Town of Winthrop : Record of Deaths 1919-1921, Part 78

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 78

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Former or usual residence

19 PLACE OF BURTAL OR REMOVAL Tome -

DATE OF BURIAL

2/16

191.

ADDRESS

· UNDERTAKER

C.R. Benman

(City or town.)

{If death occurred in a hospital or institution, give its NAME instead of street and number.]

Isabella Kachme, L'ouesten Close

' FULL NAME [If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE

manis Samuel, 8. Close Iturban

Registered No.

PERSONAL AND STATISTICAL PARTICULARS

1 SEX

4 COLOR OR RACE

what

5 SINGLE,

MARRIED,

WIDOWED,

OR DIVORCED

(Write the word)

manuel

· DATE OF BIRTH nov - 10 - 1854 (Month)

(Day)

(Year)

7 AGE

If LESS than 1 day ........ hrs.

650

yrs.

mos

ds.

or ....... min. ?

& OCCUPATION

(a) Trade, profession, or

particular kind of work

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

9 BIRTHPLACE

(State or country)

Budgewali me

10 NAME OF

FATHER

Joseph Bradstreet

WHITE PLAINLT, WITH ONFADING INK - THIS IS A PERMANENT RECORD.

The Commonwealth of Massarhusetts

STANDARD CERTIFICATE OF DEATH

1 PLACE OF DEATH

Ward)

...

Feb. 14, 1920.

STANDARD CERTIFICATE OF DEATH.

Statement of occupation. - Precise statement of occu- pation is very important, so that the relative healthfulness of various pursuits can be known. The question applies to each and every person, irrespective of age. For many occupations a single word or term on the first line will be sufficient, e. g., Farmer or Planter, Physician, Compositor, Architect, Loeo- motive cngincer, Civil engineer, Stationary fircman, etc. But in many cases, especially in industrial employments, it is necessary to know (a) the kind of work and also (b) the nature . of the business or industry, and therefore an additional line is provided for the latter statement; it should be used only when needed. As examples: (a) Spinner, (b) Cotton mill; (a) Sales- man, (b) Grocery; (a) Foreman, (b) Automobile factory. The inaterial worked on may form part of the second statement. Never return "Laborer," "Foreman," "Manager," "Dealer," etc., without more precise specification, as Day laborer, Farm laborer, Laborer - Coal mine, etc. Women at home, who are engaged in the duties of the household only (not paid House- keepers who receive a definite salary), may be entered as Housewife, Housework, or At home, and children, not gain- fully employed, as At school or At home. Care should be taken to report specifically the occupations of persons engaged in domestie service for wages, as Servant, Cook, Housemaid, etc. If the occupation has been changed or given up on account of the DISEASE CAUSING DEATH, state occupation at beginning of illness. If retired from business, that fact may be indicated thus: Farmer (retired, 6 yrs.). For persons who have no occu- pation whatever, write Nonc.

Statement of cause of death. - Name, first, the DIS- EASE CAUSING DEATII (the primary affection with respect to time and causation), using always the same accepted term for the same disease. Examples: Cercbro-spinal fever (the only definite synonym is "Epidemic cerebro-spinal meningitis"); Diphtheria (avoid use of "Croup"); Typhoid fever (never re- port "Typhoid pneumonia"); Lobar pneumonia; Broncho- pneumonia ("Pneumonia," unqualified, is indefinite) ; Tuber-

culosis of lungs, meninges, peritonaeum, etc., Carcinoma, Sar- coma, ete., of ... ............... (name origin: "Caneer" is less definite; avoid use of "Tumor" for malignant neoplasms); Measles; Whooping cough; Chronic valvular heart disease; Chronic interstitial nephritis, etc. The contributory (second- ary or intercurrent) affection nced not be stated unless im- portant. Example: Measles (disease causing death), 29 ds .; Broncho-pneumonia (secondary), 10 ds. Never report mere symptoms or terminal conditions, such as "Asthenia," "An- acmia" (merely symptomatic), "Atrophy," "Collapse," "Coma," "Convulsions," "Debility" ("Congenital," "Senile," etc.), "Dropsy," "Exhaustion," "Heart failure," "Haemorrhage," "Inanition," "Marasmus," "Old age," "Shock," "Uraemia," "Weakness," etc., when a definite discase can be ascertained as the cause. Always qualify all discases resulting from childbirth or miscarriage, as "PUER- PERAL septicaemia," "PUERPERAL peritonitis," etc. State cause for which surgical operation was undertaken.

Cases for the Medical Examiners. - Under the provi- sions of chapter 24 of the Revised Laws deaths under the fol- lowing conditions must be referred to the Medieal Examiners:

1. Deaths following injury or violence, as Burns, Falls, Drowning, Gas poisoning, Suicide, Homicide, etc.

2. Deaths supposedly caused by violence, as Criminal abortion, Poisoning, Starvation, Suffocation, Ex- posure, etc.

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

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

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

The Commonwealth of Massachusetts

STANDARD CERTIFICATE OF DEATH

1 PLACE OF DEATH

metcalf

Hospital

Stekt (Pin) Elicis

St. :

.Ward)

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

? FULL NAME

[If married or divorced woman or widow

give maiden name, also name of husband .!

@RESIDENCE

PERSONAL AND STATISTICAL PARTICULARS

MEDICAL CERTIFICATE OF DEATH

16 DATE OF DEATH

February

(Month)

(Day)

(Year)

17 I HEREBY CERTIFY that I attended deceased from

, 191.

, to

191

that I last saw h

alive on

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

191

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

·+ ...... m.

The CAUSE OF DEATH* was as follows :

stillbom

- valy

(Duration)

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

ds.

Contributory.

(SECONDARY)

(Duration)

yrs.

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

...

ds.

(Signed)

Feb 11

1920 (Address) Withrop Mara

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

18 LENGTH OF RESIDENCE (FOR HOSPITALS, INSTITUTIONS, TRANSIENTS, OR RECENT RESIDENTS).

At placa

of daath.

.. yrs.

.. mos.

ds.

State .....

... yrs.

In the

.......

.. mos.

... ds .....

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

Former or usual residence

19 PLACE OF BURIAL OR REMOVAL

DATE OF BURIAL

718

191.20

......

Filed mch. 1 marjorie DEay

Ceset. REGISTRAR

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

..........

ds.

or ........ min. ?

9 BIRTHPLACE

(State or country)

Winithat Man

10 NAME OF

FATHER

Bernan S. Elicis

11 BIRTHPLACE OF FATHER (State or country) Russa

12 MAIDEN NAME OF MOTHERS Ochet Grubrick

13 BIRTHPLACE

OF MOTHER

(State or country)

Rusza

14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE

(Informant)

B.S. Elias

Suiga

1.6

(Month)

(Day)

182

(Year)

7 AGE Stitthon

3 SEX

male

DATE OF BIRTH

...

& OCCUPATION

(a) Trade, profession, or

particular kind of work

PARENTS

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

(b) Ganaral nature of industry,

business, or establishment

which employed (or employer)

4 COLOR OR RACE

white

5 SINGLE,

MARRIED,

WIDOWED,

OR DIVORCED

(Write the word)

....

Registered No.

......

2 UNDERTAKER

CR. Beni

ADDRESS

E Bartin

M.D.

(Address)

18 Dolphin aus

Wachet

JEb. 16, 1920.

STANDARD CERTIFICATE OF DEATH.

Statement of occupation. - Precise statement of occu- pation is very important, so that the relative healthfulness of various pursuits can be known. The questien applies to eachi and every person, irrespective of age. For many occupations a single word or term on the first line will be sufficient, c. g., Farmer or Planter, Physician, Compositor, Architect, Loco- motive engineer, Civil engineer, Stationary fireman, etc. But in many cases, especially in industrial employments, it is necessary to know (a) the kind of work and also (b) the nature of the business or industry, and therefore an additional line is provided for the latter statement; it should be used only when needed. As examples: (a) Spinner, (b) Cotton mill; (a) Sales- man, (b) Grocery; (a) Foreman, (b) Automobile factory. The material worked on may form part of the second statement. Never return "Laborer," "Foreman," "Manager," "Dealer," etc., without mere precise specification, as Day laborer, Farm laborer, Laborer - Coal mine, etc. Women at home, who are engaged in the duties of the household only (not paid House- keepers who receive a definite salary), may be entered as Housewife, Housework, or At home, and children, net gain- fully employed, as At school or At home. Care should be taken to report specifically 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 faet may be indicated thus: Farmer (retired, 6 yrs.). For persons who have no occu- pation whatever, write None.

Statement of cause of death. - Name, first, the DIS- EASE CAUSING DEATH (the primary affcetion with respect to time and causation), using always the same accepted term for the same disease. Examples: Cerebro-spinal fever (the only definite synonym is "Epidemic cerebro-spinal meningitis"); Diphtheria (avoid use of "Croup"); Typhoid fever (never re- port "Typhoid pneumonia"); Lobar pneumonia; Broncho- pneumonia ("Pneumonia," unqualified, is indefinite); Tuber-

culosis of lungs, meninges, peritonaeum, etc., Carcinoma, Sar- coma, etc., of .... ........ .... (name origin: "Cancer" is less definite; aveid use of "Tumor" for malignant neoplasms) ; Mcasles; Whooping cough; Chronic valvular heart discase; Chronic interstitial nephritis, etc. The contributory (second- ary or intercurrent) affection need net be stated unless im- portant. Example: Measles (disease causing death), 29 ds .; Broncho-pneumonia (secondary), 10 ds. Never report mere sympteins or terminal conditions, such as "Asthenia," "An- acmia" (merely symptomatic), "Atrophy," "Collapse," "Coma," "Convulsions," "Debility" ("Congenital," "Senile," etc.), "Dropsy," "Exhaustien," "Heart failure," "Hacmorrhage," "Inanition," "Marasmus," "Old age," "Shock," "Uracmia," "Weakness," etc., when a definite disease can be ascertained as the cause. Always qualify all discases resulting from childbirth or miscarriage, as "PUER- PERAL septicacmia," "PUERPERAL peritonitis," etc. State cause for which surgical operation was undertaken.

Cases for the Medical Examiners. - Under the provi- sions of chapter 24 of the Revised Laws deaths under the fol- lowing conditions must be referred to the Medical Examiners:

1. Deaths following injury or violence, as Burns, Falls, Drowning, Gas poisoning, Suicide, Homicide, etc.

2. Deaths supposedly caused by violence, as Criminal abortion, Poisoning, Starvation, Suffocation, Ex- posure, etc.

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

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

M R-301

The Commonwealth of Massachusetts

STANDARD CERTIFICATE OF DEATH

OFFICE OF THE SECRETARY DIVISION OF VITAL STATISTICS

1 PLACE OF DEATH

Suffolk

State

Massachusetts

Registered No ..

St ... .. Ward

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

2 FULL NAME

Catherine Coghlan

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

(a) Residence.

No.

188 Woodside Ave.

St.,

Ward.

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

Length of residence in city or town where death occurred

years

months

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

months days

PERSONAL AND STATISTICAL PARTICULARS

4 COLOR OR RACE

Thi

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

5a If married, widowed, or divorced

HUSBAND of

(or) WIFE of

Patrick Coghlan

6 DATE OF BIRTH

Dec

1842

( Month)

(Day)

(Year)

Years

Months 22

Days

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

8 OCCUPATION OF DECEASED

(a) Trade, profession, or

particular kind of work

At Home

(b) General nature ofindustry,

business, or establishment in

which employed ( or employer ).

9 BIRTHPLACE (City)

Idfland

10 NAME OF

FATHER

Cannot be learned

11 BIRTHPLACE OF

Treland

FATHER (City)

(State or country)

12 MAIDEN NAME

OF MOTHER

Cannot be learned

13 BIRTHPLACE OF

MOTHER (City)

Ireland

(State or country)

Informant

Tohn P. Coghlan

(Address)

"modside Ave.

15 a Mch.1.1920.

marjorie team

(Month) (Day) (Year)

asst. REGISTRAR

21 | HEREBY CERTIFY that a satisfactory stan- dard certificate of death was filed with me BEFORE the hurial or transit permit was issued. state maury

Official- .position.

Health Office gerai Feb- 17

Date of

Permit

No ..

'19-XXM.)

MEDICAL CERTIFICATE OF DEATH

16 DATE OF DEATH

(Monthi)

(Day)

(Year)

17 I HEREBY CERTIFY, That I attended deceased from 20

, 19

Jeb 16, 192°,

, to

that I last saw h

M alive on

and that death occurred, on the date stated above, at 10-+ m.

The CAUSE OF DEATH was as follows :

ma of things

mos .....

șs.

.( duration) Sencial anterio Selecció

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 ?

What test confirmed diagnosis ? (Signed) Harry

of ich , M.D.

( Address ).

Date

( Month)

(Day)

(Year)

19 PLACE OF BURIAL, CREMATION, OR REMOVAL

DATE OF BURIAL

Holy Cross

Malden

(Cemetery)

(('ity or town)

2/18/20

20 UNDERTAKER

ADDRESS

Heathrow

. 150,000.

County. ....... 3 SEX Female 7 AGE 77 (c) Name of employer PARENTS 14 instructions and extracts from the laws on back of certificate. should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state CAUSE OF DEATH in plain terms, so that it may be properly classified. Exact statement of OCCUPATION is very important. See N. B. - WRITE PLAINLY, WITH ONFADING BLACK INK -THIS IS A PERMANENT RECORD. Every item of information (State or country)

inthrop

City or Town

BARTON

No ...

188 Woodside Ave.

(Usual place of abode)

... 2 .~

If STILLBORN, enter that fact here

If STILLBORN, state period of aterogestation

mos.

JEb. 16,1920. 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 he known. The question applies to each and every person, irrespective of ago. For many occupations a single word or term on the first line will he sufficient, e. g., Farmer or Plonter, Physician, Compositor, Architect, Locomotive engineer, Civilengineer, Stotionary firemon, 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 he used only when needed. As examples: (a) Spinner, (b) Cotton mill; (a) Salesmon, (b) Grocery; (a) Foreman, (b) Automobile factory. The material worked on may form part of the second statement. Never return "Lahorer," "Foreman," "Manager," "Dealer," etc., without more preciso specification, as Day loborcr, Farm loborer, Laborer - Cool mine, etc. Women at home, who are engaged in the dutics of the house- hold only (not paid Ilousekcepers 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. Carc should bo taken to report spe- cifically the occupations of persons engaged in domestic service for wages, as Servant, Cook, Housemaid, etc. If the occupation has heen 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 discase. Examples: Cere- brospinol fever (tho only definito synonym is "Epidemic cerebrospinal meningitis"); Diphtheria (avoid use of "Croup"); Typhoid fever (never report "Typhoid pneumonia"); Lobor pneumonia; Bronchopneumonia ("Pneumonia," unqualificd, is indefinite); Tuberculosis of lungs, men- inges, peritoneum, etc., Carcinomo, Sarcoma, etc., of ... . (name origin; "Cancer" is less definite; avoid use of "Tumor" for malignant neoplasms); Meusles; Whooping cough; Chronic volvulor heort disease; Chronic interstitial nephritis, etc. The contributory (secondary or inter- current) affection nced not he stated unless important. Example: Measles (disease 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," "Dehility" ("Congenital,""Senilc," etc.), "Dropsy,""Exhaustion,""Heart failure,""Hemorrhage,""Ina- nition," "Marasmus," "Old age," "Shock," "Uremia,""Weakness," etc., when a definite disease can bo ascertaincd as the cause. Always qualify all diseases resulting from childbirth or miscarriage, as "PUER- PERAL septicemio," "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.)

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, erysipolas, 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 tho date of his death. . . . - Revised Laws, Chap. 29, Secs. 10 and 1, as amended by Acts of 1910, Chop. 322.

No undertaker or other person shall bury a human body . . . until he has received a permit from the hoard 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 he 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 certificato 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 Laws, 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 he, 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 Lows, Chap. 24, Sec. 8.

RULES OF PRACTICE

The fulfilment of the purpose of these laws calls for the ohservance of tho following rules of practice:

(1) Attending physicians will certify to such deaths only as those of persons to whom they have given hedside 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 hy recognized disease unrelated to any form of injury, have died without recent medical attendance or whose physician is ahsent 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 peisons), thermal, or electrical agents, and deaths following abortion, hut 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.

M R-301

The Commonwealth of Massachusetts STANDARD CERTIFICATE OF DEATH

OFFICE OF THE SECRETARY DIVISION OF VITAL STATISTICS

1 PLACE OF DEATH

County ....

Winthrop

Suffolk

State

Massachusetts.

Registered No. .

City or Town

BUYTUY

No. 16 Pearl

Ave.

St ............... .. Ward

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

2 FULL NAME

Ann Agnes ...

MCAuliffe

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

(a) Residence. No. 1€

Pearl AvO.

(Usual place of abode,

St.,

Ward.

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

Length of residence in city or fown wbere 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)

702 18

1920

(Year)

(Day)

I HEREBY CERTIFY, That I attended deceased from

June 28

1919

, to

2018

, 19

that I last saw her. alive on

I. P.

Far 18

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

The CAUSE OF DEATH was as follows :

Carcin

about 2 duration)

.. 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 ?

What test confirmed diagnosis ?

(Signed)

, M.D.

(Address) ..

2 antun de estos

Date

( Month)

(Day)

1920

(Year)

19 PLACE OF BURIAL, CREMATION, OR REMOVAL

Holy Cross

Malden

DATE OF BURIAL

(Cemetery)

(City or town)

2/20/ 20 ADDRESS

Filed (Month) (Day) (Year)

asst. REGISTRAR

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. man

Date of Official Healthe Office of permit Heb-19 position.1

Permit

No. 98.

'19-XXM.)

4 COLOR OR RACE

5 SINGLE, MARRIED, WIDOWED, OR

DIVORCED (write the word)

Verried

White

5a If married, widowed, or divorced

AHUSBANDOf

(or) WIFE of

John

6 DATE OF BIRTH

Cannot be Learned

( Month)

(Day)

(Year)

If STILLBORN, enter that fact bere

If STILLBORN, state period of uterogestation.

DS.

If LESS than

1 day, ........ brs.

cr ....... min.

8 OCCUPATION OF DECEASED (a) Trade, profession, or At Home

9 BIRTHPLACE (CitPoughkeepsie (State or country)

10 NAME OF

FATHER

Patrick O' Connell

11 BIRTHPLACE OF

FATHER (City).

Ireland

12 MAIDEN NAME

OF MOTHER

Ann Burgess

13 BIRTHPLACE OF

MOTHER (City)

(State or country)

Ireland

Informant. John Mctulippe

(Address)

15 Pearl Ave.

15 mch. 1, 1920

marjorie DEan.

20 UNDERTAKER

Form finally

. 150,000.

3 SEX Female 7 AGE Years particular kind of work (6) General nature ofindustry, business, or establishment in which employed (or employer) (c) Name of employer PARENTS 14 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 N. B. - WRITE PLAINLY, WITH UNFADING BLACK INK - THIS IS A PERMANENT RECORD. Every item of Information (State or country)

Months

Days

...

JEb. 18,1920. REVISED UNITED STATES STANDARD CERTIFICATE OF DEATH

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Town of Winthrop : Record of Deaths 1919-1921, Part 78

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

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