USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1919-1921 > Part 162
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so that it may be properly classified. Exact statoment of OCCUPATION is very important. See instructions on back
(State or country)
of certificate.
4 COLOR OR RACE
W
5 SINGLE, MARRIED, WIDOWED, OR
DIVORCED (write the word)
WID.
5a If married, widowed, or divorced
HUSBAND of
(or) WIFE of
6 DATE OF BIRTH (month, day, and year)
---- 1845
Years
Months
Days
750
If LESS than
I day, ........ hrs.
or ....... min.
If STILLBORN, enter that fact here
8 OCCUPATION OF DECEASED
RETIRED
(a) Trade, profession, or
particular kind of work
9 BIRTHPLACE (city or town).
CAVADA
10 NAME OF FATHER
JOHN
11 BIRTHPLACE OF FATHER (eity or town)
(State or country)
IRELAND
12 MAIDEN NAME OF MOTHER
AUN GALLAGHER
13 BIRTHPLACE OF MOTHER (eity REEDA.N.D (State or country)
-
15
20 UNDERTAKER
J . L . MULDOON
ADDRESS
City or Town
Boston
No.
LONG ISLAND HOSET.
JOHN H. KELLY
(If in the Army or Nayy of the United States, give rank, organization, etc.)
(a) Residence.
State
(Usual place of abode)
Length of residence in city or town where death occurred
years
months
WINTHROP
No.
24 QUINCY AVE. - SE
may 2, 1921
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) Foreman, (b) Automobile factory. The ma- terial worked on inay form part of the second statement. Never return "Laborer.""
"Foreman," "Manager," "Dealer," ctc., 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 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 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"); Typhoid fever (never report "Typhoid pneumonia"); Lobar pneumonia; Bronchopneumonia ("Pneumonia," unquali- fied, is indefinite); Tuberculosis of lungs, meningcs, peri- toneum, etc., Carcinoma, Sarcoma, etc., of.
(namne origin; "Cancer" is less definite; avoid use of "Tumor" for malignant neoplasms); Measles; Whooping cough; Chronic valvular heart disease; Chronic interstitial nephritis, 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," "Wcakness," 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.
under the head of "Contributory." (Recommendations 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 diseasc, 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.
2-301
OFFICE OF THE SECRETARY DIVISION OF VITAL STATISTICS
STANDARD CERTIFICATE OF DEATH
(City or Town)
1 PLACE OF DEATH
County
Suffolk
State.
Massachusetts
Registered No ..
68
City or Town
No.
St ...
.Ward
(If death occurred in a hospital or institution, give its NAME instead of street and number)
[thee Dorothy Brumby
(a) Residence.
No.
0. 56 Lincoln PL
(Usual place of ahode)
Length of resideoce in city or town where death occurred
2
years
months
days.
How loog io U. S., if of foreign birth ?
years
months
days
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
Temal
4 COLOR OR RACE
white
5 SINGLE, MARRIED, WIDOWED, OR
DIVORCED (write the word)
Single
5a If married. widowed, or divorced
HUSBAND of
(or) WIFE of
6 DATE OF BIRTH
( Month)
"(Day)
(Year)
7 AGE
Years
20
Months
10
Day's
13
1 day, ........ hrs. or ....... min.
If STILLBORN, eoter that fact here
8 OCCUPATION OF DECEASED
(a) Trade, profession, or
particular kind of work
(b) Name of employer
9 BIRTHPLACE (City)
(State or country)
10 NAME OF
FATHER
Francis 9. Brumby
11 BIRTHPLACE OF
FATHER (City).
England.
(State or country)
What test confirmed diagnosis ?
(Signed)
M.D.
(Address) ......
174 undhowl
Date
In
1
1921
( Month)
(Lav)
Year)
14
19 PLACE OF BURIAL, CREMATION, OR REMOVAL
DATE OF BURIAL
(Cemetery)
(City or town)
.....
15
led May20 191
(Month) (Day) (Year)
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
may 3
1921.
(Year)
17 I HEREBY CERTIFY, That I attended deceased from
July 1919, to.
7
that I last saw her alive on may 14 19.29.
756 9 m. and that death occurred, on the date stated above, at
If LESS thao The CAUSE OF DEATH was as follows :
of both Lungo
0
(duration)
2×
.yrs ..............
mos.
ds.
....
CONTRIBUTORY ( SECONDARY)
(duration)
.yrs ...
........
mos ...............
ds.
18 Where was disease contracted
if not at place of death ?
FOR WHAT?
Did an operation precede death ?
Date of
Was there an autopsy ?
12 MAIDEN NAME
OF MOTHER
What. S. Williamin
13 BIRTHPLACE OF
MOTHER (City)
(State or country)
Informant
(Address)
20 UNDERTAKER
ADDRESS
wucht.
21 | HEREBY CERTIFY that a satisfactory stan- dard certificate of death was filed with me BEFORE the burial or transit permit was issued S.a. Maury
Official position.
Healtho Officer
Date of of permit 5/5/21.
Permit No. 2.68
2 FULL NAME
(If in the Army or Navy of the United States, give fank, organization, etc.)
St., Ward.
(If non-resident give city or town and State)
16 DATE OF DEATH.
(Month)
(Day)
umN 14 -1900
PARENTS
in plain terms, so that it may be properly classified. Exact statement of OCCUPATION is very important. See instructions and extracts from the laws on back of certificate.
The Commonwealth of Massachusetts
J. 101
REVISED UNITED STATES STANDARD CERTIFICATE OF DEATH
[Approved by U. S. Census and American Public Health Association]
.
Statement of occupation. - Preciso statement of occupation 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, Locomotive engincer, Civilengineer, Stationary fireman, etc. Butin many eascs, 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 material worked on may form part of the second statement. Never return "Laborer," "Foreman," "Manager," "Dealer," etc., without more precise specifieation, as Day laborer, Farm laborer, Laborer - Coal mine, etc. Women at home, who are engaged in the duties of the house- hold 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, ete. If the occupation has been changed or given up on account of the DISEASE CAUSING DEATH, state oceupation at beginning of illness. If retired from business, that fact may be indicated 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 tho same disease. Examples: Cere- brospinal fever (the only definito synonym is "Epidemic ecrebrospinal meningitis"); Diphtheria (avoid use of "Croup"); Typhoid fever (never report "Typhoid pneumonia"); Lobar pneumonia; Bronchopneumonia ("Pneumonia," unqualified, is indefinite); Tuberculosis of lungs, men- inges, peritoneum, 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, ete. The contributory (secondary or inter- current) affection need not be stated unless important. Example: Measles (discase causing death), 29 ds .; Bronchopneumonia (sccondary), 10 ds. Never report mere symptoms or terminal conditions, such as "Asthenia," "Anemia" (merely symptomatic), "Atrophy," "Col- lapse,""Coma,""Convulsions,""Debility" ("Congenital,""Senile," cte.), "Dropsy,""Exhaustion,""Heart failure,""Hemorrhage,""Ina- nition," "Marasmus," "Old age," "Shock," "Uremia,""Weakness," ete., when a definite discase 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 operatlon was undertaken.
(Recommendations on statement of cause of death approved by Com- mittee on Nomenclature of the American Medical Association.)
Bronchopneumonia: If primary cause, write the word "pri- mary" ; if secondary, give primary cause.
Certificates will be returned for additional information which give any of the following diseases, without explanation, as the sole cause of death: Abortion, cellulitis, childbirth, convulsions, hemorrhage, gangrene, gastritis, erysipelas, meningitis, miscar- riage, necrosis, peritonitis, phlebitis, pyemia, septicemia, tetanus.
EXTRACTS FROM THE LAWS OF THE COMMONWEALTH OF MASSACHUSETTS GOVERNING THE RETURN OF CERTIFICATES OF DEATH
A physician shall forthwith, after the death of a person whom he has attended during his last illness, at the request of an undertaker or other authorized person or of any member of the family of the deccased, furnish for registration a standard certificate of death, stating to the best of his knowledge and belief the name of the deccascd, his supposed agc, the disease of which he died [defined so that it can be classified under the international elassification of causes of death], where contractcd, the duration of his last illness, when last seen alive by the physician, and the date of his death. . . . - Revised Laws, Chap. 29, Secs. 10 and 1, as amended by Acts of 1910, Chap. 822.
No undertaker or other person shall bury a human body . .. until he has received a permit from the board of health or its agent, . . . or . . from the clerk of the city or town in which the person died; . . . no such permit shall be issued until there shall have been delivered to such board, agent or clerk, . . . a satisfactory written statement con- taining the facts required by law to be returned and recorded, which ... shall be accompanied by a satisfactory certificate of the at- tending physician, if any, as required by law, or in lieu thereof a certifi- cate as hereinafter provided. If there is no attending physician, or if, for sufficient reasons, his certificate cannot be obtained early enough for the purpose, or is insufficient, the chairman of the board of health, if a physiclan, or any physician employed by said board or by the selectmen for the purpose, shall upon application make such certificate as is required of the attending physician. If death is caused by violence, the medical examiner only shall make such certificate. . .. The person to whom the per- mit is so given and the physician who certifies to the cause of death shall thereafter furnish for registration any other necessary information which can be obtained as to the deceased, or as to the manner or eause of the death, which the clerk or registrar may require. - Revised Laws, Chap. 78, Scc. 88.
Medical examiners shall, in all cases, certify to the city or town clerk or to the eity registrar in the place where the deceased died, his name and residence, if known, otherwise a description of such person as full as may be, with the cause and manner of his death, and shall make examination upon the view of the dead bodies of only such persons as are supposed te have come to their death by violence. - Revised Laws, Chap. 24, Sec. 8.
RULES OF PRACTICE
The fulfilment of the purpose of these laws calls for the observance of the following rules of practice:
(1) Attending physicians will certify to sueh deaths only as those of persons to whom they have given bedside care during a last illness from disease unrelated to any form of injury.
(2) Board of Health Physlclans will certify to such deaths only as those of persons who, though disabled by recognized disease unrelated to any form of injury, have died without recent medical attendance or whose physician is absent from home when the certificate of death is needed.
(3) Medical examiners will investigate and ecrtify to all deaths sup- posably due to injury. These include not only deaths caused directly or indirectly by traumatism (including resulting septieemia), and by the action of chemical (drugs or poisons), thermal, or electrical agents, and deaths following abortion, but also deaths from disease resulting from injury or infection related to occupation, the sudden deaths of persons not disabled by recognized disease, and those of persons found dead.
.
-301
OFFICE OF THE SECRETARY DIVISION OF VITAL STATISTICS
STANDARD CERTIFICATE OF DEATH
(City or Town)
1 PLACE OF DEATH
County.
Suffolk
State
Massachusetts
Registered No. 69
City or Town
No ...
466 Plement St
St ..
.Ward
(If death occurred in a hospital or institution, give its NAME instead of street and number) William Ernest Medhold-
2 FULL NAME
..... 466 Plement & L
(a) Residence. No ..
(Usual place of abode)
Length of resideoce in city or town where death occurred
>
years
mooths
days.
How loog in U. S., if of foreign birth ?
years
months
days
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
thale
4 COLOR OR RACE
5 SINGLE, MARRIED, WIDOWED, OR
DIVORCED (write the word)
Inger
5a If married, widowed, or divorced
HUSBAND of
(or) WIFE of
6 DATE OF BIRTH
7 1898
( Month)
(Day)
(Year)
7 AGE
Years
Months
Days
246
If LESS thao
12
If STILLBORN, enter that fact bere
8 OCCUPATION OF DECEASED
(a) Trade, professioo, or
particular kind of work
(b) Name of employer Woods Machen. Co Gratin
9 BIRTHPLACE (City)
(State or country)
10 NAME OF
FATHER
Louis. T.
11 BIRTHPLACE OF
FATHER (City)
(State or country)
12 MAIDEN NAME
OF MOTHER
Many, Bruce
13 BIRTHPLACE OF
MOTHER (City)
(State or country)
Tia -
What test confirmed diagnosis ?
Pritin Sputum
(Signed)
Raymond B Pull
M.D.
(Address)
Winchamp
4
1921
(Month)
(Day)
(Year)
14
Informant
Miche Many Medholdt
(Address)
466 Clemensdit Which
15
Filed : 1/ 20,1971
(Month) (Day) (Year)
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
3
1921
(Day)
,
(Year)
17
I HEREBY CERTIFY, That I attended deceased from
to.
may 3
19 2 1
......
July
1920
that I last saw h.
alive on
march 17
192/
and that death occurred, on the date stated above, at
4:10 A
.m
day .... .... hrs. The CAUSE OF DEATH was as follows:
or ....... min. Pulmonary Inhumains
(duration)
.yrs.
10
mos. ds.
CONTRIBUTORY (SECONDARY)
(duration)
yrs.
mos ................ ds.
18 Where was disease contracted
if not at place of death ?
FOR WHAT?
Did an operation precede death ?......
Date of
Was there an autopsy ?
no
Date ..
19 PLACE OF BURIAL, CREMATION, OR REMOVAL
.....
(Cemetery) Winner
(City or town)
DATE OF BURIAL
May 5# 192,
ADDRESS
20 UNDERTAKER
CRB.
21 | HEREBY CERTIFY that a satisfactory stan- dard certificate of death was filed with me BEFORE the burial or transit permit was issued S. a. maury.
Official .position,
Health Officier
Date of issue of permit 5/5/21.
Permit
No.
269
in plain terms, so that it may be properly classified. Exact statement of OCCUPATION is very important. See instructions and extracts from the laws on back of certificate.
PARENTS
Queflamen
Wilmington-
16 DATE OF DEATH
(Month
(If non-resident give city or town and State)
(If in the Army or Navy of the United States, give rank, organization, etc.)
St.,
.....
Ward.
The Commonwealth of Massachusetts
In auf 3, 19 71
REVISED UNITED STATES STANDARD CERTIFICATE OF DEATH
[Approved by U. S. Census and American Public Health Association]
Statement of occupation. - Precise statement of occupatiou 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. F'or many occupations a singlo word or term on tho first line will be sufficient, e. g., Farmer or Planter, Physician, Compasitor, Architect, Locomative engineer, Civilengineer, 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 cxamples: (a) Spinner, (b) Cottan mill; (a) Salesman, (b) Grocery; (a) Foreman, (b) Automabile 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 laborcr, Laborcr - Coal minc, ete. Women at home, who are engaged in the duties of the house- hold only (not paid Hausckcepers who receive a definite salary), may be entored as Hausewife, Hausewark, or At home, and children, not gainfully employed, as At school or At hame. Care should be taken to report spe- cifically the occupations of persons engaged in domestic servico for wages, as Servant, Cook, Hausemaid, etc. If the occupation has been changed or given up on account of the DISEASE CAUSING DEATH, stato occupation at beginning of illness. If retired from business, that fact may be indicated thus: Farmer (retired, 6 yrs.). For persons who liavo no occupation whatever, write Nane.
Statement of cause of death. - Name, first, tho DISEASE CAUSING DEATH (the primary affection with respect to time and causation), using always the same accepted term for the same disease. Examples: Cere- brospinal fever (the only definite synonym is "Epidemio cerebrospinal meningitis"); Diphtheria (avoid use of "Croup"); Typhoid fever (never report "Typhoid pneumonia"); Lobar pneumania; Bronchapneumonia ("Pneumonia," unqualified, is indefinite); Tuberculosis af lungs, nicn- inges, peritaneum, etc., Curcinama, Sarcoma, etc., of .... . (nawie origin; "Cancer" is less definite; avoid uso of "Tumor" for malignant neoplasms); Measles; Whoaping cough; Chranic 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 .; Bronchapneumonia (secondary), 10 ds. Never report mere symptoms or terminal conditions, such as "Asthenia," "Anemia" (ineroly symptomatic), "Atrophy," "Col- lapso,""Coma,""Convulsions," "Dehility" ("Congenital," " Senile," etc.). "Dropsy,""Exhaustion,""Heart failure,""Hemorrhage,""Ina- nition," "Marasmus," "Old age," "Shock," "Uremia, ""Weakness," etc., when a definito disease can bo ascertained as tho 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.
(Recommendations on statement of cause of death approved by Com- mittee on Nomenclature of the American Medical Association.)
Bronchopneumonla: If primary cause, write the word "pri- mary " ; If secondary, give primary cause.
Certificates will be returned for additional Information which give any of the following diseases, without explanation, as the sole cause of death: Abortion, cellulitis, childbirth, convulsions, hemorrhage, gangrene, gastritis, erysipelas, meningitis, miscar- riage, necrosis, peritonitis, phlebitis, pyemia, septicemia, tetanus.
EXTRACTS FROM THE LAWS OF THE COMMONWEALTH OF MASSACHUSETTS GOVERNING THE RETURN OF CERTIFICATES OF DEATH
A physician shall forthwith, after the deatlı of a person whom he has attended during his last illness, at the request of an undertaker or other authorized person or of any member of the family of the deceased, furnish for registration a standard certificate of death, stating to the best of lis knowledge and belief the name of the deceased, his supposed age, the discase of which he died [defined so that it can bo classified under the international classification of causes of death], where contracted, the duration of his last illness, when last seen alive by the physician, and the date of his death. . . . - Reviscd Laws, Chap. 29, Secs. 10 and 1, as amended by Acts af 1910, Chap. 822.
No undertaker or other person shall bury a human body . . . until he has received a permit from the board of health or its agent, . . . or . . from the clerk of the city or town in which the person dicd; . . . no such permit shall be issued until there shall have boen dellverod to such board, agent or clerk, . . . a satisfactory written statement con- talning the facts required by law to be returned and recorded, which . . . shall be accompanied by a satisfactory certificate of the at- tending physician, if any, as required by law, or in licu thereof a certifi- cate as hereinafter provided. If there is no attending physician, or if, for sufficlent reasons, his certificate cannot be obtained early enough for the purpose, or Is Insufficient, the chairman of the board of health, if a physician, or any physician employed by sald board or by the selectmen for the purpose, shall upon application mako such certificate as is required of the attending physician. If death Is caused by violence, the medical examiner only shall make such certificate. . .. The person to whom tho per- mit is so given and the physician who certifies to the cause of death shall thereafterfurnish for registration any other necessary information which can be obtained as to the deceased, or as to the manner or cause of the death, which the clerk or registrar may require. - Revised Laws, Chap. 78, Scc. 38.
Medical examiners shall, in all cases, certify to the city or town clerk or to the city registrar in the place where the deceased died, his name and residence, if kuown, otherwise a description of such person as full as may be, with the cause and manner of his death, and shall make examination upon the view of the dead bodies of only such persons as are supposed to havo come to their death by violence. - Revised Laws, Chap. 24, Sec. 8.
RULES OF PRACTICE
Tho fulfilment of the purpose of these laws calls for the observance of tho following rules of practice:
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