Town of Winthrop : Record of Deaths 1919-1921, Part 12

Author: Winthrop (Mass.)
Publication date: 1919
Publisher:
Number of Pages: 1192


USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1919-1921 > Part 12


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 | Part 153 | Part 154 | Part 155 | Part 156 | Part 157 | Part 158 | Part 159 | Part 160 | Part 161 | Part 162 | Part 163 | Part 164 | Part 165 | Part 166 | Part 167 | Part 168 | Part 169 | Part 170 | Part 171 | Part 172 | Part 173 | Part 174 | Part 175 | Part 176 | Part 177 | Part 178 | Part 179 | Part 180 | Part 181 | Part 182 | Part 183 | Part 184 | Part 185 | Part 186 | Part 187 | Part 188 | Part 189 | Part 190 | Part 191 | Part 192 | Part 193 | Part 194 | Part 195 | Part 196 | Part 197 | Part 198 | Part 199 | Part 200 | Part 201 | Part 202 | Part 203 | Part 204 | Part 205 | Part 206 | Part 207 | Part 208 | Part 209 | Part 210 | Part 211 | Part 212


Boston


-XXM


3 SEX female 7 AGE Years 64 (a) Trade. profession, or particular kind of work (State or country) PARENTS 14 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. 15 N. B .- WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD. Every item of information should be (b) General nature of industry, business, or establishment in which employed (or employer) (c) Name of employer


9 BIRTHPLACE (city or tom


Hartford Conn


10 NAME OF FATHER


Sewall Bruce.


11 BIRTHPLACE OFTHEBra Conn (State or country)


12 MAIDEN NAME OF MOTHERary Harris


13 BIRTHPLACE OF MOTHERforEnConn (State or country)


If LESS than


I day, ........ hrs.


or ........ min.


arterio Schlerosis Interstitial


nephritis


8 OCCUPATION OF DECEASED


Months


8


Days


22


5 SINGLE, MARRIED, WIDOWED, OR


DIVORCED (write the word)


widowed


5a If married, widowed, or divorced


HUSBAND of


(or) WIFE of


Arthur H. Wolcott.


6 DATE OF BIRTH (month, day, and year) June 8 1854.


4 COLOR OR RACE


white


(a) Residence.


No.


(Usual place of abode)


Length of residence in city or town where death occurred


ycars


months


days.


How long in U. S., if of foreign birth ?


years


Township


Winthrop


or Village.


......


LApproved by 0. J. Uchisus abd


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 employed, as At school or At home. Care shoukl be taken to report spe- eifically the occupations of persons engaged in domestic service for wages, as Servant, Cook, IFousemaid, 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 fever (never report "Typhoid pneumonia"); Lobar pneumonia; Bronchopneumonia ("Pneumonia," unquali- fied, is indefinite); 'Tuberculosis of lungs, meninges, peri- toneum, etc., Carcinoma, Sarcoma, ete., 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 (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- inus," "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 hcad - homicide; Poisoned by carbolic acid - probably suicide. The nature of the injury, as fracture of skull, and consequences (e. g., scpsis, tetanus) may be stated


on statement of cause of death approved by Committee on Nomenclature of the American Medical Association.)


Cases 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 strect, or one supposed to be due to Alcoholism, etc.


4. Deatlıs under circumstances unknown, as A person found dead, etc.


ADDITIONAL SPACE


FOR FURTHER STATEMENTS BY


PIIYSICIAN.


1


R 15. 1-'18. 100,000.


N. B .- Every item of information should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state CAUSE OF DEATH in plain terms, so that it may be properly classified. Exact statement of OCCUPATION is very


important. See instructions on back of certificate.


The Commonwealth of Massachusetts


STANDARD CERTIFICATE OF DEATH


1 PLACE OF DEATH


Withna (No)


12 Prospect Leurs


St. ;. .......


Ward)


(City or town.) [If death occurred in a hospital or institutice, give its NAME Instead of street and number.]


Palth, Halsey Goddard


2 FULL NAME [If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE 12 Prospect are Muchnot Registered No. MEDICAL CERTIFICATE OF DEATH


PERSONAL AND STATISTICAL PARTICULARS


& SEX


Male


4 COLOR OR RACE


White


5 SINGLE,


MARRIED.


WIDOWED,


OR DIVORCED


(Write the word)


manuel


16 DATE OF DEATH


March


(Month)


4., 1919


(Day)


(Year)


" DATE OF BIRTH Cinq 3


(Month)


(Day)


(Year)


7 AGE


7


1


51


...... yrs. ........ 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).


Light the Juice


$ BIRTHPLACE


(State or country)


new London Coun


PARENTS


12 MAIDEN NAME


OF MOTHER


Licy. R. Comstock


18 BIRTHPLACE


OF MOTHER


(State or country)


new don en CX


14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE


(Informant).


Many Goodand( woke)


(Address)


16 Filed - 2. 1919


REGISTRAR


17


I HEREBY CERTIFY that I attended deceased from


28


191.Z., to


mar. of


1915.


that I last saw h ........... calive on


mar. "


1919


and that death occurred, on the date stated above, at.


11 a.m.


The CAUSE OF DEATH* was as follows :


Labar Pneumonie


.(Duration) ........... yrs. mos. ds.


Contributory.


arterio-achiová


.(Duration)


yrs. ............


.... mos. ds.


-


(Signed)


mch. 6.


1919 (Address).


* If death followed injury or violence the certificate of death must be made out by the Medical Examiner.


18 LENGTH OF RESIDENCE (FOR HOSPITALS, INSTITUTIONS, TRANSIENTS, OR


RECENT RESIDENTS).


At place


In the


of death


.yrs.


.mos.


ds.


State ..


.......... yrs.


mos. ...........


Where was disease contracted, If not at place of death ?.


Former or usual residence.


19 PLACE OF BURIAL OR REMOVAL


new bon lin ef


DATE OF BURIAL


mar 7


, 1919


....


20 UNDERTAKER C.R. Bunun J


ADDRESS


M.C.


11 BIRTHPLACE


OF FATHER


(State or country)


new London CA


10 NAME OF


FATHER


George Haley Goddard


If LESS than I day ........ hrs.


1867, 1.


-


WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD.


STANDARD CERTIFICATE OF DEATH.


1


1


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- kecpers 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 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 discase. Examples: Cerebro-spinal fever (the only definite synonym is "Epidemie cerebro-spinal meningitis"); Diphtheria (avoid use of "Croup"); Typhoid fever (never re- port "Typhoid pneumonia"); Lobar pneumonia; Broncho- pneumonia ("Pneumonia," unqualified, is indefinite) ; Tuber-


culosis of lungs, meninges, peritonaeum, etc., 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; 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" (merely symptomatic), "Atrophy," "Collapse," "Coma," "Convulsions," "Debility" ("Congenital," "Senile," etc.), "Dropsy," "Exhaustion," "Heart failure," "Haemorrhage," "Inanition," "Marasmus," "Old age," "Shock," "Uracmia," "Weakness," etc., when a definite disease can be ascertained as the cause. Always qualify all diseases resulting from childbirth or miscarriage, as "PUER- PERAL septicemia," "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, etc.


4. Deaths under circumstances unknown, as A person found dead, etc.


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 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


Winthrop ...


BOSTON


(City or town)


1 PLACE OF DEATH


County


Suffolk


State Massachusetts Registered No.


Township


Winthrop .


or Village


or


City


BOSTON


No ..


62 Thornton Street


St ..


.Ward


(If death occurred in a hospital or institution, give its NAME instead of street and number)


2 FULL NAME


Anna G.Bigelow.


(If in the Army or Mary of the United States, give "Thornton Sugarzation, etc.) ....


Ward.


(If non-resident give city or town and State)


Length of residence in city or town where death occurred


22


years


months


days.


How long in U. S., if of foreign birth ?


years


months


days


PERSONAL AND STATISTICAL PARTICULARS


MEDICAL CERTIFICATE OF DEATH


3 SEX


female


4 COLOR OR RACE


white


5 SINGLE, MARRIED, WIDOWED, OR


DIVORCED (write the word)


married.


5a If married, widowed, or divorced


HUSBAND of


(or) WIFE of


Edmond L. Bigelow


6 DATE OF BIRTH (month, day, and a) 2/ 1852.


7 AGE


Years


67


Months


1


Days


6


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 establishment in which employed (or employer) (c) Name of employer


9 BIRTHPLACE (city or town)


Boston Mass.


(State or country)


10 NAME OF FATHER


William L. Elliot


11 BIRTHPLACE OF FATHER (city of town)


Bogton Mass


(State or country)


12 MAIDEN NAME OF MOTHERLIZabeth Richar


13 BIRTHPLACE OF MOTHERTCHY PEYIh


(State or country)


14 H.D.Hall.


Informant


(Address)


67 Thornton Street


15 Filed /a) 19, 1919


REGISTRAR


16 DATE OF DEATH (month,las and Fear] 919 19


17


I HEREBY CERTIFY, That I attended deceased from


1919


., to.


19


man 5


19.


that I last saw h ......... alive on


19


19.


82° p .m.


and that death occurred, on the date stated above, at


The CAUSE OF DEATH* was as follows :


Multiple abdominal Cancer


(Utérus, lion, intestines


storach )


-(duration)


....


2 yrs. 6


CONTRIBUTORY


(SECONDARY)


(duration)


.yrs ..


mos.


ds.


18 Where was disease contracted


if not at place of death ?


X


FOR WHAT?


Did an operation precede death ?


Zco Date of.


X


Was there an autopsy ?.


200


What test confirmed diagnosis ?


Clinical


(Signed).


Oreille Efalison


M.D.


158/ 199 (Address) 123 1 Vuelcoh St. Huellas


* State the DISEASE CAUSING DEATH, or in deaths from VIOLENT CAUSES, state (I) 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 Cem.


Mar


DATE OF BURIAL


19


8


20 UNDERTAKER


ADDRESS


aston


18-XXM


mos .....


.. ds.


X


PARENTS


(a) Residence.


No.


(Usual place of abode)


[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) Salcsman, (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 inore precise specification, as Day laborer, Farm laborer, Laborcr - Coal minc, 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 homc. Care should be taken to report spe- cifieally the occupations of persons engaged in domestic service for wages, as Servant, Cook, Housemaid, ete. 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 have no occupation whatever, write None.


-


Statement of cause of death. - Naine, first, the DISEASE CAUSING DEATII (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 fcver (never report "Typhoid pneumonia"); Lobar pneumonia; Bronchopncumonia ("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 discase; 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- pncumonia (secondary), 10 ds. Never report mere symnp- toms or terminal conditions, such as "Asthenia," "Anemia" (merely symptomatie), "Atrophy," "Col- lapse," "Coma," "Convulsions,"" "Debility"? ("Con- genital," "Senile," etc.), "Dropsy," "Exhaustion," "Heart failure," "Hemorrhage," "Inanition," "Maras- inus," "Old age," c." "Shock," "Uremia," "Weakness," etc., when a definite discase can bo aseertained as the cause. Always qualify all diseases resulting from child- 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, Of 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


on Nomenclature of the American Medical Association.)


Cases 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 strcet, or one supposed to be duc 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.


Township 3 SEX 7 AGE PARENTS Informant carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state CAUSE OF DEATH in plain terms, of certificate. 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 particular kind of work.


The Commonwealth of Massachusetts


STANDARD CERTIFICATE OF DEATH


(City or town)


1 PLACE OF


County.


Suffolk


State


quan


Registered No ..


or Village ...


City.


quethrop


No.


974 Pleasant


St.,


Ward


(If teeth occurredIn a hospital or institution, give its NAME instead of street and number)


adeline E. Walker


2 FULL NAME.


(If in the Army or Navy of the United States, give rank, organization, etc.)


(a) Residence.


(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


4 COLOR OR RACE


5 SINGLE, MARRIED, WIDOWED, OR DIVORCED (write the word) Widowed


5a If married, widowed, or divorced


HUSBAND of


Windows alberto Hacker


6 DATE OF BIRTH (month, day, and year)


Years


Months


Days


If LESS than 1 day, ........ hrs. or ....... min.


8 OCCUPATION OF DECEASED


(a) Trade, profession, or athome


(b) General nature of industry, business, or establishment in which employed (or employer) (c) Name of employer


9 BIRTHPLACE (city or town)


Havana


(State or country)


n.y.


10 NAME OF FATHER


Elogios adquer


11 BIRTHPLACE OF FATHER (city or town)


(State or country)


12 MAIDEN NAME OF MOTHER $ 1


13 BIRTHPLACE OF MOTHER (city or town)


(State or country)


14 Colbert F texelker


(Address) 272 pleasant St.


15 Filed 1/2: 14 /19/19


REGISTRAR


MEDICAL CERTIFICATE OF DEATH


16 DATE OF DEATH (month, day, and year) March Q, 10,19


17


I HEREBY CERTIFY, That I attended deceased from


,1919


to


1979


that I last saw het


alive on


19 19


and that death occurred, on the date stated above, at


2,159


m.


The CAUSE OF DEATH* was as follows :


Bronchitis


(duration)


.. yrs ...........


.. mos ..


4


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)


Tery 9 Thorne


M.D.


Ich 6, 19


(Address)


218 mani


* State the DISEASE CAUSING DEATHI, 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


Hope Cet Porcenter


DATE OF BURIAL 3-8-2019


ADDRESS


20 UNDERTAKER


M. C. Skaggs


r


Жилhop


or


St., Ward.


(If non-resident give city or town and State)


80


[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) 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 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- eifically 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 DEATII (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


fever (never report "Typhoid pneumonia"); Lobar pneumonia; Bronchopneumonia ("Pneumonia," unquali- ficd, 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 (sccondary or inter- current) affection nced not be stated unless important. Example: Measles (disease causing death), 29 as .; Broncho- pneumonia (secondary), 10 ds. Never report mere symp- toins 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- inus," "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- 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




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.