USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1916-1918 > Part 8
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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 fcver (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., Careinoma, 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 necd not be stated unless im- portant. Example: Measles (disease causing death), 29 ds .; Broncho-pneumonia (secondary), 10 ds. Never report mere symptoms or terminal conditions, such as "Asthenia," "An- aemia" (merely symptomatic), "Atrophy," "Collapse," "Coma," "Convulsions," "Debility" ("Congenital," "Senile," etc.), "Dropsy," "Exhaustion," "Heart failure," "Hacmorrhage," "Inanition," "Marasmus," "Old age,". "Shock," "Uraemia," "Weakness," etc., when a definite disease ean be ascertained as the cause. Always qualify all diseases resulting from childbirth or miscarriage, as "PUER- PERAL scpticaemia," "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, 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 eircumstances 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 Winter, Maso (No ...... 26 Marshall 71
St. ;..................... ... Ward)
Ellen Forochline Jose Meliall
2 FULL NAME
[If married or divorced woman or widow give maiden name, also name of husband.] ............ @RESIDENCE . 26 maishatte the formatos
Registered No.
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
3 SEX
Vemuli
4 COLOR OR RACE
White
§ SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
Wodaw
21 1885
(Month)
(Day)
(Year)
7 AGE
If LESS than I day ......... hrs.
7
ds.
or ....... min. ?
& OCCUPATION
(a) Trade, profession, or
particular kind of work
at home
(b) General nature of industry,
business, or establishment in
which employed (or employer).
9 BIRTHPLACE
(State or country)
10 NAME OF
FATHER
Darius .W. Frs
PARENTS
11 BIRTHPLACE
OF FATHER
(State or country)
Barrington n. H.
12 MAIDEN NAME
OF MOTHER
Variety. M. Clifford
1ª BIRTHPLACE
OF MOTHER
(State or country)
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
Grace I. Metall
(Address)
26 manchais a
15
Filed 191
REGISTRAR
16 DATE OF DEATH
At27
1916
(Month)
(Day)
(Year)
17
I HEREBY CERTIFY that I attended deceased from
7625
1916
7627
1916
to
that I last saw hun alive on
2627
1916
and that death occurred, on the date stated above, at
3b
m.
The CAUSE OF DEATH* was as follows :
Broncho Premonia
.....
(Duration)
............ yrs. ................ mos.
4
ds.
Contributory.
(SECONDARY)
(Duration)
.yrs.
mos. ds.
(Signed)
Ben
M.D.
Tb 2.9.1916.
(Address).
* If death followed injury or violence the certificate of death must be made out by the Medical Examiner.
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.
19 PLACE OF BURIAL OR REMOVAL
DATE OF BURIAL
3/1
191
........
men
20 UNDERTAKER
ADDRESS
(City or town.)
[If death occurred in a hospital or institution, give its NAME instead of street and number.]
· DATE OF BIRTH
80
.... yrs.
0.
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, Architeet, Loco- motive engineer, Civil engineer, Stationary fireman, etc. But in many cases, especially in industrial employments, it is necessary to know (a) the kind of work and also (b) the nature of the business or industry, and therefore an additional line is provided for the latter statement; it should be used only when nccded. 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 gaill- 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 synonyın 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 (disease causing death), 29 ds .; Broneho-pneumonia (secondary), 10 ds. Never report mere symptoms or terminal conditions, such as "Asthenia," "An- acmia" (merely symptomatic), "Atrophy," "Collapse," "Coma," "Convulsions," "Debility" ("Congenital," "Senile," etc.), "Dropsy," "Exhaustion," "Heart failure," "Haemorrhage," "Inanition," "Marasmus," "Old age," "Shock," "Uraemia," "Weakness," etc., when a definite disease can be ascertained as the cause. Always qualify all diseases resulting from childbirthi or miscarriage, as "PUER- PERAL scptieaemia," "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, Gus 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 discase, as A death upon the street, or one supposed to be due to Alcoholism, etc.
4. Deaths under circumstances unknown, as A person found dead, etc.
N. B. - Every item of information should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state CAUSE OF DEATH in plain terms, so that it may be properly classified. Exact statement of OCCUPATION is very
important. See instructions on back of certificate.
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH
Rutland Stale Sautimin
.....
Sanatinin
as many
alias Mary E. Rodger
St. :
.........
Ward)
"FULL NAME'
Mary E, Mi Carthy
[If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE
Many F. Murray believed to he mit of at one time of
Registered No. Charlestown Mass
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
Delotras
(Month)
23
1879
(Day)
(Year)
" AGE
If LESS than
I day ......... hrs.
36
......... yrs. 4 .. mos. ... 9 ..
or ........ min. ?
8 OCCUPATION
(a) Trade, profession, or
particular kind of work
(b) General nature of Industry,
business, or establishment in
which employed (or employer).
at Stone
at least two years
(Duration)
.yrs.
..........
mos.
ds.
Contributory
(SECONDARY)
(Duration)
yrs.
.......
........
.. mos. .
ds.
(Signed)
Elliott washburn duft
M.D.
Rulland State Sanglorin
1916
(Address) Rullan Luan
* 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
life time
At place
of death ...........
. yrs
11 mos. 28 ds.
State
..... yrs.
mos.
ds
Where was disease contracted, Inkama to us
if not at place of death ?..
Former or
usual residence.).
Neutrop fremonly of Charleston man
DATE OF BURIAL
191
......
.......
16 Filed March 6 1916 Ann Hospital Records
....
REGISTRAR
(Month) This Janatoni
(Year)
17
I HEREBY CERTIFY that f) attended deceased from
March 5
1915
to
March 3
1916
that I last saw ha. alive on
mar 3
6
and that death occurred, on the date stated above, at.
191
6.50€
The CAUSE OF DEATH* was as follows : Pulmonary tuberculosis
1
10 NAME OF
FATHER
John Murray
11 BIRTHPLACE
OF FATHER
(State or country)
12 MAIDEN NAME
OF MOTHER
Ellen - Unknown
13 BIRTHPLACE
OF MOTHER
(State or country)
Unknown
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
Elliott Washburn M. D. Luft
(Address)
Rutland Staty Saznalini un
19 PLACE OF BURIAL OR REMOVAL
Hreden
20 UNDERTAKER
7. H. Nuts
ADDRESS
Holden
........
....
9 BIRTHPLACE
(State or country)
Boston
PARENTS
Rutland
ity
E- Rodger
(City or town.) [If death occurred in a hospital or institution, give its NAME instead of street and number.]
...
Thomas
of
16 DATE OF DEATH
March 3
(Day)
191
....
L
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, c. 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 materiał worked on may form part of the second statement. Never return "Laborer," "Foreman," "Manager," "Dealer," cte., without moro precise specification, as Day laborer, Farm laborer, Laborer - Coal mine, etc. Women at hoine, 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 "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: 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," ctc., when a definite disease can be ascertained as the cause. Always qualify all diseases resulting from childbirth or miscarriage, as "PUER- PERAL septieacmia," "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 deaths of persons not disabled by recognized disease, as A death upon the street, or one supposed to be duc to Alcoholism, etc.
4. Deaths under circumstances unknown, as A person found dead, etc.
COMMONWEALTH OF MASSACHUSETTS
RETURN OF A DEATH-1916.
CITY OF BOSTON.
FULL NAME
CHARLES E. NOTT
Registered No. 2743
Place of Death ¿ and Residence
Boston
Date of Death
MAR.5
PETER BENT BRIGHAM HOSPT. 1916.
Age 24
years 7
months 28 days.
STATISTICAL DETAILS.
SEX.
COLOR.
SINGLE, MARRIED, WID., DIV.
M
W
MAR .
Maiden Name
Husband's Name
Birthplace COHASSET
Name of Father
CHARLES E. NOTT
Birthplace of Father COHASSET
Maiden Name of Mother MARY SMALL
Birthplace of Mother COHASSET
Occupation SALESMAN (MACHINIST)
Informant
PHYSICIAN'S CERTIFICATE.
I HEREBY CERTIFY that I attended deceased during last illness,
1916, that to the best of my knowledge and belief death occurred, on the from 1916, to date stated above, and that the CAUSE OF DEATH was as follows :
GIS
RAR'S
CITY
OFFICE
CTYTT BOSTONIA
CONDITAA.
SREGIMIME DONATA A
STO
N. MASS.
FRAC.SPINE ( 6TH CERVICAL VERT) ASSOCIATED COMPRESSION & SOFTEN ING SPINAL CORD -SUBSEQUENT OEDEMA LUNGS & EXHAUSTION - MACHINERY ACCIDENT
Contributory · (Duration)
(Signed)
G. B. MAGRATH MED.EX.
M.D.
MAR.6
1916
SPECIAL INFORMATION from Hospitals, Institutions, Transients, or Recent Residents.
Place of Burial or removal
COHASSET ( CENTRAL CEM)
Undertaker W.F . SNOW
COHASSET
Usual Residence
WINTHROP (25 SOMERSET AV)
Filed
MAR.II 1916.
A true copy. Attest : ENMSlenen
Registrar.
ST PATRIBUS SIT DE Primary
.SICU
( Duraton)
4.1822
mar. 2. 1 6
d
[12-'15-XXM.]
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
(No.
29
St. ; .................. Ward)
1
........ ......
[If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE 29 Webbile Que Sterettrush
Registered No.
PERSONAL AND STATISTICAL PARTICULARS
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
Indicar
1
(Year)
If LESS than
1 day ........ hrs.
Or ......... min. ?
11 BIRTHPLACE
OF FATHER
(State or country)
or Aftereffects
,
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
(Addres na Pebble Deve, Slutter
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
DATE OF DEATH
march
5
(Month)
(Day)
1916
(Year)
17 I HEREBY CERTIFY that I attended deceased from
191.5
tamary 25- 1916
that I last saw him alive on January 25, 1916. and that death occurred, on the date stated above, at .... 2 cm.
The CAUSE OF DEATH* was as follows :
acute Bronchitis
Did a surgical operation precede death? no
Date
(Duration)
... yrs.
........... ... mas. .............. .ds.
Contributory
Senility
(SECONDARY)
.. (Duration) .yrs. ............... mos. ................ ds.
(Signed)
William avinck air
March 6., 1916 (Address)
166 Pearl M. Somerville.
* 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
1 Janemul
DATE OF BURIAL
Ine, 1,291)7, 1911
20 UNDERTAKER
ADDRESS
2
BOSTON
(City or town.) [If death occurred In a hospital or institution, give its NAME instead of street and number.]
BILL . 67 ..
1 PLACE OF DEATH .......... 2 FULL NAME 1 & SEX 4 COLOR OR RACE 9h. · DATE OF BIRTH (Month) (Day) 7 AGE 91 8 OCCUPATION (a) Trade, profession, or particular kind of work retired (b) General nature of Industry. business, or establishment in which employed (or employer). 9 BIRTHPLACE (State or country)? 10 NAME OF FATHER 12 MAIDEN NAME OF MOTHER PARENTS 18 BIRTHPLACE OF MOTHER (State or country) 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 .... ... yrs. mos. ................... ds.
.....
......
................... M.D.
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 nceded. As examples: (a) Spinner, (b) Cotton mill; (a) Salcs- 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 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 (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," "IIcart failure," "Haemorrhage,". "Inanition," "Marasmus," "Old age," "Shock," "Uraemia," "Weakness," etc., when a definite disease ean 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 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 dcath upon the street, or onc supposed to be due to Alcoholism, etc. -
4. Deaths under circumstances unknown, as A person found dead, etc.
R. 15-8-'15. 100,000.
important. See instructions on back of certificate. 16 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 PARENTS
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH
.......
John Henry forger
2 FULL NAME
[If married op divorced woman or widow
give maiden name, also name of husband.]
@RESIDENCE
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
mare
4 COLOR OR RACE
Mute
6 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
Manuel
· DATE OF BIRTH
....
(Month)
4 1890 (Day) (Year)
7 AGE
If LESS than
I day ........ hrs.
26
mos.
3
ds.
Or ........ min. ?
8 OCCUPATION
(a) Trade, profession, or
particular kind of work
Barkeeper
.............
(b) General nature of industry, business, or establishment in which employed (or employer).
9 BIRTHPLACE
(State or country)
Roxbury Mas
10 NAME OF
FATHER
John Henry Forger
11 BIRTHPLACE
OF FATHER
(State or country)
12 MAIDEN NAME
OF MOTHER
Amelia C. Buffer
1ª BIRTHPLACE
OF MOTHER
(State or country)
" THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
C.R. Bunun
(Address)
Filed 191
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
March
5
191 6 ....
(Month)
(Day)
(Year)
17
I HEREBY CERTIFY that I attended deceased from
Fel. 1st
to
191
6
march 7th 1916
that I last saw hokks. alive on
March 6th, 1916.
-
and that death occurred, on the date stated above, at
1. am.
The CAUSE OF DEATH* was as follows :
Pulmonary Tuberculosis
.(Duration)
2
.yrs.
................ mos.
..........
ds.
Contributory
(SECONDARY)
.. (Duration).
......... yrs. ..........
mos.
..............
ds.
(Signed)
Wit. Paret
M.D.
Yeah 7 1916 (Address)
Weatherof
* 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.
.......... yes.
.........
mos. ............ ds .............
Where was disease contracted, If not at place of death ?.
Former or usual residence
19 PLACE OF BURIAL OR REMOWIL
DATE OF BURIAL
3
1916
ADDRESS
20 UNDERTAKER
C 1 Bem-
(City or town.)
(No.
33 Cryslot Can ard
Ward)
[If death occurred In a hospital or institution, give its NAME instead of street and number.]
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