USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1919-1921 > Part 191
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
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 deceased, furnish for registration a standard certificate of death, stating to the best of his knowledge and belief the name of the deceased, his supposed age, the disease of which he died [defined so that it can be 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. . - 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 frem the beard 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 physiclan, 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 physician, 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 mako such certificate. . . . The person to whom the 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, Sec. 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 dicd, his name and residence, if known, otherwise a description of such person as full as may be, with the cause and mauner of his death, and shall make examination upon the view of the dead bodies of only such persons as are supposed to 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 such deaths only as those of persons to whom they have given bedside care during a last illuess from disease unrelated to any form of injury.
(2) Board of Health Physicians 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 certify to all deaths sup- posably due to injury. These include not only deaths caused directly or indirectly by traumatism (including resulting septicemia), and by the action of chemical (drugs or poisons), thermal, or electrical agents, and deaths following abertieu, but also deaths from disease resulting from injury or infection related to occupation, tlc sudden deaths of persons not disabled by recognized disease, and those of persons found dead.
R-302
The Conunamuralth of Massachusetts
STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH
County
Suffolk
State
Massachusetts
City or Town
Boston
No. CITY, HOSPT
Registered No. 147 (Place of residence) St., Ward
(If death occurred in a hospital or institution, give its NAME instead of street and number)
2 FULL NAME
ADOLPH L. ALTMEYER
(If in the Army or Navy of the United States, give rank, organization, etc.)
(a) Residence. State.
(Usual place of abode)
City or Town WINTHROP No.
57 SHORE DRIVE -- St.
Length of residence in city or town where death occurred
years
mooths
days
How long in U. S., if of foreigo birth?
years
months
days
PERSONAL AND STATISTICAL PARTICULARS
4 COLOR OR RACE
5 SINGLE, MARRIED, WIDOWED, OR
DIVORCED (write the word)
W
MARRIED
5a If married, widowed, or divorced
HUSBAND of
(or) WIFE of
HARRIET E.
6 DATE OF BIRTH (month, day, and year) JUNE 30. 1882
7 AGE
Years
Months
Days
If LESS than
1 day, ........ hars. or ........ min.
If STILLBORN, eoter that fact here
8 OCCUPATION OF DECEASED
(a) Trade, profession, or
ATTORNEY
9 BIRTHPLACE (city or town)
E.R.A.N.C.E.
10 NAME OF FATHER
JOHN
11 BIRTHPLACE OF FATHER (city or town)
(State or country)
FRANCE
12 MAIDEN NAME OF MOTHER ELIZABETH MITCHELLWhat test confirmed diagnosis?
13 BIRTHPLACE OF MOTHER (city of ANDE (State or country)
WIFE
19 P'
WINTHROP. MASS. (TOMB)
DATE OF BURIAL
SEPT. 121
19 21 MOMSlenen
Registrar of city or town where death occurred
Filed
Oct 25
19 21
Registrar of city or town where deceased resided
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH (month, day, and year)
SEFT.9
19 21
17
I HEREBY CERTIFY, That I attended deceased from
., 19.
..... , to ..
19.21
that I last saw h ...
alive on
19.21
and that death occurred, on the date stated above, at m. The CAUSE OF DEATH* was as follows :
* 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.)
GUNSHOT WOUND HEAD AND RESULTANT
INJURIES. ( HOMICIDAL)
.. (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?
(Signed)
W. H. WATTERS
M.D.
, 19
(Address)
ASSC, MED.EX.
15
SEPT.12
Filed
20 UNDERTAKER
C. R. BENNISON
ADDRESS
WINTHROF
. 25,000
3 SEX M 39 particular kiod of work (b) Name of employer PARENTS 14 Informant (Address) 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) of certificate.
BOSTON
( City or town) Registered No. 7039 (Place of death)
2
9
Sept. 9.1921 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 agc. 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 liome, 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- cifieally the occupations of persons engaged in domestic service for wages, as Scrvant, Cook, Housemaid, etc. If the occupation has been elianged 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 (rctired, 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 eausation), using always tlie 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); 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," "Aneinia" (merely symptomatic), "Atrophy," "Col- lapse," "Coma," "Convulsions," " "Debility"? {"Con-
genital," "Scnile," etc.), "Dropsy," "Exhaustion," "Heart failure," "Hemorrhage," "Inanition," "Maras- mus," "Old age," "Shock," "Uremia," "Weakness," etc., when a definite disease ean 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 eaused 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-301
in plain terms, so that it may be properly classified. Exact statement of OCCUPATION is very important. See
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
OFFICE OF THE SECRETARY DIVISION OF VITAL STATISTICS
1 PLACE OF DEATH
County.
Suffolk
State.
Massachusetts
Registered No.
144
City or Town
92
No.
O ..
St ........
Ward
(If death occurred in a hospital or institution, give its NAME instead of street and number) Fame Merinsan
2 FULL NAME
92 Bacon
St.
Ward.
( If non-resident give city or town and State)
months
days
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
4 COLOR OR RACE
5 SINGLE, MARRIED, WIDOWED, OR
DIVORCED (write the word)
urEu
5a If married, widowed, divorced
HUSBAND of
(or) WIFE of
Farve . W. Meryma
6 DATE OF BIRTH
(Month)
"(Day)"
(Year)
7 AGE 80 Years 5 Months tas Days 18
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)
(State or country)
10 NAME OF
FATHER
Cyrus 9. Swett.
PARENTS
11 BIRTHPLACE OF
FATHER (City)
(State or country)
Peadfield. Maike.
12 MAIDEN NAME
OF MOTHER
Mary
Hayus,
13 BIRTHPLACE OF MOTHER (City) ... (State or country) maise
14 W. E. Meryman.
19 PLACE OF BURIAL, CREMATION, OR REMOVAL DATE OF BURIAL Mt. aubu un .
(Cemetery)
(City or town)
9/12/-
19 2/
20 UNDERTAKER
Charles R. Benson St.
ADDŘESS
14.TWuthug
21 I HEREBY CERTIFY that a satisfactory stan- dard certificate of death was fled with me BEFORE the burial or transit permit was issued
Official position. of Health Offrons
Date of issue of permit 9/11/21
Permit No. 333
instructions and extracts from the laws on back of certificate.
150,000.
9-XXM.)
15
Sept 15,199
(Month) (Day) (Ycar)
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
Left
/0
1921 (Year)
17
I HEREBY CERTIFY, That I attended deceased from
July
1921, to
to
Sett 10
, 19-2/
that I last saw h.
alive on
Seff 4
and that death occurred, on the date stated above, at 29 m.
Cerebral Hemanlage
Hemi Plegia
.. (duration)
CONTRIBUTORY
(SECONDARY)
18 Where was disease contracted
if not at place of death? ........
FOR WHAT?
yrs
mos ........ ..
.. ds.
X
Did an operation precede death?
. Date of
X
Was there an autopsy ?
no
What test confirmed diagnosis ?
Clinical
(Signed).
Graille & forma M.D.
(Address)
Date.
Soft
1921.
7(Month)
(Day)
( Year)
Informant
(Address)
Mary
(If in the Army of Navy of the United States, give rank, organization, etc.)
(a) Residence.
No.
( Usual place of abode)
Length of residence ia city or town where death occurred
5 years
years
months
days.
How long in U. S., if of foreign birth ?
years
16 DATE OF DEATH.
( Month)
(Day)
Jamal
Mar 22 1841
If STILLBORN, enter that fact here
If STILLBORN, state period of uterogestation
mos.
lf LESS than
The CAUSE OF DEATH was as follows :
yrs
mos ..
10
ds.
should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state CAUSE OF DEATH
REVISED UNITED STATES STANDARD CERTIFICATE OF DEATH
[Approved by U. S. Census and American Public Health Association]
Statement of occupation. - Precise statement of oceupation is very important, so that the relativo healthfulness of various pursuits ean 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, Physicion, Compositor, Architect, Locomotive engincer, Civilengineer, Stationory firemon, cic. Butin many eases, 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) Solesmon, (b) Grocery; (a) Foremon, (b) Automobile foctory. The material worked on may form part of the second statement. Never return "Laborer," "Foreman," "Manager," "Dealer," etc., without more precise specification, as Doy loborer, Form laborer, Laborer - Cool mine, cte. Women at home, who are engaged in the duties of the house- hold only (not paid Housekcepers 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 tho occupations of persons engaged in domestie service for wages, as Servant, Cook, Housemaid, ete. If the occupation has been changed or given up on account of the DISEASE CAUSING NEATH, state occupation at beginning of illness. If retired from business, that fact may be indicated thus: Former (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 discase. Examples: Cere- brospinal fever (the only definite synonym is "Epidemie cerebrospinal 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 ncoplasms); Measles; Whooping cough; Chronic volvular heart disease; Chronic interstitiol nephritis, cte. The contributory (secondary or inter- current) affection need not be stated unless important. Example: Mcasles (disease causing death), 29 ds .; Bronchopneumonia (sccondary), 10 ds. Never report mcre symptoms or terminal conditions, such as "Asthenia," "Anemia" (merely symptomatie), "Atrophy," "Col- lapse,""Coma,""Convulsions,""Dcbility" ("Congenital,"" Senile," etc.), "Dropsy,""Exhaustion,""Heart failure,""Hemorrhage,""Ina- nition," "Marasmus," "Old age," "Shock," "Uremia,""Weakness," ete., 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," ete.
State cause for which surgical operation was undertaken.
(Recommendations on statement of eause of death approved by Com- inittec on Nomenclaturo 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 PROM 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 deceased, furnish for registration a standard certificate of death, stating to the best of his knowledge and belief the name of the deceased, his supposed agc, the discase of which he died [defined so that it can be elassified 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, Chaly. 29, Secs. 10 ond 1, as amended by Acts of 1910, Chop. 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 eity or town in which the person died; . . . nosuch 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 tlicrcof 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 physician, 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 thereafterfurnish 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, Chop. 78, Scc. 38.
Medical examiners shall, in all cases, certify to the city or town elerk or to the eity registrar in the place where the deceased dicd, his name and residence, if known, otherwise a description of such person as full as may be, with the eause and manner of his death, and shall make examination upon the view of the dead bodies of only such persons as aro supposed to have come to their death by violence. - Revised Laws, Chop. 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) Attonding physicians will certify to sueh deaths only as those of persens to whom they have given bedside eare during a last illness from disease unrelated to any form of injury.
(2) Board of Health Physicians will certify to sueh 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 certify to all deaths sup- posably due to injury. These include not only deaths eaused directly or indirectly by traumatism (including resulting septicemia), 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.
R-302
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
BOSTON
(City or town)
1 PLACE OF DEATH
County
Suffolk
Boston
No.
589 BEACON ST
2 FULL NAME
MASS.
City or Town
WINTHROP
No.
62 PLEASANT
St.
Length of residence in city or town where death occurred
years
months
days
How long in U. S., if of foreign hirth?
years
months days
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
M
4 COLOR OR RACE
WY
5 SINGLE, MARRIED, WIDOWED, OR
DIVORCED (write the word)
MAR.
5a If married, widowed, or divorced
HUSBAND of
(or) WIFE of
MARY A.
6 DATE OF BIRTH (month, day, and year)
OCT . 16 . 1857
7 AGE
Years
Months
Days 4
If LESS than
63
1 day, ........ hrs. or ........ min.
If STILLBORN, enter that fact here
8 OCCUPATION OF DECEASED
(a) Trade, profession, or
MEAT BUSINESS
particular kind of work.
(h) Name of employer
GRINNELL
9 BIRTHPLACE (city or town).
(State or country)
IA.
10 NAME OF FATHER
ALLEN ATWOOD
PARENTS
11 BIRTHPLACE OF FATHER (city or TAURO (State or country)
12 MAIDEN NAME OF MOTHER BETSEY L.RICH
TRURO
13 BIRTHPLACE OF MOTHER (city or town)
(State or country)
,19
(Address)
SEPT .11
19 PLACE OF BURIAL, CREMATION, OR REMOVAL
CAMBRIDGE (MT, AUBURN)
20 UNDERTAKER
A. L. EASTMAN CO.
DATE OF BURIAL SEL. 13 1921
ADDRESS
5
MYOCARDITIS
(duration).
1
yrs.
mos. ds.
CONTRIBUTORY
DIABETES MELLITUS
(SECONDARY)
(duration)
2
.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?
O . THOMPSON
(Signed)
M.D.
14 WIFE
Informant
(Address)
Eringlenen
Registrar of city or town where death occurred
Filed
Oct 25 1321
Registrar of city or town where deceased resided
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH (month, day, and ycar) SEPT . 10
19 21
17
I HEREBY CERTIFY, That I attended deceased from
APR.6
21
SEFT.10
1921
IM
19
to
SEPT. 15
that I last saw h
alive on
1921
and that death occurred, on the date stated above, at 11.45P m The CAUSE OF DEATH* was as follows :
* 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.)
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
25,000
of certificate.
15
Filed.
SEP. 13,21
State
Massachusetts
Registered No ...
7074
(Place of death)
Registered No.
148
(Place of residence)
St.,
Ward
City or Town
ARTHUR H. ATWOOD
(If death occurred in a hospital or institution, give its NAME instead of street and number)
(If in the Army or Navy of the United States, give rank, organization, etc.)
(a) Residence.
State
(Usual place of abode)
e 192 ) REVISED UNITED STATES STANDARD CERTIFICATE OF DEATH [Approved by U. S. Census and American Public Health Association]
Statement of occupation. - Precisc 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 Ptanter, 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 dutics 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 sehool 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.
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.