USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1916-1918 > Part 33
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In the
At place
of death.
yrs.
mos.
.........
ds.
State ............ yrs. .......
... mos.
........
Where was disease contracted, If not at place of death ?.
Former or usual residence.
19 PLACE OF BURIAL OR REMOVAL Holy - Hood - Tennatury
DATE OF BURIAL
Juht 22
1916
20 UNDERTAKER
I.D. Haller.
ADDRESS 130 autre El. Зам Р Хий
If LESS than
i day ......... hrs.
RECORD. PERMANENT
S.
Sept. 20, 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 fircman, 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 arc 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); Measles; Whooping cough; Chronic valvular heart disease; Chronic interstitial nephritis, etc. The contributory (second- ary or intercurrent) affection nced 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" (mere)y symptomatic), "Atrophy," "Collapse," "Coma," "Convulsions," "Debility" ("Congenital," "Senile," etc.), "Dropsy," "Exhaustion," "Heart failure," "Hacmorrhage,", "Inanition," "Marasmus," "Old age," "Shock," "Uraemia," "Weakness," etc., when a definite disease can be ascertained as the cause. Always qualify all Aiseases 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, Suicidc, 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.
important. See Instructions on back of certificate.
PARENTS
11 BIRTHPLACE
OF FATHER
(State or country)
Ountry) Lininglou In.
12 MAIDEN NAME
OF MOTHER
Parce Fimlos
are
18 BIRTHPLACE
OF MOTHER
(State or country) S
+ Emins
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
(Address)
15 Filed . 191
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
Sepr.
Month)
2
(Day)
(Year)
· DATE OF BIRTH
4
26
18 320 17
(Month)
(Day)
.... (Year)
7 AGE
If LESS than
1 day ......... hrs.
64 yrs.
.yrs.
4 mos.
28 de
Or ........ min. ?
* OCCUPATION
(a) Trade, profession, or
particular kind of work
Rtund
(b) General nature of industry,
business, or establishment in
which employed (or employer).
I HEREBY CERTIFY that I attended deceased from
to
Jan.
1916
Sept. 25/ 1916
that I last saw hum, alive on
Sify.
14
, 1916.
and that death occurred, on the date stated above, at 6:30pm.
The CAUSE OF DEATH* was as follows :
Cintursis of Sever
(Duration)
2
.. yrs.
......
.. mos.
ds.
Contributory
(SECONDARY)
.(Duration)
.. yrs.
mos. .
.......
ds.
(Signed)
Edward
·granger.
M.D.
Sehr- 26. 1916
(Addres) 49 Bartlett Rd.
....
* If death followed injury or violence the certificate of death must be made out by the Medical Examiner.
18 LENGTH OF RESIDENCE (FOR HOSPITALS, INSTITUTIONS, TRANSIENTS, OR RECENT RESIDENTS).
At place
of death
... yrs.
... mos ..
ds.
State ............ yrs.
......
In the
.. mos. ............
Where was disease contracted, If not at place of death ?. Former or usual residence.
19 PLACE OF BURIAL OR REMOVAL Wood Scorer.
DATE OF BURIAL
92% 1916
20 UNDERTAKER H. C. FPc= 910
ADDRESS
(1)
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
1 PLACE OF DEATH
(No.
78
Grand View air
St. :
Ward)
Gange @ Cafe
2 FULL NAME
[If married or divorced woman or widow
give maiden name, also name of husband.]
a RESIDENCE 78 Grand View 913 At. Sheiter Hacethe of
(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
1 SEX
{ COLOR OR RACE
121
' SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
Markeds
1916
9 BIRTHPLACE
(State or country)
10 NAME OF
FATHER
Christopher Cafe
....
STANDARD CERTIFICATE OF DEATH. 1
Statement of occupation. - Precise statement of occu- pation is very important, so that the relative healthifulness 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 laborer, Farm laborer, Laborer - Coal mine, etc. Women at home, who are engaged in the duties of the household only (not paid House- kcepers who receive a definite salary), may be entered as Houscwife, 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 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., 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 intercurrent) 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," "Collapsc," "Coma," "Convulsions," "Debility" ("Congenital," "Senile," etc.), "Dropsy," "Exhaustion," "Heart failure," "Haemorrhage," "Inanition," "Marasmus," "Old age," "Shock," "Uraemia," "Weakness," etc., when a definite discase can be ascertaincd as the causc. 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 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 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.
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)
New York
12 MAIDEN NAME
OF MOTHER
Gina Lary
13 BIRTHPLACE
OF MOTHER
(State or country)
London Eng.
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
Meyer Soloman
(Address)
Boston
16
Filed 191
...... REGISTRAR
MEDICAL CERTIFICATE OF DEATH
3 SEX
Secual
4 COLOR OR RACE
White
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
Single
" DATE OF BIRTH
Och.
10%
(Month)
(Day)
19/6
(Year)
7 AGE still born
.yrs.
mos.
ds.
or ....... min. ?
8 OCCUPATION
(a) Trade, profession, or
particular kind of work.
nowe.
(b) General nature of industry,
business, or establishment in
which employed (or employer) ..
9 BIRTHPLACE
(State or country)
Winthrop, Mais.
.(Duration) ........... yrs. ............. mos. ......... ds.
Contributory ..
(SECONDARY)
.(Duration).
.yrs.
mos.
ds.
(Signed)
Bah. 2. 1916
(Address)
Parti
M.D.
.....
* 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. .
ds.
State ......
.. yrs.
In the
mos. ............
Where was disease contracted, If not at place of death ?. Former or
usual residence.
258 Shirley At. Menckenoto
19 PLACE OF BURIAL OR REMOVAL
DATE OF BURIAL
Hand in Hand Cemetary Oct 2 1916
20 UNDERTAKER Power Salomon
ADDRESS Boston
(City or towa.) {If death occurred in a hospital or institution, give its NAME instead of street and number.]
Still born (tecaale) Herber
2 FULL NAME [If married or divorced woman or widow give maiden name, also name of husband. @RESIDENCE 258 Shirley At., Winthrop
Winthrop
STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH
1
Metall Hospital
(No.
174 Winthrop At.
St. :
2
Ward)
Registered No.
PERSONAL AND STATISTICAL PARTICULARS
16 DATE OF DEATH
Och.
1916
.......
(Month)
(Day)
(Year)
17
I HEREBY CERTIFY that I attended deceased from-
Och 1%
1916.
to
191
that I last saw h ............. alive on
191
and that death occurred, on the date stated above, at
m.
The CAUSE OF DEATH* was as follows :
Stell horn
.............
10 NAME OF
FATHER
Sievon Herder
If LESS than
[ day ......... hrs.
The Commonwealth of Massachusetts
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 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 DEATII, state occupation at beginning of illness. If retired from business, that fact may be indicated thus: Farmer (retired, 6 yrs.). For persons who have 110 occu- pation whatever, write None.
Statement of cause of death. - Name, first, tlie DIS- EASE CAUSING DEATH (the primary affection with respect to time and causation), using always tlic 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, peritonaeum, etc., Carcinoma, Sar- coma, etc., of ... .. (name origin: "Cancer" is less definite; avoid use of "Tumor" for malignant ncoplasms) ; Measles; Whooping cough; Chronie valvular heart disease; Chronie interstitial nephritis, etc. The contributory (second- ary or intercurrent) 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," "Uracmia," "Wcakness," etc., when a definite discase can be ascertained as the cause. Always qualify all diseases resulting from childbirthi 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 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.
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.
15
Filed .. , 191
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
3 SEX
4 COLOR OR RACE
White
$ SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word) Sim led
6 DATE OF BIRTH
June
12
(Month)
(Day)
1860 (Year)
7 AGE
If LESS than 1 day ......... hrs.
.... yrs. 3 mos. 22. . ds.
or
min. ?
& OCCUPATION
(a) Trade, profession, or particular kind of work Special Officer (Theater)
(b) General nature of industry,
business, or establishment in
which employed (or employer).
... (Duration)
.. yrs.
........
.. mos.
ds.
9 BIRTHPLACE
(State or country)
(Unknown)_ Maine
ds.
(Signed)
M.D.
MEDICAL EXAMINER
* State the DISEASE CAUSING DEATHI, 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.
....
Where was disease contracted, If not at place of death ?.
Former or usual residence.
19 PLACE OF BURIAL OR REMOVAL
DATE OF BURIAL
Oct. 3.
191 ....
6
ADDRESS
destora
10 NAME OF
FATHER
Luther Chick
PARENTS
11 BIRTHPLACE OF FATHER (State or country) (Unknown) Maine
12 MAIDEN NAME
OF MOTHER
Unknown
13 BIRTHPLACE
OF MOTHER
(State or country)
Unknown
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant).
Katherine J. bluck
(Address)
21 Delle Ave. Roxbury
The Commonwealth of Massachusetts
8203
STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH Wulhop
2 FULL NAME William Her
Chick
[If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE 409 Shirley St. Winthrop, Mass.
Registered No.
PERSONAL AND STATISTICAL PARTICULARS
Male
16 DATE OF DEATH
Que
(Month)
(Daf)
4
1916
(Ycar)
17 I HEREBY CERTIFY that I have investigated the death of the deceased. The CAUSE OF DEATH* was as follows : Pista 5
the
und unicidad
Contributory (SECONDARY)
(Duration)
In the
Mt. Hope Cem. Boston
20 UNDERTAKER
W. W. Graham
Winthrop (City or town.) [If death occurred in a hospital or institution, give its NAME instead of street and number.]
St. ............. Ward)
JIANUARU CERTIFICATE OF DEATH.
Statement of occupation. - Freeise statement of occu- 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 occupation ; 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 laborer, Farm laborer, Laborer - Coal minc, ete. 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 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- EASE CAUSING DEATH (the primary affeetion 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) ; Tube»
culosis of lungs, meninges, peritonacum, ete., Carcinoma, Sar- coma, etc., of. (name origin: "Cancer" is less definite; avoid use of "Tumor" for inalignant neoplasms); Measles; Whooping cough; Chronie valvular heart disease; Chronic interstitial nephritis, etc. The contributory (second- ary or intercurrent) 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 symptomatic), "Atrophy," "Collapse," "Coma," "Convulsions," "Debility" ("Congenital," "Senile," ete.), "Dropsy," "Exhaustion," "Heart failure," "Haemorrhage," "Inanition," "Marasmus," "Old age," "Shock," "Uraemia," "Weakness," ete., when a definite disease ean be ascertained 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- 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. 7.'16. 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.
16
Filed , 191
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
1ª DATE OF DEATH
17
I HEREBY CERTIFY that I attended deceased from
Sept 26
, 191.L., to.
ach 30
1916
that I last saw hewalive on
191
5am
och 30
16
and that death occurred, on the date stated above, at
The CAUSE OF DEATH* was as follows :
Jancomay Stomach
(Duration)
............ yrs.
.............. mos.
......
ds.
Contributory.
Ohmalinas Sage
(SECONDARY)
......
(Duration)
yrs.
ds
(Signed)
Jonathan H. Mix
M.D
Ock/5
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.
ds.
State ...........
yrs.
mos.
ds ...
............
Where was disease contracted, If not at place of death ?.
Former or usual residence.
19 PLACE OF BURJAL OR REMOVAL etter
DATE OF BURIAL
Det % 1916
...............
20 UNDERTAKER
ADDRESS
6
191
....
(Month)
(Day)
S
(Year)
PERSONAL AND STATISTICAL PARTICULARS
I SEX
4 COLOR OR RACE
" DATE OF BIRTH
Dec.
(Month)
(Day)
· AGE
4 %.
.yrs.
9
10
„ds.
mos.
& OCCUPATION
(a) Trade, profession, or
particular kind of work
(b) General nature of industry,
business, or establishment in
which employed (or employer).
11 BIRTHPLACE
OF FATHER
(State or country)
Ireland
PARENTS
WHITE PLAINLY, WTTTT ONTADING INK InIS 19 A PERMANLITT NEVUND.
9 BIRTHPLACE
(State or country)
Boston Lasz.
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