USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1916-1918 > Part 71
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Cases for the Medical Examiners. - Under the provi- sions of chapter 24 of the Revised Laws deaths under the fol- lowing conditions must be referred to the Medical Examiners:
1. Deaths following injury or violence, as Burns, Falls, Drowning, Gas poisoning, Suicide, Homicide, etc.
2. Deaths supposedly caused by violence, as Criminal abortion, Poisoning, Starvation, Suffocation, Ex- posure, etc.
3. Sudden deaths of persons not disabled by recognized disease, as A death upon the street, or one supposed to be due to Alcoholism, etc.
4. Deaths under circumstances unknown, as A person found dead, etc.
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.
Sommerville
10 NAME OF
FATHER
Tames A. Brennen
11 BIRTHPLACE
OF FATHER
(State or country)
Clinton
Minerva
Mac Dougall
1ª BIRTHPLACE
OF MOTHER
(State or country)
Chelsea
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
Tames A. Frennan
(Informant)
(Address) Too Shirley at Mindig.
16
Filed 191
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
aug.
// (Month)
(Day)
28/1917
(Year)
17 I HEREBY CERTIFY that I attended deceased from
191.2 ... , to.
1917,
that I last saw him alive on
Cards 28
191 ...
and that death occurred, on the date stated above, at
m.
The CAUSE OF DEATH* was as follows :
.. (Duration)
ds.
Contributory
(SECONDARY)
(Duration) .. yrs. .......
mos. ...........
ds.
(Signed)
Charles F. Mahoney M. D.
ana 28, 19.
( Addres
* 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
........... ds .............
Where was disease contracted, If not at place of death ?.
Former or usual residence.
19 PLACE OF BURIAL OR REMOVAL Woodlawn.
DATE OF BURIAL
8/29/17
1917
20 UNDERTAKER
John F. C. maley.
ADDRESS
winthrop
(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
4 COLOR OR RACE
White
Dec ...
21
1916
(Month)
(Day)
(Year)
If LESS than I day ......... .hrs.
8
.yrs. mos. ds.
or ........ min. ?
$ SEX Nale · DATE OF BIRTH 7 AGE ... ...... & OCCUPATION (a) Trade, profession, or particular kind of work 9 BIRTHPLACE (State or country) 12 MAIDEN NAME OF MOTHER PARENTS WHITE FLANNEL, MITIT ONFADING INK THIS IS A PERMANENT RECORD. (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
Winthror
(No
TRO Shirley St.
William Ezra Feennan
? FULL NAME
[If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE 120 Shirley St.
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word) Single
.St.
...........
.Ward)
At place
of death.
.......... yrs.
mos.
ds.
State ............ yrs.
mos.
28171/
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 cach and every person, irrespective of agc. For many occupations a single word or term on the first line will be sufficient, e. g., Farmer or Planter, Physician, Compositor, Architect, Loco- molive engineer, Civil engineer, Stationary fireman, ctc. But in many cases, especially in industrial employments, it is necessary to know (a) the kind of work and also (b) the nature of the business or industry, and therefore an additional line is provided for the latter statement; it should be used only when 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 tlic 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 gaill- 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 1
the DISEASE CAUSING DEATH, state occupation at beginning of illuicss. 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 rc- 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" (mercly symptomatic), "Atrophy," "Collapsc," "Coma," "Convulsions," "Debility" ("Congenital," "Scnilc," etc.), "Dropsy," "Exhaustion," "Heart failure," "Haemorrhage," "Inanition," "Marasmus," "Old agc," "Shock," "Uraemia," "Wcakness," etc., when a definite disease can be ascertained as the cause. Always qualify all discases resulting from childbirth or miscarriage, as "PUER- PERAL septicacmia," "PUERPERAL peritonitis," etc. State cause for which surgical operation was undertaken.
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, ctc.
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.
COMMONWEALTH
OF MASSACHUSETTS
RETURN OF A DEATH-1917.
CITY OF BOSTON
FULL NAME
CHARLES WOHLSCHLEGEL
Registered No. 8706
Place of Death }
Boston
and Residence (
Date of Death
AUG.29
1917,
Åge 65
years 8
months
days.
STATISTICAL DETAILS.
SEX.
COLOR.
SINGLE, MARRIED, WID., DIV.
M
W
WID.
Maiden Name
Husband's Name
NATURAL CAUSES -
PRESUMABLY
Birthplace
GERMANY
Name of Father
JOSEPH WOHLSCHLEGEL
Birthplace of Father
GERMANY
Contributory : (Duration )
Maiden Name of Mother
CHARLOTTE HOFFERBERT
Birthplace of Mother GERMANY
(Signed)
M.D.
AUG.30
Occupation
NIGHT WATCHMAN
1917
SPECIAL INFORMATION from Hospitals, Institutions, Transients, or Recent Residents.
Place of Burial or removal
EVERETT ( WOODLAWN )
Undertaker
E. G. BROWN & SON
Usual Residence WINTHROP ( 149 REVERE ST)
Filed
SEPT.5 1917.
A true copy. Attest :
ErMSlenen
Registrar.
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 :
RAR
CITY R
SICU
PATRIBUS Primary (DurationO SOBIS A
SOFFICE
CARDIO-VASCULAR DISEASE
BOSTONIA
A 1822.
CONDITAA.
STON. MASS.
( FOUND DEAD )
G. B. MAGRATH MED. EX.
Informant
148 STATE ST.
Bug. 29, 1917
PLAINLY, WITH UNFADING INK -THIS IS A
PERMANENT RECORD.
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH
Frost Bank
......
(No.
Hayden Price Davies
2 FULL NAME
[If married or divorced woman or widow
give maiden name, also name of husband.]
@RESIDENCE
Makaron Ciclo Pa
Registered No.
PERSONAL AND STATISTICAL PARTICULARS
& SEX
Male
4 COLOR OR RACE
White
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
Sergi
$ DATE OF BIRTH
31
18,97
17
(Month)
(Day)
(Year)
7 AGE
If LESS than
Į day ......... hrs.
20 yrs. 1
mos.
ds.
... min. ?
& OCCUPATION
Private Co 1ch
(b) General nature of industry,
business, or establishment In
which employed (or employer).
C. A.C. F.h Bankes
9 BIRTHPLACE
(State or country)
Mahanay Culpa
10 NAME OF
FATHER
Isaac. R. Davies
PARENTS
11 BIRTHPLACE
OF FATHER
(State or country)
So Waker Eng
12 MAIDEN NAME
OF MOTHER
NE Jenney Pincé
18 BIRTHPLACE
OF MOTHER
(State or country)
ashland Pa
14 THE ABOVE IS TRUE TO THE BEST OF MX KNOWLEDGE
(Informant)
Harry. P. Davis
(Address)
Makeany Caly
Pa
16
Fited
191
........ REGISTRAR
MEDICAL CERTIFICATE OF DEATH
18 DATE OF DEATH
Sept
7
....
(Month)
(Day)
191 (Year)
I HEREBY CERTIFY that I attended deceased from
Guy 25, 1912.
to
1912
that Mast saw had alive on
2
.. )
and that death occurred, on the date stated above, at .....
5
83m.
-25
The CAUSE OF DEATH* was as follows :
Cuanto ponerentuo
(Duration).
mos.
3
ds.
(SECONDARY)
5º
ds.
(Signed)
M.D.
Cypri., 1917 (Address) 7t Banka
...
* 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
........... yrs. ............ mos. ............ ds ...
Where was disease contracted, If not at place of death ?.
Former or usual residence.
19 PLACE OF BURIAL OR REMOVAL. Mahanay City
DATE OF BURIAL
deplus 1917
20 UNDERTAKER
ADDRESS
(City or town.) [If death occurred in a hospital or institution, give its NAME instead of street and number.]
St. :
............ Ward)
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 state CAUSE OF DEATH In plain terms, so that it may be properly classified. Exact statement of OCCUPATION is very
(a) Trade, profession, or
particular kind of work
Contributory
Socialites
.(Duration)
yys. ................ mos.
...
3 apr
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 caclı 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," "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 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, tlic 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 usc of,"Croup"); Typhoid fever (never re- port "Typhoid pneumonia"); Lobar pneumonia; Broncho- pneumonia ("Pneumonia," unqualificd, is indefinite) ; Tuber-
culosis of lungs, meninges, peritonaeum, etc., Carcinoma, Sar- eoma, etc., of .. ... (name origin: "Cancer" is less definite; avoid use of "Tumor" for malignant neoplasms); Mcasles; 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 .; 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," "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 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.
COMMONWEALTH OF MASSACHUSETTS
RETURN OF A DEATH-1917.
CITY OF BOSTON
FULL NAME ALBERT BLANKENHORN
8804
Registered No.
Place of Death l and Residence S
Boston
CONSUMPTIVES HOSPT.
Date of Death
SEPT.3
46
1917, Age years
months days.
STATISTICAL DETAILS.
SEX.
COLOR.
SINGLE, MARRIED, WID., DIV.
M
MAR.
Maiden Name
Husband's Name
Birthplace
FOND DU LAC. WIS. CITY
SOBIS
OFFICE
Name of Father CHARLES BLANKENHORN 1830.
Birthplace of Father
GERMANY
Maiden Name of Mother LOUISE GIELON
Birthplace of Mother
POUGHKEEPSIE . N. Y.
Occupation
MGR . SALESMAN
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 :
RAR
PATRI
aus Primary
R
PULMONARY TUBERCULOSIS
A. 1822.
STON. MASS. Contributory: (Duration )
--
(Signed) F . H. HUNT M.D.
SEPT.3
1917
SPECIAL INFORMATION from Hospitals, Institutions, Transients, or Recent Residents.
IN HOSPT. I MO.+
Place of Burial or removal
WINTHROP ( WINTHROP CEM)
Usual Residence
WINTHROP (43 LOCUST ST)
Undertaker
w. C. SKAGGS
Filed
SEPT. 8 1917.
WINTHROP
A true copy.
Attest :
Registrar.
BOSTONIA
IVITAT CONDITAA.
Sept. 3, 1917
PLAINLY, WITH UNFADING INK -THIS IS A P
PERMANENT RECORD
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
Zam OStural
1ª BIRTHPLACE OF MOTHER (State or country)
Remind me
" THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
David a. MC Donald
(Address)
16 Filed 191
REGISTRAR
2
-
(City or town.)
[If death occurred in a hospital or institution, give its NAME Instead of street and number.]
? FULL NAME
[If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE
wydaw of Jordan is Melcock
Registered No.
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
3 SEX
female
' COLOR OR RACE
white
6 SINGLE,
MARRIED.
WIDOWED,
OR DIVORCED
(Write the word)
· DATE OF BIRTH
1850
(Month)
(Day)
1
(Year)
7 AGE
67
X mot
mos.
ds.
.... yrs.
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)
Gray me
.(Duration)
........... yrs. ...............
.mos.
6
ds.
arterio
Contributory.
(SECONDA
Index.
(Duration)
.. yrs.
............. mos. ..............
ds.
(Signed)
Rep. H.
Mr. t. Porter
M.D.
., 1917 (Address)
Winthrof.
* If death followed injury or violence the certificate of death must be made out by the Medical Examiner.
18 LENGTH OF RESIDENCE (FOR HOSPITALS, INSTITUTIONS, TRANSIENTS, OR
RECENT RESIDENTS),
At place
In the
of death ..........
.yrs.
mos. ............. ds.
State ............ yrs. ............
.. mos.
........... ds ............. Where was disease contracted, If not at place of death ?.
Former or usual residence.
19 PLACE OF BURIAL OR REMOVAL
DATE OF BURIAL
191
20 UNDERTAKER
ADDRESS
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH
(No. 40 Beacon
St. ;..
Ward)
Claras
Wescott
16 DATE OF DEATH
September
4.
(Month)
(Day)
191 7 (Year)*
.... . ....
17 I HEREBY CERTIFY that Iattended deceased from
au
1.
191
...... ,
6
to
1917.
that I last saw her alive on
Delph. 3.
191,1,
and that death occurred, on the date stated above, at.
3 a.m.
The CAUSE OF DEATH* was as follows :
10 NAME OF
FATHER
If LESS than 1 day ....... hrs.+
....
WRITE PLAINLY, WITH UNFADING INK -THIS IS A PERMANENT RECORD.
ANFNT RECORD. Sept. 4, 1717
Nvwadd
STANDARD CERTIFICATE OF DEATH.
Statement of occupation. - Precise statement of oeeu- 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 cngincer, 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," 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 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 "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 .; 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," ete.), "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 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 Medieal 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.
-
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 quant. Guest
1ª BIRTHPLACE
OF MOTHER
(State or country)
Nova tertia
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
(Address)
wutthof Mann
16
Filed 191
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
Sept.
(Month)
5
(Day)
1917
(Year)
17
1 HEREBY CERTIFY that I attended deceased from
Sept. I., 1917, to
len 5
1917
.........
that I last saw h
er alive on
Seph. 3.
191 ... 2.4
and that death occurred, on the date stated above, at
8.9.
m.
The CAUSE OF DEATH* was as follows :
maraemer
.. (Duration).
.............. yrs.
mos. ds.
Contributory
(SECONDARY)
... (Duration)
.............. yrs.
.......
.. mos.
............
ds.
(Signed)
Al- Parler-
M.D.
....
Sep. 6., 1917
(Address)
Winthrop.
* 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 ............ 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
IS // 6, 1917
2 UNDERTAKER
ADDRESS
WRITE PLAINLY, WITH UNFADING INK - THIS IS A PERMANENT RECORD.
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH
.(No ...
33 Crystal Sove Live
Ward)
Dakathy Doherty- May Enceof
? FULL NAME
[If married or divorced woman or widow
give maiden name, also name of husband.]
@RESIDENCE
33 Cupolat Cove avz
Registered No.
PERSONAL AND STATISTICAL PARTICULARS
¿ SEX
dernier
4 COLOR OR RACE
6 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
Linja
· DATE OF BIRTH
Tiene 51917
(Month)
(Day)
(Year)
7 AGE
If LESS than
1 day ........ hrs.
ds.
... min. ?
8 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)
Hastuna U.H.
10 NAME OF
FATHER
11 BIRTHPLACE OF FATHER (State or country)
3
mos.
Wencherok
(City or town.)
[If death occurred in a hospital or institution, give its NAME Instead of street and number.]
Sept. 5, 171/
STANDARD CERTIFICATE OF DEATH.
Statement of occupation. - Precise statement of occu- pation is very important, so that tho 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 cngincer, Stationary fircman, etc. But in many cases, especially in industrial employments, it i; 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 Ilouscwifc, 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 (rctired, 6 yrs.). For persons who have no occu- pation whatever, write Nonc.
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