USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1916-1918 > Part 78
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- nov. 7, 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 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 discase. 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-
. . .. .
.. Board of Health, City of Newton. The within return countersigned and approved this 191
Agent.
culosis of lungs, meninges, peritonacum, cte., Carcinoma, Sar- coma, etc., of ... (name origin: "Cancer" is less definite; avoid use of "Tumor" for malignant ncoplasms) ; Mcasles; 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" (merely symptomatic), "Atrophy," "Collapse," "Coma," "Convulsions," "Debility" ("Congenital," "Senile," etc.), "Dropsy," "Exhaustion," "Heart failure," "Hacmorrhage," "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, ctc.
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, etc.
day of
HLIM A 'AINIV WRITE PLAI
UNFADING
SI SIHL - XNI ĐI
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.
92
............
Marshall
St. :
Ward)
(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
grunthop- 92 Marshal St
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
1 SEX
4 COLOR OR RACE
w
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
Single
1ª DATE OF DEATH
hor.
11
(Month)
(Day)
191 7
(Year)
· DATE OF BIRTH
12
(Month)
10
(Day)
.18% (Year)
· AGE
If LESS than I day ......... hrs.
26 yr.
........... yrs.
11 mos.
mos.
1 de.
or ........ min. ?
& OCCUPATION
(a) Trade, profession, or
particuler kind of work
Baggage Master
(b) General neture of industry. business, or establishment in
which employed (or employer)
9 BIRTHPLACE
(State or country)
E. Boston
PARENTS
12 MAIDEN NAME
OF MOTHER
Edith M Kemp ton
18 BIRTHPLACE OF MOTHER (State or country) Liverpool M.S.
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
Nadoram Smith
(Address)
92 Marshall St
15
Filed
191
REGISTRAR
17
I HEREBY CERTIFY that I attended deceased from
hor att
1917, to
hr. 11
191 .... 7 ....
...
that I last saw hualive on
200 10
1917
and that death occurred, on the date stated above, at 1/ am
The CAUSE OF DEATH* was as follows :
Chronic nephritis
,
(Duretion)
... yrs. ...
.. mos.
.........
ds.
Contributory
huitme naughtite
.
(SECONDARY)
(Duration)
20
yrs.
mos. ds
(Signed)
Nr. 1. morrison
M.D
hor !!
80 Pmetan 2FEB
1917 (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.
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
Huithox Cut 12-13
1917
20 UNDERTAKER
ADDRESS
The. Skaggs Withisk
10 NAME OF
FATHER
Hadoram Sweeth
11 BIRTHPLACE
OF FATHER
(State or country)
...........
important. See instructions on back of certificate.
Laus
............................
. R. Smith
Registered No.
SI SIHL-HNI ONIOVANO HLIMANIVIA BLUM
11,1917
STANDARD CERTIFICATE OF DEATH.
Statement of occupation. - Precise statement of occu- pation is very important, so that the relative healthfulness of various pursuits ean be known. The question applies to each and every person, irrespective of age. For many 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 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 domestie 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 faet 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 pucumonia"); Lobar pneumonia; Broncho- pneumonia ("Pneumonia," unqualified, is indefinite) ; Tubex
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 disease can be ascertaincd as the cause. Always qualify all diseases resulting from childbirth or miscarriage, as "PUER- PERAL septicaemia," "PUERPERAL peritonitis," ete. State cause for which surgical operation was undertaken.
Cases for the Medical Examiners. - Under the provi- sions of chapter 24 of the Revised Laws deaths under the fol- lowing conditions must be referred to the 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 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
(No.
15 dates are
St. :
Ward)
Nantsof (City or town.) [If death occurred in a hospital or institution, give its NAME instead of street and number.]
Lussell Fechabung
2 FULL NAME
.....
[If married or divorced woman or widow
give maiden name, also name of husband.j
@RESIDENCE
+ 15-18als ara
.... Registered No.
PERSONAL AND STATISTICAL PARTICULARS
$ SEX Male
{ COLOR OR RACE
Atutte
& SINGLE,
MARRIED,
WIDOWED,
Widower
OR DIVORCED
(Write the word)
$ DATE OF BIRTH
aug
26 1833
(Month) (Day)
(Year)
If LESS than 1 day ......... hrs.
d9.
or ........ min. ?
8 OCCUPATION
(a) Trade, profession, or
particular kind of work
Retuct
(b) General nature of industry,
business, or establishment in
which employed (or employer).
Milk leader
9 BIRTHPLACE
(State or country)
Winthrop Mars
PARENTS
12 MAIDEN NAME
OF MOTHER
Jarabe Klunges
13 BIRTHPLACE
OF MOTHER
(State or country)
" THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant).
Russell S. Jewksburg
(Address)
15 Bales are Quello7
16
Filed 191
......
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
I HEREBY CERTIFY that I attended deceased from
nov. 6
917
191 __ to
191
that ! last saw h- ..... alive on 191_
and that death occurred, on the date stated above, at 10 Am.
The CAUSE OF DEATH* was as follows : arterio-Selemais
1
(Duration)
1
.... yrs.
mos.
............
ds.
Contributory.
(SECONDARY)
.. (Duration) .. yrs. .. mos. ds.
(Signed)
11/13
M.D.
Chilean
(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
in the
of death
... yrs.
mos.
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
227 148
.....
191 ... 7
20 UNDERTAKER
ADDRESS
12
, 191.
.....
...... (Month)
(Day)
7 (Year)
1 AGE 04 2 m
.mos.
16
1
%
10 NAME OF
FATHER
amuse H.
11 BIRTHPLACE OF FATHER (State or country)
.......
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 eachı 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," "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 sehoo' or At home. Care should be taken to report specifically the occupations of persons engaged in domestie 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 froin 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, peritoneum, etc., Carcinoma, Sar- coma, etc., of .... .... (name origin: "Cancer" is less definite; avoid use of "Tumor" for malignant neoplasms); Mcasles; Whooping cough; Chronic valvular heart discase; Chronic interstitial nephritis, etc. The contributory (second- ary or intereurrent) affection nced 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," 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 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, 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.
ILIUM
00. 12.1917
N
INYA
ANI ONICVINAHIJMAINLYJA IL
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) Unknown
12 MAIDEN NAME
OF MOTHER
13 BIRTHPLACE
OF MOTHER
(State or country)
Unknown
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
Is hellie Stamelton
(Address)
38 Deal St Ninthurl
16
Filed 191
REGISTRAR
16 DATE OF DEATH
non
21
.. 1917
(Yyar)
(Month)
(Day)
17
I HEREBY CERTIFY that I have investigated the death of the deceased.
The CAUSE OF DEATH* was as follows : multiple injuries including fracture of the Skull of the riks and of the pelvis, and rupture of the Corta, presumably caused li a steam tambientry aveci don't. ds. Cant(ib FORBLIRR) (SECONDARY)
(Duration)
.yrs. ..
... mos. ds.
(Signed)
M.D.
(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.
:8 LENGTH OF RESIDENCE (FOR HOSPITALS, INSTITUTIONS, TRANSIENTS, OR RECENT RESIDENTS).
At place
of death
. yrs.
. mos.
ds.
State
In the
yrs.
mos.
ds.
Where was disease contracted, If not at place of death ?.
Former or usual residence ..
19 PLACE OF BURIAL OR REMOVAL Ately Cross malden
DATE OF BURIAL
Nov- 25 1917
20 UNDERTAKER
, it. Il maley
ADDRESS
Minttrofi
Winthrop (City or town.)
[If death occurred in a hospital or institution, give its NAME instead of street and number.]
2 FULL NAME Elizabeth or Julia.
Silkie
[If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE 65 Somerset are, Winthrop
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
Female
4 COLOR OR RACE
Muito
· SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
Single
6 DATE OF BIRTH
(Month)
(Day)
ļ (Year)
7 AGE
"6"
.. yrs.
mos.
ds.
or ....... min. ?
8 OCCUPATION
Housekeeper.
(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)
Sauber N.S.
10 NAME OF
FATHER
Unknown
known
9271
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH 1 PLACE OF DEATH
Winthrop. near Degallo Station
St. .... .Ward)
BABALAR
9517
Registered No.
MEDICAL CERTIFICATE OF DEATH
If LESS than
day,
.. r.
JNIOVANA HLIM PLAINLY. WRITE PLA
21171
STANDARD CERTIFICATE OF DEATH.
Statement of occupation. - Freeise 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 occupation ? 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 nceded. 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 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 eausation), 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," unqualificd, is indefinite) ; Tuber
culosis of tungs, 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: Mcasles (disease causing death), 29 ds .; Broncho-pneumonia (secondary), 10 ds. Never report mere symptoms or terminal conditions, such as "Asthenia," "An- aemia" (merely symptomatic), "Atrophy," "Collapse," "Coma," "Convulsions," "Debility" ("Congenital," "Senile," etc.), "Dropsy," "Exhaustion," "Heart failure," "Haemorrhage," "Inanition," "Marasmus," "Old age," "Shock," "Uraemia," "Weakness," cte.,. 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 carbolic acid - probably suicidc. 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, etc.
3. Sudden deaths of persons not disabled by recognized disease, as A death upon the street, or one supposed to be due to Alcoholism, etc.
4. Deaths under circumstances unknown, as A person found dead, ete.
R 16. 7-'16. 5,000.
The Commmuralth of Massachusetts STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH
Winthrofi
(No 18 Temple die)
St. :
Winthrop (City or town.) [If death occurred in a hospita or institution, give its NAME instead of street and number.]
ada m Austed
ada I Robertson Georgenthisted.
[If married or divorced woman or widow
give maiden name, also name of husband.]
@RESIDENCE
18 Temple ave Winthrop
Registered No.
PERSONAL AND STATISTICAL PARTICULARS
5 SINGLE,
MARRIED manned
OR DIVORCED
(Write the word)
" DATE OF BIRTH
June 16 1856
1
(Year)
(Day)
If LESS than
I day ......... hrs.
ds.
Or ........ min. ?
& OCCUPATION
(a) Trade, profession, or
particular kind of work
Housewife.
9 BIRTHPLACE
(State or country)
newport ling.
10 NAME OF
FATHER
William Robertson
11 BIRTHPLACE OF FATHER (State or country) Scotland.
12 MAIDEN NAME
OF MOTHER
annie davis
13 BIRTHPLACE
OF MOTHER
(State or country)
England
"THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Address)
Winthrop mars
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
1ª DATE OF DEATH
Av 26
1
(Month)
(Day)
1917
(Year)
17
I HEREBY CERTIFY that I attended deceased from
Sist
1917, to
1917
A 26
1
1917
that I last saw h
alive on
m 26
....
and that death occurred, on the date stated above, at
945
Am
The CAUSE OF DEATH* was as follows :
myocarditis
Chimie Endo carditis
(Duration)
1 yrs. d
„mos.
ds.
...........
Contributory
(SECONDARY)
(Duration)
mos.
............
ds.
.......
yrs.
(Signed)
Mi Smut call
M.D
Aw 27, 15
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. .........
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