Town of Winthrop : Record of Deaths 1928-1930, Part 109

Author: Winthrop (Mass.)
Publication date: 1928
Publisher:
Number of Pages: 1296

USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1928-1930 > Part 109

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STATE OF COLORADO Bureau of Vital Statistics Certificate of Death

1 PLACE OF DEATH

County.

El Paso

Town.

Registration District No ........

Registered No.

or City

Colo Spgs.

No.

Glockner ... San.

St.,

Ward

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

2 FULL NAMelga V. Bostrom

(a) Residence. No.

Boston Mass

(Usual place of abode)

St ..

Ward.

(If nonresident give city or town and State)

(b) Length of residence in city or town where death occurred 1 yrs. 7 mos.

ds.

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

yrs.

mos.

ds.

PERSONAL AND STATISTICAL PARTICULARS

3 SEX

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

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

Oct. 12, 1904

7 AGE

Years

Days

IF LESS than

1 day, .

__ hrs.

or _______ min.

8 OCCUPATION OF DECEASED (a) Trade, profession, or particular kind of work Stenographer

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

9 BIRTHPLACE (city or town).

(State or country)

Mass.

18 Where was disease contracted

if not at place of death ?.

Mass.

Did an operation precede death ?. 1Q

Was there an autopsy ?.

What test confirmed diagnosis ?.

Sputum oxam

(Signed)

5.00. Scharfer

M. D.

(Address)

Colo Spgs.

*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 addi-

tional space.)

19 PLACE OF BURIAL, CREMATION,

OR REMOVAL

Boston, Mass

DATE OF BURIAL 8/13-2919

ADDRESS

20 UNDERTAKER

Swan's Funeral Home

Colo.Spgs

PERMIT OF REGISTRAR OF VITAL STATISTICS

This Permit with above Certificate must be presented to Initial Baggage Agent and delivered with body at destination.

Permission is hereby granted to remove to.

Boston, Mass.

the body

of Olga V .Bostrom

above described, the cause of death being a

communicable disease and said body being certified to as having been prepared in accordance with the Rule.3.

of the Transportation Rules by an embalmer holding License No.

494

Ruth Bostrom

(Name of person who is authorized to accompany the body) By

(Sub. Registrar)

.. Dist.

No ..

Detach above portion at this perforation and hand to passenger in charge, to be delivered to the undertaker at destination.

COLORADO STATE BUREAU OF VITAL STATISTICS

(Always write with ink)

This Certificate with the Paster below, after being properly filled out and signed, must be detached and securely tacked on the outside box.

UNDERTAKER'S CERTIFICATE

I (or we) hereby certify that the accompanying dead body of Olga V ... Bostrom

to be transported to the City of.

Boston

State of Mass ..

has been prepared for transportation by an embalmer holding License No. 494 in conformity with Rule No ... 3

Shipping Undertaker

Swans Funeral Home

(Firm Name)

Address.

Colo. Spgs. Colo

PASTER

The Railroad or other Transportation Agent must enter hereon a description of the Ticket held by the passenger in charge of the corpse, the exact route, and VIA WHAT JUNCTIONAL POINTS it reads. Special Instructions. A burial case containing a corpse must not be received for transportation unless the person in charge presents a permit from the local Registrar, and an undertaker's certificate that the body has been prepared for shipment in accord- ance with the Laws of the State, nor will it be received even then if any fluid or offensive odors are escaping from the case.

Date 19

From .. Colorado, to ..

State of_

No. of Escort's Ticket.

.No. of Corpse Ticket

Form No. of Escort's Ticket.

Form No. of Corpse Ticket

Via To

Via

Name of Passenger in Charge.

_Place of Residence.

Signed

16 DATE OF DEATH (month, day and year)

August 13, 1929

I HEREBY CERTIFY, That I attended deceased from

Jana .10

19.28 to.

July.1.3

19.

1929

that I last saw her

alive on

July 12

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

4 A

The CAUSE of DEATH* was as follows: Pulmonary Tuberculosis

(duration) _2 ____ yrs.

nLos.

ds.

CONTRIBUTORY

(Secondary)

Laryngeal Tuberculosis.

(duration)

___ yrs.

-mos.

10 NAME OF FATHER

Olaf Bostrom

Il BIRTHPLACE OF FATHER

(City or town)

(State or country)

PARENTS

12 MAIDEN NAME

OF MOTHER

Olga Lundstedt

13 BIRTHPLACE OF MOTHER

(City or town)

(State or country)

Sweden

Informant.

Ruth Bostrom

(Address) Boston, Mass

15 Plea 8 73 29

Registrar.

of the official certificate filed at place of denth

bible

¿Approved by U. S. Census and Amortads p ... it

Revised United States Standard Certificate of Death

EXTRACTS

COPY

Months

MEDICAL CERTIFICATE OF DEATH

Female

File No ....

THE BRADFORD-ROBINSON PTO. CO., DENVER

August 13

19.

( Registrar's Name)

Date of.

Pweden

RM R-301

DIVISION OF VITAL STATISTICS

The Commonwealth of Massachusetts STANDARD CERTIFICATE OF DEATH

1 PLACE OF DEATH

County

Suffolk

State .Kass

Registered No

119

City or Town

Winthrop

No.

20 Enfield Rd.

St.,

Ward

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

2 FULL NAME

Florence Tallace

(If U. S. War Veteran, specify WAR)

(a) Residence.

No.

20 Enfield Rd.

St.,

Ward,

(Usual place of abode)

Length of residence in city or town where death occurred

yrs.

mos.

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

yrs.

mos.

days.

PERSONAL AND STATISTICAL PARTICULARS

MEDICAL CERTIFICATE OF DEATH

15 DATE OF DEATH

aug

1227

(Month)

(Day)

( Year)

16 I HEREBY CERTIFY, That I attended deceased from.

... , to

that I last saw h

alive on

. 19

and that death occurred, on the date stated above, atulup > 0.5 The CAUSE OF DEATH was as follows: (State fully)

arquia Pertonie

(duration)

yrs.

mos ..

ds.

CONTRIBUTORY

(Secondary)

(duration)

.yrs .. .

...

mos ..

ds.

17 Where was disease contracted

if not at place of death

Did an operation precede death

For what.

Date of operation

Was there an autopsy

What test confirmed diagnosis.

(Signed) Queelte E. Coli.

. M. D.

(Address)

Date .

18 PLACE OF BURIAL, CREMATION, OR REMOVAL

DATE OF BURIAL Oak RidgeSpringfield Ill (Cemetery) (City or town)

8/19/29

14 Filed 11las1,1929 (Month) (Day) (Year) /

REGISTRAR

19 UNDERTAKER Colm

ADDRESS/ HO Maly Watch

20 I HEREBY CERTIFY that a satisfactory stand- ard certificate of death was filed with me Official BEFORE the burial or transit permit was issued I.D. Children position

Date of

Health officers issue 8/16/29 Permit No .. 16/19

4.8

200M 7-'28 No. 2787-c

. 3 SEX Female 6 AGE Years (State or country) 9 NAME OF FATHER PARENTS 13 CAUSE OF DEATH in plain terms, so that it may be properly classified. Exact statement of OCCUPATION Įzurofftation should be carefully supplied. Auru Should be stated DAAVILI. FHIDIVIAND Should State 59 is very important. See instructions and extracts from the laws on back of certificate.

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

Months

Days

IF LESS than

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

07 .......... min.

IF STILLBORN, enter that fact here

7 OCCUPATION OF DECEASED

(a) Trade, profession, or

particular kind of work

At Home

(b) Name of employer

8 BIRTHPLACE (City)

Springfield

I11

Dr.George W.Wallace

10 BIRTHPLACE OF

FATHER (City)

Columbia Co.

(State or country) Ohio

11 MAIDEN NAME

OF MOTHER

Eliza Alvey

12 BIRTHPLACE OF MOTHER (City) (State or country)

Springfield Ohio

Informant Clara Wallace

( Address) 20 Enfield Rd/

(City or town)

(If non-resident, give city or town and state)

aug. 15. 1929.

Revised United States Standard Certificate of Death (Approved by U. S. Census and American Public Health Ass'n.)

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, Civil engineer, Stationary preman, etc. But in many cases, es- pecially 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 ex- amples : (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 re- turn "Laborer," "Foreman," "Manager," "Dealer," etc., with- out 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, House- work, or At home, and children, not gainfully 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 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 Caus- ing 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 meningitis") ; Diphtheria (avoid use of "Croup") ; Typhoid fever (never report "Typhoid pneumonia") ; Lobar pneumonia; Bronchopneumonia ("Pneu- monia," 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 intercurrent) 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 "Asthe- nia," "Anemia" (merely symptomatic), "Atrophy," "Collapse," "'Coma," "Convulsions." "Debility" " "Exhaustion," "Heart failure," "Hemorrhage," ("Congenital," "Senile," etc.), "Dropsy,"

"Inanition,". "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 "PUERPERAL septicemia," "PUERPERAL peri- tonitis," etc.

State cause for which surgical operation was undertaken.

(Recommendations on statement of cause of death approved by Committee on Nomenclature of the American Medical Associa- tion.)

Bronchopneumonia: If primary cause, write the word "primary"; if secondary, give primary cause.

Certificates will be returned for additional information which give any of the following diseases, without explanation, as the xole cause of death: Abortion, cellulitis, childbirth, convulsions, hemorrhage, gangrene, gastritis, erysipelas, meningitis, mis- carriage, necrosis, peritonitis, phlebitis, pyemia, septicemia, tetanus.

EXTRACTS

FROM THE LAWS OF THE

COMMONWEALTH OF MASSACHUSETTS

GOVERNING THE

RETURN OF CERTIFICATES OF DEATH

A physician or registered hospital medical officer shall forth- with, 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 de- ceased, 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 required by section one, where same was contracted, the dura- tion 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 or otherwise dispose of a human body in a town, or remove therefrom a human body which has not been buried, until he has received a permit from the board of health or its agent appointed to issue such permits, or if there is no such board, from the clerk of the town where the person died; and no undertaker or other person shall ex- hume a human body and remove it from a town, or from one cemetery to another, until he has received a permit from the board of health or its agent aforesaid or from the clerk of the town where the body is buried. No such permit shall be issued until there shall have been delivered to such board, agent or clerk, as the case may be, a satisfactory written statement con- taining the facts required by law to be returned and recorded, which shall be accompanied, in case of an original interment, by a satisfactory certificate 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 suffi- cient reasons, his certificate cannot be obtained early enough for the purpose, or is insufficient, a physician who is a mem- ber of the board of health, or employed by it or by the select- men for the purpose, shall upon application make the certificate required of the attending physician. If death is caused by vio- lence, the medical examiner shall make such certificate. If the death certificate contains a recital, as required by section ten of chapter forty-six, that the deceased served in the army, navy or marine corps of the United States in any war in which it has been engaged, such recital shall appear upon the permit. The board of health or its agent, upon receipt of such state- ment and certificate, shall forthwith countersign it and trans- mit it to the clerk of the town for registration. The person to

whom the permit is so given and the physician certifying 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 .- Chap. 114, Sec. 45, G. L., as amended.

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 the place where the deceased died his name and residence, if known: otherwise a description as full as may be, with the cause and manner of death .- Gen. Laws, Chap. 38, Sec. 7.

No undertaker or other person shall bury a human body or the ashes thereof which have been brought into the common- wealth until he has received a permit so to do from the board of health or its agent appointed to issue such permits, or if there is no such board, from the clerk of the town where the body is to be buried or the funeral is to be held, or from a person appointed to have the care of the cemetery or burial ground in which the interment is made .- Chap. 114, Sec. 46 G. L., as amended.

M R-301

DIVISION OF VITAL STATISTICS

The Commonwealth of Massachuset s

STANDARD CERTIFICATE OF DEATH

BOSTON

1 PLACE OF DEATH

County

Suffolk

State

Massachusetts

(City or town)

120

City or Town

2 FULL NAME

David P Bean

(If U. S. War Veteran, specify WAR)

(a) Residence.

(Usual place of abode)

22 Woodside Joe

St.,

.....

.Ward,

(If non-resident, give city or town and state)

Length of residence in city or town where death occurred

yrs.

mos.

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

yrs.

mos.

days.

PERSONAL AND STATISTICAL PARTICULARS

3 SEX Male.

4 COLOR OR RACE Black

5 SINGLE, MARRIED. WIDOWED, or DIVORCED (write the word) HidMod

5a If married, widowed, or divorced HUSBAND of (or) WIFE of

Alice. Dalkia u 2

6 AGE Years

Months

Days

IF LESS than

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

or ..

min.

IF STILLBORN, enter that fact here

7 OCCUPATION OF DECEASED (a) Trade, profession, or particular kind of work ... (b) Name of employer

8 BIRTHPLACE (City)

(State or country)

9 NAME OF FATHER

TRichard Jeorge Beau

10 BIRTHPLACE OF FATHER (City) (State or country)

Bermuda

Adiana Bean

11 MAIDEN NAME OF MOTHER

12 BIRTHPLACE OF MOTHER (City) (State or country)

Bermuda.

13 Robert Bean.

Informant ( Address)

aug 21, 1989

(Month) (Day) (Year)

REGISTRAR

20 I HEREBY CERTIFY that a satisfactory stand- ard certificate of death was filed with me BEFORE the burial or transit permit was issued.

Official

Health Ifices

Date of issue

permit

/19/29

Permit No .... 1620

CAUSE OF DEATH in plain terms, so that it may be properly classified. Exact statement of OCCUPATION

is very important. See instructions and extracts from the laws on back of certificate.

200M 7-'28 No. 2787-c

20M.

MEDICAL CERTIFICATE OF DEATH

15 DATE OF DEATH

( Month

(Das)

(Year)

16 I HEREBY CERTIFY, That I attended deceased from O 14 19 14, to

Quy 17

. 19.

that I Jast Baw h

alive on

aug 17. 19.29.

and that death occurred, on the date stated above, at ... The CAUSE OF DEATH was as follows: (State fully)

Maenia

(duration)

mos. ... »ds.

CONTRIBUTORY

(Secondary)

(duration)

rs.

mos. . ds.

17 Where was disease contracted if not at place of death

Did an operation precede death ..

For what

Date of operation

Was there an autopsy. If under one year, was infant Breast Fed ?.

What test confirmed diagnosis.

(Signed)

2jan

, M. D.

(Address)

Date

8/04/24

18 PLACE OF BURIAL, CREMATION, OR REMOVAL

(Cemetery )

(City or town)

DATE OF BURIAL 1 .192

19 UNDERTAKER

ADDRESS

No .. 22 Hoodie Que

Registered No

St.,

.Ward

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

642 Pm

-4

Bermuda

PARENTS

.yrs.

Ung. 17. 1929.

Revised United States Standard Certificate of Death (Approved by U. S. Census and American Public Health Ass'n.)

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, Civil engineer, Stationary fireman, etc. But in many cases, es- pecially 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 ex- amples : (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 re- turn "Laborer," "Foreman," "Manager," "Dealer," etc., with- out 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, House- work, or At home, and children, not gainfully 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 fact may be indicated thus: Farmer (retired, 6 yrs.). For persons who have no occupation whatever, write None.

(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 intercurrent) 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 "Asthe- nia," "Anemia" (merely symptomatic), "Atrophy," "Collapse," "Coma," "Convulsions," "Debility" ("Congenital," "Senile," etc.), "Dropsy,Marasmus," ." "Exhaustion," "Heart failure," "Hemorrhage," "Inanition," """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 "PUERPERAL septicemia," "PUERPERAL peri- tonitis," etc.

State cause for which surgical operation was undertaken.

(Recommendations on statement of cause of death approved by Committee on Nomenclature of the American Medical Associa- tion.)

Bronchopneumonia : If primary cause,

write the word "primary"; if secondary, give primary cause.

Certificates will be returned for additional information which give any of the following diseases, without explanation, as the mole cause of death: Abortion, cellulitis, childbirth, convulsions, hemorrhage, gangrene, gastritis, erysipelas, meningitis, mis- carriage, necrosis, peritonitis, phlebitis, pyemia, septicemia, tetanus.

EXTRACTS

FROM THE LAWS OF THE COMMONWEALTH OF MASSACHUSETTS

GOVERNING THE

RETURN OF CERTIFICATES OF DEATH

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 the place where the deceased died his name and residence, if known; otherwise a description as full as may be, with the cause and manner of death .- Gen. Laws, Chap. 38, Sec. 7.

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Town of Winthrop : Record of Deaths 1928-1930, Part 109

Author: Winthrop (Mass.) Publication date: 1928 Publisher: Number of Pages: 1296

Author: Winthrop (Mass.)
Publication date: 1928
Publisher:
Number of Pages: 1296