USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1916-1918 > Part 85
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DATE OF BURIAL
Jaw 13
191
8.
ADDRESS 12 WarrenSt Boubury mare
afgh
M.D.
PARENTS
WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD.
BOSTON
.......
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
( Write the we
Widowed
16 DATE OF DEATH
Janu
A PERMANENT RECORD.
Jan. 8. 1918
STANDARD CERTIFICATE OF DEATH.
Statement of occupation. - "recise statement of occu- pation is very important, so that the relative healthifulness 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 engincer, Civil engineer, Stationary fireman, ete. 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 laborcr, 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 en r'oycd, 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 oecu- pation whatever, write Von.
Statement of cause vi death. - Name, first, the DIS- CASE 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 ecrcbro-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 ncoplasms); Measles; Whooping cough; Chronic valvular heart discase; Chronic interstitial nephritis, etc. The contributory (second- ary or intercurrent) affection necd not be stated unless im- portant. Example: Mcaslcs (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," ete.), "Dropsy," "Exhaustion," "Heart 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 septicacmia," "PUERPERAL peritonitis," ete. 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 eaused by violence, as Criminal abortion, Poisoning, Starvation, Suffocation, Ex- posurc, etc.
3. Sudden deaths 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 eireumstanecs unknown, as A person found dead, etc.
R. 15. 1.'17. 100,000.
VINA HLIM 'AINIŲ 1d la 3LIUM
NFADING INK -THIS IS
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 1
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH I PLACE OF DEATH Winthrop No 24KapleRoad Ward) Timothy &Sullivan
BOSTON
(City or town.) [If death occurred in a hospita· 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 24 diaple Road
Registered No.
PERSONAL AND STATISTICAL PARTICULARS
* SEX
4 COLOR OR RACE
5 SINGLE,
married"
WIDOWED,
OR DIVORCED
(Write the word)
$ DATE OF BIRTH
(Month)
(Day)
1
(Year)
7 AGE
70
.yrs.
.. mos. ds.
.......
or ........ min. ?
8 OCCUPATION
Petrred
(a) Trade, profession, or
particular kind of work
(b) General nature of industry, business, or establishment In which employed (or employer).
Did a surgical operation precede death ?
Date
(Duration)
....... yrs.
........
mos. ................ ds.
Contributory ..
ilevis
.... (SECONDARY)
(Duration)
.. yrs.
........... mos. ............. ds.
(Signed)
M.D.
1 - 1915 (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 cr usual residence
19 PLACE OF BURIAL OR REMOVAL
DATE OF BURIAL
24 Maple Road Holy Rood Jan 15, 1998
Filed 191
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
(Month)
(Day)
191
.......... ( Year)
17 I HEREBY CERTIFY that I attended deceased from
.......
191
to.
........
1
1913
that I last saw h_wwwalive on
11
191
.........
and that death occurred, on the date stated above, at
.m.
The CAUSE OF DEATH* was as follows :
Care mondo
Anarcher
9 BIRTHPLACE
(State or country)
Theland
PARENTS
12 MAIDEN NAME
OF MOTHER
Ellen Healy
12 BIRTHPLACE OF MOTHER (State or country)
Ireland
" THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
Will
(Address)
16
U UNDERTAKER Richard,Ko Boston
WRITE PLAINLY, WITH UNFADING INK -THIS IS A PERMANENT RECORD.
important. See instructions on back of certificate.
10 NAME OF
FATHER
Timothy
11 BIRTHPLACE OF FATHER (State or country) theland
If LESS than
I day ........ hrs.
............ .
PERMANENT RECORD
Jan. 11 1918
STANDARD CERTIFICATE OF DEATH.
Statement of occupation. - Precise statement of oecu- 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 occupations a single word or term on the first line will be sufficient, e. g., Farmer or Planter, Physician, Compositor, Architect, Loco- molive 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; (o) Forcman, (b) Automobile factory. The material worked on inay form part of the sceond statement. Never return "Laborer," "Foreman," "Manager," "Dealer," etc., without more precise specification, as Doy laborcr, Farm laborcr, 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 DEATII, 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 DEATHI (the primary affection with respect to time and causation), using always the same accepted term for the same discase. Examples: Cerebro-spinol 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- pncumonia ("Pneumonia," unqualified, is indefinite) ; Tuber-
culosis of lungs, meninges, peritonocum, etc., Carcinoma, Sar- coma, etc., of .. (namo origin: "Cancer" is icss definite; avoid uso of "Tumor" for malignant ncoplasms); Measles; Whooping cough; Chronic valvular hcart discase; Chronic interstitial nephritis, etc. The contributory (second- ary or intercurrent) affection need not bo stated unless im- portant. Example: Meastes (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," "Scnile," ete.), "Dropsy," "Exhaustion," "Heart failure," "Haemorrhage," "Inanition," "Marasmus," "Old age," "Shock," "Uraemia," "Weakness," etc., when a definite diseaso can be ascertained as the cause. Always qualify all diseases resulting from childbirth or miscarriage, as "PUER- PERAL septicacmia," "PUERPERAL peritonitis," etc. State causo for which surgical operation was undertaken.
Cases for the Medical Examiners. - Under tho 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, cte.
4. Deaths under circumstances unknown, as A person found dead, etc.
R. 13. 1'17. 100,000.
JANA H.LIM AINLY.
NFADING INK
A SIHL
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)
n.S.
12 MAIDEN NAME OF MOTHER Elizabeth Chadsey
13 BIRTHPLACE OF MOTHER (State or country) 91.8-
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
(Address)
150 Mann St.
16
Filed
191
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
Jan. 12
198
(Year)
(Mont
17 1 HEREBY CERTIFY that I have investigated the death of the deceased.
The CAUSE OF DEATH* was as follows : natural Causes, Presumably Cardio
Vas cular diario 21 nicidental age. .. (Duration) .. yrs. Contributoundden dealto)
.mos. . . ... ds.
(SECONDARY)
mos. ds.
(Signed}
Jan il 8 018 (A)
MEDICAL EXAMINER
* State the DISEASE CAUSING DEATHI, or, in deaths from VIOLENT CAUSES, state (1) MEANS of INJURY; and (2) whether ACCIDENTAL, SUICIDAL Or HOMICIDAL.
18 LENGTH OF RESIDENCE (FOR HOSPITALS, INSTITUTIONS, TRANSIENTS, OR RECENT RESIDENTS).
At place
of death
. yrs.
mos.
In the
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 grunthoop Cent
DATE OF BURIAL 1-15- 1918
20 UNDERTAKER
ADDRESS
q.C. Skaggs Winthrop
Worthup (City or town.)
[if death occurred in a hospital or institution, give its NAME instead of street and number.]
2 FULL NAME. [If married or divorced woman or widow give maiden name, also theuse of husband.] @RESIDENCE
mani St
Registered No.
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
+ COLOR OR RACE
& SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
manuel
6 DATE OF BIRTH
(Month)
(Day)
(Year)
7 AGE
If LESS than I day, ........ hrs.
76 yrs.
10 mos.
ds.
Or ....... min. ?
& OCCUPATION Returned Computer
(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)
Lockeport. 9.8-
10 NAME OF
FATHER
Stephen Belcher
.
Serge Bugen Magrath.
yrs.
M.D.
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
9411
1 PLACE OF DEATH
Winthrop
.(No ..
0
main
St. .................. Ward)
Beleben
WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD.
RECORD. PERMANENT
A
WRITE PLAINLY, WITH UNFADING INK - THIS IS
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 ? a single word or term on the first line will be sufficient, e. g., Farmer or Planter, Physician, Compositor, Architect, Loco- motive enginecr, 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 "Laborcr," "Foreman," "Manager," "Dealer," etc., 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- keepcrs 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 eausation), using always the same accepted term for the same disease. Examples: Cerebro-spinal fever (the only definite synonym is "Epidemic eerebro-spinal meningitis"); Diphtheria (avoid use of "Croup"); Typhoid fever (never re- port "Typhoid pneumonia"); Lobar pneumonia; Broncho- pneumonia ("Pneumonia," unqualified, is indefinite) ; Tuber
culosis of lungs, meninges, 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 intereurrent) affection need not be stated unless im- portant. Example: Measles (discase eausing 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," "Haemorrhage," "Inanition," "Marasmus," "Old age," "Shock," "Uraemia," "Weakness," etc., when a definite disease can be ascertained as the cause. Always qualify all discases resulting from childbirth or miscarriage, as "PUER- PERAL septicaemia," "PUERPERAL peritonitis," ete. State eause 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 if head - homicide; Poisoned by carbolic acid - probably suicide. 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 Medieal Examiners:
1. Deaths following injury or violence, as Burns, Falls, Drowning, Gas poisoning, Suicide, Homicide, ete.
2. Deaths supposedly eaused by violence, as Criminal abortion, Poisoning, Starvation, Suffocation, Ex- posure, ete.
3. Sudden deaths of persons not disabled by recognized disease, as A death upon the street, or one supposed io bc due to Alcoholism, etc.
4. Deaths under eireumstanees unknown, as A person found dead, ete.
R 16. 7.'16. 5,000.
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.
PARENTS
11 BIRTH LACE OF FATHER (Staty or coustry)
Geland
12 MAIDEN NAME OF MOTHER any Furar Mary
13 BIRTHPLACE OF MOTHER (State or country)
of manchester A.H.
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
10 Locust Stsensual
(Address)
16
Filed
191
REGISTRAR
16 DATE OF DEATH
Jan . 16-17
(Day)(
.,
191
( Усаг)
(Month)
17 I HEREBY CERTIFY that I have investigated the death of the deceased.
The CAUSE OF DEATH* was as follows :
Exhaustion and other efecto
mos.
ds.
Contributory
(SECONDARY)
(Duration) .. yrs.
.mos. ds.
(Signed)
M.D.
MEDICAL EXAMINER
* State the DISEASE CAUSING DEATHI, or, in deaths from VIOLENT CAUSES, state (1) MEANS of INJURY; and (2) whether ACCIDENTAL, SUICIDAL or HOMICIDAL.
18 LENGTH OF RESIDENCE (FOR HOSPITALS, INSTITUTIONS, TRANSIENTS, OR RECENT RESIDENTS).
At place
of death
yrs.
In the
mos.
ds.
State
yrs.
mos.
ds.
...
If not at place of death ?.
Where was disease contracted,
Former cr usual residence.
19 PLACE OF BURIAL OR REMOVAL
IH St Joseph manchester
DATE OF BURIAL tan 2008 .....
ADDRESS
John t. CO. maley
9427
(City or town.)
[If death occurred in a hospital or institution, give its NAME instead of street and number.]
Registered No.
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
3 SEX
male Muito
6 DATE OF BIRTH
(Month) (Day)
(Year)
7 AGE 1 30-35" 32 .yrs.
If LESS than
1 day, ........ hrs.
or .....
min. ?
8 OCCUPATION
(a) Trade, profession, or
particular kind of work
Laborer
(b) General nature of industry, business, or establishment in which employed (or employer).
9 BIRTHPLACE
manchester A.H.
10 NAME OF FATHER tohan
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH
(No .. 400 Waltrop ...... St. ............ Ward)
2 FULL NAME
William
g Higgins
[If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE
me
4 COLOR OR RACE
6 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
Single
mos.
ds.
WRITE PLAINLY, WITH UNFADING INK -THIS IS A PERMANENT RECORD.
RECORD.
PERMANENT A
WRITE PLAINLY, WITH UNFADING INK -THIS 18
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 ? 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 needed. As examples: (a) Spinner, (b) Cotton mill; (a) Sales- man, (b) Grocery; (a) Foreman, (b) Automobile factory. The . material worked on may form part of the second statement. Never return "Laborer," "Foreman," "Manager," "Dealer," etc., without more precise specification, as Day laborer, Farm laborer, Laborer - Coal minc, etc. Women at home, who 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, peritonaeum, etc., Careinoma, Sar. coma, etc., of .... ............ (name origin: "Cancer" is less definite; avoid use of "Tumor" for malignant neoplasmis) ; Measles; Whooping cough; Chronic valvular heart disease; Chronic interstitial nephritis, etc. The contributory (second- ary or intercurrent) affection need not be stated unless iin- 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 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 cf head - homicide; Poisoned by carbolic acid - probably suicide. The nature of the injury, as fracture of skull, and consequences (c. 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 discase, 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 16. 7-'16. 5,000.
-
-
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.
- 2 FULL NAME 3 SEX Male 1 AGE PARENTS CAUSE OF DEATH in plain terms, so that it may be properly classified. Exact statement of OCCUPATION is very particular kind of work
The Commonwealth of Massachusetts STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH
(No. 240 Pleasant
St. :
...... Ward)
Ralph. Afellow sewolsburg
[If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE
240 Pleasant d'F Nultant
Registered No.
PERSONAL AND STATISTICAL PARTICULARS
4 COLOR OR RACE
Muito
6 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
Linjer
" DATE OF BIRTH Mar 4
1879
(Month) (Day)
(Year)
& OCCUPATION (a) Trade, profession, or
Reluct
(b) General nature of industry, business, or establishment In which employed (or employer) ...
9 BIRTHPLACE
(State or country)
Gilbert. " correcting
10 NAME OF
FATHER
albert. N. Iciokesbury
11 BIRTHPLACE
OF FATHER
(State or country)
muelleroh
12 MAIDEN NAME
OF MOTHER
Ellen V. TecTesting
1ª BIRTHPLACE OF MOTHER (State or country}
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