The volume, 1910–1912
Town Clerk, Winthrop · from the Internet Archive · 954 pages · 60.1 MB
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J. L FAIRBANKS & CO.
FILL OUT WITH
INK. —
THIS
IS A
PERMANENT RECORD
ALL
NAMES
TO BE IN FULL
COMMONWEALTH OF F M
RETURN OF A
FULL NAME
Place
of
|
0^
Death
'
Residence
/<?
^
STATISTICS DETAILS
SEX COLOR SINGLE, MARRIED,
WIDOWED, OR, ,
DIVORCED
MAIDEN NAMEt
HUSBAND'S NAME t
BIRTHPLACE!
^77 — *
NAME OF
fathc"
BIRTHPLACE /O
OFFATHE,‘
•
MAIDEN
NAME
'
'
_
BIRTHPLACE " f OF MOTHER! ^
OCCUPATION
—2^-~
| INFORMANT §
[ PLACE OF BURIAL OR REMOVAL II
UNDERTAKER
DATE OF BURIAL
,«o ADDRESS
/
o
—j
y
1
/ jys
i MtKtbY CERTIFY that I attended deceased during last
illness, from 190 to 190 ,
that to the best of my knowledge and belief death occurred on the
date stated above, and that the CAUSE OF DEATH was as follows :
Primary: * . /T? 4 Y
1
Contributory: ..
X . , 7
(duration) DAYS
(DURATION) DAY S
M.D.
V... \9tf.C. JAdXessT :
SPECIAL INFORMATION only for Hospitals, Institutions, Transients,
or Recent Residents.
How long at
Place of Death 7 years months days
Where was disease contracted,
If not at place of death?
Filed
190 Clerk
* City or town, street and number. If any. If death occurs away from USUAL RESI-
DENCE, give facts called for under “Special Information.” If In a Hospital or
Institution, give Its NAME instead of street and number,
t In case of married or divorced woman, or widow.
J State or country; also city, town or county, If known.
§ Name and address of person giving statistical details.
II Name of cemetery.
Otzy eee
Vieall 7g7e
FILL OUT WITH INK. —
THIS IS A
PERMANENT RECORD
ALL NAMES
TO BE IN FULL
COMMONWEALTH OF MASSACHUSETTS
RETURN OF A DEATH
FULL NAME Registered No. ...wL.^.V...
Place of Death *. ^r.
1
Date of Death ..££*r: Age ■tz.
years .
.months jr7. days
STATISTICAL DETAILS
SEX COLOR SINGLE, MARRIED,
WIDOWED, OR
DIVORCED
MAIDEN
NAME
+
i
-Z^^Jcc
-
oL.
HUSBAND’S NAMEt / ,
ST*
GaIAsT-A-*
BIRTHPl ACE t
>f -f - NAME OF
FATHER
BIRTHPLACE
OF FATHERt
A
I =Cace
AK
K-
MAIDEN NAME
OF MOTHER
BIRTHPLACE
OF MOTHER t
j£L2
OCCUPATION
INFORMANT §
PLACE OF BURIAL OR REMOVAL II
0
UNDERTAKER
6/
DATE OF BURIAL
.Z.~. J..: 1 $/#...
ADDRESS
PHYSICIAN'S CERTIFICATE
I HEREBY CERTIFY that I attended deceased during last
illness, from .. 19^0 .to ...190....-
that to the best of my knowledge and belief death occurred on the
date stated above, and that the CAUSE OF DEATH was as follows:
Primary:
.(duration) DAY8
Contributory:
)4-€
tion) .
(Signed ) . . P ^ ,\ . . ^T*r.
(Address) ... 9*4/1.
M.D.
ajLg__
SPECIAL INFORMATION only for Hospitals, Institutions, Transients,
or Recent Residents.
Former or How long at
Usual Residence Place orDeath?
Where was disease contracted,
If not at place of death 7
Days
Filed
.190.
Clerk
* City or town, street and number, if any. If death occurs away from USUAL RESI-
DENCE, give facts called for under “Special Information." If in a Hospital or
Institution, give Its NAME instead of street and number,
t In case of married or divorced woman, or widow,
t State or country | also city, town or county, if known.
§ Name and address of person giving statistical details.
II Name of cemetery.
el
<?- 4,
;
ALL NAMES TO BE IN FULL
COMMONWEALTH OF MASSACHUSETTS
RETURN
OF
A
DEATH
(CITY
OR
TOWN.)
t
^
-t~-
Registered
No.
r,r
\^~r.
19* « Residence Age wk .^. years months . ... lrr...'2-r: ...days
FULL NAME
Place of
Death *
STATISTICAL DETAILS
SEX — y-
c.
COLOR
p .-\,
SINGLE, MARRIED,
WIDOWED, OR /-) .
DIVORCED X
MAIDEN NAMEt
HUSBAND’S
NAMEt^_^Q^
BIRTHPLACE t
NAME OF
FATHER
Bl RTH PLACE
OF FATHER*
MAIDEN NAME
OF MOTHER
BIRTHPLACE
OF MOTHER I
(^y—'
OCCUPATION
IN FORMANT §
f
S.
PLACE OF BURIAL OR REMOVAL
UNDERTAKER
/£’<!
DATE OF BURIAL
J//
<S>
19(^6. ADDRESS
PHYSICIAN’S CERTIFICATE
I HEREBY CERTIFY that I attended deceased during last
illness, from
that to the best of my knowledge and belief death occurred on the
date stated above, and that the CAUSf OF DEATH yyas as follows:
Primary:
Contributory
r
(du ration) DAYS
\\-nmff. day 8
(Signed) M . D.
(Address)
^
SPECIAL INFORMATION only for Hospitals, Institutions, Transients,
or Recent Residents.
How long at
Place of Death 7 years months days
Where was disease contracted,
if not at place of death?
Filed
.190.
Clerk
‘City or town, street and number, If any. If death occurs away from USUAL RESI-
DENCE, give facts called for under “Special Information.” If In a Hospital or
Institution, give Its NAME Instead of street and number,
t In case of married or divorced woman, or widow.
J State or country | also city, town or county, If known.
§ Name and address of person giving statistical details.
II Name of cemetery.
/ a- - < ^ / o
#
\
i
1 — ^
ALL NAMES TO BE IN FULL
COMMONWEALTH OF MASSACHUSETTS
RETURN OF A DEATH (CITY OR TOWN.)'
FULL NAME A.. r^A~Arr^*r..f~rf. '..... n.. .".. A. nA) z Registered N
months ifrr. days
STATISTICAL DETAILS
SEVts
/*"
COLOR
LAO SINGLE, MARRIED,
WIDOWED, OR
DIVORCED
MAIDEN
NAMEt ^
^
HUSBAND’S NAM^tL,
BIRTHPLACE*
NAME OF
FATHER
^
^1-'
BIRTHPLACE
OF FATHER*
MAIDEN NAME
OF MOTHER ^ ,
BIRTHPLACE
OF MOTHER* ✓ . . ,
_
y’' rAi
OCCUPATION
INFORMANTS
* S'
PHYSICIAN’S CERTIFICATE
I HEREBY CERTIFY that I attended deceased during last
illness, from !9lfF*..to
that to OikAest of my knowledge and belief deaw occurred on the
date stated above, and that the CAUSE OF DEATH was as follows :
Primary:
i
Contributory:
(Signed).
4/ei
. ..f DURATION) 0AY8
. (Addres
5ECIAL INFORMATION only for Hospitals, Institutions, Transients,
or Recent Residents.
How long at
Place of Death? years months days
Where was disease contracted,
if not at place of death 7
Filed
.190.
Clerk
* City or town, street and number, if any. If death occurs away from USUAL RESI-
DENCE, give facts called for under "Special Information." If in a Hospital or
Institution, give its NAME instead of street and number,
t In case of married or divorced woman, or widow.
I State or country | also city, town or county, If known.
§ Name and address of person giving statistical details.
II Name of cemetery.
/ S', 'Q >o
ALL NAMES TO BE IN FULL
COMMONWEALTH OF MASSACHUSETTS
FULL NAME
Death
Residence
yyu//f#.ss (CITY OR T&WN.)
Registered No..
RETURN OF A DEA!
^
at
IQt
i fas? f ...//. ^
./If/f.S.i— Age ...years.. Z/.& ..months .ttt days
STATISTICAL DETAILS
SEX COLOR SINGLE, MARRIED,
WIDOWED, OR f D,VORCED
MAIDEN NAMEt *
HUSBAND’S NAMEt . -
BIRTHPLACE*
NAME OF
FATHER
~
?%*&//)
BIRTHPLACE
OF FATHER*
MAIDEN NAME
OF MOTHER
n
BIRTHPLACE
OF MOTHER*
■s? <y_)
OCCUPATION
y
INFORMANT §
PLACE OF BURIAL OR REMOVAL II
I1 sMa is
DATE OF BURIAL
y 19/ 0
UNDERTAKER / ADDRESS
SfMfAmyj/ctfs
PHYSICIAN’S CERTIFICATE
I HEREBY CERTIFY that I attended deceased during last
illness, \9/0.,
that to the best of my knowledge ansufelief death occurred on the
date stated above, and that the CAUSE OF DEATH was as follows: Primary
Contributor
(DURATION).. DAYS
SPECIAL INFORMATION only for Hospitals, Institutions, Transients,
or Recent Residents.
How long at
Place of Death 7 years months days
Where was disease contracted,
if
not
at place
of
death?
Filed
. 190-
Clerk
* City or town, street and number, If any. If death occurs away from USUAL RESI-
DENCE, give facts called for under "Special Information.” If In a Hospital or
Institution, give Its NAME instead of street and number,
t In case of married or divorced woman, or widow,
t State or country; also city, town or county. If known.
§ Name and address of person giving statistical details.
II Name of cemetery.
COMMONWEALTH OF MASSACHUSETTS
FULL NAME.
Place of Death*.
Date of Death
RETURN OF A DEATH
.Os.-CXst^ r. 7-'■ .7/: d.. Age
Registered No.
..years .
7'.
.months .
jCy?.. ...days STATISTICAL DETAILS
SEX COLOR
I Mr
.smetrc, iviAnm&o,
WIDOWED, OR
B+VOROSD
MAIDEN NAMEt
HUSBAND’S NAME t
BIRTH Pt ACEt
Cl
—
NAME OF
FATHER
<'Z<'/Ls7tsL
BIRTHPLACE
OF FATHER*
,
...
- T
MAIDEN NAME
OF MOTHER
BIRTHPLACE
OF MOTHER
OCCUPATroN
<7.
INFORMANT §
—
^
PLACE OF BURIAL OR REMOVAL I
7c*c*c*<. —
UNDERTAKER
DATE^Sf BURIAL
s ADDRESS
FIITSICIAN’S CERTIFICATE
I HEREBY CJJRIjFY that I attended deceased during last
illness, from 190^ to 1^0 ,
death occurred on the
s as follows:
that to the best of my knowledge and
date stated above, and that the CAUSE
U<W
Primary:
attended di
,0 h
and benef de
CAUSE OF DEATH wai
/I
. (duration). '....../I...7T.
Contributory :
''cyrpKZ’
(Signed) r:..y.
;u;
190 (Address).
SPECIAL INFORMATION only for Hospitals, Institutions, Transients,
or Recent Residents.
former or How long at
Usual Residence Place of Death?
Where was disease contracted.
If not at place of death?
How long at
Days
Filed
190
Clerk
* City or town, street and number, if any. If death occurs away from USUAL RESI-
DENCE, give facts called for under “Special Information.” If In a Hospital or
Institution, give Its NAME Instead of street and number,
t In case of married or divorced woman, or widow,
t State or country! also city, town or county, If known.
§ Name and address of person giving statistical details.
II Name of cemetery.
——
fae 27,8G00 /
COMMONWEALTH OF
FULL NAME......... Hovis
}
Place of Death
and Residence
Date of Death..
RETURN OF A DEATH—1910.
MASSACHUSETTS.
CITY OF
BOSTON.
STATISTICAL DETAILS.
PHYSICIAN'S CERTIFICATE.
COLOR SINGLE, MARRIED, WID., DIV.
Maidens Netrie sci. o.oc0: BOCEILccccessssssecssessstsccceeeeeey
Goorge F Gay
Husband’s Name.............
Birthplace Boston
Name of
Father
Birthplace
Ciel = (11217
Place of Burial
| HEREBY CERTIFY that | attended deceased during last illness,
Pees. re 1910, to.
that to the best of my knowledge and belief death occurred on the
date stated above, and that the CAUSE OF DEATH was as follows:
A
aes
‘Brianao)
(Borage
Angina Peetoris - 10 min
Contributory : Selerosis of eorona
(Duration) seceecerssescaerassestesnsenssnesensecenenasssseneeneaseescanerares
Maiden Name 2 yr
OP MOT ITEN comes -2>-.... Soe ae
Birthplace J
1) Lie UG, ee RR (Signed)
os -
Oceupatione:...........0..4 Pn ceiteenchenctteeteeeee... || d: BN... 1910. 2
| SPECIAL INFORMATION from Hospitals, Institutions, Transiests, or Recent
RIC | Residents.
Winthrop
or removal......- Usual Residence...................
Undertaker. nth... BEAStman Co. Filed..... 1910
A true copy.
et EAU Slemenr
Registrar.
V*
MOT-t
■
.
\
*
(r ni
ALL NAMES TO BE IN FULL
COMMONWEALTH OF MASSACHUSETTS
FULL NAME
Place of
Death
.years /....months .
STATISTICAL DETAILS
SEX hscsJtjL SINGLE, MARRIED,
WIDOWED, OR
DIVORCED
MAIDEN NAMEt
HUSBAND’S NAME t
BIRTHPLACE!
NAM
FATHER
h%f
<£-
BIRTHPLACE
OF FATHER
MAIDEN NAM
OF MOTHER
^'fRTmHoPtLhAeCrE!
&
OCCUPATION
INFORMANT §
bu
f—
l^PlRIAL
PLACE QF BURIAL OR REMOVAL II
UNDERTAKER i AlSttt ,-»
(2 $ —
DATE OF
t? 3
PHYSICIAN’S CERTIFICATE
I HEREE$)A CERTIFY that I attended^ deceased during last
illness, from. \9/& 19/6 ,
that to the bi^/t of my knowledge and belief death occurred on the
date stated abo^vand that the CAUSE OF DEATH was as follows :
Primary: Y.K
Contributory:
(Signed)
190 (Address)..
SPECIAL INFORMATION only for Hospl^s, Institutions, Transients,
or Recent Residents.
How long at
Place of Death 7 years months days
Where was disease contracted,
if not at place of death?
Filed
.190.
Clerk
ADDRESS ia£iv t in
* ± St;
* City or town, street and number, if any. If death occurs away from USUAL RESI-
DENCE, give facts called for under "Special Information.” If In a Hospital or
Institution, give its NAME Instead of street and number,
case of married or divorced woman, or widow,
t State or country; also city, town or county, If known.
§ Name and address of person giving statistical details.
II Name of cemetery.
??
C
\
Cane Je-
1460
ALL NAMES TO BE IN FULL
COMMONWEALTH OF MASSACHUSETTS
%
RETURN OF A DEATH (CITY OR TO tYN.)
Registered No.
FULL NAME
■SL? I ULL rr 1 ^ 6 i
. . . if?"?:., fr'. £v. . ^X.3.. ' Age years months
Residence
•19?^
. .days
STATISTICAL DETAILS
SEX /->
A COLOR
/A
SINGLE, MARRIED,
WIDOWED,
OR
/
DIVORCED //{6sl l Le i
MAIDEN NAMEt <fu
Cc*
HUSBAND'S
NAME
/3
birthplace!
NAME OF
FATHER
j/ BIRTHPLACE
OF FATHER!
-<
MAIDEN NAME
OF MOTHER
BIRTHPLACE
OF MOTHER!
/7
OCCUPATION
INFORMANTS
PLACE OF BURIAL OR REMOVAL II
A/ 0%^^
UNDERTAKER
DATE OF BURIAL
ADDRESS
PHYSICIAN’S CERTIFICATE
I HEREBY CERTIFY that I attended deceased during last
96.
....to
.....9^^r.rid.vf..
illness, from IS
19/3 , that to the best of my knowledge and belief death occurred on the
date stated abov^, and that the CAUSE OF DEATH was as follows:
Primary:
.(duration)..
Contributory:
(duration) DAYS
SPECIAL INFORMATION only for Hospitals, Institutions, Transients,
or Recent Residents.
How long at
Place of Death 7 years months days
Where was disease contracted,
if not at place of death 7
Filed
.190.
Clerk
* City or town, street and number, If any. If death occurs away from USUAL RESI-
DENCE, give facts called for under "Special Information." If In a Hospital or
Institution, give Its NAME instead of street and number,
t In case of married or divorced woman, or widow,
t State or country; also city, town or county, if known,
§ Name and address of person giving statistical details.
II Name of cemetery.
be —_ faethe
Prong baa
: Vi
/
. 4 > Fos
COMMONWEALTH OF MASSACHUSETTS
RETURN OF A DEATH
* H {CITY OR TOWN.)
Death
STATISTICAL DETAILS
SEX COLOR
IAJ
SINGLE, MARRIED
WIDOWED, OR
DIVORCED
MAIDEN NAMEt
HUSBAND’S NAME t
BIRTH PLACE t
NAME OF
FATHER
BIRTHPLACE
OF FATHER
MAIDEN NAME
OF MOTHER
BIRTHPLACE
OF MOTHER t
OCCUPATION
INFORMANT §
PLACE OF BURIAL OR REMOVAL II DATE OF BURIAL
ia
j UNDERTAKER
ADDRESS
PHYSICIAN’S CERTIFICATE
I HEREB^-GERTIFY that I attended deceased during last
illness,
{com
* * * §
190 .ta...rntrr-rr.
'¥*■■>
that to the best of my knowledge and belief death occurred on the
date stated above, and that the CAUSE OF DEATH was as follows:
Primary:
.
(DURATION) DAYS
Contributory :
dsufi..-. i). l9(/<3.. (Address).r^£}LA^^ hi
SPECIAL INFORMATION only for Hospitals, Institutions, Transients,
or Recent Residents,
How long at
Place of Death 7 years months days
Where was disease contracted,
If not at place of death?
Filed
.190. Clerk
* City or town, street and number, if any. If death occurs away from USUAL RESI-
DENCE, give facts called for under "Special Information." If In a Hospital or
Institution, give Its NAME Instead of street and number,
t In case of married or divorced woman, or widow,
t State or country; also city, town or county. If known.
§ Name and address of person giving statistical details.
II Name of cemetery.
— / a
6h ate —F q eett
q ae
Aut.
t4-- 5/710
COMMONWEALTH OF MASSACHUSETTS
RETURN OF A DEATH
FULL NAMh ...^y..^..^.....U,.: Registered No.
Place of
Death
...
f'.../'2"'...
"
^
_
-T
Date of Death Age .2?./. years ^^.months ..^L^ days
PHYSICIAN'S CERTIFICATE
I HEREBY CERTIFY that I attended deceased during last
illness, from ... ,^.£T<w I9C)(> to S 19^^..,
that to the best of my knowledge and belief death occurred on the
date stated above, and that the CAUSE OF DEATH was as follows :
.(duration) DAYS
:
(Signed). . . V
..^*£^....^....l9d.D.. (Address) .
SPECIAL INFORMATION only for Hospitals, Institutions, Transients,
or Recent Residents.
Former or How long at
Usual Residence Place of Death?
Where was disease contracted,
if not at place of death?
Days
190 Clerk
* City or town, street and number, If any. If death occurs away from USUAL RESI-
DENCE, give facts called for under "Special Information." If in a Hospital or
Institution, give Its NAME instead of street and number,
t In case of married or divorced woman, or widow.
I State or country) also city, town or county. If known.
§ Name and address of person giving statistical details.
II Name of cemetery.
[l.’09-37-XXXM.]
Permit No...
RETURN OF DEATH.
BOSTON, MASS.
Name in full,...
Sex, ....
r .19/0
(If married or divoraed woman give maiden name, also name of husband.)
Color, ...J'/w&O. .Condition
(White, Black, Mixed, Chinese, Indian, etc.)
ition,.
(Single, Married, Widowed or
Divorced.)
Ward,
Age, ^Years, ^... Months, ...H*-" Days. Occupation, ...hifjtk-LLil
Residence, *
Place of Death, *'-« is* (State year, month and da,
y^Date of Birth, "T:
* Place of Birth, \
Name and Birthplace
of Father,
Maiden Name and
Birthplace of Mother
Place of Interment,
* If an institution, state how long an inmate and previous residence.
wi Undertaker.
Name and Age
of Deceased
PHYSICIAN’S CERTIFICATE OF THE CAUSE OF DEATH.
Boston,.. S. 19.\ ^ .
,fe} Age, 5 years.
I hereby
certify that I
attended deceased
from. .19 y
to..
*\
19\^ , that I last saw alive on the... sr._ ..day of.. 19 Vd,
that. .died on the day of.. 19 \ 0 , ab.out \\ o’clock
** 4* SL-
A.M., or P.M., and that, to the best of my knowledge and belief, the cause o/T. death
was as
follows:
\
v
^
Chief cause ,
Disease
Contributing cause,
Chief Cause,
.
I
Duration
j Chief Contributing cause,.
Z3P' PHYSICIANS BEFORE STATING CAUSE OF DEATH
"vlf. D.
I ARE REQUESTED tb SEE THE OTHER SIDE OF THIS BLANK.
LIST OF INDEFINITE TERMS WHICH SHOULD BE AVOIDED
IN GIVING CAUSES OF DEATH.
Acute gastritis.
Ascites.
Asphyxia.
Asthenia.
Atrophy.
^ Blood poisoning.
Convulsions.
Debility.
Dentition.
Dropsy.
Dyspepsia.
Eclampsia.
Edema of lungs.
Gastric fever.
General paralysis.
Heart failure.
Hemorrhage of
lungs.
Hypostatic
congestion.
Imperfect
nutrition.
Inanition.
State cause. Was it due to some irritant poison? Infantile asthenia. See “Asthenia." The term “infantile" adds no precision to an indefinite statement.
Name disease causing ascites. See “Dropsy.” Infantile atrophy. See "Atrophy.”
How? Was it accidental? If so, state fully the nature
of the accident. If by gases or poisonous vapors, give
particulars. Was it a case of “overlying” (child)? What disease caused this condition?
Malassimilation. What disease caused the malassimilation ?
Malnutrition. What disease caused the malnutrition?
A practically worthless statement. See “ Debility.” What was the cause?
What caused the atrophy? Was it tuberculous wasting
(phthisis)? Was it syphilis? What organ or part
atrophied?
Do you mean septicemia, syphilis, or any other definite
disease? If septicemia, what was the cause? Was it
puerperal?
Was this not pulmonary tuberculosis?
Was it acute bronchitis, broncho-pneumonia, or lobar-
pneumonia? If so, state definitely. Was it passive
or hypostatic congestion? If so, name disease causing
the condition.
What caused the convulsions? Were they epileptic,
puerperal, or caused by diarrhea or enteritis (infants) ?
Name the disease in which the convulsions occurred.
“Convulsions” are mere symptoms and should not be
given as equivalent to a proper statement of cause of
death.
What disease caused the "marasmus” ? Was it due to
tuberculosis, syphilis, or cholera infantum? State
fully, as this return in itself is practically worthless for
compilation.
Was it’epidemic cerebro-spinal meningitis? If so, write
exactly in this form Did it follow scarlet fever, pneu-
monia, or some acute infection? If so, name the pri-
mary disease. Was it traumatic? If so, state the
nature of the violence which caused the meningitis.
Was it tuberculous meningitis?
Was it acute or chronic ? ■ If acute, occurring in the course
of some disease, name the disease causing death.
This is not a satisfactory return. The influence of age is
shown by the statement of age in years, months, and ;
days. To this the statement of “old age ” as a cause of
death adds nothing of value. Name the disease to
which the old person succumbed.
What was the cause of the peritonitis ? “ Idiopathic peri-
tonitis” should be rarely returned. Was it puerperal
or traumatic? In the latter case, state mode of injury, j
If any definite cause can be assigned for the anemia, it - !
should be reported. Anemia due to tuberculosis, syph-
ilis, etc., should be returned under the primary disease. V
Marasmus.
Meningitis.
Nephritis.
Old age.
Peritonitis.
Pernicious anemia.
What caused the debility? Name the acute or chronic
disease. Debility might follow typhoid fever, diph-
theria, tuberculosis, Bright’s disease, and a host of other causes. The return is worthless and should
never be made.
Pneumonia.
Pyemia.
What was the disease causing death of the teething child?
“Dentition” is not a proper cause of death, and, like
“infantile” and “old age,” does little except to mark
the approximate age of decedents.
Name the disease in which the "dropsy” occurred.
Senile asthenia.
Senile atrophy.
Specify definitely whether broncho-pneumonia or lobar- ^
pneumonia. If sequel to influenza, state that fact.
What caused the pyemia? Was it puerperal or trau-^
matic? If traumatic, state nature of accident causing^' l injury. v
See “Old age” and “Asthenia.” Give disease causing^ ' death. I
See “Old age” and “Atrophy.” State disease causing death.
Was there organic disease of the stomach or other organs?
If so, name the disease causing death.
Give cause of convulsions. Were they puerperal?
Give cause. See “Congestion of lungs.”
Senile decay.
Senile decline.
Senile marasmus.
See “ Old age.” State disease causing death.
See “ Old age.” Name the disease, if any, that caused the
decline.
See “Old age” and “Marasmus.” Name disease causing death.
A worthless return. Was it acute gastritis (q. v.) or some
definite form of fever, as typhoid, malarial, etc. ?
Shock. What caused the shock? If from injury, state nature of
accident. If from surgical operation, state disease or
injury requiring the operation.
If extended paralysis resulted from cerebral hemorrhage,
the cause should be given and the expression “general
paralysis” should be avoided. “General paralysis”
should be written only for “general paralysis of the
insane,” or paretic dementia, and the statement of the
fact of insanity should always be included.
What disease caused the “heart failure”? The heart
always “fails” before death from any cause. Be par-
ticularly careful that deaths from diphtheria, tubercu-
losis, etc., are not so reported. If organic heart disease
is meant it should be so stated.
Was this not due to pulmonary tuberculosis? If so, the
primary cause should be reported without fail.
Name the disease causing the passive or hypostatic con-
gestion.
State name of disease causing imperfect nutrition. Did it
follow some disease? If so, give name of disease.
This is a particularly pernicious term and is responsible
for a multitude of worthless certificates. It sounds as
if it meant something definite, but, in the majority of
cases, it does not. What disease caused the inanition ?
Was it syphilis, tuberculosis, cholera infantum? If
inability to take food, state cause.
Surgical
operation.
Surgical shock.
Teething.
Toxemia.
Tuberculosis.
Tumor.
Typhoid condition.
Typhoid pneumonia.
Typho-malarial fever.
Always state the disease or injury requiring operaoiuu
Unless the operation was improper or unskilfully per-
formed, itshould not be given as the primary cause oi
death.
Name the disease affecting the teething child. See "Deni
tition.” 1
Was this acute or chronic poisoning due to some externa
agent? Was it auto-intoxication, due to poisons gen-
erated in the body by disease? If so, state the naml
of the disease.
State organ affected. Do not fail to state as pulmonarl
tuberculosis if lungs were affected. "
Was it a cancer? Whether a cancer or tumor, do not fa|
to specify organ or part of body affected.
Avoid this term as it is likely to be mistaken for typhoil fever.
Was the primary disease typhoid fever or pneumonia?
Was it typhoid fever? Was it malarial fever? A mil
ture of these diseases rarely occurs, the great majoril
of cases of so-called “typho-malarial fever ’’[being not!
ing more nor less than typhoid fever. "
COMMONWEALTH OF MASSACHUSETTS
(jQ&Ci
RET F A .DEATH (CITY OB TOWN.)
RN
FULL NAME C Cksl-S&IL, / . Registered No /A.E
,°.f } /?•.?. . &j$. f{5e®tJf }.Z.!.<:..(z. / . ...\^\0
"]&$. ..£....<<Rjr£ (^.hry^y^LJ. . . . 'JvsSTtrTl. .'.....Age tL.5. years <£?. months /^*
Place
Death
Residence
day 3
STATISTICAL DETAILS
SEX COLOR SINGLE, MARRIED, «
WIDOWED, OR *7
divorced
h^iSlAA-Ai.
maiden name t
HUSBAND’S NAME t
BIRTHPLACE!
tTHPLACE
OF FATHER!
■/L,
ft
!^£'1 7-
MAIDEN NAME
OF MOTHER
TV'/r^x^ i 'b'Z /XT BIRTHPLACE
OF MOTHER!
Pyx <
OCCUPATION
INFORMANT 5
PLACE OF BURIAL OR REMOVAL II
UNDERTAKER
'M
'/OXsCL,
£#ATE OF BURIAL
19#^..
ADDRESS * / t
2.<i$
y^veA^y^-t
PHYSICIAN'S CERTIFICATE
I HEREBY CERTIFY that I attended deceased during last
illness, from...^.. 190 to 190 ,
that to the best of my knowledge and belief death occurred on the
date stated above, and that the CAUSE OF DEATH was as follows:
Primary:
(duration) DAYS
Contributory:
(OURATION) DAYS
(Signed) M.D.
19^}. ...(Address)
SPECIAL INFORMATION only for Hospitals, Institutions, Transients,
or Recent Residents.
How long at
Place of Death? years months days
Where was disease contracted,
if not at place of death? •
Filed
.190. Clerk
•City or town, street and number. If any. If death occurs away from USUAL RESI-
DENCE, give facts called for under "Special Information." If In a Hospital or
Institution, give Its NAME Instead of street and number,
t In case of married or divorced woman, or widow.
4 - t State or country) also city, town or county, If known.
§ Name and address of person giving statistical details.
II Name of cemetery.
LIST OF INDEFINITE TERMS WHICH SHOULD BE AVOIDED
IN GIVING CAUSES OF DEATH.
Acute gastritis.
Ascites.
Asphyxia.
State cause. Was it due to some irritant poison?
Name disease causing ascites. See “ Dropsy.”
How? Was it accidental? If so, state fully the nature
of the accident. If by gases or poisonous vapors, give
particulars. Was it a case of “overlying” (child)? What disease caused this condition?
Infantile asthenia.
Infantile atrophy.
Malassimilation.
Malnutrition.
See "Asthenia.” The term “infantile” adds no precision
to an indefinite statement.
See “Atrophy.”
What disease caused the malassimilation?
What disease caused the malnutrition?
Asthenia.
A
practically
worthless
statement. See
"Debility.”
What
was
the
cause?
Marasmus.
Atrophy. What caused the atrophy? Was it tuberculous wasting
(phthisis)? Was it syphilis? What organ or part
atrophied?
Meningitis.
y Blood poisoning. Do you mean septicemia, syphilis, or any other definite
disease? If septicemia, what was the cause? Was it
puerperal?
Was this not pulmonary tuberculosis?
Was it acute bronchitis, broncho-pneumonia, or lobar-
pneumonia? If so, state definitely. Was it passive
or hypostatic congestion? If so, name disease causing
the condition.
Nephritis.
Old age.
What disease caused the “marasmus” ? Was it due to
tuberculosis, syphilis, or cholera infantum? State
fully, as this return in itself is practically worthless for
compilation.
Was it’epidemic cerebro-spinal meningitis? If so, write
exactly in this form Did it follow scarlet fever, pneu-
monia, or some acute infection? If so, name the pri-
mary disease. Was it traumatic? If so, state the
nature of the violence which caused the meningitis.
Was it tuberculous meningitis?
Was it acute or chronic? If acute, occurring in the course
of some disease, name the disease causing death.
This is not a satisfactory return. The influence of age is
shown by the statement of age in years, months, and
days. To this the statement of “ old age ” as a cause of
death adds nothing of value. Name the disease to
which the old person succumbed.
Convulsions. What caused the convulsions? Were they epileptic,
puerperal, or caused by diarrhea or enteritis (infants) ?
Name the disease in which the convulsions occurred.
“Convulsions” are mere symptoms and should not be
given as equivalent to a proper statement of cause of
death.
Peritonitis. What was the cause of the peritonitis ? “ Idiopathic peri-
tonitis” should be rarely returned. Was it puerperal
or traumatic? In the latter case, state mode of injury.
Pernicious anemia. If any definite cause can be assigned for the anemia, it
should be reported. Anemia due to tuberculosis, syph-
ilis, etc., should be returned under the primary disease.
Debility.
Dentition.
Dropsy.
Dyspepsia.
Eclampsia.
Edema of lungs.
Gastric fever.
What caused the debility? Name the acute or chronic
disease. Debility might follow typhoid fever, diph-
theria, tuberculosis, Bright’s disease, and a host of
other causes. The return is worthless and should
never be made.
Pneumonia.
Pyemia.
What was the disease causing death of the teething child?
“Dentition” is not a proper cause of death, and, like
“infantile” and “old age,” does little except to mark
the approximate age of decedents.
Name the disease in which the “dropsy” occurred.
Senile asthenia.
Senile atrophy.
Specify definitely whether broncho-pneumonia or lobar- ^
pneumonia. If sequel to influenza, state that fact.
N.
What caused the pyemia? Was it puerperal or trau-^.
matic? If traumatic, state nature of accident causing' injury. v
See "Old age” and "Asthenia.” Give disease causing
death.
See “Old age” and “Atrophy.” State disease causing
death.
W as there organic disease of the stomach or other organs ?
If so, name the disease causing death.
Give cause of convulsions. Were they puerperal?
Give cause. See “Congestion of lungs.”
Senile decay.
Senile decline.
Senile marasmus.
See " Old age.” State disease causing death.
See “ Old age.” Name the disease, if any, that caused the
decline.
See “Old age” and “Marasmus.” Name disease causing death.
A worthless return. Was it acute gastritis (q. v.) or some
definite form of fever, as typhoid, malarial, etc. ?
Shock. What caused the shock? If from injury, state nature of
accident. If from surgical operation, state disease or
injury requiring the operation.
General paralysis. If extended paralysis resulted from cerebral hemorrhage, a.1 — — — — -U^.*lrl ^ ml nnrl fKa Avnroocmn 44 rrnnoro 1 Surgical
\ Always state the disease or injury requiring opera
# TTnlp«Q f.hp nnprat.inn toqb imnrnnnr nr iinsTtrilfiTlNr
ALL NAMES TO BE IN FULL
COMMONWEALTH OF MASSACHUSETTS
FULL NAME
Place of ‘
Death *
RETURN OF A .DEATH
(J^ iC (X^C^cCJzh
(CITY Oil TOWN.)
/
>^
cz
°Deathf
1
Residence
.
„caill
,
/
=2.
x
19
1o
Age ZlLZfZ. years <6?. months /.ZZk days
STATISTIC Ah DETAILS
SEX
COLOR
p
^IvzckJ^ (MUIl
SINGLE, MARRIED, ,
WIDOWED, OR *y
divorced
h^tyiA^uX
MAIDEN NAMEt
HUSBAND'S NAME t
BIRTHPLACE*
MAIDEN NAME
OF MOTHER
8IRTHPLACE
OF MOTHER *
OCCUPATION
''[ifhe-os/
^
tZ^Cc^
INFORMANT 5
PLACE OF BURIAL OR REMOVAL U
ZL ■LVTTX.
(fat
UNDERTAKER
'h
UsisO.
IATE OF BURIAL
19*^..
AUUH too * / p
Z A2- lo > I
PHYSICIAN’S CERTIFICATE
I HEREBY CERTIFY that I attended deceased during last
illness, from . 190 to 190 ,
that to the best of my knowledge and belief death occurred on the
date stated above, and that the CAUSE OF DEATH was as follows:
Primary:
.(duration) OAYS
Contributory:
. (duration) DAYS
I —/
(Signed) M.D.
19^}.. ..(Address)
SPECIAL INFORMATION only for Hospitals, Institutions, Transients,
or Recent Residents.
How long at
Place of Death? years months days
Where was disease contracted,
if not at place of death?
Filed
.190. Clerk
•City or town, street and number, If any, If death occurs away from USUAL RESI-
DENCE, give facts called for under "Special Information." If In a Hospital or
Institution, give Its NAME Instead of street and number,
t In case of married or divorced woman, or widow.
4 - t State or country) also city, town or county, If known.
§ Name and address of person giving statistical details.
II Name of cemetery.
a.
¥
Le
/2-1902
SE.
Cece G Vokl.
em)
tH
ALL NAMES TO BE IN FULL
COMMONWEALTH OF MASSACHUSETTS
RETURN OF A DEATH Registered No.
sept.22 L854. FULL NAME...
PIDea
th°f
...
...Cot
tage
Ave
. .
wint.hr
op.
.Mass
.
°Deltb
.
Fob-ls
1910
• NAME OF HOSPITAL OR INSTITUTION, IF ANY
Residence 89 G o 1 1 age Ave Wi nthrop Mas s CITY OR TOWN
Age 56
days
STATISTICAL DETAILS
SEX
male
|
COLOR
! white
SINGLE, MARRIED,
WIDOWED, OR
divorced
widowed
MAIDEN
NAME
John Prescott
HUSBAND'S
FULL NAME
BIRTHPLACE
Derryall
en
C
oun
t
y
Tyron
,
Ire
1
and
<
NAME OF
FATHER
BIRTHPLACE OF
FATHER
MAIDEN NAME
OF MOTHER
OCCUPATION
Th omas Prescott
Ireland
Margaret Brown
England
PHYSICIAN’S CERTIFICATE
I HEREBY CERTIFY that I attended deceased during last
illness from l^6<^...to.. 19^0-,
that to the best of my knowledge and belief death occurred on the
date stated above, and thatthe CAUSE OF D,£ATH was as follows :
n
i)
(\
Primary :
jj
Duration
Ctki
Contributory
Duration
M. D.
BIRTHPLACE OF
MOTHER
Liquor Dealer
FULL NAME OF
INFORMANT
RELATIONSHIP
TO DECEASED
Miss Prescott ( daught er )
! ADDRESS daughter
1
89 Cottage Ave
PLACE OF BURIAL Cemetery
Mt Hope City or Town
Boston
UNDERTAKER'S
NAME
j.B.Cole 3c Son
ADDRESS
124 Dorchester St. South Boston
SPECIAL INFORMATION only for Hospitals. Institutions,
Transients, or Recent Residents.
i Former or How long at
j Usual Residence Place of Death? Days
Where was disease contracted,
if not at place of death?
Recorded 190
Clerk of Board of Health
Filed
190
CITY ON TOWN ' City Clerk
7
aie.
| Yi.)
i (ie | Mter f
Pet. SESH ®
ALL NAMES TO BE IN FULL
COMMONWEALTH OF MASSACHUSETTS
RETURN OF A DEATH
FULL NAME. Registered No. .
Place of Death *. ...J!..<?. . . .y*
Date of Death Age ^../ ..years ^....mon
'..days
STATISTICAL DETAILS
SEX
£
COLOR
uJ
StNOLC, MARRIED,
WIDOWED, OR
DIVORCfcD
MAIDEN
NAMEt
(/^UP^tAjL
HUSBAND’S NAMEt / / y*) If J „ .
o*
H*
OCCUPATION
INFORMANT §
\MA;< rt PLACE OF BURIAL OR REMOVAL II
h (jLd-AL#-*
i UNDERTAKER
2
DATE OF BURIAL
ADDRESS
PHYSICIAN’S CER TIFICA TE
I HEREBY CERTIFY that I attended deceased during last
?*. I90^...to .Q*4rr.
that to the best of my knowledge and belief death occurred on the
illness, from
19/A..,
date stated above, and that the CAUSE OF DEATH was as follows:
Primary:
O-QStAAJL-*
.(duration) DAYS
Contributory:
(Signed)..
... 190/?.. (Ad d ress)
SPECIAL INFORMATION only for Hospitals, Institutions, Transients,
or Recent Residents.
Former or How long at
Usual Residence Place of Death 7 Days
Where was disease contracted.
If not at place of death 7
Filed
190 Clerk
* City or town, street and number, if any. If death occurs away from USUAL RESI-
DENCE, give facts called for under "Special Information.” If in a Hospital or
Institution, give Its NAME Instead of street and number,
t In case of married or divorced woman, or widow,
t State or country) also city, town or county. If known.
§ Name and address of person giving statistical details.
II Name of cemetery.
J£
7^ -i7 7/f/°
[l-’09-37 -X-XXM. ]
Permit No..,
RETURN OF DEATH.
Name in full,.
Date of DeaJth,..:.
f/.fL. Jig..:.
V)
.19
(/
(If married or divorced woman give maiden name, also name of husband.)
Sex, .%I.JJ..1IfkArr. Color, (White, Black, Mixed, Chinese, Indian, etc.)
.Condition, .
(Single, Married, Widowed or Divorced.)
—
Age, .A.y Years, Months, ~ Days. Occupation,
Residence,* Ward,
Place of Birth,
Name
and
Birthplace
j
us.
of
Father,
)
"
Maiden Name and ^ kf/ <kfNL —
Birthplace of Mother,
Place of Interment,
* If an institution, state how long an inmate and previous residence.
Undertaker.
PHYSICIAN’S CERTIFICATE OF THE CAUSE OF DEATH.
&JLp, f$%A. if...!... j9/d ■
X«me
and
A(e
)
(f
Age,.M.D..
Of
Deceased,
I
..
1.1
......B.tyv
•aJfe,-.fc.y.
years.
0
f)
/
y
I hereby certify that I attended deceased from.....,f~y^>. 19/0 , to /..... .v
19 1~>, that I last saw.. m ...alive on the.. Uf. ..day of.... 19 /A
that... jyU.... ..died on the.. /i ...day of. M 19/ (J, about ^./..o’clock
A,M., or P.M., and that, to the best of my knowledge and belief, the cause of. death,
was as follows:
Disease
j
Chief cause,
.
|Contributing cause
Duration
Chief Cause, -V
Contributing cause,
(M
m. d. ^PHYSICIANS before stating cause of death are requested to see the other side of this blank.
LIST
OF
INDEFINITE
TERMS
WHICH
SHOULD
BE
AVOIDED
IN
GIVING
CAUSES
OF DEATH.
Acute gastritis.
Ascites.
Asphyxia.
Asthenia.
Atrophy.
Blood poisoning.
Chronic
pneumonia.
Congestion of
lungs.
Convulsions.
Debility.
Dentition.
Dropsy.
Dyspepsia.
Eclampsia.
Edema of lungs.
Gastric fever.
General paralysis.
Heart failure.
Hemorrhage of
lungs.
Hypostatic
congestion.
Imperfect
nutrition.
Inanition.
State
cause. Was
it
due
to
some
irritant
poison?
Infantile
asthenia.
Name disease causing ascites. See “Dropsy.” Infantile atrophy.
See "Asthenia.” The term “infantile” to an indefinite statement.
See “Atrophy.”
adds no precision
How?
Was
it
accidental?
If so,
state
fully
the
nature
of
the
accident.
If
by
gases
or
poisonous
vapors,
give
particulars.
Was
it
a
case
of
“overlying
(child)
l
What
disease
caused
this
condition?
A
practically
worthless
statement. See
“Debility.”
What
was
the
cause?
What
caused
the
atrophy?
Was
it
tuberculous
wasting
(phthisis)?
Was
it
syphilis?
What
organ
or
part
atrophied?
Do
you
mean
septicemia,
syphilis,
or
any
other
definite
disease?
If
septicemia,
what
was
the
cause?
Was
it
puerperal
?
Was
this
not
pulmonary
tuberculosis?
Was
it
acute bronchitis,
broncho-pneumonia,
or
lobar-
pneumonia?
If
so,
state
definitely.
Was
it
passive
or
hypostatic
congestion?
If
so,
name
disease
causing
the
condition.
What
caused
the
convulsions?
Were
they
epileptic,
puerperal,
or
caused by
diarrhea
or
enteritis
(infants
l
/
Name
the disease
in
which
the
convulsions
occurred.
“Convulsions”
are
mere
symptoms
and should
not
be
given
as
equivalent
to
a
proper
statement
of
cause
oi
death.
Malassimilation.
Malnutrition.
Marasmus.
Meningitis.
Nephritis.
Old age.
Peritonitis.
Pernicious anemia.
What
caused
the
debility?
Name
the
acute
or
chronic
disease.
Debility
might
follow
typhoid
fever,
diph-
theria, tuberculosis,
Bright’s
disease,
and
a
host
ot
other
causes.
The
return
is
worthless
and
should
never
be
made.
Pneumonia.
Pyemia.
What
was
the
disease
causing death
of
the
teething
child?
“Dentition”
is
not
a
proper
cause
of
death, and,
like
“
infantile”
and
“old age,” does
little
except
to
mark
the
approximate
age
of
decedents.
Name
the disease
in
which
the
“dropsy”
occurred.
Was
there
organic
disease
of
the
stomach
or
other
organs?
If
so,
name
the disease
causing
death.
Give
cause
of
convulsions. Were
they
puerperal?
Give
cause.
See
“Congestion
of
lungs.”
A
worthless
return. Was
it
acute
gastritis
(q.
v.)
or
some
definite
form
of
fever,
as
typhoid,
malarial,
etc.?
Senile asthenia.
Senile atrophy.
Senile decay.
Senile decline.
Senile marasmus.
Shock.
What disease caused the malassimilation?
What disease caused the malnutrition?
What disease caused the “marasmus” ? Was it due to
tuberculosis, syphilis, or cholera infantum? State
fully, as this return in itself is practically worthless for
compilation.
Was it epidemic cerebro-spinal meningitis? If so, write
exactly in this form Did it follow scarlet fever, pneu-
monia, or some acute infection? If so, name the pri-
mary disease. Was it traumatic? If so, state the
nature of the violence which caused the meningitis.
Was it tuberculous meningitis?
Was it'acute or chronic ? If acute, occurring in the course
of some disease, name the disease causing death.
This is not a satisfactory return. The influence of age is
shown by the statement of age in years, months, and
days. To this the statement of “ old age ” as a cause of death adds nothing of value. Name the disease to
which the old person succumbed.
What was the cause of the peritonitis? “ Idiopathic peri-
tonitis” should be rarely returned. Was it puerperal
or traumatic? In the latter case, state mode of injury^.
If any definite cause can be assigned for the anemia, it\
should be reported. Anemia due to tuberculosis, syph- l
ilis, etc., should be returned under the primary disease, i
Specify
definitely
whether
broncho-pneumonia
or
lobar-1*
pneumonia.
If
sequel
to
influenza,
state
that
fact.
^
What caused the pj'emia? Was it puerperal or trau-*
matic? If traumatic, state nature of accident causing j, injury.
See "Old age” and “Asthenia.” Give disease causing death.
See “Old age” and “Atrophy.” State disease causing
death.
See “ Old age.” State disease causing death.
See “ Old age.” Name the disease, if any, that caused the decline.
See “Old age” and “Marasmus.” Name disease causing
death.
What caused the shock? If from injury, state nature of
accident. If from surgical operation, state disease or
injury requiring the operation.
If
extended
paralysis resulted
from
cerebral
hemorrhage,
the
cause
should
be
given
and
the
expression
general
paralysis” should be
avoided.
General
paralysis
should
be written only
for
"general
paralysis
of the
insane,”
or
paretic
dementia, and
the
statement
ot
the
fact of
insanity
should always
be
included.
Surgical
operation.
Surgical shock.
Always state the disease or injury requiring operation.
Unless the operation was improper or unskilfully per-
formed, itshould not be given as the primary cause of death.
Teething. Name the disease affecting the teething child. See “ Den-
tition.”
What
disease
caused
the
"heart
failure”?
The
heart
always
“fails” before
death from any
cause.
Be
par-
ticularly careful
that
deaths from diphtheria, tubercu-
losis, etc.,
are
not
so
reported.
If
organic
heart disease
is
meant
it
should
be
so
stated.
Toxemia.
Was this acute or chronic poisoning due to some external
agent? Was it auto-intoxication, due to poisons gen-
erated in the body by disease? If so, state the name
of the disease.
Was this not due to pulmonary tuberculosis? If so, the
primary cause should be reported without fail.
Name the disease causing the passive or hypostatic con-
gestion.
State name of disease causing imperfect nutrition. Did it
follow some disease? If so, give name of disease.
This is a particularly pernicious term and is responsible
for a multitude of worthless certificates. It sounds as
if it meant something definite, but, in the majority of
cases, it does not. What disease caused the inanition?
Was it syphilis, tuberculosis, cholera infantum? If
inability to take food, state cause.
Tuberculosis. State organ affected. Do not fail to state as pulmonary
tuberculosis if lungs were affected.
Tumor.
Was it a cancer? Whether a cancer or tumor, do not fai
to specify organ or part of body affected.
Typhoid condition. Av0>d
this
term
as
it is
likely to be
mistaken
for
typhoit
Typhoid pneumonia.
Typho-maiarial fever.
Was the primary disease typhoid fever or pneumonia?
Was it typhoid fever? Was it malarial fever? A mix
ture of these diseases rarely occurs, the great majorit:
of cases of so-called “typho-maiarial fever ’’[being noth
ing more nor less than typhoid fever.
COMMONWEALTH OF MASSACHUSETTS
DEATH
FULL NAME
Place
Death
(CITY OR TOWN.)
Residence
llL
2s. 2/
isterad No.
□„«, ( wit 40
Registe Date of
.years..
..months...
days
STATISTICAL DETAILS
SE)0^ CQLQR*/ SINGLE, MARRIEDo
rs
0R
JUwd.
MAIDEN NAMEt
HUSBAND’S NAME t
BIRTHPLACEt
NAME OF
FATHER
BIRTHPLACE
OF FATHER
: /J?
MAIDEN NAME^i
OF MOTHER/ J
BIRTHPLACE /
OF MOTHER
OCCUPATION
INFORMANT §
^55kV
PLACE OF BURIAL OR REMOVAL!
UNDERTAKER
GifLi r\L
DATE OF BURIAL
t| ./.C
ADDRESS
l^ * fHi
<so
PHYSICIAN'S CERTIFICATE
I HEREBY CERTIFY that I attende deceased during last
illness, from l9(/A..to.i y-*4r...-...j(..*j!. 190 Q.
that to the best of my knowledge and belief death occurred on the
date stated above, and that the CAUSE OF DEATH was as follows:
Primary:
(duration).... A . DAY 3
Contributory:
(duration) DAYS
M.D.
(a 1a.. (Address)
(Signed) All.,
k? 19^^. (Address)
SPECIAL INFORMATION only for Hospitals, Institutions, Transients,
or Recent Residents.
How long at
Place of Death? years months days
Where was disease contracted,
If
not
at place
of
death?
Filed
.190.
Clerk
* City or town, street and number, If any. If death occurs away from USUAL RESI-
DENCE, give facts called for under "Special Information.” If In a Hospital or
Institution, give Its NAME Instead of street and number,
t In case of married or divorced woman, or widow,
t State or country; also city, town or county. If known.
§ Name and address of person giving statistical details.
II Name of cemetery.
7 te 147-1960
nee o ooo
ee ey ee ae ae Le ee Se eS ee eee
FILL OUT WITH INK.. — 1 nlo 13 A
COMMONWEALTH OF MASSACHUSETTS
RETURN OF A DEATH
FULL NAME Registered No
(CITY OR TOWN.)
months. .V:. days
-i
_i
3
111
03
O
H
(0
u
3E
<
z
j
_i
<
STATISTICAL DETAILS
SE COLOR SINGLE, MARRIED,
WIDOWED, OR
DIVORCED
MAIDEN NAMEt
HUSBAND’S NAME t
-
—
—
’
BIRTHPLACE*
NAME OF J,
FATHER ^
'
c.
BIRTHPLACE x ■
OF FATHER*
MAIDEN NAME ^ ~ . / /
OF
MOTHER
{
^
f
BIRTHPLACE
OF MOTHER* ^
^
— OCCUPATIO
fMANT
$
X
INFORMANT §
PLACE OF BURIAL OR REMOVALII
6,
0.
£
UNDERTAKER
DATE OF BURIAL
Z X 7_
19
0...
ADDRESS
PHYSICIAN’S CERTIFICATE
I HEREBY CERTIFY that I attended deceased during last
illness, from 190 to 190 ,
that to the best of my knowledge and belief death occurred on the
date stated above, ana that the CAUSE OF DEATH was as follows:
Primary:
.(DURATION) DAYS
Contributory:
(duration). .S3 . DA Y8
(Signed^/ M.D.
. 19^.0. (Address) . . r.}£rr^£h<‘. <27^. . /.
7
SPECIAL INFORMATION only for Hospitals, Institutions, Transients,
or Recent Residents.
How long at
Place of Death? years months days
Where was disease contracted,
if not at place of death?
Filed
.190.
Clerk
•City or town, street and number, If any. If death occurs away from USUAL RESI-
DENCE, give facts called for under "Special Information.” If In a Hospital or
Institution, give its NAME Instead of street and number,
t In case of married or divorced woman, or widow,
t State or country; also city, town or county, if known.
§ Name and address of person giving statistical details.
II Name of cemetery.
1"
- " 2 “9 ‘
Li 2, Ag. tw 4h
Can ap Clear Sf aex
FEp-—19 ~ FLO
COMMONWEALTH OF MASSACHUSETTS.
CITY OF
FULL NAME
RETURN OF A DEATH-1910.
Ida J Jordan
BOSTON.
Registered
1002
Place _of Death i Boston ITew Baptist Hospt .
and
Residence
)
Date of Death .T.. ?. 1910. Age years l.Q months days.
STATISTICAL DETAILS. PHYSICIAN’S CERTIFICATE.
SEX COLOR SINGLE, MARRIED, WID., DIV.
F W M
1 HEREBY CERTIFY that 1 attended deceased during last illness,
from 1910, to 1910
. , .. Harsters Maiden Name
u u j. ki Laynard E Jordaja&^S Husband s Name
that to the best of my knowledge and belief death occurred on the
date stated above, and that the CAUSE Or DEATH was as follows:
Phlebitis - rt.leg - 2 wks
Birthplace
St
John^B
,
(Efrif&wftA \ V
^ . ,y\\ l
JJ m 1
1
l
\\2
BOSTi
VI r ^ \ T0NODII
^aTeof
Joseph
B*
Marster^v
««« Father ±
0Bi'Vh,te
V/ina.sor,tI.,,S>
miA sjjl 1 a,®. /
D, .Jffl /
o ;
Contributory
:
j
PulftL Enb
OllLS
-
...4....dyS
Eliz_a..J...langan
(Duration) l °
MS' V.'indsor
Housev;i fo
(Signed) T.P.PA&Ll: M.D.
Fgb.,19 .1910
SPECIAL INFORMATION from Hospitals, Institutions, Transients, or Recent
Residents.
Place of
Burial
St John.IT.B.
Usual
Residence V/inthr ov( 40
..
Fro emont. at
„ . 0 R Bonnison Undertaker
V.'inthrop
•
Foh 2*5
Filed 1910.
Cig mr 2
Teh
"ag
are, a ee
Po-sgr i
ALL NAMES TO BE IN FULL
COMMONWEALTH OF MASSACHUSETTS
RETURN
OF
A
DEATH
{CITY
OR
TOirtf.)
FULL NAME Registered No.
of) C "* Date of { Zy^2- / i * \ —■ V Death i
Place
Death
Residence Age
STATISTICAL DETAILS
SEX
JaJ
COLOR SINGLE, MARRIED,
WIDOWED, OR
DIVORCED
MAIDEN NAMEt
HUSBAND’S NAME t
BIRTHPLACE
NAME OF
FATHER
BIRTHPLACE
OF FATHER t
MAIDEN NAME
OF MOTHER c
Ju
v
Jz^crtruz
BIRTHPLACE
OF MOTHER*
y
— OCCUPATION
INFORMANT
'
y^-j
-
—
PLACE OF BURIAL OR REMOVAL II
& *
UNDERTAKER
-tf -
DATE OF BURIAL
^3
ADDRESS
PHYSICIAN’S CERTIFICATE
I HEREBY _C^ERTIFY that I attended deceased during last
illness, from 19*/?.. .to.. I9A<$)..,
that to the best of my knowledge and belief death occurred on the
date stated above, and that the CAUSE OF DEATH was as follows:
Primary:
.(duration) DAYS
Contributory:
..(DURATION) DAYS
(Signed)
..19 i.d...
M.D.
(Address).. JlL^itiuZ. iu. . ...i^Y. . . .
SPECIAL INFORMATION only for Hospitals, Institutions, Transients,
or Recent Residents.
How long at
Place of Death? years. months days
Where was disease contracted,
If not at place of death?
Filed
.190.
Clerk
* City or town, street and number, If any, If death occurs away from USUAL RESI-
DENCE, give facts called for under “Special Information.” If In a Hospital or
Institution, give its NAME instead of street and number,
t In case of married or divorced woman, or widow.
I State or country; also city, town or county, If known.
§ Name and address of person giving statistical details.
II Name of cemetery.
y
J a bee eierr—"
fet g/- 1970
"
ALL NAMES TO BE IN FULL
COMMONWEALTH OF MASSACHUSETTS
FULL NAME
Place of Death*.
RETURN OF A DEATH
Registered No.
Date of Death A, A Age years ....Jr:.. months .
.d ays
STATISTICAL DETAILS
SEX
Sr COLOR smauE,- MARrrrrD,
WIDOWED, OfT* IXLVORCE.D
MAIDEN
NAME
t
VT/AA,
HUSBAND’S NAME t
BIRTHPt ACE +
MAIDEN NAME
OF MOTHER
BIRTHPLACE
OF MOTHER +
OCCUPATION
INFORMANT §
ta
PLACE OF' BURIAL OR REMOVAL A
______ _
UNDERTAKER
DATE OF BURIAL
S- ■ 19g^-
ADDRESS
PHYSICIAN'S CERTIFICATE
I HEREE^-CERTIFY that I attendepf-cfeceased during last
illness, from SpP?..-..?.(a. I9lf0...to ./AT
that to the best of my knowledge and belief death occurred on the
date stated above, and that the CAUSE OF DEATH was as follows:
Primary:
Contributory :
feigned) •• (FfSSSSZ .
fes. . >r?. .... 19</lC? (Ad d ress)
(DURATION) DAYS
. (duration) OAYS
M.D.
SPECIAL INFORMATION only for Hospitals, Institutions, Transients,
or Recent Residents.
Former or
Usual Residence.
How long at
Place of Death? Days
Where was disease contracted,
if not at place of death 7
Filed 190
Clerk
•City or town, street and number, if any. If death occurs away from USUAL RESI-
DENCE, give facts called for under "Special Information.” If in a Hospital or
Institution, give Its NAME instead of street and number,
t In case of married or divorced woman, or widow,
t State or country | also city, town or county, If known.
§ Name and address of person giving statistical details.
II Name of cemetery.
wf
—_, ne
y
, 2 Spe’
ft.
COMMONWEALTH OF MASSACHUSETTS.
CITY OF
FULL NAME.
Place of Death )
and Residence (
Date of Death
RETURN OF A DEATH-1910. BOSTON.
Samuel
..White
Registered
No
1886
Boston
llass.Homoo.Hospt.
Fel) . 24 .1910. Age years months days.
STATISTICAL DETAILS. PHYSICIAN’S CERTIFICATE.
S£X COLOR SINGLE, MARRIED, WID., DIV.
gw s 1 HEREBY CERTIFY that 1 attended deceased during last illness,
from 1910, to 1910,
Maiden Name
Husband's Name
that to the best of my knowledge and belief death occurred on the
date stated above, and that the CAUSE OF DEATH was as follows:
lobar Pneumonia
Birthplace
B°St°n
M-li
(fru rfj\j
Efrfcn ifr ■ miii Y
Ol
Ijm 1
Dirtnpiace
i
iSoaT
Name
of
Charles
White
\V;-
§ji J
rA^nt
W J
Birthplace
HUSSia
—
-
^ibu.ory:)
Soarlet fever
-
6
days
Maiden Name Etta S.77aiIlG
(Duration)
J
Birthplace IhlSSia
of Mother J A Hayvjard
(Signed) M. D.
Feb. 24
.... * 1910
SPECIAL INFORMATION from Hospitals, Institutions, Transients, or Recent
Residents.
Place of
Burial WobumFKniarhts of
lihi or removal .— . 1 ^Residence . h T.QP. .( . 6 . . . 8X9. )
Jacob Stanetsky Undertaker Filed 1910.
A'7„T
ALL NAMES TO BE IN FULL
COMMONWEALTH OF MASSACHUSETTS
FULL NAME
Place
Death
Residence
RETURN OF A DEATH
vc
.TwttsiX
- {CITY OR
} , sB)....Sbx.a^ SJfcr: I
...Age.
fcvT.. ..years.
Registered No.
.4.4<| 19# O
months days
STATISTICAL DETAILS
-fd.
'A..
■
•'
COLOR SINGLE, MARRIED,
WIDOWED, OR/, . ^
DIVORCED (
MAIDEN NAMEt
HUSBAND’S NAME t
'£4*^0
NAME OF
FATHER
BIRTHPLACE
OF FATHER*
V
4("S' MAIDEN NAME
OF, MOTHER /~f
C
l
-\
(2^1^
BIRTHPLACE
OF MOTHER*
OCCUPATION
INFORMANT §
PLACE OF BURIAL OR PEMOVALlI
X
UNDERTAKER
d LAAcn.
DATE OF BURIAL
^
19
/P
ADDRESS
^RM-V&ICIA^S -CER TIFICA TE
I HEREBY CERTIFY tNrt-+ attended -deceased- duTtng" last
ilL"oce, from i^fr m — — — ■ — .. 196-r-— ,
^that to the best of my knowledge and belief death occurred on the
date stated above, and that the CAUSE OF DEATH was as follows :
Primary:
At^r*A^ .
Contributory:
.(duration) DAYS
SPECIAL INFORMATION only for Hospitals, Institutions, Transients,
or Recent Residents.
How long at
Place of Death? years months days
Where was disease contracted,
if not at place of death?
Filed
.190.
Clerk
* City or town, street and number, If any. If death occurs away from USUAL RESI-
DENCE, give facts called for under "Special Information.” If In a Hospital or
Institution, give Its NAME instead of street and number,
t In case of married or divorced woman, or widow.
I State or country; also city, town or county, If known,
§ Name and address of person giving statistical details.
II Name of cemetery.
Loge Il TaMole, |
Ak. 2Zye-l9FL0 |
/
COMMONWEALTH OF MASSACHUSETTS.
CITY OF
RETURN OF A DEATH-1910. BOSTON.
FULL NAME
Osoar
C
Berry Registered No. l?.l.v?.
Place_of Death
\
Boston
and
Residence
)
Date of Death .'f..®..1?. 5..
Eliot Hospt.
1910.
Age fi.5. years
.6.
months.
jLS-days.
STATISTICAL DETAILS. PHYSICIAN’S CERTIFICATE.
SEX COLOR SINGLE, MARRIED, WID., DIV.
M W M
1 HEREBY CERTIFY that 1 attended deceased during last illness,
from 1910, to 1910
Maiden Name
Husband's Name
that to the best of my knowledge and belief death occurred on the
date stated above, and that the CAUSE OF DEATH was as follows:
'
)
Pe
rf
.
Duodenal nicer
-
9
dys "
Birthplace
Heading Jlpj I
eirtnpiace ^
riMsf
\
UONIDD
Father0
Marc
e
11ns
)N3A gm T
•a /a $// /
x J/.J
of
Father".
Brn
Ifc
rt.Tt
y
contributory
:
j
Pe r
ivLenitis...-
...£L.d.ay.s (Duration) \
Maiden
Name
Hannah
A
Evans
Birthplace — , .
of
Mother
r1-.
‘P.
3>.d
ing (Signed) V/ .T Mixter m.d.
Insurance
SPECIAL INFORMATION from Hospitals, Institutions, Transier.ts, or Recent
Residents.
Place of Burial
Usual Residence 68 ^
W C
Skaggs
Undertaker
’.Vint
hr op
Peb.28
~'u)
Filed 1910.
•
y;
FILL OUT WITH INK. — THIS IS A PERMANENT RECORD
ALL NAMES TO BE IN FULL
COMMONWEALTH OF MASSACHUSETTS
DEATH
FULL NAME..
Place
Death
(CITY OR TOWN.)
Registered No.
STATISTICAL RETAILS
SE COLOR SINGLE, MARRIED,
WIDOWED, OR
DIVORCED
MAIDEN NAMEt
*
HUSBA„O.S
BIRTHPLACES
NAME OF
FATHER
birthplace
OF FATHERS
MAIDEN NAME
OF MOTHER^;
^ BIRTHPLACE
OF MOTHERS
INFORMANT §
PLACE OF BURIAL OR REMOVAL II
—
J
UNDERTAKER
PHYSICIAN’S CERTIFICATE
I HEREBY CERTIFY that I attended dece^ed during last
illness, 1^0 to^T^T7...^r'..y?
that to the best of my knowledge and belief death occurred on the
date stated above, and that the CAUSE OF DEATH was as follows :
Primary:
Contributory :
URAT!On)....*PT DAYS
(Signed).
duration). DAYS
M.D.
‘
190 (Address)..
t SPECIAL INFORMATION only for Hospitals, Institutions, Transients,
or Recent Residents.
How long at
Place of Death? years months days
Where was disease contracted,
if not at place of death?
Filed
.190. Clerk
* City or town, street and number, if any. If death occurs away from USUAL RESI-
DENCE, give facts called for under “Special Information.” If In a Hospital or
Institution, give Its NAME Instead of street and number,
t In case of married or divorced woman, or widow,
t State or country; also city, town or county, if known,
§ Name and address of person giving statistical details,
II Name of cemetery,
COMMONWEALTH OF MASSACHUSETTS.
CITY OF
RETURN OF A DEATH-1910. BOSTON.
FULL NAME Regie,, red No...2.0!7
Place of
Death
\
Boston
'aS":
*
G°n
*
'
°Spt
*
and
Residence
)
liter. 1 39 3 19
Date of Death 1910, Age years months. days.
STATISTICAL DETAILS. PHYSICIAN’S CERTIFICATE.
SEX COLOR SINGLE, MARRIED, WID., DIV.
F w s 1 HEREBY CERTIFY that 1 attended deceased during last illness,
from 1910, to 1910,
Maiden Name
/ Q.
Husband's Name fh
that to the best of my knowledge and belief death occurred on the
date stated above, and that the CAUSE Or DEATH was as follows:
sggsAS'X
Tr%®A Gen . Peritonitis - 3 dys
Birthplace
ffOOnSOCkO t
,P..
I
(Dura^rtXj
w».i . ,r/>A V
J
DiiuipiaLC
i
ua
fetP^T
&*,!! M5l5...R.S.oqtt \|k«
o^Faf Blaokstone
D
W
f
A
M
J
rAiHA. ■S?y /
Contributory : \ Appendicitis - 6 DOS
Maiden
Name
Henrietta
Abbott of Mother
(Duration) j
BirV? p|fce Engl and
Manicurist
(Signed)
TAiMoalf
M.D.
....Ma r.l |9|0
SPECIAL INFORMATION from Hospitals, Institutions, Transier.ts, or Recent
Residents.
Admitted to hospital Fob. 24. 1910
Placeof
Burial
V.OOnSOCkot
,
H.I
.
Usual
Residence Wint.^T^
Undertaker Filed 1910.
FILL OUT WITH INK. — THIS IS A PERMANENT RECORD
ALL NAMES TO BE IN FULL
COMMONWEALTH OF MASSACHUSETTS
RETURN OF A DEATH
. Registered N
{CITY OR TOWN/,
FULL NAME.
P0eathO.f \ ~ }
Residence Age V .X...... ..years..
%^<L
-
<^7ccXw^3
19/C
months days
STATISTICAL DETAILS • J‘TfT&I*JTAN!f> CERTIFICATE
SEX COLOR SINGLE, MARRIED, ' .
WIDOWED, OR USC Cten^°~ DIVORCED
MAIDEN NAMEt
HUSBAND’S NAME f
BIRTHPLACE*
NAME OF
FATHER
BIRTHPLACE
OF FATHER*
MAIDEN NAME
OF MOTHER
BIRTHPLACE
OF MOTHER t
OCCUPATION
INFORMANT §
/
PLACE OF BURIAL OR REMOVAL II DATE OF BURIAL
At*?.
UNDERTAKER ADDRESS
I HEREBY CERTIFY I rWoacofl during Inct
Him ~ij fi mu nn iQn r
that to the best of my knowledge and belief death occurred on the
date stated above, and that the CAUSE OF DEATH was as follows:
Primary:
,ktw*i
DAYS
Contributory:
(duration) DAYS
SPECIAL INFORMATION only for Hospitals, Institutions, Transients,
or Recent Residents.
How long at
Place of Death 7 years months days
Where was disease contracted,
If not at place of death 7
Filed 190
Clerk
* City or town, street and number. If any. If death occurs away from USUAL RESI-
DENCE, give facts called for under “Special Information.11 If In a Hospital or
Institution, give its NAME instead of street and number,
t In case of married or divorced woman, or widow,
t State or country; also city, town or county, If known,
§ Name and address of person giving statistical details.
II Name of cemetery.
; oe
Dare! ;
wine Ceca :, CE
fran .J-t
7-97
d
[l-’09-37-XXXM.]
-Vvvffk
if'.
Cl
w
Permit
JYo.
RETURN ^OF DEATH.
mass.
Date(
Name in full, j CVlucl -<?/ CIz.
*Q.
i maiden name, also name of hustfand.) f n (If married or divorced woman give mal
, sd/j. blPDtlAAptl... Color, (Single, Married, Widowed or
Divorced.)
Sex, SAfN..C/JfldiXIffT/.. Color, ....Condition,
(White, Black, Mixed, Chinese, Indian, etc.)
Age, jCj. ...).. Years, ii*^:..>Months, ...Srrrr.....Days . Occupation,
Residence,*
Ward,
Place
of
Death (Btate year, moij^h and day.)
Place
of
Birth,
C^g
Date
of Birth,
Name and Birthplace ) )c c A
of Father,
Maiden Name and
Birthplace of Mother, I
Place of Interment,
* If an institution, state how long an ini
£.lNfj(2lfU C- . . . £
i residence. //” /«=: .. >
PHYSICIAN’S CERTIFICATE *^OF THE CAUSE OF DEATH.
^
Boston
,
1
9.f
f
.
X7k::LT }
years.
I hereby
certify that I
attended deceased from
'
190
(J
,
to
>$.
19/ 0 , that I last saw alive on the day of 19/0,
that died on the day of v 19 to , about rrrLLTTo’ clock
A.M., or P.M., and that, to the best of my knowledge and belief, the cause of death
f> , \
was as follows: ( a ' i t ' l\
, \gLxnju\xkX-'
|
Chief cause,
cNoju^Or>^u>
.
cA^th^
Disease
Contributing cause, .
f Chief Cause, QnN.
Duration \ < a
Contributing
cause, Vxrx *~KJ ^
fghjjTU*\ \v &r<Kiuuuys^
«
M.D.
PHYSICIANS BEFORE STATING CAUSE OF DEATH ARE REQUESTED JO SEE THE OTHEtt SIDE OF THIS BLANK.
LIST
OF
INDEFINITE
TERMS WHICH SHOULD
BE
AVOIDED
IN
GIVING
CAUSES
OF DEATH.
Acute
gastritis.
State
cause. Was
it
due
to
some
irritant
poison?
Ascites.
Name
disease
causing
ascites.
See
“Dropsy.”
Infantile
asthenia.
See
“
Asthenia.”
The term
“infantile”
adds
no
precision
to
an
indefinite
statement.
Infantile atrophy. See “Atrophy.”
Asphyxia.
How?
Was
it
accidental?
If
so,
state
fully
the
nature
of
the
accident.
If
by
gases
or
poisonous
vapors,
give
particulars.
Was
it a
case of
“overlying
(child)?
What
disease
caused
this
condition?
Asthenia.
A
practically
worthless
statement.
See
"Debility.”
What
was
the
cause?
Atrophy.
What
caused
the
atrophy?
Was
it
tuberculous
wasting
(phthisis)?
Was
it
syphilis?
What
organ
or
part
atrophied?
Blood poisoning.
Do
you
mean
septicemia,
syphilis,
or
any
other
definite
disease?
If
septicemia,
what
was
the
cause?
Was
it
puerperal
?
Chronic
pneumonia. Was
this
not
pulmonary
tuberculosis?
Congestion of
lungs.
Was
it
acute
bronchitis,
broncho-pneumonia,
or
lobar-
pneumonia?
If
so,
state
definitely.
Was
it
passive
or
hypostatic
congestion?
If
so,
name
disease
causing
the
condition.
Convulsions.
What
caused
the
convulsions?
Were
they
epileptic
puerperal,
or
caused
by
diarrhea
or
enteritis
(infants)
f
Name
the disease
in
which
the
convulsions
occurred.
“Convulsions”
are
mere
symptoms
and should
not
De
given
as
equivalent
to
a
proper
statement
of
cause
oi
death.
Debility.
What
caused
the
debility?
Name
the
acute
or
chronic
disease.
Debility
might
follow,
typhoid fever
diph-
theria, tuberculosis,
Bright’s
disease,
and
a
host
ot
other
causes.
The
return
is
worthless
and
should
never
be
made.
Dentition.
What
was
the
disease
causing death
of
the
teething child?
“Dentition”
is
not
a
proper
cause
of
death, and,
like
“infantile”
and
"old
age,” does
little
except
to
mark
the
approximate
age
of
decedents.
Dropsy.
Name
the disease
in
which
the
“dropsy"
occurred.
Dyspepsia.
Was
there
organic
disease
of
the
stomach
or
other
organs?
If
so,
name
the disease
causing
death.
Eclampsia.
Give
cause
of
convulsions. Were
they
puerperal?
Edema of lungs.
Give
cause.
See
“Congestion
of
lungs.”
Gastric fever.
A
worthless
return. Was
it
acute
gastritis
(q.
v.)
or
some
definite
form
of
fever,
as
typhoid,
malarial,
etc. t
General paralysis.
If
extended
paralysis resulted
from
cerebral
hemorrhage,
the
cause
should
be
given and
the
expression
general
paralysis” should be
avoided.
General
paralysis
should
be written only
for
general paralysis
of
the
insane,”
or
paretic
dementia,
and
the
statement
of
the
fact
of
insanity
should always
be
included.
Heart failure.
What
disease
caused
the
"heart
failure”? The
heart
always
“fails” before
death from
any
cause.
Be
par-
ticularly careful
that
deaths from diphtheria, tubercu-
losis, etc.,
are
not
so
reported.
If
organic heart disease
is
meant
it
should
be
so
stated.
Hemorrhage of
lungs.
Was
this
not due
to
pulmonary tuberculosis?
If so,
the
primary
cause should
be
reported without
fail.
Hypostatic
congestion.
Name
the disease causing the passive
or
hypostatic
con-
gestion.
Imperfect
nutrition. State
name
of
disease
causing imperfect nutrition.
Did
it
follow
some disease?
If so,
give
name
of
disease.
Inanition.
This
is a
particularly pernicious term and
is
responsible
for a
multitude
of worthless certificates.
It
sounds
as
if it
meant something
definite, but, in the majority
of
cases,
it
does not. What
disease caused the inanition?
Was
it syphilis, tuberculosis, cholera infantum?
If
inability to take food, state cause.
Malassimilation. What disease caused the malassimilation?
Malnutrition. What disease caused the malnutrition?
Marasmus. What disease caused the “marasmus” ? Was it due to |
tuberculosis, syphilis, or cholera t infantum? State 1
fully, as this return in itself is practically worthless for
compilation.
Meningitis.
Was
it
epidemic
cerebro-spinal
meningitis?
If
so,
write
exactly
in
this
form.
Did
it
follow
scarlet fever,
pneu-
monia, or
some
acute
infection?
If so,
name
the
pri-
mary disease.
Was
it
traumatic?
If so,
state
the
nature
of
the violence
which
caused
the meningitis.
Was
it
tuberculous meningitis?
Nephritis.
Was
it
acute
or
chronic ?
If
acute,
occurring
in
the
course
of
some
disease,
name
the
disease
causing
death.
Old age.
This
is
not
a
satisfactory
return.
The
influence
of
age
is
shown
bv
the
statement
of
age
in
years,
months,
and
days.
To
this
the
statement
of
“
old
age
”
as
a
cause
of
death
adds
nothing
of
value.
Name
the
disease
to
which
the
old
person
succumbed.
Peritonitis.
What
was
the
cause
of
the
peritonitis?
“
Idiopathic
peri-
tonitis” should
be
rarely
returned.
Was
it
puerperal
or
traumatic?
In
the
latter case,
state
mode
of
injury,
i
Pernicious anemia.
If
any
definite
cause can be
assigned
for
the
anemia,
it
should
be
reported. Anemia
due
to
tuberculosis,
syph-
j
ilis,
etc.,
should
be
returned under
the
primary
disease.
Pneumonia.
Specify
definitely
whether
broncho-pneumonia
or
lobar-
pneumonia.
If
sequel
to
influenza,
state
that
fact.
Pyemia.
What
caused
the
pyemia?
Was
it
puerperal
or
trau-
matic? If
traumatic,
state
nature
of
accident
causing
injury.
Senile asthenia.
See
“Old age”
and
"Asthenia.”
Give
disease
causing death.
Senile atrophy.
See
“Old age”
and
“Atrophy.”
State
disease
causing
death.
Senile decay.
See “ Old age.” State disease causing death.
Senile decline.
See
“
Old
age.” Name
the
disease,
if
any,
that
caused
the decline.
Senile marasmus.
See
"Old age”
and
“Marasmus.”
Name
disease
causing
death.
Shock.
What
caused
the
shock?
If
from
injury, state
nature
of
accident.
If
from
surgical
operation,
state disease
or
injury requiring
the
operation.
Surgical
]
operation. > Surgical shock. ) Always
state
the disease
or
injury requiring operation.
Unless
the
operation
was
improper
or
unskilfully
per-
formed, it
should
not be
given
as
the
primary
cause
of
death.
Teething.
Name
the
disease affecting
the
teething
child.
See
“Den-
tition.”
Toxemia. Was this acute or chronic poisoning due to some external
agent? Was it auto-intoxication, due to poisons gen-
erated in the body by disease? If so, state the name
of the disease.
Tuberculosis. State organ affected. Do not fail to state as pulmonary
tuberculosis if lungs were affected.
Tumor. Was it a cancer? Whether a cancer or tumor, do not fail
to specify organ or part of body affected.
Typhoid condition.
Avoid this term as it is likely to be mistaken for typhoid
fever.
Typhoid pneumonia.
Was the primary disease typhoid fever or pneumonia?
Typho-malarial
fever. .
Was
it
typhoid fever? Was
it
malarial fever? A mix-
ture of
these diseases rarely occurs, the great majority of cases of so-called “typho-malarial fever” being noth-
ing more
nor less than typhoid fever.
UNDERTAKER’S RETURN. , ,
To the Board of Health of the City ofWorcester.
£L 'VT'
Date of Death ,(J[ Name..
Maiden Name Sex..
Color ' . 1 c ' Married, Single or Widowed
..Years,-. /J.J.. sf Months
&. ,.l.
Age
Name of the Physician
_
rZL
Residence of the Deceased, No jt&ck-Z*
/
Husband’s Name
< ..;. <„...
Occupation &<.*■. *...4*:....*ggcz., „. nusuduu s XNaiuc .-.
Place of Death, No % <i ^..Z.::.../: Street
Place of Birth ..._..s^.tsr£c
Father’s
Name
....-
^
d.
Father’s Birthplace
Mother’s Maiden Name *?.f / 2. ^ £-*£-.
Mother’s Birthplace z Z <„ ^,-c .<?... - r
/ j ^ ^ /-s .
Place
of
Interment PCeZ^..
Cemetery
z...
Date
of
Burial
.
_
LI
..Information given
by.„.?..i.Z
//
- -
Signature of Undertaker
Dated at Worcester, this /b ™ day of
Physician’s
Certificate
of
the
Cause
of
Death.
Date of Death,
Name and Sex of Deceased,
Place of Death . . .
Disease
or
Cause
Primary
of
Contributory
Death J
1 9 * * *
dN
y
f)l
Duration of*
Duration of
I certify that the above is»a true Return, to the best of my recollection and belief.
Name
and Professional
Title
,
Z
L
Z
■
^
y
^
•
Residence , No. SJfj f
Dated at
[Be very particular to fill all llte Blanks .]
Approved,
19 /f>
Reckoned to the time of death.
Board of Health.
— <a —— =
—_ Tnnless the operation was improper or unskilfully
ee ——
{ifs cause Should be given end the expression “general
COMMONWEALTH OF MASSACHUSETTS.
CITY OF
RETURN OF A DEATH-1910. BOSTON.
Ruth A Thompson 2294-
full NAME Registered No.
Place
of
Death
\
Boston
and
Residence
)
Date of Death Mar. 9
Boothby Kospt.
,0,0
*
35
3
13 .1910, Age years months days.
STATISTICAL DETAILS. PHYSICIAN’S CERTIFICATE.
SEX COLOR SINGLE, MARRIED, WID., DIV.
F ¥ M 1 HEREBY CERTIFY that 1 attended deceased during last illness,
Folsom that to the best of my knowledge and belief death occurred on the
date stated above, and that the CAUSE OF DEATH was as follows:
John S Thompson
Post-Opr. shock - 20 hrs
Carmel, Me . 1
* V 11 .'tv---1?'
pyj . . Y
ol
m ]
Dirinpiace i- o' jjgiji
Name
of
Oliver
J
FolSOm\«%
m:
DNff
A
ifll
J
rAm
Jjw
]
Birthpi,.,
Blue
Hill.Me.
S'
Contributory : \ Opr. Uterine fibroid -
Maiden Name Elizabeth A Clapham
(Duration)
J
n ■ , Carmel ,Me.
Birthplace 9
of Mother
n
hone
I) D Soannell
(Signed) M.D.
I.lar. 9
1910
SPECIAL INFORMATION from Hospitals, Institutions, Transients, or Recent
Residents.
Place of
Burial Spring, h.H.
¥
in th ro
p
Undertaker A. . . X*. i Q "fcTTlrlTl . .C.O. Filed LI&X...1Q - 1910.
I
.
ALL NAMES TO BE IN FULL
COMMONWEALTH OF MASSACHUSETTS 1387
oe OF A DEATH
FULL NAME
Piace of Death*...
Date of Death...“
STATISTICAL DETAILS PHYSICIAN’S CERTIFICATE
“SEX | cotor SINGLE, MARRIES,
fir | | WIDOWED; OR | HEREBY CERTIFY that | attended deceased during last
x _lW
— iliness, from .. Hee & 1980... to pipeeer &-) 192,
that to the best of my knowledge and belief death occurred on the
MAIDEN NAME T
BASS EYAND 5 WA || date stated above, and that the CAUSE OF DEATH was as follows:
BIRTHPLACE? || Primary: .... Or cccttnn. Preeege lia
Garaslf ten al
NAME OF
FATHER B oa
BIRTHPLACE
OF FATHER?
MAIDEN NAME
OF MOTHER f
ee es 0 ns A
pani APUACES © SPECIAL INFORMATION only for Hospitals, Institutions, Transients,
OF MOTHER es or Recent Residents,
o fi ae
Nee ea SO CA: Former or How long at
BCCUeATION Usual Residence... Place of Death? ceeeeeses Days
Where was disease contracted,
if not at place of death?
INFORMANT § Filed
OC—— tC ———————— —_
Clerk
.
PLACE OF BURIAL OR REMOVAL II E DATE OF BURIAL * City or town, street and number, if any. If death occurs away from USUAL RESI-
DENCE, give facts called for under “Special Information.” If in a Hospital or
institution, give Its NAME Instead of street and number,
t In case of married or divorced woman, or widow.
State or country; also city, town or county, If known,
Name and address of pers iving statistical details,
2 i ~ Lat 2 | || Name thoartlteyys ——
i/ Yi
. mer Cun 14
UNDERTAKER | AODRESS
ui
fol aden B ez Cowrk
Grae 13-190 a
FILL OUT WITH INK. -THIS IS A PERMANENT RECORD
ALL NAMES TO BE IN FULL
COMMONWEALTH OF MASSACHUSETTS
RETURN OF A DEATH ( CITY OR TOWN.)
FULL NAME . . 5f5f^fL7.‘r. . . Registered No
plaoe »'S '/ ^^7 — ■ c D»“^}
@2 .y .• '.AAyl.. 4„ 6 3 ..... -i.
Death
Residence
.19^
•Age.
..years..
months A.../.. day3
STATISTICAL DETAILS
SEX
”7'.
u>
SINGLE, MARRIED,
WIDOWED, OR ’ . DIVORCED IsO
MAIDEN NAMEt f
HUSBAND’S
NAME^^^^
— L \S 'l- i t f '1^2^-'
BIRTHPLACEt
NAME OF
FATHER
BIRTHPLACE
OF FATHER t
MAIDEN NAME . _ / , . , * .
OF
MOTHER
^
^
BIRTHPLACE
OF MOTHER*
/J^LC^
OCCUPATION
_[
IN FORMANT §
^ (tylA- 0.
PLACE OF BURIAL OR REMOVAL II
A
UNDERTAKER
-tf /A.
DATE OF BURIAL
ADDRESS
PHYSICIAN’S CERTIFICATE
I HEREBY CERTIFY that I attended deceased during last
illness, from ..k.f&*x..-..../. I90£... to. .'.... .....£ /.if.. I9G (<?...,
that to the best of my knowledge and belief death occurred on the
date stated above, and that the CAUSE OF DEATH was as follows :
Primary:
Contributory :
r/.... (duration) DAY 8
(Signed)... M.D.
<k/i. ./.C. 19 dress). <Z3~Lq. /.
SPECIAL INFORMATION only for Hospitals, Institutions, Transients,
or Recent Residents.
How long at
Place of Death? years months days
Where was disease contracted,
If not at place of death?
Filed
.190. Clerk
* City or town, street and number, If any, If death occurs away from USUAL RESI-
DENCE, give facts called for under "Special Information." If In a Hospital or
Institution, give Its NAME Instead of street and number,
t In case of married or divorced woman, or widow,
t State or country; also city, town or county, If known.
§ Name and address of person giving statistical details.
II Name of cemetery.
24
_-
Pree 1S 7 qe °
ALL NAMES TO BE IN FULL
THE COMMONWEALTH OF MASSACHUSETTS
FULL NAME...'^C^
Place of )
Death *
STATISTICAL DETAILS
SEX SINGLE^ MARRIED,
WIDOWED, OR
DI>*BRCED
MAIDEN NAMEt
HUSBAND’S NAME t
BIRTHPLACE*
NAME OF
FATHER /V /}
’u.
f
BIRTHPLACE
OF FATHER*
MAIDEN NAME
OF MOTHER
BIRTHPLACE
OF MOTHER*
OCCUPATION
Filed
PHYSICIAN’S CERTIFICATE
I HEREBY CERTIFY that I attended deceased during last
illness,
from...rilA^fjVv(.
I9U^
\o
W
l
i/,
that to the best of my knowledge and belief death occurred on the
date stated above, and that the CAUSE OF DEATH was as follows :
Primary: above, and that the CAUSE OF DEATH was as follows:
/La
(duration). DAY8
Contributory
(duration).. .'*/ M.D.
(Signed).
__
_
(Address).
SPECIAL INFORMATION only for Hospitals, Institutions, Transients,
or Recent Residents.
How long at
Place of Death? years months days
Where was disease contracted,
If not at place of death?
.19
Clerk
* City or town, street and number, If any. If death occurs away from USUAL RESI-
DENCE, give facts called for under "Special Information.” If In a Hospital or
Institution, give its NAME Instead of street and number,
t In case of married or divorced woman, or widow,
t State or country | also city, town or county, If known.
§^lame and address of person giving statistical details.
Marne of cemetery.
f
7
"
/
y C O
.
ALL NAMES TO BE IN FULL
COMMONWEALTH OF MASSACHUSETTS
RETURN OF A DEATH
FULL NAME Registered N
Place
Death '
Residence /..Z... Age.
(city on TOWN.)
} r«r ( .19/^
..years..
..months ...... 77T. days
STATISTICAL DETAILS
SEX
0?/'
COLOR 0^
SINGLE, MARRIED,
WIDOWED, OR
DIVORCED
MAIDEN NAMEt
HUSBAND’S NAME t z
BIRTHPLACE!
tecs
BIRTHPLACE
OF FATHER!
OF MOTHER
OF MOTHERt
OCCUPATION
INFORMANT §
PLACE OF BURIAL OR REMOVAL II
UNDERTAKER
DATE OF BURIAL
1 9$. .
ADDRESS
PHYSICIAN'S CERTIFICATE
I HEREBY CERTIFY that I attended deceased during last
illness, from .. 196 to..^^^./^....<.....l96 ,
that to the best of my knowledge and belief death occurred on the
date stated above, and that the CAUSE OF Df^ATH was as follows:
SPECIAL INFORMATION only for Hospitals, Institutions, Transients,
or Recent Residents.
How long at
Place of Death? years. months days
Where was disease contracted,
if not at place of death?
Filed
.190
Clerk
* City or town, street and number, if any. If death occurs away from USUAL RESI-
DENCE, give facts called for under "Special Information." If In a Hospital or
Institution, give Its NAME instead of street and number,
t In case of married or divorced woman, or widow,
t State or country; also city, town or county, If known.
§ Name and address of person giving statistical details.
II Name of cemetery.
J/
//-
'J'
°
ALL NAMES TO BE IN FULL
COMMONWEALTH OF MASSACHUSETTS CITY OF MEDFORD
RETURN OF A DEATH Registered No.
full NAME MmBIUUMBtJMBCm
P Iace o f
Death 1.2. 5. ..Monument. . . S.t.r.e. e.t. ,. . . ,M.e.df o r.d . NAME OF HOSPITAL OR INSTITUTION, IF ANY
Place of
Residence 5.1...W±nt.hrop... .Street •..■••W.inthrop*-Eass-. Age 4 years ^ months Q days
CITY OR TOWN '
STATISTICAL DETAILS
SEX
Male- MAIDEN
NAME
COLOR SINGLE. MARRIED
WIDOWED, OR
„„
.
DIVORCED
-White .^idw-e4-
HUSBAND'S FULL NAME
BIRTHPLACE AND
DATE OF BIRTH
NAME OF
FATHER
BIRTHPLACE OF
FATHER
. . . . . .?.o.rt smart h.v..M . ...II. Me n ..... .1 5 1861
Gr.e.orge . . . ,W... . . . Saab orn.
. Pq r.t . siao nth * . . . II. ...II
Kai e . . . .And r eisr.s
Lon.e.ll,....Mas.s..
.C.l.erh
.Ade.rp.hus.. . .Le avltt
MAIDEN NAME
OF MOTHER
BIRTHPLACE OF
MOTHER
OCCUPATION
1 FULL NAME OF
INFORMANT
OFFICIAL TITLE ADDRESS
..Me&f.Qr.r!
PHYSICIAN'S CERTIFICATE
I HEREBY CERTIFY that I attended deceased during last
illness from Mai’Ch IS , . 19 ]_0,
March- 21, 19 10,
that to the best of my knowledge and belief death occurred on the
date stated above, and that the CAUSE OF DEATH was as follows :
-Primary
Alcohol!
Sin-
Duration
.Many.-yrs...
contributory
q rdia.e.
Asthenia
Duration
PLACE OF BURIAL Cemetery
.Pair. ...View., De dham .Maas. . * .
City or Town
UNDERTAKER'S NAME
ADDRESS .Joh-.-E.. 'airier.
84 — Line
o,l
!-i
—
2
1-
■
oomerviLl' Is Ma s 5 CITY OR TOWN
I..Many...w:e.e.ks....
..(Sl?.ned.)
J.ame.s....
S..„.
Kennedy.
M.D:
(Address)
T/fcdf.Qrd
Date
M.ar>...211...10
SPECIAL INFORMATION only for Hospitals, Institutions,
Transients, or Recent Residents.
Where was
Disease ^ How long at
Contracted? O Place of Death ? Days
Recorded
Mar.
.22,...I9...1Q
A.--EU-£eed, Clerk of Board of Health
Filed
ft
cuJ
City Clerk
ALL NAMES TO BE IN FULL
>
)
)
J
3
3
D
J
J
I
COMMONWEALTH OF MASSACHUSETTS
(CITY OR TOWN.)
y
RETURN
OF
A
DEATH
FULL NAME . Registered No
°f } ...^Z. — DDeath 1 .$£S.*TZ:$£.. &.L 19/ (9
Place
Death
Residence Age.
..years.. ./. , .months. .T^ — .^..TT: days
STATISTICAL DETAILS
sF*t —
COLOR SINGLE, MARRIED,
WIDOWED, OR
DIVORCED
MAIDEN
NAMEt^^^
^
^
_
HUSBAND'S
NAMEt^^
BIRTHPLACE t
' /9 9" NAME OF
FATHER
BIRTHPLACE
OF FATHER t
/iy.
MAIDEN NAME
OF MOTHER
*0
«L^"L-i7 BIRTHPLACE
OF MOTHERt
^-9^-
OCCUPATION
INFORMANT §
PLACE OF BURIAL OR REMOVAL II
;. /2-7.
UNDERTAKER
<9 /t c
DATE OF BURIAL
Z- 3
19/c.
ADDRESS
PHYSICIAN’S CERTIFICATE
I HEREBY CERTIFY that I attended deceased during last
illness, from fr.9. .7. l9^f/5..to... : . . .^T.7.. ..19 (/>>. . ,
that to the best of my knowledge and belief death occurred on the
date stated above, and that the CAUSE OF DEATH was as follows :
Primary
, s<3 . (duration). ...TTt:. DAY
Contributory
SPECIAL INFORMATION only for Hospitals, Institutions, Transients,
or Recent Residents.
How long at
Place of Death 7 years months days
Where was disease contracted,
if not at place of death?
Filed
190. Clerk
* City or town, street and number. If any. If death occurs away from USUAL RESI-
DENCE, give facts called for under "Special Information.” If In a Hospital or
Institution, give Its NAME Instead of street and number,
t In case of married or divorced woman, or widow,
t State or country; also city, town or county, If known.
§ Name and address of person giving statistical details.
II Name of cemetery.
V .
7^
*3
^
"2- / ' . *- ^
ALL NAMES TO BE IN FULL
COMMONWEALTH OF MASSACHUSETTS
RETURN OF A DEATH
FULL NAME .... Z3.'.
Place of Death *. ^^CrrTT^</^t
Date of Death c3. Age ^... .^years.. .rrTrr:. ..:TTr. .. mmont hs
Registered No.
STATISTICAL DETAILS
SEX
^h\ TV-*-
SINCL-F, MARRIED,
wteewee^-erfl
MAIDEN NAMEt
HUSBAND’S NAME t
BIRTHPt ACE +
NAME OF
FATHER
BIRTHPLA
OF FATHER*
.J
.
2/ MAIDEN NAME
OF MOTHER
3
BIRTHPLACE
OF MOTHER *
OCCUPATION
INFORMANT §
PLACE OF BURIAL OR REMOVAL I
iu£_ UNDERTAKER
DATE OF BURIAL
ADDRESS
PHYSICIAN’S CERTIFICATE
I HEREBY CERTIFY that I attended deceased during last
illness, from -T&~'.?rrxi. 190 ).. to ... I9<f 0...t
that to the Jtfest of my knowledge and belief death occurred on the
date stated above, and that the CAUSE OF DEATH was as follows:
Primary: ... til- froJUM-
OdLCM-
SPECIAL INFORMATION only for Hospitals, Institutions, Transients,
or Recent Residents.
Former or How long at
Usual Residence Place of Death? Days
Where was disease contracted,
if
not
at place
of
death?
Filed
190 Clerk
* City or town, street and number, if any. If death occurs away from USUAL RESI-
DENCE, give facts called for under “Special Information." If in a Hospital or
Institution, give Its NAME instead of street and number,
t In case of married or divorced woman, or widow,
t State or country) also city, town or county. If known.
§ Name and address of person giving statistical details.
Name of cemetery.
———— ee —<“<))’””rmrmrmrmrtr
3-3
Ss
(a a a ce it
Pees oe ae
ALL NAMES TO BE IN FULL
COMMONWEALTH OF MASSACHUSETTS
(CITY OR TOWN.) RETURN OF A DEATH
FULL NAME ... .Tr. Registered No
Place of
Death *
Date of
iJk'ftr.AJZ.
Residence f. ScrTrT >r...rW^. Age.
.years.. X. months..
.days
STATISTICAL DETAILS
SEX COLOR SINGLE, MARRIED,
WIDOWED, OR
DIVORCED
MAIDEN NAMEt
HUSBAND’S NAME t
BIRTHPLACE?
NAME
fatheS^^^.
birthplace
OF FATHER?
r
MAIDEN NAME
OF MOTHER
BIRTHPLACE
OF MOTHER?
-'Z'O
OCCUPATION
I N FORMANT §
?
PLACE OF BURIAL OR REMOVAL II
'J/ £
t
UNDERTAKER
DATE OF BURIAL
19 6.Q..
ADDRESS
FHYSIC IAN’S CERTIFICATE
I HEREBY CERTIFY that I attended deceased during last
illness, fronr..(!fcC...?rr..3. I$0 to 19,6 ,
that to the best of my knowledge and belief death occurred on the
date stated above, and thatjthe CAUSE OF DEATH was as follows :
Primary:
. (duration).. ............... days
Contributory:
(duration) 0AY8
SPECIAL INFORMATION only for Hospitals, Institutions, Transients,
or Recent Residents.
How long at
Place of Death? years months days
Where was disease contracted,
if not at place of death?
Filed
.190. Clerk
•City or town, street and number, if any, If death occurs away from USUAL RESI-
DENCE, givo facts called for under "Special Information.” If In a Hosp!tal or
Institution, give its NAME instead of street and number,
t In case of married or divorced woman, or widow.
I State or country j also city, town or county, If known.
§ Name and address of person giving statistical details.
II Name of cemetery.
It
ALL NAMES TO BE IN FULL
COMMONWEALTH OF MASSACHUSETTS
.Registered No.
RJETURN OF A DEATH
FULL NAME
^
ath* * * §
S
,
;
°££
1
M^..AA
,9
{0
Residence L.C.. years J.. .months r. days
STATISTICAL DETAILS
COLOR
fa^TCz^r
SINGLE, MARRIED,
WIDOWED, OR
DIVORCED
MAIDEN NAME t <*• C/7 ■ , *» x-
HUSBAND’S NAME t
L * S* d<-
BIRTHPLACE t
NAME OF
FATHER
BIRTHPLACE
OF FATHER t
A /S^c^ -C /f'
MAIDEN NAME
OF MOTHER
BIRTHPLACE
OF MOTHER t
OCCUPATION
INFORMANT § A
j: ^ —•-O
PLACE OF BURIAL OR REMOVAL II DATE OF BURIAL
UNDERTAKER ADDRESS
PHYSICIAN’S CERTIFICATE
I HEREBY CERTIFY that 1 attended deceased during last
illness, from 190 to ...A: A.. r?~rf?. I<j4) , that to the best of my knowledge and belief death occurred on the
date stated above, and that the CAUSE OF DEATH was as follows:
primary.
7
SPECIAL INFORMATION only for Hospitals, Institutions, Transients,
or Recent Residents.
How long at
Place of Death? years months days
Where was disease contracted,
If not at place of death 7
Filed
.190.
Clerk
* City or town, street and number, if any. If death occurs away from USUAL RESI-
DENCE, give facts called for under "Special Information." If In a Hospital or
Institution, give Its NAME instead of street and number,
t In case of married or divorced woman, or widow,
t State or country; also city, town or county. If known.
§ Name and address of person giving statistical details.
II Name of cemetery.
0 Fahy
QO A . . Chotaeeee -
besser
Hewk 260410
ALL NAMES TO BE IN FULL
COMMONWEALTH OF MASSACHUSETTS
FULL NAME....^
Place of Death *
Date of Death
RETURN OF A DEATH
'■&
No.
months days
STATISTICAL DETAILS
“,r COLOR
AO
SINGLE,— MARftlEJ^,
WIDOWED, Oft
DIVORCED
N NAMEt
/3.
HUSBAND’S NAME t
BIRTHPl ACEt
NAME OF
FATHER
m
BIRTHPLACE
OF FATHERt
MAIDEN NAME
OF MOTHER
£L^M£L BIRTHPLACE
OF MOTHER* 1
OCCUPATION
tAT
INFORMANT §
PLACE OF BURIAL OR REMOVAL II
Axl''
UNDERTAKER
H&-J&
DATE OF BURIAL
ADDRESS
%<)/.£)■
PHYSICIAN’S CERTIFICATE
I HEREBY CERTIFY that I attended deceased during last
illness, from VU .A A-. . .(. l9fT?.to ' 19^.0,
that to the best of my knowledge and belief death occurred on the
date stated above, and that the CAUSE OF DEATH was as follows:
\si
aa<_-
S
.4
'
't
"
Primary :
.(duration) DAYS
Contributory
. (duration) DAYS
(Signed). Kb
'WVgOVW
V:.. v> .
19^®.
(Address)
-
M.D.
SPECIAL INFORMATION only for Hospitals, Institutions, Transients,
or Recent Residents.
Former or How long at
Usual Residence Place of Death? Days
Where was disease contracted,
If not at place of death 7
Filed
.190. Clerk
* City or town, street and number. If any. If death occurs away from USUAL RESI-
DENCE, give facts called for under "Special Information.” If in a Hospital or
Institution, give Its NAME instead of street and number,
t In case of married or divorced woman, or widow.
J State or country) also city, town or county, If known.
§ Name and address of person giving statistical details.
II Name of cemetery.
Z-'ff'
i
. I *'i 1 ,
ALL NAMES TO BE IN FULL
COMMONWEALTH OF MASSACHUSETTS
RETURN OF DEATH
FULL NAME
Place of
Death
Residence
1 } "Death’ \9jScJ
. . Age year*. montl)^ day*
STATISTICAL DETAILS
SEX
lUaL.
COL°V..z SINGLE, MARRIED,
WtDUWtU, UK Mwrt rvrtg p*
t/l WTTVE. U
MAIDEN NAMEt
HUSBAND’S NAME t
< JaA
NAME OF
FATHER
BIRTHPLACE
OF FATHER t
/a), X/
MAIDEN NAME
OF MOTHER
BIRTHPLACE
OF MOT
rHER^
OCCUPATION
INFORMANT §
PLACE OF BURIAL
l fptS&O' - /l^C^L
UNDERTAKER
3'M-M U^C-Ll '?*' " / l
DATE OF BURIAL
PHYSICIAN’S CERTIFICATE
I HEREBY CERTIFY that I attended deceased during last
illness, from .... I90£...to \9jp'..".., that to the best of my knowledge and belief death occurred on the
date stated above, and that the CAUSE OF DEATH was as follows;
Primary : jve, ana tnat tne UAUst ur utA i h was as follows ;
Contributory:
ration) DA> J
S t/ v'-fx*? t*>-z arz.
(Signed).
r
|9(&>... (Address)
(duration) DAY 8
ZJ? .... M.D.
SPECIAL INFORMATION only for Hospitals, Institutions, Transients,
or Recent Residents,
How long at
i Place of Death 7 years months days
Where was disease contracted,
If not at place of death?
Filed
.190. Clerk
* City or town, street and number, If any, If death occurs away from USUAL RESI-
DENCE, give facts called for under “Special Information." If In a Hospital or
Institution, give its NAME Instead of street and number,
t In case of married or divorced woman, or widow.
I State or country i also city, town or county, If known.
§ Name and address of person giving statistical details.
II Name of cemetery.
a ~
Vara ten
Daedhdhig -
mC \ s
. Siglo
ahar\ ot
ALL NAMES TO BE IN FULL
THE COMMONWEALTH OF MASSACHUSETTS
RETURN OF A DEATH Sit.QUxrM.on (CITY OR TOWN.)
■mi,
mamp
James Freeman Drake
Mason FULL NAME r. _ Registered No
Place of) Stoughton Date of ( ^pr 3
Death * S Death J *
76
10
16
.19
10
„
Winthrop Residence Age
.years..
..months days
STATISTICAL DETAILS
SEX
M COLOR
w SINGLE, MARRIED,
WIDOWED, OR W
DIVORCED
INFORMANT § Mrs. H. D. M. Crane,
Stoughton
Daughter .
PLACE OF BURIAL OR REMOVAL II
Mt. Pleasant
Cem,
Taunton
UNDERTAKER
Lowe , °mith & Power
ADDRESS
St oughton
MAIDEN NAMEt
HUSBAND’S NAMEt
BIRTHPLACE?
Swansea
NAME OF
FATHER
EJeorge
Mason
BIRTHPLACE
OF FATHER?
Swansea
MAIDEN NAME
OF MOTHER
Sarah E. Davis
BIRTHPLACE
OF MOTHER?
Rehot oth
OCCUPATION
Pattern maker
I HEREBY CERTIFY that I 2BfeXd£areS6eased
^5^^ . . . On n . ^ iqo 19
DATE OF BURIAL
..Apr...„„4 ? 19!0
PHYSICIAN’S CERTIFICATE
red—
vi e\
that to the best of my knowledge and belief death occurred on the
date stated above, and that the CAUSE OF DEATH was as follows:
Concussion
of
Brain
Primary :
Contributory :
(duration) DAYS
Alscess of Brain
..(duration) DAY 8
rsirrnpH)
W.
0. Eaxon
,
Medical Examiner
(Signed)
.
...XX..
*.....
SL*....-F.
?
5
-
^
Stoughton . Apr...... 4 iglO (Address) .
SPECIAL INFORMATION only for Hospitals, Institutions, Transients,
or Recent Residents.
How
long
at
^
Place of Death? years months .days
„.
.
,
,Hai
a
fall #211 fountain
I
Filed
I9i<
....M.ay.....6 19 10, &&&. Clerk
* City or town, street and number, if any. If death occurs away from USUAL RESI-
DENCE, give facts called for under "Special Information." If In a Hospital or
Institution, give its NAME Instead of street and number,
t In case of married or divorced woman, or widow.
? State or country) also city, town or county, if known.
§ Name and address of person giving statistical details.
II Name of cemetery.
-----
ALL NAMES TO BE IN FULL
COMMONWEALTH OF MASSACHUSETTS
RETURN OF
FULL NAME...
Place of Death *.../..
Date
of
Death
^
STATISTICAL DETAILS
SEX COLOR SINGLE, MAMtEO,
WIDOWtOj-OR- DIVORGED
MAIDEN NAMEt
HUSBAND’S NAME t
BIRTH
NAME OF
FATHER
PI ACE t
&
-
1
0
KJ
iJsLr-ZS&X—
BIRTHPLACE
OF FATHER*
MAIDEN NAME
OF MOTH
_ ,, . .
ME _ \
*, r -I /? y.
H
^R-
'
/X )///[ <
.ace 7/2 /? Jrr~^ . — ✓
BIRTHPLACE ; //7 /? / r/ . „
OF MOTHER * ^ ^ ( /£-. ZK fT?
OCCUPATION
INFORMANT §
PLACE OF BURIAL.-OfT REMOVATX
UNDERTAKER
DATE OF BURIAL
J).—/..<2..- 19/^..
ADDRESS
Z2>/Zz / /s,er/C'Kf‘/~'
MUSICIAN'S CERTIFICATE
I HEREBY CERTIFY that I attended deceased during last
illness, from ofo to . 'Xr7 . ) 1^0 ,
that to the best of my knowledge and beliefvdeath occurred on the
date stated above, and.that the^AUSE QF"t>EATH/wasas follows : Primary:
(duration) DAYS
Contributory:
^ — v f\.. (dURATI/On) DAYS
(Signed) L..™..KSLr L./TaJ. M.D.
i i I^fo (Address) .
SPECIAL INFORMATION only for Hospitars^l nstitutlons, Transients,
or Recent Residents.
Former or How long at
Usual Residence Place of Death? Day*
Where was disease contracted,
If not at place of death?
Filed
190 Clerk
* City or town, street and number, if any. If death occurs away from USUAL RESI-
DENCE, give facts called for under "Special Information.” If in a Hospital or
Institution, give Its NAME instead of street and number,
t In case of married or divorced woman, or widow,
t State or country | also city, town or county. If known.
§ Name and address of person giving statistical details.
II Name of cemetery.
a¢
oprah ww, ' G10
ALL NAMES TO BE IN FULL
THE COMMONWEALTH OF MASSACHUSETTS
Registered No.
RETURN OF A DEATH
FULL
NAME
^
Place
of)
9
Death*
)
••■■
Residence .<?. ? 1 Age /...9. years t?..
Date of
Death $
..years..
t
(CITY OR TOWN.)
!U
19/
°
months .”5 days
STATISTICAL DETAILS
SEX COLOR SINGLE, MARRIED, WIDOWED, OR y
DIVORCED
MAIDEN NAMEt
HUSBAND’S NAME t
BIRTHPLACE t
NAME OF
FATHER
Zrr A
BIRTHPLACE
OF FATHER!
MAIDEN NAME
OF MOTHER
BIRTHPLACE
OF MOTHER t
OCCUPATION
INFORMANT §
PLACE OF BURIAL OR REMOVAL II
UNDERTAKER
.. 19 < <“>
PHYSICIAN'S CERTIFICATE
I HEREBY CERTIFY that I attended deceased during last
illness, from lX)U1AaX 1 19 f 0 to Or T'.A. 19 I O ,
that to the best of my knowledge and belief death occurred on the
date stated above, and that the CAUSE OF DEATH was as follows:
Primary:
. (duration).
n) U. DAYS
Contributory: .A3
..(X LcX-^s
(Signed). Ha
(duration).
[Apia
.19 (Address)'
. \L) .(r A M.D.
U/
v/La.
*
p
^
SPECIAL INFORMATION only for Hospitals, Institutions, Transients,
or Recent Residents.
How long at
Place of Death7 years. months days
Where was disease contracted,
if not at place of death?
Filed
.19
Clerk
* City or town, street and number, if any. If death occurs away from USUAL RESI-
DENCE, give facts called for under “Special Information.” If In a Hospital or
Institution, give its NAME Instead of street and number,
t In case of married or divorced woman, or widow,
t State or country; also city, town or county, If known.
§ Name and address of person giving statistical details.
II Name of cemetery.
84
—— er
3 Stig SidQuau Morr
os q4qdto
COMMONWEALTH OF MASSACHUSETTS.
CITY OF
RETURN OF A DEATH-1910. BOSTON.
FULL
NAME
Registered
No.
3571
p. *n . Lias s. Gen. Eos pt*
Place
of
Death
(
Boston
and
Residence
)
,
35
2
10
Date of Death t'.V.G*.— . .Tr 1910. Age years months days.
STATISTICAL DETAILS. PHYSICIAN’S CERTIFICATE.
SEX COLOR SINGLE, MARRIED, WIO., DIV.
F W M 1 HEREBY CERTIFY that 1 attended deceased during last illness,
M
M
Smith Maiden Name
Paul Draeger
Husband's Name
that to the best of my knowledge and belief death occurred on the
date stated above, and that the CAUSE OF DEATH was as follows:
Pgx
Gen. Peritonitis, Intestinal oh
Birthplace
SnElana
(Dur^f^y) -
isyfc) struct! on, fol: Salpingectomy
\ C©NIDII
^!a,yie of 17111 ian H Smith mi
)W¥A'
m
}
A
AX
Mu
J
and append oc to my - 11 dys
^rtFhP|aff England
1 Contributory : )
Maiden Name Clara E Throtcher
(Duration)
j
Birthplace England
of Mother
..
Housewife
(Signed) C-..H..-Ivlet.Ga,!f M.D.
1910
SPECIAL INFORMATION from Hospitals, Institutions, Transients, or Recent
Residents.
Admitted to hospital Liar. 21 ,1910
Place of Burial ~-t .Ope
or removal
Smith & Pea]:
Undertaker
17 inth r op (14 7 Llai n st )
Usual Residence
Apr .14 Filed 1910
A true copy. __ /7
Registrar,
ALL NAMES TO BE IN FULL
THE COMMONWEALTH OF MASSACHUSETTS (7
FULL NAME:
Place
of
|
^
I
*
)
"rr*
RETURN OF A DEATH ue
Syo years..
(CITY OR TOWN .)
Hr
0
Registered No
..months days
STATISTICAL DETAILS
SEX-.
r2Wr <£-<£<-
COLOR SINGLE, MARRIED,
WIDOWED, OR
DIVORCED
MAIDEN NAMEt
HUSBAND’S NAME t
'-£X: •- ntyCU ryl
BIRTHPLACEt
BIRTHPLACE
OF FATHER t
MAIDEN NAME
OF MOTHER
/IE
7
BIRTHPLACE
OF MOTHER t
OCCUPATION
PLACE OF BURIAL OR REMOVAL!
UNDERTAKER
DATE OF BURIAL
. 19
( o
df? /Z<?<
ADDRESS
PHYSICIAN’S CERTIFICATE
I HEREBY CERTIFY that I attended deceased during last
illness, from )%<hV I9c^ to cyt/lAsL> \9/0 ,
that to the best of my knowledge and belief death occurred on the
date stated above, and that the CAUSE OF DEATH was as follows :
Primary:
Contributory : ...C
DURATION) DAYS
1 .^4yvvA,//.l9/f? (Address)
SPECIAL INFORMATION only for Hospitals, Institutions, Transients,
or Recent Residents.
How long at
Place of Death 7 years. months days
Where was disease contracted,
if not at place of death?
Filed .19
Clerk
* City or town, street and number, if any. If death occurs away from USUAL RESI-
DENCE, give facts called for under "Special Information.” If In a Hospital or
Institution, give its NAME Instead of street and number,
t In case of married or divorced woman, or widow,
t State or country; also city, town or county, If known.
§ Name and address of person giving statistical details.
II Name of cemetery.
4 oO
@ pen VCO weal
ahouk VA, 4G1 0
Every item
of
information should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state CAUSE
OF DEATH
in plain
terms,
so that
It
may be properly classified. Exact statement
of
OCCUPATION
is
very
important.
See
instructions on back
of
certificate.
' ■ ■ m i mm Lm i,
STANDARD CERTIFICATE OF DEATH
[If death occurred in
Ward) a hospital or institution, give its NAME instead of street and number.]
[If married or divorced
woman or widow
give maiden name,
also name of husband ] Registered No.
PERSONAL AND STATISTICAL PARTICULARS
3 SEX 6 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCEC
(Write the word)
w
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
(Month)
(Day) 191.^...
(Year)
6 DATE OF BIRTH
(Month)
(Day) \M.
(Year)
7 AG E
..yrs.
,.mos ds.
If LESS than
I day, hrs
or min.?
8 OCCU PATION
(a) Trade, profession, or
particular kind of work
(b) General nature of Industry,
business or establishment in
which employed (.or employer)..
r.
e
/
• BIRTHPLACE
(State or country)
>0 NAM E OF
(fl 11 birthplace
I- OF FATHER
2 (State or country) Id
(Informant)
(Address) 3 T
17 I HEREBY CERTIFY, That I attended deceased from
, I91 d...., to /./. I9I.Q.,
that I last saw h.iortv. alive on , ISTT^...,
and
that
death
occured,
on
the
date stated above,
at.
•"//
m-
The
CAUSE OF
DEATH*
was
as
follows:
OirtL.(yioJ
(Duration) yrs mos ds.
(^Duration) M...frs mos. . ..../CT'Tds.
♦If death followed injury or violence the certificate (ry death must be made
out Try the Medical Examiner.
18 LENGTH OF RESIDENCE (FOR HOSPITALS, INSTITUTIONS, TRANSIENTS, OR
recent residents).
At place In the
of death ....yrs mos ....ds. State yrs mos ds
Where was disease contracted,
If not at place of death ?
Former or usual residence
'•PLACE OF BURIAL OR REMOVAL
Filed.. 191
REGISTRAR
DATE OF BURIAL
± 1 \9\&.
ADDRESS
(
RTAKER
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ALL NAMES TO BE IN FULL
THE COMMONWEALTH OF MASSACHUSETTS
FULL NAME
Place
Death
RETURN OF A DEATH
(/ J . /C X <. r <- <>
°fi
iff
Residence f?. h.S. Age
c c Registered No
Date
of
(
Death
i
years..
(CITY OR TOWN.)
S.%0
months days
STATISTICAL DETAILS
SEX
9*1 COLOR
2As
SINGLE, MARRIED,
WIDOWED, OR -I
DIVORCED
MAIDEN NAMEt
HUSBAND’S N Al\
BIRTHPLACE!
/3^n
—
NAME OF
FATHER
BIRTHPLACE
OF FATHER !
MAIDEN NAME .
OF MOTHER
BIRTHPLACE
OF
MOTHER!
/
?
y
[
Cm-'
(fat
OCCUPATION y.
INFORMANTS // ^7
PLACE OF BURIAL OR REMOVAL II DATE OF BURIAL
«,*
UNDERTAKER ADDRESS
(A/
l’HYSICI AN’S CERTIFICATE
I HEREBY CERTIFY that I attended deceased during last
illness, from....f^S??...<r...:. ^ 19 to. 19 /A
that to the best of my knowledge and belief death occurred on the
date stated above, and that the CAUSE OF DEATH was as follows:
-JL~ £!_-
Primary :
(duration) DAYS
Contributory:
(duration) DAYS
/c (Address)
SPECIAL INFORMATION only for Hospitals, Institutions, Transients,
or Recent Residents.
How tong at
Place of Death 7 years. months days
Where was disease contracted,
if not at place of death?
Filed
19
Clerk
* City or town, street and number. If any. If death occurs away from USUAL RESI-
DENCE, give facts called for under "Special Information." If In a Hospital or
Institution, give Its NAME Instead of street and number,
t In case of married or divorced woman, or widow,
t State or country; also city, town or county, If known,
§ Name and address of person giving statistical details.
II Name of cemetery.
4 2
Calor “Page dew
Ak m4, 1416
COMMONWEALTH OF MASSACHUSETTS.
FULL NAME
Place of Death )
and Residence j
Date of Death
CITY OF
RETURN OF A DEATH-1910. BOSTON.
Smeline G- Heme nv? ay 3722 Registered No.
Faulkner Hospt
Boston
rIP. rr . . r. .-Pr./r. 1910. Age V V? years *?. months (Y./f days.
STATISTICAL DETAILS. PHYSICIAN’S CERTIFICATE.
SEX COLOR SINGLE, MARRIED, WID., DIV.
F W M
1 HEREBY CERTIFY that 1 attended deceased during last illness,
Webber
Maiden Name . ..T .. . .
Edwin A Webber
Husband’s Name /, ...
that to the best of my knowledge and belief death occurred on the
_jjate stated above, and that the CAUSE OF DEATH was as follows:
l Peritonitis - 7 days
I.lonroe,LIe. lotesS
(DurabApA i
s®***4**- ml
\
57015,111,11
of
Horace
C
Webber
vs^
)rrr&.'"Zjr"j
'AXE.
W
j
Birthplace BOStOil
of Father
"Contributory:!
Hysterectomy
for Fibroid
Maiden
Name
Eliza
A GrOldSmitll
(Duration)
j
cancer of Uterus
Birthplace
-
■
•
of Mother
Housewife
Occupation
F.Cogge shall
(Signed) M.D.
Apr. 15 ' 1910 -
SPECIAL INFORMATION from Hospitals, Institutions, Transients, or Recent
Residents.
Place of
Burial
Hass
.
Crematory
Usual Rasidenc
...’'iS^T°P.
.. . t . J S Waterman & Sons Undertaker r.. . Apr. 20 ,„ln
A true copy. _ /?
Registrar.
-
COMMONWEALTH OF MASSACHUSETTS
i
{/J
^
'
RETURN
/OF
A
DEATH
(CITY
OR
TOWN.)
Registered No !±..&
1 | DDeathf 1 19/ O
Age k.k years Z.
FULL NAME
Place of
Death
A
Residence !/ ..months — .V? days
STATISTIC AX DETAILS
SEX / COLOW
%!
KM
SINGLE, MARRIED, ’ WIDOWED, OR/fy. .t* .. yf
DIVORCED H/f
MAIDEN NAMEt
HUSBAND’S NAME t
BIRTHPLACE*
fS
$V(
04L4
.
NAME OF
FATHER
BIRTHPLACE
OF FATHER
MAIDEN
OF MOT
(Ft
0*
BIRTHPLACE
OF MOTHER i Y 4 /fdyt(rVv-
OCCUPATION
INFORMANT §
/jii
OAM^ J*
PLACE OF BUBIAL OR REMOVAL II ^
// rxAL. /LpAahLJ % /x£c(xt\-
dat^ of
dyfuUA BURIAL
^3 Mo
undertaker
nLd. a'ddress /
/2-0 fi sis]
c, yl erJ-to—
PHYSICIAN’S CERTIFICATE
I HEREB^ CERTIFY that I attended deceased during last
illness, from / 19/#. .to
that to the best of my knowledge and belief death occurred on the
date stated above, and that the CAUSE OF DEATH was as follows:
eriA^y
.(duration)..
Contributory:
. (DURATION) DAYS
M.D.
(Signed)..T^^^xrrt5^(^.^\,....<^*.<3t^Vr^[f/V.....-:
.
. .
.0^
:
^
V
.
.
1
9»6^.
.
..(Add ress) .*
SPECIAL INFORMATION only for Hospitals, Institutions, Transients,
or Recent Residents.
How long at
Place of Death 7 years months days
Where was disease contracted,
If not at place of death?
Filed
.190.
Clerk
* City or town, street and number, if any. If death occurs away from USUAL RESI-
DENCE, give facts called for under "Special Information.” If In a Hospital or
Institution, give its NAME Instead of street and number,
t In case of married or divorced woman, or widow,
t State or country | also city, town or county, If known.
§ Name and address of person giving statistical details.
II Name of cemetery.
3
Sree \eany
e he ree fal
Oe ar.
Co}
(4
Uy NGL,
ayn
COMMONWEALTH OF MASSACHUSETTS.
CITY OF
RETURN OF A DEATH-1910. BOSTON.
FULL NAME P4ckson Registered No.. .3.9-52
Place
of
Death
(
Boston
"
-
'
!
•
Gi.VO.
and Residence ) '
Apr,
22
19
5
16
Date of Death 1910. Age years months days.
STATISTICAL DETAILS. PHYSICIAN’S CERTIFICATE.
SEX COLOR SINGLE, MARRIED, WID., DIV.
w S
1 HEREBY CERTIFY that 1 attended deceased during last illness,
that to the best of my knowledge and belief death occurred on the
date stated above, and that the CAUSE OF DEATH was as follows:
Husband's Name Tft SoK ulm. Tuberculosis - 1 vr
, , Chelsea (ofe£fS R rthnhrp I lA***"1^- ^
| b j
\ VTv
of
Robert
LI
Mckso\<$%.r1®a
olVThe" M®.. Can,
iKIA
M
j
'A
/IX
I
contributory
:
j
c
ari
i
a.l
.
.
.
do.
&q
2i
q
ra
t i
o
h
. .
.
ofaMotherame
(Duration)
J
”
^
A
"
of r Mother Male ?..» Ont,.iCm). (Signed) R P. RU g~l0 S M.D.
Occupation --Au-r-^-2 2 1910
SPECIAL INFORMATION from Hospitals, Institutions, Transients, or Recent
Residents.
Place of
Burial
Win thro puWi2ithro
'0
Cem
'usual Residence Rahant ...ayo
Undertaker Filed Ap. 1910.
Registrar.
'
:
.
'
...
■
*
£■
\
Every Item of
information should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state CAUSE
OF DEATH
in plain
terms,
so that
it
may be properly classified. Exact statement
of
OCCUPATION
is
very
important.
See
instructions on
back
of
certificate.
STANDARD CERTIFICATE OF DEATH .
—
a*
» FULL NAME
[If married or divorced woman or
give maiden name, also name of^
»a RESIDENCE
(No..,.y.i.../„ .
-tg,
&
___
[If
death
occurred
in
St.;
a
hospital
or
institution,
^
’**
give
its
NAME
instead
of s.treet and number.]
Registered No.
H- 4-
PERSONAL AND STATISTICAL PARTICULARS MEDICAL CERTIFICATE OF DEATH
•SEX
if
•COLOR OR RACE
Of
6 SINGLE,
MARRIED,
WIDOWED,
OR
DIVORCED
/
{Write the word) f
‘•DATE OF DEATH
Cu0*OL ..wWVf.S.S.!
^
(Mo
(Month)
is
(Day)
191.$).....
(Year)
•DATE OF BIRTH
,L„ !. I
(Month) (Day) (Year)
7 AGE
AZ yrs. J ,mos J
....ds.
If LESSthan
I day, hrs.
,.min.?
80CCUPATI0N
(a) Trade, profession, or
particular kind of work
(b) General nature of industry,
business, or establishment in
which employed (or employer)..
17
I
HEREBY
CERTIFY
that
I
attended deceased
from
, 1 91. J... to. 191 A.,
that
I
last
saw
h.A^r.
alive on
I9I.&...,
and
that
death occurred,
on
the
date
stated above,
at....
$>W.
m.
The
CAUSE OF DEATH*
was
as
follows:
'
t
5 BIRTHPLACE
(State or country)
•
7
(Duration) yrs. ,«,..mos. J ds^
Co n t r ib u to ry . . JL . Vifeitok • • A ■ ■
(secondary) * ’ \
■•NAME OF
FATHER
c<2 /x/^ (S) ■■ BIRTHPLACE
z
Id
IK
(State
or
country)
/
/I
/
<
a
■•MAIDEN NAME
OF MOTHER
■•BIRTHPLACE /?
/)
OF
MOTHER
V
,
^
S/
(State or country)
S
* If de:
out by*t
(Duration) yrs.
, I 9 I (^Address)
mos ds.
M. D.
.eath followed injury or violence the certificate
he Medical Examiner.
e of death must be ma<
(Informant)
(Address)
i«THE ABOVE IS TRU^TO THE BEST OF MY KNOWLEDGE/
Q.
,,pLACE 0F 8UR,AL 0R
Removal
~>7>
Of.
/00&
20 U NDi^^Ki
Filed. 191
REGISTRAR
18 LENGTH OF RESIDENCE (FOR HOSPITALS, INSTITUTIONS, TRANSIENTS, OR
recent Residents).
At place VI? 'n 3
of death XV.yrs A.mos ....ds. State ...jfaytyrs mos. .^.....ds
Where wes disease contracted
If not at place of death 1
Former or
usual residence .
• JZ. & a. Ca-+a%) \* £;h x/t
DATE OF BURIAL
)DRESS
9/
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ALL NAMES TO BE IN FULL
COMMONWEALTH OF MASSACHUSETTS
RETURN OF A DEATH
FULL NAME..
Place of
Death
Residence
.{/.S'.. III. C. .//
(CITY OR TOWN.)
H- 5
Registered No.
DDeathf
\
jT
190
0
Age . ...&?. ...years.. //..... ..months /£.. ...days
STATISTICAL DETAILS
SEX
*•- -4
MAIDEN NAMf; '
COLOR
MAIDEN NAMEt
HUSBAND’S NAME t 7
8metepM7TfmrE o, WIDOWED, OR
PtVOROE-P
f.t&Lrt
BIRTHPLACE!
NAME OF
FATHER
//
1
St
BIRTHPLACE
OF FATHER!
MAIDEN NAME
OF MOTHER
^xJihAuCAXL
BIRTHPLACE
OF MOTHER!
OCCUPATION
A INFORMANT 5
PLACE OF BURIAL OR REMOVAL II DATE OF BURIAL
19 4.1.
ADDi^SS.
•Lyzc -
PHYSICIAN’S CERTIFICATE
I HEREBY CERTIFY that I attended deceased during last
illness, from — . ■». l90.5-.to....‘&#s^..*T. .19 49... ,
that to the best of my knowledge and belief death occurred on the
date stated above, and that the CAUSE OF DEATH was as follows :
Primary:
(DURATION)..
Contributory:
(duration) DAYS
M.D.
(Signed)
i/^....fe...l90ig,....(Address)
SPECIAL INFORMATION only for Hospitals, Institutions, Translonts,
or Recent Residents.
How long at
Place of Death 7 years months.
. days
Where was disease contracted,
if not at place of death?
Filed
i-4'
.1904).
L2.
Clerk
•City or town, street and number, If any. If death occurs away from USUAL RESI-
DENCE, give facts called for under “Special Information.” If In a Hospital or
Institution, give its NAME instead of street and number,
t In case of married or divorced woman, or widow,
t State or country | also city, town or county, If known.
§ Name and address of person giving statistical details.
] Name of cemetery.
Us. 4S
7 Waag 5, 1910
ALL NAMES TO BE IN FULL
FULL NAME
Place of
COMMONWEALTH OF MASSACHUSETTS
RETURN OF A DEATH
Registered
€
„
7/7
/I
/z
77/
za
Dat®
°f
i
rr* i Doa:r \2^. Age &.L. years Z - .
SVESTHELD,
MASS. (CITY OR TOWN.)
Wo./7'l 196
Residence months days
STATISTICAL RETAILS
sqZ
COLOR^
SINGLE, MARRIED,
WIDOWED, OR , , ■ /
DIVORCED
7
yA^7U/yf
MAIDEN NAMEt c l A). >z^/ZA
HUSBAND’S
BIRTHPLACE*
NAME OF
FATHER
0
BIRTHPLACE
OF FATHER*
MAIDEN NAME
OF MOTHER
BIRTHPLACE
OF MOTHER*
OCCUPATION
INFORMANTS
PLACE OF BURIAL OR REMOVAL0
/ QJfyuj
DATE OF BURIAL
^zmJu /So.
I HEREBY CERTIFY that I attended deceased during last
illness, irorr77y//..ly..f7.^. I9*( to I9<5 ,
that to the best of my knowledge and belief death occurred on the
date stated above, and that the CAUSE OF DEATH was as follows :
Primary: 777/7/77^^7777^^
Contributory:
PHYSICIAN'S CERTIFICATE
z/
.(duration).. aL. ..DAYS
(duration) *2. DAY8
(Signed) .SC ..'... ' . M.D
:.^.I90 (Address)...rC^£i*&£r
SPECIAL INFORMATION only for Hospitals, Institutions, Transients,
or Recent Residents.
How long at
Place of Death 7 years months days
Where was disease contracted,
If not at place of death?
Clerk
* City or town, street and number, If any, If death occurs away from USUAL RESI-
DENCE, give facts called for under "Special Information.” If In a Hospital or
Institution, give Its NAME Instead of street and number,
t In case of married or divorced woman, or widow.
t State or countryi also city, town or county, If known.
§ Name and address of person giving statistical details.
IName of cemetery.
■
..
ALL NAMES TO BE IN FULL
a
t
5
J
U
t
Z
J
S
3
0
J
J
I
THE COMMONWEALTH OF MASSACHUSETTS
<4-
RETURN OF A DEATH
FULL NAME Registered No.
i.ML loc^u^^z -r } ? ,9/0
^ifQ-W Age dtjfz ,..,1....^"- months fL..-2...
Death
'
Residence
. days
STATISTICAL DETAILS
SEX
9K 2SL
COLOR SINGLE, MARRIED,
WIDOWED, OR
DIVORCED
MAIDEN NAMEt
HUSBAND’S NAME t-
BIRTHPLACE t
NAME OF
FATHER
MAIDEN NAME
OF MOTHER
INFORMANTS
•
(\C~w
DATE OF BURIAL
S C) 19 f O
PHYSICIAN’S CERTIFICATE
I
HEREBY
CERTIFY4Jjat
I
attended
deceased
enuring
last
illness,
from
19/0
%
19
ft)
,
that to the best ^f my knowledge and belief de^h occurred on the
date stated above, and that the CAUSE OF DEATH was as follows:
I) 1
.(duration).
Contributory: iXLci. <M <
Xt/
(Signed)
n .19 /O (Address)
(duration)
M.D.
SPECIAL INFORMATION only for Hospitals, 'Institutions, Transients,
or Recent Residents.
How long at
Place of Death 7 years months days
Where was disease contracted,
if not at place of death?
Filed
*+
.19 I 0.
Clerk
‘City or town, street and number, if any. If death occurs away from USUAL RESI-
DENCE, give facts called for under "Special Information.” If In a Hospital or
Institution, give Its NAME instead of street and number,
t In case of married or divorced woman, or widow,
t State or country; also city, town or county, If known.
lame and address of person giving statistical details.
Name of cemetery,
xo q. .
C>
'
ALL NAMES TO BE IN FULL
2
I
■
)
)
l
*
■
J
THE COMMONWEALTH OF MASSACHUSETTS
RETURN OF A DEATH
;!
i
.
"
«
-
/
Dp“,r
! Residence
(CITY OR TOWN.)
.19 /° Age.
..years..
STATISTICAL DETAILS PHYSICIAN’S CERTIFICATE
COLOR SINGLE, MARRIEtX
WIDOWED, C~
DIVORCEDT' MAIDEN NAMEt
HUSBAND’S NAME t
BIRTH PLACE $ ^
NAME OF
FATHER y
*
'
(
BIRTHPLACE
OF FATHER!
< y/C^C'
MAIDEN NAME
Of
“0THW
/'lo-O&f
BIRTHPLACE
OF MOTHER !
OCCUPATION
INFORMANT §
PLACE OF BURIAL OR REMOVALII
9^
I HEREBY CERTIFY that I attencted deceased during last
illness, from . 19 to A 9^44^.. f.(a... I9^C> ,
that to the best of my knowledge and belief death occurred on the
date stated above, and that the CAUSE OF DEATH was as follows:
:
Primary :
.(duration) DAYS
Contributory:
'SPECIAL INFORMATION only for Hospitals, Institutions, Transients,
or Recent Residents.
How long at
Place of Death7 .’ years
Where was disease contracted,
if not at place of death 7
months days
Filed
j^^r7r?....dTT
19 I 0.
Clerk
* City or town, street and number, If any. If death occurs away from USUAL RESI-
DENCE, give facts called for under "Special Information." If In a Hospital or
Institution, give Its NAME instead of street and number,
t In case of married or divorced woman, or widow,
t State or country; also city, town or county, If known.
§ Name and address of person giving statistical details.
II Name of cemetory.
“Bawwkh Lay Odeney
TVA \o 1 4to.
os
THE COMMONWEALTH OF MASSACHUSETTS
RETURN OF A DEATH
FULL
NAME
°/| ' Z^/1 S' < ^- ' 5^
$sC
^
Place
Death
Residence Age.
7x
Date
of
l
Death
1
..years..
(CITY OR TOWN.)
±
K
/..XT. 19/ 0 S * >
months./.
Registered No
hi-
..months./. days
STATISTICAL DETAILS
COLOR SINGLE, MARRIED^,
WIDOWED, OR ~f ,
DIVORCED
MAIDEN NAMEt
HUSBAND’S NAME t
BIRTHPLACE t
Oxt
NAME OF
FATHER
BIRTHPLACE
OF FATHERt
MAIDEN NAME
OF MOTHER
INFORMANT 5
PLACE OF BURIAL OR REMOVAL II
UNDERTAKER
DATE OF BURIAL
X IESS
'
C
'Ola,
iXX-^ £
ADDRESS
PHYSICIAN'S CERTIFICATE
I HEREBY CERTIFY that I attended deceased during last
illness, from 19/0 to h&*f. 19 ft,
that to the best of my knowledge and belief dezph occurred on the
date stated abave, and that the CAUSE OF DEATH was as follows:
Primary: ....
4
...(duration) DAYS
Contributory :
.. (duration) DAYS
(Signed).. IXWhic^. ... M.0.
(Address)
^ ^
fi_
SPECIAL INFORMATION only for Hospitals, liMtltutlons, Transients,
or Recent Residents.
How long at
Place of Death? Place of Death7 years. months
Where was disease contracted, 'l r-Xl
if not at place of death?... . ! . .<TJ .
3
days
Filed
19 1 0.
Clerk
* City or town, street and number, If any. If death occurs away from USUAL RESI-
DENCE, give facts called for under "Special Information.” If In a Hospital or
Institution, give Its NAME Instead of street and number,
t In case of married or divorced woman, or widow,
t State or country; also city, town or county, If known.
§ Name and address of person giving statistical details.
II Name of cemetery.
4B ‘
Rodrerdk addons Prowl
Wrong 15 UO,
Every item
of
information should
be carefully
supplied. AGE
should
be
stated EXACTLY.
•PHYSICIANS
should state
CAUSE
OF
DEATH
in
plain
terms,
so that
it
may be properly classified. Exact statement
of
OCCUPATION
is
very
important.
See
instructions on back
of
certificate.
i PLACE OF DEATH
STANDARD CERTIFICATE OF DEATH
... St.;
2 FULL NAME
Ward)
[If married or divorced
woman or widow
give maiden name
also name of husband ]
[If death occurred in
a hospital or institution,
give its NAME instead
of street and number.]
’ed
A 1 V Registered No. H" ^
PERSONAL AND STATISTICAL PARTICULARS
3 SEX 4 COLOR OR RACE 5 SINGLE
MARR
WIDOWED
OR DIVORCED
(Write the word)
i ,
weDd,
/Vuzui^^
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
.1^7*7 M I9l.fi?....
(Month) (Day) (Year)
6 DATE OF BIRTH
(Month)
(Day)
(Year)
7 AG E
3M
..yrs.
H.
I k „ mos ! ds.
If LESS than
I day, hrs
,.min.?
8 OCCUPATION
(a) Trade, profession, or
particular kind of work....
17 I HEREBY CERTIFY, That I attended deceased from
1910 to .7 ~ 191 ,
that I last saw h-iJCT. alive on /....., 191.?...,
and that death occured, on the date stated above, at ...m.
The CAUSE OF DEATH* was as follows:
(b) General nature of Industry,
business or establishment in
which employed (or employer).,
. S*rS .
8 BIRTHPLACE
(State or country)
io NAM E OF
FATHER
)
“BIRTHPLACE
//
OF FATHER
(State or country) [J /7
12 M AIDE N NAME
OF
MOTHER
^ t
13
BIRTHPLACE //fl
/7
OF MOTHER [/ „ . y**' (State or country)
(Duration) yrs mos /.....ds.
ributory 7*..
(Duration) ..yrs, . Nj mos. ...» ds.
Cont
(secondary)
3n) ..yrs
(Signed) M. D.
.
191
a..
(Address)
M
.T*-1.
.
^
^
' *If death followed injury or violence the certificate of death must be made
out by the Medical Examiner.
18 LENGTH OF RESIDENCE (FOR HOSPITALS, INSTITUTIONS, TRANSIENTS, OR
recent Residents).
At place In the
of death ....yrs mos ....ds. State yrs mos ds
Where was disease contracted,
If not at place of death ?
"THE ABOVE IS TRUE TO THE BEST OF MV KNOWLEDGE Former or
usual residence
(Informant) ....
(Address) (
. YL-. ■SPLACE OF BURIAL OR REMOVAL DATE OF BURIAL
Filed ..'rtr...., 191 Registrar
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ALL NAMES TO BE IN FULL
THE COMMONWEALTH OF MASSACHUSETTS
RETURN OF A DEATH
STATISTICAL DETAILS
SEX COLOR SINGLE, MARRIED,
WIDOWED, OR
DIVORCED
MAIDEN NAMEt
HUSBAND’S NAME t
BIRTHPLACE!
BIRTHPLACE
OF FATHER
1
MAIDEN NAME
OF MOTHER /X.
BIRTHPLACE
OF MOTHER t SJ /
kL
7
T^7
OCCUPATION
V
INFORMANT §
PLACE OF BURIAL OR REMOVAL II DATE OF BURIAL
11 i «r\ ^4 | ALfUnt^
PHYSICIAN’S CERTIFICATE
I HEREIMf CERTIFY that I attended deceased during last
illness, from ...(TT. - 19 to "rr:. 19 ,
that to the best of my knowledge and belief death occurred on the
date stated above, and that the CAUSE OF DEATH was as follows: Pri
'rim
ary
:
.(duration) DAYS
Contributory :
(Signed) •
"K?.. I9^ Address)
(duration) DAYS
M.D.
rSPECIAL INFORMATION only for Hospitals, Institutions, Transients,
or^tecent Residents. How long at
Place of Death7 years. months days
Where was disease contracted,
if not at place of death?
Filed
ft-’
U-r191
0
cxaju^ Cierk
* City or town, street and number, if any. If death occurs away from USUAL RESI-
DENCE, give facts called for under “Special Information.” If In a Hospital or
Institution, give Its NAME Instead of street and number,
t In case of married or divorced woman, or widow,
t State or country; also city, town or county, If known.
§ Name and address of person giving statistical details.
II Name of cemetery.
¥
ge 7
GQreeorde,
Way 28, VAN oO.
CAUSE
OF DEATH
in
plain terms,
so
that
it
may
be
properly
classified. Exact
statement
of
OCCUPATION
is
very
important.
See
instructions on back
of certificate.
Sty? (ErnttuumumtUh of fHaoBarfjusrtta
STANDARD CERTIFICATE OF DEATH
PLAC
St.
2FULL NAME
[If married or divorced woman or widow -y -
give maiden name, also name of husband.] expertize.. ^
“RESIDENCE
(No. zzzcz. C-—
(City or town.)
[If death occurred in
Ward) a hospital or institution, give its NAME instead
of street and number.]
nstered No. v5~ 0
co
z
PERSONAL AND STATISTICAL PARTICULARS
3 SEX 1 COLOR OR RACE s SINGLE, „ .
MARRIED, ✓
WIDOWED,
Ofi-OWGRCETT
( Write the word)
DATE OF BIRTH
-2- ^
(Month) (Day)
MEDICAL CERTIFICATE OF DEATH
>« DATE OF DEATH
(MontljjTT^
^
,
191.0
(Day) (Year)
(Year)
6
eZ
mos. ds.
If LESS than
I day, hrs.
or min. i
8 OCCUPATION
(a) Trade, profession, or
particular kind of work..
(b) General nature of industry,
business, or establishment in
which employed for employer)...
1 BIRTHPLACE
(State or country)
>0 NAME OF
FATHER
S. 11 BIRTHPLACE
OF FATHER
(State or country)
1* BIRTHPLACE
OF MOTHER
(State or country)
“THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(In for m a nt)^_J^?
(A
<£/.
f
rA-
Filsd^i^wwJ .
Hr 191.0- REGISTRAR
I HEREBY CERTIFY that I attended deceased from
fo&y A 6 , 1 9 1° , to Tup^r *6 ,191.0 ..,
that I last saw h >*rV- alive on ~)’\4.c*-y it b , |gi © ,
and that death occurred, on the date stated above, at &
s as foil The CAUSE OF DEATH* was as follows :
Q ArrfefeAJL
yrs.
Contributory.
(secondary)
ds.
(Signed)
I 9 1 (Address)
''Sr,
M.D.
* If death followed injury or violence the certificate of death must he made
out by the Medical Examiner.
18 LENGTH OF RESIDENCE (FOR HOSPITALS, INSTITUTIONS, TRANSIENTS, OR
Recent residents).
At place In the
of death yrs. mos. ds. State yrs. mos. ds.
Where was disease contracted,
if not at place of death 7
Former or
usual residence
“ PLACE OF BURIAL OR REMOVAL DATE OF BURIAL
» UNDERTAKER J
ZZ
ADDRESS
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ALL NAMES TO BE IN FULL
THE COMMONWEALTH OF MASSACHUSETTS
RETURN OF A DEATH
FULL NAME Registered No.
rr' <lL Doar ! 19/^
Residence ■■■■'■ Age ^p7^.(P. years .months .days
STATISTICAL DETAILS
SEX
1
COLOR
lAJ ■
StNStE, MARRIED,
WtBOWEP,"OR- DfV^fteCD
DEN NAMEt ^yuvcx_^ 'y
HUSBAND’S NAME t
BIRTHPLACE!
—
NAME OF
FATHER 7
egos'-
X
f-
BIRTHPLACE
OF FATHERt 7
MAIDEN NAME
OF MOTHER
y f) A
IaA
BIRTHPLACE
OF MOTHER!
V
PLACE OF BURIAL OR REMOVAL II
Z74.
UNDERTAKER
DATE OF BURIAL
19/2^-
ADDRESS
PHYSICIAN’S CERTIFICATE
I HEREBY CERTIFY that I attended deceased during last
illness, from 19 to ..
that to the best of my knowledge and belief death Recurred on the
date stated above, and that Ibe CA^ISE OF DEATH was as follows:
Primary:
(oUBATIOn) DAYS
Contributory: ... MV^rV
’
. (DURATION) DAY8
(Signed)... M.D.
19 Vi (Address)
SPECIAL INFORMATION only for Hospitals, Institutions, Transients,
or Recent Residents.
How long at
Place of Death 7 years. months days
Where was disease contracted,
If not at place of death?
* City or town, street and number. If any. If death occurs away from USUAL RESI-
DENCE, give facts called for under “Special Information.” If In a Hospital or
Institution, give Its NAME Instead of street and number,
t In case of married or divorced woman, or widow,
t State or country; also city, town or county. If known.
§ Name and address of person giving statistical details.
II Name of cemetery.
JlV.
Every item of information 9hould be carefully supplied. AGE should be stated
EXACTLY. PHYSICIANS should state CAUSE OF
DEATH
in plain terms, so that
it
may be properly classified. Exact statement
of
OCCUPATION
is
very
important.
See instructions on back
of
certificate.
0% dammmmttaltl? of fHassarljusTtts
STANDARD CERTIFICATE OF DEATH
PLACE OF DEATH
St.
[If death occurred in
Ward) a hospital or institution, give its NAME instead of street and number.]
Hospital, For t Bai^s, lias 3.
Thomas ?olo^ , Hvt . l/ol. , Hospital Corps , IT. D . A.
Registered No. A
TULL NAME
[If married or divorced woman or widow H-* ;"I .1
give
maiden
name,
also
name
of
husband.]
1
J
'
LI
“RESIDENCE
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
Male
4
COLOR
OR
RACE
1
5
MARRIED, WIDOWED,
’ i t- ■■ OR DIVORCED [Ji v i'lp
“
1
■'
1
(
Write
the
word)
J
6 DATE OF BIRTH
liCi: 0 '.7X1
(Month)
(Day)
.,
|3
7
•
-
(Year)
^ AGE
36 11
ds.
If LESS than
I day, hrs.
or min. ?
8 OCCUPATION
(a)' Trade, profession, or
particular kind of work. Soldier
(b) General nature of industry,
business, or establishment in
which employed (or employer)...
» BIRTHPLACE
(State or country)
Has. ‘3 .
n> NAME OF
FATHER
Unknown.
(!)
F-
z LU
” BIRTHPLACE
OF FATHER
(State or country)
Unknown .
<
CL 12 MAIDEN NAME
OF MOTHER
Ur. hr. or; r. .
'» BIRTHPLACE
OF MOTHER
(State or country) Unknown .
“THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant) ' " Kl 1.
(Address) Hospital, Ht. Hanks ^
Filed V ' - v(
I 91 As.
MEDICAL CERTIFICATE OF DEATH
10 DATE OF DEATH
11 a v (Month)
jgyth
(Day)
I9 I 0.*..
(Year)
17 I HEREBY CERTIFY that I attended deceased from
: . . 1st igiO , ^ , 1 9 10 ,
that I last saw h L .,l. alive on - - ' ; ‘ ■ - ’Tlx ( |9 |0 f
and that death occurred, on the date stated above, at ' 1 • •' * m.
The CAU.SE OF DEATH* was as follows :
'he CAUSE O'
ytwTjo
(Duration)
Contributo/y.t41’^^ ^ • ... .• Y
(secondary)/
^
1.
f
(Duration) yrs. mos.
(Signed) ^ J ?..? ? * ^ M.D.
. . 0 , 31 . (Address) Fort; < r * , Mass,.
* If death followed injury or violence the certificate of death must he made
out by the Medical Examiner.
18 LENGTH OF RESIDENCE (FOR HOSPITALS, INSTITUTIONS, TRANSIENTS, OR
recent Residents).
At place (i In the
of death yrs. mos. ... ds. State yrs. mos. ds.
Where was disease contracted, 7 / w..
If not at place of death? If not at place 1
usual residence
Former
or
<lUUu^
» PLACE OF BURIAL OR REMOVAL
» UhLDeRTAKER '
DATE OF BURIAL
'"// ® UNDERTAKER ADDRESS v / q J
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ALL NAMES TO BE IN FULL
COMMONWEALTH OF MASSACHUSETTS
^RETURN OF A DEATH
Death *
Residence (k..K.. year,/.
STATISTICAL DETAILS PHYSICIAN’S CERTIFICATE
z
u
h
3
0
J
J
I
SEX COLOR SINGLE, MARRIED,
WIDOWED, OR ty' y
DIVORCED s s
MAIDEN NAMEt
HUSBAND’S NAME t
BIRTHPLACE!
NAME OF
FATHER
BIRTHPLACE
OF FATHER*
MAIDEN NAME
OF MOTHER
I
HEREBY
CERTIFY
that
I
attended
deceased
during
last
illness,
from
I90//0.to
.
....A**.
1^6
,
that to the best of my knowledge and belief death occurred on the
date stated above, and that the CAUSE OF DEATH was as follows :
SPECIAL INFORMATION only for Hospitals, Institutions, Transients,
or Recent Residents.
How long at
Place of Death? years months days
Where was disease contracted,
If
not
at place
of
death?
Filed 190
Clerk
* City or town, street and number. If any. If death occurs away from USUAL RESI-
DENCE, give facts called for under "Special Information.” If in a Hospital or
Institution, give Its NAME instead of street and number,
t In case of married or divorced woman, or widow,
t State or country / also city, town or county. If known.
§ Name and address of person giving statistical details.
II Name of cemetery.
^
'^v
Every Item
of
information should
be carefully
supplied. AGE should
be
stated
EXACTLY. PHYSICIANS
should state
CAUSE
OF
DEATH
in
plain
terms,
so that
It
may be properly classified.
Exact statement
of
OCCUPATION
Is
very
important.
See
instructions
on
back
of
certificate.
«- STANDARD CERTIFICATE OF DEATH
O , QA£Lr....L
r&t ,; . —
» FULL NAME..
%
Yd
UJ
ha
twur)i
rh
oaj
.
BOSTON
[If death occurred in
.Ward) a hospital or institution, give its NAME instead of street and number.]
[If married or divorced woman or widow
give maiden name, also^name of husband.]
*» RESIDENCE O 0 {f\XLA
S
f-
PERSONAL AND STATISTICAL PARTICULARS MEDICAL CERTIFICATE OF DEATH
8 S EX
]rV(
oJjt-
‘COLOR OR RACE
{jo
6 SINGLE, ,
widows, UA £>AL^ A OR DIVORCED
{Write the word)
16 DATE OF DEATH /?
/.K
(Month) ' (Day)
., 191
(Year)
•DATE OF BIRTH
I.
(Month)
(Day)
(Year)
7 AGE
8 OCCU PATION
(a)
part
cj 7 ..7 yrs mos.
f— < v — M
If LESS than
I day, hrs
..ds. or.. ,.min.?
(a) Trade, profession, or fx: (^ai %, s.
particular kind of work...i ILXX.. fC.*L.V:.?
[/
(b) General nature of industry,
business, or establishment in
which employed (or employer).
ft-
HEREBY CERTIFY that I attended deceased from
...A. 191*...:, I9 1.9..,
that
I
last
saw
h.Vrcr? alive
on
and that death occurred, on the date stated above, at.^.^^f.m.
The CAUSE OF DEATH* was as follows: ^
*
BIRTHPLACE
I
//
/
(State
or
country)
y
cJ(
'•NAME OF
FATHER
H BIRTHPLA
OF FATHER
(State or country)
</>
h
Z
UJ tr
< l* M AIDE N NAME
Q. OF MOTHER
U BIRTHPLACE
OF MOTHER
(State or country)
(Duration) yrs.
,.ds.
Contributory .
(Secondary)
(Signed).. I
I 1 .0.. (Address) ..
4 * If death followed inj
(Duration) yrs mos ds.
injury or violence the certi
out by the Medical Examiner.
of death must be made
l«THE ABOVE IS TRUE TO THE BEST OF MV KNOWLEDGE
'l
‘
(Informant)
(Add ress *3 OJ^
Filed.. 191
Registrar
18 LENGTH OF RESIDENCE (FOR HOSPITALS, INSTITUTIONS, TRANSIENTS, OR
recent Residents).
At place In the
of death ....yrs mos _...ds. State yrs mos ds
Where was disease contracted,
If not at place of death ? : ..•
Former or uaual reaidence >» PLACE
CE OF BURIAL OR I^&MOVAI/
(U
^ //
/ I •- ku £
DATE OF BURIAL
/LilT
./A,
191
O..
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Every item of information should be carefully supplied. AGE should be stated
EXACTLY. PHYSICIANS ould
CAUSE
OF
DEATH
in plain terms,
so that
it
may be
properly
classified. Exact statement
of
OCCUPATION
is
very
important. See instructions on back
of
certificate.
©fj? (Kommonuttalth of Massarljuaftts
STANDARD CERTIFICATE OF DEATH
PLACE OF DEATH
/<^^7^ (No / X^ . ....
FULL NAME
[If married or divorced woman or widow
give maiden name, also name of imsband.]
"RESIDENCE
cZ.
(Ot>y or town.)
[If death occurred in a hospital or institution,
give its NAME instead of street and number.]
Registered
No.
5"
■
PERSONAL AND STATISTICAL PARTICULARS
3 SEX 4 COLOR OR RACE
3 SINGLE,
MARRIED, - . .
WIDOWED,
OR DIVORCED
(Write the word)
• DATE OF BIRTH
(Month)
(Day)
(Year)
^ AGE
S1
f
yrs.
ZA ds.
If LESS than
I day, hrs.
or min. ?
8 OCCUPATION
(a) Trade, profession, or
particular kind of work
(b) General nature of industry,
business, or establishment in
which employed (or employer)...
9 BIRTHPLACE
(State or country)
MU
>0 NAME OF
FATHER i/O
11 BIRTHPLACE
OF FATHER
(State or country)
12 MAIDEN NAME
OF MOTHER
.£\Co
'2 BIRTHPLACE
OF MOTHER
(State or country)
“THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
0~cZ=n. — (Informant)
Filed
/ L
191
Registrar
MEDICAL CERTIFICATE OF DEATH
i® DATE OF DEATH
(Month)
I
r
Jo*'
,
191.:
O
(Day) (Year;
17 I HEREBY CERTIFY that I have investigated the
death of the deceased.
The CAUSE
^
(Duration) yrs. mos. ds.
Contributory
(secondary)
191..“... (Address)
MEDICAL EXAMINER
* State the Disease Causing Death, or, in deaths from Violent Causes,
state (1) Means of Injury; and (2) whether Accidental, Suicidal or
Homicidal.
18 LENGTH OF RESIDENCE (FOR HOSPITALS, INSTITUTIONS, TRANSIENTS, OR
Recent Residents).
At place In the
of death yrs. mos ds. State yrs. mos. d3.
Where was disease contracted,
If not at place of death 7
Former or
usual residence
>» PLACE OF BURIAL OR REMOVAL DATE OF BURIAL
Us 20 UNDERTAKER / f 191(0.
ADDRESS
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ALL NAMES TO BE IN FULL
i
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J
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L
THE COMMONWEALTH OF MASSACHUSETTS
FULL NAME
Place of
Death * >
RETURN OF A DEATH
i Registered No
2a
(CITY OR TO liy.)
S
L>
\°>/Z
.‘;'.....years months /^(^..days
Date of
Death i
STATISTICAL DETAILS
SEX
r sS
COLOR
AO
smett; MARRIED,
WIDOWED/DR’
■DEVOROe-D a.
MAIDEN NAMEt Ajn ICO*’*'}- /AZ&ZA V -
'
‘
Cj
HUSBAND’S
NAME
t
^
—
-
/
////^
„
U
Cf
°
^
^ BIRTHPLACEt "
O A / r Ac- (7. :
-Jcc
A
-A-
NAME OF
FATHER / /T
/
'
, CT
2
BIRTHPLACE
OF FATHER!
9?
A
-
MAIDEN NAME
OF MOTHER
7 / f r
l7?sr
<
/ ^ f7
( ///. / /. ( V
BIRTHPLACE
OF MOTHER t
L
T
^
OA
i
ci
n
/1-c-
'
)
/-
.
(
-
OCCUPATION
/
'
"
S
INFORMANT §
PLACE OF BURIAL OR REMOVAL!!
J 7/rr.
-
DATE OF BURIAL
UNDERTAKER
J'i- n-y
(/ADDRESS
(2i7
PHYSICIAN’S CERTIFICATE
I HEREBY CERTIFY that I attended deceased during last
illness, from 19 /O to ..AAcA. AA.l. A 19 lO ,
that to the best of my knowledge and belief death occurred on the
date stated above, and that Jhe CAUSE OF DEATH was as follows:
Primary : QArdf. V?*
.(duration) SE.... days
Contributory:
S
URATIOn) 0AY8
(Signed) M.D.
.iC^-....±.h...\9/d (Address) ZZZAAZZj}.
SPECIAL INFORMATION only for Hospitals, Institutions, Transients,
or Recent Residents,
How long at
Place of Death? years months days
Where was disease contracted,
If not at place of death?
Filed
19 Clerk
‘City or town, street and number, If any. If death occurs away from USUAL RESI-
DENCE, give facts called for under "Special Information." If In a Hospital or
Institution, give its NAME Instead of street and number,
t In case of married or divorced woman, or widow,
t State or country; also city, town or county, If known,
§ Name and address of person giving statistical details.
II Name of cemetery.
COMMONWEALTH OF MASSACHUSETTS.
CITY OF
RETURN OF A DEATH-1910. BOSTON.
FULL NAME ^ .9 f?.T.® . . . .9 Registered No. .5 78.3.
Place_of Death \ Boston MESS , Geil. HOS pt.
and
Residence
)
Date of Death V..L.“.».?.l 1910. Age 3.2 years 1.0 months 4 days.
STATISTICAL DETAILS. PHYSICIAN’S CERTIFICATE.
SEX COLOR SINGLE, MARRIED, WID., DIV.
M 17 !5
1 HEREBY CERTIFY that 1 attended deceased during last illness,
Maiden Name j***Z^r
that to the best of my knowledge and belief death occurred on the
stated above, and that the CAUSE OF DEATH was as follows:
PriWi \ Sz/neope .Opr. ac. retention -
Husband's Name
'///
Birthplace Bos toi^East.). °i(§E3i
(Duration) 1
lTHi,* h--. \ y
stricture of urethra
KSJr'*
ISaa°
L
BOyi
B;rVhl'ale Cuba
'Aa
•§/
J
Contributory : )
Maiden
Name
I.Iary
Carpenter of Mother
(Duration) j
mrth
place
St
John,
IT.
3.
Laborer
(Signed) M . D.
Jun.23 1910
SPECIAL INFORMATION from Hospitals, Institutions, Transients, or Recent
Residents.
Place of
Burial
Winthrop’* Winthrop
Co ^Usual Residence M5thrOp.(30 . C .0171. ,S.t]
W C Skaggs
Undertaker
Winthrop
Filed JUnL2.5. 19,0.
Registrar.
_
ALL NAMES TO BE IN FULL
FULL NAME
THE COMMONWEALTH OF MASSACHUSETTS
DEATH (CITY OR TOWN.)
Registered No. .—-7-
Plz*
/ZaJL
L/..
I
■'
<
»'•
.
Ag6
years
X.
months.
...Z^..
days
RETURN OF
Cl/L c
Residence
STATISTICAL DETAILS
SEX COLOR SINGLE, MARRIED, ,
WIDOWED, OR /?
DIVORCED
MAIDEN NAMEt
HUSBAND’S NAME t
BIRTHPLACE*
rf'/i
BIRTHPLACE
OF MOT
OCCUPATION
INFORMANT §
c
PLACE OF BURIAL OR REMOVAL II DATE OF BURIAL
J!c/2'L't^c-^'^. ' j /t... ,i & ^ i
UNDERTAKER j ADDRESS
To- <r*
O
PHYSICIAN’S CERTIFICATE
I HEREBY CERTIFY that I attended deceased during last
illness, from .19/45’ ,
that to the best of my knowledge and belief death occurred on the
date stated above, and that the CAUSE OF DEATH was as follows:
Primary: ..
(Signed).. \^s. U . ,^r. • '. . . r M . D .
.^T..I9/£7 (Address)
SPECIAL INFORMATION only for Hospitals, Institutions, Transients,
or Recent Residents.
How long at
Place of Death 7 years months days
Where was disease contracted,
If not at place of death 7
Filed
.19
Clerk
* City or town, street and number, if any. If death occurs away from USUAL RESI-
DENCE, give facts called for under "Special Information.” If In a Hospital or
Institution, give its NAME instead of street and number,
t In case of married or divorced woman, or widow,
t State or country; also city, town or county. If known.
§ Name and address of person giving statistical details.
II Name of cemetery.
Every item of information should be carefully supplied. AGE should be stated
EXACTLY. PHYSICIANS should state CAUSE OF
DEATH
in plain terms, so that
it
may be properly classified. Exact statement of
OCCUPATION
is
very
important. See instructions on back
of certificate.
PLACE of death
;FU
LL
NAME
[If married or divorced worn:
give maiden name, nani
“RESIDENCE
Sty? (Eommmtuiealtij of Haoaartjusptto
STANDARD CERTIFICATE OF DEATH
(o.
(City or town.)
[If death occurred in
St. ; Ward) a hospital or institution, give its NAME instead
of street and number.]
Registered No
•
rr
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
^fauJu.
‘COLOR
DR
RACE
1
5
mA^nI’d,
Uy
'
,
rUfat/
\
'
'
^
W
|
(Write
the
word)
1 6 DATE OF BIRTH , if7$
/ (Month) (Day)
(Year)'
■>
AGE If LESS than
1 day, hrs.
\3 / yrs. mos. ds. or min. ?
8 OCCUPATION
(a) Trade, profession, or
particular kind of work.... a
(b) General nature of industry,
business, or establishment in
which employed (or employer)..
‘7
» BIRTHPLACE
(State or country
fab
fU
10 NAME OF
FATHER
i> BIRTHPLACE
JO I OF FATHER
ET (State or conntry)
MEDICAL CERTIFICATE OF DEATH
“ DATE OF DEATH
(Month) C 191 o .
(Day) (Year)
HEREBY CERTIFY that I attended deceased from
91 , to...7TW -2. jf'' , 191. .0,
th'at I last saw h Anv». alive on A. , 191 O ,
and that death occurred, on the date stated above, at£<3d<?m. 4
The CAUSE OF DEATH* was as follows:
I HEREBY
t)M4
*Jr
I U -
(Duration)
Contributory. ]r t
(Secondary) _
fNy >«%
(Duration)
,.~r
yrs.
■‘T
moj. O
ds.
(^igned) P-S ' (T CJtCfrr*? , M.D.
191 C> (Address)
>3 BIRTHPLACE
OF MOTHER
(State or country)
jy/b (U^U3U/~ “THE ABOVE IS TRUE TO THE BEST OF M W KNOWLEDGE
»)
5'°^
K<w>
Filed^v‘~'
.
... 191 0 Vtt
(Informant)
(Address)
STRAP.
* If death followed injury or violence the certificate of death must be made
out by the Medical Examiner.
18 LENGTH OF RESIDENCE (FOR HOSPITALS, INSTITUTIONS, TRANSIENTS, OR
Recent Residents).
At place i/ In the
of death. T'-yrt. mos. ...JY . ds. State yrs, mo*. ds.
Where
was
disease
contracted,
(W/il
yd
dM/f
/
If not
at place of
dea^h?.. l//V7
Former or
usual residence..
DATE OF BURIAL “ PLACE OF BURIAL OR MMOVAL ^
WsC, k^Jzs _ \ J±^±z
1
laddress
191 0
» UNDERTAKER wsrnwa
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ALL NAMES TO BE IN FULL
THE COMMONWEALTH OF MASSACHUSETTS
/?
FULL NAME
RETURN OF A DEATH (CITY OR TOWN.)
Registered No
Residence /— Age
r, r( 3, »;«
(z±yd..yea:s months... £/.. days
STATISTICAL RETAILS
SEX
/T'
L-T^eZA-*
COLOR
/■! ~->t. t‘
smeLE, MARftteo,
WIDOWED, Oft-
-DLV«RC€D-
MAIDEN NAME
HUSBAND’S NAME t
U<C.L L
v
//
L.Z,-
BIRTHPLACE t
-^V
<=f
s/cSZ
NAME OF
FATHER
V"
7 ^ c^) /?
. /T /<--£• -t. , /c
BIRTHPLACE
OF FATHER t
FT
A
MAIDEN NAME
OF MOTHER
1
r
BIRTHPLACE
OF MOTHER*
C-a — 2-
OCCU PATION
/ A"' /
4^
INFORMANT §
PLACE OF BURIAL OR REMOVAL II
<fir*-rUs*d^ /4<jZX*r±
UNDERTAKER
DATE OF BURIAL
*7-
4*.
ADDRESS / •
<Zh«
PHYSICIAN’S CERTIFICATE
I HEREBY CERTIFY that I attended deceased during last
illness, from...T 194 1'' to.^V?4r^T...vJ 19^ ,
that to the best of my knowledge and b©tfef death occurred on the
date stated above, and that the CAUSE OF DEATH was as follows:
Primary :
Contributory:
(Signed)
rTtIOnT. DAYS
M.D.
'-■
\9
(Address)
XT SPECIAL INFORMATION only for Hospitals, Institutions, Transients,
or Recent Residents,
How long at
Place of Death 7 years months days
Where was disease contracted,
if not at place of death?
Filed
19
Clerk
* City or town, street and number, If any, If death occurs away from USUAL RESI-
DENCE, give facts called for under "Special Information." If In a Hospital or
Institution, give Its NAME Instead of street and number,
t In case of married or divorced woman, or widow,
t State or country; also city, town or county, if known,
§ Name and address of person giving statistical details.
II Name of cemetery.
54
Sadly Clay abt Beod
cdg 3,17 10
ALL NAMES TO BE IN FULL
SEX
COLOR
____
hrCc^T SINGLE, MARRIED,
WIDOWED, OR ~ .
DIVORCED
6<Sl/lsCCc\
MAIDEN NAMEt
HUSBAND’S
NAMEt
"
BIRTHPLACE!
NAME OF
FATHE"
/Vfa^A
BIRTHPLACE
OF FATHER! /I
MAIDEN NAME
OF MOTHER
7y
BIRTHPLACE
OF MOTHER !
7vi
ta
OCCUPAT^JN
A ANT S
I HEREBY CERTIFY that I attended deceased during last
illness, from \-S 0- 19/ 5 to... /0 19 f 0 ,
that to the besVjof my knowledge and belief death occurred on the
date stated above, and that the CAUSE OF DEATH was as follows:
Primary:
.
^
\y<J\UjLsVT^/\~C\
(duration) Y? DAYS
Contributory : d...... ( JJ...I
T>. a y (duration) ) DA Y8
S
t {'.J
nl
,
L.I9/
0
.Address-
.
fM,
M.D.
SPECIAL INFORMATION only for Hospitals, Institutions, Transients,
or Recent Residents.
How long at
Place of Death 7 years months days
Where was disease contracted.
If not at place of death?
Filed
.19
Clerk
PLACE OF BURIAL OR REMOVAL 1]
CVjsl. —
DATE OF BURIAL
.... 19/0
UNDERTAKER
‘
ADDRESS 1
•City or town, street and number, If any. If death occurs away from USUAL RESI-
DENCE, give facts called for under “Special Information.” If In a Hospital or
Institution, give Its NAME instead of street and number,
t In case of married or divorced woman, or widow,
t State or country; also city, town or county, If known.
§ Name and address of person giving statistical details.
II Name of cemetery.
Lo
oo. LO ,VILO
Every item of information should be carefully supplied. AGE should be stated
EXACTLY. PHYSICIANS should state CAUSE OF
DEATH
in plain terms, so that
it
may be properly classified. Exact statement
of
OCCUPATION
is very
important. See instructions on back
of certificate.
1 PLACE
a): EAyTH
<y\A-
(ftommmtuttaltt? of ifasartjuHPtts
STANDARD CERTIFICATE OF DEATH
1m I D
FULL NAME
[If married or divorced woman or widow iy ) * _ Z . . / (X,
gtvn maiden name, algo name of husband.l \fiJ (^CJ-iyytS r *
“RESIDENCE ^ 3 7 a) AJ-. f-uJ
St.
BOSTON
(City or town.)
[If death occurred in
Ward) a hospital or institution, give its NAME instead
of street and number.]
/tec
Sfa(
,
/Registered
No. PERSONAL AND STATISTICAL PARTICULARS
3 SEX 4 COLOR ,OR RACE 3 SINGLE, . .
MARRIED, //) (v/rtttr-
WIDOWED,1^
OR DIVORCED
( Write the word)
13 DATE OF DEATH
ft:
/9/° , i9i
(Month) (Day) (Year)
3 DATE OF BIRTH
(Month) (Day)
(Year)
r AGE
It yrs.
ds.
If LESS than
I day, hrs.
or min. ?
s OCCUPATION
(a)' Trade, profession, or
particular kind of work
(b) General nature of industry,
business, or establishment in
which employed (or employer)..
9
BIRTHPLACE
,
/
/>
g (State or country)
NAME OF
FATHER
f(
CvrX
a£i
H
«0
h-
Z
Ld
» BIRTHPLACE
OF FATHER,
(State oVcountry)
< a. 12 MAIDEN NAME i/ f ' /)
OF
MOTHER
<1 tX
■3 BIRTHPLACE 'L cf OF MOTHER
(State or country)
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
fat UAsttfixf (jpc^c (Informant)
Filed. 191
Registrar
MEDICAL CERTIFICATE OF DEATH
I HEREBY CERTIFY that I attended deceased from
/ ? O § ,191. , to \R-L~n / ^ , 191 0,
that I last saw h alive on 'lO 191 V,
and that death occurred, on the da\e stated above, at jj m.
The CAUSE OF DEATH* was as follows :
idl:
Contributory.
(secondary)
(Duration) yrs. . mos. ds.
„ (Duratron)’
mos. . ds.
(Signed)
fi
*
a ... , M.O.
191 D. (Address)
* jjf death followed injury or violence the certificate of death must be made
out by the Medical Examiner.
18 LENGTH OF RESIDENCE (FOR HOSPITALS, INSTITUTIONS, TRANSIENTS, OR
Recent Residents).
At place In the
of death yrs. mos. ds. State yrs. mos ds
Where was disease contracted,
If not at place of death 7
Former or
usual residence
“ PLACE OF BURIAL OR REMOVAL
JO
DATE OF BURIAL
9-0/
“ UNDERTAKER
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^ | H,
1910...
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Every item of information should be carefully supplied. AGE should be stated
CAUSE
OF DEATH
in
plain terms,
so
that
it
may be
properly
classified. Exact statement
of
OCCUPATION
is
very
important. See instructions on back
of certificate.
m
Gtfjp (Commxmuipaltti of iHassarliusrtts
STANDARD CERTIFICATE OF DEATH (City or town.)
[If death occurred in
Ward) a hospital or institution, give its NAME i nstead
of street and number.]
8 OCCUPATION
(a)' Trade, profession, or — Ia . - /> a
particular kind of work. W'C’
(b) General nature of industry,
business, or establishment in
which employed (or employer)
5 BIRTHPLACE
(State or country) /j
0) 'I BIRTHPLACE
OF FATHER
(State
or
country)
^
>2 MAIDEN NAM£^"
OF MOTHER
u BIRTHPLACE
OF MOTHER
(State or country)
}hwu n THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
(Address)
Filed REGISTRAR
I HEREBY CERTIFY that 1 attended deceased from
, 191 P ., r/...4?a> 191
that I l^st saw h.^0^alive on c / ■ , 191 ^ „
and that death occurred, on the^clate stated above, at m.
The CAUSE OF DEATH* was as follows:
'CL.
* I£/4eath followed injury or violence the certificate fit death must be made
ouVby the Medical Examiner.
18 LENGTH OF RESIDENCE (FOR HOSPITALS, INSTITUTIONS, TRANSIENTS, OR
Recent Residents).
At place In the
of death ,yrs. mos. ds. State yrs. mos. ds.
Where was disease contracted,
if not at place of death 1
Former or
usual residence
“ PLMiE OF BURIAL OR REMOVAL
K DATE OF BURIAL
/ S , 191.0.
s>
s*
03
3
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P-
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ALL NAMES TO BE IN FULL
THE COMMONWEALTH OF MASSACHUSETTS
RETURN OF A DEATH {CITY OR TOWN.)
FULL NAME
Place
of
I
/
^
Death
* §
>
■■■/■■
/■
Residence
STATISTICAL RETAILS
SEX COLOR
JV 1
SINGLE, -M-JTRRIED,- WIDOWED, OR
OtVORCED
MAIDEN NAMEt
HUSBAND’S NAME t
BIRTHPLACE*
NAME OF
FATHER
BIRTHPLACE
OF FATHERt
MAIDEN NAME
OF MOTHER
BIRTHPLACE
OF MOTHER!
OCCUPATION
INFORMANT §
UNDERTAKER
PHYSICIAN’S CERTIFICATE
I HEREBY CERTIFY that I attended deceased during last
illness, A... 194? to 19 ,
that to th^best of my knowledge and Belief desfth occurred on the
date stated above, and that the CAUSE OF DEATH was as follows:
Primary:
. (duration)... Jtb'.jj...
Contributory :
(duration) DAY8
SPECIAL INFORMATION only for Hospitals, Institutions, Transients,
or Recent Residents.
How long at
Place of Death7 years. months days
Where was disease contracted,
if not at place of death 7
Filed .19
Clerk
* City or town, street and number, if any. If death occurs away from USUAL RESI-
DENCE, give facts called for under “Special Information.” If In a Hospital or
Institution, give Its NAME instead of street and number,
t In case of married or divorced woman, or widow,
t State or country; also city, town or county, If known.
§ Name and address of person giving statistical details.
|| Name of cemetery.
important. See instructions on back
of certificate.
<D >,
-*-> s_
03 CD
« >
2-2
og J= o
"l-
co<
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0.
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S)
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■o 4) 4)
— jQ
Q. .
<Flje (Cmumottumtltl) of ilaasarlpiHrtts
STANDARD CERTIFICATE OF DEATH
PLACE OF DEATH ruMuc. c'r L/ l_ m 1 n >*
$ (jM*- O&Axijh* .^L
..St.
unUM^ (J& gMju l. !FULL NAME
[If married or divorced woman or widow
give maiden name, also name of husband.]
(City or town.)
[If death occurred in
..Ward) a hospital or institution. give its NAME instead of street and number.]
“RESIDENCE
g
I
Registered No.
PERSONAL AND STATISTICAL PARTICULARS
3 SEX 1 COLOR OR RACE '}**&-
Ia/XuAc
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
DATE OF BIRTH
(Year J (Month) (Day)
t AGE
z 2..$.
If LESS than
I day, hrs.
or min. ?
8 OCCUPATION
(a) Trade, profession, or
particular kind of work..
(b) General nature of industry,
business, or establishment in
which employed (or employer) business, or establishment in C' _ f) r)
3 BIRTHPLACE
(State
or
country)
— ^
^
g
a
y o (rtZfyv J'3'V^lO'O C! s
MEDICAL CERTIFICATE OF DEATH
18 DATE OF DEATH
f
7
(Month)
(Day) 191.® ...
(Year)
17 I HEREBY CERTIFY that I have investigated the
death of the deceased.
The CAUSE OF DEATH* was as follows :
JL
..(Duration) yrs. mos. . ds.
Contributory..
(secondary)
1° NAME OF
FATHER
(jOClJLGu ^aJtko
n BIRTHPLACE
OF FATHER
(State or country)
I* MAIDEN NAME
OF MOTHER
TSjt 8 ^ * State the Disease Causing Death, or, in deaths from Violent Causes,
•state (1) Means of Injury; and (2) whether Accidental, Suicidal or
■dOMICIDAL.
MOTHER
rum *cc ^ _ 13 BIRTHPLACE
OF MOTHER
(State or country
14 the above is true to the best of my knowledge
(Informant) .J
(Address) -C,
...
R
■
Filed 1910
REGISTRAR
(Duration) yrs. . mos. ds.
(Signed)
ZV? I9I.P... (Address)..
MEDICAL EXAMINED
18 LENGTH OF RESIDENCE (FOR HOSPITALS, INSTITUTIONS, TRANSIENTS, OR
recent Residents).
At place In the
of death yrs....! mos. ds. State yrs. mos. ds.
Where was disease contracted,
not at place of death 7
■ Former or
usual residence
18 PLA&E OF J3URIAL
UNDERTAKER
DATE OF BWUAL. ,
191 O
ADDRESS
STANDARD GERTIFIGATE OF DEATH.
——_
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 each
and every person, irrespective of age. For many occupations
a single word or term on the first line will be sufficient, ©. g.5
Farmer or Planter, Physician, Compositor, Architect, Loco-
motive engineer, Civil engineer, Stationary fireman, ete. But
im 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: (4) Spinner, (b) Cotton mill; (a) Sales-
man, (b) Grocery; (a) Foreman, (b) Automobile factory. The
material worked on may form part of the second statement.
Never return “* Laborer,” “ Foreman,’ “‘ Manager,’”’ Dealer,”
etc., without more precise specification, as Day laborer, Farm
laborer, Laborer — Coal mine, etc. Women at home, who are
engaged in the duties of the household only (not paid House-
keepers who receive a definite salary), may be entered as
Housewife, Housework, or At home, and children, not gain-
fully employed, as At school or At home. Care should be taken
to report specifically the occupations of persons engaged in
domestic service 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 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. Examples Cerebro-spinal fever (the only
definite synonym is ‘‘ Epidemic cerebro-spinal meningitis”) 5
Diphtheria (avoid use of “Croup ); Typhoid fever (never re-
port ‘* Typhoid pneumonia”) ; Lobar pneumonia ; Broncho-
pneumonia (“ Pneumonia,” unqualified, is indefinite) ; Tuber-
culosis of lungs, meninges, peritonacum, ete., Carcinoma, Sar-
coma, CtC., 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 (second-
ary or intercurrent) affection need not be stated unless im-
portant. Example: Measles (disease causing death), 29 ds. ;
Broncho-pneumonia (secondary), 10 as. Never report mere
symptoms or terminal conditions, such as “ Asthenia,” ‘ An-
aemia’’ (merely symptomatic), “ Atrophy,” “ Collapse,”
“Coma,” “* Convulsions,” “* Debility” (*“* Congenital,”
“Senile,” etc.), ‘ Dropsy,”” « Exhaustion,” ‘‘ Heart failure,”
“ Haemorrhage,” ‘ Inanition,”” “ Marasmus,” ‘“ Old age,”
“ Shock,’” “<Uraemia,” «« Weakness,” etc., when a definite
disease can be ascertained as the cause. Always qualify all
diseases resulting from childbirth or miscarriage, as * PUER-
PERAL septicaemia,” ‘ PUERPERAL peritonitis,” etc. State
cause for which surgical operation was undertaken. For
VIOLENT DEATHS state MEANS OF inauRY and qualify as
ACCIDENTAL, SUICIDAL, OF HOMICIDAL, OF 48 probably such,
if impossible to determine definitely. Examples: Accidental
drowning; Struck by railway train — accident ; Revolver
wound of head — homicide ; Poisoned by carbolic acid — prob-
ably suicide. The nature of the injury, as fracture of skull,
and consequences (@. g-, sepsis tetanus) may be stated under
the head of “‘ Contributory.”
Cases for the Medical Examiners.— Under the provisions
of chapter 24 of the Revised Laws deaths under the following
conditions must be referred to the Medical Examiners:
4. Deaths following injury or violence, as Burns, Falls,
Drowning, Gas Poisoning, Suicide, Ho: icide, etc.
i)
. Deaths supposedly caused by violence, as Criminal
Abortion, Poisoning, Starvation, Suffocation, Ex-
posure, etc.
2
. Sudden deaths of persons not disabled by recognized
disease, as A death upon the street, or one supposed to
be due to Alcoholism, ete.
>
Deaths under circumstances unknown, as A person found
dead, etc.
FILL OUT WITH INK. -THIS IS A PERMANENT KECOKU
ALL NAMES TO BE IN FULL
THE COMMONWEALTH OF MASSACHUSETTS
FULL NAME
Place
of
I
/
7
(
/
Death
*
S
{CITY OR TOlIN\) RETURN OF A DEATH Registered
No.
DDeathf
!
X
^
19/
*
Residence
Age
*7.
.3..
years
months
.^T.
days
■--r: STATISTICAL DETAILS
SE
/'IJiTUU-
COLOR SINGLE, MARRIED, WIDOWED,
DIVORCED
WIDOWED,
OR
^
MAIDEN NAMEt
HUSBAND’S NAMEt - —
BIRTHPLACE*
NAME OF FATHER
fa^Cr
BIRTHPLACE ^
OF FATHER*
MAIDEN NAME /7<
OF MOTHER U
BIRTHPLACE
OF MOTHER* y?
OCCUPATION
^2'//
~^Z^Lc>
<2^
INFORMANT?
PLACE OF BURIAL OR REMOVAL II ,2
/%Cjl
~
DATE OF BURIAL
UNDERTAKER
19/^
ADDRESS
'*+
PHYSICIAN'S CERTIFICATE
I HEREBY CERTIFY that I attended deceased during last
illness, from 19 1 ^ to 19 /x> ,
that to the best of my knowledge and belief death occurred on the
date stated above, and that the CAUSE OF DEATH was as follcjws:
Primary: cIa^JZj
Dr-.y...
.(duration).. — days
Contributory :
(Signed)
ATIONt DAY8
%7?..[9i o (Address)
M.D.
SPECIAL INFORMATION only for Hospitals, Institutions, Transients,
or Recent Residents.
How
long
at
_
Ca
7/V~)
Place of Death? 4_..W...TLrfMi*..(. months..^.^. days
Where was disease contracted,
If not at place of death ?...... J .... J V. If.
Filed .19
Clerk
‘City or town, street and number, If any. If death occurs away from USUAL RESI-
DENCE, give facts called for under "Special Information." If In a Hospital or
Institution, give its NAME Instead of street and number,
t In case of married or divorced woman, or widow,
t State or country; also city, town or county, if known.
§ Name and address of person giving statistical details.
II Name of cemetery.
ces a2 'qte
THE COMMONWEALTH OF MASSACHUSETTS
aj.
RETURN OF A DEATH
°„f
}
W
Residency Age
O/t.
FULL NAME
Place
Death
{CITY OK TOWN.)
^T?..^?^S....j Registered No.
nsaiucnvv ........... %***
//£VaKx^ 44*2
S/0
Date
of
(
Death
i
.years..
19/
^ ? months. days
STATISTICAL DETAILS
SEX COLOR
l/lr&&6c:
SINGLE, MARRIED,
WIDOWED, OR s, *
DIVORCED
MAIDEN NAMEt
HUSBAND’S NAME t
BIRTHPLACE t
PHYSICIAN’S CERTIFICATE
I HEREB^ CERTIFY tha^ I attended deceased during last
illness, y~^... 19/0 „
that to merest of my knowledge antt-tfelief death occurred on the
date stated above, and that the CAUSE OF DEATH was as follows:
Primary: * a
NAME OF
FATHER
BIRTHPLACE
OF FATHER*
MAIDEN NAME
OF MOTHE
Mint
y
BIRTHPLACE
OF MOTHER X
OCCUPATION
SPECIAL INFORMATION only for Hospitals, Institutions, Transients,
^rRecent Residents. How long at
Place of Death? years months days
Where was disease contracted,
if not at place of death?
INFORMANT § Filed .19
Clerk
PLACE OF BURIAL OR REMOVAL II DATE OF BURIAL
Sc
19 /<=>
UNDERTAKER ADDRESS
* City or town, street and number, if any. If death occurs away from USUAL RESI-
DENCE, give facts called for under "Special Information.” If In a Hospital or
Institution, give Its NAME instead of street and number,
t In case of married or divorced woman, or widow,
t State or country; also city, town or county, if known.
§ Name and address of person giving statistical details.
II Name of cemetery.
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STANDARD CERTIFICATE OF DEATH
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RESIDENCE
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( Write the word)
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6 DATE OF BIRTH
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< 12 MAIDEN NAME
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14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant) C ' SI t -*r* --»««-» V~V~ I f_
(Address)
/tTf
ff/~ 7*.
^
,
Filed..
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
36 DATE OF DEATH
(Month)
(Day)
19!
(Year)
17 I HEREBY CERTIFY that I attended deceased from
, 191 , to ,191 ,
that I last saw h... alive on , 191 ,
and that death occurred, on the date stated above, at, m.
The CAUSE OF DEATH* was as follows :
(Duration)
yrs. .
Contributory
(Secondary) (Duration)
(Signed) ...
ds.
mos. ds.
, M.D.
191 (Address)..
* If death followed injury or violence the certificate of death must he made
out by the Medical Examiner.
18 LENGTH OF RESIDENCE (FOR HOSPITALS, INSTITUTIONS, TRANSIENTS, OR
Recent residents).
At place In the
of death,, yrs. mos. ds. State yrs. mos. ds.
Where was disease contracted,
if not at place of death 7
Former or
usual residence ,
39 PLACE OF BURIAL OR REMOVAL
?}/ ste- pZ*- y2~ 33* 20 UNDERTAKER
DATE OF BURIAL
191 O
ADDRESS
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Wo roaster .
2 FU LL NAME
[If married or
give maiden nai
“RESIDENCE
(CnmttumumtUIj nf Iftaaaarljusrtts
STANDARD CERTIFICATE OF DEATH
fffcr. State Ho spit il St. ; -
George W Scctt
(City or town.)
[If death occurred in
Ward) a hospital r»r institution, give its NAME instead
of street and number.]
[If married or divorced woman or widow
give maiden mime, al&o name of husband.]
Winthrop . Registered No.
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
Male
* COLOR OR RACE
w
5 SINGLE,
MARRIED,
WIDOWED, , .. j*
OR DIVORCED iVi -VT .Tl Q(|
( Write the word)
* DATE OF BIRTH
, IR56
(Month)
(Day)
(Year)
t AGE
54 yrs. mos. ds.
If LESS than
I day, hrs.
or min. ?
8 OCCUPATION
(a) Trade, profession, or
particular kind of work
Steamboat captain
Midi .
(b) General nature of industry,
business, or establishment in
which employed (or employer)..
5 BIRTHPLACE
(State or country) Be othbay % Me*
io NAME OF
FATHER Thomas
CO
•
H
z
Ul
u BIRTHPLACE
OF FATHER
(State or country)
Nova Scotia
< 0- 1= MAIDEN NAME
OF MOTHER Ha flora McNeil
'3 BIRTHPLACE
OF MOTHER
(State or country)
Nova Sootia
“THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
Ray L Whitney
(Informant) _ .
Ycrooster.
Jt
WT TT Filed 191.
T Registrar
MEDICAL CERTIFICATE OF DEATH
>» DATE OF DEATH
July 29, I9 I...0
(Month) * ITIirl CYfiarl
(Day)
(Year)
I HEREBY CERTIFY that I attended deceased fron
0
Ncv
2
,
190§( , to July 29,
that I last saw h...~" . alive on . 1 \ , 191 ^ ,
and that death occurred, on the date stated above, at^:‘ ' m.
The CAUSE OF DEATH* was as follows :
General piralysia of the insane
ds. (Duration) yrs
Contributory...
at
ion
of
general paral
(SEOON^Rj^-1 g — . "j_ (Duration) yrs.
Ltney
Worcester •
mos. ds.
,, R L Whitney Jul 30, 0
.?, 191 (Address)..
* If death followed injury or violence the certificate of death must be made
out by the Medical Examiner.
18 LENGTH OF RESIDENCE (FOR HOSPITALS, INSTITUTIONS, TRANSIENTS, OR
Recent Residents! _
At place 1 H 2 8 In the! 'nknC’VTl
of death yrs. mos ds. State yrs. mos. ds.
Where was disease contracted, Unknown
if
not
at
place of
death?
W****'ta*EH.*iK
Former
or
WlnthrOP. usual residence
» PLACE OF BURIAL OR REMOVAL
Boston
30
underta
rff*R
g \ Pu t n
T
DATE OF BURIAL
Aug 2,
191
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ALL NAMES TO BE IN FULL
FULL NAME
Place
Death
THE COMMONWEALTH OF MASSACHUSETTS
DEATH
(CITY
OR
TOWN.)
Registered No \p. J.
RETURN
?}...*iz<l r,r !■ ^ ^ .9
Residence Age
^r,
f£
..years.. .X. £ . .months.r^T. ...fi days
STATISTICAL DETAILS
SEX COLOR SINGLE, MARRIED, • WIDOWED, OR s
DIVORCED /^/1/L‘A-^n^O
MAIDEN NAMEt
HUSBAND’S
NAMEt
^
-6
BIRTHPLACE*
NAME OF
FATHER
/Qxj>
BIRTHPLACE
OF FATHER*
MAIDEN NAME
OF MOTHER
(s~> --C — t
BIRTHPLACE
OF MOTHER*
OCCUPATION
INFORMANT §
<S ■?
PLACE OF BURIAL OR REMOVAL II
UNDERTAKER
f /l /H 4
DATE OF BURIAL
ADDRESS
PHYSICIAN'S CERTIFICATE
I HEREBY CERTIFY that I attended deceased during last
illness, from I9\vj to .19 L ,
that to the best1 of my knowledge and belierdfcath occurred on the
date stated above, and that the CAUSE OF DEATft wa^as follpws:
Primary: \.A^vKjAj>..kr^ ^
.CoosaVion). .
Contributory:
(Signed)...
M.D.
.^sA^.^X-19 (Addres^.-^Cr
vT
SPECIAL INFORMATION only for Hospitals, Institutions, Transients,
or Recent Residents,
How long at
Place of Death 7 years months days
Where was disease contracted,
If not at place of death?
Filed .19
Clerk
•City or town, street and number, If any, If death occurs away from USUAL RESI-
DENCE, give facts called for under "Special Information.” If in a Hospital or
Institution, give Its NAME Instead of street and number,
t In case of married or divorced woman, or widow,
t State or country; also city, town or county. If known.
§ Name and address of person giving statistical details.
II Name of cemetery.
Oo
2 t4to
pe 7
ALL NAMES TO BE IN FULL
THE COMMONWEALTH OF MASSACHUSETTS
FULL NAME
RETURN OF A DEATH
Place
Death
°!\ £0.±.&4^tSy Mr.. Residence .< ■■■■■■■ Age
• Mi
(CITY OR TOWN.)
...Registered
No.
'
Date of *7 m
Death
\
19/®
^....^ years... .d. months
. days
STATISTICAL DETAILS
SEX COLOR
yrTLJZk:
SINGLE, MARRIED,
WIDOWED, OR
DIVORCED
MAIDEN NAME
HUSBAND’S NAME t
BIRTHPLACE!
NAME OF
FATHER
BIRTHPLACE
OF FATHER!
MAIDEN NAME
OF MOTHER
BIRTHPLACE
OF MOTHERt
INFORMANT §
PLACE OF BURIAL OR REMOVAL II
UNDERTAKER
DATE OF BURIAL
19^0
ADDRESS
/^4
PHYSICIAN’S CERTIFICATE
I HEREBY CERTIFY that I attended; deceased during last
illness, froip^AArrfe^^...^:^.. I9A? ,
that to the Dest of my knowledge andMielief death occurred on the
date stated above, and that the CAUSE OF DEATH was as follows:
Primary :
(Signed). ..y /j ,
> '.IS/c (Address *:'./! * . ' .A
SPECIAL INFORMATION only for Hospitals, Institutions, Transients,
o^ecent Residents. How long at
Place of Death7 years months days
Where was disease contracted,
if not at place of death 7
Filed
.19
Clerk
* City or town, street and number, If any. If death occurs away from USUAL RESI-
DENCE, give facts called for under “Special Information.” If In a Hospital or
Institution, give Its NAME Instead of street and number,
t In case of married or divorced woman, or widow,
t State or country; also city, town or county, If known.
§ Name and address of person giving statistical details.
II Name of cemetery.
' . • • I-
o
—
— 0 ~o
THE COMMONWEALTH OF MASSACHUSETTS
RETURN
OF
A
DEATH
(CITY
OR
TOWN.)
FULL NAM Registered No.
Place of I O „ ■. x- — V Date of {/
Death * ) Death \
Residence .V. '■■'■■ Age.
.y^y^.months.
STATISTICAL DETAILS
SEX
<F COLOR
CO
SI NOtE,- MAfifttEB ,
WIDOWED, OW
DIVORGEB /?
MAIDEN NAME t
HUSBAND’S NAME t
BIRTHPLACEt
MAIDEN NAME
OF MOTHER
BIRTHPLACE
OF MOTHER!
/?
<■
OCCUPATION
-V-.
INFORMANT?
PLACE OF BURIAL OR REMOVAL II
UNDERTAKER 7
DATE OF BURIAL
a
*<-
.
,
t **
/^Lrc /^z
PHYSICIAN’S CERTIFICATE
I HEREBY CERTIFY that I attended deceased during last
illness, UortShJl*p...£0>. W" 19 /O ,
that to the best of my knowledge and belief death occurred on the
date stated above, and that the CAUSE OF DEATH was as follows:
Primary:
. (DURATION).. ..V^^ DA VS
Contributory:
(duration) DAYS
(Signed ) v wr. . . . :r. . . . . .7:. : TTt- M . D.
&y.A7..\9“' (Address)..
SPECIAL INFORMATION only for Hospitals, Institutions, Transients,
or Recent Residents.
How long at
Place of Death? years. months days
Where was disease contracted,
If not at place of death?
Filed .19
Clerk
* City or town, street and number, If any. If death occurs away from USUAL RESI-
DENCE, give facts called for under "Special Information." If In a Hospital or
Institution, give its NAME Instead of street and number,
t In case of married or divorced woman, or widow,
t State or country; also city, town or county, If known.
§ Name and address of person giving statistical details.
II Name of cemetery.
—
Every item of information should be carefully supplied. AGE should be stated
EXACTLY. PHYSICIANS should
state
CAUSE
OF
DEATH
in
plain terms,
so that
it
may be
properly
classified. Exact statement
of
OCCUPATION
is
very
important. See instructions on back
of certificate.
utyp GJmtroumnifaltt} of Massarljusftts
STANDARD CERTIFICATE OF DEATH
PLACE OF DEATH
•FULL NAME £
[If married or divorced woman or widow 3^-7^ Z , // . / - , - -
giv«' maiden name, algo name of husband.] ^ -
BOSTON
(City or town.)
[If death occurred in
Ward) a hospital or institution, give its NAME instead
of street and number.]
“RESIDENCE Registered No. 7 ®
PERSONAL AND STATISTICAL PARTICULARS
3 SEX 1 COLOR OR RACE 3 SINtj-CE, MA-RRfED,
WIDOWED,
OR -oivoncED
( Write the word)
6 DATE OF BIRTH
, i fel)
(Month) (Day) (Year)
* AGE
-y
J-
/
ds.
If LESS than
I day, hrs-
or min. ?
8 OCCUPATION
(a)' Trade, profession, or
particular kind of work.
(b) General nature of industry,
business, or establishment in
which employed (or employer)..
9 BIRTHPLACE . -
(Stfite or country) //
>0 NAME OF
FATHER
1
.
ii BIRTHPLACE V OF FATHER
(.State or country)
1’ MAIDEN NAME ^ —
OF MOTHER
?
-t-ds
(C
1’ BIRTHPLACE
OF MOTHER
(State or country)
*
>* THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant).
(Address)
191.
Registrar
MEDICAL CERTIFICATE OF DEATH
“ DATE OF DEATH
(Month)
(Day)
I9 I.0 .
(Year)
HEREBY CERTIFY that I attended deceased from
, 1 9 1 ^ , to C -~f ' , I9l£?..,
/'
191..
Q>,
and that death occurred, on the date stfated above, at m.
The CAUSE OF DEATH* was as follows :
that I last saw h alive on
L
(Address)..
* If death followed injury or violence the certificate of death must he made
out bv the Medical Examiner. _ 18 LENGTH OF RESIDENCE (FOR HOSPITALS, INSTITUTIONS, TRANSIENTS, OR
RECENT RESIDENTS).
At place In the
of death yrs. mos. ds. State yrs. . mos. ds.
Where was disease contracted,
If not at place of death 7
Former or
usual residence
» PLACE OF BURIAL OR REMOVAL i DATE OF BURIAL
dl*
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SB E.
Every item of information should be carefully supplied. AGE should be stated
EXACTLY. PHYSICIANS should
state
CAUSE
OF
DEATH
in plain terms,
so that
it
may be
properly classified. Exact statement
of
OCCUPATION
is
very
important. See instructions on back
of
certificate.
(jJljp (Eomnummealiti of fHassarfyuaptls
STANDARD CERTIFICATE OF DEATH
PLACE
OF
DEATH
,
t
(No.
3
L 'y.
>
\
j
!FULL
NAME
[If married or divorced woman or widow
give maiden name, also name of husband.] inuiuvii uauiO) oiou mum, vx uuoin*uu.j ...... . .
“RESIDENCE 3 b V OX SL& f
[If death occurred in
Ward) a hospital or institution, give its NAME instead
of street and number.]
Registered No. "J J '
m
z
PERSONAL AND STATISTICAL PARTICULARS
3 SEX ' COLOR OR RACE
6 DATE OF 8iRTH
Q
(Month;
&
SINGLE,
n
MARRIED,
V
J
WIDOWED, I
OR OIVORCED (j
( Write the word)
1.1 , 1 1.0 % (Day) (Year)
7 AGE
yrs.
/ 0
V? ds.
If LESS than
I day, hrs.
or min. ?
8 OCCUPATION
(a) Trade, profession, or
particular kind of work
(b) General nature of industry,
business, or establishment in
which employed (or employer)
3 BIRTHPLACE
(State or country)
>» NAME OF
FATHE
PLACE C u BIRTHPLACE
OF FATHER
(State or country)
12 MAIDEN NAME
OF MOTH
n BIRTHPLACE
OF MOTHER
(State or country)
L - -j*
u THE ABOVE IS TtfUS TO THE BEST OF MY KNOWLEDGE
(Informant) J...
(Address) j (, V () /*Jb . jdL
Filed 191
Registrar
i« DATE OF DEATH
MEDICAL CERTIFICATE OF DEATH
CX^_ (Month) 1
(Day) 191..©.
(Year)
I9I£> , to
191 ©
that
HEREBY CERTIFY that I attended deceased from
0—1
-
*
>r
las't saw h alive on w ... , 191 O,
at °< m.
and that death occurred, on the date stated abtrve,
The CAUSE OF DEAJH* was as follows :
(Duration)
s.
/
ds.
Contributory.
(secondary)
* If death followed injury or violence the certificate of (death must he made
out byHne Medical Examiner.
18 LENGTH 01- RESIDENCE (FOR HOSPITALS, INSTITUTIONS, TRANSIENTS, OR
Recent residents).
At place In the
of death yrs. mos. ds. State yrs. mos. ds.
Where was disease contracted,
If not at place of death 7 .
Former or
usual residence
1» PLACE OF BURIAL OR REMOVAL
Gu
UNDERTAKER /V
DATE OF BURIAL
fC/-L [9 1 (/
—
STANDARD CERTIFICATE OF DEATH.
Statement of occupation. — Precise statement of occupa-
tion is very important, so that the relative healthfulness of
yarious 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, Loco-
motive engineer, Civil engineer, Stationary Jireman, ete. But
in many cases, especially in industrial employments, it is
necessary to know («) the kind of work and also (}) 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. Asexamples: («) Spinner, (b) Cotton mill; (a) Sales-
man, (b) Grocery ; (a) Foreman, (b) Automobile factory. The
material worked on may form part of the second statement.
Never return ‘‘ Laborer,” ‘‘ Foreman,” Manager,”’ Dealer,”
etc., without more precise specification, as Day laborer, Farm
luborer, Laborer — Coul mine, ete. Women at home, who are
engaged in the duties of the household only (not paid House-
Keepers who receive a definite salary), may be entered
Housewife, Housework, or At home, and children, not gain-
fully employed, as 1d school or At home. re should be taken
to report specifically the occupations of persons engaged in
domestic service for wages, as Servunt, Cook, Housemaid, ete.
Ifthe 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: Furver (retired, 6 urs.)- For persons who have no
occupation whatever, write None.
Statement of cause of death.— Name, first, the pisEAsE
CAUSING DMATH (the primary affection with respect to time
and causation), using always the came accepted term for the
same disease. Examples: (crebro-spinul fever (the only
definite synonym is ‘' Epidemic cerebro-spinal meningitis”)
Diphtheria (avoid use of “Croup”) ; Tuphoid fever (never re-
port ‘* Typhoid pneumonia”); Lovar preumonia; Bronecho-
pneumonia ( Pileumonia,” unqualified, is indefinite) ; Tuber-
culosis of lungs, meninges, peritonacun, ete., Carcinoma, Sar-
coma, ete., of.. _(name origin: ‘Cancer’? is less
definite; avoid use of ‘Tumor’ for malignant neoplasms) ;
Meusles; Whooping cough; Chronic valvular heart disease ;
Chronic interstitial nephritis, etc. The contributory (second-
ary or intercurrent) affection need not be stated unless im-
portant. Example: Measles (disease causing death), 29 ds. ;
Broncho-pneumonia (secondary), 70 ds. Never report mere
symptoms or terminal conditions, such as ‘‘ Asthenia,’’ ‘‘ An-
aemia’? (merely symptomatic), ‘‘ Atrophy,” ‘‘ Collapse,’””
“Coma,’”’ ‘“ Convalsions,’’ ‘* Dability ’” (!Congenital,”
“Senile,” etc.), ‘ Dropsy,’’ ‘‘ Exhaustion,”” “Heart failure,’’
“Haemorrhage,” ‘“ Inanition,” ‘ Marasmus,” ‘' Old age,’?
“Shock,” ‘‘ Uraemia,” ‘* Weakness,’”’ etc., when a definite
disease can be ascertained as the cause. Always qualify all
diseases resulting from childbirth or miscarriage, as ‘* PUER-
PERAL septicaemia,” ‘‘ PUBRPERAL peritonitis,” ete. State
cause for which surgical operation was undertaken.
Cases for the Medical Examiners. — Under the provisions
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, etc.
. Deaths supposedly caused by violence, as Criminal
Abortion, Poisoning, Starvation, Suffocation, Be-
posure, etc.
3. Sudden deaths of persons not disabled by recognized
disease, as A deuth upon the street, or one supposed to
be due to Alcoholisin, ete.
os
. Deaths under circumstances unknown, as uf person found
dead, etc.
COMMONWEALTH OF MASSACHUSETTS.
FULL NAME
Place of Death )
and Residence J
Date of Death
CITY OF
RETURN OF A DEATH-1910. BOSTON.
. Hie hard. . . GgcMan Registered No... 71. 4.0
B o s ton St... Marys . Inf; t ...Asylum
Aug.. 7 1910. Age
years
6 month* days.
STATISTICAL DETAILS. PHYSICIAN’S CERTIFICATE.
SEX COLOR SINGLE. MARRIED, WID., DIV.
M W S
1 HEREBY CERTIFY that 1 attended deceased during last illness,
from . A.U./T 2 S |q |o
Maiden Name
Husband’s Name
Birthplace
BOStO.n
that to the best of my knowledge and belief death occurred on the
date stated above, and that the CAUSE OF DEATH was as follows:
| Acute Gastro Enter! sit
(DuTdykwQV
j
^ ,rJ]\ -* \ 7 ds
\
m
«®nidb ?aar, John w Vsir;
>WfA'
M
j
M
Mf
J
xJ$/.
»;,F,P.'h" Halifax. N . S .1°'
Contributory
:
|
of,iM^,,me
Ellen.
Purcell
(Duration) i
ra“.*
Woburn
Occupation
(signed) E . J . .p.lRourke m.d.
Au.g .^10 S..M...I. A
informant Tolm ...Vy. C.Q.clir.QLn
SPECIAL INFORMATION from Hospitals, Institutions, Transients, or Recent
Residents.
o??:m°o,!l’.ris' Maiden - Holy Cross
Usual Residence
437 WinthrOp
St
Undertaker I.HQlQ£t£ tT Heine
Winthrop
Filed Aug .12... 1910
A true copy. ^ /7
Registrar,
—
■
: ''
*
' .
aT K
. ;
-
'
£
- : . • . . ."
= • t!
:
..A ....
- r- : • • .
.
' ■
. . * t
i ■ ,
!
&
«
*
1 .
■ . v ■- ■
*
A
0
* ■
Every item of information should be carefully supplied. AGE should be stated
EXACTLY. PHYSICIANS should
state
CAUSE
OF
DEATH
in plain terms,
so that
it
may be
properly
classified. Exact statement
of
OCCUPATION
is
very
important.
See instructions on back
of
certificate.
(Enmmmtttti'altli of fteaarf}us#tt0
STANDARD CERTIFICATE OF DEATH
(No/
2 FULL NAME
/3Z
' /(L^/ ^
BOSTON
(City or town.)
St. [If death occurred in
Ward) a hospital or institution, give its NAME instead
of street and number.]
(If married #r divorced woman or widow
give maiden name, also name of husband.]
“RESIDENCE Registered No. *] ^
00
2
PERSONAL AND STATISTICAL PARTICULARS MEDICAL CERTIFICATE OF DEATH
3 SEX
7#
I
<
COLOR
OR
RACE
I
5
SINGLE,
MARRIED,
, M f" WIDOWED,
/ 7/7 / 1 OR DIVORCED
v
w
\
(
Write
the
word)
15 DATE OF DEATH
8 DATE OF BIRTH
(Month)
(Day)
I9 140.
(Year)
HEREBY CERTIFY that I attended deceased fror
hptuto.
\
a
ria>/^
-
ID,n (Year)
7 AGE
,,yrs.
ft mos. ^?ds.
If LESS than
I day, hrs.
,191 0 , to , 1 9 \0 ,
or min.
> OCCUPATION
that 1 fast saw h^<*# alive on
and that death occurred, on the date ^t/ted above
The CAUSE OF DEATH* was as follows :
(a) Trade, profession, or
particular kind of work..
(b) General nature of industry,
business, or establishment in
which employed (or employer)...
,J BIRTHPLACE
(State or country')
io NAME OF
FATHER
>1 BIRTHPLACE
OF FATHER
(State or country)
12 MAIDEN NAME
OF MOTHER
i followed injury or violence the certificate of death must he made
out lit the Medical Examiner.
>* BIRTHPLACE
OF MOTHER
(State or country)
'ay
18 LENGTH OF RESIDENCE (FOR HOSPITALS, INSTITUTIONS, TRANSIENTS, OR
recent Residents).
At place In the
of death yrs. mos. ds. State yrs.. mos. ds.
H THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
Where was disease contracted,
If not at place of death 7 ...
Former or
usual residence
1» PLACE OF BURIAL OR REMOVAL DATE OF BURIAL
,Qi c
a
REGISTRAR
M UNDERTAKER A ADDRESS <0.
= ion
STANDARD CERTIFICATE OF DEATH.
Statement of occupa
tion is yery important, so that the relative healthfulness of
n.— Precise statement of occupa-
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 he sufficient, e. g.,
Farmer or Planter, Physician, Compositor, Architect, Leco-
motive engineer, Civil engineer, Stationary sireman, ete. But
in many cases, especially in industrial employments, it is
necessary to know (a) the kind of work and also (b) the nature
of the business or industry, and therefore an additional line is
provided for the latter statement ; it should be used only when
needed. As examples: (a) Spinner, (b) Cotton mill; (a) Sales-
man, (b) Grocery ; (a) Foreman, (b) Automobile factory. The
material worked on may form part of the second statement.
Never return ‘‘ Laborer,” Foreman,” “‘ Manager,” ‘‘ Dealer,”
etc., without more precise specification, as Day laborer, Farm
laborer, Laborer — Coal mine, ete. ‘Women at home, who are
engaged in the duties of the household only (not paid Howse-
keepers who receive a definite salary), may be entered as
Housewife, Housework, or At home, and children, not gain-
fully employed, as At school or At home. Care should be taken
to report specifically the oceupations of persons engaged in
domestic service for wages, as Servant, Cook, Housemaid, etc.
T£ the occupation thas been changed or given up on account of
the DISEASE CAUSING DEATH, state cecupation 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 team for the
disease. Examples: Cerebro-spinal fever
same (the only
definite synonym is “Epidemic cerebro- pinal meningitis ”’)
Diphtheria (avoid use of “Croup ”) ; Typhoid fever (never re-
port ‘* Typhoid pneumonia”) ; Lobar pneumonia, Broncho-
pneumonia (' Pneumonia,” unqualified, is indefinite) ; Tuber-
Wy
,
yopeuee
culosis of lungs, meninges, peritonaeum, ete., Carcinoma, Sar
coma, ete., of.. .(name origin “Cancer”? is less
definite; avoid use of ‘‘ Tumor’? for malignant neoplasms) ;
Measles; Whooping cough; Chronic valvular heurt disease:
Chronic interstitial nephritis, etc. The contributory (second-
ary or intercurrent) affection need not be stated unless im-
portant. Example: Meusles (disease causing death), 29 ds. 5
Broncho-pneumonia (secondary), 17 ds. Never report mere
symptoms or terminal conditions, such as ‘‘ Asthenia,’’ ‘* An-
anemia’? (merely symptomatic), “Atrophy,” ‘ Collapse,”
“Coma,” ‘ Convulsions,” “* Debility” (‘‘Congenital,”
“Senile,” etc.), ‘ Dropsy,” ‘ Exhaustion,” “Heart failure,”
“ Haemorrhage,” ‘‘ Inanition,” ‘ Marasmus,” ‘* Old age,’””
“Shock,’’ ‘‘ Uraemia,”’ “Weakness,” etc., when a definite
disease can be ascertained as the cause. Always qualify all
diseases resulting from childbirth or miscarriage, as ‘* PUER-
PERAL septicuemia,” ‘* PUERPERAL peritonitis,’ etc. State
cause for which surgical operation was undertaken,
Cases for the Medical Examiners. — Under the provisions
of chapter 24 of the Revised Laws deaths under the following
conditions must be referred to the Medical Examiners:
Deaths following injury or violence, as Burns, Falls,
Drowning, Gas Poisoning, Suicide, Homicide, etc.
2, Deaths supposedly caused by violence, as Criminal
Abortion, Poisoning, Starvation, Suffocation, Ha-
posure, ete.
3, Sudden deaths of persons not disabled by recognized
disease,22 A deuth-upen the strect, or oue supposed fo
be due to Alcoholism, etc.
Deaths under circumstances unknown, as A person found
dead, etc.
Every item of information should be carefully supplied. AGE should be stated
EXACTLY. PHYSICIANS
should
state CAUSE OF DEATH
in plain terms, so that
it
may be properly classified. Exact statement
of
OCCUPATIO
is very
important.
See instructions on back
of certificate.
(Htjp (Cammonuipaltlj of fHassarfjuaptta
STANDARD CERTIFICATE OF DEATH
PLACE OF DEATH
k/
(City or towny
Vl (No. lt %y~ , O/y ^ St.
a. « ,
IIS' GUr*_ v
[If death occurred in
Ward) a hospital or institution, give its NAME instead
of street and number.]
2 FULL NAME.
[If married or divor<A(jJvoman or widow
give maiden name, also name ofjrasband.]
“RESIDENCE Registered No. 7 *7
PERSONAL AND STATISTICAL PARTICULARS
3 SEX 4 COLOR OR RACE
7,/uA
-
» SINGLE,
MARRIED,
WIDOWED,
or- Divoncco
(Write the -word)
3 DATE OF BIRTH
(Month)
./&
(Day) ... iVsJX
(Year)
7 AGE
/.M> ds.
If LESS than
I day,..x/...hrs.
3 OCCUPATION
(a)
part
.Ur A I I Ol IN A /,
(b) General nature of industry,
business, or establishment in
which employed (or employer)...
<L
3 BIRTHPLACE
(State or country)
>» NAME OF
FATHER
■1 BIRTHPLACE
OF FATHER/
(State or country)
33 MAIDEN NAME
OF MOTHER
'* BIRTHPLACE
OF MOTHER
(State or country)
^LUxJ!-
flbxjdz
14 TH E ABOVE ISTRUE TO THE BEST OF MY KN9WLEDGE
(Informant) Aj~)
(Addra.a)
//y
^
'SL
Fil.d.. 191.
Registrar
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
3
/
1
9
Q
(Montjsy (Day) (Year)
I HEREBY CERTIFY that I have investigated the
death of the deceased.
The CAUSE OF DEATH* was as follows :
C vAA ds.
Contributory..
(secondary)
(Duration) yrs.
(Signed)
., M.D.
, iVffli (Address). y
MEDICAL EXAMINER
* State the Disease Causing Death, or, in deaths from Violent Causes,
state (1) Means of Injury; and (2) whether Accidental, Suicidal or
Homicidal.
18 LENGTH OF RESIDENCE (FOR HOSPITALS,
Recent Residents).
At place In the
of death. yrs. mos ...ds. State...
Where was disease contracted,
If not at place of death 7
Former or
usual residence.
Institutions, Transients, or
yrs. mos. ds.
»9 PLACE OF BURIAL OR REMOVAL DATE of burial
— ' . •. •" 3.
i
I9I(7t
ADDRESS
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Every item of information should be carefully supplied. AGE should be stated
EXACTLY. PHYSICIANS
should
state CAUSE OF
DEATH
in plain
terms, so that
it
may be properly classified. Exact statement of
OCCUPATION
is
very
important.
See instructions on back
of certificate.
(Emtmumuiealtl) of fiassartjusrita
PLACE >F DEATH
STANDARD CERTIFICATE OF DEATH
(City or town.)
[If death occurred in a hospital or institution,
give its NAME instead
of street and number.]
'•FULL
NAME
[If married or divorced w<5man or widow ■
gtv<' maiden name, also name of husband.]
“RESIDENCE Registered No.
I.
cd
z
PERSONAL AND STATISTICAL PARTICULARS
* SEX
(^F~
Jjy
COLOR
OR
RACE
I
5
m^RRiId
WIDOWE
OR
DIVORCED
(
Write
the
word)
..
^
6 DATE OF BIRTH
(Month)
(Day)
(Year)
1 AGE If LESS than
I day, hrs.
or min. ?
8 OCCUPATION
(a)‘ Trade, profession, or
particular kind of work ft
(b) General nature of industry,
business, or establishment in
which employed (or employer).
0 BIRTHPLACE
(State or country)
■i BIRTHPLACE^
OF FATHER
(State or country)
< i >= MAIDEN NAME
Q- OF MOTHER iMt _
1» BIRTHPLACE
OF MOTHER
(State or country)
14 THE ABOVE IS
17 I HEREBY CERTIFY that I attended deceased from
...., rar6 , to 7* .,191.10.,
that I last saw h. t^| alive on ^ < I9 I ^ <
and that death occurred, on the date slated above, at m.
The CAUSE OF DEATH* was as follows :
(Duration)
yrs.
% ds.
Contributory
(secondary)
I 9 I Q (Address)
* If death followed injury or violence the certiflcate/jbf death must be made
out by the Medical Examiner.
18 LENGTH OF RESIDENCE (FOR HOSPITALS, INSTITUTIONS, TRANSIENTS, OR
RECENT RESIDENTS).
At place In the
of death yrs. mos. ds. State yrs mos. ds.
Where was disease contracted,
if not at place of death 7
Former or
usual residence.,
DATE OF BURIAL
191 .
ADDRESS
oo
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3 s.
Every item of information should be carefully supplied. AGE should be stated
EXACTLY. PHYSICIANS
should
state CAUSE OF
DEATH
in plain terms, so that
it
may be properly classified. Exact statement of
OCCUPATION
is very
important.
See instructions on back
of
certificate.
©Ij? (EnmmumuraltJj of
STANDARD CERTIFICATE OF DEATH
•
PLACE
OF
DEATH
^
(No ..yj* Q ,
(City or town.) Ward)
TULL NAME
[If death occurred in
a hospital or institution,
give its NAME instead
of street and number.]
[If married or divorced woman or widow'
give maiden name, also name of husband.]
-RESIDENCE
J
g Registered No.
I.
cd
z
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
\1
c_ -
1 COLOR OR RACE
DATE OF BIRTH 4T
iiC.
S SINGLE,
W+OCTWED,
uivorttld
( Write the word)
? \%>J.
(Month) (Day) (Year)
* AGE
J i
£.
ds
If LESS than
I day, hrs.
or min. r
8 OCCUPATION
(a) Trade, profession, or
particular kind of work.. a utns.
(b) General nature of industry,
business, or establishment in
which employed (or employer) \ 'L 'Z-TTVr1rr<^--
3 BIRTHPLACE
(State or country)
NAME OF
/
.
•"
FATHER ' * .
'1 BIRTHPLACE
CO OF FATHER
£
(State
or
country),
.
yf-
^
£
L
<
CT'
r
< maiden name
o- OF MOTHER
'* BIRTHPLACE _ . ,,
OF MOTHER CU. ’ 7/ .Jr \ a . „ (State or country)
“THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
£)
J
/I S fa (Informant) ---■
^
kus
191
Registrar
MEDICAL CERTIFICATE OF DEATH
>6 DATE OF DEATH
I (Month)
(Day)
i9:.P
(Y ear)
I HEREBY CERTIFY that I attended deceased Tor
, I9|0 , to ^ ILsjabuH^KA. ( O , 191 0
that I last saw h.l.jK,. alive on L 0 , |9|£J
and that death occurred, on the date stated above, at*? 8 0 m
The CAUSE OF DEATH* was as follows :
(Duration)
yrs.
, Lf d.
Contributory
(secondary) (Duration) .
(Signed) (/
,i 191 ess).. ds.
M.D.
* If death followed injury or violence the certificate of death must be made
out by the Medical Examiner.
18 LENGTH OF RESIDENCE (FOR HOSPITALS, INSTITUTIONS, TRANSIENTS, OR
Recent residents).
At place In the
of death yrs. mos. ds. State yrs. mos. ds.
Where was disease contracted,
If not at place of death 7
Former or
usual residence
» PLACE OF BURIAL OR REMOVAL DATE OF BURIAL
//- , I9I^>
=° UNDERTAKER ADDRESS
* />
/ V
STANDARD CERTIFICATE OF DEATH.
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 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, Loco-
motive engineer, Civil engineer, Stationary fireman, ete. 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: («) Spinner, (b) Cotton mill; (a) Sales-
man, (b) Grocery; («) Foreman, (b) Automobile factory. The
material worked on may form part of the second stateiment.
Never return ‘‘ Laborer,” “ Foreman,” ‘‘ Manager,’’‘‘ Dealer,”
etc., without more precise specification, as Day luborer, Karn
ludborer, Laborer — Coal mine, ete. Women at home, who are
engaged in the duties of the household only (not paid Iouse-
keepers who receive a definite salary), may bo entered as
Housewife, Housework, or At home, and children, not gain-
fully employed, as .1¢ 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, 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: Furmer (retired, urs.). For persons who have no
occupation whatever, write None.
Statement of cause of death.— Name, first, the piszask
CAUSING DEATH (the primary affection with respect to time
and causation). using always the same accepted term for the
same disease. Examples: Cerebro-spinal fever (the only
definite synonym is ‘‘ Epidemic cerebro-spinal meningitis”) ;
Diphtheria (avoid use of Croup”) ; Typhoid sever (never re-
port ‘* Typhoid pneumonia’’); Lobar pneumonia; Broncho-
prewnonia (* Pneumonia,” unqualified, is indefinite) ; Tuber-
culosis of lungs, meninges, peritonacumn, ete., CarcinomaThe text goes on. The rest is in the file.