Town of Winthrop : Record of Deaths 1919-1921, Part 55

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 55


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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mos ......


.ds.


24 Gerdlestore Rd.


Did an operation precede death? ele


Date of.


Sept. 20.


Was there an autopsy ?


What test confirmed diagnosis ?


Clinical.


(Signed)


William le Porter


, M.D.


(Address).


5


1914,


(Month)


(Day)


(Year)


DATE OF BURIAL


1919


(Cemetery)


(City or town)


20 UNDERTAKER


g. S. Waterman + Sove


ADDRESS


2326 Washington


St


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


Samo


Official position


Henkel Offices


Date of issoe of permit .. 15


Permit Na


'19. 150,000. -7- 19-XXA1.)


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


PARENTS


mano.


Date


19 PLACE OF BURIAL, CREMATION, OR REMOVAL


Evergreen


marion muss


5


18 Where was disease contracted


if not at place of death ?


FOR -WHAT?


General Peritonitis


5.


1919.


( Usual place of abode)


.No ....


metcalf Hospital


City or Town


BOSTON


REVISED UNITED STATES STANDARD CERTIFICATE OF DEATH


[Approved by U. S. Census and American Public llealth 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, irrespectivo of age. For many occupations a single word or term on tho first line will be sufficient, e. g., Former or Plontcr, Physicion, Compositor, Architect, Locomotive engineer, Civilengineer, Stotionory firemon, etc. But in many cases, especially in industrial employments, it is necessary to know (o) 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: (0) Spinner, (b) Cotton mill; (o) Solcsmon, (b) Grocery; (o) 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 loborer, Loborer - Cool mine, ete. Women at home, who are engaged in the duties of the house- hold only (not paid Housekeepers who receive a definite salary), may be ontered as Housewife, Ilouscwork, 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 servico for wages, as Servont, Cook, Houscmoid, 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: Former (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: Cere- brospinol fever (the only definite synonym is "Epidemie cerebrospinal meningitis"); Diphtherio (avoid use of "Croup"); Typhoid fever (never report "Typhoid pneumonia"); Lobor pneumonio; Bronchopneumonio ("l'neumonia," 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 volvulor heart discuse; Chronic interstitiol nephritis, etc. The contributory (secondary or inter- current) affection need not bo stated unless important. Example: Meosles (disease causing death), 29 ds .; Bronchopneumonia (secondary), 10 ds. Never report mero symptoms or terminal conditions, such as " Asthenia," "Anemia" (merely symptomatic), "Atrophy," "Col- lapse,""Coma,""Convulsions,""Debility" ("Congenital,""Senile," etc.), "Dropsy,""Exhaustion,""Heart failure,""Hemorrhage,""Ina- nition," "Marasmus," "Old age," "Shock," "Urcmia,""Weakness," etc., when a definite disease can be 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 As"" .ation.)


Bronchopneumonla: If primary cause, write ' > word "pri- mary " ; If secondary, glve 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 deceased, furnislı for registration a standard certificate of death, stating to the best of his knowledgo and belief the name of the deceased, his supposed age, the discase 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 Lows, Chop. 29, Secs. 10 ond 1, os omended 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 city or town in which the person dicd; . . . 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, hls certificate cannot be obtained early enough for the purpose, or is insufficient, the chairman of the board of health, if a physician, or any physiclan 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 cause of the death, which the clerk or registrar may require. - Revised Lows, Chop. 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 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. - Reviscd Lows, 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


CERTIFICATE OF DEATH OF NON-RESIDENT ..... (City or town)


Chelsea


County


.......................


Suffolk


State


MASS.


Registered No.


647


(Place of death)


City or Town


Chelsea


No.


Frost Hospital


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


2 FULL NAME


Mary A .Wyman


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


City or Town


Winthrop


No


16 Willow AV.


.St.


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


MEDICAL CERTIFICATE OF DEATH


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


cet . 10


19 19


17


I HEREBY CERTIFY, That I attended deceased from


Jn17.25


19 ... 0, to


Oct.


10


19


19


that I last saw h ........ @.Talive on


Oct . 10


19


19


and that death occurred, on the date stated above, at .... 5.15 j.m.


If LESS than


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.)


Malignant disease of large intes- tire


indef.


.... (duration)


.. yrs ................. mos.


ds.


CONTRIBUTORY


(SECONDARY)


(duration)


.yrs.


........ mos.


......


ds.


18 Where was disease contracted,;


if not at place of death?


Willow Av. winthrop


Did an operation precede death? Yes Date of Aug. 26119


Was there an autopsy?


NO


What test confirmed diagnosis? Clinical


(Signed)


William J.Porter


M.D.


10-1.0 ]( Address)


Winthro


19 PLACE OF BURIAL, CREMATION, OR REMOVAL


forrest Hills


DATE OF BURIAL


Oct. 121919


15


FiledOct ........ 10 19 19


Registrar of city or town where death occurred


Oct. 15


Filed.


1919


intatie Churchill


....


ass Registrar of city or town where deceased resided


N. B .- WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD. Every item of information should be 1


carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state CAUSE OF DEATH in plain terms, If STILLBORN, enter that fact here of certificate.


1 PLACE OF DEATH


(a) Residence.


State


Nass.


(Usual place of abode)


3 SEX


4 COLOR OR RACE


White


Female


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


1857


7 AGE


Years


Months


Days


62


-


-


- -


8 OCCUPATION OF DECEASED


(a) Trade, profession, or


it Home


particular kind of work


(b) General nature of industry,


business, or establishment in


which employed (or employer)


(c) Name of employer


PARENTS


14


Informant


w. Stanley Maman


so that it may be properly classified. Exact statoment of OCCUPATION is very important. See instructions on back


(State or country)


Less.


5 SINGLE, MARRIED, WIDOWED, OR


DIVORCED (write the word)


Married


5a If married, widowed, or divorced


HUSBAND of


(or) WIFE of


Stanley C. Wyman


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


or ....... min.


9 BIRTHPLACE (city or town)


Charlestown


10 NAME OF FATHER


James F.Hastings


11 BIRTHPLACE OF FATHER (city or town)


(State or country)


unknown


12 MAIDEN NAME OF MOTHER


Mar Littlefield


13 BIRTHPLACE OF MOTHER (city or town) Somerville (State or country) Mass.


(Address)


lo Lill o. Jv. , Winthrop


20 UNDERTAKER Chas. R. Benniden


ADDRESS


147 Winthrop


st.


Registered No. (Place of residence) St., Ward


......


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 healthifulness 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 ou 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 ina- 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, etc. Women at home, who are engaged in the duties of the household only (not paid Housekeepers wlio 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 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 Nonc.


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- fied, is indefinite); 'Tuberculosis of lungs, meninges, peri- loncum, 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 Gs .; Broncho- pneumonia (secondary), 10 ds. Never report mere symp- toms or terminal conditions, such as "Asthenia," "Anemia" (merely symptomatic), "Atrophy," "Col- lapse," "Comna," "Convulsions,"" "Debility" ("Con-


genital," "Senile," etc.), "Dropsy," "Exhaustion," "Heart failure," "Hemorrhage," "Inanition," "Maras- Inus," "Old age," "Shock," "Uremnia," "Weakness," ete., 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 suchi, 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 (c. g., sepsis, tetanus) may be stated


under the head of "Contributory." (Recommendations on statement of cause of death approved by Committee on Nomenclature of the American Medical Association.)


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, Gus poisoning, Suicide, Homicide, etc.


2. Deaths supposedly caused by violence, as Criminal abortion, Poisoning, Starvation, Suffocation, Exposure, etc.


3. Sudden deaths of persons not disabled by recognized disease, as A death upon the street, or one supposed to be duc lo Alcoholism, etc.


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


ADDITIONAL SPACE FOR FURTHER STATEMENTS BY


PHYSICIAN.


-


R 303. 6-'18. 50,000.


The Commamuralth of Massachusetts STANDARD CERTIFICATE OF DEATH


(City or town)


1 PLACE OF DEATH


County.


Suffolk


......


State


Mark


Registered No.


.or .......


St.,.


... Ward


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


many B. Toall


2 FULL NAME


(If Vi the Army Navy of the United States, gire rank, organization, etc.)


(a) Residence.


No. IS Eenwoodvz


St.,


...... Ward.


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


days


PERSONAL AND STATISTICAL PARTICULARS


4 COLOR OR RACE


w


5 SINGLE, MARRIED, WIDOWED, OR


DIVORCED (write the word)


undourd


5a If married, widowed, or divorced


HUSBAND of


(or) WIFE of


Samuel Colt


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


7 AGE 86 Years


Months


Days


3


If LESS than


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


or ........ min.


8 OCCUPATION OF DECEASED


athome


(a) Trade, profession, or


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


9 BIRTHPLACE (city or town).


no. Ireland


(State or country)


10 NAME OF FATHER R andrew Breaky


11 BIRTHPLACE OF FATHER (city or town)


(State or country)


No, Ireland


12 MAIDEN NAME OF MOTHER Cannot ter le ine


13 BIRTHPLACE OF MOTHER (city or town).


(State or country)


moreland


14 Mas. Nur Selcher


(Address)


15


Filed. Oct. 21, 1919.


REGISTRAR


MEDICAL CERTIFICATE OF DEATH


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


Oct 10"


1919


17


I HEREBY CERTIFY, That I attended deceased from


June 1


1918


, to.


Oct-10"


1914


that I last saw


alive on


Oct 10m


1919


and that death occurred, on the date stated above, at 130 P m. The CAUSE OF DEATH* was as follows : Senility


hypertrophy+ delala tion of heart


. (duration)


3


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


.mos.


ds.


CONTRIBUTORY


Uremia


(SECONDARY)


(duration)


.. yrs ......


6 mos. -


ds.


-


-


if not at place of death ?


Did an operation precede death ?


110


Date of.


Was there an autopsy ?..


100


What test confirmed diagnosis ?


2000me


(Signed)


Horace Soule


Caf/ 1919 (Address)


Wirallerop, 1021


M.D.


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


19 PLACE OF BURIAL, CREMATION, OR REMOVAL


Charlottetown


MORE, J.


DATE OF BURIAL 10-15 1919


20 UNDERTAKER


M.C. Skaggs


ADDRESS


Wielhops


N. B .- WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD. Every item of information should be


Township


City


3 SEX


PARENTS


Informant


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


particular kind of work


of certificate.


or Village No 15 Elmwood Luz.


(Usual place of abode)


Length of residence in city or fewa wbere death occurred


14


/mooths


days.


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


years


months


18 Where was disease contracted


REVISED UNITED STATES SIANUR


[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 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," "Dcaler," etc., without more precise specification, as Day laborer, Farm laborer, Laborer - Coal mine, ete. Women at home, who are engaged in the duties of the household only (not paid Housekeepers who receive a definite salary), may be entered as Housewife, Housework, or At home, and children, not gainfully employed, as At school or At home. Care should be taken to report spe- cifically the occupations of persons engaged in domestic service for wages, as Servant, Cook, Housemaid, etc. If the occupation has been changed or given up on account of the DISEASE CAUSING DEATH, state occupation at beginning of illness. If retired from business, that fact may be indi- eated 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, meninges, peri- toncum, etc., Carcinoma, Sarcoma, etc., of.


(name origin; "Cancer" is less definite; avoid use of "Tuunor" 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: Mcasles (disease causing death), 29 ds .; Broncho- pneumonia (secondary), 10 ds. Never report mere symp- toms or terminal conditions, such as "Asthenia," "Anemia" (merely symptomatic), " Atrophy," "Col- lapse," "Coma," ""Convulsions," "Debility" (“ Con- genital," "Senile," etc.), "Dropsy," "Exhaustion," "Heart failure," "Hemorrhage," "Inanition," "Maras- mus," "Old age," "Shock," "Uremia," "Weakness," etc., when a definite disease can be ascertained as the cause. Always qualify all diseases resulting from child- birth or miscarriage, as "PUERPERAL septicemia," "PUER- PERAL peritonitis," etc. State cause for which surgical operation was undertaken. For VIOLENT DEATHS STATE MEANS OF INJURY and qualify as ACCIDENTAL, SUICIDAL, or HOMICIDAL, or as probably such, if impossible to de- termine definitely. Examples: Accidental drowning; Struck by railway train - accident; Revolver wound of head - homicide; Poisoned by carbolic acid - probably suicide. The nature of the injury, as fracture of skull, and consequences (e. g., sepsis, tetanus) may be stated


under the niead of


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 street, or one supposed to be due to Alcoholism, etc.


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


ADDITIONAL SPACE


FOR FURTHER STATEMENTS BY PHYSICIAN.


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


The Commonwealth of Massachusetts STANDARD CERTIFICATE OF DEATH


(City or town)


1 PLACE OF DEATH


County.


Township


or Village No 265 Pleasant


St.,


.Ward


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


Bernard


moody


2 FULL NAME


(If m the Army or Nury orthe United States give runk; organization, etc.)


St., ...


.Ward.


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


Length of residence in city or town where death occurred


3 8 years


months


days.


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


years


months


days


PERSONAL AND STATISTICAL PARTICULARS


3 SEX


4 COLOR OR RACE


finale Schote


5 SINGLE, MARRIED, WIDOWED, OR


DIVORCED (write the word)


Widow


5a If married, widowed, or divorced


HUSBAND of


(or) WIFE of


of John r. monday


6 DATE OF BIRTH (month, day, and year )19-1850


7 AGE Years 68


Months


11


Days


2.5-


8 OCCUPATION OF DECEASED


(a) Trade. profession, or


particular kind of work


Ut +forme


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


9 BIRTHPLACE (city or town)


Portland


(State or country) me


10 NAME OF FATHER Charles J. Hurrely


11 BIRTHPLACE OF FATHER (city or town) Portland (State or country)




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