USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1928-1930 > Part 130
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(b) Name of employer
Soldier
8 BIRTHPLACE (city or town)
(State or country)
Brocheta
Mark.
PARENTS
10 BIRTHPLACE OF
FATHER (city or town)
(State or country)
Sweden.
11 MAIDEN NAME
OF MOTHER
Anna?
12 BIRTHPLACE OF
MOTHER (city or town)
(State or country)
Sweden.
13
Recorde Hoxboro State
Inform (Address) 16 amps 4 Man.
14 Filed 1 2-15, 1929
Filed.
1, 19 -
1
Registrar of city or town where death occurred
Registrar of city or town where deceased resided
MEDICAL CERTIFICATE OF DEATH
15 DATE OF DEATH Dec 14 1929 (Year)
(Month)
(Day)
16
I HEREBY CERTIFY,
That I attended deceased from
Oct 14
192%, to Dec 14
19.29.
that I last saw h m alive on Su-14 192%.
and that death occurred, on the date stated above, at
7.30
R
.m. The CAUSE OF DEATH was as follows: (State fully)
Pulmonary Tuberculosis
(duration)
yTE.
mos ..
CONTRIBUTORY
(SECONDARY)
(duration)
yrs.
.mos
17 Where was disease contracted
if not at place of death.
Did an operation precede death
NO
For what
Date of operation
Was there an autopsy
No
What test confirmed diagnosis.
(Signed)
William le Sabbie
M. D.
(Address)
Hox0000 State lauft.
Date
Dec 14-1929
18 PLACE OF BURIAL, CREMATION, OR REMOVAL Mehace Brocklin
(Cemetery)
(City or town)
DATE OF BURIAL 12-17-1929
19 UNDERTAKER
ADDRESS Some Brocklin CIT DahlboryF
Man-
12
1 PLACE OF DEATH
County
Nontek
State Mark.
No. Statelorpital
City or town
2 FULL NAME
Elmen R Lan
Man.
Hoxton
9 NAME OF
FATHER
Card Lawson
De.c. 14. 1929.
The Commonwealth of Massachusetts STANDARD CERTIFICATE OF DEATH
Boston
1 PLACE OF DEATH
County
Suffolk
State
Registered No.
(Place of residence'
.St.,
Ward
(If death occurred in a hospital or institution, give its NAME instead of street and number)
2 FULL NAME
ANNA SOLOMON
(If in the Army of Navy of the United States, give r'
organization, etc.)
17 Forrest
St.
(Usual place of abode)
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
3 SEX
F.
4 COLOR OR RACE
W.
5 SINGLE, MARRIED, WIDOWED, OR
DIVORCED (write the word)
.
5a If married, widowed, or divorced
§ HUSBAND
Name of ? (or) WIFE
SIGMOND
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.
AT HOME
(b) Name of employer
8 BIRTHPLACE (city or town)
(State or country)
ROUMANIA
9 NAME OF
FATHER
WILLIAM
(Unknown)
10 BIRTHPLACE OF
FATHER (city or town)
(State or country)
ROUMANIA
11 MAIDEN NAME
OF MOTHER
MOLLIE
(Unknown)
12 BIRTHPLACE OF
MOTHER (city or town)
(State or country)
ROUMANIA
13
Informant
WILLIAM A. SOLOMON
(Address)
10 SHAILE ST BROOKLINE
14
Filed
DEC 18 , 19
Filed
JAN - 2 1930
Registrar of city or town where death occurred
Registrar of city or town where deceased resided
812
MEDICAL CERTIFICATE OF DEATH
15 DATE OF DEATH
DEC 15. 1929
(Month)
(Day)
(Year)
16
I HEREBY CERTIFY,
DEC 15
19
29to.
DEC 15
That I attended deceased from
19
29
ER
that I last saw h
alive on
DEC 15
20
19
and that death occurred, on the date stated above, at
10 P
m.
The CAUSE OF DEATH was as follows: (State fully)
CHOLELITHIASIS PERFORATED EMPEMA
(duration)
yTS.
mos ..
3
.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
YES
What test confirmed diagnosis.
(Signed)
J. B. SEARS
M. D.
(Address)
Date
DEC 16. 1929
EVERETT (mmutuale cem)
18 PLACE OF BURIAL, CREMATION, OR REMOVAL WINTHROP.
(Cemetery) Montvale
(City or town)
DATE OF BURIAL 8
12-16
. 19
ADDRESS
19 UNDERTAKER I. EINSTEIN
(City or town)
Registered No.
11062
(Place of death) . 184
City or town
Boston
No.
BETH ISRAEL HOSPITAL
WINTHROP
(a)
Residence.
State
MASS.
City or Town
60
may be properly classified. Exact statement of OCCUPATION is very important. PARENTS
PERITONITIS
fully supplied. AGE should be stated
Dec. 15. 1929.
The Commonwealth of Massachusetts STANDARD CERTIFICATE OF DEATH
Boston
1 PLACE OF DEATH
County
Suffolk
State
Registered No.
(Place of residence
Ward
(If death occurred in a hospital or institution, give its NAME instead of street and number)
2 FULL NAME
(FEMALE)
EVANS
(a) Residence.
State.
MASS.
(Usual place of abode)
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
3 SEX
4 COLOR OR RACE
W
5 SINGLE, MARRIED, WIDOWED, OR
DIVORCED (write the word)
5a If married, widowed, or divorced
& HUSBAND Name of ? (or) WIFE
6 AGE
Years
Months
XXDays
2 HRS
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 or town)
BOSTON
(State or country)
MASS.
9 NAME OF
FATHER
HAROLD EVANS
10 BIRTHPLACE OF
FATHER (city or town)
WINTHROP
(State or country)
MASS.
11 MAIDEN NAME
OF MOTHER
ALICE WALDRON
12 BIRTHPLACE OF
MOTHER (city or town)
WINTHROP
(State or country)
MASS
13
Informant
HAROLD EVANS
(Address)
14 Filed DEC 20.
Filed JAN - 2 1930
Registrar of city or town where death occurred
Registrar of city or town where deceased resided
4312
MEDICAL CERTIFICATE OF DEATH
15 DATE OF DEATH
DEC 17. 1929
(Month)
(Day)
(Year)
16
I HEREBY CERTIFY,
That I attended deceased from DEC 17
19
29
that I last saw h
alive on
ER
DEC 17
19 29
and that death occurred, on the date stated above, a
1 P
m
The CAUSE OF DEATH was as follows: (State fully)
HYDROCEPHALUS
SPINA BIFIDA
(duration)
yrs ..
mos.
1
ds.
CONTRIBUTORY
(SECONDARY)
(duration)
yrs.
mos.
de.
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.
CLINICAL SIGNS
(Signed)
R. J. HEFFERNAN
, M. D.
(Address)
Date
DEC 17. 1929
18 PLACE OF BURIAL, CREMATION, OR REMOVAL
DATE OF BURIAL 12-18 . 19
ADDRESS
19 UNDERTAKER A. R. BENNISON
may be properly classified. Exact statement of OCCUPATION is very important. PARENT 8
(City or town) Registered No .___ [29
( Place of death)
City or town
Boston
No.
ST MARGARETS HOSPITAL
St.,
GROVENOR AVE
).[etc.)
City or Town
WINTHROP
(If in the Army or Navy of the United States giv
No.
.St.
F.
19
29 to.
DEC 17
III GROVENOR AVE WINTHROPHOLYHOOD BROOKLINE (Cemetery) (City or town)
um Seinen
1 ٧ Dec. 17.1929
I R-301
DIVISION OF VITAL STATISTICS
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH
County
Sui. ol.
State
Registered No.
(City or town) 18%
City or Town
Vinding
No. winthro. COM
St. Ward
(If death occurred in a hospital or institution, give its NAME instead of street and number)
2 FULL NAME
317 Wiedeman
(If U. S. War Veteran, specify WAR)
(a) Residence.
No.
(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
3 SEX ramle
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 AGE
Years
Months
Days
3
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
Winthrop
8 BIRTHPLACE (City) (State or country) Mass
PARENTS
10 BIRTHPLACE OF FATHER (City) (State or country)
11 MAIDEN NAME
OF MOTHER
Lulua anderren
12 BIRTHPLACE OF MOTHER (City) (State or country)
13
07
Informant
( Address):
Webster St
14
Filed (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
Position
Heath Depièces
Date of issue of permit
1/9/2.
Permit No ... .
1665
15 DATE OF DEATH Que. 18 140g (Years
(Month)
(Day)
16 I HEREBY CERTIFY, That I attended deceased from.
19 24 Den 18
to
19.
Jan 18
, 19
that I last saw h .. C ..... alive en
and that death occurred, on the date stated above, at The CAUSE OF DEATH was as follows: (State fully)
(duration)
yrs ....
.mos. 3
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)
. M. D.
(Address)
Date 12/19 mg
18. PLACE OF BURIAL, CREMATION, OR REMOVAL. Winthrop
DATE OF BURIAL 12 / 19/20
(Cemetery) (City or town )
19 /UNDERTAKER ADDRESS ohn & @maxey Minthade
200M 7-'28 No. 2787-c
CAUSE OF DEATH in plain terms, so that it may be properly classified. Exact Statement Of DOVOL A JAVA is very important. See instructions and extracts from the laws on back of certificate.
1
11.30An m.
9 NAME OF
FATHER
CIcic.
MEDICAL CERTIFICATE OF DEATH
St.,
.Ward,
Revere
(If non-resident, give city or town and state)
pinoys 32) 35Y peuddns/
To.
akc. 18. 1927.
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.
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" ("Congenital," "Senile," etc. ), "Dropsy,"" y," "Exhaustion," "Heart failure," "Hemorrhage," "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 sole 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.
The Commonwealth of Massachusetts STANDARD CERTIFICATE OF DEATH
Boston
1 PLACE OF DEATH
County
Suffolk
State
Registered No.
(Place of residence .
.St.,
Ward
(If death occurred in a hospital or institution, give its NAME instead of street and number)
2 FULL NAME
FRANCES HAINES
MASS.
City or Town
WINTHROP
No.
19 BELLEVUE AVES.
(a) Residence.
State
(Usual place of abode)
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
3 SEX
F.
4 COLOR OR RACE
W.
5 SINGLE, MARRIED, WIDOWED, OR
DIVORCED (write the word)
S.
5a If married, widowed, or divorced
$ HUSBAND
Name of ? (or) WIFE
6 AGE
Years
Months
Days
4
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 or town)
BOSTON
(State or country)
MASS
9 NAME OF
FATHER
FRANCIS
10 BIRTHPLACE OF
FATHER (city or town)
SALEM
(State or country) MASS.
11 MAIDEN NAME
OF MOTHER
CECELIA MC GARRY
12 BIRTHPLACE OF
MOTHER (city or town)
BOSTON
(State or country)
MASS
13
Informant
FATHER
(Address)
435 WINTHROP ST. WINTHROP
14
Filed
DEC 24. 19 200M Stenen
Filed.
JAN - 2 1930
Registrar of city or town where death occurred
Registrar of city or town where deceased resided
MEDICAL CERTIFICATE OF DEATH
15 DATE OF DEATH
DEC 20, 1929
(Month)
(Day)
(Year)
16
I HEREBY CERTIFY,
That I attended deceased from
DEC 16
19
29, to.
DEC 20
19
29
that I last saw h.
alive on
DEC 20
19
29
and that death occurred, on the date stated above, as
The CAUSE OF DEATH was as follows: (State fully)
m
BRONCHO PNEUMONIA
(duration)
yrs ..
mos ..
3
ds.
CONTRIBUTORY
PERITONITIS
(SECONDARY)
(duration)
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)
MARJORIE WOODMAN
M.D.
(Address)
Date
DEC 20. 1929
18 PLACE OF BURIAL, CREMATION, OR REMOVAL
WOODLAWN
EVERETT
(Cemetery) (City or town)
DATE OF BURIAL
12-21
, 19
29
ADDRESS
19 UNDERTAKER
T. F. BRADY
(City AF 7043
Registered No.
(Place of death)/
City or town
Boston
No. N . E. HOSPITAL FOR WOMEN
(If in the Army or Navy of the United States, give rank, organ zation, etc.)
ER
8 P
PARENTS
312
Tully supplied. AGE
Dec, 20-1929.
The Commonwealth of Massachusetts STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH
CountySuffolk
State
Registered No. L Registered No.
( Place of death)
(Place of residence!
St.,
Ward
(If death occurred in a hospital or institution, give its NAME instead of street and number)
2 FULL NAME
TERESA
AMERENA
MASS.
City or Town
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
3 SEX
F.
4 COLOR OR RACE
5 SINGLE, MARRIED, WIDOWED, OR
DIVORCED (write the word)
M.
5a If married, widowed, or divorced
F & HUSBAND
Name of ? (or) WIFE
VINCENT
6 AGE
Years
58
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
AT HOME
(b) Name of employer
8 BIRTHPLACE (city or town)
(State or country)
ITALY
9 NAME OF
FATHER
DOMENICO CANZONIER
PARENTS
10 BIRTHPLACE OF
FATHER (city or town)
(State or country)
ITALY
11 MAIDEN NAME
OF MOTHER
TERESA MIRAGLIA
12 BIRTHPLACE OF
MOTHER (city or town)
(State or country)
ITALY
13 HUSBAND
Informant
(Address)
71 PAINE ST. WINTHROP
14
Filed
DEC 26 , 19200M Stenen
Filed Vili
19:30
Registrar of city or town where deceased resided
MEDICAL CERTIFICATE OF DEATH
15 DATE OF DEATH
DEC 21. 1929
(Month)
(Day)
(Year)
16
I HEREBY CERTIFY,
That I attended deceased from
DEC 20
19
29 to
DEC 21
,
19
29.
that I last saw h
ER
alive on
DEC
21
19 29.
8 P
and that death occurred, on the date stated above, as The CAUSE OF DEATH was as follows: (State fully)
UREMTA
(duration)
yrs ..
mos
X
ds.
CONTRIBUTORY
PYONEP HROSIS
(SECONDARY)
(duration)
yrs ..
mos ..
de.
17 Where was disease contracted
if not at place of death.
Did an operation precede death
YES For what
DRA INA GE
Date of operation
12-21-29
OF RT. KIDNEY
Was there an autopsy
What test confirmed diagnosis
BLOOD CULTURE
(Signed)
HOWARD M. CLUTE
M. D.
(Address)
605 COMMONWEALTH AVE.
Date
DEC. 22. 1929
18 PLACE OF BURIAL, CREMATION, OR REMOVAL HOLY CROSS MALDEN
(Cemetery) (City or town)
DATE OF BURIAL
12-24
29
, 19
ADDRESS
19 UNDERTAKER
F. A.
MAGRA TH
Boston
(City or towp) 11291
City or town
Boston
No.
N. E. DEACONESS HOSPITAL
Naxy of the United States, give rank, organization, etc.)
(If in the APHROP
No.
7| PAINE
St.
(a) Residence.
State
(Usual place of abode)
Registrar of city or town where death occurred
312
Dec. 21.1929.
P
Une Commonwealth ot flassachusetts
STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH fagfolk
County
OD Winthrop.
State Mass
(City or town)
Registered No. Three
No.
63.
Prospect ave
"St ..
189
Ward
(If death occurred in a hospital or institution, give its NAME instead of street and number)
2 FULL NAME
(a) Residence.
No ...
63. Prostect ine
29
(Usual place of abode)
St.,
3
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
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
6. Daniel Downes
6 AGE
92
Years
Months
7
Days
27
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
Roxbury- Boston
8 BIRTHPLACE (City)
(State or country)
vilash
9 NAME OF
FATHER
1
Im P. Jargent
10 BIRTHPLACE OF FATHER (City) (State or country)
Newfury nort
11 MAIDEN NAME OF MOTHER
Sophia Sweet
12 BIRTHPLACE OF MOTHER (City)
(State or country)
13 1/1 m &. Dawson
Informant (Address) 63 Prospect ave - Winthrop Mass
14 Filed le 06. 29 (Month) (Day) (Year)
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
15 DATE OF DEATH (Month) 21 (Day) ( Year)
1929
16 I HEREBY CERTIFY, That I attended deceased from
, 1929, 10
19.29.
that I last saw h ............ alive on 21 19 2%
and that death occurred, on the date stated above, at. The CAUSE OF DEATH was as follows: (State fully) Brambor Framnon m. a [following Bronchitis 2 why duration]
(duration) yTS ....... .... mos .. Z_ds. Senility General arterio
CONTRIBUTORY (Secondary)
17 Where was disease contracted if not at place of death
Did an operation precede death 20 . For what.
Date of operation
200
Was there an autopsy
What test confirmed diagnosis
(Sig
. , M. D.
(Address) 123
Date 23
1827
18 PLACE OF BURIAL, CREMATION, OB REMOVAL
DATE OF BURIAL
Spolufem Dec 24/29
(Cemetery)/
(City cr :own)
19 UNDERTAKER Vaiter :1. 1 nite
ADDRESS
20 I HEREBY CERTIFY that a satisfactory stand- ard certificate of death was filed with me BEFORE the burial or transit permit was issued Hab. Chilares Official Ili inte Officer
Date of issue
permit 12/24/29
.No ...
Permit 1666
is very important. See instructions and extracts from the laws on back of certificate. PARENTS
200M 7-'28 No. 2787-c
.
)
5
City or Town Elizabeth@Ann 4 ounces
(If U. S. War Veteran, specify WAR)
11280
1
yrs. ~ mos .. . ds.
Boston
NW. 21. 1924
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 Nonc.
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