USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1916-1918 > Part 84
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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 discase. 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 ncoplasms); Mcasles; 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 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 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
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH Finishwh Brack Mars (No. 74
Underhill
St. :....
;.... .............
.Ward)
"FULL NAME
Clarences . Venuurugay Dielings
[If married or divorced woman or widow give maiden name, also name of husband,] @RESIDENCE 24 Underbrill. Se
Registered No.
PERSONAL AND STATISTICAL PARTICULARS
· SEX
4 COLOR OR RACE
Vr.
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
Married
" DATE OF BIRTH
27
(Month)
(Day)
I
(Year)
' AGE
If LESS than
1 day ......... hrs.
67 yrs. 10
.yrs ....
.. mos.
.......
ds.
-
... min. ?
& OCCUPATION
(a) Trade, profession, or
particular kind of work
Tailor (Retirea. ( IN)
(b) General nature of industry, business, or establishment in which employed (or employer) ......
9 BIRTHPLACE
(State or country)
Canton Mariachiretts.
PARENTS
11 BIRTHPLACE
OF FATHER
(State or country)
Canton Marcachuretts
12 MAIDEN NAME
OF MOTHER
Luscittà tialden
13 BIRTHPLACE
OF MOTHER
(State or country)
Gratou. n. H.
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
Exarence E. Biecings
(Address) 11d how ST. Tien Have CX
15
Filed ., 191
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
10 DATE OF DEATH
lan
1918
(Month)
(Day)
....
............
(Year)
17
I HEREBY CERTIFY that I attended deceased from
to
ahr 30
1917
Dan 4th 198
that I last saw halive on
Jan 3 th, 1918
and that death occurred, on the date stated above, at 12-20my
The CAUSE OF DEATH* was as follows :
Service Paresis
(Duration)
1 yrs. 6
.mos. .............
ds.
Contributory ....
Hemorrhage of
the
.......
DUmach
(Duration) .
.......... yrs.
mos.
5
ds
(Signed)
le harles P Bean
..........
M.D
Jau HMY (Addres).
.....
42€ Mars Que
-
* 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 ...........
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
DATE OF BURIAL
Jan 7, 1919
20 UNDERTAKER M. C. Skaggs
( ADDRESS
Winchrok.
(City or town.) [If death occurred in a hospital or institution, give its NAME instead of street and number.]
WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD.
important. See instructions on back of certificate.
10 NAME OF
FATHER
Uriah Billings
Jan . 4 1918
STANDARD CERTIFICATE OF DEATH.
Statement of occupation. - Frecise statement of occu- pation is very important, so that the relative hcalthfulness of various pursuits can be known. The question applies to each and every person, irrespective of agc. 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 ncedcd. 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 laborcr, 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 diseasc. Examples: Cerebro-spinal fever (the only definite synonym is "Epidemic cercbro-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 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" (mercly 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 ascertained as the cause. Always qualify all discases 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 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.
U
WRITE PLAINLY, WITH UNFADING INK -THIS IS
PERMANENT RECORD. m
V
WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD.
CAUSE OF DEATH in plain terms, so that it may be properly classified. Exact statement of OCCUPATION is very N. B. - Every item of Information should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state important. See instructions on back of certificate.
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH Winthrop Mars (No. 34 Brookfield /Psd. ....
Ward)
(City or town.) {If death occurred In a hospital or institution, give its NAME instead of street and number.]
............
[If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE 34 Brookfield Pool
Registered No.
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
& SEX
Male
' COLOR OR RACE
White
§ SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
Single
16 DATE OF DEATH
Jan
....
0
(Month)
(Day)
1918
(Year)
$ DATE OF BIRTH
1200
-
6
-1913
(Month)
(Day)
(Year)
Jan 2"
1918
1918
7 AGE
that I last saw himq alive on
If LESS than
[ day ......... hrs.
1915.
4
and that death occurred, on the date stated above, at 0. m.
........ yrs.
2
mos.
29
ds.
or ........ min. ?
The CAUSE OF DEATH* was as follows :
.
1
1
Influenza
acidosio
& OCCUPATION
(a) Trade, profession, or
particular kind of work
(b) General nature of industry, business, or establishment - which employed (or employer) ............ +
(Duration)
.. yrs.
mos.
5
ds.
Contributory
(SECONDARY)
.. (Duration).
.... yss.
.. mos. .ds.
(Signed)
M.D.
tam 7, 1918
(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
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
DATE OF BURIAL
191
........
20 UNDERTAKER text Semuon
ADDRESS
Filed. 191
REGISTRAR
PARENTS
11 BIRTHPLACE
OF FATHER
(State or country)
Burton Mars
12 MAIDEN NAME
OF MOTHER
Ruch. E. Tucker
13 BIRTHPLACE
OF MOTHER
(State or country)
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
Cherti H. Poha
(Address)
34 Brookfield Rd Wanting
16
Chester Henry Pope
' FULL NAME
9 BIRTHPLACE
(State or country)
Winthrop Plass
10 NAME OF
Chester. H. Pole, SR.
17 I HEREBY CERTIFY that I attended deceased from
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 agc. For many occupations a single word or term on the first line will be sufficient, e. g., Farmer or Planter, Physician, Compositor, Architect, Loco- 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," "Dcaler," 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 discase. Examples: Cerebro-spinal fever (the only definite synonym is "Epidcinic 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 .; 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," "Uracmia," "Weakness," etc., when a definite disease can be ascertained as the cause. Always qualify all diseases resulting fromn childbirth or miscarriage, as "PUER- PERAL septicemia," "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 PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD.
CAUSE OF DEATH in plain terms, so that it may be properly classified. Exact statement of OCCUPATION is very N. B. - Every item of information should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state important. See instructions on back of certificate.
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH Huithop ......
(No. 40 ....
Collage Kid
St. ..... .............. Ward)
'FULL NAME.
......
{If married or divorced woman or widow
give maiden name, also name of husband.]
@RESIDENCE
Ho cottage pot Rd Huithop
Registered No.
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
1º DATE OF DEATH
(Month)
1
(Day) 6. , 1918 (Year)
17
I HEREBY CERTIFY that I attended deceased from
1917, to
famil
1918
that | last saw had
alive on
1
1919
and that death occurred, on the date stated above, at
................ m
The CAUSE OF DEATH* was as follows :
to de fuite
.(Duration)
......... yrs. ................ mos. ................ ds.
Contributory.
(SECONDARY)
(Duration)
www ..... YES.
mos.
ds
(Signed)
Teras G 1 hours
M.D
191 ...... (Address).
218 Luann 12 Winther
* 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
Jan.
...............
1918.
Filed 191
REGISTRAR
(City or town.)
[If death occurred in a hospital or institution, give its NAME instead of street and number.]
* DATE OF BIRTH
(Month)
(Day)
1
(Year)
? AGE
If LESS than
I day ......... hrs.
or ........ min. ?
B OCCUPATION
(a) Trade, profession, or
particular kind of work
Retired- Lucches
(b) General nature of industry, business, or establishment in which employed (or employer).
9 BIRTHPLACE
(State or country)
Bangor que
PARENTS
11 BIRTHPLACE
OF FATHER
(State or country
Jusque Islams
12 MAIDEN NAME
OF MOTHER
Sarah Libbets
18 BIRTHPLACE
OF MOTHER
(State or country)
Exitin THE.
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
(Address)
HO Cottage RK Rd
18
1 SEX
m
4 COLOR OR RACE
6 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
manuel
83
....... yrs.
8
...... mos.
2 ds.
..................
10 NAME OF
FATHER
John Huckuns
Invendita
............
20 UNDERTAKER
I.S. Skaggs
VADDRESS
Jan . 6. 1918
STANDARD CERTIFICATE OF DEATH.
Statement of occupation. - Frccise 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 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 "Laborer," "Foreman," "Manager," "Dealer," ctc., 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 "Epidemic cerebro-spinal meningitis"); Diphtheria (avoid use of "Croup"); Typhoid fever (never rc- port "Typhoid pneumonia"); Lobar pneumonia; Broneho- pneumonia ("Pneumonia," unqualificd, is indefinite) ; Tubes
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- acmia" (mcrely 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 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 circumstances unknown, as A person found dead, etc.
COMMONWEALTH OF MASSACHUSETTS
RETURN OF A DEATH-1918.
CITY OF BOSTON
FULL NAME
LAWRENCE M.SMITH
Registered No.
200
Place of Death { and Residence (
Boston
MASS .HOMEO .HOSPT .
Date of Death
JAN.6
1918,
Age
20
years 8
months
days.
STATISTICAL DETAILS.
SEX.
COLOR.
SINGLE, MARRIED, WID., DIV.
M
W
S
Maiden Name
Husband's Name
Birthplace
BELMONT.N.H.
Name of Father
Birthplace of Father
SANDWICH.N.H.
+-Contributory : (Duration )
Maiden Name of Mother
FLORENCE M.KNOWLES
Birthplace of Mother
BOSTON(EAST)
Occupation
CLERK
JAN.7
1918
SPECIAL INFORMATION from Hospitals, Institutions, Transients, or Recent Residents.
Place of Burial
or removal
CONCORD.N.H.
Usual Residence
WINTHROP (226 MAIN ST)
JAN.II
Undertaker
E.J.FIELD
1918.
Registrar.
1
LOBAR PNEUMONIA
CITY
COBISA
OFFICE
CORDITAA. CIVITA BOSTONIA
LA. 1822.
STON
(Signed)
H.M.POLLOCK M.D
Informant
PHYSICIAN'S CERTIFICATE.
I HEREBY CERTIFY that I attended deceased during last illness, from 1918, to
1918, 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:
IST
RAR
RE
PATRICK
Pramary (Duration)
SICUT
JASPER D. SMITH TIS e 16 CO. REGIMINE DONATA A MASS.
1
Filed
A true copy,
Attest :
.
WRITE PLAINLY, WITH UNFADING INK -THIS IS
A PERMANENT RFCC
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.
15-'17 XXM | The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH
399Winthrop StreetNo. ......... ... Winthrop Mass. St.
..... Ward)
(City or .own.) [If death occurred In a hospita· or institution, give its NAME instead of street and number.]
? FULL NAME
Maria .... Grazia .... Mancuso.,
[If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE 399 Winthrop St Winthrop Mass
Salvatore. ..... Rinaldi ....
Registered No.
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
4 COLOR OR RACE
Female
White
" DATE OF BIRTH
1
(Month) (Day)
(Year)
7 AGE
If LESS than I day ......... hrs.
6.4 ......_. yrı. ................. mos. ds.
„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)
Italy
10 NAME OF
FATHER
Joseph Rinaldi
11 BIRTHPLACE OF FATHER (State or conntry)
Italy
12 MAIDEN NAME
OF MOTHER
Unknown
1] BIRTHPLACE
OF MOTHER
(State or country)
Italy
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
Micheal Mancuso
( Address)
399 Winthrop Street
Filed
191
-
REGISTRAR?
MEDICAL CERTIFICATE OF DEATH
8
191 ......
(Month)
(Day)
(Year)
17 I HEREBY CERTIFY that I attended deceased from
....
1
191
to ... y
1918
that I last saw he alive on
1918
and that death occurred, on the date stated above, at ....
90 m.
The CAUSE OF DEATH* was as follows ;
Did a surgical operation precede death ?
Date
(Duration) . .............. yrs. ............ .. mos. ............... ds. Contributory Semana Puntero Salamino ....
(SLCONDARY)
(Duration) \ .......... yrs. mos. ............. ds.
(Signed)
Jung, 1915 (Address) .... 200 Celeron]Ser
Mf 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
Holy Cross Cemetery
20 UNDERTAKER F. J. Crosby
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