USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1916-1918 > Part 79
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
.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 newburgh 3 4.
DATE OF BURIAL
220028 1912
ADDRESS
20 UNDERTAKER
OFounce Cheken
WRITE PLAINLY, WITH UNFADING INK -THIS IS A PERMANENT RECORD.
.......... ...... ...... 2FULL NAME * SEX Female 4 COLOR OR RACE White .... (Month) 1 AGE (b) General nature of Industry, business, or establishment in which employed (or employer) PARENTS (Informant) Syfusted important. See instructions on back of certificate. 18 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 .......... 61 vice. 5 mos 10
Filed 191
....
.... . ....... Ward)
HOUSE -NANVASAG Y SI SIHL - ANI ONIOYANDI ALIM AINITI ALIUM
wiru. 26, 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 caelı and every person, irrespective of age. For many occupatious 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 inaterial 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 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, peritonacum, 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: 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," 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 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 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, E.x- 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
15-17-XXM !
The Commonwealth of Massachusetts STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH winthrop (No .. 53 Summit AVE. ....
St. ;
......... Ward)
BOSTON ........... .
(City or town.) [If death occurred in a hospital or institution, give its NAME instead of street and number.]
? FULL NAMI
JOHN JOSEPH CALL JR.
[If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE53 SUMMIT AVE.
Registered No.
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
4 COLOR OR RACE
WHITE
5 SINGLE,
MARRIED.
WIDOWED,
OR DIVORCED
(Write the word) SINGLE
16 DATE OF DEATH
30"
1917
(Month) .
(Day)
(Year,
· DATE OF BIRTH
Feb.
(Month)
(Day)
I,9I
(Year)
7 AGE
If LESS than
( day ......... hrs.
3
.. yrs.
9
mos.
3
ds.
.... 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)
winthrop
10 NAME OF
FATHER
JOHN J. CAT.I.
PARENTS
11 BIRTHPLACE
OF FATHER
(State or country)
FAST BOSTON
12 MAIDEN NAME
OF MOTHER
MARY A. "HOMAS
13 BIRTHPLACE
OF MOTHER
(State or country) Fontreal P. C.
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
John J. Call
(Address) 5.3 Summit Ave.
16
Filed 191
REGISTRAR
...
17
I HEREBY CERTIFY that I attended deceased trom
In 30"
1 230
1917, to
1917.
that I last saw him alive on
Thu 29"
191.2 ... ,
and that death occurred, on the date stated above, a
12.20 AM. .m. The CAUSE OF DEATH* was as follows : acidosis
Did a surgical operation precede death ?
Date
(Duration)
............. yrs.
.........
mos.
10
ds.
Contributory
(SECONDARY)
{Duration)
yrs.
mos.
ds.
(Signed)
191 ... 7 ... (Address).
* If death followed injury or violence the certificate of death must be made out by the Medical Examiner.
IS 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 HOLY CRUS- MALDEN
DATE OF BURIAL
12/1/17
191
20 UNDERTAKER
John F: O'malley
ADDRESS
Winthrop
WRITE PLAINLY, WITH UNFADING INK -THIS IS A PERMANENT RECORD.
important. See instructions on back of certificate.
MEDICAL CERTIFICATE OF DEATH
MALE
27,
M.D.
. 30,1917
A PERMANENT SI SIHL - MNI DNIOYJNOHLIM ATNIVTHELIUM
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 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 necded. 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 "Laborcr," "Foreman," "Manager," "Dealer," ete., without more precise specification, as Day laborer, Farm laborer, Laborcr - 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 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, peritonacum, etc., Carcinoma, Sar- coma, etc., of. .(name origin: "Cancer" is less definite; avoid use of "Tumor" for malignant neoplasms); Measles; Whooping cough; Chronic valvular heart disease; Chronic interstitial nephritis, etc. The contributory (second- ary or intercurrent) affection need not be stated unless im- portant. Example: Measles (discase causing death), 29 ds .; Broncho-pneumonia (secondary), 10 ds. Never report mcre symptoms or terminal conditions, such as "Asthenia," "An- acmia" (mcrely symptomatic), "Atrophy," "Collapse," "Coma," "Convulsions," "Debility"' ("Congenital," "Senile," etc.), "Dropsy," "Exhaustion," "Heart failure," -
¡'Hacmorrhage," "Inanition," "Marasmus," "Old age," "Shock," "Uraemia," "Weakness," ctc., which 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 ior 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 onc 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.
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH
(No.
State Hospital
St. :
Ward)
(City or town.) {If death occurred in a hospital or institution, give its NAME instead of street and number.]
2 FULL NAME
Setuge W me Siffer
[If married or divorced woman or widow
give maiden name, also name of husband.]
@RESIDENCE
74 Quincy ave Winthrop Highlands Registered No.
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
3 SEX
male
COLOR OR RACE
White
6 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
'Write the word)
named
· DATE OF BIRTH
24
1871
(Month)
(Day)
(Year)
7 AGE
If LESS than
I day ........ hrs.
46
„yrs.
mos.
6
ds.
or ......... min. ?
& OCCUPATION
(s) Trade, profession, or
particular kind of work ..
Insurance
(b) General nature of Industry,
business, or establishment
which employed (or employer)
-
9 BIRTHPLACE
(State or country)
(Duration) -yrs ..
......... mos. ..
- ds.
Contributory
(SECONDARY)
(Duration)
- mos ._ de.
(Signed)
M.D.
nor 30, 191 7 (Address) GreTtewithany
* 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
3 yrs. 4
mos.
2 ds.
In the
19.T
State
mos.
Where was disease contractad,
If not at place of death ?.
Former or
74 Quincy are Winthrop Highland
usual residence
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
bratton stete Hospital
(Address)
16
Filed 191 abbi R. Sullivan amit REGISTRAR
19 PLACE OF BURIAL OR REMOVAL maso Crematory
DATE OF BURIAL
191
7
20 UNDERTAKER
Frede 1. Brags
ADDRESS
Boston
PARENTS
10 NAME OF
FATHER
Flower the me suffer
11 BIRTHPLACE
OF FATHER
(State or country)
naine
12 MAIDEN NAME
OF MOTHER
inquesta 2. Hig gin
13 BIRTHPLACE
OF MOTHER
(State or country)
Maire
16 DATE OF DEATH
novembre
30
(Month)
(Day)
. 191.
7
(Year)
17 I HEREBY CERTIFY that I attended deceased from Ruamet 21. 1917, to novembre 30, 1917. that I fast saw h/ vy alive on herenth 30 1917 45 and that death occurred, on the date stated above, atle -um. The CAUSE OF DEATH* was as follows : General Prezzo
of death.
Dec 1, 1917
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.
[10-'16-XXM. The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
I PLACE OF DEATH
(No.
4 Court Road
St. ;..
. .........
Ward)
(City or town.) [If death occurred in a hospital or institution, give its NAME instead of street and number.]
Hannah In Harrey
'FULL NAME
[If married or divorced woman or widow
give maiden name, also name of husband.]
@RESIDENCE
4 Court Road Winthro
Registered No.
PERSONAL AND STATISTICAL PARTICULARS
1 SEX
female
' COLOR OR RACE
White
6 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
Single
1963
(Month)
(Day)
(Year)
· AGE
41
.Угв.
2
mos.
14
ds.
or ....... min ?
& OCCUPATION
(e) Trade, profession, or
particular kind of work
none
(b) General nature of industry,
business, or establishment in
which employed (or employer)
Did a surgical operation precede death? 200
Date
unknown (Duration) ................ yrs. ............ .mos. ds.
Contributory
(SECONDARY)
(Duration)
... yrs.
mos.
ds
(Signed)
Horatio & Card
M.D
SEC.1
...
191 7 (Address)
676 Tremont St.
* 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.
In the
mos. ..
ds.
State ............ yrs.
mos.
....... .ds.
Where was disease contracted, If not at place of death ?.
Former or usual residence.
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
albert R Surrey
(Address)
4 Carat Rd.
16 Filed 19! ........
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
10 DATE OF DEATH
December
(Month)
/, 19
(Day)
......
( Year)
17
1 HEREBY CERTIFY that I attended deceased from
May
1917
, to.
Non 80
1912
........
that I last saw her ...
alive on
hov, 90
191 7 .....
and that death occurred, on the date stated above, at
9-30 am,
The CAUSE OF DEATH* was as follows :
tuberculosis ful.
9 BIRTHPLACE
(State or country)
madison me
10 NAME OF
FATHER
avanda Harres
PARENTS
11 BIRTHPLACE
OF FATHER
(State or country)
madison me
12 MAIDEN NAME
OF MOTHER
Calcar
Sarah Reed
13 BIRTHPLACE
OF MOTHER
(State or country)
Caliar me
19 PLACE OF BURIAL OR REMOVAL mais Cenemato
DATE OF BURIAL
Slee 3
191
-
20 UNDERTAKER
S'illa Verman Sous
ADDRESS
Bertin
If LESS than
! day ........ hrs.
· DATE OF BIRTH
1
-BOSTON ...
Dec. 1,1917
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 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 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, 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," 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.
WRITE PLAINL
NINYWH3d V SI SIHL - XNI_ONIGVINO. HUIM AT 6
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
I PLACE OF DEATH
(No 9
... wheelock St. ... Ward) .......
Holdswith
Barbara
[If married or divorced woman or widow
give maiden name, also name of hygband.]
@RESIDENCE
9 wheelockst. Winthrop
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
* SEX
4 COLOR OR RACE
w
5 SINGLE,
MARRIEDUL
WIDOWED,
OR DIVORCED
(Write the word)
Single
1ª DATE OF DEATH
12
(Month)
(Day)
. 191 7
(Year)
· DATE OF BIRTH
11 (Month)
7 19/5-17
(Day)
(Year)
'AGE
If LESS than
1 day ......... hrs.
2 yrs.
timos.
23 ds.
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).
Hinthoop Mars
10 NAME OF
FATHER
George W. Goldsmith
PARENTS
11 BIRTHPLACE
OF FATHER
(State or countryyh
Manchester Maas
12 MAIDEN NAME
OF MOTHER
Christiana 8. Felter
13 BIRTHPLACE
OF MOTHER
(State or country)
Sherbourne falls med
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
GeorgeW Goldsmith
(Address)
9 wheelock st.
16 Filed 191 .....
REGISTRAR
I HEREBY CERTIFY that I attended deceased from
1912, to.
the 3º
1912
that I last saw h M
alive on
191.2 ...
the 3º
and that death occurred, on the date stated above, at 4:40pm
The CAUSE OF DEATH* was as follows :
icedosis
(Duration)
.............. yrs. ................ mos.
4 ds.
Contributory
(SECONDARY)
(Duration)
1 .. yrs.
mos.
ds
(Signed)
631 mil call
M.D
... .
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).
In the
mos.
............ ds .............
Where was disease contracted, If not at place of death ?...
Former or usual residence.
DATE OF BURIAL
19 PLACE OF BURIAL OR REMOVAL Huithoop Cent 12-5
20 UNDERTAKER
W.C. Skaggs
ADDRESS
Winthrop
1
At place
of death
.......
yrs.
mos.
ds.
State ........... yrs.
..........
1917
(City or town.) [If death occurred In a hospital or institution, give its NAME Instead of street and number.]
"FULL NAME
Registered No.
A PERMANENT RECORD. SI-SIHL=XNL
1000 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 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 engincer, 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) Forcman, (b) Automobile factory. The material worked on may form part of the second statement. Never return "Laborcr," "Foreman," "Manager," "Dealer," etc., without more precise specification, as Day laborer, Farm laborcr, Laborcr - Coal mine, ete. Women at home, who are engaged in the duties of the household only (not paid House- kecpers 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 Scrvant, 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 (retircd, 6 yrs.). For persons who have no occu- pation whatever, write None.
Statement of cause of death. - Name, first, the DIS- EASE CAUSING DEATH (the primary affection with respect to time and eausation), using always the same accepted term for the same disease. Examples: Cerebro-spinal fever (the only definite synonym is "Epidemie cerebro-spinal meningitis"); Diphtheria (avoid use of "Croup"); Typhoid fcvcr (never re- port "Typhoid pneumonia"); Lobar pneumonia; Broncho- pneumonia ("Pneumonia," unqualified, is indefinite) ; Tuber-
culosis of lungs, meninges, peritonaeum, ete., 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 symptomatie), "Atrophy," "Collapse," "Coma," "Convulsions," "Debility" ("Congenital," "Senile," etc.), "Dropsy," "Exhaustion," "Heart failure," "Haemorrhage," "Inanition," "Marasmus," "Old age," "Shock," "Uraemia," "Weakness," ete., 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.
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.