USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1916-1918 > Part 48
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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 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," "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 scpticaemia," "PUERPERAL peritonitis," etc. State eause for which surgical operation was undertaken.
Cases for the Medical Examiners. - Under the provi- sions of chapter 24 of the Reviscd 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-'16. 100,000.
[10-'16-XXM.]
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH
Winthrop
(No.
54
Locust
St .; Ward)
Jermie E Donahoe
* FULL NAME
[If married or divorced woman or widow
give maiden name, also name of husband.]
@RESIDENCE
54
Societ It Winthrop
Winthrop
BOSTON ....
(City or town.)
[If death occurred in a hospital or institution, give its NAME instead of street and number .!
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
4 COLOR OR RACE
WI
Married
· DATE OF BIRTH
Oct. 71862
(Month)
(Day)
(Year)
7 AGE
If LESS than { day ......... hrs.
54 yre. 4 mos.
8
ds.
or ......... min. ?
8 OCCUPATION
(a) Trade, profession, or
particular kind of work
House-Wife
(b) General nature of Industry
business, or establishment in
which employed (or employer).
Robe 1
Did a surgical operation precede death ?
10
Date
(Duration)
............. yrs. ...............
.mos.
6
-
Contributory.
(SECONDARY)
(Duration)
„yrs.
.mos.
da.
31 Met cal
M.D.
* If death followed injury or violence the certificate of death must be made out by the Medical Examiner.
18 LENGTH OF RESIDENCE (FOR HOSPITALS, INSTITUTIONS, TRANSIENTS, OR RECENT RESIDENTS).
At place
of death
... yrs.
mos.
.......
In the
ds.
State ...........
yrs.
.. mos ..
Where was disease contracted, If not at place of death ?.
Former or usual residence.
19 PLACE OF BURIAL OR REMOVAL W.In Calvary Cemetery
DATE OF BURIAL
Helly
191
..............
17
20 UNDERTAKER
ADDRESS
Filed
191 .....
REGISTRAR
16 DATE OF DEATH
76
(Month) 15 1917 (Year.
(Day)
.....
17
I HEREBY CERTIFY that I attended deceased trom
76-10
1912, to
.....
.....?
Feb 15"
1912
that I last saw h M alive on
76 14
1917
......
and that death occurred, on the date stated above,
230Am.
The CAUSE OF DEATH* was as follows :
Lobar Pracumia (righthowy
da.
9 BIRTHPLACE
(State or country)
Beton Mars
10 NAME OF
FATHER
James Healey
11 BIRTHPLACE
OF FATHER
(State or country)
Ireland
PARENTS
12 MAIDEN NAME
OF MOTHER
Unknown
12 BIRTHPLACE
OF MOTHER
(State or country)
NTHE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
Patrick M Damalige
(Address)
16
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
Jennie & Healey wife Patrick M Dinahoe
Registered No.
MEDICAL CERTIFICATE OF DEATH
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.
(Signed)
76 /6/ 1917
(Address).
Feb. 15, 1917
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 applics 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, Architect, Loco- motive enginecr, Civil cngincer, 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 "Laborcr," "Foreman," "Manager," "Dcaler," etc., without more precise specification, as Day laborer, Farm laborer, Laborer - Coal minc, etc. Women at home, who are engaged in the duties of the household only (not paid House- keepers who receive a definite salary), may be entered as Housewife, 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 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; Broneho- 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 (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" ("Congenital," "Senile," etc.), "Dropsy," "Exhaustion," "Heart failure," "Hacmorrhage," "Inanition," "Marasmus," "Old age," "Shock," "Uraemia," "Weakness," etc., when a definite discase 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.
1 PLACE OF DEATH
2 FULL NAME
alonzo E. Moore
[If married or divorced woman or widow
give maiden name, also name of husband.]
@RESIDENCE
Winthrop, Maxx
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
3 SEX.
Male
4 COLOR OR RACE
Ethiopian
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
Single
16 DATE OF DEATH
Feb
(Month)
(Day)
16, 1917
(Year,
" DATE OF BIRTH
14
898
17
I HEREBY CERTIFY that I attended deceased trom
(Month)
(Day)
(Year)
7 AGE
If LESS than [ day ........ hrs.
17
... yrs.
mos.
2
ds.
Or ........ min. ?
· OCCUPATION
(a) Trade, profession, or
particular kind of work
at School
(b) General nature of Industry, business, or establishment in which employed (or employer).
Tubercular Meningitis
mos.
ds.
Contributory.
y Pulmonary tuberculosis
(SECONDARY)
(Duration)
yrs.
mos. ds.
Richard H. Morris
M.D.
Feb. 16, 1917
(Address)
Everett
* 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.
In the
...... d ............ Where was disease contracted, If not at place of death ?.
Former or usual residence.
19 PLACE OF BURIAL OR REMOVAL
DATE OF BURIAL
Winthrop Sem Hin Feb. 18, 1917
20 UNDERTAKER
N.C. Skaggs
ADDRESS
Winthrop
important. See Instructions on back of certificate.
PARENTS
[] BIRTHPLACE
OF FATHER
(State or country)
Barbadaes
12 MAIDEN NAME
OF MOTHER
Franklin
13 BIRTHPLACE
OF MOTHER
(State or country)
Barbados
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
glanzo a moores
(Address)
Winthrop, mass.
16 Filed.
Feb. 19, 1917 Jeph A Sannell REGISTRAR
N B .- Every item of information should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state CAUSE OF DEATH in plain terms, so that it may be properly classified. Exact statement of OCCUPATION is very
WRITE PLAINLY, WITH UNFADING INK -THIS IS A PERMANENT RECORD.
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
Everett
(No Tuberculosis Hospital
Jufler St.
Ward)
Everett (City or town.) [If death occurred in a hospital or institution, give its NAME instead of street and number.]
Registered No.
1917
to
Feb 16
1917
....
Feb. 2
that I last saw bem alive on
Feb. 16
191/
and that death occurred, on the date stated above, at
12 m.
The CAUSE OF DEATH* was as follows :
(Duration)
.yrs.
......
9 BIRTHPLACE
(State or country)
malden
10 NAME OF
FATHER
Honza a. Moore(Signed)
tel . 16, 1917
STANDARD CERTIFICATE OF DEATH.
Statement of occupation. - Precise statement of oeeu- pation is very important, so that the relative healthfulness of various pursuits ean be known. The question applies to each and every person, irrespective of age. For many occupations a single word or term on the first line will be sufficient, e. g., Farmer or Planter, Physician, Compositor, Architect, Loco- motive engineer, Civil engineer, Stationary fireman, ete. But in many 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," ete., 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, Housework, or At home, and children, not gain- fully employed, as At school or At homc. Care should be taken to report specifically the occupations of persons engaged in domestic service for wages, as Servant, Cook, Housemaid, ete. If the occupation has been changed or given up on account of the DISEASE CAUSING DEATH, state occupation at beginning of illness. If retired from business, that fact may be indicated thus: Farmer (retired, 6 yrs.). For persons who have no oceu- 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., 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- aemia" (merely symptomatie), "Atrophy," "Collapse," "Coma," "Convulsions," "Debility" ("Congenital," "Senile," ete.), "Dropsy," "Exhaustion," "Heart failure," "Haemorrhage," "Inanition," "Marasmus," "Old age," "Shock," "Uracmia," "Weakness," ete., when a definite disease ean be ascertained as the cause. Always qualify all diseases resulting from childbirth or miscarriage, as "PUER- PERAL scpticacmia," "PUERPERAL peritonitis," etc. State eause for which surgical operation was undertaken.
Cases for the Medical Examiners. - Under the provi- sions of chapter 24 of the Revised Laws deaths under the fol- lowing conditions must be referred to the Medical Examiners:
1. Deaths following injury or violence, as Burns, Falls, Drowning, Gas poisoning, Suicide, Homicide, etc.
2. Deaths supposedly 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, ete.
R 18. 3_'16. 10,000.
COMMONWEALTH OF MASSACHUSETTS
RETURN OF A DEATH-1917.
CITY OF BOSTON
FULL NAME
JOHN J. MC GLINCEY
Registered No.
1941
MASS .HOMEO .HOSPT.
1917,
Age
4
years
months days.
STATISTICAL DETAILS.
SEX
COLOR.
SINGLE, MARRIED, WID., DIV.
M
W
S
Maiden Name
Husband's Name
Primary
PA (Duration
BORIS
Birthplace
BOSTON
Name of
JOHN J.MC GLINCEY
Father
Birthplace
BOSTON
of Father
Maiden Name of Mother
MARY MC PHERSON
Birthplace of Mother
-N. S.S
(Signed) S.A.CLEMENT
M.D.
FEB. 16 1917 SPECIAL INFORMATION from Hospitals, Institutions, Transients, or Recent Residents.
IN HOSPT. MONTH
Place of Burial or removal
CALVARY(NEW)
J.F.O MALEY
Undertaker
Filed 1917.
A true copy. Attest :
WINTHROP (64 PROSPECT AV)
Usual
Residence
FEB.20
WINTHROP
PHYSICIAN'S CERTIFICATE.
I HEREBY CERTIFY that I attended deceased during last illness, from
1917, 1917, 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 :
RAR
SCARLET FEVER - 1 MONTH
SOFFICE
BOSTONIA
CONDΙΤΑ ΛO.
4.1822.
IC3O.
GIM
MINE DONATA A
TON. MASS.
Contributory: { (Duration )
ACUTE NEPHRITIS - 3 DAYS
Occupation
Informant
Place of Death l and Residence §
Boston
Date of Death
FEB. 16
3
1
Registrar.
Feb 16, 1917
..
COMMONWEALTH OF MASSACHUSETTS
RETURN OF A DEATH 1917.
CITY OF BOSTON
FULL NAME
SUSAN S. BOWSER
Registered No. 2087
Place of Death { and Residence
Date of Death
Boston ELM HILL HOSP. FEB 18
1917, Age 72
years
months
days.
STATISTICAL DETAILS.
SEX.
COLOR.
SINGLE, MARRIED, WID., DIV.
F
W
WIDOWED
Maiden Name
STODDARD
Husband's Name
WILLIAM L. BOWSER
R
TRAR' Primary rt (Duration)
GOBIS
Birthplace
BOSTON MASS
Name of Father
ISAIAH STODDARD
Birthplace of Father BOSTON MASS
Maiden Name of Mother
ELIZABETH M CLARK
Birthplace of Mother
-
N.H.
(Signed)
CHARLES B. DARLING M. D.
FEB 19
1917
SPECIAL INFORMATION from Hospitals, Institutions, Transients, or Recent Residents.
Informant
PHYSICIAN'S CERTIFICATE.
I HEREBY CERTIFY that I attended deceased during last illness,
from 1917, to 1917, 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 :
CERE. HEMORRHAGE (3RD ATTACK)
CITY
OFFICE
BOSTONIA
TTAT
CONDITA A
ST 8 SREGIMINE DONATA 1633. ON. MASS. Contributory: { (Duration)
ARTERIO-SCLEROSIS- SENILITY)
Place of Burial or removal
Undertaker
J.S. WATERMAN & SONS
Usual Residence WINTHROP
Filed A true copy. Attest :
FEB
24 1917.
Registrar.
D. 1822
Occupation
BOSTON (MT.HOPE)
1
1
1
1
3 1
1
1
» 1
Feb. 18, 1917 RECURU.
A PERMANENT
SI SULL-ANI
DNIO
SONICVINO
AINIY Te
WRITE
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)
plymouth
12 MAIDEN NAME
OF MOTHER
Butey Sampson
13 BIRTHPLACE
OF MOTHER
(State or country)
Plymouth
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
Matt. M. Petanca,
(Addres
1566 Shitty ff
16
Filed
191
REGISTRAR
16 DATE OF DEATH
2
(Month)
(Day)
(Year)
· DATE OF BIRTH
(Month)
(Day)
1
(Year)
7 AGE
about 65.
mos.
ds.
or ........ min. ?
· OCCUPATION
(a) Trade, profession, or
particular kind of work
Dential
(b) General nature of industry.
business, or establishment In
which employed (or employer).
mitral regurgstation
Chromic Endocarditis
1
(Duration)
„yrs.
.............. mos.
...........
Contributory
(SECONDARY)
(Duration) .
www ............ yrs.
.mos.
ds.
(Signed)
76-21
.. 191 .... ) ... (Address)
M.D.
....
* 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 ............ yra.
mos. ............
................
Where was disease contracted, if not at place of death ?.
Former or usual residence.
19 PLACE OF BURIAL OR REMOVAL not Hope Cent
DATE OF BURIAL
2-22-197
20 UNDERTAKER
W.C. Skaggs
ADDRESS
Winthrop
1
[If death occurred in a hospital or institution, give its NAME Instead of street and number.]
Dr. H. Mason Perfil
2 FULL NAME
[If married or divorced woman or widow
give maiden name, also name of husband.]
@RESIDENCE
Harthrop 566 Shirley St.
(City or town.)
1 PLACE OF DEATH
Winthrop (No. 566 Shirley
.St. ;...
.......
Ward)
....
Registered No.
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
3 SEX
4 COLOR OR RACE
6 SINGLE,
MARRIED, Z
WIDOWED,
OR DIVORCED Luca
(Write the word)
19. 1917
....
17
I HEREBY CERTIFY that I attended deceased from
to ......
1916
191.
Feb 19
1917.
that I last saw him
alive on
7619
1912 .... and that death occurred, on the date stated above, at. 850% m. The CAUSE OF DEATH# was as follows : General artino stenovo.
9 BIRTHPLACE
(State or country)
Plymouth, mars
10 NAME OF
FATHER
Thomas Duteria
If LESS than
I day ......... hrs.
The Commonwealth of Massachusetts STANDARD CERTIFICATE OF DEATH
ANTONIOYENA HLIM AINVII
STANDARD CERTIFICATE OF DEATH. P 17. 1917
Statement of occupation. - Preeise 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 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 eases, especially in industrial employments, it is necessary to know (a) the kind of work and also (b) the nature of the business or industry, and therefore an additional line is provided for the latter statement; it should be used only when 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 speeifieation, as Day laborer, Farm laborer, Laborer - Coal mine, 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 domestie serviee for wages, as Servant, Cook, Houscmaid, etc. If the occupation has been changed or given up on aecount 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 eausation), using always the same accepted term for the same disease. Examples: Cerebro-spinal fever (the only definite synonym is "Epidemic eerebro-spinal meningitis"); Diphtheria (avoid use of "Croup"); Typhoid fever (never re- port "Typhoid pneumonia"); Lobar pneumonia; Broncho- pneumonia ("Pneumonia," unqualified, is indefinite) ; Tuber-
culosis of lungs, meninges, peritonacum, cte., Carcinoma, Sar- coma, ete., of .... ........ ......... (name origin: "Cancer" is less definite; avoid use of "Tumor" for malignant neoplasms); Measles; Whooping cough; Chronic valvular heart discase; Chronic interstitial nephritis, etc. The contributory (second- ary or intereurrent) affection need not be stated unless im- portant. Example: Mcosles (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," etc.), "Dropsy," "Exhaustion," "Heart failure," "Haemorrhage," "Inanition," "Marasmus," "Old age,". "Shoek," "Uraemia," "Weakness," ete., when a definite disease can be aseertained as the eausc. Always qualify all diseases resulting from childbirth or misearriage, as "PUER- PERAL septicacmia," "PUERPERAL peritonitis," ete. 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 eaused 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.
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 PARENTS
The Commonwealth of Massachusetts STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH
Had lo Club
.....
St. .......... .Ward)
[If death occurred in a hospital or institution, give its NAME instead of street and number.]
Registered No.
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
m
4 COLOR OR RACE
w
& SINGLE,
WIDOWED,
OR DIVORCED
(Write the word)
6 DATE OF BIRTH
(Month)
(Day)
7 AGE
78 yrs. 6 mos.
== ds.
or ........ min. ?
8 OCCUPATION
(a) Trede, profession, or particular kind of work
(b) General nature of industry. business, or establishment in which employed (or employer).
9 BIRTHPLACE (State or country) Canbuge n.13.
10 NAME OF
FATHER
John Golding
11 BIRTHPLACE OF FATHER (State or country) Cambuge, 9, 13.
12 MAIDEN NAME OF MOTHER Elizabeth adams
13 BIRTHPLACE OF MOTHER (State or country) Cambiare n. 13
" THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informent)
Horton 4, Chanchulaun
(Address)
45 Cheêtes aus.
Filed
191
REGISTRAR
16 DATE OF DEATH
17
I HEREBY CERTIFY that I have investigated the death of the deceased.
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