USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1916-1918 > Part 146
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Cases for the Medical Examiners. - Under the provi- sions of chapter 24 of the Revised Laws deaths under the following conditions must be referred to the Medical Examiners:
1. Deaths following injury or violence, as Burns, Falls, Drowning, Gas poisoning, Suicide, Homicide, etc.
2. Deaths supposedly caused by violence, as Criminal abortion, Poisoning, Starvation, Suffocation, Exposure, etc.
3. Sudden deaths of persons not disabled by recognized 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. .L
ADDITIONAL SPACE
FOR FURTHER STATEMENTS BY
PHYSICIAN.
1-
7
L
C
R 15. 1-'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
City
No.
70 Atlantic St.
St.,.
......
.Ward
(If death occurred in a hospital or institution, give its NAME instead of street and number)
2 FULL NAME
Julia Teresa Peardon
"(If in the Army or for the United States, give rank, organization, etc.)
(a) Residence.
No.
(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
MEDICAL CERTIFICATE OF DEATH
3 SEX
Female
4 COLOR OR RACE
White
5 SINGLE, MARRIED, WIDOWED, OR
DIVORCED (write the word)
Widowed
16 DATE OF DEATH (month, day, and year)
nous 19.
19
18
17 I HEREBY CERTIFY, That I attended deceased from
19/6, to
19
....
that I last saw h
en
alive on
2018
19.(
and that death occurred, on the date stated above, at
m.
The CAUSE OF DEATH* was as follows :
If LESS than
1 day, ........ hrs.
or ........ min.
anita Dilatation want
8 OCCUPATION OF DECEASED
(a) Trade. profession, or
At How
particular kind of work.
(b) General nature of industry, business, or establishment in which employed (or employer) (c) Name of employer
(duration)
.yrs ...
mos.
ds.
CONTRIBUTORY
antein silenzio
(SECONDARY)
.. (duration)
yrs ....
......
.. mcs ..
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)
11/2/19/14 (Address) 856 Katholik
MI.D.
12 MAIDEN NAME OF MOTHER Catherine Tobin
13 BIRTHPLACE OF MOTHER (city or town)
(State or country)
Ireland
* 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
Holy Cross Melden
DATE OF BURIAL
11/2 2/18
19
Informant
Teresa Peardor
(Address)
70 Atlantic St.
15
Filed. 19
8
REGISTRAR
20 UNDERTAKER
John F. C maly
ADDRESS
Winthrop
7 AGE
Years
Months
Days
9 BIRTHPLACE (city or town)
(State or country)
Ireland
10 NAME OF FATHER John Mccarthy
11 BIRTHPLACE OF FATHER (city or town)
(State or country)
Ireland
PARENTS
14
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,
70 Atlanti
St.,
.Ward.
(If non-resident give city or town and State)
5a If married, widowed, or divorced HUSBAND of (or) WIFE of Dennie Feardon
6 DATE OF BIRTH (month, day, and year)
80
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 ean be known. The question applies to each and every person, irrespective of age. For many occupations a single word or terin on the first line will be sufficient, e. g., Farmer or Planter, Physician, Compos- itor, Architcet, Locomotive engineer, Civil engineer, Stationary fireman, ete. But in many eases, 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 exaniples: (a) Spinner, (b) Cotton mill; (a) Salesman, (b) Grocery; (a) Foreman, (b) Automobilc factory. The ma- terial worked on may form part of the second statement. Never return "Laborer,"
"Foreman," "Manager," "Dealer," cte., 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 reecive a definite salary), may be entered 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 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 faet may be indi- cated thus: Farmer (retired, 6 yrs.). For persons who have no oceupation whatever, write None.
Statement ot cause of death. -- Naine, first, the DISEASE CAUSING DEATH (the primary affeetion with respect to time and eausation), 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- toncum, cte., Carcinoma, Sarcoma, ete., of_
(name origin; "Cancer" is less definite; avoid use of "Tuinor" for malignant neoplasms); Measles; Whooping cough; · Chronic valvular heart disease; Chronic interstitial nephritis, cte. The contributory (secondary or inter- current) affeetion need not be stated unless important. Example: Measles (disease eausing death), 29 ds .; Broncho- pneumonia (secondary), 10 ds. Never report mere symp- toms or terminal conditions, such as "Asthenia,' "Anemia" (increly symptomatie), " Atrophy," "Col- lapse," "Coma," "Convulsions," "Debility" ("Con- genital," "Senile," cte.), "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 child- birth or miscarriage, as "PUERPERAL septicemia," "PUER- PERAL peritonitis," ete. State eause for which surgical operation was undertaken. For VIOLENT DEATIIS STATE MEANS OF INJURY and qualify as ACCIDENTAL, SUICIDAL, or HOMICIDAL, or as probably such, if impossible to de- terinine 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 (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.)
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 Medieal 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, etc.
3. Sudden deaths of persons not disabled by recognized disease, as A death upon the street, or one supposed to bc due to Alcoholism, etc.
4. Deaths under eireumstanecs unknown, as A person found dead, etc.
ADDITIONAL SPACE
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 classified. Exact statement of OCCUPATION is very
important. See instructions on back of certificate.
PARENTS
11 BIRTHPLACE OF FATHER (State or country)
12 MAIDEN NAME OF MOTHER
18 BIRTHPLACE
OF MOTHER
(State or country)
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE 1
(Informant)
(Address)
15
Filed
191
REGISTRAR
902
(City or town.)
{If death occurred in a hospital or institution, give its NAME instead of street and number.]
* FULL NAME
Eviit hurts vinweit,
[If married or divorced woman or widow
give maiden name, also name of busband.]
@RESIDENCE
266 - Numit
Registered No.
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
20
191
(Month)
(Day)
(Year)
· DATE OF BIRTH
(Month)
(Day)
(Year)
7 AGE
If LESS than 1 day ....... , hrs.
yrs. mos. ds.
or ........ min. ?
-
8 OCCUPATION
(a) Trade, profession, or
particular kind of work
(b) General nature of industry,
business, or establishment In
which employed (or employer).
tome.
9 BIRTHPLACE
(State or country)
......
(Duration)
................ yrs.
Contributory Lunatic Sucurgracias
(SECONDARY)
mos.
ds.
preferred Duration)
„yrs.
(Signed)
.....
M.D.
1/01 /20. 1918 (Address)
* 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).
At place
of death.
....... yrs.
.mos.
......
In the
.. ds.
State
.... y:8.
mos.
Where was disease contracted, If not at place of death ?..
Former or usual residence.
19 PLACE OF BURIAL OR REMOVAL
DATE OF BURIAL
C
191
20 UNDERTAKER
ADDRESS
1
3 SEX
{ COLOR OR RACE
6 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
1
17
I HEREBY CERTIFY that I attended deceased from
Ortatin 25-
191
8
Nov. 20
191
8
......
to
191. ....... that I last saw h.E. alive on por 19 8 and that death occurred, on the date stated above, at 2 A.m. The CAUSE OF DEATH* was as follows : Feciline and Sortir Discon.
THIS IS A ILIMANENT REVUND.
The Commonwealth of Massachusetts STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH
(No. 266 lacri it-
St. :
..... Ward)
10 NAME OF
FATHER
-
nov . 20, 1918
STANDARD CERTIFICATE OF DEATH.
Statement of occupation. - Precise statement of occu- pation is very important, so that the relative healthfulness of various pursuits can be known. The question applies to each and every person, irrespective of age. For many occupations a single word or term on the first line will be sufficient, e. g., Farmer or Planter, Physician, Compositor, Architect, Loco- motive engineer, Civil engineer, Stationary fireman, etc. But in many cases, especially in industrial employments, it is necessary to know (a) the kind of work and also (b) the nature of the business or industry, and therefore an additional line i 3 provided for the latter statement; it should be used only when needed. As examples: (a) Spinner, (b) Cotton mill; (a) Sales- man, (b) Groccry; (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, Laborcr - Coal mine, etc. Women at home, who are engaged in the duties of the household only (not paid House- kcepers 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, ctc. If the occupation has been changed or given up on account of the DISEASE CAUSING DEATH, state occupation at beginning of illness. If retired from business, that fact may be indicated thus: Farmer (retired, 6 yrs.). For persons who have no occu- pation whatever, write Nonc.
Statement of cause of death. - Name, first, the DIS- LASE CAUSING DEATH (the primary affection with respect to time and causation), using always the same accepted term for the same discase. Examples: Cercbro-spinal fever (the only definite synonym is "Epidemie cerebro-spinal meningitis"); Diphtheria (avoid use of "Croup"); Typhoid fever (never re- port "Typhoid pneumonia"); Lobar pneumonia; Broncho- pneumonia ("Pneumonia," unqualificd, 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) ; Mcasles; 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 (discase causing death), 29 ds .; Broncho-pneumonia (secondary), 10 ds. Never report mere symptoms or terminal conditions, such as "Asthenia," "An- acmia" (merely symptomatic), "Atrophy," "Collapse," "Coma," "Convulsions," "Debility" ("Congenital," "Senile," etc.), "Dropsy," "Exhaustion," "Heart failure," "Haemorrhage," "Inanition," "Marasmus," "Old age," "Shoek," "Uracmia," "Weakness," etc., when a definite discase 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, etc.
The Commonwealth of Massachusetts
County ..
E DEATE Colle
STANDARD CERTIFICATE OF DEATH
(City or town)
1 PLACE OF DEATH
States
mass.
Registered No.
Township
City
or Village. No 103 Donnert
or
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 ..
1103 SonstQUE
.. 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
4 COLOR OR RACE
White
5 SINGLE, MARRIED, WIDOWED, OR
DIVORCED (write the word)
Marvid
5a If married, widowed, or divorced
HUSBAND of
(or) WIFE of
lottie Kellehers
6 DATE OF BIRTH (month, day, and year)
1876
7 AGE
421
Years
Months
Days
If LESS than
1 day, ....... hrs.
or ........ min.
8 OCCUPATION OF DECEASED
(a) Trade. profession, or
Salesman
particular kind of work
(b) General mature of industry, business, or establishment in which employed (or employer) (c) Name of employer
9 BIRTHPLACE (city or town)
Cambulgo
(State or country)
бураса.
10 NAME OF FATHER wie.
PARENTS
11 BIRTHPLACE OF FATHER (city or town)
(State or country)
Canada.
12 MAIDEN NAME OF MOTHER Leulenoun.
13 BIRTHPLACE OF MOTHER (city or town).
(State or country)
Canada.
14
Informant
(Address)
163 Saniert Que
15 Filed 7.55.29.196
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH (month, day, and year)
20
19
17
I HEREBY CERTIFY, That I attended deceased from
19
1
..... , to./
19
that I last saw h
.. alive on
,19
4
and that death occurred, on the date stated above, at
.m. The CAUSE OF DEATH* was as follows :
1
(duration)
yrs ..
mos.
ds.
CONTRIBUTORY
(SECONDARY)
18 Where was disease contracted
if not at place of death ?
(duration)
... yrs.
mos.
1
ds.
Did an operation precede death ?
Date of
Was there an autopsy ?.
What test confirmed diagnosis ?
(Signed)
1/2/ 19/8 (Address)
15 -
1.
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 spacc.)
19 PLACE OF BURIAL, CREMATION, OR REMOVAL
Holy Cross malden
DATE OF BURIAL
1 19 .
20 UNDERTAKER
Film J. O'malley
ADDRESS
Winthrop
...
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,
Edmund Javeous
(If non-resident give eity 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 applics 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," 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 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 spc- eifically 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 liave no occupation whatever, write Nonc.
Statement of causo of death. -- Name, first, tlie DISEASE CAUSING DEATH (the primary affection with respect to time and causation), using always the same accepted term for the same discasc. Examples: Cerebrospinal fevcr (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- ficd, 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 ncoplasms); 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 deatlı), 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 discases resulting from child- birth or miscarriage, as "PUERPERAL septicemia," "PUER- I'ERAL peritonitis," etc. State cause for which surgical opcration was undertaken. For VIOLENT DEATHS STATE MEANS OF INJURY and qualify as ACCIDENTAL, SUICIDAL, or HOMICIDAL, or as probably such, if impossible to de- terinine 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 cause of death approved by Coinmittce 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 eaused 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 onc 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.
1
-
1
R 15. 1-'18. 100,000.
COMMONWEALTH OF MASSACHUSETTS
RETURN OF A DEATH-1918.
CITY OF BOSTON
FULL NAME
FRANCIS E.LYMAN
Registered No.
15387
Place of Death
Boston
Date of Death
NOV .20
1918,
Age
4
years 6
months
14
days
STATISTICAL DETAILS.
SEX.
COLOR
SINGLE, MARRIED, WID., DIV.
M
S
Maiden Name
Husband's Name
Birthplace
Name of Father
FRANCIS E.LYMAN
Birthplace of Father
EASTHAMPTON
Maiden Name of Mother
CLEO WILDER
Birthplace
of Mother
NATAL.SO.AFRICA
Occupation AT HOME
Informant
PHYSICIAN'S CERTIFICATE.
I HEREBY CERTIFY that I attended deceased during last illness from 1918, to
1918, 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'
AT'
U.S. Primary ( Duration
ROBIS
OFFICE
CT BOSTONIA CONDITA AL
D. 1829
B
MINY DONATA
Contributory: {EPIDEMIC INFLUENZA - DAYS (Duration)
(Signed) S.A.CLEMENT M.D.
NOV.20
1918
SPECIAL INFORMATION from Hospitals, Institutions, Transients, or Recent Residents.
IN HOSPT.2 DAYS
Place of Burial or removal WINTHROP (WINTHROP CEM)
Undertaker
C .R .BENNISON
Date of Burial
WINTHROP
Usual
Residence
WINTHROP ( 62 CRYSTAL COVE AV)
Filed
NOV .25
1918
A true copy.
Attest :
Registrar.
DOUBLE LOBAR PNEUMONIA-DAYS
WINTHROP
CITY
TON MASS.
MASS .HOME O .HOSPT.
2200 . 20 1918
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
906
Minitoast.
(City or town.)
[If death occurred in a hospital or institution, give its NAME Instead of street and number.]
? FULL NAME
[If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE 9 Welshwrist Wertlidt
& Wilshere St Wallet man
Registered No.
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
$ SEX
7
Fernando
COLOR OR RACE
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
manuel
1 (Year)
7 AGE
If LESS than [ day ........ hrs.
Or ........ min. ?
& OCCUPATION
(a) Trade, profession, or
particular kind of work
(b) General nature of industry,
business, or establishment
which employed (or employer)
9 BIRTHPLACE
(State or country)
Pullspieth mas
PARENTS
11 BIRTHPLACE
OF FATHER
(State or country)
England,
12 MAIDEN NAME
OF MOTHER
Grace. . E Bur lingham
13 BIRTHPLACE
OF MOTHER
(State or country)
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
(Address)
16 Filed 2-05-9/1912 ....
REGISTRAR
(Duration)
yrs.
mos.
................ ds.
Contributory.
Bracho Pneumonia
(SECONDARY)
(Duration) ......
yrs.
mos. ds.
(Signed)
M.D.
non V 191(Address)
8
..............
.......
* 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).
At place
of death
yrs.
mos.
ds.
State.
.yrs. ...
In the
mos.
ds.
Where was disease contracted, if not at place of death ?.
Former or usual residence
19 PLACE OF BURIAL OR REMOVAL
DATE OF BURIAL
191
.......
20 UNDERTAKER
ADDRESS
-
1 PLACE OF DEATH
9 Wils hat St
(No ..
....
St. ;............... Ward)
22 98.
...
(Month)
(Day)
(Year)
" DATE OF BIRTH
July 15-1883
(Month)
(Day)
35
yrs.
4
mos.
7
ds.
16 DATE OF DEATH
nos
17
I HEREBY CERTIFY that I attended deceased from
Mon, 18
191
to
nov. 22. 191
that I last saw her alive on
Non. 2.2. 1918.
and that death occurred, on the date stated above, at
„.m.
The CAUSE OF DEATH* was as follows :
......
10 NAME OF
FATHER
George, & Malthus
STANDARD CERTIFICATE OF DEATH
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