USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1916-1918 > Part 65
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England
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant):
important. See instructions on back of certificate.
(Address)
June 25
191
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
18
yrs.
2
mos.
14 ds.
15 Filed
REGISTRAR
CHELSEA (City or town.)
:
.
--
1
June 23,191%
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 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," "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, Housework, or At home, and children, not gain- fully employcd, 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 eausation), 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, peritoneum, etc., Carcinoma, Sar- coma, etc., of .. ............... (name origin: "Cancer" is less definite; avoid use of "Tumor" for malignant ncoplasms); Measles; Whooping cough; Chronic valvular heart discase; Chronic interstitial nephritis, etc. The contributory (second- ary or intercurrent) affection necd not be stated unless im- portant. Example: Measles (disease causing death), 29 ds .; Broncho-pneumonia (secondary), 10 ds. Never report mere symptoms or terminal conditions, such as "Asthenia," "An- aemia" (merely symptomatic), "Atrophy," "Collapse," "Coma," "Convulsions," "Debility" ("Congenital," "Senile," etc.), "Dropsy," "Exhaustion," "Heart failure," "Haemorrhage," "Inanition," "Marasmus," "Old age," "Shock," "Uraemia," "Weakness," etc., when a definite disease can be ascertained as the cause. Always qualify all diseases resulting from childbirth or miscarriage, as "PUER- PERAL septicaemia," "PUERPERAL peritonitis," etc. State cause for which surgical operation was undertaken.
Cases for the Medical Examiners. - Under the provi- sions of chapter 24 of the Revised Laws deaths under the fol- lowing conditions must be referred to the Medical Examiners:
1. Deaths following injury or violence, as Burns, Falls, Drowning, Gas poisoning, Suicide, Homicide, etc.
2. Deaths supposedly caused by violence, as Criminal abortion, Poisoning, Starvation, Suffocation, Ex- posure, etc.
3. Sudden deathis of persons not disabled by recognized disease, as A death upon the street, or onc supposed to be duc to Alcoholism, etc.
4. Deaths under circumstances unknown, as A person found dead, etc.
R 18. 1.'17. 10,000.
· SEX · DATE OF BIRTH 'AGE $ OCCUPATION PARENTS important. See instructions on back of certificate. 16 Filed 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. 50
....
......
St. :
. ..... ...............
Ward)
'FULL NAME
George h. Afibland
[If married or divorced woman of widow give maiden name, also name of husband.] RESIDENCE 50 Moon St, Heuteich
Registered No.
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
4 COLOR OR RACE
5 SINGLE,
MARRIED.
WIDOWED,
OR DIVORCED
(Write the word)
8
(Month)
(Day)
18
1857
(Year)
If LESS than 1 day, ........ hrs.
65 Tro. 10 m
mos. ..
„ds.
or ........ min. ?
(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)
" So. Boston
10 NAME OF
FATHER
Hortitic Mittibland
11 BIRTHPLACE
OF FATHER
(State or conntry)
Boston.
12 MAIDEN NAME
OF MOTHER
13 BIRTHPLACE
OF MOTHER
(State or conntry)
Boston
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
Ins. Gilbert
(Address)
50 moon st.
REGISTRAR
17
I HEREBY CERTIFY that i attended deceased from
23
1917, to.
23
1911.
that i last saw h llLl alive on
23
1917
and that death occurred, on the date stated above, at
7 P.m.
The CAUSE OF DEATH* was as follows :
Cerebral
8
1
Contributory.
Gritarial
.(Duration)
....
... yrs. .......
mos.
ds.
. (SECONDARY)
Mistifical Wellmit (Duration).
2 yrs +
ds
......
(Signed)
25.1917 (Address)
Winterop hear
F
* 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. ds ............. Where was disease contracted, If not at place of death ?. Former or usual residence.
19 PLACE OF BURIAL OR REMOVAL Just Hope
DATE OF BURIAL
6-26.
1917
ADDRESS
20 UNDERTAKER
H.C. Staged Wichtig
(City or town.) [If death occurred in a hospital or institution, give its NAME instead of street and number.]
-
.-.
....
1ª DATE OF DEATH
June
(Month)
23
(Day)
.
(Year)
-
Sclerosis
.....
5
........... .
M.D
19! ....
June 23, 1917
BNYWHALY.SI SIHI.
FINLANIGHINA HUM SAMUELL
STANDARD CERTIFICATE OF DEATH.
Statement of occupation. - Frccise 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 occupation 3 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 examplcs: (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," "Dcaler," etc., without more precise specification, as Day laborer, Farm laborcr, Laborer - Coal mine, ctc. Women at home, who are engaged in the duties of the household only (not paid House- kccpers 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, Ilousemaid, 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: Ccrebro-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 (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," ctc.), "Dropsy," "Exhaustion," "Heart failure," "Haemorrhage," "Inanition," "Marasmus," "Old age," "Shock," "Uraemia," "Weakness," etc., when a definite disease can be ascertained as the cause. Always qualify all diseases resulting from childbirth or miscarriage, as "PUER- PERAL septicaemia," "PUERPERAL peritonitis," etc. State cause for which surgical operation was undertaken.
Cases for the Medical Examiners. - Under the provi- sions of chapter 24 of the Revised Laws deaths under the fol- lowing conditions must be referred to the Medical Examiners:
1. Deaths following injury or violence, as Burns, Falls, Drowning, Gas poisoning, Suicide, Homicide, etc.
2. Deaths supposedly caused by violence, as Criminal abortion, Poisoning, S Starvation, Suffocation, Ex- posure, etc.
3. Sudden deaths of persons not disabled by recognized discase, 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.
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH
Wanthet
(No.
183 Wendlerof
St. :
..........
... Ward)
.......
(City or town.)
[if death occurred in a hospital or institution, give its NAME instead of street and number.]
Elvira. a. Baxter-
Widow of Elijah . a. Baxter
[If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE 183 Wintherat &t.
Registered No.
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
17
I HEREBY CERTIFY that I attended deceased from
June 23
.....
...........
1917
to
June 25, 1917.
.......
.....
that I last saw him
alive on
25
1917.
and that death occurred, on the date stated above, at
7Pm.
The CAUSE OF DEATH* was as follows :
Cerebral humanhago
(Duration)
3
............. yrs.
.mos. ......
ds.
Contributory ...
arterial sclerosis
(SECONDARY)
(Duration)
2 yrs. #
mos.
ds.
(Signed)
Parker
.........
M.D.
June 26, 1917 (Address)
Winthrop hass
/* 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 piace
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
June 27 1912
20 UNDERTAKER
C.R. Bunun
ADDRESS
REGISTRAR .....
:
191
7
(Day)
(Year)
· DATE OF BIRTH
Oct
2
1849
1
(Year)
If LESS than
1 day ........ hrs.
or .. ... min. ?
10 NAME OF
FATHER
Daniel Wilson
12 MAIDEN NAME
OF MOTHER
Margaret Bustin
14 THE ABOVE IS TRUE TO THE BEST, OF MY KNOWLEDGE
(Informant)
4 COLOR OR RACE
& SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
(Month)
(Day)
(a) Trade, profession, or
particular kind of work
at Home
N
11 BIRTHPLACE
OF FATHER
(State or country)
n. B.
11.13.
CAUSE OF DEATH in plain terms, so that it may be properly classified. Exact statement of OCCUPATION is very
....
............... yrs.
8
mos.
25
ds.
? FULL NAME
3 SEX
geral
7 AGE
68
8 OCCUPATION
(b) General nature of industry,
business, or establishment
n
which employed (or employer).
9 BIRTHPLACE
(State or country)
PARENTS
18 BIRTHPLACE
OF MOTHER
(State or country)
important. See instructions on back of certificate.
(Address)
16
Filed
191
N. B .- Every item of information should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state
.....
F
-
F
(Month)
25
June 25, 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 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) Salcs- 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, etc. Women at home, who are engaged in the duties of the houschold 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 "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 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 discase can be ascertaincd 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 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
12 MAIDEN NAME
OF MOTHER
Olive Eaton
1ª BIRTHPLACE
OF MOTHER
(State or country)
" THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
(Address)
15
Filed 191
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
3 SEX
устав
4 COLOR OR RACE
$ SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
· DATE OF BIRTH
Dec
251916
(Month)
(Day)
(Year)
7 AGE
X y. 6
... yr .. ........
...... mos.
ds.
If LESS than
day ...... hrs.
or ..... min. ?
8 OCCUPATION (a) Trade, profession, or particular kind of work.
(b) General nature of industry,
business, or establishment
which employed (or employer)
9 BIRTHPLACE
(State or country)
(Duration)
.yrs.
.............. mos.
ds.
Contributory
Berekend Megureter
(SECONDARY)
(Duration)
.... yrs.
.. mos.
23
ds.
(Signed)
M.D.
-
Cucina 28/ 1997
(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.
............
In the
de.
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
June 29
1915
20 UNDERTAKER
ADDRESS
E
.
1
16 DATE OF DEATH
17
I HEREBY CERTIFY that I attended deceased from
June 25
191_2., to
1912.,
that I last saw her
alive on ....
Klau 27
1917
and that death occurred, on the date stated above, at
104.
The CAUSE OF DEATH* was as follows :
-
-
1 F
..
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH
(No 5-73 Deiley
St. ; ...... .Ward)
Edua.
Walsh
2 FULL NAME
[If married or divorced woman or widow
give maiden name, also name of husband.]
@RESIDENCE
573 thmay DL
PERSONAL AND STATISTICAL PARTICULARS
Waltherof
(City or town.) [If death occurred in a hospital or institution, give its NAME instead of street and number.]
Registered No.
(Month)
(Day)
M
V
1917.
(Year)
6
10 NAME OF
FATHER
Williani J. Walsh
11 BIRTHPLACE OF FATHER (State or country)
June 27,1917
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 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) Forcman, (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 homc. 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 110 occu- pation whatever, write Nonc.
Statement of cause of death. - Nanic, first, thic 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, peritonaeum, etc., Carcinoma, Sar- coma, etc., of ... ... (name origin: "Cancer" is less definite; avoid use of "Tumor" for malignant ncoplasms); 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- acmia" (merely symptomatic), "Atrophy," "Collapse," "Coma," "Convulsions," "Debility" ("Congenital," "Senile," etc.), "Dropsy," "Exhaustion," "HIcart failure," "Haemorrhage," "Inanition," "Marasmus," "Old age," "Shock," "Uracmia," "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 dcad, etc.
-
-
COPY OF THE RECORD OF A DEATH
Returned to the clerk of. waldoboro Maine
as is provided in Section 27 of the Law re-
lating to the registration of Vital Statistics.
Name,
Charles S. Belcher
Place of Death, WaldoboroMaine.
Street,
No.
Ward
Date of Death: Year, 1917 Month June Day, 30
Age: Years, .. 5.1. ..... Months,
Days,
Place of Birth,
WinthropMass
Married, Šingle **
Married
Sex,M ..... ......
Color, IN ..
Divorced,y
Occupation,
Milkman
Name of Father, Cyrus Belcher.
Maiden Name of Mother,
Nellie Stephens
Birthplace of Father,
Winthrop Mass
Michigan
Birthplace of Mother,
Occupation of Father,
Farmer
Deceased was wife of
Widow of
Cause of Death,
Acute CardiacDilatation
Contributing Cause
Valvular Heart Disease
If death was in a hospital, or other institution, give its name,
How long an inmate,
Previous residence,
Winthrop
[OVER]
Waldoboro Maine
P. O. Address, . ... Dr .G.H. Coombs Place of BurialComery Cemetery
Undertaker,
K. L. Deymore
Waldoboro
Maine
P. O. Address,
State of Maine.
I hereby certify that the above is a true copy of the
Record of a Death made by the clerk of Waldoboro
in the month of
June
19
17
Otto villa
Clerk of
France
2 FULL NAME 3 SEX MALE 6 DATE OF BIRTH 7 AGE 64 6 OCCUPATION 12 MAIDEN NAME OF MOTHER PARENTS 1ª BIRTHPLACE OF MOTHER (State or country) 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 (b) General nature of industry. business, or establishment in which employed (or employer).
The Commonwealth of Massachusetts STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH
WINTHROP
(No.
35 BATES AVE.
St. :
Ward)
WINTHROP (City or town.) [If death occurred in a hospital or institution, give its NAME instead of street and number.]
HUBERT
OW MAN
[If married or divorced woman or widow give maiden name, also name of bnsband.] @RESIDENCE 35 BATES AVE
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