USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1916-1918 > Part 87
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2 FULL NAME
[If married or divorced woman or widow give maiden name, also name ef husband.] @RESIDENCE 18 Herman St Wintrots
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
Female
4 COLOR OR RACE
White
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
'Write the word)
Married.
· DATE OF BIRTH
(Month)
(Day)
1
(Year)
? AGE
46
........ yrs.
.......... mos.
.........
or ........ min. ?
& OCCUPATION
(a) Trade, profession, or
particular kind of work
Housewife
(b) General nature of industry,
business, or establishment in
which employed (or employer).
9 BIRTHPLACE
(State or country)
RA
10 NAME OF
FATHER
PARENTS
11 BIRTHPLACE
OF FATHER
(State or country)
Rax
12 MAIDEN NAME
OF MOTHER
Rossunna
una
1ª BIRTHPLACE
OF MOTHER
(State or country)
Ireland
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
James Regan
(Address)
16 Filed 191
REGISTRAR
17
I HEREBY CERTIFY that I attended deceased from Rug, 15., 198, to Date 2014 that I last saw her alive on Li ZC., 1918 .. and that death occurred, on the date stated above, at 9 am The CAUSE OF DEATH* was as follows :
Epithelinne of Cervix, iltere
Did & surgical operation precede death ? che
Date defet 15.
(Duration)
2
yrs. 1
Contributory
Baldige Drokey
.. mos.
ds.
(SECONDARY)
1 st's
(Duration)
mos.
ds.
(Signed)
Wti Parte
M.D.
Fille. 2/2/1918 (Address)
Neuchips
* 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
Calveses Cenado 1,24, 1918
20 UNDERTAKER
ADDRESS
Patrick + Rally 1175/ Lemans
4
BOSTON
(City or town.) [If death occurred In a hospital or institution, give its NAME instead of street and number.]
....... Registered No.
/ MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
191
(Month)
(Day)
(Year)
If LESS than
! day ......... hrs.
ds.
James Regan
St. ; Ward)
Jan. 22.1918
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 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, ctc. Women at home, who are engaged in the dutics 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 domestic service for wages, as Servant, Cook, Houscmaid, 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 fcvcr (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); Tubcr
culosis of lungs, meninges, peritonaeum, etc., Carcinoma, Sar- roma, 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" (mercy 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 can be ascertained as the cause. Always qualify all Aiseascs 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 strcct, or one supposed to be due to Alcoholism, etc.
4. Deaths under circumstances unknown, as A person found dcad, etc.
R. 15. 1-'17. 100,000.
1
COMMONWEALTH OF MASSACHUSETTS
RETURN OF A DEATH-1918.
CITY OF BOSTON
FULL NAME
MAYBELLE CUTTING
Registered No.
903
Place of Death / and Residence S
Boston
BAY STATE HOSP.
Date of Death
JAN 23
1918,
Age
25
years
months
days.
STATISTICAL DETAILS.
SEX.
COLOR.
SINGLE, MARRIED, WID., DIV.
F
W
SINGLE
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:
Maiden Name
Husband's Name
Birthplace
BOSTON MASST
Name of Father
FREDERICK CUTTING
Birthplace of Father
NEW YORK N. Y.
Contributory : (Duration)
1 MYOCARDIAL WEAKNESS
Maiden Name of Mother
ELLEN MURRAY
Birthplace of Mother
HYDE PARK MASS
(Signed)
H. H. HOWARD M.D.
Occupation
SECRETARY
JAN 23
1918
SPECIAL INFORMATION from Hospitals, Institutions, Transients, or Recent Residents.
Place of Burial or removal
CALVARY BOSTON
Usual Residence
WINTHROP (93 COURT ROSD)
Undertaker
J.F. O'MALEY WINTHROP. Filed
JAN 29 1918.
-
Registrar.
3 .
UT PATRIBŪS ..
Primary (Duration)
-
DOBIS
CITY
JOFFICE
CARCINOMA OF INTESTINE AND BL BLADDER ( OPER . JAN 21 1918)
CONDITADO. 1611.
A.182
VITA
BOSTONIA
MINE DONATA A. STON. MASS.
Informant
PHYSICIAN'S CERTIFICATE.
RAR
A true copy. Attest :
C
... .. . -
COMMONWEALTH OF MASSACHUSETTS
RETURN OF A DEATH-1918.
CITY OF BOSTON
FULL NAME
HAROLD G. CARVER
Registered No.
1008
Place of Death { and Residence
Boston MASS GEN HOSP.
Date of Death
JAN 25
1918,
Age
31
years 4 months 9
days.
STATISTICAL DETAILS.
SEX.
COLOR.
SINGLE, MARRIED, WID., DIV.
M
W
WIDOWED
Maiden Name
STRAR
PATRIBU
Primary # (Duration)
PABIS
COFFICE
Name of Father
GEORGE H. CARVER
Birthplace of Father
BOSTON MASS
-Contributory : (Duration)
Maiden Name of Mother
NELLIE G. GOODEIN
Birthplace of Mother
NEWBURYPORT MASS
(Signed)
H. M. HERSEY M. D.
JAN 26 1918
SPECIAL INFORMATION from Hospitals, Institutions, Transients, or Recent Residents.
Place of Burial or removal
SALEM
Undertaker W. C. SKAGGS WINTHROP
Usual Residence
WINTHROP ( 7 VINE AV)
Filed
A true copy.
Attest :
JAN 31
1918.
Registrar.
-
Husband's Name
Birthplace
BOSTON MASS
CITY
BOSTONIA
CONDITAA
A.1822
18 80.
EGIMINE DONATH A ON. MASS.
ST
-
Occupation
CLERK
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:
MENINGITIS (MENINGOCOCCUS )
.
..... .
COMMONWEALTH OF MASSACHUSETTS
RETURN OF A DEATH-1918.
CITY OF BOSTON
FULL NAME
HANNAH E.SULLIVAN
Registered No.
1095
Place of Death l and Residence
Boston
ST. ELIZABETH'S HOSP.
Date of Death
JAN 28
1918,
Age 57
years 5
months 16 days.
STATISTICAL DETAILS.
PHYSICIAN'S CERTIFICATE.
SEX.
COLOR.
SINGLE, MARRIED, WID., DIV.
F
W
MARRIED
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:
Maiden Name
CLIFFORD
STRAR'
Husband's Name
TIMOTHY SULLIVAN
R
PATRIEU
(Duration)
OBIS 9
Birthplace
BANGOR ME.
CITY
Name of Father
GEOFFREY CLIFFORD
16 30.
VE DONATH A.
Birthplace of Father
IRELAND
Maiden Name of Mother
MARY CASEY
Birthplace of Mother
IRELAND
(Signed)
T. J. O' BRIEN
M.D.
Occupation
AT HOME
JAN 28
1918
SPECIAL INFORMATION from Hospitals, Institutions, Transients, or Recent Residents.
Place of Burial or removal
BANGOR ME. (BIRCH HILL) Usual Residence WINTHROP (67 CENTRE ST )
Undertaker
J.F . SULLIVAN BOSTON
Filed A true copy. Attest :
FER
1
1918.
Registrar.
-
BOSTONIA
CONDITAA.
A. 1822
TO
N. MASS. Contributory: (Duration)
MINE
DOUBLE PLEURISY WITH
EFFUSION
informant
primary: AC. CARDIAC DILATATION
OFFICE
-
WRITE HLIM 'A INIV'
FADING INK - THIS IS VINA
PERMANENT RF RFCORD
(5-'17-XXMI
The Commonwealth of Massachusetts STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH winthrop (No 29 Elmwood dve St;
................. Ward)
' FULL NAME
Emilie FLoudon
maiden name
[If married or divorced woman or widow give maiden name, also name of husband.] .
Henry B. Souton.
@RESIDENCE
29 Elmwood Que winthrop
Registered No.
PERSONAL AND STATISTICAL PARTICULARS
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED Chedora
(Write the word)
10
1836
(Month)
(Day)
(Year)
If LESS than
f day ......... hrs.
....... yrs.
mos.
19
ds-
Or ......... min. ?
(a) Trade, profession, or
particular kind of work
at Home
-
Searsport,
Otra Me
11 BIRTHPLACE
OF FATHER
(State or country)
alnames.
12 MAIDEN NAME
OF MOTHER
Clara 11 Difer
Stembert, me
13 BIRTHPLACE
OF MOTHER
(State or country) antwort, me.
"THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant) .
John gallen.
(Address) 29 El ninood alise.
16
Filed
191 ....
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
10 DATE OF DEATH
25th
1918
(Year,
-
17 I HEREBY CERTIFY that I attended deceased trom 191_7 .... to Oct 10 Jan 27 1915 ...
that I last saw halive on 22 1918 and that death occurred, on the date stated above, at 3 45m. The CAUSE OF DEATH* was as follows :
Did
surgical operation precede death? no
Date
"Fila Telinie Neat Dure
(Duration)
2 yrs.
mos. ............ ds.
artini-schlie
.(Duration)
10 yrs.
.yrs.
mos. ..................
(Signed)
Jan-30, 1918 (Address)
462 Boy lotro St Barth
......
M.D.
* 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.
In the
de.
State
... yrs.
...........
mos.
ds .............
Where was disease contracted, If not at place of death ?.
Former or usual residence.
19 PLACE OF BURIAL OR REMOVAL
Everett
woodlawn Pem
DATE OF BURIAL
Jan. 3.1. 1915
20 UNDERTAKER
Pearl Boston
ADDRESS
300 meridian
ST.
WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD.
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.
3 SEX Female 4 COLOR OR RACE white " DATE OF BIRTH Fejet ' AGE 8 OCCUPATION Ca Embalses (b) General nature of Industry. business, or establishment in which employed (or employer) 9 BIRTHPLACE (State or country) 10 NAME OF FATHER PARENTS CAUSE OF DEATH in plain terms, so that it may be properly classified. Exact statement of OCCUPATION is very 83 4
BOSTON
(City or town.) [If death occurred in a hospital or institution, give its NAME instead of street and number.]
(Month)
(Day)
Contributory
(SECONDARY)
m . 29 1918
STANDARD CERTIFICATE OF DEATH.
Statement of occupation. - Precise statement of occu- pation is very important, so that the relative healthfulness of various pursuits can be known. The question applies to each and every person, irrespective of age. For many occupations a single word or term on the first line will be sufficient, e. g., Farmer or Planter, Physician, Compositor, Architect, Loco- motive engineer, Civil engineer, Stationary fireman, etc. But in many cases, especially in industrial employments, it is necessary to know (a) the kind of work and also (b) the nature of the business or industry, and therefore an additional line is provided for the latter statement; it should be used only when necdcd. 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 laborcr, 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 Nonc.
Statement of cause of death. - Name, first, the DIS- EASE CAUSING DEATH (the primary affection with respect to time and causation), using always the same accepted term for the same discase. Examples: Cerebro-spinal fever (the only definite synonym is "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, 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 disease; Chronic interstitial nephritis, etc. The contributory (second- ary or intercurrent) affection need not bo stated unless im- portant. Example: Measles (discase 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," "Senilc," etc.), "Dropsy," "Exhaustion," "Heart failure," "Hacmorrhage," "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 septieacmia," "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, Suieidc, Homicide, etc.
2. Deaths supposedly caused by violence, as Criminal abortion, Poisoning, Starvation, Suffocation, Ex- posurc, etc.
3. Sudden deaths of persons not disabled by recognized discasc, 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.
R. 15. 1-'17. 100,000.
so that it may be properly classified. Exact statement of OCCUPATION is very important. See instructions on back carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state CAUSE OF DEATH in plain terms, N. B .- WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD. Every item of information should be of certificate.
The Commonwealth of Massachusetts STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH
County
Township
or Village
or
St ... ...... . Ward
(If death occurred in a hospital or institution, give its NAME instead of street and number)
Georga
7 Lichand
2 FULL NAME
(a) Residence.
No.
172
(Usual place of abode)
Length of residence in city or town where death occurred
years
months
days.
How long in U. S., if of foreign birth ?
years
months days
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
4 COLOR OR RACE
White
5 SINGLE, MARRIED, WIDOWED, OR
DIVORCED (write the word)
5a If married, widowed, or divorced
HUSBAND of
(or) WIFE of
6 DATE OF BIRTH (month, day, and year)
Jefe1- 8-1917-
7 AGE
Years
Months
Days
28
If LESS than I day, ........ hrs. or ........ min.
8 OCCUPATION OF DECEASED
(a) Trade, professinn, or particular kind of work
(b) General nature of industry, business, or establishment in which employed (or employer) (c) Name of employer
9 BIRTHPLACE (city or town)
(State or country)
10 NAME OF FATHER George Fuller Peine
PARENTS
11 BIRTHPLACE OF FATHER (city or town) ... (State or country) l'enthrop
12 MAIDEN NAME OF MOTHER Matteo Duona
13 BIRTHPLACE OF MOTHER (city or town) (State or country) EnfiBração Miss
14
Informant
Geo. Futter Paris
(Address)
15 Filed , 19
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH (month, day, and year) Hel. 4 19
18
17 I HEREBY CERTIFY, That Iattended deceased from Jan. 22
19/8, to
Heb 4
, 19.
18
that I last saw h UM
alive on
Нев 3
1918
and that death occurred, on the date stated above, at
19
m.
The CAUSE OF DEATH* was as follows :
auto Meningitis
.
yrs.
... mos ....
1
ds.
Scorbutus
(duration) yrs 1 mos. ds.
18 Where was disease contracted
if not at place of death ?
Did an operation precede death?
Date of
Was there an autopsy ?
What test confirmed diagnosis 2.
(Signed).
2/5, 19/8 (Address) 193 Huntington Que Brislas
* State the DISEASE CAUSING DEATH, or in deaths from VIOLENT CAUSES, state (1) MEANS AND NATURE OF INJURY, and (2) whether ACCIDENTAL, SUICIDAL, or HOMICIDAL. (See reverse side for additional space.)
19 PLACE OF BURIAL, CREMATION, OR REMOVAL Winthrop man
DATE OF BURIAL 461
20 UNDERTAKER
ERBennem
ADDRESS
Wanting
(City or town)
State Mace accesselté
Registered No ..
City.
No
1 timon S
Ward. 1
(If non-resident give city or town and State)
4
CONTRIBUTORY
(SECONDARY)
(duration)
CHOO3H ININVWW3d V SI SIHJ
REVISED UNITED STATES STANDARD LEKIITIVAIL Ur VEAIII [Approved by U. S. Census and American Public Health Association]
Statement of occupation. -- Precise statement of occupa- tion 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 terin on the first line will be sufficient, e. g., Farmer or Planter, Physician, Compos- itor, Architect, Locomotive 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) Salesman, (b) Grocery; (a) Foreman, (b) Automobile factory. The ma- terial worked on may form part of the second statement. Never return
"Laborer," "Foreman," " Manager,' "Dealer," ete., 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 Housekeepers who receive a definite salary), may be entered as Housewife, Housework, or At home, and children, not gainfully employed, as At school or At home. Care should be taken to report spe- cifically 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 indi- cated thus: Farmer (retired, 6 yrs.). For persons who have no occupation whatever, write None.
Statement of cause of death. - Name, first, the DISEASE CAUSING DEATH (the primary affection with respect to time and causation), using always the same accepted term for the same disease. Examples: Cerebrospinal fever (the only definite synonym is "Epidemie cerebrospinal menin- gitis"); Diphtheria (avoid use of "Croup"); Typhoid fcver (never report "Typhoid pneumonia"); Lobar pneumonia; Bronchopneumonia ("Pneumonia," unquali- fied, is indefinite); Tuberculosis of lungs, meninges, peri- toncum, etc., Carcinoma, Sarcoma, etc., of __.
(namne origin; "Cancer" is less definite; avoid use of "Tumor" for malignant neoplasms); Measles; Whooping cough; Chronic valvular heart disease; Chronic interstitial
nephritis, ete. The contributory (secondary or inter- current) affection need not be stated unless important. Example: Measles (disease causing death), 29 ds .; Broncho- pneumonia (secondary), 10 ds. Never report mere symp- toms or terminal conditions, such as "Asthenia," "Anemia" (merely symptomatic), "Atrophy," "Col- lapse," "Coma," "Convulsions,"" "Debility" (“Con- genital," "Senile," etc.), " Dropsy," "Exhaustion," "Heart failure," "Hemorrhage," "Inanition," "Maras- mus," "Old age," "Shock,"Uremia," "Weakness," etc., when a definite disease can be ascertained as the cause. Always qualify all diseases resulting from child- birth or miscarriage, as "PUERPERAL septicemia," "PUER- PERAL peritonitis," etc. State cause for which surgical operation was undertaken. For VIOLENT DEATHS STATE MEANS OF INJURY and qualify as ACCIDENTAL, SUICIDAL, or HOMICIDAL, or as probably such, if impossible to dc- termine definitely. Examples: Accidental drowning; Struck by railway train - accident; Revolver wound of 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
HNI ONIOVANA H.LIM ATINIV7.
under the head of "Contributory." (Recommendations on statement of cause of death approved by Committee on Nomenclature of the American Medical Association.)
Casas for the Medicai Examiners. - Under the provi- sions of chapter 24 of the Revised Laws deaths under the following conditions must be referred to the Medical Examiners:
1. Deaths following injury or violence, as Burns, Falls, Drowning, Gas poisoning, Suicide, Ilomicide, etc.
2. Deaths supposedly caused by violence, as Criminal abortion, Poisoning, Starvation, Suffocation, Exposure, etc.
3. Sudden deaths of persons not disabled by recognized disease, as A death upon the street, or one supposed to be due to Alcoholism, ete.
4. Deaths under circumstances unknown, as A person found dead, etc.
ADDITIONAL SPACE FOR FURTHER STATEMENTS BY
PHYSICIAN.
-
R 15. 1-'18. 100,000.
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
I PLACE OF DEATH
Junto Hall
St. .Ward)
2 FULL NAME. Charles Franck Hargrave
[If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE 68 hundrop St
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
male
4 COLOR OR RACE
White
6 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
Married
6 DATE OF BIRTH
13
(Month)
(Day)
(Year)
7 AGE
If LESS than I day, ........ hrs.
.yrs.
1[ ._ mos
mos.
23
ds.
or min. ?
S OCCUPATION
(a) Trade, profession, or particular kind of work Building Inspector
(b) General nature of industry, business, or establishment in which employed (or employer).
9 BIRTHPLACE (State or country)
East Doston Mass
10 NAME OF
FATHER
Serge Hargran
11 BIRTHPLACE OF FATHER (State or country)
England
12 MAIDEN NAME OF MOTHER Mary Leohold
13 BIRTHPLACE OF MOTHER (State or country)
Germany
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant) ....
que hacgrave
(Address)
15
Filed 191
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
(Month)
(Day)
5, 195 (Year)
I HEREBY CERTIFY that I have investigated the death of the deceased.
The CAUSE OF DEATH* was as follows :
Piste Shot the Head, Suicida Y
.(Duration)
.yrs.
mos.
ds.
Contributory. (SECONDARY)
(Duration) . .... .
yrs. ...
. mos. ds.
(Signed)
Jorge Burger Magn
M.D.
(Address) MEDICAL EXAMINER
* State the DISEASE CAUSING DEATII, or, in deaths fron VIOLENT CAUSES, state (1) MEANS of INJURY; and (2) whether ACCIDENTAL, SUICIDAL or HOMICIDAL.
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