USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1916-1918 > Part 98
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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 diseasc. Examples: Cerebrospinal fever (the only definite synonym is "Epidemie cerebrospinal menin- gitis"); Diphtheria (avoid use of "Croup"); Typhoid (never
fever 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- eurrent) affection necd 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," "Ancmia" (merely symptomatic), "Atrophy," "Col- lapse," "Coma," "Convulsions,"""Debility" ("Con- genital," "Senile," etc.), " Dropsy," "Exhaustion," "Heart failure," "Hemorrhage," "Inanition," "Maras- inus," "Old age," "Shock," "Uremia," "Weakness," etc., when a definite disease ean be ascertained as the cause. Always qualify all discases 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 liead of "Contributory.' (Recommendations on statement of cause of death approved by Committee on Nomenclature of the American Medical Association.)
Casos 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 onc 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. 2-'18. 100,000.
WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD.
CAUSE OF DEATH in plain terms, so that it may be properly classified. Exact statement of OCCUPATION is very N. B. - Every item of Information should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state important. See instructions on back of certificate.
15-'17-XXM|
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH Winthrop
(No.
24 Neptune
Hranle Rea
2 FULL NAME [ If married or divorced woman or widow give maiden name, also name of husband.] "RESIDENCE 24 Neptune que Winthrop
PERSONAL AND STATISTICAL PARTICULARS
¿ SEX
' COLOR OR RACE
§ SINGLE.
MARRIED.
WIDOWED,
OR DIVORCED
(Write the word)
Married
· DATE OF BIRTH
(Month) (Day)
1
(Year)
7 AGE
70
... yrs.
....... mos. ds.
or ........ min. ?
$ OCCUPATION
(a) Trade, profession, or
particular kind of work
Retired
(b) General nature of industry, business, or establishment in which employed (or employer).
9 BIRTHPLACE
(State or country)
Boston Mass
PARENTS
11 BIRTHPLACE
OF FATHER
(State or country)
Cartland Maine
12 MAIDEN NAME
OF MOTHER
Clive Libby
18 BIRTHPLACE
OF MOTHER
(State or country)
New Hampshire
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant) ....
Sarah Rea
(Address)
24 Neptune Ave
16
Filed
191
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
15 DATE OF DEATH
(Month)
9.
1918
(Year)
(Day)
17 I HEREBY CERTIFY that I attended deceased from
mov.
15
191
Mer. 9
to
191
....
that I last saw heech alive on
afor. 7.
191
8
8 and that death occurred, on the date stated above, at m. The CAUSE OF DEATH* was as follows :
Cerebral Necesarhage.
Did a surgical operation precede death ? 200. Bate.
.(Duration)
...... yrs. ................ mos.
da.
Contributo ...
....
(SECONDARY)
In def.
(Signed)
I.P. Parts
M.D.
aber
91/1918
(Address)
....
{ If death followed injury or violence the certificate of death must be made ont 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 disease contracted, If not at place of death ?
Former or usual residence
19 PLACE OF BURIAL OR REMOVAL Holy Cross Malden
DATE OF BURIAL
April 11
..
1918
20 UNDERTAKER
ADDRESS
Keating amitchell Charleston Mans
BOSTON
......
ABis
.Ward)
Registered No.
(City or town.) [If death occurred In a hospital or institution, give its NAME instead of street and number.]
.(Duration)
.. yrs.
mos. ds.
10 NAME OF
FATHER
Edward
If LESS than
1 day ........ hrs.
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) 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 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 occu- pation whatever, write None.
Statement of cause of death. - Name, first, the DIS- EASE CAUSING DEATH (the primary affection with respect to time and causation), using always the same accepted term for the same disease. Examples: Cerebro-spinal fever (the only definite synonym is "Epidemic cerebro-spinal meningitis"); Diphtheria (avoid use of "Croup"); Typhoid fever (never re- port "Typhoid pneumonia"); Lobar pneumonia; Broncho- neumonia ("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 neoplasms); Measles; Whooping cough; Chronic valvular heart disease; Chronie 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" (mcrely 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 discases 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, 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 one supposed to be due to Alcoholism, etc
4. Deaths under circumstances unknown, as A person found dead, etc.
R. 15. 1-'17. 100,000.
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
(City or town)
1 PLACE OF DEATH folke
County.
State
Mask
Registered No. ......
Cit Winthrop
or Village lo. 14 Linduer
St.,
Ward
(If death occurred in a hospital or institution, give its NAME instead of street and number)
2 FULL NAME
gillam Mation
(a) Residence.
No. 14 Lunden
.St.
Ward.
(Usual place of abode)
Length of residence in city or towo where death occorred
66 years
4 moths
25 days.
How loog in U. S., if of foreign birth ?
years
months
days
PERSONAL AND STATISTICAL PARTICULARS
5 SINGLE, MARRIED, WIDOWED, OR
DIVORCED (write the word)
Wedound
5a If married, widowed, or divorced
HUSBAND of
(or) WIFE of
Ferie . Malson
6 DATE OF BIRTH (month, day, and year)
1851-11-16
(a) Trade, profession, or
Marine Engineer
9 BIRTHPLACE (city or town).
new Castle
10 NAME OF FATHER Thomas gation
11 BIRTHPLACE OF FATHER (city or town)
(State or country)
12 MAIDEN NAME OF MOTHER R Steanne Inui
13 BIRTHPLACE OF MOTHER (city or town). (State or country) Scotland
14 William . Watson
Informant
(Address) 14 Lunde S/
15 Filed , 19
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH (month, day, and year) April 9, 1918
17
I HEREBY CERTIFY, That I attended deceased from
19/5, to
1918
& that I last saw h./ .??... alive on
, 1918
and that death occurred, on the date stated above, at
U
m. The CAUSE OF DEATH* was as follows :
If LESS thao
1 day ......... hrs.
or ........ min.
Celerio scleroseo
Endocarditeto daortica metralve
Hypertroping + dilatación of heav
unknown
(duration)
yrs.
mos.
ds.
CONTRIBUTORY
Passen congestion general
(SECONDARY)
unknown (duration)
yrs .. . ... mos.
ds.
18 Where was disease contracted
if not at place of death?
Did an operation precede death ?
no
.Date of.
Was there an autopsy ?.
no
What test confirmed diagnosis ?
(Signed)
Horace
02.9,1918 (Address)
180 Winthrop St.
I.1.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
DATE OF BURIAL 1-11 1918
20 UNDERTAKER
W.C. Skaggs
ADDRESS Wiretkort
N. B .- WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD. Every item of information should be
Township
3 SEX
911
4 COLOR OR RACE
w
7 AGE
Years
Months
66
4
8 OCCUPATION OF DECEASED
particular kind of work
(b) General nature of industry,
bosiness, or establishment in
which employed (or employer)
(c) Name of employer
PARENTS
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
(State or country)
Leng.
of certificate.
or
(If non-resident give eity or town and State)
Days
23
[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 cngincer, 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) Groecry; (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 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. - Namc, 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- 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 .; 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-
"Senile,"
genital," 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
on statement of cause of death approved by Committee on Nomenclature of the American Medical Association.)
Cases 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, 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 onc supposed to be due to Alcoholism, etc.
4. Deaths under circumstances unknown, as A person found dead, ctc.
ADDITIONAL SPACE FOR FURTHER STATEMENTS BY
PHYSICIAN.
R 15. 1-'18. 100,000.
The Commonwealth of Massachusetts STANDARD CERTIFICATE OF DEATH
(City or town)
1 PLACE OF DEATH
County
Juffick
Township
Жигевор
or Village.
or
No.
15 Elbilt &t Winterof sela Ward
(If death occurred in a hospital or institution, give its NAME instead of street and number)
Gunilla. Beaue Daggett
(a) Residence.
No.
Bourne
St., .Ward.
(Usual place of abode)
Length nf residence in city or towo wbere death occurred
years
7
months
days.
How loog in U. S., if of foreign birth ?
years
months
days
PERSONAL AND STATISTICAL PARTICULARS
3 SEX,
Semule
4 COLOR OR RACE
White
5 SINGLE, MARRIED, WIDOWED, OR
DIVORCED (write the word)
Widow
5a If married, widowed, or divorced
HUSBAND of
(or) WIFE of
Willow of Moses. W. Dagget
6 DATE OF BIRTH (month, day, and year) Deb 4 15 1845
7 AGE
Years
53
Months
2
Days
6
If LESS than 1 day, ........ hrs. or ........ min.
8 OCCUPATION OF DECEASED
Z
(h) Geoeral nature of industry,
business, or establishment in
which employed (or employer)
(c) Name of employer
9 BIRTHPLACE (city or town)
(State or country) muss
10 NAME OF FATHER Samuel. W. Mallows
PARENTS
11 BIRTHPLACE OF FATHER (eity or town)
(State or country) Chatham Muss
12 MAIDEN NAME OF MOTHER Curella Brane
13 BIRTHPLACE OF MOTHER (city or town) ..
Chalkum
(State or country)
maso
14 H. F. J. KlasyE
Informant
(Address)
Elliot IL Wucht
15
Filed , 19
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH (month, day, and year) april 10 1018.
17
HEREBY CERTIFY, That I attended deceased from
to
March 31,
1918
april a
, 1918.
that I last saw h eralive on
19.
and that death occurred, on the date stated above, at
9.A.
m.
The CAUSE OF DEATH* was as follows :
1 groucho/maumonia
(duration)
yrs.
mos.
ds.
CONTRIBUTORY
acute bronchitis
(SECONDARY)
(duration)
yrs ... ...........
.. mos ..
ds.
18 Where was disease contracted
if not at place of death ?
Did an operation precede death?
No
Date of
Was there an autopsy ?
What test confirmed diagnosis ?
(S:goed)
E. Coleman Brown
I.D.
4/10.19 /8 (Address)
27 Central Sql, E. v Boston
* 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
Bourne nuno
DATE OF BURIAL
4 /2
19 / 8
ADDRESS
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,
of certificate.
so that it may be properly classified. Exact statement of OCCUPATION is very important. See instructions on back
State
Registered No.
City
2 FULL NAME
(If non-resident give city or town and State)
20 UNDERTAKER
ER Benoni
(a) Trade, profession, or
particular kind of work
Retira
[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, Arehitcet, Locomotive engineer, Civil engineer, Stationary fireman, etc. But in many cases, especially in industrial cinployments, 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 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 "Epidemic cerebrospinal menin- gitis"); Diphtheria (avoid use of "Croup"); Typhoil 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," "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 discase 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.
₹
R 15. 1-'18. 100,000.
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
(City or town
1 PLACE OF DEATH
County.
Suffolk
State muss
Registered No ... ....
Township
or Village
or
No .. Triton avec undene gar Point the Ward (If death occurred in a hospital or institution, give its NAME instead of street and number)
2 FULL NAME
Robert. andrew. Vihartan -.
(a) Residence.
No.
Tritón + lendiri con
St.,
Ward.
(Usual place of abode)
Length of resideoce in city or town where death occurred
years
8 months 3
days. How long in U. S., if of foreign birth ? years
months days
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
Male
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) Ceny 10-1917
7 AGE Ycars
Months
8
Days
If LESS than 1 day, ........ hrs. or ........ min.
8 OCCUPATION OF DECEASED
(a) Trade, profession, or particular kind of work
(h) General nature of industry, business, or establishment in which employed (or employer) (c) Name of employer
9 BIRTHPLACE (city or town).
Winthink
(State or country) nino
10 NAME OF FATHER Elmer. W. Wharton
11 BIRTHPLACE OF FATHER (city or town) East Boston-
(State or country) mars 12 MAIDEN NAME OF MOTHER Lama. My. Morrow
13 BIRTHPLACE OF MOTHER (city or town).
Chulistora
(State or country) maso -
14 Elmer. W. Wharton
Informant (Address)
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