USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1916-1918 > Part 21
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10 NAME OF
FATHER
Robert Reach
y 25 1916
STANDARD CERTIFICATE OF DEATH.
Statement of occupation. - Precise statement of oceu- pation is very important, so that the relative healthfulness of various pursuits can be known. The question applies to eaclı 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, Architcet, 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) 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 domestie service for wages, as Servant, Cook, Housemaid, etc. If the oceupation 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 indicated thus: Farmer (retired, 6 yrs.). For persons who have no oeeu- pation whatever, write None.
Statement of cause of death. - Name, first, the DIS- CASE CAUSING DEATH (the primary affection with respect to time and eausation), 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, etc., Careinoma, 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 intereurrent) 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," etc.), "Dropsy," "Exhaustion," "Heart failure," "Haemorrhage," "Inanition," "Marasmus," "Old age," "Shock," "Uraemia," "Weakness," etc., when a definite disease can be ascertained as the cause. Always qualify all discases resulting from childbirth or miscarriage, as "PUER- PERAL septicaemia," "PUERPERAL peritonitis," etc. State cause for which surgical operation was undertaken. For VIOLENT DEATHS state MEANS OF INJURY and qualify as ACCI- DENTAL, SUICIDAL, or HOMICIDAL, or as probably such, if impossible to determine definitely. Examples: Accidental drowning; Struck by railway train - accident; Revolver wound cf 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, Gus 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 duc to Alcoholism, etc.
4. Deaths under circumstances unknown, as A person found dead, etc.
R. 16.8.'15. 5,000.
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.
times
PARENTS
11 BIRTHPLACE OF FATHER (State or country) VMfast Veland
12 MAIDEN NAME OF MOTHER
Paul y ordner
13 BIRTHPLACE OF MOTHER
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
Mar Efusar (
(Address) / Ost-Juidne
16
Filed - 191
REGISTRAR
7921
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH Wirthump Mutcall Hospital
nes Mi quillan
2 FULL NAME [If married or divorced woman or widow give maiden name, also naine of husband.] @RESIDENCE Renéve -
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
6
(Month)
(Day)
(Year)
17 I HEREBY CERTIFY that I have investigated the death of the deceased.
The CAUSE OF DEATH* was as follows :
éte
internal
canned ly a .... ling (ice lift) accident ds. (Duration) .yrs.
......... mos. ...........
Contributory (SECONDARY)
(Duration) .yrs.
.mos. ds.
M.D.
(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 in -Grove
DATE OF BURIAL
20 UNDERTAKER
ADDRESS
.
-
19603
Registered No. . !
3 SEX
Male
4 COLOR OR RACE
White
5 SINGLE;
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
Married
6 DATE OF BIRTH
(Month)
(Day)
BAZA (Year)
7 AGE
If LESS than I day .hrs.
301
yrs. mos. ds.
or
min. ?
S OCCUPATION
(a) Trade, profession, or particular kind of work Valor
(b) General nature of industry, business, or establishment in which employed (or employer).
· BIRTHPLACE
(State or country)
Lekfact Ireland
10 NAME OF FATHER Men Milan
(Signed)
Sorry Burgas Magneto,
3
., 191
. ,
Willing (City or town.) [If death occurred in a hospital or institution, give its NAME instead of street and number.]
St. ..... ... Ward)
C
MARGIN
ump 3 , 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 each and every person, irrespective of age. For many occupations a single word or term on the first line will be sufficient, e. g., Farmer or Planter, Physician, Compositor, Architect, Loco- motive engineer, Civil engineer, Stationary fireman, etc. But in many cases, especially in industrial employments, it is necessary to know (a) the kind of work and also (b) the nature of the business or industry, and therefore an additional line is provided for the latter statement; it should be used only when needed. As examples: (a) Spinner, (b) Cotton mill; (a) Sales- man, (b) Grocery; (a) Foreman, (b) Automobile factory. The material worked on inay 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, 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, Houscwork, 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 domestie 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 None.
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 discase. Examples: Cerebro-spinal fever (the only definite synonym is "Epidemie cercbro-spinal meningitis"); Diphtheria (avoid use of "Croup"); Typhoid fever (never re- port "Typhoid pneumonia"); Lobar pneumonia; Broncho- pneumonia ("Pneumonia," unqualified, is indefinite); Tuber-
culosis of lungs, meninges, peritonaeum, etc., Carcinoma, Sar- coma, etc., of ... (name origin: "Caneer" 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 intereurrent) affection need not be stated unless im- portant. Example: Mcasles (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," ctc., when a definite disease ean be aseertained as the eause. Always qualify all diseases resulting from childbirth or miscarriage, as "PUER- PERAL septicaemia," "PUERPERAL peritonitis," ete. 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 (e. 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, ete.
2. Deaths supposedly caused by violence, as Criminal abortion, Poisoning, Starvation, Suffocation, Ex- posure, ete.
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.
R. 16-8-'15. 5,000.
CAUSE OF DEATH in plain terms, so that it may be properly classified. Exact statement of OCCUPATION is very N. B. - Every item of information should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state important. See instructions on back of certificate.
The Commonwealth of Massachusetts STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH
Waltham
MSFM
(No ..........
St. ;.................... Ward)
Elf death occurred in a hospital or institution, give its NAME Instead of street and number.]
2 FULL NAME
John Kean White
[If married or divorced woman or widow
give maiden name, also name of husband.]
@RESIDENCE
Winthrop
Registered No.
210
PERSONAL AND STATISTICAL PARTICULARS
$ SEX
{ COLOR OR RACE
5 SINGLE,
MARRIED.
WIDOWED,
OR DIVORCED
(Write the word)
· DATE OF BIRTH
(Month)
(Day)
1
(Year)
7 AGE
13
... yrs. ...
6
mos.
14
ds.
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)
Winthrop
(Duration)
............. yrs.
.......
.. mos.
ds.
Contributory.
Congenital mental defect
(SECONDARY)
(Duration)
.. yrs.
„mos. ..............
ds.
(Signed)
....
Walter E Fernald
M. D.
June 4
191.
(Address).
6
Waverley
* 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 6
3
of death
yrs.
mos.
8
In the
ds.
State ............ yrs. ...........
mos. ............ ds ......
Where was disease contracted, If not at place of death ?
Former or usual residence.
1 PLACE OF BURIAL OR REMOVAL
DATE OF BURIAL
191
--
......
...
........
16
Filed June 139,
........ Richard VESTER
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
June 3 1916
191
(Month)
(Day)
(Year)
.....
17
I HEREBY CERTIFY that I attended deceased from
May 31
6
June 3 1916
191
191
to
that I last saw him
June 3 1916
. 191
alive on
and that death occurred, on the date stated above, at 6.15 m?
The CAUSE OF DEATH* was as follows :
Exhaustion from Epilepsy
PARENTS
11 BIRTHPLACE
OF FATHER
(State or country)
Gardiner Me
12 MAIDEN NAME OF MOTHER Minnie M kean
1ª BIRTHPLACE
OF MOTHER
(State or country)
Augusta Me
" THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
School Records
(Address)
Winthrop
20 UNDERTAKER
George A Clark
ADDRESS
Waltham
(City or town.)
WRITE PLAINLY, WITH UNFADING INK -THIS IS A PERMANENT RECORD.
10 NAME OF
FATHER
Jares E
If LESS than
[ day ........ hrs.
Jump 3, 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 each and every person, irrespective of age. For many occupations a single word or term on the first line will be sufficient, e. g., Farmer or Planter, Physician, Compositor, Architect, Loco- motive engineer, Civil engineer, Stationary fireman, etc. But in many cases, especially in industrial employments, it is necessary to know (a) the kind of work and also (b) the nature of the business or industry, and therefore an additional line is provided for the latter statement; it should be used only when needed. As cxamples: (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 dutics 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 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 indicated thus: Farmer (retired, 6 yrs.). For persons who have no occu- pation whatever, write None.
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 "Epidemic 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, peritonacum, etc., Carcinoma, Sar- coma, 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 (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 mcre symptoms or terminal conditions, such as "Asthenia," "An- aemia" (mcrely symptomatic), "Atrophy," "Collapse," "Coma," "Convulsions," "Debility" ("Congenital," "Senile," etc.), "Dropsy," "Exhaustion," "Heart failure," "Haemorrhage," "Inanition," "Marasmus," "Old age," "Shock," "Uraemia," "Weakness," etc., when a definite disease can be ascertained as the cause. Always qualify all diseases resulting from childbirth or miscarriage, as "PUER- PERAL septicacmia," "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 deathis 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.
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
Winehurt (No.
St. : ......................... Ward)
Mary Mc Cabe
" FULL NAME
[If married or divorced woman or widow
give maiden name, also name of/husband.]
@RESIDENCE
Catherine Cottage Tevere It Was Registered No.
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
8 SEX
4 COLOR OR RACE
White
5 SINGLE,
MARRIED
Linde
OR DIVORCED
(Write the word)
16 DATE OF DEATH
frame
3
(Month)
(Day)
191
(Year)
· DATE OF BIRTH
abril
9
(Month)
(Day)
(Year)
7 AGE
If LESS than
I day ......... hrs.
............ 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).
Cridosis
.(Duration)
.......
... yrs. ................ mos.
ds.
Contributory
(SECONDARY)
(Duration) .....
yrs.
....
mos. ds.
(Signed)
Charles+ makines
.. , M.D.
Jums 4, 1916 (Adres).
055 Um Helix
* 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).
In the
At place
of death.
.yrs.
... mos.
ds.
State ............ yrs. ...........
mos. .........
ds.
Where was disease contracted, If not at place of death ?.
Former or usual residence
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
Mr Josefele M= Cabe.
(Address)
Catherine Cottage Penceatent
16
Filed 191
REGISTRAR
7
19 PLACE OF BURIAL OR REMOVAL
DATE OF BURIAL
June 56/ 1916
P UNDERTAKER
ADDRESS
583 Berry
PARENTS
10 NAME OF
FATHER
Josefa ME Cabe
11 BIRTHPLACE
OF FATHER
(State or country)
3) refand
12 MAIDEN NAME
OF MOTHER
Mary & Hard
18 BIRTHPLACE
OF MOTHER
(State or country)
South Boston
(City or town.)
[If death occurred in a hospital or institution, give its NAME instead of street and number.]
5
......
Female
5 yrs.
2 mos
mos.
ds.
1911
17
I HEREBY CERTIFY that I attended deceased from
3
1916, to.
Aucune 3, 1915
that I last saw halive on
Que 3, 1916,
and that death occurred, on the date stated above, at ...
7 Pm.
The CAUSE OF DEATH* was as follows :
9 BIRTHPLACE
(State or country)
Covereth.
U gummy 3, 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 second stateinent. Never return "Laborer," "Foreman," "Manager," "Dealer," etc., without more precise specification, as Day laborcr, Farm laborer, Laborer - Coal minc, etc. Women at home, who are engaged in the duties of the household only (not paid Housc- 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 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 indicated thus: Farmer (retired, 6 yrs.). For persons who have no occu- pation whatever, write None.
Statement of cause of death. - Name, first, thie DIS- EASE CAUSING DEATH (the primary affection with respect to time and causation), using always the same accepted term for the same discase. Examples: Cerebro-spinal fever (the only definite synonym is "Epidemic cerebro-spinal meningitis"); Diphtheria (avoid use of "Croup"); Typhoid fever (never re- port "Typhoid pneumonia"); Lobar pneumonia; Broncho- pneumonia ("Pneumonia," unqualified, is indefinite) ; Tuber-
culosis of lungs, meninges, peritonaeum, ete., 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 (disease causing death), 29 ds .; Broncho-pneumonia (secondary), 10 ds. Never report mere symptoms or terminal conditions, such as "Asthenia," "An- aemia" (merely symptomatic), "Atrophy," "Collapse," "Coma," "Convulsions," "Debility" ("Congenital," "Senile," etc.), "Dropsy," "Exhaustion," "Heart failure," "Haemorrhage," "Inanition," "Marasmus," "Old age," "Shock," "Uraemia," "Weakness," etc., when a definite disease can be ascertained as the cause. Always qualify all diseases resulting from childbirth or miscarriage, as "PUER- PERAL septicaemia," "PUERPERAL peritonitis," etc. State cause for which surgical operation was undertaken.
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, ctc.
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH
Winthrop
(No 50 Marshal
St. ;
.......
Ward)
................
(City or town.)
{if death occurred in a hospital or institution, give its NAME Instead of street and number.]
2 FULL NAME
Hubert It Kempton
[If married or divorced woman or widow
give maiden name, also name of husband.1
aRESIDENCE 50 Marshal St. Winthrop
Registered No.
PERSONAL AND STATISTICAL PARTICULARS
$ SEX
In
4 COLOR OR RACE
G SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
manned
· DATE OF BIRTH
4
(Month)
(Day)
1
18/13
(Year)
7 AGE
If LESS than
[ day .........
hrs.
73
„.yrs.
2 mos
8 .
or ........ min. ?
* OCCUPATION
(a) Trade, profession, or
particular kind of work
Builder
(b) General nature of industry, business, or establishment in which employed (or employer).
9 BIRTHPLACE
(State or country)
novascotia
PARENTS
12 MAIDEN NAME
OF MOTHER
Sarah right-
13 BIRTHPLACE
OF MOTHER
(State or country)
n.8-
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant
I. N. W. Kempton
(Address) 30 Marshalst.
16
Filed 191
........ .........
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
18 DATE OF DEATH
(Month)
(Day)
1916.
(Year)
17 ., 191 I HEREBY CERTIFY that I attended deceased from 8th 6. to luna get 1916
7 ....
.....
that I last saw hlere alive on
. 191
. .
and that death occurred, on the date stated above, at 3. a.m.
The CAUSE OF DEATH* was as follows :
Sondefinito
(Duration)
............ yrs.
mos.
............
ds.
Contributory
(SECONDARY)
(Duration)
.yrs.
............... mos.
........
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