USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1916-1918 > Part 144
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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
Male
4 COLOR OR RACE
5 SINGLE, MARRIED, WIDOWED, OR
DIVORCED (write the word)
Varried
5a If married, widowed, or divorced HUSBAND of Mary Carpenter (or) WIFE of
6 DATE OF BIRTH (month, day, and year)
1871
7 AGE
Years
Months
Days
If LESS than 1 day, ........ hrs. or ........ min.
8 OCCUPATION OF DECEASED
(a) Trade, profession, or
particolar kind of work
Insurance
(b) General nature of industry, business, or establishment in which employed (or employer) (c) Name of employer
9 BIRTHPLACE (city or town)
(State or country) Mass
10 NAME OF FATHER John
PARENTS
11 BIRTHPLACE OF FATHER (city or town)
(State or country) Ireland
12 MAIDEN NAME OF MOTHER Mary Farmer
13 BIRTHPLACE OF MOTHER (city or town).
(State or country) Treland
14
Informant
Mary .Murray
(Address)
100 Waldemar Ave.
15 Filed 1- , 19
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH (month, day, and year)
19
17
I HEREBY CERTIFY, That I attended deceased from
Cect-14
1916, to.
Mar 11
19.8.
in
that I last saw h
alive on
Nur 11
, 198
and that death occurred, on the date stated above, at ....... . ........... m. The CAUSE OF DEATH* was as follows :
Chimie Dyfress Nephritis
(duration)
yrs.
.mos ..
ds.
CONTRIBUTORY
(SECONDARY)
.(duration)
.. yrs ..
18 Where was disease contracted
if not at place of death ?
Did an operation precede death?
.Date of
Was there an autopsy ?
What test confirmed diagnosis ?
(Signed)
starry affelly
M.D.
1/13.19/8 (Address) * 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
Holyhood Brookline
DATE OF BURIAL
IT 14/18
19
ADDRESS
20 UNDERTAKER
John F: O'malley
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.
.. mos. ds.
Poston
47
White
[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 engincer, 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) Automobilc 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 laborcr, Laborer - Coal mine, etc. Women at home, who are engaged in the duties of the household only (not paid Housckecpers 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 Scrvant, 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 same disease. Examples: Cerebrospinal fever (the only definite synonym is "Epidemic 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- toncum, etc., Carcinoma, Sarcoma, etc., of_
(name origin; "Cancer" is less definite; avoid use of "Tumor" for malignant neoplasms); Measles; Whooping cough; Chronic valvular hcart discase; Chronic interstitial nephritis, etc. The contributory (secondary or inter- current) affection need not be stated unless important. Example: Mcasles (disease causing death), 29 Gs .; Broncho- pneumonia (secondary), 10 ds. Never report mere symnp- toms or terminal conditions, such as "Asthenia." "Aneinia" (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 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
(Recommendations under the head of "Contributory." 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 circumstances unknown, as A person found dcad, 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
THEODORE R. GARDNER
Registered No.
15135
Place of Death
Boston
Date of Death
NOV.11
CHILDRENS HOSPT.
1918,
Age
5
years
5
months ろ
days.
STATISTICAL DETAILS.
SEX
COLOR
SINGLE, MARRIED, WID., DIV
M
W
S
1918,
Maiden Name
Husband's Name
Birthplace
Name of
THEODORE R . GARDNER
Father
Birthplace of Father
WORCESTER
TON
-
Maiden Name of Mother
MARGUERITE HOLMES
Birthplace of Mother
GLOUCESTER
(Signed) G. H. JACKSON JR. M.D.
NOV . 12 1918
SPECIAL INFORMATION from Hospitals, Institutions, Transients, or Recent Residents.
Place of Burial or removal
WINTHROP (WINTHROP CEM)
Undertaker C.R.BENNISON
Filed
NOV. 18 1918.
Date of Burial
WINTHROP
PHYSICIAN'S CERTIFICATE.
I HEREBY CERTIFY that I attended deceased during last illness 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:
TRAR'
PATRIBU
Primary É (Duration
TUBERCULOUS PERITONITIS
CITY
ROBIS
SOFFICE
2 YRS
BOSTONIA
.1022
CONDITAAL
COTMINE DONAT MASS.
Contributory : (Duration )
Occupation
Informant
Usual Residence WINTHROP (31 OAKLAND ST)
A true copy. Attest :
Filed Mich. 27, 1919
Registrar.
WINTHROP
1200. 11, 1918
The Commonwealth of Massachusetts STANDARD CERTIFICATE OF DEATH
Melrose
(City or town)
1 PLACE OF DEATH
County.
Middlesex
State
Massachusetts
Registered No.
Township
or Village
or
City
Melrose
No.
Melrose
Hospital
St., ...
Ward
(If death occurred in a hospital or institution, give its NAME instead of street and number)
2 FULL NAME
William H. Barter
(a) Residence. No.
33 Circuit .... Road,
.St.,
.. Ward.
Winthrop.Mass
(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
Male
4 COLOR OR RACE
White
5 SINGLE, MARRIED, WIDOWED, OR
DIVORCED (write the word)
Married.
5a If married, widowed, or divorced
HUSBAND of
(or) WIFE of
Margaret Callaghan
6 DATE OF BIRTH (month, day, and year)
Oct. 1, 1878
7 AGE
40
Years
Months
Days
12
1 day, tog hrs.
1
8 OCCUPATION OF DECEASED
(a) Trade, profession, or
particular kind of work ....
Lawyer
. MALDE
(b) General nature of industry,
business, or establishment in
which employed (or employer)
(c) Name of employer
9 BIRTHPLACE (city or town).
Boston,
(State or country) Mass
10 NAME OF FATHER
William H. Barter
11 BIRTHPLACE OF FATHER (city or town)
Bos.t.o.n.,
(State or country) Mass
12 MAIDEN NAME OF MOTHER Mary E. Ahearn
Boston,
13 BIRTHPLACE OF MOTHER (city or town)
(State or country)
Mass .
14
Informant
Mns Margaret Barter,
(Address)
wife. Winthrop, Mass.
15 11/ 16/18
., 19 WeHaven Jones REGISTRAR
ADDRESS
20 UNDERTAKER W. J. Cassidy, 160 Harrison Av.e Boston, Mass.
1
Did an operation precede death ?
Date of.
Was there an autopsy ?.
What test confirmed diagnosis ?
(Signed)
Roscoe D. Perley Med. Ex. . M.D.
11 /12/18des)
Melrose, Mass.
* 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 Holyhood Cem. Brookline.
DATE OF BURIAL
Nov . 15g/ 18
Filed
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH (month, day, and year)
Nov. 12,1918
17
I HEREBY CERTIFY, That I attended deceased from
, 19
.. , to.
.,19
that I last saw h
alive on
19
and that death occurred, on the date stated above, at
m.
If LESS than
The CAUSE OF DEATH* was as follows :
ME Automobile accident
TON EX CHARLESTON .
NORTH F. 1649. /1860. 0200.
mos.
(duration)
yrs.
.ds.
)CONTRIBUTORY
Fracture base of skull
(SECONDARY)
(duration)
.. yrs
mos ...
10hours
ds.
18 Where was disease contracted
if not at place of death ?
Upham St. Melrose.
PARENTS
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,
POND FEILDE .38
RATER
(Usual place of abode)
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- ilor, Architeet, 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 preeise 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 serviec 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 DEATH (the primary affection with respect to time and causation), using always the same accepted term for the saine 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; Bronehopneumonia ("Pneumonia," unquali- fied, is indefinite); Tuberculosis of lungs, meninges, peri- toneum, ete., Carcinoma, Sarcoma, etc., of_
(name origin; "Canecr" is less definite; avoid use of "Tumor" for malignant neoplasms); Measles; Whooping cough; Chronic valvular heart disease; Chronie interstitial nephritis, ete. The contributory (secondary or inter- current) affection need not be stated unless important. Example: Measles (disease causing death), 29 ds .; Broneho- pneumonia (secondary), 10 ds. Never report mere symnp- toms 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- 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," ete. State eausc 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 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, cte.
2. Deaths supposedly caused by violence, as Criminal abortion, Poisoning, Starvation, Suffocation, Exposure, ete.
3. Sudden deaths of persons not disabled by recognized diseasc, as A death upon the street, or one supposed to be due to Alcoholism, etc.
4. Deaths under circumstances unknown, as A person found dead, etc.
ADDITIONAL SPACE
FOR FURTHER STATEMENTS
PHYSICIAN.
BY
R 15. 1-'18. 20,000.
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 N. B .- WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD. Every item of information should be of certificate.
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH
County
Township
or Village .... No. 132 Pauline St
St.,
.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 rank, organization, etc.)
(a) Residence.
No. 132 Pauline at
St.,
Ward.
(Usual place of abode)
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
males
4 COLOR OR RACE
White,
5 SINGLE, MARRIED, WIDOWED, OR“
DIVORCED (write the word)
married
5a If married, widowed, pr divorced HUSBAND of (or) WIFE of batterine Coffie
6 DATE OF BIRTH (month, day, and year)
1867
7 AGE
Years
5%.
Months
Days
If LESS than I day, ........ hrs. or ....... min.
8 OCCUPATION OF DECEASED
(a) Trade, profession, or
particular kind of work
ForEn
(b) General nature of industry,
business, or establishment in
which employed (or employer)
(c) Name of employer
Der Company.
9 BIRTHPLACE (city or town)
(State or country)
OSova Scotia.
John.
PARENTS
11 BIRTHPLACE OF FATHER (city or town)
Nova Scotia
(State or country)
12 MAIDEN NAME OF MOTHER margaret Burling/13, 1978 (Adress)
13 BIRTHPLACE OF MOTHER (city or town) .... (State or country) Sala Scotia.
14 Yoerth Onelawson
Informant 132 Jaulime At (Address)
15 Filed ............... .... , 19
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH (month, day, and year) Nov-12 19/8
17 I HEREBY CERTIFY, That I attended deceased from nov 8 , 19/8 to .to. 194
that I last saw his
alive on
Vvv- 12H
.19:
and that death occurred, on the date stated above, at
8 pm m. The CAUSE OF DEATH* was as follows: .
Gente Meningitis
(duration)
yrs.
... mos.
2
ds.
CONTRIBUTORY
(SECONDARY)
Influenza
(duration)
.yrs ....
mos.
4
ds.
18 Where was disease contracted
if not at place of death ?
Did an operation precede death ?
Date of.
Was there an autopsy ?
What test confirmed diagnosis ?
(Signed).
Beachment.
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
Holy Cross malden
DATE OF BURIAL Nov 15 19 18
20 UNDERTAKER
John JO maly
ADDRES'S Winthrop
Winthrop (City or town)
State
grass
Registered No.
or
City
Frances Concilia
Melanson
con
(If non-resident give city or town and State)
10 NAME OF FATHER
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 healthifulness 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) 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 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. 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 None.
Statement of cause of death .- Name, first, the DISEASE CAUSING DEATHI (the primary affection with respect to time and causation), using always the same accepted term for the same disease. Examples: Cerebrospinal fever (the only definite synonym is "Epidemie cerebrospinal menin- gitis"); Diphtheria (avoid use of "Croup"); Typhoid fever (never report "Typhoid pneumonia"); Lobar pneumonia; Bronchopneumonia ("Pneumonia," unquali- fied, is indefinite); Tuberculosis of lungs, meninges, peri- toncum, etc., Carcinoma, Sarcoma, etc., of ..
(naine origin; "Cancer" is less definite; avoid use of
"Tumor" for malignant neoplasms); Measles; Whooping cough; Chronie valvular heart disease; Chronic interstitial nephritis, etc. The contributory (secondary or inter- current) affection need not be stated unless important. Example: Measles (disease causing death), 29 Gs .; 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, Of 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 earbolie 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 circumstances unknown, as A person found dead, etc.
ADDITIONAL SPACE FOR FURTHER STATEMENTS BY
PHYSICIAN.
R 15. 1-'18. 100,000.
TRANSPORTATION OF CORPSE
Always write with black ink)
1 PLACE OF DEATH
State of New Jersey DEPARTMENT OF HEALTH BUREAU OF VITAL STATISTICS CERTIFICATE OF DEATH
County of- DIVIMFED BY O. S.
St .;
Ward)
[If death occurred in a hospital or in- stitution give its
NAME
instead of
2 FULL NAME_Sgt. Arthur I. Fletcher 164607 Maj.Co. C.
street and number.]
PERSONAL AND STATISTICAL PARTICULARS 14th Engfs.
MEDICAL CERTIFICATE OF DEATH
16 Date of Death
11
12 19 __ 18
(Month)
(Day)
(Year)
6 Date of Birth
now.
12
1892
(Month) (Day)
(Year)
286
7 Age
yrs mos .ds.
8 Occupation
Seargent major
(State_or Country)
PARENTS
11 Birthplace
of Father
(State or country) Liverpool. Eng
12 Maiden name
of Mother
Julia Keeley
13 Birthplace
of Mother
(State or country) /
Manchester. ông
14 The above is true to the best of the knowledge and belief of
(Informant)
family
(Addres
815 Shirley St.
15 Place where remains are to be sent
augrett.
Date of Shipment Woodlawn, Ce
Shipping Undertaker
@ a Cela S. GOVERNMENT
ABLY FILL
Address
East Boston
(Firm Name)
PERMIT OF BOARD OF HEALTH OR REGISTRAR
This Permit with above Certificate, must be presented to Initial Baggage Agent and delivered with body at destination
.
Permission is hereby granted to remove for burial at Fast.Boston Mass the body
of _. Sgt. Arthur N. Fletcher above described, if prepared in accordance with the laws of this State. If contagious or communicable, state name of person who is authorized to accompany the body.
Health Officer or Registrar.
Detach above portion at this perforation, and hand to passenger in charge, to he delivered to the undertaker at destination. If burial is made in this State this blank should be exchanged for a local burial permit at place of burial.
17 I HEREBY CERTIFY, That death occurred, on
date stated above, at.
France
The CAUSE OF DEATH was as follows:
Hemorraghes
(Duration)
-yrs,-
_mos.
.ds.
Contributory
Secondary
(Duration) ._ yrs mos ds.
(Signed)
M. D.
19 (Address)
18 Length of Residence (for Hospitals, Institutions, Transients or Recent Residents)
At place In the
of death _____ yrs.
____ mos ____ ds
State_
-yrs
mos ____ ds.
Where was disease contracted,
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