Town of Winthrop : Record of Deaths 1916-1918, Part 20

Author: Winthrop (Mass.)
Publication date: 1916
Publisher:
Number of Pages: 1316

USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1916-1918 > Part 20

Note: The text from this book was generated using artificial intelligence so there may be some errors. The full pages can be found on Archive.org (link on the Part 1 page).

Statement of cause of death. - Name, first, the DIS- EASE CAUSING DEATH (the primary affection with respect to time and causation), using always the same accepted term for the same disease. Examples: Cerebro-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," unqualified, is indefinite) ; Tuber-

culosis of lungs, meninges, peritonaeum, etc., Carcinoma, Sar- coma, ete., of .... .. (name origin: "Cancer" is less definite; avoid use of "Tumor" for malignant neoplasms); Measles; Whooping cough; Chronic valvular heart discase; Chronic interstitial nephritis, ete. The contributory (second- ary or intercurrent) affection need not be stated unless im- portant. Example: Measles (disease causing death), 29 ds .; Broncho-pneumonia (secondary), 10 ds. Never report mere symptoms or terminal conditions, such as "Asthenia," "An- acmia", (merely symptomatic), "Atrophy," "Collapse," "Coma," "Convulsions," "Debility" ("Congenital," "Senile,"" ete.), "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 scpticaemia," "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 onc supposed to be due to Alcoholism, ete.

4. Deaths under circumstances unknown, as A person found dead, etc.

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

1 PLACE OF DEATH Winthrop (No. 187, Lincoln St. :. ................ Ward)

(City or town.)

[If death occurred in a hospital or institution, give its NAME instead of street and number.]

......

.... Registered No.

PERSONAL AND STATISTICAL PARTICULARS

MEDICAL CERTIFICATE OF DEATH

* SEX

4 COLOR OR RACE

6 SINGLE,

MARRIED,

WIDOWED,

OR DIVORCED

(Write the word)

Married

16 DATE OF DEATH

May

(Month)

(Day)

(Year)

$ DATE OF BIRTH

1849

(Month)

(Day)

(Year)

7 AGE

If LESS than 1 day ......... hrs.

yrs.

mos.

19 ds.

or ....... min. ?

* OCCUPATION

(a) Trade, profession, or

particular kind of work

Carpenter

(b) General nature of industry, business, or establishment in which employed (or employer)

9 BIRTHPLACE

(State or country)

Jamouth 4.8-

10 NAME OF

FATHERY

James B. Kinney

PARENTS

11 BIRTHPLACE

OF FATHER

(State or country)

yamouth

12 MAIDEN NAME OF MOTHER . many Problems

13 BIRTHPLACE

OF MOTHER

(State or country)

yarmouth-

14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE

(Informant)

Mrs. Sayil a. Kinney

(Address)

187 Lincoln St.

REGISTRAR

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,

If not at place of death ?.

Former or

usual residence

19 PLACE OF BURIAL OR REMOVAL Yamouth U. S.

DATE OF BURIAL

5-24- 1916

UNDERTAKER

D. C. Skaggs.

ADDRESS

Winthrop

1916

.......

I HEREBY CERTIFY that I attended deceased from

1916

, to

May 20'

1916

that ! last saw h ........ alive on

may 20

191

and that death occurred, on the date stated above, at.

8.50km

The CAUSE OF DEATH* was as follows : General activo selemais Carmina Inbathat Reflects.

.(Duration)

... yrs.

mos.

20 ds.

Contributory

(SECONDARY)

(Duration)

mos.

... yrs.

ds.

M.D.

(Signed)

Muy 21, 1916 (Address)

.....

Whenthings

* If death followed injury or violence the certificate of death must be made out by the Medical Examiner.

.....

Filed 191

.........

Samuel a. Kunnen

2 FULL NAME

[If married or divorced woman or widow

give maiden name, also name of husband.]

@RESIDENCE

187 LinealesSt. Winthrop

way

201916 -

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 engincer, 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 House- 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 (rctired, 6 yrs.). For persons who have no occu- pation whatever, write None.

culosis of lungs, meninges, peritonacum, 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 eause. Always qualify all diseases resulting from childbirth or miscarriage, as "PUER- PERAL septicaemia," "PUERPERAL peritonitis," etc. State eause 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 eaused by violence, as Criminal abortion, Poisoning, Starvation, Suffocation, Ex- posure, etc.

3. Sudden deaths of persons not disabled by recognized discase, 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.

COMMONWEALTH OF MASSACHUSETTS

RETURN OF A DEATH-1916.

CITY OF BOSTON.

FULL NAME

JOHN GRADY

Registered No.

5475

Place of Death ¿ and Residence §

Boston

Date of Death

MAY 20

1916.

Age

years

months

days.

STATISTICAL DETAILS.

SEX.

COLOR.

SINGLE, MARRIED, WID., DIV.

Maiden Name

Husband's Name

Birthplace

BOSTON

Name of Father

PATRICK GRADY

Birthplace of Father IRELAND

Maiden Name of Mother

Birthplace of Mother IRELAND

Occupation OFFICER (DEER ISLAND)

Informant

Place of Burial or removal MT.BENEDICT

Undertaker J.F.O MALEY

WINTHROP

PHYSICIAN'S CERTIFICATE.

I HEREBY CERTIFY that I attended deceased during last illness,

1916, from 1916, 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 :

EGIST

RAR'S

RE T PATRIDUS. SIT DE Primary

CUT (Duraton

OFICE

LLAL BOSTONIA

CONDITAA

4 . 1022

STO TISREGIMINE DONATA A N. MASS. 14 BO.

Contributory · 3 (Duration)

CHR. INT.NEPHRITIS - YRS

(Signed)

E. W.WILSON

M.D.

1916

MAY 21 SPECIAL INFORMATION from Hospitals, Institutions, Transients, or Recent Residents.

ADMITTED TO HOSPT. APR.29.1916

Usual

Residence

WINTHROP (20 NEPTUNE AV)

Filed

MAY 24

1916.

A true copy.

Attest :

Eumseinen

Registrar.

AORTIC REGURGITATION - YRS

CITY

CITY HOSPT.

C ILLary 20, 1916

The Commonwealth of Massachusetts STANDARD CERTIFICATE OF DEATH

1 PLACE OF DEATH winthrop (No. 00 ., Sagamr Ward)

7887 winter (City or town.) [If death occurred in a hospital or institution, give its NAME instead of street and number.]

2 FULL NAME no Hamon

[If married or divorced woman on widow give maiden name, also name of husband.] @RESIDENCE No Sagamme ans.

PERSONAL AND STATISTICAL PARTICULARS

3 SEX

4 COLOR OR RACE

& SINGLE,

MARRIED,

WIDOWED,

OR DIVORCED

(Write the word)

1859

(Day)

(Year)

7 AGE

If LESS than 1 day ......... hrs.

77 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).

Sea Caplan-

9 BIRTHPLACE

(State or country)

Dearing me

Contributory (SECONDARY)

(Duration) .. yrs.

mos. ds.

(Signed)

Burgers Magmulti,

M.D.

Thay 21 1916 (Address) 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).

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 Portland me

DATE OF BURIAL

5/24.

191

0 UNDERTAKER

ADDRESS

Filed

-. , 191

REGISTRAR

MEDICAL CERTIFICATE OF DEATH

16 DATE OF DEATH

(Month)

(Day)

21, 191

...

(Year)

17 I HEREBY CERTIFY that I have investigated the death of the deceased.

The CAUSE OF DEATH* was as follows : Pincel Shot

resultin Shock

.(Duration)

.yrs.

.........

.......... .. mos. .. ds.

10 NAME OF

FATHER

11 BIRTHPLACE OF FATHER (State or country)

12 MAIDEN NAME OF MOTHER

13 BIRTHPLACE OF MOTHER (State or country)

14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE

(Informant)

(Address)

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

WRITE PLAINLY, WITH UNFADING INK -THIS IS A PERMANENT RECORD.

important. See instructions on back of certificate.

PARENTS

Registered No.

6 DATE OF BIRTH

any 20

(Month)

may 21, 1916 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 cach 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 sccond statement. Never return "Laborer," "Foreman," "Manager," "Dealer," etc., without more precise specification, as Day laborer, Farm laborer, Laborer - Coal minc, etc. Women at home, who are engaged in the duties of the household only (not paid House- 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. re 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 occu- pation whatever, write Nonc.

Statement of cause of death. - Name, first, the DIS- CASE 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 "Epidemie 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, peritonacum, cte., 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 (discase causing deatlı), 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," "Marasınus," "Old age," "Shock," "Uraemia," "Weakness," etc., when a definite disease can be ascertained as the cause. Always qualify all diseases resulting from childbirtli or miscarriage, as "PUER- PERAL scpticaemia," "PUERPERAL peritonitis," etc. State cause for which surgical operation was undertaken. For VIOLENT DEATHS state MEANS OF INJURY and qualify as ACCI- DENTAL, SUICIDAL, or HOMICIDAL, or as probably such, if impossible to determine definitely. Examples: Accidental drowning; Struck by railway train - accident; Revolver wound of head - homicide; Poisoned by carbolic acid - probably suicide. The nature of the injury, as fracture of skull, and consequences (c. g., sepsis tetanus) may be stated under the head of "Contributory."

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, 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, ete.

4. 'Deaths under circumstances unknown, as A person found dead, ete.

R. 16-8-'15. 5,000.

The Commonwealth of Massachusetts

STANDARD CERTIFICATE OF DEATH

(No

31 Hawthorne

Ward)

{If death occurred in a hospital or institution, give its NAME Instead of street and number.]

2 FULL NAME

Marilla E. Howard

Marilla E. Brackett Edwin

@RESIDENCE

31 Hawthorne ave.

Registered No.

MEDICAL CERTIFICATE OF DEATH

16 DATE OF DEATH

May

220 1916.

(Month)

(Day)

(Year)

6, to

I HEREBY CERTIFY that I attended deceased from

ahr. 11.

May 2, 1916

2 ......

that I last saw her alive on

mode Nº

1916

and that death occurred, on the date stated above, at

6-20 Pm

The CAUSE OF DEATH* was as follows :

arteria- Ackerora

.....

............. ds.

Contributory ..

acute n. phritis

(SECONDARY) ,

.(Duration)

.......

.. yrs.

mos.

ds.

(Signed)

Frf. Pantes

M.D.

Play 23ch 1916 (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

............ yrs.

mos.

Where was disease contracted, If not at place of death ?.

Former or usual residence

19 PLACE OF BURIAL OR REMOVAL Forest Hills. Ceur

DATE OF BURIAL

May 24

191.6

20 UNDERTAKER

Les. Sessions Sous to.

ADDRESS

Worcester

WATTE PLAINLT, WITH ONFADING INK THIS IS A PERMANENT RECORD.

1 PLACE OF DEATH

Winthrop

[If married or divorced woman or widow

give maiden name, also name of husband.]

....

3 SEX

Female

4 COLOR OR RACE

White

$ DATE OF BIRTH

(Month)

(Day)

7 AGE

yrs.

mos.

ds.

8 OCCUPATION

(a) Trade, profession, or

(b) General nature of industry,

business, or establishment in

which employed (or employer).

9 BIRTHPLACE

(State or country)

Harmon, ME.

12 MAIDEN NAME

OF MOTHER

Nancy

Dilatte

PARENTS

14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE

(Informant)

CHfar. W. Fraught

important. See instructions on back of certificate.

(Address)

Filed

191

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

particular kind of work

at hours

PERSONAL AND STATISTICAL PARTICULARS

6 SINGLE,

MARRIED,

WIDOWED,

OR DIVORCED

(Write the word)

Widowed

(Year)

If LESS than

1 day ........ hrs.

„min. ?

10 NAME OF

FATHER

John Brackett

11 BIRTHPLACE

OF FATHER

(State or country)

Wolfabow, N.H.

13 BIRTHPLACE

OF MOTHER

(State or country)

athens. Marie

............

....

REGISTRAR

(City or town.)

......

.(Duration)

yrs. .............

... mos.

22,1916

STANDARD CERTIFICATE OF DEATH.

Statement of occupation. - Preeise statement of oecu- pation 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 term on the first line will be sufficient, e. g., Farmer or Planter, Physician, Compositor, Architect, Loco- motive 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 nceded. 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," ete., without more precise specifieation, as Day laborer, Farm laborer, Laborcr - Coal mine, ete. Women at home, who are engaged in the duties of the household only (not paid House- 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, ete. If the occupation has been changed or given up on account of the DISEASE CAUSING DEATH, state occupation at beginning of illness. If retired from business, that fact may be indicated thus: Farmer (retired, 6 yrs.). For persons who have no oecu- pation whatever, write Nonc.

Statement of cause of death. - Name, first, the DIS- CASE CAUSING DEATH (the primary affection with respect to time and causation), using always the same accepted term for the same disease. Examples: Ccrebro-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," unqualified, is indefinite); Tuber-

culosis of lungs, meninges, peritonaeum, ete., Carcinoma, Sar- coma, ete., of ... ........... (name origin: "Cancer" is less definite; avoid use of "Tumor" for malignant neoplasms); MMeasles; Whooping cough; Chronic valvular heart disease; Chronic interstitial nephritis, ete. The contributory (second- ary or intereurrent) affection need not be stated unless im- portant. Example: Measles (disease eausing death), 29 ds .; Broncho-pneumonia (secondary), 10 ds. Never report mere symptoms or terminal conditions, such as "Asthenia," "An- aemia" (merely symptomatie), "Atrophy," "Collapse," "Coma," "Convulsions," "Debility" ("Congenital," "Senile," etc.), "Dropsy," "Exhaustion," "Heart failure," "Haemorrhage,". "Inanition," "Marasmus," "Old age," "Shock," "Uraemia," "Weakness," ete., when a definite disease ean be aseertained as the eause. Always qualify all Aiseases resulting from childbirth or miscarriage, as "PUER- PERAL septicacmia,". "PUERPERAL peritonitis," ete. State eause 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, ete.

2. Deaths supposedly eaused by violenee, as Criminal abortion, Poisoning, Starvation, Suffocation, Ex- posure, 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.

R. 15-8-'15. 100,00.

important. See instructions on back of certificate.

PARENTS

11 BIRTHPLACE OF FATHER (State or country) Scotland

12 MAIDEN NAME

OF MOTHER

Hellen Stewart

13 BIRTHPLACE OF MOTHER (State or country) Scotland

14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE

(Informant) ..

Jus. n. G. Koch

(Address)

HG tillude aur. Wintera

Filed ., 191

REGISTRAR

MEDICAL CERTIFICATE OF DEATH

16 DATE OF DEATH

May

1916

(Year)

(Month)

(Day)

6 DATE OF BIRTH

(Month)

(Day)

1879

(Year)

7 AGE

If LESS than

I day ......... hrs.

3.5 yrs.

mos.

ds.

or ..

..... min. ?

8 OCCUPATION

(a) Trade, profession, or

particular kind of work

Orthodontist

(b) General nature of industry, business, or establishment in which employed (or employer)

(Duration)

............ yrs.

...........

mos.

ds.

Contributemelden death

(SECONDARY)

(Duration) .. yrs.

mos. ds.

(Signed)

M.D.

2.6.199

5. 6 (Address)

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).

At place

of death

.. yrs.

mos.

In the

ds.

State

.yrs.

mos.

ds ...

Where was disease contracted, If not at place of death ?.

Former or usual residence.

19 PLACE OF BURIAL OR REMOVAL

DATE OF BURIAL

5-29, 1916

:0 UNDERTAKER

W. C. Skaggs.

ADDRESS

Winthrop

WRITE PLAINLY, WITH UNFADING INK - THIS IS A PERMANENT RECORD.

The Commonwealth of Massachusetts

STANDARD CERTIFICATE OF DEATH

1 PLACE OF DEATH Win Cheap (No. 46 Hillside Que. St. Ward)

norman

Reach-

7901

(City or town.)

[If death occurred in a hospital or institution, give its NAME instead of street and number.]

2 FULL NAME [If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE 46 Hilesiale ave ..

Registered No.

19240

PERSONAL AND STATISTICAL PARTICULARS

3 SEX

4 COLOR OR RACE

5 SINGLE,

MARRIED,

WIDOWED,

OR DIVORCED

(Write the word)

I HEREBY CERTIFY that I have investigated the death of the deceased.

The CAUSE OF DEATH* was as follows : Jedema Vjetra Lomas an

rain and die

.......

6 at, due to causes

9 BIRTHPLACE (State or country)

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Town of Winthrop : Record of Deaths 1916-1918, Part 20

Author: Winthrop (Mass.) Publication date: 1916 Publisher: Number of Pages: 1316

Author: Winthrop (Mass.)
Publication date: 1916
Publisher:
Number of Pages: 1316