USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1928-1930 > Part 21
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--
m H.)
march 29.1928 84
Copy of the Record of a Death
rned to the clerk of Sant Bouton. is provided in Section 28 of the Law relating the registration of Vital Statistics.
e of Death .. Thompsone Camb .
Traselex. Mr No .. Richard , Kirby e
long a resident 3 days.
lous residence 25-4 main St Mauthrite Max
Married, Single, !
Color.
Widowed Widerred
- or Divorced
ised was husband
elizabeth Driscoll
wife of
of Birth: Year .:
.Month ... Day .: ....
Years .. 50m Months ........ Days ... - ation Undertaker
of Birth
East Boston Marc
of Father ..
Richard Kirby
place of Father .. Sretand.
ation of Father Bridget Lyone
n Name of Mother.
place of Mother .. Iseland.
Richard Cikirby Ir.
of Informant
of Death:
Year 1928 Month Man Day 29
of Death.
Qneumonia.
Duration
buting cause.
Heart
Failure
Duration on
A
4
802
Where was disease comtpoted, if not at "death" .
If death was in a hospital, or other institutih its name
Did an operation precede death? 200 Date
Was there an autopsy? 200 Name of Physician (or other person) said death John M. Bischoff
naplex. ME
P. O. Address ..
Place of Burial
Holy Croce, Mar
Date of Burial.
April 2
Z
Name of Cemetery ..
Holy Cro
Undertaker
Richard @.Kul
P. O. Address ..
Eart Breton
State of Maine
I hereby certify that the above is a true
the Record of a Death made by the clerk of Naklex- Mane. in the m March, XL Walter
Clerk of. naplex me ( fully
c plied. AGE should be stated EXACTLY. PHYSICIANS should stats CAUSE Of OFATH In plain terms, so th". €
-
.
The Commonwealth of Massachusetts STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH
Registered No.
(Place of death)/
County
State
Registered No.
8
(Place of residence) St., Ward
(If death occurred in a hospital or institution, give its NAME instead of street and number)
2 FULL NAME
(If in the Army or Navy of the United States, give rank, organization, etc.)
No. St.
(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
4 COLOR OR RACE
5 SINGLE, MARRIED, WIDOWED, OR DIVORCED (write the word)
5a If married, widowed, or divorced
Name of 3
S HUSBAND ¿ (or) WIFE
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 or town) (State or country)
9 NAME OF FATHER
10 BIRTHPLACE OF FATHER (city or town)
(State or country)
11 MAIDEN NAME OF MOTHER
12 BIRTHPLACE OF MOTHER (city or town) (State or country)
13
Informant (Address)
14
Filed
. 19
Registrar of city or town where death occurred
Filed .19
312
MEDICAL CERTIFICATE OF DEATH
15 DATE OF DEATH
(Month)
(Day)
(Year)
16 - HEREBY CERTIFY,
That I attended deceased from
19 ., to 19
that I last saw h
alive on
19
and that death occurred, on the date stated above, at. The CAUSE OF DEATH was as follows: (State fully)
m.
(duration)
yrs.
mos. 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
(Signed)
M. D.
(Address)
Date
18 PLACE OF BURIAL, CREMATION, OR REMOVAL
DATE OF BURIAL
(Cemetery)
(City or town)
, 19
19 UNDERTAKER
ADDRESS
may beproperly classified. Exact statement of OCCUPATION is very important. PARENTS
City or town)
-
City or town
No.
City or Town
Registrar of city or town where deceased resided
+ --
102
The Commonwealth of Massachusetts STANDARD CERTIFICATE OF DEATH
Medfield
62
(Place of death)
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
John F. Hennessy
(If in the Army or Navy of the United States, give rank, organization, etc.)
.No.
35 Summit Avenuest.
(Usual place of abode)
Length of residence in city or town where death occurred
6
years
7
months
2
days.
How long in U. S., if of foreign birth?
years
months
days
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
Male
4 COLOR OR RACE
White
5 SINGLE, MARRIED, WIDOWED, OR
DIVORCED (write the word)
Single
5a If married, widowed, or divorced S HUSBAND Name of ¿ (or) WIFE
6 AGE
Years
35
Months
10
Days 8
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
None
(b) Name of employer
8 BIRTHPLACE (city or town)
Roxbury,
(State or country)
Mass.
9 NAME OF
FATHER
Patrick B. Hennessy
PARENTS
10 BIRTHPLACE OF
FATHER (city or town)
Lynn,
(State or country)
Mass.
11 MAIDEN NAME
OF MOTHER
Alice Ross
12 BIRTHPLACE OF
MOTHER (city or town)
(State or country)
Boston
Mass.
13
Informant
State Hospital Records
Medfield, Mass.
(Address)
14 5/2/28
Filed
19 William H. Werth
Filed
3/3/208
. 19
Registrar of city or town where death occurred
Registrar of city or town where deceased resided
MEDICAL CERTIFICATE OF DEATH
15 DATE OF DEATH April 2 1928
(Month)
(Day)
(Year)
16
I HEREBY CERTIFY,
That I attended deceased from
June 30,
1921
that I last saw him alive on
April 2, , 128 .
and that death occurred, on the date stated above, at.
4:20 p.
The CAUSE OF DEATH was as follows: (State fully)
Pulmonary Tuberculosis
(duration)
4
yrs.
mos.
ds.
CONTRIBUTORY
(SECONDARY)
(duration)
mos ..
de.
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 Physical & Laboratory
(Signed)
George E. Poor
, M. D.
(Address)
Medfield, Mass.
Date April 2, 1928.
18 PLACE OF BURIAL, CREMATION, OR REMOVAL
Mt. Benedict. Boston
(Cemetery)
(City or town)
DATE OF BURIAL
4/4/28.
. 19
ADDRESS
19 UNDERTAKER
Frederick A.Magrath
East Boston
No. 4312
fully 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.
1 PLACE OF DEATH
Registered No.
County
Norfolk
State
Mass.
City or town
Medfield
No.
State Hospital
(a) Residence.
State Mass.
City or Town-
Winthrop
to
April 2, .128
Four J. crew
apr. 2.1928
١٢
02
The Commonwealth of Massachusetts STANDARD CERTIFICATE OF DEATH
Boston
(City or towp)
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
ALPHONSUS F. BIGGIO
(If in the Army or Navy of the United States, give rank, organization, etc.)
(a) Residence.
State.
MASS.
City or Town
WINTHROP
No.
170 HERMAN
.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
4 COLOR OR RACE
M.
5 SINGLE, MARRIED, WIDOWED, OR
DIVORCED (write the word)
S
5a If married, widowed, or divorced
Name of & HUSBAND
¿ (or) WIFE
6 AGE
Years
Months
Days
20
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.
PARENTS
10 BIRTHPLACE OF
FATHER (city or town)
BOSTON
(State or country) MASS.
11 MAIDEN NAME
OF MOTHER
ROSE M. FOPIANO
12 BIRTHPLACE OF
MOTHER (city or town)
BOSTON
(State or country)
MASS.
13
Informent
FATHER
(Address) 170 HERMAN ST. WINTHROP
14
"File APR. 4 . 1928
Filed
Dejar 6, 1928
Registrar of city or town where deceased resided
MEDICAL CERTIFICATE OF DEATH
15 DATE OF DEATH
APRIL 2
1928
(Month)
(Day)
(Year)
16
I HEREBY CERTIFY,
That I attended deceased from
MAR. 19
19
2.80.
APRIL L
1928
that I last saw h | M alive on
APRIL
-
19.28
and that death occurred, on the date stated above, as
12.27
A
m.
The CAUSE OF DEATH was as follows: (State fully)
NEPHRITIS
(duration)
mos.
10
ds.
CONTRIBUTORY
(SECONDARY)
(duration)
mos
3
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.
AUTOPSY
(Signed)
W. R. MASON
, M. D.
(Address)
Date
APRIL 2, 1928
18 PLACE OF BURIAL, CREMATION, OR REMOVAL
CALVARY, W. ROXBURY
(Cemetery)
(City or town)
DATE OF BURIAL 4-2
, 19 28
19 UNDERTAKER P. J. MC ARDLE
ADDRESS
-No. 4312
fully 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.
Registered No.
3163
(Place of deathy
City or town
Boston
No. N. E. HOSPITAL FOR WOMEN
Eumylenen
Registrar of city or town where death occurred
PNEUMONIA
9 NAME OF
FATHER
ANDREW
@ 199 eq pinoys u
alphonsus + leggio april 2, 1928
02
The Commonwealth of Massachusetts STANDARD CERTIFICATE OF DEATH
Boston
(City or town)
1 PLACE OF DEATH
County
Suffolk
State
Registered No.
(Place of residence,
City or town
Boston
No. 221 LONGWOOD AVE
St.,
Ward
(If death occurred in a hospital or institution, give its NAME instead of street and number)
2 FULL NAME
(MALE SMALLEY)
(If in the Army or Navy of the United States, give rank, organization, etc.)
WINTHROP
No. 964 SHIRLEY ST.
-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
M.
4 COLOR OR RACE W.
5 SINGLE, MARRIED, WIDOWED, OR
DIVORCED (write the word)
5a If married, widowed, or divorced
S HUSBAND Name of ? (or) WIFE
6 AGE Years
Months
X NaksX
If LESS than 1 day, .... hrs.
20 HRS
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.
PARENTS
9 NAME OF
FATHER
UNKNOWN
10 BIRTHPLACE OF FATHER (city or town) (State or country)
11 MAIDEN NAME
OF MOTHER
MAUDE SMALLEY
12 BIRTHPLACE OF
MOTHER (city or town)
NORFOLK
(State or country)
MASS.
13 BOSTON LYING IN HOSPITAL
Informant
(Address)
221 LONGWOOD AVE. BOSTON
14
Filed AP R. 1.2928
Registrar of city or town where death occurred
Filed aps. 17 1928
Registrar of city or town where deceased resided
No. 4312
MEDICAL CERTIFICATE OF DEATH
15 DATE OF DEATH
APRIL 2
1928
(Month)
(Day)
(Year)
16
I HEREBY CERTIFY,
That I attended deceased from
APRIL I
28
APRIL 2
19
APRIL 2
that I last saw h
alive on
1928
and that death occurred, on the date stated above, at 5 P m
The CAUSE OF DEATH was as follows: (State fully)
CEREBRAL HEMORRHAGE
(duration). yTS ..
mos. da.
CONTRIBUTORY
HYPERTROPHIED THYMUS GLAND
(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)
PAUL GUSTAFSON
, M. D.
(Address)
Date APRIL 2, 1928
18 PLACE OF BURIAL, CREMATION, OR REMOVAL
(ST. JOSEPH) BOSTON (Cemetery) (City or town)
DATE OF BURIAL 4-11
, 1928
19 UNDERTAKER
J. F. LINEHAN
ADDRESS
fully 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.
Registered No.
3468
(Place of death) 64
(a) Residence.
State
MASS.
City or Town
1928
IM
april 2. 192$
RM R-301
OFFICE OF THE SECRETARY DIVISION OF VITAL STATISTICS
The Commonwealth of Massachusetts STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH
County
Suffolk
State Mess.
Registered No.
St., Ward
(If death occurred in a hospital or institution, give its NAME instead of street and number)
2 FULL NAME Elmira Elizabeth Martin
(If in the Army or Navy of the United States, give rank, organization, etc.)
(a) Residence. No ..
61 Seaview Ave.
St.
Ward.
(If non-resident give city or town and state)
(Usual place of abode)
Length of residence in city or town where death occurred
I 6 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
White
5 SINGLE, MARRIED, WIDOWED, OR
DIVORCED (write the word)
Married
5a If married, widowed or divorced
HUSBAND of
(or) WIFE of
Frank P. Martin
6 AGE
Years 75
Months
Days
4
If LESS than 1 day, __ hrs. or __ min.
If STILLBORN, enter that fact here
7 OCCUPATION OF DECEASED
particular kind of work
ion. "Housewife
(b) Name of employer
at home
8 BIRTHPLACE (City) Hampden
(State or country)
Maine
(SECONDARY)
(duration)
1
yrs. . mos.
.ds
9 NAME OF
FATHER
George W. Hopkins
PARENTS
10 BIRTHPLACE OF
FATHER (City)
Hampden
(State or country)
Maine
11 MAIDEN NAME
OF MOTHER
Lucy B. Kempton
12 BIRTHPLACE OF
MOTHER (City)
Hampden
(State or country)
Maine
17 Where was disease contracted
if not at place of death?
Did an operation precede death?
200
Date of
Was there an autopsy?
200
What test confirmed diagnosis ?.
clinical
(Signed Driver & Johnson
M. D.
(Address) 12 324 Whittich St
te prie 4 1/28
(Month)
(Day)
(Year)
13
Informant
Frank P. Martin
(Address)
6I Seaview Ave. Winthrop, Mass.
14
Many 8/28
Filed
(Month) (Day) (Year)
REGISTRAR
18 PLACE OF BURIAL, CREMATION OR REMOVAL
Laurel
Wilton N. H.
DATE OF BURIAL
4/5/28
(Cemetery)
(City or town)
19 UNDERTAKER
Long & Margeson
ADDRESS
Winthrop
20 | HEREBY CERTIFY that a satisfactory stan- dard certificate of death was filed with me BEFORE the burial or transit permit was issued. WWW. Childress
Official
position
agent
Date of issue of permit man & # 28
Permit NO. 1394
200,000 9-25 NO. 2662 - 3.
N. B .- WRITE PLAINLY, WITH UNFADING BLACK INK- THIS IS A PERMANENT RECORD. Every item of information instructions and extracts from the laws on back of certificate. in plain terms, so that it may be properly classified. Exact statement of OCCUPATION is very important. See should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state CAUSE OF DEATH
MEDICAL CERTIFICATE OF DEATH
15 DATE OF DEATH
april
2
1928
/(Month)
(Day)
(Year)
16
I HEREBY CERTIFY, That I attended deceased from
March 30
H 28 to april 2 1928 to
that I last saw h
alive on
april 2
1925
and that death occurred, on the date stated above, at
200 .
The CAUSE OF DEATH was as follows:
Carcinoma Viteri
CONTRIBUTORY.
Queria
_yrs.
temos.
ds.
City or Town
Winthrop
No. 6T Seaview Ave.
(City or town)
Female
3
apr. 2. 1928
REVISED UNITED STATES STANDARD CERTIFICATE OF DEATH
(Approved by U. S. Census and American Public Health Association)
Statement of occupation .- Precise statement of occupation ia very important, so that the relative healthfulness of various pursuits can be known. The question applies to each and every person, irre- spective of age. For many occupations a single word or term on the first line will be sufficient, e. g., Farmer or Planter, Physician, Com- positor, Architect, Locomotive engineer, Civil engineer, Stationary fire- man, 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. Ag 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 "Laborer," "Fore- man," "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 Housekeepers who receive a definite salary), may be entered as House- wife, Housework, 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 occupa- tion 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 disease. Exam- ples: Cerebrospinal fever (the only definite synonym is "Epidemic cerebrospinal meningitis"); Diphtheria (avoid use of "Croup"); Typhoid fever (never report "Typhoid pneumonia"); Lobar pneu- monia; Bronchopneumonia ("Pneumonia," unqualified, is indefinite); Tuberculosis of lungs, meninges, 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), 89 ds .; Bronchopneumonia (secondary), 10 da. Never report mere symptoms or terminal conditions, such as "Asthenia," "Anemia" (merely symptomatic), "Atrophy," "Collapse," "Coma," "Convul- sions," "Debility" ("Congenital," "Senile," etc.), "Dropsy," "Ex- haustion," "Heart failure," "Hemorrhage," "Inanition," "Maras- mus," "Old age," "Shock," "Uremia,", "Weakness," etc., when a definite disease can be ascertained as the cause. Always qualify all diseases resulting from childbirth or miscarriage, as "PUERPERAL 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 "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, miscarriage, 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 deceased, furnish for registra- tion a standard certificate of death, stating to the best of his knowl- edge 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 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 be issued until there shall have been delivered to such board, agent or clerk. .. a satisfactory written statement con- taining the facts required by law to be returned and recorded, which shall be accompanied, 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 sufficient reasons, his certificate cannot be obtained early enough for the pur- pose, or is insufficient, a physician 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 certificate. .. 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 re- quire .- 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 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.
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 unre- lated to any form of injury, have died without recent medical at- tendance or whose physician is absent from home when the certificate of death is needed.
(3) Medical examiners will investigate and certify to all deaths supposably due to injury. These include not only deaths caused directly or indirectly by traumatism (including resulting septicemia), and by the action of chemical (drugs or poisons), thermal, or electrical agents, and deaths following abortion, but also deaths from disease resulting from injury or infection related to occupation, the sudden deaths of persons not disabled by recognized disease, and those of persons found dead.
MR-301
OFFICE OF THE SECRETARY DIVISION OF VITAS STARSTICSI K
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH
County
Suffolk
State_
Lass
(City or town ) Registered No.
St. Ward (If death occurred in a hospital or institution, give its NAME instead of street and number)
2FULL NAME
Delphine Senecal
(If U. S. War Veteran, specify WAR)
Ka) Residence. No.
270 Main St.
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
3 SEX
Female
4 COLOR OR RACE
White
5 SINGLE, MARRIED, WIDOWED, OR
DIVORCED (write the word)
Widowed
5a If married, widowed or divorced
HUSBAND of
(or) WIFE of
Charles
6 AGE
Years
Months
Day:
IF LESS than
1 day ......... hrs.
c ......... min.
89
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)
Champlain
(State or country)
N.Y.
PARENTS
9 NAME OF
FATHER
Henry Goodrow
1 O BIRTHPLACE OF
FATHER (City)
Champlain
(State or country)
N.Y.
1 1 MAIDEN NAME
OF MOTHER
Adeline DERoche
12 BIRTHPLACE OF
MOTHER (City).
Montreal
(State or country)
P
13
informant
Augustus Roberts
(Address)
270 Main St. Winthrop
14 Filed (Month) (Day) (Year)
20 | HEREBY CERTIFY that a satisfactory stan- dard certificate of death was filed with me BEFORE the burial or transit permit was issued/
REGISTRAR
18 PLACE OF/BURIAL, CREMATION, OR REMOVAL
St.Marys Champlain N.Y.
(Cemetery)
( City or town)
DATE OF BURIAL 4/6/28
ADDRESS Winthroh
Www. D. Childress Mich Health Officer
mos
_yrs.
_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)
M. D.
(Address) Chalupy
Date
4/3/28
1,9| UNDERTAKER HO maley
2
1920
15 DATE OF DEATH
(Month)
(Day)
(Year)
16 I HEREBY CERTIFY , That I attended deceased from march 31 19_421, to
1920
that I last saw h
alive on
1
19.
and that death occurred, on the date stated above, at
The CAUSE OF DEATH was as follows: (State fully)
200.000. 9-26. NO. 6373
Exact statement of OCCUPATION is very important. See instructions and extracts from the laws on back of certificate.
N. B .- WRITE PLAINLY, WITH UNFADING BLACK INK-THIS IS A PERMANENT RECORD. Every item of information should be carefully sup-
plied. AGE should be stated EXACTLY. PHYSICIANS should state CAUSE OF DEATH in plain terms, so that it may be properly classified-
City or Town
Winthrop
No. 270 Main St
(Usual place of abode)
MEDICAL CERTIFICATE OF DEATH
Date of Issue of permit / 14/3/28 Permit 1392
.
1 apr. 2. 1928 REVISEDUNITED STATESSTANDARD CERTIFICATE OF DEATH
(Approved by U. S. Consus and American Public Health Association)
Statement of occupation .- Precise statement of occupation is very important, so that the relative healthfulness of various pursuits can be known. The question applies to each and every person, irre- spective of age. For many occupations a single word or term on the first line will be sufficient, e. g., Farmer or Planter, Physician, Com- positor, Architect, Locomotive engincer, Civil engineer, Stationary fire- man, 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 "Laborer," "Fore- man," "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 Housekeepers who receive a definite salary), may be entered as House- wife, Housework, 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 occupa- tion 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.
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