USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1922-1924 > Part 10
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 | Part 213 | Part 214 | Part 215 | Part 216 | Part 217 | Part 218 | Part 219 | Part 220 | Part 221 | Part 222 | Part 223 | Part 224 | Part 225 | Part 226 | Part 227 | Part 228 | Part 229
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, erysipelas, meningitis, miscar- riage, necrosis, peritonitis, phlebitis, pyemia, septicemia, tetanus.
FROM THE LAWS OF THE COMMONWEALTH OF MASSACHUSETTS GOVERNING THE RETURN OF CERTIFICATES OF DEATH
A physician or registered hospital medical officer shall forthwith, after the death of a person whom he has attended during his lastillness, 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 as re- quired by section one, where same was contraeted, the duration of his last illness, when last seen alive by the physician or officer and the date of his death. . ..- Gen. Laws, Chap. 46, Sec. 9.
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 town where the person died; . . . No such permit shall beissued until there shall have been delivered to such board, agent or clerk ... a satisfactory written statement containing the facts required by law to be returned and recorded, which shall be accompanied, in case of an original interment, by a satisfactory certi- ficate of the attending physician, if any, as required by law, or in lieu thereof a certificate 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, a physi- cian who is a member of the board of health, or employed by it or by the selectmen for the purpose, shall upon application make the certificate required of the attending physician. If death is caused by violence, the medical examiner shall make such certi- ficate. ... The person to whom the permit is so given and the physi- eian certifying the cause of death shall thereafter furnish for registration any other necessary information which ean be obtained as to the deceased, or as to the manner or cause of the death, which the clerk or registrar may require .- Gen. Laws, Chap. 114, Sec. 45.
Medical examiners shall make examination upon the view of the dead bodies of only such persons as are supposed to have died by violenee. - Gen. Laws, Chap. 38, Sec. 6.
. . . He shall in all cases certify to the town clerk or registrar in the place where the deceased died his name and residenee, if known; other- wise a deseription as full as may be, with the cause and manner of death. -Gen. Laws, Chap. 38, Sec. 7.
RULES OF PRACTICE
The fulfilment of the purpose of these laws calls for the observanec 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 & 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 front disease resulting from injury or infection related to occupation, the sudden deaths of persons not disabled by recognized disease, and those of persone found dead.
02
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
BOSTON ( City or town)
1 PLACE OF DEATH
County
.........
Suffolk
State
Massachusetts
Registered No.
2750
(Place of residence)
St.,
Ward
City or Town
(If death occurred in a hospital or institution, give its NAME instead of street and number) .. ,
2 FULL NAME
LIBBIE ROSENBERG
(If in the Army or Navy of the United States, give rank, organization, etc.)
(a) Residence.
State
(Usual place of abode)
MASS.
City or Town
WINTHROP No.
164 PAULINE
St.
Length of resideoce 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
3 SEX
F
4 COLOR OR RACE
W
5 SINGLE, MARRIED, WIDOWED, OR
DIVORCED (write the word)
WID.
5a If married, widowed, or divorced
HUSBAND of
(or) WIFE of
HARRY
6 DATE OF BIRTH (month, day, and year)
7 AGE
82
Years
Months
Days
If LESS than
1 day ......... brs.
or ........ min.
If STILLBORN, enter that fact bere
8 OCCUPATION OF DECEASED
(a) Trade, profession, or
particular kind of work
NONE
(b) Name of employer
.(duration)
mos.
ds.
ARTERIO-SCLEROSIS
9 BIRTHPLACE (city or town).
RUSSIA
CONTRIBUTORY
(SECONDARY)
(duration)
... yrs. .......
mos.
ds.
10 NAME OF FATHER
LOUIS MARCUS
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?
(Signed) ...
FS PARSONS
, 19 22 (Address)
FEB.21
M.D.
19 PLACE OF BURIAL, CREMATION, OR REMOVAL
WOBURN (BETH JOSEPH)
DATE OF BURIAL
FEB. 2 | 19 22
15 Filed.F.E.B.,.2.4., 19 22 Mar. 25, 1922.
Registrar of city or town where death occurred
20 UNDERTAKER
MANUEL STANETSKY
ADDRESS
20,000.
of certificate.
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
PARENTS
11 BIRTHPLACE OF FATHER (city or town)
(State or country)
RUSSIA
12 MAIDEN NAME OF MOTHERESTHER
13 BIRTHPLACE OF MOTHER (city or town)
(State or country)
RUSSTA
14 S. ROBERTS
Informant
(Address)
Registrar of city or town where deceased resided
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH (month, day, and year)
FEB.20
19 22
17
I HEREBY CERTIFY, That I attended deceased from
FEB.19
1922
to
FEB.20
19 .. 22 ..... ,
that I last saw h.
IM.
FEB.20
19 .. 22 .... ,
and that death occurred, on the date stated above, at
......
9.40 P m. The CAUSE OF DEATH* was as follows :
-
CERE. HEMORRHAGE
?
1
yrs ...
(State or country)
Registered No.
1692
(Place of death)
Boston
No.
ALVISEL DEV UNITED SIAILO DIA
STANDARD CERTIFICATE OF DEATH
[Approved by U. S. Census and American Public Health Association]
FROM THE LAWS OF THE
CUMMUNYCALIN Vr
GOVERNING THE
RETURN OF CERTIFICATES OF DEATH
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 singlo word or term on the first line will he 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 "Lahorer," "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 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 servico for wages, as Servant, Cook, Housemaid, ete. 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 Lo 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 "Epidemio 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, ete., Carcinoma, Sarcoma, etc., of ... . (name origin; "Cancer" is less definite; avoid use of "Tumor" for malignant neoplasms); Measles; Whooping cough; Chronic valvular heart disease; Chronic interstitial nephritis, ete. The contributory (secondary or inter- current) affection need not be stated unless important. Example: Measles (disease causing death), 29 ds .; Bronchopneumonia (secondary), 10 ds. Never report mere symptoms or terminal conditions, such as "Asthenia," "Anemia" (merely sym tomatic), "Atrophy," "Col- lapse," "Coma,""Convulsions," "Lebility" ("Congenital,""Senile," etc.), "Dropsy,""Exhaustion,""Heart failure,""Hemorrhage,""Ina- nition," "Marasmus," "Old age," "Shock," "Uremia,""Weakness," ete., when a definite disease ean 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- mittee on Nomenclature of the American Medical Association.)
Bronchopneumonia: If primary cause, write the word "pri- mary" ; if secondary, give primary cause.
Certificates will be returned for additional information which give any of the following diseases, without explanation, as the sole cause of death: Abortion, cellulitis, childbirth, convulsions, hemorrhage, gangrene, gastritis, erysipelas, meningitis, miscar- riage, necrosis, peritonitis, phlebitis, pyemia, septicemia, tetanus.
A physician or registered hospital medical officer 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 tho deceased, his supposed age, the discase of which he died, defined as re- quired by section one, where same was contracted, the duration of his last illness, when last seen alive by the physician or officer and the date of his death. . ..- Gen. Laws, Chap. 46, Sec. 9.
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 tho town where 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 containing the facts required by law to be returned and recorded, which shall be accompanied, in case of an original interment, by a satisfactory certi- ficate of the attending physician, if any, as required by law, or in licu thercof a certificate 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, a physi- cian who is a member of the board of health, or employed by it or by the selectmen for the purpose, shall upon application make the certificate required of the attending physician. If death is caused by violence, the medical examiner shall make such certi- ficate .... The person to whom the permit is so given and the physi- cian certifying the cause of death shall thereafter furnish for registration any other necessary information which can he obtained as to the deceased, or as to the manner or cause of the death, which the elerk or registrar may require. - Gen. Laws, Chap. 114, Sec. 45.
Medical examiners shall make examination upon the view of the dead bodies of only such persons as are supposed to have died by violence. - Gen. Laws, Chap. 38, Sec. 6.
. . . He shall in all cases certify to the town clerk or registrar in tho place where the deceased died his name and residence, if known; other- wise a description as full as may he, with the cause and manner of death. - Gen. Laws, Chap. 38, Sec. 7.
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 attendanco 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 direetly 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 persona found dead.
The Commonwealth of Massachusetts
CERTIFICATE OF DEATH OF NON-RESIDENT
(City or town)
1 PLACE OF DEATH
Registered No.
(Place of death)
City or Town
Springfield
No.
45 North Main
(Place ofresidence)
Sty
Ward
(If death occurred in a hospital or institution, give its NAME instead of street and number)
2 FULL NAME
John W. Swint
Mass.
City or Town
Winthron
No.
81 Otis
St.
(a) Residence.
State
(Usual place of abode)
Length of resideoce io city or town where death occurred
years
2
mooths
18 days
How loog io 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 February 2119
22
17
I HEREBY CERTIFY, That I attended deceased from
Dec.
3
192-1 ..... , to.
Feb ....... 21-
., 19
22
that I last saw h
im alive on
Feb. 21
19.
22
and that death occurred, on the date stated above, at
2 P.
.. 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.)
Angina Pectoris
(duration)
10
yrs ..
mos ....
ds.
9 BIRTHPLACE (city or town).
Syracuse
(State or country)
New York
10 NAME OF FATHER
John W. Swint
11 BIRTHPLACE OF FATHER (city or town) Worms.
(State or country)
Germany
12 MAIDEN NAME OF MOTHER Margaret Matzen-
Kuşsel
bacher
13 BIRTHPLACE OF MOTHER (city of town).
(State or country)
Germany
Feb
22 1922 Address)
45 No. Main
Informant
Dr. S. A. Lewis
Mass.
( Address)
45 No. Main St Springfiel
Filed Feb 24 .19 22 clifforde with
Registrar of city or town wbere death occurred
Filed Mar 13, 1923
Registrar of city or towo where deceased resided
18 Where was disease contracted- -
if not at place of death ?
Did an operation precede death ?.
No
Date of
Was there an autopsy?
No
What test confirmed diagnosis?
Clinical
(Signed)
Seth A. Lewis
.M.D.
19 PLACE OF BURIAL, CREMATION, OR REMOVAL
Woodlawn,
Everett
DATE OF BURIAL
Feb 24 19
22
20 UNDERTAKER
Cheney D. Washburn
ADDRESS
Springfield
Mass.
3 SEX
Male
7 AGE
70
(a) Trade, professioo, or
PARENTS
14
15
carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state CAUSE OF DEATH in plain terms,
80 that it may be properly classified. Exact statoment of OCCUPATION is very important. See instructions on back
of certificate.
N. B. - WRITE PLAINLY, WITH UNFADING INA - THIS IS A PERMANENT NEGUND. Every item of information should be
(b) General oatore of industry,
business, or establishment io
which employed (or employer)
(c) Name of employer
4 COLOR OR RACE
White
5 SINGLE, MARRIED, WIDOWED, OR
DIVORCED (write the word)
Married
5a If married, widowed, or divorced
HUSBAND of
WHs - Delia Richardson
6 DATE OF BIRTH (month, day, and year) February 2 1852
Years
Months
Days
--
19
If LESS than
1 day, ........ brs.
or ....... mio.
If STILLBORN, eoter that fact bere
8 OCCUPATION OF DECEASED
particular kiod of work
Baker - Retired
CONTRIBUTORY
(SECONDARY)
(duration)
.yrs.
mos.
ds.
County
Hampden
State
Mass.
Registered No.
27
(If in the Army or Navy 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 term on the first line will be sufficient, e. g., Farmer or Planter, Physician, Compos- itor, Architcet, Locomotive engincer, 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, etc. Women at home, who are engaged in the duties of tlie 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 domestie service for wages, as Servant, Cook, Housemaid, etc. If the occupation has been changed or given up on account of the DISEASE CAUSING DEATH, state occupation at beginning of illness. If retired from business, that fact may be indi- 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 saine disease. Examples: Cerebrospinal fever (the only definite synonyın is "Epidemic eerebrospinal 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- 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, ete. 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 symnp- toms or terminal conditions, such as " Astlicnia," "Anemia" (merely symptomatie), "Atrophy," "Col- lapse," "Coma," "Convulsions," "Debility" ("Con- genital," "Senile," ete.), "Dropsy," "Exhaustion," "Heart failure," "Hemorrhage," "Inanition," "Maras- inus," "Old age," "Shock," "Uremia," "Weakness," ete., when a definite discase ean be ascertained as the cause. Always qualify all diseases resulting from ehild- birthi or miscarriage, as "PUERPERAL septicemia," "PUER- PERAL peritonitis," ete. 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 sueli, 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 licad of "Contributory." (Recommendations on statement of eause 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, ete.
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, ete. .
4. Deaths under eireumstanecs unknown, as A person found dead, etc.
ADDITIONAL SPACE
FOR FURTHIER STATEMENTS BY PHYSICIAN.
R$ 303. 6-'18. 50,000.
The Commonwealth of Massachusetts
BOARD OF HEALTH PHYSICIAN'S CERTIFICATE OF DEATH
OFFICE OF THE SECRETARY DIVISION OF VITAL STATISTICS
To be used only in case there is no attending physician or if for sufficient reason the attending physician's certificate cannot 1 PLACE OF DEATH be obtained early enough for the purpose of granting a burial permit, as provided by Revised Laws, Chapter 78, Section 38.
County
Suffolk
State
mass
Registered No. 22
City
Winthrop
No.
St.,
Ward
(1) death occurred in a hospital or institution, give its NAME instead of street and number) -
2 FULL NAME
Sollte Weight
30 Temple are W intrat
(If in the Army of Xavy of the United States, give rank, organization, etc.)
(a) Residence.
No ..
(Usual place of abode)
Length of residence io city or town where death occurred
years
months
8
days
How loog in U. S., if of foreign hirth? years
mooths
days
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
C
4 COLOR OR RACE
5 SINGLE, MARRIED, WIDOWED, OR
DIVORCED (write the word)
Widowed
5a If married, widowed, or divorced
HUSBAND of
(or) WIFE of
charles
6 DATE OF BIRTH (month, day, and year)
June 3.1858
7 AGE 63 Years
Months 19) Days
If LESS than
1 day, ........ hrs.
or ........ mio.
8 OCCUPATION OF DECEASED
Home
(a) Trade, profession, or
particular kiod of work
(h) Geoeral nature of industry, business, or establishment in which employed (or employer) (c) Name of employer
9 BIRTHPLACE (city or town) ...
London England
(State or country)
10 NAME OF FATHER Unknown
11 BIRTHPLACE OF FATHER (city or town;
(State or country)
11
12 MAIDEN NAME OF MOTHER "
13 BIRTHPLACE OF MOTHER (city or town)
(State or country)
14 Eugene f Campbell
19 PLACE OF BURIAL, CREMATION, OR REMOVAL
Masscrematory
DATE OF BURIAL
Feb 24 1922
ADDRESS
20 UNDERTAKER
& SWaterman & ou A Boston
2123:25 995
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,
of certificate.
15
Filed.
Feb. 23. 1922
(Month) (Day) (Year)
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
(Month)
22
1942
(Day)
(Year)
17 I HEREBY CERTIFY, That I have ascertained the nature of the disease from which the person above-named died, and that the CAUSE OF DEATH* was as follows : *State the DISEASE CAUSING DEATH. (See reverse side for additional space and instructions.)
Carmin
.
Brunts and
(duration)
15
+
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?
yes
Date of about 15 your
ago .
Was there an autopsy?
no
What test confirmed diagnosis ?.
Payment Blanken
M.D.
(Signed)
(Address)
W meting Brands of Health
Date.
(Month)
(Day)
I nau medical Exammen
19 22
( Year)
Informant
(Address)
PARENTS
If STILLBORN, eoter that fact here
Ward.
(If non-resident give city or town and State)
tel. 22. 17 EXTRACTS
FROM THE LAWS OF THE COMMONWEALTH OF MASSACHUSETTS
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.