USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1916-1918 > Part 9
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19
STANDARD CERTIFICATE OF DEATH.
Statement of occupation. - Precise statement of oecu- 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 fircman, etc. But in many cases, especially in industrial employments, it is nceessary to know (a) the kind of work and also (b) the nature of the business or industry, and therefore an additional linc 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," "Dcaler," ete., 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, Houscwork, 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.
4
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 eerebro-spinal meningitis"); Diphtheria (avoid use of "Croup"); Typhoid fever (never re- port "Typhoid pneumonia"); Lobar pneumonia; Broncho- mcumonia ("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," "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 septicacmia," "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 duc to Alcoholism, etc.
4. Deaths under circumstances unknown, as A person found dead, etc.
WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD.
important. See instructions on back of certificate. 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
Winthrop
(No.
57 Marshall
467/
Winthrop
BOSTON ....
(City or town.) {If death occurred in a hospital or institution, give its NAME instead of street and number.]
Richard Francis Doherty 2 FULL NAME
[If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE 5) Marchall
Registered No.
PERSONAL AND STATISTICAL PARTICULARS
3 SEX male
4 COLOR OR RACE
white
SINGLE,
Single
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
$ DATE OF BIRTH
dug
(Month)
16
(Day)
1915
(Year)
7 AGE
If LESS than 1 day ........ hrs.
.yrs.
6
mos.
21
ds.
Or ........ min. ?
8 OCCUPATION
(a) Trade, profession, or
particular kind of work
Fathers = Shipper
(b) General nature of Industry, business, or establishment In which employed (or employer) ..
Fish
19 BIRTHPLACE (State or country) Winthrop
PARENTS
12 MAIDEN NAME
OF MOTHER
Lillian Cochran
1ª BIRTHPLACE OF MOTHER (State or country) Chelsea Mass
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
Mrs Lillian Doherty
(Address)
54 Marshall St.
16
Filed 191
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
(Month)
......
(Day)
8 96
(Year)
17
I HEREBY CERTIFY that I attended deceased from
Tilauch 1
..... .
1916
2 ...
to ......
Tauch 8
1916
that I last saw h ....... alive on
1916
and that death occurred, on the date stated above, at.
57 m.
The CAUSE OF DEATH* was as follows : whooping Cough
Did a surgical operation precede death ?
Date
.(Duration)
.... yrs.
.. mos. ..
.............. ds.
Contributory Hormonio
(Broncho)
(SECONDARY)
(Duration)
.. yrs.
mos.
ds.
(Signed) ...
M.D.
TX auch 8, 1916 (Address)
2000 leasen SI
* 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 ............ yra. ...
......... mos. ..........
Where was disease contracted, If not at place of death ?.
Former or usual residence ..
19 PLACE OF BURIAL OR REMOVAL Holy leross
DATE OF BURIAL
1
Mar cet 9 6
20 UNDERTAKER
M.r. Kelly
ADDRESS
11 Meridian St
10 NAME OF
FATHER
James A. Doherty
11 BIRTHPLACE
OF FATHER
(State or country>
Boston mass.
St. ;..
Ward)
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 needed. As examples: (a) Spinner, (b) Cotton mill; (a) Sales- man, (b) Grocery; (a) Forcman, (b) Automobile factory. The material worked on may form part of the second statement. Never return "Laborer," "Foreman," "Manager," "Dealer," etc., without more precise specification, as Day laborer, Farm laborer, Laborer - Coal mine, etc. Women at honie, who are engaged in the duties of the household only (not paid Housc- 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 wagcs, 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 tiinc and causation), using always the same accepted term for the same discase. Examples: Cercbro-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; Broncho- pneumonia ("Pneumonia," unqualified, is indefinitc) ; 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, ctc. 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 discase can be ascertained as the causc. 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 deaths of persons not disabled by recognized disease, as A death upon the street, or one supposed to be due to Alcoholism, ctc.
4. Deaths under circumstances unknown, as A person found dead, etc.
3 SEX Male 1 PARENTS important. See instructions on back of certificate, (Address) 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 ......
The Commonwealth of Massachusetts STANDARD CERTIFICATE OF DEATH
465
1 PLACE OF DEATH
Winthink
(No.
17 butter
St. :
Ward)
Wenthul (Citzor town.) [If death occurred in a hospital or institution, give its NAME Instead of street and number.]
of felhin
2 FULL NAME Haward Earl Had a dow Father-
[If married or divorced woman or widow give maiden name, also name of husband. ] @RESIDENCE 17 tutte th.
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
4 COLOR OR RACE
White
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
Finger
16 DATE OF DEATH
mich.
(Month)
9., 1916.
(Day)
(Year)
" DATE OF BIRTH march 8 th 19/6 17 I HEREBY CERTIFY that I attended deceased from (Month) (Day) (Year) Mich, 8 th 1916 Mah, 9, 1916 to TAGE If LESS than | day ......... hrs. that I last saw h de alive on Mah 8., 1916 and that death occurred, on the date stated above, at 1.9m. .yrs. mos. or ....... min. ? ds. The CAUSE OF DEATH* was as follows :
8 OCCUPATION
(a) Trade, profession, or
particular kind of work
(b) General nature of industry,
business, or establishment in
which employed (or employer)
non
9 BIRTHPLACE
(State or country)
Wirthud-
10 NAME OF
FATHER
Itoward Gare Hodydin
11 BIRTHPLACE
OF FATHER
(State or country)
12 MAIDEN NAME
OF MOTHER
Dorise ada Gatti
13 BIRTHPLACE
OF MOTHER
(State or country)
tomarvier Was
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
Broward E Hodadon
Filed 191
REGISTRAR ....
Premature Birch
.(Duration)
.yrs.
...... mos. ..... da.
Contributory (SLCONDARY)
.(Duration)
.. yrs.
mos. ......... ds.
(Signed)
Dr.l. Partes
Michael, 19 ....... (Address)
Menitrato
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
In the
of death ............ yrs.
mos.
ds.
State
.. yrs. .........
mos.
ds .............
Where was dlsease contracted, If not at place of death ?. Former or usual residence.
19 PLACE OF BURIAL OR REMOVAL
DATE OF BURIAL
Tomb
1916
20 UNDERTAKER * E Henderson
ADDRESS
Everest grass
Registered No.
JIANUANU UENIIFIUMIC Ur UCAIA.
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 needed. As examples: (a) Spinner, (b) Cotton mill; (a) Sales- man, (b) Grocery; (a) Foreman, (b) Automobile factory. The material worked on may form part of the second statement. Never return "Laborer," "Foreman," "Manager," "Dealer," etc., without more precise specification, as Day laborer, Farm laborer, Laborer - Coal mine, etc. Women at home, who are engaged in the duties of the household only (not paid House- keepers who receive a definite salary), may be entered as Housewife, Housework, or At home, and children, not gain- fully employed, as At school or At home. Care should be taken to report specifically the occupations of persons engaged in domestic service for wages, as Serrant, Cook, Housemaid, etc. If the occupation has been changed or given up on account of the DISEASE CAUSING DEATH, state occupation at beginning of illness. If retired from business, that fact may be indicated thus: Farmer (retired, 6 yrs.). For persons who have no occu- pation whatever, write Nonc.
Statement of cause of death. - Name, first, the DIS- EASE CAUSING DEATH (the primary affection with respect to time and causation), using always the same accepted term for the same disease. Examples: Cerebro-spinal fever (the only definite synonym is "Epidemie cerebro-spinal meningitis"); Diphtheria (avoid use of "Croup"); Typhoid fever (never re- port "Typhoid pneumonia"); Lobar pneumonia; Broncho- pneumonia ("Pneumonia," unqualified, is indefinite) ; Tuber-
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 symptomatie), "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 ean be ascertained as the cause. Always qualify all diseases resulting from childbirth or miscarriage, as "PUER- PERAL septicaemia," "PUERPERAL peritonitis," etc. State cause for which surgical operation was undertaken.
Cases for the Medical Examiners. - Under the provi- sions of chapter 24 of the Revised Laws deaths under the fol- lowing conditions must be referred to the Medical Examiners:
1. Deaths following injury or violence, as Burns, Falls, Drowning, Gas poisoning, Suicide, Homicide, ete.
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 one supposed to be due to Alcoholism, etc.
4. Deaths under circumstances unknown, as A person found dead, etc.
The Commonwealth of Massachusetts STANDARD CERTIFICATE OF DEATH
' PLACE OF DEATH
-Charlton
(No ..
St. ;.
Ward)
Charlton (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
17 I HEREBY CERTIFY that I attended deceased from Alarch 10, 1916, to March 11 , 1916 that I last saw her ... alive on March 10, 1916 and that death occurred, on the date stated above, at 10 Pm. The CAUSE OF DEATH* was as follows : Cerebral Hemorrhage
(Duration)
yrs.
mos.
2 ds.
Contributory.
(SECONDARY)
(Duration)
.. yrs.
mos.
ds.
(Signed)
Paul y Abell
M.D.
March 12 1916 (Address)
Charlton
* If death followed injury or violence the certificate of death must be made out by the Medical Examiner.
18 LENGTH OF RESIDENCE (FOR HOSPITALS, INSTITUTIONS, TRANSIENTS, OR RECENT RESIDENTS).
At place
of death
... yrs.
In the
mos. ............. ds.
State ............ yrs.
..........
mos. ............ ds .............
Where was disease contracted, If not at place of death ?.
Former or usual residence.
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
Ah2 H. M. Bangs
(Address)
Winthroh
16 Filed. March 121916 Frank O Statufield .......
REGISTRAR
16 DATE OF DEATH
March
(Month)
(Day)
11
- 1916
(Year)
6 DATE OF BIRTH
Cet
18
(Month)
(Day)
, 1875
(Year)
If LESS than
I
day ......... hrs.
40 yrs. 5 mos 23 ds.
or min. ?
9 BIRTHPLACE
(State or country)
Sharon
10 NAME OF
FATHER
Alexander Mac Donald
11 BIRTHPLACE
OF FATHER
(State or country)
Scotland
12 MAIDEN NAME
OF MOTHER
Jeanie Allan
19 PLACE OF BURIAL OR REMOVAL Winthrop
DATE OF BURIAL
March 15 1916.
20 UNDERTAKER
LA Me Intype
ADDRESS
Charlton
3 SEX
Female
7 AGE
8 OCCUPATION
(a) Trade, profession, or
particular kind of work
PARENTS
13 BIRTHPLACE
OF MOTHER
(State or country)
important. See instructions on back of certificate.
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
(b) General nature of industry,
business, or establishment in
which employed (or employer).
4 COLOR OR RACE
White
5 SINGLE,
MARRIED,
Widowed
WIDOWED,
OR DIVORCED
(Write the word)
[If married or divorced woman or widow
give maiden name, also name of husband
@RESIDENCE
Winthrop
.....
2FULL NAME
Nancy Al Cole
STANDARD CERTIFICATE OF DEATH.
Statement of occupation. - Precise statement of occupa- tion is very important, so that the relative healthifulness of various pursuits can be known. The question applics 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 nceded. As examples: (a) Spinner, (b) Cotton mill; (a) Sales- man, (b) Grocery ; (a) Foreman, (b) Automobile factory. The material worked on may form part of the second statement. Never return " Laborer," " Foreman," " Manager," " Dealer," etc., without more precise specification, as Day laborer, Farm laborer, Laborer - Coal mine, etc. Women at home, who are engaged in the duties of the household only (not paid House- keepers who receive a definite salary), may be entered as Housewife, Housework, or At home, and children, not gain- fully employed, as At school or At home. Care should be taken to report specifically the occupations of persons engaged in 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 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: Cerebro-spinal fever (the only definite synonym is "Epidemic cerebro-spinal meningitis") ; Diphtheria (avoid use of "Croup") ; Typhoid fever (never re- port " Typhoid pncumonia ") ; Lobar pneumonia ; Broncho- pneumonia (" Pneumonia," unqualified, is indefinite) ; Tuber-
culosis of lungs, meninges, peritoneum, 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," "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 septicaemia," " PUERPERAL peritonitis," etc. State cause for which surgical operation was undertaken.
Cases for the Medical Examiners. - Under the provisions 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, 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
important. See instructions on back of certificate.
PARENTS
12 MAIDEN NAME
OF MOTHER
Mary
O Brien
13 BIRTHPLACE OF MOTHER (State or country) Ireland
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
(Address)
15
Filed
191
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
march
(Month)
(Year)
17 I HEREBY CERTIFY that I attended deceased from
March 11, 1916.
that I last saw h Lemalive on
march 16, 1916,
and that death occurred, on the date stated above, at 8:30Am.
The CAUSE OF DEATH* was as follows :
Cachal Nemmlang
ge
Did a surgical operation precede death ?
ho Date
(Duration)
yrs. ................ mos.
ds.
Contributory
arterio - soluna
(SECONDARY)
(Duration)
.yrs.
mos.
ds.
(Signed)
march 11, 1916. (Address)
355 cmclients
* If death followed injury or violence the certificate of death must be made out by the Medical Examiner.
In the
18 LENGTH OF RESIDENCE (FOR HOSPITALS, INSTITUTIONS, TRANSIENTS, OR
RECENT RESIDENTS).
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
ADDRESS
Wirthof
BOSTON -.....
(City or town.)
[If death occurred in a hospital or institution, give its NAME instead of street and number.]
David Sorella Muntlig
? FULL NAME
[If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE 419 Revere
May Celuile
Registered No.
PERSONAL AND STATISTICAL PARTICULARS
3 SEX Male.
4 COLOR OR RACE
Keite.
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
Michonne
· DATE OF BIRTH
(Month)
(Day)
1 (Year)
7 AGE
If LESS than [ day ......... hrs.
.............. mos. ds.
or ........ min. ?
* OCCUPATION (a) Trade, profession, or particular kind of work
(b) General nature of Industry, business, or establishment in which employed (or employer)
9 BIRTHPLACE
(State or country)
Ireland
10 NAME OF
FATHER
Edward Mufly.
11 BIRTHPLACE OF FATHER (State or country)
WRITE PLAINLY, WITH UNFADING INK -THIS IS A PERMANENT RECORD.
The Commonwealth of Massachusetts g STANDARD CERTIFICATE OF DEATH
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