Town of Winthrop : Record of Deaths 1919-1921, Part 54

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 54


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).


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of certificate.


PARENTS


CONTRIBUTORY


INFLUENZA


9 BIRTHPLACE (city or town)


KENT


16 DATE OF DEATH (month, day, and year) Sert . 26 ,


1919


5a If married, widowed, or divorced


HUSBAND of


(or) WIFE of


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


... m.


The CAUSE OF DEATH* was as follows :


1


* 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.)


THOMPSONVI


LLE


Did an operation precede death?


Date of


13 BIRTHPLACE OF MOTHER (city or town) HOMPSONVILLE (State or country) CONN.


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


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 terin on the first line will be sufficient, c. 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," ete., without more precise specification, as Day laborer, Farm laborer, Laborer - Coal mine, cte. Women at home, who are engaged in the duties of thic 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 .- Namc, first, the DISEASE CAUSING DEATH (the primary affection with respect to time and causation), using always the same accepted terin for the same diseasc. Examples: Cerebrospinal fever (the only definite synonyın 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- toncum, etc., Carcinoma, Sarcoma, cte., 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" (Increly symptomatic), "Atrophy," "Col-


lapse," "Coma," ""Convulsions,"" "Debility"


(“Con-


genital," "Senile," etc.), "Dropsy," "Exhaustion," "Heart failure," "Hemorrhage," "Inanition," "Maras- Inus," "Old age," "Shock,""" "Uremia," "Weakness," cte., when a definite disease can be ascertained as the cause. Always qualify all discases resulting from child- birth or miscarriage, as "PUERPERAL septicemia," "PUER- PERAL peritonitis," ete. State cause for which surgical operation was undertaken. For VIOLENT DEATHIS 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."(Recon 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, cte.


3. Sudden deaths of persons not disabled by recognized discase, as A death upon the street, 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.


Il 303. 6.'18. 50,000.


RM R-301


The Commonwealth of Massachusetts


STANDARD CERTIFICATE OF DEATH


OFFICE OF THE SECRETARY DIVISION OF VITAL STATISTICS


1 PLACE OF DEATH doFR County ........


State.


Registered No.


City or Town


No.


462 Khives Sch


St.


Ward


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


Thunces


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


(a) Residence. No.


( Usual place of abodc)


462 Chute,


Length of residence io city or town where death occurred


X


years


4 months


days.


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


years


months days


PERSONAL AND STATISTICAL PARTICULARS


3 SEX


Génial


4 COLOR OR RACE


22hete


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)


29-1919


(Day)


( Year)


7 AGE


Years


Months 29 Days


# LESS than


If STILLBORN, enter that fact bere


# STILLBORN, state period of uterogestation


mos.


1 day,


lars.


or oin.


8 OCCUPATION OF DECEASED (a) Trade, profession, or particular kind of work. (b) General oature of industry, business, or establishment in which employed (or employer)


(c) Name of employer


9 BIRTHPLACE (City)


(State or country)


?Hurz.


10 NAME OF


FATHER


11 BIRTHPLACE OF


FATHER (City)


IL Forum


(State or country) Newfoundland


12 MAIDEN NAME OF MOTHER TE Factura, Cezatella


13 BIRTHPLACE OF MOTHER (City) (State or country) 2200 20


14


Informant ...


(Address)


15 Sept 30 1919 Filed (Month) (Day) (Year)


REGISTRAR


MEDICAL CERTIFICATE OF DEATH


16 DATE OF DEATH


September 28, 1919


(Month)


(Day)


(Year)


17


I HEREBY CERTIFY, That I attended deceased from


I did not altered Philes


, 19


, 19


that I last saw h


alive on


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


The CAUSE OF DEATH was as follows :


.


Loban Uneu


(duration)


„yrs ..


CONTRIBUTORY


(SECONDARY)


(duration)


yrs ....... .


mos.


ds.


18 Where was disease contracted


if not at place of death ?


0


Did an operation precede death ?


no


Date of


0


Was there an autopsy? no


What test confirmed diagnosis? ?


(Signed ) ...


. M.D.


(Address) - Credin


30


1919


Date


( Month)


(Day)


( Year)


19 PLACE OF BURIAL, CREMATION, OR REMOVAL


(Cemetery) Burcht


(City or town)


DATE OF BURIAL


stift 30 #2914


20 UNDERTAKER


ADDRESS


21 I HEREBY CERTIFY that a satisfactory stan- dard certificate of death was filed with me BEFORE the borial or transit permit was issued


Official~ positi " Hearthe Oficer


22 Date of issue of burial Lekt. 30M or transit permit


PARENTS


-'18. 100,000.


N. B. - WRITE PLAINLY, WITH UNFADING BLACK INK-THIS IS A PERMANENT RECORD. Every item of information instructions and extracts from the laws on back of certificate. in plain terms, so that it may be properly classified. Exact statement of OCCUPATION is very important. See should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state CAUSE OF DEATH


2 FULL NAME


St.,


Ward.


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


mos.


ds.


malnutrition


sem .


REVISED UNITED STATES STANDARD CERTIFICATE OF DEATH


[Approved by U. S. Census and American Public Health Association]


Statement of occupation. - Precise 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 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 examples: (a) Spinner, (b) Cotton mill; (a) Salesman, (b) Grocery; (a) Foreman, (b) Automobile factory. The material worked on may form part of the second statement. Never return "Laborer," "Foreman," "Manager," "Deaier," 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 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, 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 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: 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 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 .; Bronchopneumonia (secondary), 10 ds. Never report mere symptoms or terminal conditions, such as "Asthenia," "Anemia" (merely symptomatic), "Atrophy," "Col- lapse," "Coma,""Convulsions,""Debility" ("Congenital,""Senile,"" ete.), "Dropsy,""Exhaustion,""Heart failure,""Hemorrhage,""Ina- nition," "Marasmus," "Old age," "Shock," "Uremia,""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.


(Recommendations on statement of cause of death approved by Com- mittec 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, erysipeias, 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 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. 322.


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 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 shali thercafter furnish 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 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 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 illness 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 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.


The Commonwealth of Massachusetts STANDARD CERTIFICATE OF DEATH


(City or town)


1 PLACE OF DEATH


County


Suffolk


State


Mass.


Registered No ...


Township


Winthror


or Village


or


No395 Pleasant St.


St., Ward


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


2 FULL NAMEEDWARD ANDREW HARRINGTON (If in the Army or Navy of the United States, give rank, organization, etc.)


(a) Residence.


No. 305 Pleasant St.


St.,


Ward.


(Usual place of abode)


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


Length of residence in city or town where death occurred


2


years


months


days.


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


years


months


days


PERSONAL AND STATISTICAL PARTICULARS


MEDICAL CERTIFICATE OF DEATH


16 DATE OF DEATH (month, day, and year)


19


19


17 I HEREBY CERTIFY, That I attended deceased from


10


19


Cœur,


19.


that I last saw


h


alive on


Ceux


1


19.9.


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


1/A m.


The CAUSE OF DEATH* was as follows : acidorio


(duration) yrs.


mos.


ds.


CONTRIBUTORY


Diabetes


Mellitus


(duration)


yrs .....


.. mos ..


ds.


18 Where was disease contracted


if not at place of death?


Did an operation precede death?


The Date of.


Was there an autopsy ?


What test confirmed diagnosis ?


(Signed).


10/1,19/9 (Address)


* State the DISEASE CAUSING DEATH, or in deaths from VIOLENT CAUSES, state (1) MEANS AND NATURE OF INJURY, and (2) whether ACCIDENTAL, SUICIDAL, or HOMICIDAL. (See reverse side for additional space.)


19 PLACE OF BURIAL, CREMATION, OR REMOVAL


Fastport. Kaine


DATE OF BURIAL


10/3/19.


19


(Address)


305 Pleasant St. Winthrop


File Och, 21, 1919 Eulalie Churchill asit REGISTRAR


20 UNDERTAKER


John F. I'Maley


ADDRESS


Winthrop


MARVIN REPLAY


City 3 SEX Male 7 AGE 1 particular kind of work PARENTS Informant of certificate. 15 N. B .- WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD. Every item of information should be so that it may be properly classified. Exact statement of OCCUPATION is very important. See instructions on back carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state CAUSE OF DEATH in plain terms, (c) Name of employer


4 COLOR OR RACE


5 SINGLE, MARRIED, WIDOWED, OR


DIVORCED (write the word)


White


Married


5a If married, widowed, or divorced HUSB (or) WIFE ASEHEATH A. NEWCOMB


6 DATE OF BIRTH (month, day, and year) aug 31857


Years


62


Months 1


Days


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


8 OCCUPATION OF DECEASED


(a) Trade, profession, or


Foreman Petired


(b) General nature of industry, business, or establishment in which employed (or employer) Sardine Packing


9 BIRTHPLACE (city or town)


Eastport


(Statc or country) Me.


10 NAME OF FATHER Igrao!


11 BIRTHPLACE OF FATHER (city or town)


(State or country)


Fastport


Me.


12 MAIDEN NAME OF MOTHER Cannot be learned


13 BIRTHPLACE OF MOTHER (city or town)


(State or countryCannot be learned


14 Edward Harrington


M.D.


(SECONDARY)


, to


.


29


[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 agc. For many occupations a single word or terin on the first line will be sufficient, e. g., Farmer or Planter, Physician, Compos- itor, Architect, Locomotive engineer, Civil engineer, Stationary fireman, etc. But in many cases, especially in industrial employments, it is necessary to know (a) the kind of work and also (b) the nature of the business or industry, and therefore an additional line is provided for the latter statement; it should be used only when needed. As examples: (a) Spinner, (b) Cotton mill; (a) Salesman, (b) Grocery; (a) Foreman, (b) Automobile factory. The ma- terial worked on may form part of the second statement. Never return "Laborer," "Foreman," "Manager," "Dealer," etc., without more precise specification, as Day laborer, Farm laborer, Laborer - Coal mine, etc. Women at home, who are engaged in the duties of the household only (not paid Housekeepers who receive a definite salary), may be entered as Housewife, Housework, or At home, and children, not gainfully employed, as At school or At home. Care should be taken to report spe- cifically the occupations of persons engaged in domestic service for wages, as Servant, Cook, Housemaid, etc. It 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- 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 (discase causing death), 29 Gs .; Broncho- pneumonia (secondary), 10 ds. Never report mere symp- toms or terminal conditions, such as "Asthenia," "Anemia" (merely symptomatic), "Atrophy," "Col- lapse," "Coma," "Convulsions," "Debility" ("Con- genital," "Senile," etc.), "Dropsy," "Exhaustion," "Heart failure," "Hemorrhage," "Inanition," "Maras- mus," "Old age," "Shock," "Uremia," "Weakness," etc., when a definite disease 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, 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 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, ctc.


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.


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


RM R-301


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.


St., ...


.. Ward


Winthrop


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


2 FULL NAME


Wendell


Blankenship


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


(a) Residence.


No.


marion mass


St.,


Ward.


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


Leogth of resideoce in city or town where death occorred


1


years


months


days.


How loog in U. S., if of foreigo birth ?


years


mooths


days


PERSONAL AND STATISTICAL PARTICULARS


3 SEX


Male


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


25


1901


6 DATE OF BIRTH


may


(Month)


"(Day)


( Year)


7 AGE


11


Years


4


Months


10


Days


If STILLBORN, eoter that fact here


If STILLBORN, state period of oterogestatioo


. mos.


If LESS than


1 day ......... hrs.


or ........ min.


app en de citas


8 OCCUPATION OF DECEASED


(a) Trade, profession, or


particular kiod of work.


(b) Geograi oatore of industry,


business, or establishment io


which employed ( or employer )


clerk


(c) Name of employer


9 BIRTHPLACE (City)


marion


( State or country)


mass


10 NAME OF


Henry V. Blankenship


FATHER


11 BIRTHPLACE OF


FATHER (City ) ..


marion


(State or country)


mass


12 MAIDEN NAME


OF MOTHER


Sarah Stetson


13 BIRTHPLACE OF


MOTHER (City)


(State or country)


Fall River


14


Informant


Frank Blankenship


(Address)


marion mass


15


File


Oct 21 1919


(Month) (Day) (Ycaf)


....


REGISTRAR


MEDICAL CERTIFICATE OF DEATH


16 DATE OF DEATH


(Month)


(Day)


(Year)


17


I HEREBY CERTIFY, That I attended deceased from


Bekt. 30


199, to


Oct. 5. 1914.


:


that 1 last saw


I cicalive on


Och. 4.


.. , 19./9 ,


and that death occurred, on the date stated above, at 3 cc.


The CAUSE OF DEATH was as follows :


.. (duration)


. yrs ...


mos ..


8 ds.


CONTRIBUTORY


(SECONDARY)


(duration)


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




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