Ward.
(Usual place of abode)
(If non-resident give city or town and State)
Length of residence in city or towa where death occorred years
months
days.
How long in U. S., if of foreign birth ?
years
months
days
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
3 SEX
4 COLOR OR RACE
Female W.
5 SINGLE, MARRIED, WIDOWED, OR
word)
Married
5a If married, widowed, or divorced HUSBAND of (or) WIFE of wife of Obretain
6 DATE OF BIRTH (month, day, and year)
7 AGE
Years
36
Months
Days
If LESS than 1 day, ........ brs. or ........ min.
8 OCCUPATION OF DECEASED
(a) Trade, profession, or
particular kind of work
House- Wife
(h) General nature of industry, business, or establishment in wbich employed (or employer) (c) Name of employer
.. (duration)
. yrs ..
.......
mos ....
3
ds.
CONTRIBUTORY
Influenza
(SECONDARY)
_(duration)
........ yrs ...........
mos.
3
ds.
18 Where was disease contracted if not at place of death?
FOR WHAT?
Did an operation precede death ?
Date of.
Was there an autopsy ?
What test confirmed diagnosis?
(Signed)
12 MAIDEN NAME OF MOTHER Sarah Goldman , 19 (Address)
13 BIRTHPLACE OF MOTHER (city or town) (State or country)
pursia
14
Informant
A. Cohen
(Address)
22 nevada It
15 Filed
., 19
Winthrop
REGISTRAR
16 DATE OF DEATH (month, day, and year)
av. J
194
17 I HEREBY CERTIFY, That I attended deceased from hr. 2 1914 to 192
that I last saw ht alive on
www.F
, 1910
and that death occurred, on the date stated above, at 830% .m. The CAUSE OF DEATH* was as follows :
9 BIRTHPLACE (city or town)
Russia
(State or country)
10 NAME OF FATHER
Simon Cohen
11 BIRTHPLACE OF FATHER (city or town) (State or country)
Russia
PARENTS
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.)
DATE OF BURIAL
19 PLACE OF BURIAL, CREMATION, OR REMOVAL
Wolven, Pride of Boston
20 UNDERTAKER Love ole Stanetsky
ADDRESS Boutony
XXM.
=
of certificate.
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,
(a) Residence.
No.
1 Coral Que
[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 form part of the second statement. Never return "Laborer,"
"Foreinan," "Manager," "Dealer," ete., 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, 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 domestic service for wages, as Servant, 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 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 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- loneum, etc., Carcinoma, Sarcoma, ete., of.
(name origin; "Cancer" is less definite; avoid usc of "Tumor" for malignant neoplasms); Measles; Whooping cough; Chronic valvular heart disease; Chronic interstitial nephritis, ete. 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," cte.), "Dropsy," "Exhaustion," "Heart failure," "Hemorrhage," "Inanition," "Maras- mus," "Old age," "Shoek," " Uremia," "Weakness," ete., when a definite discase can be ascertained as the cause. Always qualify all diseases resulting from ehild- birth or miscarriage, as "PUERPERAL septicemia," "PUER- PERAL peritonitis," cte. 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 eausc 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, ete.
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 dea:1, etc.
ADDITIONAL SPACE FOR FURTHER STATEMENTS BY
PHYSICIAN.
R 15. 2-'18. 100,000.
The Commonwealth of Massachusetts STANDARD CERTIFICATE OF DEATH
(City or town)
1 PLACE OF DEATH
County
Suffolk
State
Mass ..
Registered No .....
Township
Winthrop
or Village
or
No.1.5
Buchanan
St.,
Ward
(If death occurred in a hospital or institution, give its NAME instead of street and number)
2 FULL NAME
Walter D. Olafson
(a) Residence.
No ..
15 Buckanan
St.
.Ward.
(If non-resident give eity 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
mooths
days
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
4 COLOR OR RACE
Male
White
5 SINGLE, MARRIED, WIDOWED, OR
DIVORCED (write the word)
Single
5a If married, widowed, or divorced
HUSBAND of
(or) WIFE of
6 DATE OF BIRTH (month, day, and year)
May 26-1911
7 AGE 7
Years
Months
Days
1 day, ........ hrs. or ........ min.
8 OCCUPATION OF DECEASED
(a) Trade, profession, or
particular kiod of work.
(b) General nature of industry, business, or establishment in which employed (or employer) - (c) Name of employer
9 BIRTHPLACE (city or town)
Winthrop, Mass.
(State or country)
10 NAME OF FATHER
Johan A. Olafson
11 BIRTHPLACE OF FATHER (city or town) ...
(State or country)
Sweden
12 MAIDEN NAME OF MOTHER
Hilda Anderson /2019/(Address)
13 BIRTHPLACE OF MOTHER (eity or town).
(State or country)
Sweden
14
Informant
Mrs. .... Olafson
(Address)
15 Buckanan St.
15
File Nr === 1, 19(
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH (month, day, and year) 2000.10 1918.
17
I HEREBY CERTIFY, That I attended deceased from
Sub 12.
19.
to
18
200. 10
19.
22.00. 8,
19/8
and that death occurred, on the date stated above, at / N. m.
......... ....
(duration)
yrs ..
.mos ... .
ds.
CONTRIBUTORY (SECONDARY)
(duration)
. yrs ...
............ mos ..
ds.
18 Where was disease contracted
if not at place of death?
Did an operation precede death ?
L & Date of
Gug.18, 1918;
Was there an autopsy ?
2,50.
What test confirmed diagnosis ?
(Signed).
I.I.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
Woodlawn Cem.
DATE OF BURIAL
Nov. 12,18
20 UNDERTAKER
C. a. Rollers
ADDRESS
F. Boston
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
5
i
15
that I last saw h .......... alive on
If LESS thao
The CAUSE OF DEATH* was as follows :
(Usual place of abode)
City
Winthrop;
[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, 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 statcinent; 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," "Forcnian," "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 (lefinite salary), may be cutered 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 DEATII, 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 tiine and causation), using always the same accepted term for the same discasc. Examples: Cerebrospinal fever (the only definite synonym is "Epidemie cerebrospinal menin- gitis"); Diphtheria (avoid use of "Croup"); Typhoid fcver (never report "Typhoid pneumonia"); Lobar pneumonia; Bronchopneumonia ("Pneumonia," unquali- fied, is indefinite); Tuberculosis of lungs, meninges, peri- toneum, etc., Carcinoma, Sarcoma, etc., of_
(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 symnp- 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- mus," "Old age," "Shock,"" "Uremia," "Weakness," etc., 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," 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 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
(Recommendations under the head of "Contributory." on statement of cause of death approved by Committee on Nomenclature of the Ainerican 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, ctc.
.
ADDITIONAL SPACE FOR FURTHER STATEMENTS BY PHYSICIAN.
R 15. 1-'18. 100,000.
The Commomuralth of Massachusetts STANDARD CERTIFICATE OF DEATH
(City or town)'
1 PLACE OF DEATH
County
Suffolk
State ..
Mass.
Registered No ..
Township
Winthrop
Village
or
City
No. IO0, Waldemar .... Ave ..
St.,
. Ward
(If death occurred in a hospital or institution, give its NAME instead of street and number)
2 FULL NAME
LEFILVUEFAY.
(If in the Army or Navy of the United States, give rank, organization, etc.)
(a) Residence.
No ..... 100 Waldemar Ave,
St.,
Ward.
(If non-resident give city or town and State)
(Usual place of abode)
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