USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1916-1918 > Part 68
Note: The text from this book was generated using artificial intelligence so there may be some errors. The full pages can be found on Archive.org (link on the Part 1 page).
Part 1 | Part 2 | Part 3 | Part 4 | Part 5 | Part 6 | Part 7 | Part 8 | Part 9 | Part 10 | Part 11 | Part 12 | Part 13 | Part 14 | Part 15 | Part 16 | Part 17 | Part 18 | Part 19 | Part 20 | Part 21 | Part 22 | Part 23 | Part 24 | Part 25 | Part 26 | Part 27 | Part 28 | Part 29 | Part 30 | Part 31 | Part 32 | Part 33 | Part 34 | Part 35 | Part 36 | Part 37 | Part 38 | Part 39 | Part 40 | Part 41 | Part 42 | Part 43 | Part 44 | Part 45 | Part 46 | Part 47 | Part 48 | Part 49 | Part 50 | Part 51 | Part 52 | Part 53 | Part 54 | Part 55 | Part 56 | Part 57 | Part 58 | Part 59 | Part 60 | Part 61 | Part 62 | Part 63 | Part 64 | Part 65 | Part 66 | Part 67 | Part 68 | Part 69 | Part 70 | Part 71 | Part 72 | Part 73 | Part 74 | Part 75 | Part 76 | Part 77 | Part 78 | Part 79 | Part 80 | Part 81 | Part 82 | Part 83 | Part 84 | Part 85 | Part 86 | Part 87 | Part 88 | Part 89 | Part 90 | Part 91 | Part 92 | Part 93 | Part 94 | Part 95 | Part 96 | Part 97 | Part 98 | Part 99 | Part 100 | Part 101 | Part 102 | Part 103 | Part 104 | Part 105 | Part 106 | Part 107 | Part 108 | Part 109 | Part 110 | Part 111 | Part 112 | Part 113 | Part 114 | Part 115 | Part 116 | Part 117 | Part 118 | Part 119 | Part 120 | Part 121 | Part 122 | Part 123 | Part 124 | Part 125 | Part 126 | Part 127 | Part 128 | Part 129 | Part 130 | Part 131 | Part 132 | Part 133 | Part 134 | Part 135 | Part 136 | Part 137 | Part 138 | Part 139 | Part 140 | Part 141 | Part 142 | Part 143 | Part 144 | Part 145 | Part 146 | Part 147 | Part 148 | Part 149 | Part 150 | Part 151 | Part 152
3. Sudden deaths of persons not disabled by recognized disease, as A death upon the street, or one supposed to be duc to Alcoholism, etc.
4. Deaths under circumstances unknown, as A person found dead, ete.
R 16. .. '16. 5,000.
THE COMMONWEALTH OF MASSACHUSETTS OFFICE OF THE MEDICAL EXAMINER SUFFOLK COUNTY, NORTHERN DISTRICT 274 BOYLSTON STREET, BOSTON.
August 8, 1917.
To the Overseers of the Poor,
Winthrop, Massachusetts.
Sirs :-
In accordance with the provisions of Chapter 24, Sec- tion 21, of the Revised Laws, I hereby surrender for burial the body of the following named man :-
Number Name Place and date of death
9008 Seymour A. Peters
16 Bowdoin St., Winthrop, July 23. 1917. (Twelve cents and a key at this office - property of Mr. Peters. )
This body now lies in the North Mortuary. Enclosed herewith is certificate of death.
Yours respectfully, Garage Burger Mu 0 for. net
Medical Examiner, Suffolk County.
-
-1
-
.
٤
<
WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD.
important. See Instructions on back of certificate. N. B .- Every item of information should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should sta CAUSE OF DEATH in plain terms, so that it may be properly classified. Exact statement of OCCUPATION is ve
STANDARD CERTIFICATE OF DEATH
I PLACE OF DEATH Pinturaje (No Marty Are.
St. „. Ward)
(City or town.) [If death occurred il a hospital or institution give its NAME Instead of street and number.]
John F. Buckley
2 FULL NAME [If married or divorced woman or widow give maiden name, also name of hastind.] @RESIDENCE 40 Myrtle Are Winthrop
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
* SEX
m
' COLOR OR RACE
W.
5 SINGLE. MARRIED, WIDOWED, OR DIVORCED (Write the word)
Married
· DATE OF BIRTH
1
(Month)
(Day)
(Year)
7 AGE
If LESS than I day ......... hrs.
.yrs.
...... mos.
ds.
or ...... .min. ?
& OCCUPATION
(a) Trade, profession, or particular kind of work Cigar mfg
(b) General nature of industry, business, or establishment In which employed (or employer). ..........
9 BIRTHPLACE (State or country)
Vialtham, mais:
PARENTS
12 MAIDEN NAME
OF MOTHER
Mary Durch
1ª BIRTHPLACE OF MOTHER (State or conntry)
Ireland
"THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant) Salut Buckley
(Address))
Walthay
16 Filed
191
.
REGISTRAR
16 DATE OF DEATH July 25 ,
(Month) (Day)
1917 (Year]
Wattended deceased fro I HEREBY CERTIFY that 1916 to
, 1917
" ..... ... Haly/24 . 1917 that I last saw h WW alive on and that death occurred, on the date stated above, at
1/10
The CAUSE OF DEATH* was as follows: Interstitial nephritis and valvular disease of heart
(Duration).
....
........ yrs.
d
Contributory (SECONDARY)
fill Brauch (Ducation) .... yrs. ...... ... mos. ................ ..... ds
€
M.0
(Signed) ....
July 26, 1917 (Address). ) Valition maß
* 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, OF RECENT RESIDENTS).
At place of death. .. yrs.
......
... mos.
ds. State ............ yrs. ...... .mos. ............ .ds ...........
Where was disease contracted, If not al place of death ?.
Former or
usual residence
19 PLACE OF BURIAL OR REMOVAL
DATE OF BURIAL Calvary Halthan July 28, 197
@ UNDERTAKER L.C. Lawless
ADDRESS Skalthay
The Commonwealth of Massachusetts
te y
10 NAME OF
FATHER
Timothy Buckley
11 BIRTHPLACE OF FATHER (State or country)
Ireland
In the
...... Registered No.
July 25,1917 C
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 employ ats, 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 DEATH, state occupation at beginning o illness. If retired from business, that fact may be indicated thus: Farmer (retired, 6 yrs.). For persous 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 rest port "Typhoid pneumonia"); Lobar pneumonia; Broncho- neumonia ("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 discase; 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," "Hacmorrhage," "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" c. 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 duc to Alcoholism, etc
4. Deaths under circumstances unknown, as A person found dcad, etc.
R. 15. 1'17. 100,000.
-
.
.
.
A INIY IO
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)
Cer can n. Y.
ericans
12 MAIDEN NAME
OF MOTHER
Elizabeth Burnham
1ª BIRTHPLACE
OF MOTHER
(State or country)
Scotland.
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
P.S. Parson's.
16
Filed 191
REGISTRAR
1
1
(City or town.) [If death occurred in a hospital or institution, give its NAME instead of street and number.]
2 FULL NAME
harriet F. Passons
[If married or divorced woman or widow
give maiden name, also name of husband.]
@RESIDENCE
Winthrop
Registered No.
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
$ SEX
4 COLOR OR RACE
Female. White
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
Married.
$ DATE OF BIRTH
June
(Month)
28
(Day)
1866
(Year)
7 AGE
54
.yrs. mos. ds.
or ........ min. ?
$ OCCUPATION
(a) Trade, profession, or
particular kind of work.
Housewife.
(b) General nature of industry, business, or establishment in which employed (or employer) ..
9 BIRTHPLACE
(State or country)
Bileams n. 4.
(Duration)
......
yrs.
.............. mos.
...........
ds.
Contributory
(SECONDARY)
Kulto 9 Tycy
.. mos. ds.
.......
M.D.
&Signed)
July 28 recadrage
* 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.
... mcs.
............. ds.
State ............ yrs.
mos.
Where was disease contracted, If not at place of death ?.
Former or usual residence
19 PLACE OF BURIAL OR REMOVAL
(Address) 139 Cold Sont Build Sont Bufala n.2.
20 UNDERTAKER
C.R. Ben nison
DATE OF BURIAL July 27, 197 --
ADDRESS
, 191
1
(Month)
(Day)
(Year)
17
I HEREBY CERTIFY that I attended deceased from
191
, to,
1
191
that ! last saw h
alive on
July 41
191
and that death occurred, on the date stated above, at 150m.
The CAUSE OF DEATH*was as follows :
7
annemie den
.....
.........
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH
Metcalf Hospital (No. 179. Winthrop St
St. ; ........ Ward)
Harriet H. I orbe
16 DATE OF DEATH
July 28
If LESS than
I day ........ hrs.
10 NAME OF
FATHER
Milton Boris.
July 28, 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, 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 linc 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 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, 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 occu- pation whatever, write Nonc.
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, peritonaeum, etc., Carcinoma, Sar- coma, etc., of ........................... ... (name origin: "Cancer" is less definite; avoid use of "Tumor" for malignant neoplasms) ; Measles; Whooping cough; Chronic valvular heart disease; Chronic interstitial nephritis, etc. The contributory (second- ary or intercurrent) affection need not be stated unless im- portant. Example: Measles (disease causing death), 29 ds .; Broncho-pneumonia (secondary), 10 ds. Never report mere symptoms or terminal conditions, such as "Asthenia," "An- aemia" (merely symptomatic), "Atrophy," "Collapse," "Coma," "Convulsions," "Debility" ("Congenital," "Senile," etc.), "Dropsy," "Exhaustion," "Heart failure," "Haemorrhage," "Inanition," "Marasmus," "Old agc," "Shock," "Uracmia," "Weakness," etc., when a definite disease can be ascertained as the cause. Always qualify all diseases resulting from childbirth or miscarriage, as "PUER- PERAL 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, ctc.
2. Deatlıs 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
11 BIRTHPLACE OF FATHER (State or country)
12 MAIDEN NAME OF MOTHER
13 BIRTHPLACE OF MOTHER (State or country)
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
(Address)
16
Filed. .191
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
3 SEMale
I COLOR OR RACE
White
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
Married
G DATE OF BIRTH
Sept. 23rd 1857
(Month) (Day)
(Year)
17 AGE
If LESS than I day .......... hrs.
54
yrs. 10
mos.
10
ds.
or ........ min. ?
-
8 OCCUPATION
Salesman
(a) Trade, profession, or particular kind of work
(b) General nature of industry, business, or establishment in which employed (or employer).
9 BIRTHPLACE
(State or country)
Rock Island Ill.
10 NAME OF
FATHER
Ernest Zeiss
(Signed)
gange.
(Address) .. MEDICAL EXAMINER
* State the DISEASE CAUSING DEATH, or, in deaths from VIOLENT CAUSES, state (1) MEANS of INJURY; and (2) whether ACCIDENTAL, SUICIDAL or HOMICIDAL.
18 LENGTH OF RESIDENCE (FOR HOSPITALS, INSTITUTIONS, TRANSIENTS, OR RECENT RESIDENTS).
In the
At place
of death ...
......... yrs.
mos.
ds.
State
.... yrs.
........ mos. .ds ............. Where was dlsease contracted, If not at place of death ?.
Former or usual residence.
19 PLACE OF BURIAL OR REMOVAL Forest Hills
DATE OF BURIAL
Aug 3 1917
20 UNDERTAKER
L& Waterman& Say
ADDRESS
2326 Wash
16 DATE OF DEATH
Month )
(Day)
31, 1917 (Yçar)
17 I HEREBY CERTIFY that I have investigated the
death of the deceased. The CAUSE OF DEATH* was as follows : natural Causes. Cardio-renal disease
(Sudden death while bathing)
(Duration) .............. yrs. ......... .. mos. ds.
Contributory (SECONDARY)
.(Duration)
.. yrs. .............
mos.
............
ds.
ـو
M.D.
1 PLACE OF DEATH Wultrop
STANDARD CERTIFICATE OF DEATH
11 Back Beauti St. Ward)
ruent 1. Zeiss
2 FULL NAME [If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE Walian-
Registered No.
5631
PERSONAL AND STATISTICAL PARTICULARS
WRITE PLAINLY, WITH UNFADING INK -THIS IS A PERMANENT RECORD.
The Commonwealth of Massachusetts
9016
Wruttup (City or town.) [If death occurred in a hospital or institution, give its NAME Instead of street and number.]
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, Architeet, 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 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 "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., cura, ww coma, etc., of. .... (name origin: "Cancer" is less definite; avoid use of "Tumor" for malignant ncoplasms); 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 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," "Hacmorrhage," "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. 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 earbolie 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- posure, cte.
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.
N. B .- Every item of information should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state CAUSE OF DEATH in plain terms, so that it may be properly classified. Exact statement of OCCUPATION is very
Important. See Instructions on back of certificate.
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH
(No,
125 Pleasant
St. :. ..... .Ward)
{If death occurred in a hospital or institution, give its NAME instead of street and number.]
Sarah + Jordan
? FULL NAME
[If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE 25 Placard DA limiction
Selton- William f Indan
Registered No.
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
$ SEX
Female
4 COLOR OR RACE
White
& SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
Widowed
" DATE OF BIRTH
(Month)
(Day)
1842 (Year)
or ........ min. ?
& OCCUPATION
(a) Trade, profession, or
particular kind of work
(b) General nature of industry, business, or establishment in which employed (or employer)
9 BIRTHPLACE
(State or country)
Portland Me.
Contributory
(SECONDARY)
(Duration)
... yrs.
mos. ....
......
·
M.D.
(Signed)
2
1917 (Address)
Winthrop wars.
* 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.
Stato ............ yrs ..
mos.
......
ds
Where was disease contracted, If not at place of death ?.
Former or usual residence
19 PLACE OF BURIAL OR REMOVAL Wirdlawn
DATE OF BURIAL
aug 4, 19%.
(Address)
3) 125 Pleasant St Vethin
15
Filed 191
REGISTRAR
16 DATE OF DEATH
ana
2
7
191
....
(Month)
(Day)
(Year)
I HEREBY CERTIFY that I attended deceased from
2
1917.
15
1917
, to.
If LESS than 1 day ......... hrs. that I last saw h 22 alive on
2
1917.
and that death occurred, on the date stated above, at ..
9 Am.
The CAUSE OF DEATH* was as follows :
Chroni Intestinal Whatis
(Duration)
2 yrs.
.............
10 NAME OF
FATHER
Nichollin Sefton
PARENTS
11 BIRTHPLACE
OF FATHER
(State or country)
Denmarle.
12 MAIDEN NAME
OF MOTHER
Unknown
VAR
13 BIRTHPLACE
OF MOTHER
(State or country)
Portland Me
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
Robert Indan.
20 UNDERTAKER El Bounkon
ADDRESS
East Breton
7 AGE
74 9 mos. 2.3 ds.
10
WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD.
(City or town.)
............... mos. ds.
ds.
ung. 2, 171/ STANDARD CERTIFICATE OF DEATH.
Statement of occupation. - Precise statement of occu- pation is very important, so that the relative healthfulness of various pursuits can be known. The question applies to cach and every person, irrespective of age. For many occupations a single word or term on the first line will be sufficient, 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 uceded. As examples: (a) Spinner, (b) Cotton mill; (a) Sales- man, (b) Grocery; (a) Foreman, (b) Automobile factory. The material worked on may form part of the second statement. Never return "Laborer," "Forcman," "Manager," "Dealer," etc., without more precise specification, as Day laborer, Farm laborer, Laborer - Coal mine, etc. Women at home, who are engaged in the duties of the household only (not paid Ilouse- 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 terin 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 usc 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 disease can be ascertaincd as the cause. Always qualify all diseases resulting from childbirth or miscarriage, as "PUER- PERAL septicaemia," "PUERPERAL peritonitis," etc. State cause for which surgical operation was undertaken.
Need help finding more records? Try our genealogical records directory which has more than 1 million sources to help you more easily locate the available records.