USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1916-1918 > Part 93
Note: The text from this book was generated using artificial intelligence so there may be some errors. The full pages can be found on Archive.org (link on the Part 1 page).
Part 1 | Part 2 | Part 3 | Part 4 | Part 5 | Part 6 | Part 7 | Part 8 | Part 9 | Part 10 | Part 11 | Part 12 | Part 13 | Part 14 | Part 15 | Part 16 | Part 17 | Part 18 | Part 19 | Part 20 | Part 21 | Part 22 | Part 23 | Part 24 | Part 25 | Part 26 | Part 27 | Part 28 | Part 29 | Part 30 | Part 31 | Part 32 | Part 33 | Part 34 | Part 35 | Part 36 | Part 37 | Part 38 | Part 39 | Part 40 | Part 41 | Part 42 | Part 43 | Part 44 | Part 45 | Part 46 | Part 47 | Part 48 | Part 49 | Part 50 | Part 51 | Part 52 | Part 53 | Part 54 | Part 55 | Part 56 | Part 57 | Part 58 | Part 59 | Part 60 | Part 61 | Part 62 | Part 63 | Part 64 | Part 65 | Part 66 | Part 67 | Part 68 | Part 69 | Part 70 | Part 71 | Part 72 | Part 73 | Part 74 | Part 75 | Part 76 | Part 77 | Part 78 | Part 79 | Part 80 | Part 81 | Part 82 | Part 83 | Part 84 | Part 85 | Part 86 | Part 87 | Part 88 | Part 89 | Part 90 | Part 91 | Part 92 | Part 93 | Part 94 | Part 95 | Part 96 | Part 97 | Part 98 | Part 99 | Part 100 | Part 101 | Part 102 | Part 103 | Part 104 | Part 105 | Part 106 | Part 107 | Part 108 | Part 109 | Part 110 | Part 111 | Part 112 | Part 113 | Part 114 | Part 115 | Part 116 | Part 117 | Part 118 | Part 119 | Part 120 | Part 121 | Part 122 | Part 123 | Part 124 | Part 125 | Part 126 | Part 127 | Part 128 | Part 129 | Part 130 | Part 131 | Part 132 | Part 133 | Part 134 | Part 135 | Part 136 | Part 137 | Part 138 | Part 139 | Part 140 | Part 141 | Part 142 | Part 143 | Part 144 | Part 145 | Part 146 | Part 147 | Part 148 | Part 149 | Part 150 | Part 151 | Part 152
2 FULL NAME
Daschle Laurence Visalle
(a) Residence.
No. 186 Pleasant
St.,
.Ward.
(Psunt place of abode)
Length of residence in city or towo where death occurred
10
years
months
days.
How long in U. S., if of foreign birth ?
years
months
days
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
male
4 COLOR OR RACE
achète
5 SINGLE, MARRIED, WIDOWED, OR
DIVORCED (write the word)
married
5a If married, widowed, or divorced?
HUSBAND of anany. 4.
(01) WIFE of
any & Visalle
6 DATE OF BIRTH (month, day, and year)
7 AGE
Years
64
Months
8
Days
If LESS than
1 day, ........ hrs.
or ........ min.
8 OCCUPATION OF DECEASED
(a) Trade, profession, or
particular kind of work
Retired 10 yrs
(b) General nature of industry, business, or establishment io which employed (or employer) (c) Name of employer
9 BIRTHPLACE (city or town)
Boston
(State or country)
mass.
10 NAME OF FATHER
Jourple
PARENTS
11 BIRTHPLACE OF FATHER (ity or town
Town Italy.
(State or country)
12 MAIDEN NAME OF MOTHER
Julia Bowe Freland.
13 BIRTHPLACE OF MOTHER (eity or toyn) .. (State or country)
14
Informant
anna
Visall
(Address)
196 Pleasant SX Mintlundi
15
Filed
.......... ., 19
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH (month, day, and year) Folhas 2 10/F
17 I HEREBY CERTIFY, That I attended deceased from L
to
2 1918
that I last saw h .... Zoom. alive on
2
, 1978
and that death occurred, on the date stated above, at
Ing.m.
The CAUSE OF DEATH* was as follows :
General Cuterio Seleveras
(duration)
yrs ..
mos ...
ds.
CONTRIBUTORY
(SECONDARY)
.. (duration)
yrs ...
.. 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 ?
(Signed)
3/3.19/8 (Address)
200 pleasant Sf
1
MA.D.
* 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 St Mary's Dorchester
DATE OF BURIAL 2 3/4 19/8
20/UNDERTAKER John T. CO. maley
ADDRESS Wintherof
.......
State
mass.
Registered No.
or
or Village. No. 186, Pleasant St
St.,
......
Ward
(If non-resident give city or town and State)
N. B. - WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD. Every item of information should be 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,
of certificate.
RD. Eve A PERMANENT REGO
REVISED UNITED STATES STANDARD CERTIFICATE OF DEATH [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 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) 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," 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 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 ot 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 ecrebrospinal menin- gitis"); Diphtheria (avoid use of "Croup"); Typhoid fever (never report "Typhoid pneumonia"); Lobar pneumonia; Bronchopneumonia ("Pneumonia," unquali- fied, is indefinite); Tuberculosis of lungs, meninges, peri- toneum, etc., Carcinoma, Sarcoma, 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 (secondary or inter- current) affection need not be stated unless important. Example: Measles (disease causing death), 29 ds .; Broneho- 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," ete., 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 de- 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 (c. g., sepsis, tetanus) may be stated
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 Medical 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, Homicide, etc.
2. Deaths supposedly caused by violence, as Criminal abortion, Poisoning, Starvation, Suffocation, Exposure, ete.
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.
ADDITIONAL SPACE
FOR FURTHER STATEMENTS BY PHYSICIAN.
1
R 15. 1-'18. 100,000.
The Commonwealth of Massachusetts STANDARD CERTIFICATE OF DEATH
(City or town
1 PLACE OF DEATI
County
Suffolk
Township
Wuchsof
or
Village
mars-
. or
City
No. 116X
are
St.,
.Ward
(If death occurred in a hospital or institution, give its NAME instead of strect and number)
2 FULL NAME
albert: Fielding
T'essenden
(a) Residence.
No. 116 Groves are 0
.St., .....
.. Ward.
(Usual place of abode)
Length of residence in city or town wbere death occurred
years
mooths
days.
llow loog 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)
June 25 - 1857
7 AGE
Ycars
60
Months
7
Days
8
If LESS than
1 day, ........ hrs.
or ........ min.
8 OCCUPATION OF DECEASED
(a) Trade, profession, or
particular kind of work
(b) General nature of industry,
business, or establisbmeot in
which employed (or employer)
(c) Name of employer
agent
9 BIRTHPLACE (city or town).
Lavell
Maso
(State or country)
10 NAME OF FATHER fom B.
11 BIRTHPLACE OF FATHER (city or town) ..
mass
(State or country)
Sandurch
12 MAIDEN NAME OF MOTHER Sarah. a. Rund.
13 BIRTHPLACE OF MOTHER (city or town)
(State or country)
n.H.
14
Informant
Elawenn. Hessenden
(Address)
168 Nombre Th ave 18 show
15 Filed ,19
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH (month, day, and year)
Ich 3
1918
17
I HEREBY CERTIFY, That I attended deceased from
Yuck 3
afri
19/>, to.
,19 .....
that I last saw h ..... alive on
, 1918.
and that death occurred, on the date stated above, at
1
A .m.
The CAUSE OF DEATH* was as follows :
Car
1
1 Sygmand & Return
(duration)
yrs ...
.mos.
ds.
CONTRIBUTORY
(SECONDARY)
(duration)
.yrs.
.. 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 ?
Presana + menos 2 Timmars
(Signed)
3/ 3.19/8 (Address)
218 month
* 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
It auto Cambuly
DATE OF BURIAL
2/6
19 / 9
20 UNDERTAKER
ADDRESS
so that it may be properly classified. Exact statement of OCCUPATION is very important. See instructions on back
of certificate.
N. B .- WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD. Every item of information should be
carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state CAUSE OF DEATH in plain terms,
State
Registered No ...
(If non-resident give city or town and State)
., [].D.
PARENTS
REVISED UNITED STATES STANDARD CERTIFICATE OF DEATH [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 term on the first line will be sufficient, e. g., Farmer or Planter, Physician, Compos- itor, Architect, Locomotive 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) 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," 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 houschold 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 DEATII, state occupation at beginning of illness. If retired from business, that fact may be indi- cated thus: Farmer (retired, 6 yrs.). For persons who liave 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 "Epidemic cerebrospinal menin- gitis"); Diphtheria (avoid use of "Croup"); Typhoid fever (never report "Typhoid pneumonia"); Lobar pneumonia; Bronchopneumonia ("Pneumonia," unquali- fied, is indefinite); Tuberculosis of lungs, meninges, peri- toncum, etc., Carcinoma, Sarcoma, 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 (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,"
"Col- "Anemia" (merely symptomatic), "Atrophy," lapse," "Coma," "Convulsions," ""Debility" ("Con- genital," "Senile," etc.), "Dropsy," "Exhaustion," "Heart failure," "Hemorrhage," " "Inanition," "Maras- mus," "Old age," "Shock,"" "Uremia," "Weakness," ete., when a definite disease ean be ascertaincd as the cause. Always qualify all diseases resulting from ehild- birth or miscarriage, as "PUERPERAL septicemia," "PUER- PERAL peritonitis," ete. 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 de- terinine 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
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 Medical 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, Homicide, 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 bc due to Alcoholism, etc.
4. Deaths under circumstances unknown, as A person found dead, etc.
ADDITIONAL SPACE
FOR FURTHER STATEMENTS BY
PHYSICIAN.
-
R 15. 1-'18. 100,000.
pinc
Quoday ANINVWW3d V SI SIHL - XNI UNIQVANN HUMAINIVId 3LUMEN
Fv
AJUA
N. B .- WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD. Every item of information should be 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,
of certificate.
14
Informant
Ella. a. Immich.
(Address)
27 Try dank are Whether
15
Filed 19
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH (month, day, and year)
1918
17
I HEREBY CERTIFY, That I attended deceased from
Jet 25
1918
to
that I last saw he alive on 1916. and that death occurred, on the date stated above, at m.
The CAUSE OF DEATH* was as follows :
chivu
(duration)
yrs ..
mos. .. ..
.ds.
CONTRIBUTORY (SECONDARY)
.(duration)
......
.yrs ...
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 ?
.. .
(Signed)
٢٠
9/7, 19/8 (Address) * 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
Woodlawn Connely
DATE OF BURIAL
3/8
1918
ADDRESS Wacht
(City- Ar town)
1 PLACE OF DEATH
County
Suffolk
Township
winchnot
or
Village
No.
27 Try dank are
St.,
... Ward
(If death occurred in a hospital or institution, give its NAME instead of street and number)
2 FULL NAME
Harinah: MyE.
Smith
(a) Residence.
No.
2) Try dent
/care
Ward.
(Usual place of abode)
Length of residence in city or town where death occurred
years
months
days.
How long ia U. S., if of foreign birth ?
years
months
days
PERSONAL AND STATISTICAL' PARTICULARS
3 SEX
female
4 COLOR OR RACE
5 SINGLE, MARRIED, WIDOWED, OR
DIVORCED (write the word)
Widow
5a If married, widowed, or divorced HUSBAND of (or) WIFE of
widow of Boeck. m. Smith
6 DATE OF BIRTH (month, day, and ycar)
Lun 2 - 1830
7 AGE
88
Years
Months
2
Days
3
If LESS thao 1 day, ........ brs. or ........ min.
8 OCCUPATION OF' DECEASED
(a) Trade, profession, or particolar kind of work
(b) General nature of industry,
business, or establishment in
which employed (or employcr)
(c) Name of employer
2
-
9 BIRTHPLACE (city or town).
(State or country) Banalatte mass
10 NAME OF FATHER Feras Small
PARENTS
11 BIRTHPLACE OF FATHER (city or town) Free town (State or country) Barnstable -Co. men
12 MAIDEN NAME OF MOTHER
13 BIRTHPLACE OF MOTHER (city or town) ... .. (State or country)
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
State
Maso
Registered No ..
or
City. ......
(If non-resident give city or town and Stato)
20 UNDERTAKER
RECORD. A PERMANENT
4 PINQue 3OY
SI SIHL - XNI DNIOYJNA HIM XINIVId 3LIHM
REVISED UNITED STATES STANDARD CERTIFICATE OF DEATH [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 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, Compos- itor, Architect, Locomotive 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) Salesman, (b) Grocery; (a) Forcman, (b) Automobile factory. The mna- terial 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 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 tiine and causation), using always the same accepted term for the same disease. Examples: Cerebrospinal fever (the only definite synonym is "Epidemic cerebrospinal menin- gitis"); Diphtheria (avoid use of "Croup"); Typhoid fever (never report "Typhoid pneumonia"); Lobar pneumonia; Bronchopneumonia ("Pneumonia," unquali- ficd, is indefinite); Tuberculosis of lungs, meninges, peri- toneum, etc., Carcinoma, Sarcoma, etc., of.
(name origin; "Cancer" is less definite; avoid use of "Tumor" for malignant neoplasms); Mcasles; Whooping cough; Chronic valvular heart disease; Chronic interstitial nephritis, etc. The contributory (secondary or inter- current) affection need not be stated unless important. Example: Mcasles (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 de- 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
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 Medical 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, Homicide, 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, etc.
4. Deaths under circumstances unknown, as A person found dead, etc.
ADDITIONAL SPACE
FOR FURTHER STATEMENTS BY
PHYSICIAN.
1
-
R 15. 1-'18. 100,000.
The Commonwealth of Massachusetts
Winthrop (City or towns
1 PLACE OF DEATH
County
unfolle
State
mass.
Registered No.
Township
City No.
St ...
Ward
(If death occurred in a hospital or institution, give its NAME instead of street and unmber)
2 FULL NAME
Harriet Genova Monahan
(a) Residence.
No.
75 Walden
.St.,
......
... Ward.
(Usual place of abode)
Length of residence in city or towo where death occurred
13
years
months
days.
How long in U. S., if of foreign hirth ?
years
months
days
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
Female White
4 COLOR OR RACE
5 SINGLE, MARRIED, WIDOWED, OR
DIVORCED (writethe word)
Single
5a If married, widowed, or divorced
HUSBAND of
(o:) WIFE of
6 DATE OF BIRTH (month, day, and year)
Mar 11,1904
7 AGE
Years
13
Months
Days
23
If LESS than 1 day, ........ hrs. or ........ min.
8 OCCUPATION OF DECEASED
(a) Trade, professioo, or
particular kind of work
Student
(h) Geoeral nature of industry, business, or establishment in which employed (or employer) (c) Name of employer
9 BIRTHPLACE (city or town)
Winthrop
(State or country) mark
10 NAME OF FATHER
Michael
PARENTS
11 BIRTHPLACE OF FATHER (city or town)
(State or country)
12 MAIDEN NAME OF MOTHER
Julia Leave
13 BIRTHPLACE OF MOTHER (afty or town).
Brandon
(State or country)
14 Julia Monahan
Informant
(Address)
75 Malden &t
15 Filed ..
,19
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH (month, day, and year)
mar 6
1918
17
I HEREBY CERTIFY, That I attended deceased from
Feb 255
1918
mar 65
to
1918
that I last saw hel
alive on
Mar s'
1918.
and that death occurred, on the date stated above, at
m. The CAUSE OF DEATH* was as follows :
(duration)
... yrs ................. mos.
6 ds.
CONTRIBUTORY
Depleemía
(SECONDARY)
.(duration)
.......
... mos.
6
ds.
18 Where was disease contracted
if not at place of death?
Did an operation precede death ?
150
.. Date of
Was there an autopsy ?.
NO
What test confirmed diagnosis ?
None
(Signed)
3/6, 1918 (Address) 150 Whetherog St Hintting Mans
M.D.
* 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
Holy Cross Malden
DATE OF BURIAL 3/8/2018
20 UNDERTAKER
John F. O maley
ADDRESS
Wantto
N. B .- WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD. Every item of information should be 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,
of certificate.
Julia
STANDARD CERTIFICATE OF DEATH
or Village.
or
(If non-resident give city or town and State)
........ yrs.
REVISED UNITED STATES STANDARD CERTIFICATE OF DEATH [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 term on the first line will be sufficient, e. g., Farmer or Planter, Physician, Compos- itor, Architect, Locomotive 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) 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," 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 Housekeepers who receive a definite salary), may be entered as Housewife, Housework, or At home, and children, not gainfully cinployed, as At school or At home. Care should be taken to report spc- 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 ..
Need help finding more records? Try our genealogical records directory which has more than 1 million sources to help you more easily locate the available records.