USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1916-1918 > Part 25
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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.
R 18. 3-'16, 10,000,
COMMONWEALTH OF MASSACHUSETTS
RETURN OF A DEATH-1916.
CITY OF BOSTON.
Registered No. 6812
1
FULL NAME
Place of Death ¿ and Residence
Boston
Date of Death
JULY I
1916.
Age -
years 9
months 22 days .
STATISTICAL DETAILS.
SEX.
COLOR.
SINGLE, MARRIED, WID., DIV.
F
W
S
Maiden Name
STR
AR'S
R
T PATRIBA
SIT D Primary (Durationh
FICE
Name of Father
MAURICE J . SHALLOW
Birthplace of Father
CAMBRIDGE
Contributory . (Duration)
PULM.EMBOLUS
(Signed)
W.E.LADD
M.D.
H.GREEN
JULY I
1916
SPECIAL INFORMATION from Hospitals, Institutions, Transients, or Recent Residents.
Place of Burial
or removal
ST .JOSEPHS
P.J.MC ARDLE
Usual Residence
WINTHROP (54 LOCUST ST)
JULY 5
Filed
1916.
Undertaker
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 :
Husband's Name
CITY
BOSTON
Birthplace
BOSTONIA
CONDITAAL
STO TTA UISREGIMINE DONATA A. 1381. N. MASS.
Maiden Name of Mother
MARY V.DONAHUE
Birthplace of Mother
BOSTON
Occupation
Informant
SARCOMA NECK -1 YR. OPR.JUNE
30.1916
A true copy.
Attest :
Emblemen
Registrar.
MARY J. SHALLOW
CHILDRENS HOSPT.
July 1 , 19
0
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
Menchol
(No.
Rear 414 Shiiles
St. : ....... Ward)
(aller)
2 FULL NAME
[If married or divorced woman or widow
give maiden name, also name of husband.]
@RESIDENCE
414 Shirley SL
Registered No.
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
3 SEX
gemall
4 COLOR OR RACE
white
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
16 DATE OF DEATH
July
(Month)
(Day)
1. 196
(Year)
" DATE OF BIRTH
(Month)
(Day)
(Year)
7 AGE
If LESS than I day .... .... hrs. ......
yrs.
.........
mos. ............. ds.
or ..
... min. ?
8 OCCUPATION
(a) Trade, profession, or
particular kind of work
Working
(b) General nature of industry,
business, or establishment in
which employed (or employer)
9 BIRTHPLACE
(State or country)
.. (Duration)
.............. yrs. ................ mos. ..............
ds.
Contributory.
(SECONDARY)
.(Duration)
yrs.
mos.
ds.
(Signed)
Frl. Para
.........
M.D.
fale 2, 1016
Wanttros
......
* 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.
In the
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
DATE OF BURIAL
1916
.......
16
Filed 191
REGISTRAR
17 I HEREBY CERTIFY that I attended deceased from
, 1916 0
taly /
1916
that I/ last saw hlu alive on
1916
and that death occurred, on the date stated above, at
.......... m. The CAUSE OF DEATH* was as follows :
Premature barth
10 NAME OF
FATHER
Joseph. 2.
PARENTS
11 BIRTHPLACE
OF FATHER
(State or country)
Barbecues, Siland
12 MAIDEN NAME
OF MOTHER
Mary Joturion
13 BIRTHPLACE
OF MOTHER
(State or country)
Barbacoa Island
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
(Address)
20 UNDERTAKER
ADDRESS
(City or town.)
[If death occurred in a hospital or institution, give its NAME Instead of street and number.j
....... ,
1,1916
July
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, c. 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 nccded. 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 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 tiine and causation), using always the same accepted term for the same diseasc. Examples: Cerebro-spinal fever (the only definite synonym is "Epidemic cerebro-spinal meningitis") ; Diphtheria (avoid use of "Croup"); Typhoid fever (never rc- 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); 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" (mcrely symptomatic), "Atrophy," "Collapse," "Coma," "Convulsions," "Debility" ("Congenital," "Senile," ctc.), "Dropsy," "Exhaustion," "Heart failure," "Hacmorrhage," "Inanition," "Marasmus," "Old age," "Shock," "Uraemia," "Wcakness," ctc., when a definite disease can be ascertaincd 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 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 dcad, etc.
COMMONWEALTH OF MASSACHUSETTS
RETURN OF A DEATH-1916.
CITY OF BOSTON.
FULL NAME
LEO MOSES
Registered No. 6857
Place of Death ¿
Boston
and Residence S
Date of Death
JULY 2
1916.
Age
39
years
4
months 12 days.
STATISTICAL DETAILS.
SEX.
COLOR.
SINGLE, MARRIED, WID., DIV.
M
W
MAR.
Maiden Name
Husband's Name
Birthplace HOLLAND
Name of Father
AHREN MOSES
Birthplace of Father HOLLAND
Maiden Name of Mother
JULIANA BANDUCA
Birthplace of Mother HOLLAND
Occupation CIGARMAKER
Informant
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
R
SICUT
OFFICE
CIVYT.
BOSTONIA CONDITAD
4. 1822
STO
N. MASS.
Contributory · ULCERATION-& PERF . THROUGH (Duration)
DUODENUM WITH HEMORRHAGE - 32 DYS
(Signed)
G.H. STONE
M. D.
JULY 3
1916
SPECIAL INFORMATION from Hospitals, Institutions, Transients, or Recent Residents.
IN HOSPT.7 DAYS
Place of Burial or removal
MELROSE (NETHERLANDS CEMQual
Residence WINTHROP (7 SEAFOAM AVE)
Undertaker M. SOLOMON
Filed
JULY 6
1916.
A true copy . Attest : Emblemen
Registrar.
CITY
T PATRIDAS SIT DE Primary ( Duration) A:IS
ANEURYSM ABDOMINAL AORTA
TISS REGIMINE DONATA A
PETER BENT BRIGHAM HOSPT.
--- -
July
2,1916
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) Waltertouring-me
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)
16
Filed 191
REGISTRAR
17
I HEREBY CERTIFY that I attended deceased from
Jan
1916, to
.,
1916.
that I last saw hla alive on
1916,
and that death occurred, on the date stated above, at 10, 25 July
The CAUSE OF DEATH* was as follows :
Carcinoma / anach
0
(Duration).
1 ys
......
....... yrs. ................ mos.
ds.
........
Contributory
(SECONDARY)
(Duration)
yrs.
mos. ds.
(Signed)
al 30
. 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
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.
DATE OF BURIAL
191
ADDRESS
20 UNDERTAKER
CR Bemun
....... .Ward)
(City or town.) [If death occurred in a hospital or institution, give its NAME instead of street and number.]
2 FULL NAME
Lydia Jane
Suck
& Wiley of Chas. W. Such
[If married or divorced woman or widow give maiden name, also name of husband. Covered @RESIDENCE 145 MIGUEL
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
: SEX
4 COLOR OR RACE
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
Widow
DATE OF BIRTH
29
(Month)
(Day)
1
(Year)
7 AGE 79
If LESS than
I 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).
9 BIRTHPLACE
(State or country)
Walterbought
A
10 NAME OF
FATHER
Nathan Thompson
WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD.
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH/
1 PLACE OF DEATH
somerset
(No. 145 Heatherof St. ;.
.
16 DATE OF DEATH
Jul
(Month)
21
(Day)
....
, 191.6
(Year)
M.D.
19 PLACE OF BURIAL OR REMOVAL newfield me
1
July 2, 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, 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 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 IFouse- 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 Scrvant, 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 "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, 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- acmia" (merely symptomatie), "Atrophy," "Collapse," "Coma," "Convulsions," "Debility" ("Congenital," "Senile," etc.), "Dropsy," "Exhaustion," "Heart failure," "Haemorrhage," "Inanition," "Marasmus," "Old age," "Shock," "Uracmia," "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 one supposed to be due to Alcoholism, etc.
4. Deaths under cireuinstances unknown, as A person found dead, etc.
WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD.
important. See instructions on back of certificate. 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
[12-13-XXM]
The Commonwealth of Massachusetts STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH Winthrop
- 292 Winthink St. :.
Daniel 1. Inc
meinen
? FULL NAME
[If married or divorced woman or widow
give maiden name, also name of husband.]
a RESIDENCE 292Winthat
.... Registered No.
PERSONÁL AND STATISTICAL PARTICULARS
3 SEX
Vale
4 COLOR OR RACE
6 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
WidowEd
·DATE OF BIRTH
(Month)
(Day)
(Year)
7 AGE
82
mos. ds.
or ........ min. ?
& OCCUPATION
(a) Trade, profession, or
particular kind of work
Vrant Officer
(b) General nature of industry,
business, or establishment in
which employed (or employer)
Retired
9 BIRTHPLACE
(State or country)
Boston Mass
10 NAME OF
FATHER
PARENTS
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)
tranh
(Address) 43 Gowy Lt Eterett Holy Cross Malder
15
Filed
191
REGISTRAR
...
(Month)
(Day)
., (Year)
17 I HEREBY CERTIFY that I attended deceased from
........
3
..... .
, 191 __ z., to
July
4
191 3,
that I last saw h __
alive on
1916
and that death occurred, on the date stated above, at ..
A m.
The CAUSE OF DEATH* was as follows :
Did a surgical operation precede death ?
Date
(Duration)
............. yrs.
................
................
.ds.
Contributory
(SECONDARY)
.(Duration) .............. yrs. .. ........ mãos. ........... .ds.
(Signed)
M.D.
, 1916 (Address)
* If death followed injury or violence the certificate of death must be made ont 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. ........... ds ...
Where was disease contracted, If not at place of death ?.
Former of usual residence
19 PLACE OF BURIAL OR REMOVAL
DATE OF BURIAL
Jules 6, 1916.
20 UNDERTAKER
ADDRESS
Viedlo A. Magrath Cost Bouton
BOSTON
. (City or town.) [If death occurred in a hospital or institution, give its NAME instead of street and number.]
MEDICAL CERTIFICATE OF DEATH
6
191
If LESS than
I day ......... hrs.
16 DATE OF DEATH
......... Ward)
July 4 1916 U 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 necded. 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," "Forcman," "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 (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," unqualified, 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 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: Mcasles (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" ("Congonital," "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 deaths of persons not disabled by recognized disease, as A death upon the strcet, or one supposed to be due to Alcoholism, etc.
4. Deaths under circumstances unknown, as A person found dead, etc.
R. 15-8-'15. 100,000.
WRITE PLAINLY, WITH UNFADING INK - THIS IS A PERMANENT RECORD.
important. See instructions on back of certificate.
PARENTS
11 BIRTHPLACE OF FATHER (State or country) mystic Com
12 MAIDEN NAME OF MOTHER miknown
13 BIRTHPLACE OF MOTHER (State or country) Mystic Com-
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
Ings.
Juanes
(Address)
56 Sea View ( 20"
:5
Filed 191
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
(Day)
5
191.
(Year)
I HEREBY CERTIFY that I have investigated the death of the deceased.
The CAUSE OF DEATH* was as follows : Cento Jeden of The Langs plus posible asphyxia m todental to a convulsion presumably due to cardio al diseaseturation) .yrs. mos. ds.
Contributory. (SECONDARY)
(Duration) .. yrs.
mos.
ds.
(Signed)
.. 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.
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
7-7-
195
:0 UNDERTAKER
H. C. Skaggs
ADDRESS
Winther
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
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
(No. 56, Seaview
St. ............. Ward)
Withup (City or tow5 [If death occurred in a hospital or institution, give its NAME instead of street and number.]
Estelle Sestrude Bauer-
2 FULL NAME
[If married or divorced woman or widow
give maiden name, also name of husband.]
@RESIDENCE
Philadelphia, Pa
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
4 COLOR OR RACE
W
SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
Widowed
6 DATE OF BIRTH
20
(Month)
(Day)
1860 17
(Year)
7 AGE
If LESS than 1 day, ........ hrs.
... yrs. „mos 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).
' BIRTHPLACE
(State or country}
mystic conn:
10 NAME OF
FATHER
1 Ste Stema Deunion
In the
8008
1 PLACE OF DEATH Winthrop
Registered No.
NIANIA JOH CHAYASAH NIRHYW
July 5, 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 oceupations 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) 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 (retired, 6 yrs.). For persons who have no occu- pation whatever, write None.
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