USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1916-1918 > Part 32
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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 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, ctc., Carcinoma, Sar- coma, ctc., 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," "Haemorrhagc,". "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, ctc.
4. Deaths under circumstances unknown, as A person found dead, etc.
R. 15-8.'15. 100,000.
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH Winthrop
Therese
Daffer
[If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE 63 chentes Que, withup
22645
Registered No.
PERSONAL AND STATISTICAL PARTICULARS
3 SEX Female
4 COLOR OR RACE
w
6 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
Widound
6 DATE OF BIRTH
11 (Month)
(Day)
6
1890
(Year)
7 AGE
45 46
yrs.
9
mos.
26 ds.
or ....... min. ?
S OCCUPATION
(a) Trade, profession, or particular kind of work
- at home
(b) General nature of industry, business, or establishment in which employed (or employer)
9 BIRTHPLACE
(State or countryy
Sumany
PARENTS
11 BIRTHPLACE OF FATHER (State or country) Germany
12 MAIDEN NAME OF MOTHER
unknown
13 BIRTHPLACE OF MOTHER (State or country)
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant) ..
Diana Doffin
(Address)
63 chester dve Winthrop
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
Sept
2, 1916 (Year)
(Month)
(Day)
17
I HEREBY CERTIFY that I have investigated the death of the deceased.
The CAUSE OF DEATH* was as follows : Piste Shot avund the Head, Suicidal A 8
(Duration) ....
.... yrs. ...
ds.
Contributory (SECONDARY)
(Signed)
Lenge Burger Magnat,
mos.
......
ds.
Sapo 3, 1916 (Address)
0
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.
8 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
9-5, 1916
"0 UNDERTAKER W.C. Skaggs
ADDRESS
Würthute
WRITE PLAINLY, WITH UNFADING INK -THIS IS A PERMANENT RECORD.
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.
8129
(City or town.) [If death occurred in a hospital or institution, give its NAME instead of street and number.]
2 FULL NAME
(No. 63 chester Que
St. ............. Ward)
Filed ., 191
....
M.D.
10 NAME OF FATHER goingkousky
If LESS than
I day, ........ hrs.
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, ctc. 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) Automobilc 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 minc, etc. Women at home, who are engaged in the duties of the household only (not paid House- keepers who reccive 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 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- 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 "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 "Tuinor" 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- aeinia" (mercly 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 septicacmia," "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 (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, etc.
2. Deaths supposedly caused by violence, as Criminal abortion, Poisoning, Starvation, Suffocation, Ex- posurc, 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. 16.8-'15. 5,000.
The Commonwealth of Massachusetts STANDARD CERTIFICATE OF DEATH
(No .....
Shirley
.. ,
St. :
Ward)
(City or town.) [If death occurred in a hospital or institution, give its NAME Instead of street and number.]
? FULL NAME
S. Ralph Seavers
[If married or divorced woman or widow
give maiden name, also name of husband.]
@RESIDENCE
Reed Chanchun
.... Registered No.
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
Sift 4^
1916
......
(Month)
(Day)
(Year)
I HEREBY CERTIFY that I attended deceased from
any 30
1916, to
Sist 4"
1916
that Mast saw him alive on
RyT 4
1916.
.... .
and that death occurred, on the date stated above, .40 m.
The CAUSE OF DEATH* was as follows :
Autral Regurgitation
Canchic Aplicastation
(Duration)
2 yrs.
................ mos.
..............
ds.
Contributory.
(SECONDARY)
.. yrs.
.. mos. .............
ds.
(Duration)
31 notcall
M.D.
(Signed)
SAT 8, 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).
In the
At plece
of death ........
yrs. ...
mos. ..
ds.
Stete ............ 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
Cambodia Cent 9-7. 1916
20 UNDERTAKER
ADDRESS
W. C. Skaggs Winthrop
1 PLACE OF DEATH
Winthrop
$ SEX
' COLOR OR RACE
. w
DATE OF BIRTH
7 AGE
(b) General nature of industry.
business, or establishment
which employed (or employer).
PARENTS
(Informent)
mas. Ray
important. See instructions on back of certificate.
16
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
....
35 yrs. 18
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
Single
10
(Month)
(Day)
13
1850
(Year)
If LESS than
I day ........ hrs.
mos.
22 ds.
or ......... min. ?
& OCCUPATION
(a) Trade, profession, or
particular kind of work
Bookkeeper
9 BIRTHPLACE
(State or country)
Cambridge Mars.
10 NAME OF
FATHER
W. H. Seguro
11 BIRTHPLACE
OF FATHER
(State or country)
Cambridge mara
12 MAIDEN NAME
OF MOTHER
Swan Schaffner
13 BIRTHPLACE
OF MOTHER
(State or country)
Canada
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Address)
69 Haundace Ste ams
Filed 191
REGISTRAR
...... ....
PERSONAL AND STATISTICAL PARTICULARS
O
weyn
STANDARD CERTIFICATE OF DEATH. 1
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 terin on the first line will be sufficient, e. g., Farmer or Planter, Physician, Compositor, Architeet, Loeo- 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: (o) 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, Form 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- 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 "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); Measles; Whooping cough; Chronic volvular 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 .; Broneho-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 septieaemia,", "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 Medieal Examiners:
1. Deaths following injury or violence, as Burns, Falls, Drowning, Gas poisoning, Suicide, Homicide, etc.
2. Deaths supposedly caused by violence, as Criminol 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.
HELLIM
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-'15-XXM.]
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH
Winthrop
(No.
30
Bellevue CANNES
Ward)
BOSTON
(City or town.) [If death occurred in a hospital or institution, give its NAME instead of street and number.]
? FULL NAME
William Francis TEgletE
[If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE 30 Bellevue AVE, Winthrop
Registered No.
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
$ SEX
m
4 COLOR OR RACE
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
Married
" DATE OF BIRTH
March
(Month)
6 1876 ....
(Day)
(Year)
7 AGE
40
yrs.
6
mos.
5
ds.
or ........ min. ?
8 OCCUPATION
(a) Trade, profession, or
particular kind of work
Retired
(b) General nature of industry, business, or establishment In which employed (or employer).
9 BIRTHPLACE
(State or country)
Roxbury
PARENTS
11 BIRTHPLACE
OF FATHER
(State or country)
Roxbury
12 MAIDEN NAME
OF MOTHER
Frances BuEchler
13 BIRTHPLACE
OF MOTHER
(State or country)
Roxbury
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
Sarah E VEghle
(Address)
30 Bellevue Ave, Vin,
16
Filed 191
REGISTRAR ....
16 DATE OF DEATH
(Month)
11
, 1916
,
....
191
Sache-11
1916
17
I HEREBY CERTIFY that I attended deceased from
may 13
6.
...
to
that I last saw h
alive on.
Shv11
196
....
and that death occurred, on the date stated above, at
10 p. m.
The CAUSE OF DEATH* was as follows :
Setuntities Publicitar
Did a surgical operation precede death ?
10.
Date
.(Duration)
............. yrs.
.mos. .............
„ds.
General attering Schon
Contributory
(SECONDARY)
(Duration).
1
.yrs.
mos.
ds.
(Signed)
Branch of Tillan
M.D.
5126, 1914 (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
19 PLACE OF BURIAL OR REMOVAL
Holy Cross
Malden
DATE OF BURIAL
Sept. 14, 1916
20 UNDERTAKER Phos. J. Lane
ADDRESS &, Boston
120 Have St
WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD.
important. See instructions on back of certificate.
...
(Day)
(Year)
If LESS than
1 day ......... hrs.
10 NAME OF
FATHER
William Q. VeghelE
Sept. 11, 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 may form part of the second statement. Never return "Laborer," "Foreman," "Manager," "Dealer," etc., without more precise specification, as Day laborcr, Farm laborer, Laborcr - Coal mine, etc. Women at home, who are engaged in the duties of the household only (not paid House- keepcrs 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, Houscmaid, 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: Cercbro-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, peritoneum, 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 (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," "Senilc," 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 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. 100,000.
COMMONWEALTH OF MASSACHUSETTS
RETURN OF A DEATH 1916.
CITY OF BOSTON.
FULL NAME
JOSEPH OPNITSKY
Registered No.
9059
Place of Death ¿
Boston
MASS.GEN. HOSPT .
and Residence S
Date of Death
SEPT.12
1916.
Age
48
years
months days.
STATISTICAL DETAILS.
SEX.
COLOR.
-
SINGLE, MARRIED, WID., DIV.
M
W
M
Maiden Name
Husband's Name
Birthplace
RUSSIA
Name of
Father
HAICKEL OPNITSKY
SREGIMINE
STO
IN. MASS.
Contributory . (Duration)
(Signed)
S. M.BUNKER
M.D.
SEPT. 13 1916 SPECIAL INFORMATION from Hospitals, Institutions, Transients, or Recent Residents.
IN HOSPT.2 DAYS
Usual Residence
WINTHROP( II SEA FOAM AVE)
Filed
1916.
LOUIS MILLER
PHYSICIAN'S CERTIFICATE.
I HEREBY CERTIFY that I attended deceased during last illness,
1916, 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 : from 1916, to
IST
RAR'S
CITY
(Duration) FFICE
BOSTONIA
CONDITA
E DONATA A.
Birthplace of Father RUSSIA
Maiden Name
of Mother
IDA GREENBERG
Birthplace of Mother
RUSSIA
METAL DEALER
Occupation
Informant
Place of Burial or removal WOBURN( OHEL JACOB)
Undertaker
A true copy.
Attest :
SEPT. 15
Emblemen
Registrar.
AC.& CHR. MITRAL ENDOCARDITIS
0 Sept. 12, 1916 0
C
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-'15-XXM ]
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH
Nathrop
(No. 24 Sindbretons Rd
....
St. : .Ward)
BOSTON (City or town.) {If death occurred in a hospital or institution, give its NAME instead of street and number.]
Carrie R Dolan
2 FULL NAME.
[If married or divorced woman or widow give maiden name, also name of husband.] .
Carrie R. Fredrickes
Weder of Thos Tri. Dolan
@RESIDENCE
24 Sindlistonr Rd - Winthrop
Registered No.
PERSONAL AND STATISTICAL PARTICULARS
4 COLOR OR RACE
White
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
Vedou-
$ SEX
Female
· DATE OF BIRTH
7 AGE
8 OCCUPATION
11 BIRTHPLACE
OF FATHER
(State or country)
12 MAIDEN NAME
OF MOTHER
PARENTS
WRITE PLAINLT, WTTTT ONFADING INK THIS IS A PERMANENT NEVonD.
(b) General nature of industry,
business, or establishment in
which employed (or employer).
(Month)
(Day)
1
(Year)
44
........ yrs.
-
mos. - ..........
„ds.
or ........ min. ?
(a) Trade, profession, or
particular kind of work
Troms -
9 BIRTHPLACE
(State or country)
Boston
mass
10 NAME OF
FATHER
Fredericles
18 BIRTHPLACE
OF MOTHER
(State or country)
Philadelphia Pa
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
(Lista) - Louisen Fredandes
(Address)
24 Girdlestour Rd-
16 Filed 191
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
Sift
(Month)
20
1916
(Day)
(Year)
17
I HEREBY CERTIFY that I attended deceased from
1916, to
....
SAA 202
1916
.....
that I last saw him alive on
QAT 20"
1916
and that death occurred, on the date stated above, at
4.45pm
The CAUSE OF DEATH* was as follows :
Chronic Interstitial reports
Did a surgical operation precede death? WO Date
............
ds.
(Duration)
1
... mos ..
.yrs.
Contributory
(SECONDARY)
(Duration) .. yrs.
.......
.. mos.
ds.
......
(Signed)
M.D.
2121, 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).
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