USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1916-1918 > Part 77
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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 synonyın is "Epidemie 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, 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, ete. The contributory (sceond- 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 age," "Shoek," "Uraemia," "Weakness," ete., 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 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 Exami- are.
1. Deaths following injury or violence, as Bu Drowning, Gas poisoning, Suicide, Homicrae, 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, ete.
4. Deaths under circumstances unknown, as A person found dead, ete.
COMMONWEALTH OF MASSACHUSETTS
RETURN OF A DEATH-1917.
CITY OF BOSTON
FULL NAME
WILL MERCHANT
Registered No. 10659
Place of Death }
Boston
INFANTS HOSPT.
and Residence S
Date of Death
OCT . 31
1917,
Age
years 6
months
20
days.
STATISTICAL DETAILS.
SEX.
COLOR.
SINGLE, MARRIED, WID., DIV.
M
W
S
Maiden Name
Husband's Name
WINTHROP
Birthplace
Name of Father
EVERETT MERCHANT
Birthplace of Father
GLOUCESTER
Maiden Name of Mother
SARAH HARRIS
Birthplace of Mother
YARMOUTH.N.S.
(Signed)
W.W.HOWELL
M.D.
1917
SPECIAL INFORMATION from Hospitals, Institutions, Transients, or Recent Residents.
Place of Burial or removal
WINTHROP (WINTHROP CEM)
Undertaker
C .R. BENNISON WINTHROP
Usual Residence
WINTHROP(5 WAVE WAY)
Filed
A true copy.
Attest :
NOV . 5
ErMSlenen
1917.
Registrar.
-
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: S
RAR
T PATRI
IBUSPITOMATy { Duration
INANITION FROM FAT INDIGESTION
CITY
SOBIS
AOFFICE
5 MOS.
BOSTONIA CONDITAA
A 1822.
STON 1680. B GIMINE DONATA A MASS. Contributory: (Duration )
PULM.ATELECTASIS (CONGENITAL)
Occupation
Informant
PHYSICIAN'S CERTIFICATE.
Oct. 31, 1917
[5-'17-XXM.]
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
Winthrop Mass. (No. Cliff House. St. : ............. Ward)
Winthrop
-BOSTON
(City or town.) .
[If death occurred in a hospital or institution, give its NAME Instead of street and number.]
MarymJ.O'Brien
[If married or divorced woman or widow Mary J. Gildart wife of Isaac B. O' Brema
give maiden name, also name of husband.]
@RESIDENCE
Glover Ave Winthrop
Registered No.
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
Nov. 2 1917
(Month)
(Day)
191
(Year)
17
I HEREBY CERTIFY that I attended deceased from
(Year)
Och. 15.
191.2 ....
to
nov. 2.
191.25,
....
If LESS than
1 day ........
....... hrs.
that I last saw h ...... alive on
nov. 2.
1917
and that death occurred, on the date stated above, at
or ........ min. ?
2Pm
m
The CAUSE OF DEATH* was as follows :
Interstitial Nelphritis
pid a surgical operation precede death?
no_ Date
.. (Duration)
3
.yrs.
mos.
.ds.
Contributory
Dichter
mellitus
(SECONDARY)
(Duration)
10 yrs.
mos.
ds.
(Signed)
Tr.f. Portio
M.D.
Nov. V., 191/7 (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).
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
Winthrop Cem.
DATE OF BURIAL
Nach You 4, 1917
(Address)
Billerica Mass.
REGISTRAR
& SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
'Write the wordmarried.
· DATE OF BIRTH
Dec 5 1860
(Month)
(Day)
1
10
.yrs.
mos.
28
ds.
......
10 NAME OF
FATHER
John Gildart
12 MAIDEN NAME OF MOTHER Eliza McFarland,
13 BIRTHPLACE
OF MOTHER
(State or conntry) Nixon N.B.
"THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
1 PLACE OF DEATH 2 FULL NAME 3 SEX { COLOR OR RACE female white .... 7 AGE 56 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 Nixon 11 BIRTHPLACE OF FATHER (State or country) Nixon N.B. PARENTS (Informant) H. B. Wadely important. See instructions on back of certificate. 16 Filed 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 (State or country) Macon N. B.
WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD.
20 UNDERTAKER cantons
ADDRESS
Bastón
any y Nov .2.1917
SOUHR ANINVAHJA V SI SIHL - ANI ONIOVINA HUM ANIVI IIIHM
STANDARD CERTIFICATE OF DEATH.
Statement of occupation. - Precise statement of oecu- 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 occupation ? a single word or term on the first line will be sufficient, e. g., Farmer or Planter, Physician, Compositor, Architcet, Loco- motive engineer, Civil engineer, Stationary fireman, etc. But in many cases, especially in industrial employments, it is necessary to know (a) the kind of work and also (b) the nature of the business or industry, and therefore an additional line is provided for the latter statement; it should be used only when needed. As examples: (a) Spinner, (b) Cotton mill; (a) Sales- man, (b) Grocery; (a) Foreman, (b) Automobile factory. The material worked on may form part of the second statement. Never return "Laborer," "Foreman," "Manager," "Dealer," 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 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 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 pncunonia; Broncho- pneumonia ("Pneumonia," unqualified, is indefinite) ; Tube:
culosis of lungs, meninges, peritonaeum, etc., Carcinoma, Sar- coma, etc., of .. „(name origin: "Cancer" is less deunite; 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- acmia" (mercy 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 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. 1-'17. 100,000.
-
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.
11 BIRTHPLACE · OF FATHER (State or country)
TTELAND
12 MAIDEN NAME
OF MOTHER
1ª BIRTHPLACE
OF MOTHER
(State or country)
T MOT
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
TATO VIELNING
(Address)
24 DEPLAIN AVF.
16
Filed ....... 191
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
Noi
(Month)
(Day)
191. (Year)
MAI.
· DATE OF BIRTH
(Month)
(Day)
1 (Year)
7 AGE
50
.. mos. ds.
or ......... min. ?
8 OCCUPATION
(a) Trade, profession, or
particular kind of work .........
STWANTITTTE
(b) General nature of Industry, business, or establishment f which employed (or employer)
9 BIRTHPLACE
(State or country)
(Duration) .yrs.
mos.
......
ds.
Contributory
Cvais Parenchymaticas
(SE Nejchutes
(Duration)
2
Yrs .
mos. ds.
(Signed)
....
Harvey af Ell
M.D.
Mor 4, 197 (Address)
200 Pleurantfu
* 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
TANVETS
DATE OF BURIAL PCT. F
...... 191
20 UNDERTAKER
John J. O Malley
(City or town.)
[If death occurred in a hospital or institution, give its NAME instead of street and number.]
2 FULL NAME
MICHAFI RINFTL
[If married or divorced woman or widow
give maiden name, also name of husband.]
@RESIDENCE
21 Vermeid Ave.
......
....
Registered No.
PERSONAL AND STATISTICAL PARTICULARS
¿ SEX
COLOR OR RACE
6 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word) STUGLT
17
I HEREBY CERTIFY that I attended deceased from
191 .. 2 ... , to
191.2
.........
If LESS than
I day ......
„ hrs.
that I last saw h ....
alive on
Nor 3
1917
and that death occurred, on the date stated above, at: 1Pm.
The CAUSE OF DEATH* was as follows :
Cerebral Htimarchage
10 NAME OF
FATHER
PARENTS /
The Commonwealth of Massachusetts STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH WINTHROP ......... (No. 24 LEPLAID ATT .
St. ; . . Ward)
ADDRESS
Minellerof
HO93Y JN3NVAN3.
3.1917
V SI SIHAYNI DNIAYANA HLIM'AINIZIA ZUUM
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 thereforo 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 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 terni 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- mmcumonia ("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 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 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, 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.
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH
Winetwork
(No.
461 Lhely It-
St. :
........... Ward)
(City or town.) [If death occurred In a hospital or institution, give its NAME instead of street and number.]
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
non
191 7
(Month)
(Day)
(Year)
· DATE OF BIRTH
Jamany (Monthi)
14
(Day)
(Year)
7 AGE
If LESS than I day ......... hrs.
81 yrs. „.yrs.
11 mos. ds.
2
or ........ min. ?
& OCCUPATION
(a) Trade, profession, or
particular kind of work ...
refined Engine
.
(b) General nature of industry, business, or establishment which employed (or employer).
9 BIRTHPLACE
(State or country)
10 NAME OF
FATHER
Black.
11 BIRTHPLACE OF FATHER (State or country) Not Known
12 MAIDEN NAME
OF MOTHER
18 BIRTHPLACE OF MOTHER (State or country)
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
(Address)
13 kock
16 Filed 191 ........
REGISTRAR
17 I HEREBY CERTIFY that I attended deceased from Sept. 1. .1912 to
nar
....
1917
..
that I last saw hle alive on
Por. 3d
191/1
and that death occurred, on the date stated above, at ...
2.m.
The CAUSE OF DEATH* was as follows :
artères-sclerosis
(Duration)
... yrs. ........
mos.
ds.
Contributory Interetial nekhast
(SECONDARY)
........ (Duration)
yrs.
............. mos.
„.ds.
(Signed)
fre Porter
M.D.
nor.4. 1917. (Address) Minitinto
* 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
1-5, 1917
20 UNDERTAKER
ADDRESS
...
Jeremiah B. Black
" FULL NAME
[If married or divorced woman or widow
give maiden name, also name of husband.]
.........
@RESIDENCE
461 Shirley
Registered No.
3 SEX vitale
4 COLOR OR RACE
White
6 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
........
PARENTS
ad V SI SIHL-XNL ONIOYANO HLIM AINIVIA ILIUM-
3.1917
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 fircman, etc. But in many cases, especially in industrial employments, it is necessary to know (a) the kind of work and also (b) the nature of the business or industry, and therefore an additional line is provided for the latter statement; it should be used only when needed. As examples: (a) Spinner, (b) Cotton mill; (a) Sales- man, (b) Grocery; (a) Foreman, (b) Automobile factory. The material worked on may form part of the second statement. Never return "Laborer," "Foreman," "Manager," "Dealer," etc., without more precise specification, as Day laborer, Farm laborer, Laborer - Coal minc, etc. Women at home, who arc engaged in the duties of the household only (not paid House- keepers who receive a definite salary), may be entered as Housewife, Housework, or At home, and children, not gain- fully employed, as At school or At home. Care should be taken to report specifically the occupations of persons engaged in domestic service for wages, as Servant, Cook, Housemaid, etc. If the occupation has been changed or given up on account of the DISEASE CAUSING DEATH, state occupation at beginning of illness. If retired from business, that fact may be indicated thus: Farmer (retired, 6 yrs.). For persons who have no occu- pation whatever, write 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-
4
1
culosis of lungs, meninges, peritonaeum, etc., Carcinoma, Sar- coma, etc., of .... ....... (name origin: "Cancer" is less definite; avoid usc of "Tumor" for malignant ncoplasms) ; Measles; Whooping cough; Chronic valvular heart disease; Chronic interstitial nephritis, etc. The contributory (second- ary or intercurrent) affection nced not be stated unless im- portant. Example: Measles (disease causing death), 29 ds .; Broncho-pneumonia (sccondary), 10 ds. Never report mere symptoms or terminal conditions, such as "Asthenia," "An- aemia" (merely symptomatic), "Atrophy," "Collapsc," "Coma," "Convulsions," "Debility" ("Congenital," "Senile," etc.), "Dropsy," "Exhaustion," "Heart failure," "Haemorrhage," "Inanition," "Marasmus," "Old age," "Shock," "Uracmia," "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," 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 diseasc, 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.
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH
Winthrop
..............
.(No. 7 Temple Ave. „St.
Ward)
(City or town.) [If deeth occurred in e hospital or institution, give its NAME instead of street and number.]
2 FULL NAME
Phoebe 0 Parker
Meluck Badtaky Photo Ratto
[If married or divorced woman or widow
give maiden name, also name of husoand.]
@RESIDENCE
7 Temple Ave. Wimthrop.
Registered No.
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
3 SEX
Female
4 COLOR OR RACE
White
5 SINGLE,
MARRIED.
WIDOWED,
OR DIVORCED
(Write the word)
Married
* DATE OF BIRTH
(Month)
(Day)
(Year)
7 AGE
52
.yrs.
...... mos. .ds.
min. ?
8 OCCUPATION
(a) Trade, profession, or
particular kind of work ..
non
(b) General nature of Industry,
business, or establishment in
which employed (or employer).
9 BIRTHPLACE
(State or country)
New York City.
10 NAME OF
FATHER
Chilik Riti
PARENTS
Il BIRTHPLACE
OF FATHER
(State or country)
New York
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)
7 Temple Dr.
16
Filed ., 191
REGISTRAR
Indefento
.(Duretion)
............. yrs,
mos. ................
Contributory
Organic Heart Disease
(SECONDARY) Call (Duration)
me Porter
.yrs,
mos. ...............
ds.
M.D.
(Signed)
.....
2200.7
. 191 ........ (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
ds.
State ............ yre.
............
nos ...
.ds ...
Where was disease contracted, If not at place of death ?.
Former or usual residence
19 PLACE OF BURIAL OR REMOVAL
Forest Hills
DATE OF BURIAL
400 10. 1917
20 UNDERTAKER
a.L. Cartman C.
ADDRESS
Boutons,
191
V
(Month)
(Day)
7.
(Year)
19655
....
If LESS then
1 day ........ hrs.
16 DATE OF DEATH
Noreculer
17
I HEREBY CERTIFY that I attended deceased from
July 31od
,1915 to November 7.
191_2,
that I last saw her alive on
non. 6th
, 1917
and that death occurred, on the date stated above, at
9a.m.
The CAUSE OF DEATH* was as follows :
Chronic Interstitial Nephritis
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