The volume, 1913–1915
Town Clerk, Winthrop · from the Internet Archive · 1092 pages · 76.7 MB
open the file ↗ · original at the source ↗
J.L FAIRBANKS & CO.
Stationers
43 FRANKLIN STREET
— ROfiTON —
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WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD.
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STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH
winthrop» Mass. (Ho. .1-1 Bowdoln St.
2 FULL NAM E..
[If married m><aivorced woman or widow
give maiden name, also name of husband.]
“residence 357 Bowdoin Street* vrinthrop, Mass.
rintlirop.
(City or town.)
[If death occurred in
..Ward) a hospital or institution,
give its NAME instead
of street and number.]
Registered No.
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PERSONAL AND STATISTICAL PARTICULARS
3 SEX
Msle
* COLOR OR RACE
■Vhite
8 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
( Write the word)
Widower. .
8 DATE OF BIRTH
May 5. 1829.
(Month)
(Day)
(Year)
1 AGE
83 7
...... yrs. mos.
28
.ds.
If LESS than
I day, hrs.
or min. ?
8 OCCUPATION
(a) Trade, profession, or (IP VT*R }
particular kind of work t \ _ . ;.
Examiner of*
(b) General nature of industry,
business, or establishment in Ifpsvt I r> P 1 n cr
which employed (or employer) M > 1 1 O *.
9 BIRTHPLACE
(State or country)
north or Ireland.
10 NAME OF
FATHER
Janes Warnock.
CO
H
z
LlI
ii BIRTHPLACE
OF FATHER
(State or country)
North of Ireland.
1
<
0-
“ MAIDEN NAME
OF MOTHER
Martha Smith.
■» BIRTHPLACE
OF MOTHER
(State or country)
North of Ireland.
“THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
“M 1 1 ■»
(Informant)
'-Villi an j. Varnaok,
MEDICAL CERTIFICATE OF DEATH
i« DATE OF DEATH
onth)
...1... , t9ijL.
(Day) (Year)
17 I HEREBY CERTIFY that I attended deceased from
±£h^^...A9.. I9IJ2L, to 191^...,
that I last saw h t*-M. alive on , 1 9 lS... .
and that death occurred, on the date stated alytve, at../.. ...SL m.
The CAUSE OF DEATH* was as follows :
....(Duration) ...V yrs. mos. ... ds.
* If death followed injury or violence the certificate ot^fKiith must
out by the Medical Examiner. Is
be made
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
is
Filed __
11. A u. L1 11 T* T
oaribridf e *
“ PLACE OF BURIAL OR REMOVAL
Mt. Aulmrn Cemetery,
Maas.
DATE OF BURIAL
J 9lla G « |9| 3 -
191
Registrar
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WRITE PLAINLY, WITH UNFADING INK-THJ2 IS A PERMANENT RECORD.
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“ DATE OF BIRTH
Sty? OInmmxmm?alth nf fSaasarfjttsptts
STANDARD CERTIFICATE OF DEATH
(City or town.)
[If death occurred in
St. : Ward) a hospital or institution.
give its NAME instead
of street and number.]
2 FULL NAME ^ J.
[If married or divorced woman or widow
give maiden name, also najp^of husband.]
“RESIDENCE
(o T
PERSONAL AND STATISTICAL PARTICULARS
SEX
1 COLOR OR RACE
s SINGLE,
MARRIED,
WIDOWED,
OR DIVORCE
( Write the word)
<31 )M%
(Month) (Day) '(Year)
1 AGE
..yrs. mosr
2e=l
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)
io NAME OF
FATHER f
/> LlL f/i
/?
11 BIRTHPLACE
OF FATHER
(State or country)
12 MAIDEN NAM
OF MOTHE^^
IE
1» birthplace
OF MOTHER
(State or country)
JSCE S? ~ . t
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
(Address^
.../ "( y f/c^yC y tA.;
Filed..
191.
REGISTRAR
Registered No.
MEDICAL CERTIFICATE OF DEATH
18 DATE OF DEATH
(Month)
(Day)
I 9 I 2rrr:..
(Year)
17 I HEREBY CERTIFY that I attended deceased 'from
, I9l?rr, to...Ags^....^....^;. 19!...^
that I last saw h.A^^, alive on , 1 9 1
and that death occurred, on the date stated above,
The CAUSE OF DEATH* was as follows:
t~\
at (jja.. m.
(Duration) yrs. mos. ds.
Contributory
(secondary)
(Duration) yrs. mos. ds.
(&g"ed) , M.D.
191 (Address)
ff death followed injury or violence the certificate of death must be made
out by the Medical Examiner.
deatl
18 LENGTH OF RESIDENCE (FOR HOSPITALS, INSTITUTIONS, TRANSIENTS, OR
Recent Residents).
At place . i In the
of death yrs mos. ,,..*4!. ds. Statp. yrs mos. ds. Jl...
Where was disease contracted, \
If not at place of death 7 ^ / -•■i*
Former or . Qy T &7
usual residence .la..." xl. /
L Off REMOJAL
'VZui
DATE OF BURIAL
50 UNDERTAKER
*7^
ftl, 191 3.
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WRITE PLAINLY, Wl I H UNLADINU INK- I HIS IS A rtnlYIANhN I KtUUKU.
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.
co
PLACE OF DEATH
t (Cmmmimufattl) of HlassarljusTtts
STANDARD CERTIFICATE OF DEATH
BOSTON
(City or town.)
[If death occurred in
Ward) a hospital or institution,
give its NAME instead
of street and number.]
I1} 22.Q
DATE OF BIRTH
(Month)
(Day)
(Year)
1 AGE
•/S . • t
mos. ds.
If LESS than
I day, hrs.
1 OCCUPATION
(a)' Trade, profession, or
particular kind of work
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 :
(b) General nature of industry,
business, or establishment in
which employed (or employer)...
3 BIRTHPLACE
(State or country)
(Duration) yrs. mos. .
..ds.
Contributory..
(secondary)
(Duration) yrs.
(Signed)
, mos. ds.
, .VI. D.
.., 191 (Address)..
* If death followed injury or violence the certificate of death must be made
out by the Medical Examiner.
LENGTH OF RESIDENCE (FOR HOSPITALS, INSTITUTIONS, TRANSIENTS, OR
recent Residents).
At place In the
of death yrs. mos. ds. State yrs. mos. ds.
"THE ABOVE IS TRUE TO THE BEWOT MY KNOWLEDGE
Where was disease contracted,
if not at place of death 7
Former or
usual residence..
(Informant)
(Address)
DATE OF BURIAL
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2% (Cimmunmti'alth of iiaasarliuBftts
STANDARD CERTIFICATE OF DEATH
PLACE OF DEATH
..(No...
St. ;..
Ward)
2 FULL NAME
[If married or divorced woman or widow
give maiden name, also name of husband.]
“RESIDENCE
* 1
(City or town.)
[If death occurred in
a hospital or institution,
give its NAME instead
of street and number.!
Registered No.
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PERSONAL AND STATISTICAL PARTICULARS
SEX
* COLOR OR RACE
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
( Write the word)
8 DATE OF BIRTH
(Month)
(Day)
(Year)
t AGE
,.yrs. mos.
. 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)
in NAME OF
FATHER
ii BIRTHPLACE
OF FATHER
(State or country)
m MAIDEN NAME
OF MOTHER
i» BIRTHPLACE
OF MOTHER
(State or country)
(Informant)
(Address)
“THE ABOVE IS TRUE TO THE BEST Of MY KNOWLEDGE ,,
1 ,
Filed..
191.
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
1» DATE OF DEATH
&
(Month)
(Day)
I9l.r£>..
(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..7.-!+.?./)f m ■
The CAUSE OF DEATH* was as follows :
..(Duration) yrs.
..mos, ds.
Contributory
(secondary)
(Duration) yrs mos. ds.
(Signed) M.D.
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 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
i» PLACE OF BURIAL OR REMOVAL
® UNDERTAKER
DATE OF BURIAL
191
ADDRESS
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T7T
STATE OF OHIO
Secretary of State
Bureau of Vital Statistics
Permit No...
Reg. Dist. No.
I.U
7
e
\ \ ' * .
rmati
BURIAL OR REMOVAL PERMIT
Sex
£ie, — ___ _ Age,.....^^
causing death^^TC"
,» burial,
tfficate of death having been filed in my office in accordance with the Laws of Ohio, I hereby authorize the
ofYhe body of said deceased person as stated above. (BurU! or Removal)
.(?. 1 JO... Registrars name....
BuriM permits must be delivered by the undertaker to the sexton or other persons in charge of the burial ground or cemetery where
takas place. When the body is to Be shipped to a distant point, requiring the service of a common carrier, in addition to the removal
the body must be accompanied with a transit permit as required by the State Board of Health. For full particulars see Rules and
itlons Governing the Transportation of Dead Bodies.
n’s signature Date of interment
This permit must be Indorsed by the sexton and returned to the Local Registrar in his district within ten days.
.19.
!\ a
rt
14
(ORIGINAL) Form B. H. — 15-60M-6-18-11.
OHIO STATE BOARD OF HEALTH
TRANSPORTATION OF CORPSE
Transit Permit No.
3 *0 / ■■■
PHYSICIAN’S OR CORONER’S CERTIFICATE
Date
w 'I A / \ H A/ .&■ t
Npww/fi A
Name of Deceased
190..
Sex Color-
Place of Death... ...A ......
(Township, Village or City.)
Date of Death L , .
' ' f
County State
Hour of Death ,
Cause of Death 4 < Duration Days.
Contributory Causes of Death Duration Days.
Age : Years A Months Days
Occupation — Single, Married, Widowed, -Divorced.
(Cross out all but answer required.)
Place of Birth f„" —
(State or Country.)
(State or Country.)
Maiden Name of Mother _ Birthplace of Mother ,<£
- (State or Country.)
SPECIAL INFORMATION
Name of Father Birthplace of Father
(Only for hospitals, institutions or recent residents.)
Former or Usual Residence
How Long at Place of Death ?..
Where was the Disease Contracted if not at Place of Death?
I hereby certify that the above is true to the best of my knowledge and belief.
..M. D. or Coroner.
Residence..
.Countv of State of..
PERMIT OF LOCAL REGISTRAR
This Permit must be properly signed, and with Physician’s Certificate presented to the Railroad
or Express agent before body can be shipped.
In the : of.
(City, Village or Township.)
State of..*
.County of..
..ojf' the day of.
.190-
r
FWZft C~
Permission is hereby given to remove for burial at -
in the County of
the body of-
who died at.“t^.k...*.: i /A. in the County of State of.„i?_!— — 7!—
on the day of-.^— 190..—.. Aged .years months days.
The cause of death being..—. _ .• — which is a | communicable ( disease.
* I j .... J non-eommunicabie \
To be accompanied by — as escort.
Rule 1. The transportation of bodies dead of smallpox or tuibonlc plague from pne state, territory, district or province to another, Is
absolutely forbidden.
Signed. — ™ Tx>cnl Registrar.
A WHITE BLANK is only to be used when death did not result from any of the following diseases, to-wit: Asiatic cholera,
yellow fever, typhoid fever, diphtheria (membranous croup), scarlet fever (scarlatina, scarlet rash), erysipelas, glanders, puerperal
fever, anthrax, leprosy and when the body has not been disinterred.
Rules and Regulations of the Ohio State Board of Health Govern
ing the Transportation of Dead Bodies.
Rule 1. The transportation of bodies dead of smallpox or bubonic plague from one state, territory, district or province
to another, is absolutely prohibited.
Rule 2. The transportation of bodies dead of Asiatic cholera, yellow fever, typhoid fever, diphtheria (membraneous croup),
scarlet fever (scarlatina, scarlet rash), erysipelas, glanders, puerperal fever, anthrax or leprosy, shall not be accepted for transpor-
tation unless prepared for shipment by being thoroughly disinfected by (a) arterial and cavity injection .jviiRVan approved disin-
fecting fluid; (b) disinfection and stopping of all orifices with absorbent cotton, ^nd/ (f) washing the body with the disinfectant,
all of which must be done by an embalmer holding a certificate as such, issued by the state or provincial board of health, or other
state or provincial authority provided for by law.
After being disinfected as above, such body shall be enveloped in a layer of dry cotton, not less than one inch thick, com-
pletely wrapped in a sheet securely fastened, and encased in an air-tight zinc, tin, copper, or lead-lined coffin or iron casket, all
joints and seams hermetically sealed, and all enclosed in a strong, tight wooden box. Or the body being prepared for shipment by
disinfecting and wrapping as above, may be placed in a strong coffin or casket, and said coffin or casket encased in an air-tight
zinc, copper, or tin-lined box, all joints and seams hermetically soldered.
Rule 3. The bodies of those dead from any cause not stated in Rule 2 may be received for transportation when encased in a
sound coffin or casket and enclosed in a strong outside wooden box, provided they can reach their destination within thirty hours :
from the time of death. If the body cannot reach its destination within thirty hours from the time of death, it must be prepared
for shipment by arterial and eavity injection with an approved disinfecting fluid, washing the exterior of the body with the same,
and enveloping the entire body with a layer of dry cotton not less than one inch thick, and all wrapped in a sheet securely fast-
ened. and encased in an air-tight metallic coffin or casket or an air-tight metal-lined box. But when the body has been prepared
for shipment by being thoroughly disinfected by a licensed embalmer, as defined and directed in Rule 2, the air-tight sealing and
bandaging with cotton may be dispensed with.
Rule 4. In the shipment of bodies dead from any disease named in Rule 2, such body must not be accompanied by persons
or articles which have been exposed to the infection of the disease, unless certified by the health officer as having been properly
disinfected.
Before selling tickets, agents should carefully examine the transit permit and note the name of the passenger in charge, and
of any others proposing to accompany the body, and see that all necessary precautions have been taken to prevent the spread of the
disease. The transit permit in such cases shall specifically state who is authorized by the health authorities to accompany the
remains. In all cases where bodies are forwarded under Rule 2, notice must be sent by telegraph by the shipping embalmer to the f
health officer, or, when there is no health officer, to other competent authority at destination, advising the date and train on which
the body may be expected.
Rule 5. Every dead body must be accompanied by a person in charge, who must be provided with a passage ticket and also
present a full first-class ticket marked “Corpse" for the transportation of the body, and a transit permit showing physician’s or
coroner’s certificate, name of deceased, date and hour of death, age, place of death, cause of death, and all other items of the stand-
ard certificate of death recommended by the American Public Health Association and adopted by the United States Census Bureau,
as far as obtainable, including registrar’s permit for removal, whether a communicable or non-communicable disease, the
point to which the body is to be shipped, and when death is caused by any of the diseases specified in Rule 2, the names
of those authorized by the health authorities to accompany the body. Also the undertaker’s certificate as to how the body has been
prepared for shipment. The transit permit must be made in duplicate, and the signature of physician or coroner, local registrar,
and undertaker, must be on both the original and duplicate copies. The undertaker’s or registrar’s certificate and paster of the
original shall be detached from the transit permit am’ securely fastened on the end of the coffin box. All coffin boxes must be pro-
vided with at least four handles. The physician’s .^icificate and transit permit shall bi handed to the passenger in charge of the
corpse. The whole duplicate copy shall be sent to the official in charge of the baggage department of the initial line, and by him
to the secretary of the state or provincial board of health of the state or province from which shipment is made.
Rule 6. When bodies are shipped by express, a transit permit, as described in Rule 5, must be made out in duplicate. The
undertaker’s certificate and paster of the original shall be detached from the transit permit and securely fastened on the coffin box.
The physician’s certificate and transit permit shall be attacaed to and accompany the express way-bill covering the remains, and
be delivered with the body at the point of destination to the person to whom it is consigned. The whole duplicate copy shall be
sent by the forwarding express agent to the secretary of the state or provincial board of health of the state or province from which
shipment was made.
Rule 7. Every disinterred body, dead from any disease or cause, shall be treated as infectious or dangerous to the public
—health gjul_plia.il- not- he accented for transmutation unless said removal has been approved by the state or provincial health autho-
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
to
atyp (Emitmimitipaltl) of ilassarljoaftts
STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH
(No...,
FULL NAME
JA k
/S...
(City or town.)
[If death occurred in
....St. ; Ward) a hospital or institution,
give its NAME instead
of street end number.]
[If married or divorced woman or widow
give maiden name, also namjfe of husband.]
"RESIDENCE U*,
Registered No.
PERSONAL AND STATISTICAL PARTICULARS
* SEX
* COLOR OR RACE
U/
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
( Write the
K. .
word)
6 DATE OF BIRTH
_J_
(Month)
..... t*&
(Day) (Year)
AT
r AGE
../Lf.sA... yr». mos. ,.J?.:^:...d8.
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)...
3 BIRTHPLACE
(State or country)
c f>
NAME OF
FATHER
H BIRTHPLACE
OF FATHER
(State or country)
>8 MAIDEN NAME
OF MOTHER
'» BIRTHPLACE
OF MOTHER
(State or country)
(Informant)
(Address)
E IS TRUE TO THEJ5EST OF MY KNOWLEDG
191 ......
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
>• DATE OF DEATH
(Month)
7 , i s i i.
(Day) (Year)
I HEREBY CERTIFY that. I attended deceased from
.3. , 1 9 1 .3., to... r . 1 9 1 .~i,
that j 1 last saw h.l/^. alive on .7...... 191.3..,
and that death occurred, on the dato stated above, at../...„^r....m.
The CAUS^ OF DEATH* was as follows:
..(Duration) yrs.
...^S....ds.
Contributory..
(secondary)
(Signed)
f Duration) yrs.
.3.
(Address)
* If death followed injury or violence the certificate of death must be made
out by the Medical Examiner. V J
18 LENGTH OF RESIDENCE (FOR HOSPITALS, INSTITUTIONS, TRANSIENTS, OR
Recent Residents).
At place In the
of death. yrs. mos ds. State yrs.. mos ds..
V/here was disease contracted,
if not at place of death 1
Former or
usual residence
“ PLACE OF BURIAL OR REMOVAL
<2
31 UNDERTAKER
DATE OF BURIAL
... 191™
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.
I
od
(Ffj? (Eommnnumiltfj of U8aHsarlpjsptta
STANDARD CERTIFICATE OF DEATH
BOSTON
PLACE OF DEATH
..(N
(City or town.)
[If death occurred in
..St. ; * .-...Ward) a hospital or institution,
give its NAME instead
of street and number.]
‘FULL NAME
[If married or divorced womai/S/r widow
give maiden name, also name oThusband.] .... J c l/. At £ Sj/ a, / £ *- sf
ZZI * n , /Z Remi
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
pKO$L
4 COLOR OR RACE
HidJctt.
<• SINGLE,
MARRIED, _
WIDOWED, 'V/S J
OR DIVORCED
( Write the word) —
• DATE OF BIRTH
. __ .
. i -
(Month) (Day)
(Year)
1 AGE
(ij^yre.
mos. ZZ. ds.
If LESS than
1 day,. hrs.|
or . min.?
8 OCCUPATION
(a) Trade, profession, or JLJ . * D M
(b) General nature of industry,
business, or establishment in
which employed (or employer)
—
9 BIRTHPLACE n ~ ^ n
<s““"“un,rrt /?
10 NAME OF
FATHER
V)
h-
z
LU
ii BIRTHPLACE
(State or country) ^ ^
<
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12 MAIDEN NAME _ ^
OF MOTHER J s. SJ
“BIRTHPLACE ^ ^ /f (1*
OF MOTHER Ds (± Z7 V/ C~~$-
(State or country) ($/ C ’ Sr ' ( 1 r .
C\r3
Registered No.
“THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
i
T-
(Informant).
(Address)
Filed..
191.
Registrar
MEDICAL CERTIFICATE OF DEATH
» date of death
J,
(Month)
ZL
(Day)
I 9 1)3
(Year)
I HEREBY CERTIFY that I attended deceased from
...Jt ., 191.3...,
and that death occurred, on th&£<tate stated above, at..(^„£S...m .
The CAUSE OF DEATH* was as follows:
..(Duration) yrs. ,
Contributory..
(secondary)
„„ (Duration) .y.^yrs mo
(Signed) h.ZZ{?Lr!}. TiN-Y^d-V...'
, I 91. >3.. (Address)
' * If death followed injury or violence the certificai
out by t hey Medical Examiner.
“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...
T* 0- 4 ' OSL'tt _ HiVCE 0F BU^L OR removal date of burial^
Jm
“UNDERTAKER
ADDRESS . . ^
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(HI]? Clmnmmuwaltt} of fSaBsarljosplts
STANDARD CERTIFICATE OF DEATH
SFULL NAME..
[If married or divorced
give maiden name, also
o
(jtJ^
ed woman or widow /
10 name of husbgnd.]
(City or town.)
[If death occurred in
St. ; Ward) a hospital or institution,
give its NAME instead
of street and number.]
“RESIDENCE
(AyUXyCA 'is
Registered No.
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PERSONAL AND STATISTICAL PARTICULARS
* SEX
4 COLOR OR RACE
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
( Write the word)
» DATE OF BIRTH
(Month)
(Day)
(Year)
, >
» AGE
£A:
yrs. mos.
,.ds.
If LESS than
I day, hrs.
or min. ?
8 OCCUPATION
(a) Trade, profession, or / j/ 7 /fr—i/i ,4*
particular kind of work
(b) General nature of industry,
business, or establishment in
which employed (or employer)...
3 BIRTHPLACE / ,
(State or country) / J M- — " I
10 NAME OF „
FATHER j) !
V)
\-
z
LU
‘1 BIRTHPLACE
OF FATHER
(State or country)
<
Cl.
“ MAIDEN NAME .
OF MOTHER /
“ BIRTHPLACE
OF MOTHER
(State or country)
“THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant).
(Address)
Filed,
191.
MEDICAL CERTIFICATE OF DEATH
“ DATE OF DEATH
TM
(Month)
a
(Da
(Day)
I9lj3._
(Year)
I HEREBY CERTIFY that I attended deceased from
191..^, to JtaTL 9... , 1 9 1 _CL,
that I last saw h.,t^)„ alive on I9l..3i,
and that death occurred, on the date ^stated above, at.
The CAUSE„OF DEATH* was as follows
m.
U w u Aw I U Ln I n W a j do I Ul I U W o • ,
2_
...*tr^TT..yrs.
..(Duration) rr..yrs. mos, .
„ds.
Contributory..
(secondary)
(Duration
on)JtlMM^jrrs. ....
(Signed) V^. .yt m.u.
X 9I,J> (Address),..„..^^„...^^y^)([!!^^^^ Ik*
mos. ds.
M.D.
death followed injury or violence the certificate of death must be made
ouf by the Medical Examiner.
18 LENGTH OF RESIDENCE (FOR HOSPITALS, INSTITUTIONS, TRANSIENTS, OR
Recent Residents).
At place In the
of death, yrs.. mos. ids. State yrs. mos ds.
Where was disease contracted,
if not at place of death 7
Former or
usual residence
“ Pt^CE OF BURIAL OR REMOVAL^
/f hX&>.
DATE OF BURIAL
191 jJ?
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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.
00
z
ck
olljp (EmtmumamtUfy of iMaBsarljusptta
STANDARD CERTIFICATE OF DEATH
(City or town.)
[if death occurrei
Ward) a hospital or institution
give its NAME instead
of street and number.]
'FULL NAME-
[If married or divorced woman or widow
give maiden name, al60 name of husband.]
“RESIDENCE 3 ^ j
i/vyuzxj
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
< COLOR OR RACE 5 S+N«tf.
MARRIED,
WID&WEO,
OR-fftVORCED I ’ /
( Write the word)
6 DATE OF BIRTH
, \lh
(Year)
7 AGE
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)
Ztufo/
>0 NAME OF
FATHER
rtAAA.inu
11 BIRTHPLACE
OF FATHER
(State or country)
l L&Laa^a^
It MAIDEN NAME
OF MOTHER
>» BIRTHPLACE I /) a
OF MOTHER r J // /
(State or country) Jy{ iCi /
14 TH E ABOVE IS TRUE TO THE BE£T OF MY KNOWLEDGE
TP')' 1/ErkAj
(Informant) /.A.L/1..J.A1- /../.JJ..
(Add,.,.) / Jj J C&fjQHV jdLrW
Fil.d
_, 191
Registrar
MEDICAL CERTIFICATE OF DEATH
m DATE OF DEATH
fypiMMrXnSiL ...../, 0 , 191 3
fj L/Month ) (Day) (Year)
17 I HEREBY CERTIFY that I attended deceased from
, I 9 I j , to (0 . I 9 m3 .
that I last saw hjtt alive on ^**4*444^ lO , 191.7 ,
and that death occurred, on the date stated above, at..
The CAUSE OF DEATH* was as follows :
(Duration).^" yrs. mos.^ ds.
Contributory.
(Secondary)
.... ,
(Signed)
(Duration)
l 6...., 19' Q
V * If death followed iniur
191 tj (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 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
]bts (
KER
i/ l A=,
0 TE OF BURIAL
'll' /<$ , 191.3...
ADDRESS
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SIIjp (Cnmmonuipaltlf of IHassarljufiftta
STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH
( N o . SO &
..X^iAAXtvC#^
(City or town.) J)
[If death occurred in
..St. ; Ward) a hospital or institution,
give its NAME instead
of street and number.]
2 FULL NAME
[If married or divorced woman Xir tftidow
give maiden name, also name of rrasuand.]
“RESIDENCE
^
arced woman Or widow 0 / <? / fl. J~v —<
also name ofWknd.]
. AND STATISTICAL PARTICULARS
-dZ/h CM-' oL..
Registered No.
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
1 COLOR OR RACE
chr
6 SINGLE,
MARRIED,
WIDOWED, Wl/lrU (A.
OR DIVORCED
( Write the word)
6 DATE OF BIRTH
I
(Month)
(Day)
(Year)
3 AGE
42
mos. ds.
8 OCCUPATION
(a) Trade, profession, or
particular kind of work
If LESS than
I day hrs.
or min. ?
(b) General nature of industry,
business, or establishment in
which employed (or employer)...
» BIRTHPLACE
(State or country)
io NAME OF
FATHER
ii BIRTHPLACE
OF FATHER
(State or country)
>1 MAIDEN NAM
OF MOTHER
1* BIRTHPLACE
OF MOTHER
(State or country) /\
Filed
MEDICAL CERTIFICATE OF DEATH
10 DATE OF DEATH
* I 3 191.3....
nth) (Day) (Year)
17 I HEREBY CERTIFY that I have investigated the
death of the deceased.
The CAUSE OF DEATH* was as follows:
Atw JLrtVfV^Ltca....
tv<24L_
..(Duration) yrs.
mos. ds.
Contributory.
(secondary)
..(Duration) yrs.
(Signed
,..^aa-»../.3.P i 9 i .3.
mos. ds.
7
j , M.D.
(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. ds.
Where was disease contracted.
If not at place of death 7
Former or
usual residence
'» PLAGE OF BURIAL OR REMOVAL
REGISTRAR
DATE OF BURIAL
So. 2*
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MARGIN RESERVED EOR BINDING.
COMMONWEALTH OF MASSACHUSETTS
RETURN OF A DEATH-1913.
Heil A.McKenna
CITY OF
BOSTON.
FULL NAME Registered No.
477
Place of Death \ Rnstnn City Hospt.
and Residence f
Date of Death 1913. Age
50
. years .
months days.
STATISTICAL DETAILS.
PHYSICIAN'S CERTIFICATE.
SEX
H
COLOR
w
SINGLE, MARRIED, WID., DIV.
M
Maiden Name
Husband’s Name
Birthplace
Name of
Father
Ireland
William McKenna
Birthplace
of Father..
Maiden Name
of Mother
Birthplace
of Mother
Occupation.
Ireland
Margaret Doherty
Ireland
Clerk
I HEREBY CERTIFY that I attended deceased during last illness,
from I 9 1 3, to 1913,
that to the best of my knowledge and belief death occurred, on the
ate stated above, and that the CAUSE OF DEATH was as follows:
XpM<s\) Myocarditis
' r (Dffraf^v^A
yrs,
Bronchitis ( Acute ) ds •
(Signed) M.D.
Jan, 13
1913.
Informant .
Place of Burial
or removal
Undertaker
Malden (Holy Cross)
Timothy P. Callahan
SPECIAL INFORMATION from Hospitals, Institutions, Transients, or Recent
Residents.
Admitted to Hospt. Jan. 1,1913.
" Winthrop " 112 Locust St.
Usual Residence
Filed.
A true copy.
Attest:
Jan. 16
1913.
Registrar.
...
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MARGIN RESERVED EOR BINDING.
COMMONWEALTH OF MASSACHUSETTS
RETURN OF A DEATH-1913.
FULL NAME Edwin G. Judkins
and Residence |
Date of Death T.TTT...TT 1913
CITY OF
BOSTON.
Registered No.
601
Place of Death ) Boston. Grace Hospt.
Jan. 16
Age
63
years .
.days..
STATISTICAL DETAILS.
PHYSICIAN’S CERTIFICATE.
SEX
H
COLOR
Maiden Name
Husband's Name
jj Birthplace
Name of
Father....
Birthplace
of Father..
Maiden Name
of Mother...
Birthplace
of Mother
Occupation
! nformant ...
Place of Burial
or removal
Undertaker.
SINGLE, MARRIED, WID., DIV.
H
Meredith N.H.
John D. Judkins
Sanbornton N.H.
Mahala P. Doll off
Warren N.H.
Belt maker
Lawrence
J. 5. Waterman & Sons
I HEREBY CERTIFY that I attended deceased during last illness,
from 1913, to 1913,
that to the best of my knowledge and belief death occurred, on the
e stated above, and that the CAUSE OF DEATH was as follows:
Chro. Interstitial Nephritis
and Chro.Myooarditis
ontributory :
(Duration)
Cerebral Hemorrhage 2 ds.
(Si^ed) Myron F. Cutler M.0.
Jan. 16
1913.
SPECIAL INFORMATION from Hospitals, Institutions, Transients, or Recent
Residents.
Usual Residence
Filed
A true copy.
Attest :
" Winthrop ” 66 Plummer St.
Jan. 22
.1913.
Registrar.
WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD.
0)
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dommoumpaltl) of Ulaasarljosptta
STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH
ty/V ( No 4.....
(/Yur •</, / / 'u (<v) //'
otnan or widow
me of husband.]
t y :» /A. .....
(City or town.)
2 FULL NAME
[If death occurred in
..St. ; Ward) a hospital or institution,
give its NAME instead
of street and number.]
[If married or^dlvor/cd woman or widow
give maiden name, also name of husband.]
“RESIDENC
Registered No.
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PERSONAL AND STATISTICAL PARTICULARS
3 SEX
4 COLOR OR RACE
3 SINGLE,
MARRIED,
WIDOWED, y/,,
OR DIVORCED « ‘ 1 ‘ ^ "
( Write the word)
8 DATE OF BIRTH
/ dLt<\'
t AGE
Month)
(Day)
(Year)
A 5^yra. .6 .
..mos. ds.
If LESS
I day,
hrs.
or min. ?
8 OCCUPATION
(a) Trade, profession
particular kind of work
(b) General nature of industry, v,
business, or establishment
which employed (or employer).
, or ^ CL__
—
//T- 191 a.. , h../....: 191 £ . '
that I last saw hJdfeft-^live on / V/ » 191.3..,
and that death occurred, on th^/date stated above, at.. '/<?< m .
The CAUSE OF DEATH* was as follows :
* BIRTHPLACE
(State or country)
E”i
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|h.5
.E< ®
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pLu •
|o-£
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OF FATHER
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>3 MAIDEN NAME
OF MOTHER ' /r
/// 7"
/[ -JY' J/y
“ BIRTHPLACE
OF MOTHER W
(State or country) (
(T/ A cu
“THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)..
^ - j/. U/£f&-
(Addr...) ^ $ /'Ac
MEDICAL CERTIFICATE OF DEATH
18 DATE OF DEATH
i , ^ * |9| Of ■
(Montl^ (Day) (Year)
* ♦ *
I HEREBY CERTIFY that I attended deceased from
^£***4^
a^.;
..(Duration) yrs. mos. ....7. ds.
Contributory u**a...
(secondary) /
(Dura/on) yrs.
(Signed) , M.D.
. mos. ^ ds.
1 9!^Vj^ddress)..
* 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 yrt mos. ds. State yrs mos. ds.
Where was disease contracted,
If not at place of death 7
Former or
usual residence
t/A Afy i^oC-AceA's.
“ PLACE OF BURIAL OR REMOVAL
J
Filed..
.. 191.
» UNDERTAKER
REGISTRAR
ULKIAALK .
& /? /
DATE OF BURIAL
1 9Ui-
ADDRESS
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COMMONWEALTH OF MASSACHUSETTS
RETURN OF A DEATH-1913.
FULL NAME - — . Plakias Registered No
Place of Death ( Boston Des Bri say Hospt,
and Residence )
Date of Death 1913
CITY OF
BOSTON.
814
Age.
years .
months..
.days..
STATISTICAL DETAILS.
PHYSICIAN’S CERTIFICATE.
SEX
COLOR
w
SINGLE, MARRIED, WID., DIV.
Maiden Name
Husband’s Name
Birthplace
Name of
Father
Birthplace
of Father-
Maiden Name
of Mother
Birthplace
of Mother.
Winthrop
Thomas Plakias
Greece
Georgia Papal ano
Greece
I HEREBY CERTIFY that I attended deceased during last illness,
from 1913, to 1913,
that to the best of my knowledge and belief death occurred, on the
stated above, and that the CAUSE OF DEATH was as follows:
Occupation
! nformant ...
Place of Burial
or removal
Undertaker
Mt Hope
J S Wat e.rroan. Sons .
Hemorrhagic Disease of
Newborn 18 hrs
ontributory :
(Duration)
(Signed) D L Jackson M.D.
Jan 23
.1913.
SPECIAL INFORMATION from Hospitals, Institutions, Transients, or Recent
Residents.
Usual
Residence..winthr0P"28 ...Trident Ave"
Filed
A true copy.
Attest :
Jan 28
1913.
Registrar.
' C1 1
. ■ f : ■ ■ ■ ' -
■ ■’
- •
.. .
-■ " ■
f
.
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.
co
z
©Ijp (£ommimuipaltl| nf ftasarliuspita
STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH
<r:jC (No. ...J?
.St.
Ward)
BOSTON
(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 woman or widow
give maiden name, also name of husband.]
"RESIDENCE
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
<J^C
' COLOR OR RACE
.
"Tjii'i otte;"
MARRIED.,
'WIDOWECL___
(Effi-OTVORCED
( Write the word)
1 DATE OF BIRTH
(Month)
(Day)
I
(Year)
1 AGE
..yrs. mos,
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)
>0 NAME OF
FATHER
i> BIRTHPLACE
« OF FATHER
(State or countryj
< >2 maiden name
Q.
** BIRTHPLACE / " 1 /D (J .
,'c“OTH" /r
OF MOTHER
(State or country /.
“THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant) cx VA
Filed ...
MEDICAL CERTIFICATE OF DEATH
« DATE OF DEATH
(side,
(Month)
2.
(Day)
191.3
( Y ear)
:7 I HEREBY CERTIFY that I attended deceased from
, 191^., to / , 191.3 ,
that I last saw h.fHLc alive on / , 1913 ,
and that death occurred, on the date stated above, ■
The CAUSE OF DEATH* was as follows:
..(Duration) ...yrs. mos
. , ^ . ds.
Contributory
(secondary)
X j/ (Duration^ yrs.
Signed) . v 4 , l-
( Address).
* If death followed injury or violence the certificate of deatbf 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
0-^* 2 ‘
=0 UNDERTAKER/
REGISTRAR
2^ 1 91 tL.
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.
(Hfjp (Commimuipaltlj of fHasaarljusftto
PLACE OF DEATH
(City or town.)
2 FULL NAME.
[If married or divorce<TVotnan or widow
give maiden name, also name of husband
“RESIDENCE
[If death occurred in
.St. ; Ward) a hospital or institution,
give its NAME instead
of street and number.]
STANDARD CERTIFICATE OF DEATH
Li/} ( N o . ,....’*dTljdL...
x £
' O' Registered No. I
I.
03
z
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
* COLOR OR RACE
l/v~Ycz\^
s SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
( Write the word)
l/*j\
» DATE OF BIRTH
^ / P/c
(Month) (Day) (Year)
1 AGE
$1.
mos. 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)
)* L < r L-'
3 BIRTHPLACE
(State or country)
10 NAME OF , .
F*TH6R . J
'> BIRTHPLACE
OF FATHER
(State or country)
>2 MAIDEN NAME
OF MOTHER
Cst^rdx^ c
>» BIRTHPLACE
OF MOTHER
(State or country)
“THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
U i >- t / ^
(Informant).
(Address) VL. to Ut < /'A- ' t'/r I
MEDICAL CERTIFICATE OF DEATH
18 DATE OF DEATH
(Mon tit)
I9l.r?.„.
(Day) (Year)
I HEREBY CERTIFY that I attended deceased from
^rW...v5^ 1 9 1 ..<£». , 2-z. 19-WL,
that I last saw alive on .2—,... , 1 9 1
and that death occurred, on the date stated above, at.vl....£^..m.
The CAUSE OF DEATH* was as follows:
...(Duration) ...JL... .yrs. mos. .^Srr.,,ds.
Contributory !NC...
(secondary)
..(Duration) yrs. .
(Signed)
’...VL, l9l^...aAd<i«*ss).
mos. ds.
M.D.
* If death followed injury or violence the certificate oMenth must be made
out by the Medical Examiner.
'8 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
Filed..
191.
Registrar
® UNDERTAKER
c SI
DATE OF BURIAL
/ ^
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.
I.
GO
z
©Ijf (ftmmtumuipaltl) of fKasBarijuartto
STANDARD CERTIFICATE OF DEATH
[If death occurred in
a hospital or institution,
give its NAME instead
of street and number.]
3 SEX
4 COLOR OR RACE
6 SINGLE, v \
widowed,
no niunor-cn
OR DIVORCED
( Write the word)
8 DATE OF BIRTH
(Month)
(Day)
I
(Year)
i AGE
U^L.i
,ds.
If LESS than
I day, hrs.
or min. ?
8 OCCUPATION
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particular kind of work...^
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business, or establishment in
which employed (or employer)..
9 BIRTHPLACE
(State or country)
lOLl
'UUiL.jA.u.'
CtA/3 -
>» NAME OF
FATHER
•» BIRTHPLACE
OF FATHER
(State or country)
‘t MAIDEN NAME
OF MOTHER
i* BIRTHPLACE
OF MOTHER
(8tate or country)
> TRUE TO THE BEST OF MY KNOWLEDGE
>—i/ ^ A A/A^L-jT^ AVAaI
Filed
«2/,
■r */■
REGISTRAR
18 DATE OF DEATH
UaJ £.9 1 ■£
(Month) (Day)- (Year)
I
(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 :
* 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 mo$. ds.
Where was disease contracted,
if not at place of death 7
Former or
usual residence
» PLACE OF B,
DATE OF BURIAL
» UNDERTAKER
191 ,„3
ADDRESS » YltXXA/
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STANDARD CERTIFICATE OF DEATH
aKsSaat (No. d..Tj,
St.
(City or town.)
[If death occurred in
Ward) a hospital or institution,
give its NAME instead
of street and number.]
2FU LL NAME
[If married or divorced woman or
give maiden name, also name of husband
“RESIDENCE
ne of husband'] y/ ...^.....l^^^
Registered No,
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
3 COLOR OR RACE
5 singt-E.
toWTR"RT£D, . .
WIDOWED, r/^Z-d4rze^y '
o«-&tv©Re6o
( Write the word)
MEDICAL CERTIFICATE OF DEATH
1« DATE OF DEATH
r. £ 191
(Month) (y (Day) (Year)
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3 DATE OF BIRTH
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(Year)
3 AGE
..£2 ..yrs. . .^.... . mos.
If LESS than
I day, hrs.
or min. ?
8 OCCUPATION
(a) Trade, profession, or
particular kind of work
HEREBY CERTIFY that I attended deceased from
191 .2*. to I 91-1 ,
that I last saw h.^jr^. alive on .£L , 1 9 1 r?..... ,
and that death occurred, on the date stated above, z‘0.— m .
The CAUSE OF DEATH* was as follows:
Ctf...
(b) General nature of industry,
business, or establishment in
which employed (or employer).,.
• BIRTHPLACE
(State or country)
10 NAME OF
FATHER
< Z >
1-
Z
UI
>1 BIRTHPLACE
OF FATHER
(State or country)
<
1= MAIDEN NAME
CL
OF MOTHER
. (Duration) ...
..yrs. / mos. ....
' ds.
Contributory
(secondary)
(Duration) yrs mos. ds.
(Signed)
M.D.
191 3 (Address) ,
* If denth followed injury or violence the certificate of death must be made
out by the Medical Examiner.
1* BIRTHPLACE
OF MOTHER
(State or country)
14 THE A80VE IS TfJJJE TO THEJBEST OF MY KNOWLEDGE
(Informant) j.
(Address)
Filed.
* 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 „...._
t
» PLACE OF BURIAL, OR REMOVAL,
( ^—-e-s, - ,
REGISTRAR
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c^-e^r
50 UNDERTAKER
DATE OF BURIAL
S^O>..., >9 1 3.
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Ety dommomupaltl) of HaBaarfiusptts
STANDARD CERTIFICATE OF DEATH
PLACE OF DEATH
> (No..
E ^/TVV
r divorced woman o<£yrido vr , ' — '
Iso name of husband.] L — Q. .a. r\ ,n
CKn~< ~~
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give maiden name, also name £f husband.] . ^y.^A^rr. . .d C\_k. .'
“RESIDENCE
.aJJLjL,.
If V Rdjri stayed Nc
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
2r
* COLOR OR RACE
AaT
3 SINGLE,
MARRIED,
WIDOWED, I vVOu^Aj^OU
OR DIVORCED
( Write the word)
DATE OF BIRTH
(Month)
(Day)
... I
(Year)
7 AGE
» OCCUPATION
(a) Trade, profession, or
particular kind of work
£
yrs.
. mos. ds.
If LESS than
I day, hrs.
^XTU_^JU_ A
(b) General nature of industry,
business, or establishment in
which employed (or employer)...
3 BIRTHPLACE
(State or country)
co_Jc^
10 NAME OF
FATHER C\
V-
>1 BIRTHPLACE
OF FATHER ]
(State or country) , J A 0 \ ) 1
‘7 MAIDEN NAME
OF MOTHER
13 BIRTHPLACE
OF MOTHER
(State or country)
d
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant) y
(Address) (g Ai.
Filed.™...
191
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
(Month)
(tfay
I 9 1 .3...
(Day) (Year)
17 I HEREBY CERTIFY that I have investigated the
death of the deceased.
The CAUSE OF DEATH* was as follows :
,..(T'y\ax'V'\ (r>\ r*.
<X^Aa/>L^ (QrAsOj
(Duration) yrs. .
..mos. ds.
Contributory..
(Secondary)
(Duration) yrs.
..mos. ds.
(Signed) .
I 9 1 3s. (Address)..
It^yxrXX.Wn MEDICAL EXAMINER
M.D.
* 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 ds.
Where was disease contracted,
If not at place of death 7
Former or
usual residence
18 PLACE OF BURIAL OR REMOVAL
L
A- C
» UNDERTAKER
DATE OF BURIAL
J2bdk, IA 191.3..
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.
(HIjp (CmtrouittMpalili of fHassarijusi'tts
STANDARD CERTIFICATE OF DEATH
G ^f ci^
(City or town.)
[If death occurred in
Ward) a hospital or institution,
give its NAME instead
of street and number.]
2 FULL NAME
[If married or divorced woman or wirJCw
give maiden name, also name of husband.]
“RESIDENCE
, 0
(.Mti/' , • / fa-
I.
CO
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
3 SEX
/
< COLOR OR RACE
8 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
( Write the word)
18 DATE OF DEATH
8 DATE OF BIRTH
(Month)
/ ?
(Day)
m,
(Year)
/■
onth)
a
(Day)
i9L-9af..
(Year)
l AGE
..yr»-
vS\
. mos. ..77!7 ds.
If LESS than
I day, hrs.
or min. ?
8 OCCUPATION
(a) Trade, profession, or
particular kind of work
17 I HEREBY CERTIFY that I attended deceased from
. I9I..£.., to ..... , I9I..<_£-
that I last saw h.^du.. alive on (..} , I9I....J?,
. / c/ P
and that death occurred, on the date stated above, at JL..T.m.
The CAUSE OF DEATH* was as follows :
USE OF DEATH* was
u -S--
(b) General nature of industry,
business, or establishment In
which employed (or employer)...
9 BIRTHPLACE
(State or country)
-e//<
10 NAME OF /T,
FATHER (y
\J$a^a+d.
to
H
Z
LU
11 BIRTHPLACE
OF FATHER
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l/~f+
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13 MAIDEN NAME
OF MOTHER
i» BIRTHPLACE
OF MOTHER
(State or country)
&
(Duration) yrs. mos. ds.
Contributory
(Duration) yrs. mos. ds.
(Secondary)
(Signed)
MjL±u 191.3 (Address)....?.4nr
M.D.
* If death followed injury or violence the certificate of death must be made
out by the Medical Examiner.
‘•THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
A
(Informant) _
. r T&.
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
(Address) ^ V (J C*-*^-*
» PLACE OF BURIAL OR REMOVAL
/2~
t ^
OATE OF BURIAL
V*°.
191
d.
Filed..
191.
20 UNDERTAKER
Registrar
ADDRESS
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Every item of information should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state
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important. See instructions on back of certificate.
1 PLACE OF DEATH
(Enmnumuiealtt) of USa&aarljuHPttH
STANDARD CERTIFICATE OF DEATH
(City or town.)'
w - / -j, r a. v rz> < 4 ~s — [If death occurred in
<- C, * * St. ; Ward) a hospital or institution,
“ give its NAME instead
of street and number.!
2 FU LL NAME
[If married or divorced woman or widow
give maiden name, also name of husband.] .>.
“RESIDENCE
Registered No.
PERSONAL AND STATISTICAL PARTICULARS
SEX
4 COLOR OR RACE
4-
s SINGLE,
MARRIED,
. WIDOWED,
OR DIVORCED
( Write the word)
MEDICAL CERTIFICATE OF DEATH
18 DATE OF DEATH
3*4 a <
(Month)
(Day)
., I9I_3.. .
(Year)
I.
m
z
• DATE OF BIRTH
(Month)
Z2.
(Day)
, |W
(Year)
7 AGE
. mos. 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)..,
17 I HEREBY CERTIFY that I attended deceased from
2^.. LI 191.3, to 5^6 Z. l. J. , 1 9 1(3..,
that I last saw h..P]L. alive on , 191 ,
and that death occurred, on the date stated above, at....V ... .ft. m.
The CAUSE OF DEATH* was as follows:
(nr'Y'^-'v. ,
5
» BIRTHPLACE
(State or country)
..(Duration) .
..yrs. mos. .OneD-.d*.
V)
>0 NAME OE_
FATHER S'
Contributory..
(secondary)
11 BIRTHPLACE
OF FATHER
(State or country)
(Signed)
3±ifl2 191.3..
Z&nM
(Duration) yrs.
(Address)..
jUi
.mos ds.
M.D.
12 MAIDEN NAME
OF MOTHEF
,./r
* If death followed injury or violence the certificate oV death must be made
out by the Medical Examiner.
1« BIRTHPLACE
OF MOTHER o
(State or country) * f
“THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
'Mr /Pi S e*—.
18 LENGTH OF RESIDENCE (FOR HOSPITALS, INSTITUTIONS, TRANSIENTS, OR
Recent Residents).
At place /i In the
of death yrs. mos. ,'VO .ds. State yrs. mos. ds.
Where was disease contracted,
If not at place of death 7
Former or
usual residence
(Informant).
(Address)
» PLACE OF BURIAL OR REMOVAL
2
M
f
DATE OF BURIAL
1 91. A
Filed..
_, 191.
Registrar
50 UNDERTAKER
ADDRESS
o z.
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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.
I.
CO
2
[If death occurred in
Ward) a hospital or institution,
give its NAME instead
of street and number.]
Stye (Eomnuntumtltlj nf iKa&sarhusrtis
STANDARD CERTIFICATE OF DEATH
BOSTON
(City or town.)
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
£
1 COLOR OR RACE
(Mr
t SINGLE,
MARRIED, (Jj. •
WIDOWED,
OR DIVORCED
( Write the word)
6 DATE OF BIRTH
(Month)
(Day)
(Year)
7 AGE
yrs.
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)..
•> BIRTHPLACE
(State or country)
10 NAME OF
FATHER
11 BIRTHPLACE
OF FATHER
(State or country)
A?
>7 MAIDEN NAME
OF MOTHER
i* BIRTHPLACE
OF MOTHER
(State or country)
'« THE ABOVE IS TRUE TO THE BEST OF
(Informa
KNOWLEDGE
nt) .<£
f Address) /y TJa/T M'sludLjBti..
.., 191.
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
*JL,
(Month)
/f
(Day)
I9I.:S&
(Year)
HEREBY CERTIFY that I attended deceased from
, | 9 1 to :l. , 191
that I last saw h ."^“Slive on — __ . _ , I 9 I ^7-
and that death occurred, on the date stated above, at.-^~~~^ m.
The CAUSE OF DEATH* was as follows : ,
ci CruAe
..(Duration) .
yrs. mos.
ds.
Contributory.
(secondary)
(Duration) yrs. mos.
(Signed) . Kcrrabu^A* .t'j 1
f^r-lT , ip I P>. , (Address ).. f/f/ Ji
* If death followed injury or violence the certillcate 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
16 PLACE OF BURIAL OR REMOVAL
UNDERTAKER
DATE OF BURIAL
-Z J . , 191,3...
ADDRESS
(X (7 //Caw
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 i3 very
important. See instructions on back of certificate.
I
od
1 PLACE OF DEATH
Kin.throp
2% (£mntmmuipaltl| of fHassarljusftts
STANDARD CERTIFICATE OF DEATH
..(No...
11Q ..Cr.ro ver. Ave.., st.
BOSTON
(City or town.)
[If death occurred in
.Ward) a hospital or institution.
give its NAME instead
of street and number.]
’full name S11Y5. F. Holmes.
[If married or divorced woman or widow A] -j XT' D 0 n e> 1 o Vr H -I r,TJ n "P P "i r* V. P T* rl
give maiden name, also name of husband.] .’.....4r..".y..!
“RESIDENCE
110 CtY o ver Ave . P mthrcp
PERSONAL AND STATISTICAL PARTICULARS
» SEX
f nnale
4 COLOR OR RACE
white
5 SINGLE, ■ -i a
MARRIED, YFldCWi'd.
WIDOWED,
OR DIVORCED
( IVriU the word)
* DATE OF BIRTH
.J.an..._2.3 1.82..3..,
(Month) (Day)
... I
(Year)
? AGE
9B.
yrs. mos.
...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)..
Registered No.
3 BIRTHPLACE
(State or country)
Poston kacs
v>
10 NAME OF
FATHER
James Peas lee.
•i BIRTHPLACE
OF FATHER
(State or country)
urrkrcrn
12 MAIDEN NAME
OF MOTHER
Hep*! bah P perry
n BIRTHPLACE
OF MOTHER T I /-_> Vi m
(State or country) lit- 1 II. J. / 1 . •
“THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant).
(Address)
Fil.d.
191.
Registrar
MEDICAL CERTIFICATE OF DEATH
1* DATE OF DEATH
Feb 18 1913.
(Month) (Day)
., 191
(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:
ClQo( . If
..(Duration) yrs. mos. .
,.ds.
Contributory
(Secondary)
..(Duration) yrs mos. ds.
(Signed) . .% M.D.
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 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 -
12 PLACE OF BURIAL OR REMOVAL
Forest Pills.
DATE OF BURIAL
191^.
ADDRESS
2 63 rj
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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.
(EnmmxmutMltl) of fHassarimsrtts
i> & P. F. < i t- 1 - *'
STANDARD CERTIFICATE OF DEATH
PLACE OF DEATH
Winthrop (No.
81 Faun Bar Ave
WIN1HHR0P
BOSTON
(City or town.)
[If death occurred in
St. ; Ward) a hospital or institution,
give its NAME instead
of street and number.]
2 full name Jennie Maria Cowles
[If married or divorced woman or widow Rnl 1 T it+ Vinr> I?
give maiden name, also name of husband.] DOiiBn hiUlI'tr ^ •
81 Faun Bar Ave* Winthrop
“RESIDENCE
Registered No.
I.
ca
z
PERSONAL AND STATISTICAL PARTICULARS
SEX
Fiatale
« COLOR OR RACE
White
* SINGLE,
MARRIED, ]'/ c: rnyv t rri/d
WIDOWED,
OR DIVORCED
( Write the word)
* DATE OF BIRTH
Jan * 23 * 1959
(Month) (Hay)
(Year)
1 AGE
54
0
27
mos. ^ r . ..ds,
If LESS than
I day, hrs.
or min. ?
8 OCCUPATION
(a) Trade, profession, or Housewife
particular kind of work
(b) General nature of industry,
business, or establishment in
which employed (or employer)...
9 BIRTHPLACE
(State or country)
Hartford, Conn
>0 NAME OF
FATHER
Lucius S.
<f>
h-
z
UJ
“ BIRTHPLACE
OF FATHER
(State or country)
Hartford, Conn*
<
0-
“ MAIDEN NAME
OF MOTHER
Ann E. Weatcott
'* BIRTHPLACE
OF MOTHER
(State or country)
Unknovrn, Conn*
“THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant) .
Katherine B. Bolles
(Address)
674 Walk Hill St -Dor*
Filed..
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
18 DATE OF DEATH
ZZ 4Z
(Month)
(Hay)
!9lZ.
(Year)
17 I HEREBY CERTIFY that I attended deceased from
I9A<£1, to 212,. 4Z 191 JL.
TO*t I last saw alive on^lUL./) 191:?..,.,
and that death occurred, on the date stated above, at.ZZ m.
The CAUSE OF DEATH* was as follows :
..(Duration) yrs.
..mos. ds.
Contributory
(Secondary)
(Duration) yrs mos ds.
(Signed) <£>. . M.D.
\rtOb. /..f.. ■ 1917?..... (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 In the
of death yrs. mos ds. State yrs mos. ds.
Where was disease contracted,
If not at place of death 7 4*
usual residence ... at place of death
» PLACE OF BURIAL OR REMOVAL /J
Hartford ,Conn*
DATE of burial
** Ob • 1 9 1 .3
» undertaker
I ADORESS
111
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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.
Stye (Commomuealtlj of ftasarljuafftts
STANDARD CERTIFICATE OF DEATH
PLACE OF DEATH
(City or tow if.)
(No. 4 St. ; Ward) a hospital or institution,
_ jK ^ give its NAME instead
give
of street and number.]
“RESIDENCE
Registered No.
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
< COLOR OR RACE
<25
s SINGLE,
MARRIED,
WIDOWED,
OR DIVORCE
( Write the word)
MEDICAL CERTIFICATE OF DEATH
19 DATE OF DEATH
^JL
(Month)
(Day)
I9»~!
(Year)
9 DATE OF BIRTH
(Month)
AJL.
(Day)
, i*.a
(Year)
t AGE
yr«. ..
If LESS than
I day, hrs.
or min. ?
I HEREBY CERTIF
,,,1.
8 OCCUPATION
(a) Trade, profession, or
particular kind of work
HEREBY CERTIFY that I attended deceased from
to 191
that I last saw h alive on 191
and that death occurred, on the date stated above, at
The CAUS£v^DF JD E4TH*^vas as follows
(b) General nature of industry,
business, or establishment in
which employed (or employer)...
9 BIRTHPLACE
(State or country)
iv^QF CEV?TH*^as as f
>0 NAME OF
FATHER
11 BIRTHPLACE
(SteteAorHconntry)
(Dur^rtion) yrs^. mos. ds.
'y%'
(Signed)
...JAt-LC. Z, I91.J.... (Address)^^?*
12 MAIDEN NAME
OF MOTHER//*
* If death followed injury or violence the certificate of death must be made
out by the Medical Examiner.
1» BIRTHPLACE
OF MOTHER
(State or country)
s-/'
■‘THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
criscrz-** c~~>—
18 LENGTH OF RESIDENCE (FOR HOSPITALS, INSTITUTIONS, TRANSIENTS, OR
Recent Residents).
At place In the
of death yrs. mot., ds. State mos. ds.
Where was disease contracted,
If not at place of death 7
Former or
usual residence
(Informant) .
i» PLACE OF BURIAL OR REMOVAL
, '/ (- /^IsC j ' S C- : *
DATE OF BURIAL
Vi Jr
191..^..
Filed..
191.
® UNDERTAKER
ADDRESS
REGISTRAR
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STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH
Y\J <No.^C
nan or wid
3 of husba:
J-Sl
[If death occurred in
.St. ; Ward) a hospital or institution,
give its NAME instead
of street and number.]
2 FULL NAMf _
[If married or divorced Woman or widow
give maiden name, also name of husband.]
“RESIDENCE
Ij iT~ aSt>
PERSONAL AND STATISTICAL PARTICULARS
Registered No.
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6 DATE OF BIRTH
/S’ /&(-&
(Month)
(»ay)
(Year)
? AGE
--foP
yrs. mos. ds.
If LESS than
I day, hrs.
8 OCCUPATION
(a) Trade, profession, or
particular kind of work..
(b) General nature of industry,
business, or establishment in
which employed (or employer)...
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5"
13 MAIDEN NAME
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^
i» BIRTHPLACE , J
OF MOTHER AY''
(State or country)
s
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
3^3 A?
(Informant) .
(Addr
Filed .
191
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
X4.
(Month)
24
(Daj/)
., 191.3...
(Year)
17 I HEREBY CERTIFY that I have investigated the
death of the deceased.
The CAUSE OF DEATH* was as follows :
^ ^ *
(Duration) yrs.
u tip r . . . . JUjJ&l)
aryt
mos. ds.
Contrib
(secondary,
(Duration) yrs. mos ......ds.
(Signed) Ajb) M-D-
JJULJI Sra I (AddUs) Q..
’L.'LvP
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. ..ds.
Where was disease contracted.
If not at place of death 7
Former or
usual residence
>» PLACE OF BURIAL Ott-YtEMOVAtr
l ty -c-
» UNDERTAKER
uiiutn i f\r\c.rv ^
<3 A? /<? ^
-if 4-
DATE OF BURIAL
m2.
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.
QJI?p (Ecmmmwiealttj of fHassartjusptts
STANDARD CERTIFICATE OF DEATH
DEATH
(City or town.)
(No.. A->
a 0
\jLcu C£rxz St. ;
“FULL NAME Yl
[If man’ied or divorced woman or widow '
give maiden name, also name of husband.J
[If death occurred in
Ward) a hospital or institution,
give its NAME instead
of street and number.]
“RESIDENCE
1/l/lMc
1 MEDICAL CERTIFICATE OF DEATH
m
z
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
> COLOR OR RACE
jyr
6 DATE'OF BIRTH
5
WIDOWED,
S4A(OnC6D"
( Write the word)
(Mont
ft
ay)
(Year
2 AGE
/ '/ & J b
/ / yrs. mos. /
s
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)
5 BIRTHPLACE
(State or country)
BIRTHPLACE
» OF FATHER
(State or country) J/
aui
< 1 12 MAIDEN NAM
OF MOTHE
OF
'* BIRTHPLACE
OF MOTHER
(State or country)
vcraJ\ UcMtUI^
^aAAO^i/) luAAJ
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informan
61 !J 1 12.UL
t) , C&A
'Adfi,°- ' J H Per hfaljhmufi )oaa^
™ DATE OF DEATH
(Month)
J-Y
(Day) (Year)
17 I HEREBY CERTIFY that I attended deceased from
JetAr i C .., 1913 , to D . ,91 3,
that I last saw h.i^*»^alive on X-f( , I 9 1 3 ,
and that death occurred, on the date stated above, at fi.-v.frn.
The CAUSE OF DEATH* was as follows
(Duration)
Contributory.
(secondary)
7
(Duration) yrs
(Signed) .
,Sd( , 191.3.. (Address).., J S
* 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
Filed.
DATE OF BURIAL
Jbj _y y
191 1
ADDRESS
Registrar
Jf) &
GO
WRITE PLAINLY. WITH UNFADING INK -THIS IS A PERMANENT RECORD.
c n <
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ttUje (Eomnunutmtltb of IHaasarljuflTtta
STANDARD CERTIFICATE OF DEATH
‘PLACE OF
2 FULL NAME
[If married or divorced womau'tfr widow
give maiden name, also namcraT husband.]
"RESIDENCE
BOSTON
(City or town.)
[If death occurred in
Ward) a hospital or institution,
give its NAME instead
of street and number.]
i, also namecsr nu^uana.j .... -
iL AND STATISTICAL PARTICULARS "" MEDICAL Cl
Registered No.
PERSONAL AND STATISTICAL PARTICULARS
5 SINGL
MARRI
WID
OR
( fPrtietl Te word)
■ Z£ .Ms
(My) (Year)
7 AGE
/ r"
yrs.
“Z d
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).
MEDICAL CERTIFICATE OF DEATH
i» DATE OF DEATH
, 191.3
(bay) (Year)
” — . I HEREBY CERTIFY that I attended deceased from
, i9i.iL, toS^d ?'■*’/ , 191.3..,
that I last saw h.^Vr^- alive oni^^ ’^.V 1 , 191.
and that death occurred, on the date stated above, at m.
The CAUSE OF DEATH* was as follows :
(Duration) yrs. mos. 4-?... ds.
Contributory..^5^i^^t5rT*.. i
(Duration) yrs. .. -e. .. mos. ds.
(secondary)
...^...5... i I9I..3L (Address)
11 THE ABOVE IS TRUE TO THE BESJ OF MY^ffio
JCTl / WF/ * ML
* If death followed injury or violence the certificate of death must he made
out by the Medical Examiner.
8 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 U ,
(Informant) .
(Address
>» PLACE OF BURIAL OR REMOVAL
Filed
191
DATE OF BURIAL
\<K'
£u*- Fl I91.M.
VVm I L rLftllYLT, Wl 1(1 UINhAUlWU INK — I hlo 13 n rtKIVIrtIVLIY I tttOUKL/.
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.
03
Z
PLACE OF DEATH
(Eommottuiealth of fflassarfjusrtta
STANDARD CERTIFICATE OF DEATH
Jo *3
(City or town.)
[If death occurred in
Ward) a hospital or institution,
give its NAME instead
of street and number.]
[If married or divorced woman or wido
give maiden name, also name of husband.]
“RESIDENCE ^
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
* COLOR OR RACE
' SINGLE,
marrieb,
wieeweo, —
OR -BtVCrRCE'D
( Write the word)
6 DATE OF BIRTH
(MiaET”
(Day)
,
(Year)
7 AGE
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)...
^ BIRTHPLACE
(State or country)
7^
» BIRTHPLAC
OF FATHER
(State or country)
MAIDEN NAME
OF MOTHER
•» BIRTHPLAC
OF MOTH
(State or country)
ACE /TD /> ' y, ,
“THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant) '' 7 ' ' ' ( ~ * * gg
Filed 101
Registrar
Registered No.
MEDICAL CERTIFICATE OF DEATH
*« DATE OF DEATH
■fete,
(Month)
$/(&. , I 9 1^.
(Day) (Year)
■fU-.
HEREBY CERTIFY that I attended deceased from
*i7. 1913...., to ois(p ...., 191.3.,
that I last saw h Vi-., alive on , 191 ^ ,
• / f
and that death occurred, on the date stated above, at m.
The CAUSE OF DEATH* was as follows:
. (Duration) yrs.
..mos. ds.
Contributory..
(secondary)
(Signed) ... Zf .
191 3 (Address). ..$?./[
* If death followed injury or violence the certificate of death
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 resldonce
» PUCE OF BURIAL OR REMOVAL
r </_ -c^cryZs
/g_.
20 UNDERTAKER
DATE OF BURIAL
191 A-
ADDRESS
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COMMONWEALTH OF MASSACHUSETTS
RETURN OF A DEATH-1913.
FULL NAME Annie F,Heardon Registered No
piace_of Death ( Boston Carney Hospt.
and Residence )
Date of Death 1913
CITY OF
BOSTON
1992
Age
42
months. .
.Hays..
STATISTICAL DETAILS.
PHYSICIAN’S CERTIFICATE.
SEX
P
COLOR
W
SINGLE, MARRIED, WID., DIV.
1Z
Maiden Name
Husband's Name
Birthplace
Name of
Father
Birthplace
of Father..
Maiden Name
of Mother
Birthplace
of Mother..
Occupation
! nformant ...
Sheridan
Align s tus F . Hear don
Watertown
John P. Sheridan
Ireland
Mary J.Gray
Cambridge
at Home
Place of Burial
or removal
Undertaker .
Malden (Holy Cross)
W.H. Thomas (Newton)
I HEREBY CERTIFY that I attended deceased during last illness,
from 1913, to 1913,
that to the best of my knowledge and belief death occurred, on the
,te stated above, and that the CAUSE OF DEATH was as follows:
Surgical Shock
Operation for Fibroid of Uterus
and Salpingitis
Hjy art erect omy. Salpingectomy
2 ds.
contributory :
(Duration)
(Signed) ??.^?..“.r.Scott M.D.
Feb. 26
1913.
SPECIAL INFORMATION from Hospitals, Institutions, Transients, or Recent.
Residents.
Usual Residence
Filed .
Win t hr op, Winthrop Beach
A true copy.
Attest :
Washington Chambers
Har. 3 1913.
Registrar.
i
v
■'*
•H'
i - : ! ■
i ; •;
.i!i ,i: >«!H ' -.1 ■! ' ' i ■ ■" • *
. r: • ’ ■ ■ ••
■
'
P
r
&
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 OF DEATH
2 FULL NAME^C.:
[If married or divorced woman or widow
give maiden name, also name of husband.]
“RESIDENCE
(Eommxntmpaltli of fHasaarljusrtts
STANDARD CERTIFICATE OF DEATH
(City or to\Yh.)
..(No... % <Sl
. r y-
/ <!
-a ", A 1
[If death occurred in
,.St. ; Ward) a hospital or institution,
give its NAME instead
of street and number.]
Registered No.
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
* COLOR OR RACE
LA--''
i SINGLE.
MARRIED,
WIDOWED,
OR DIVORCED
( Write the wo:
MEDICAL CERTIFICATE OF DEATH
10 DATE OF DEATH
(Day) (Year)
I.
cd
z
» DATE OF BIRTH
T AGE
-- Zx'*'*- r
(Moi
(Month)
./o, mi .
(Day)
I
(Year)
J..JL y«. b
mos. ds.
If LESS than
I day, hrs.
or min. ?
8 OCCUPATION
(a) Trade, profession, or
particular kind of work
> —
17 I HEREBY CERTIFY that I attended deceased from
, 191*- , to ,9|£-.
that I last saw alive on., I 1 9 1 ft.... ,
and that death occurred, on the date stated above, at/4*^.
The CAUSE OF DEATH* was as follows :
(b) General nature of industry,
business, or establishment in
which employed (or employer)...
9 BIRTHPLACE
(State or country)
10 NAME OF
FATHER
ii BIRTHPLACE
OF FATHER
(State or country)
11 MAIDEN NAME
OF MOTHER
rt>1
-r
^>r (Duration) yrs. . .
mos. ds.
7/
Contributory...
(Secondary) (/
(Duration) vrs.
mos. ds.
(Signed)
..Ild&Jl..../..
, 191.^.. (Address)^rr
, M.D.
* If death followed injury or violence the certificate of death must he made
out by the Medical Examiner.
“THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
rr\s ^
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
(Informant).
(Address)
uifC
» PLACE OF BURIAL OR REMOVAL
Filed ..
191.
“UNDERTAKER
Registrar
u
/
ct
DATE OF BURIAL
-rTVTHL. , 191
ADDRESS
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STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH
(City or town.)
Ward)
[If death occurred in
a hospital or institution,
give its NAME instead
of street and number.]
[If married or (jfirorced woman or widow
give maiden naitje, also name of husband.]
gnw iiiaiuv/u uuiuC) uioo iiuine in. uuooxuu.j •••■/f
“RESIDENCE ^
Registered No.
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MEDICAL CERTIFICATE OF DEATH
» DATE OF DEATH
/ mo
(Month)
24l
(Day)
I 9 I .3...
(Year)
I HEREBY CERTIFY that I attended deceased from
1913..., to "24.S. 1 91. .X,
(a) Trade, profession, or
particular kind of work
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business, or establishment in
which employed (or employer).
thaTl last saw hfcs^V. alive on....ZTL!T^y 191...?...,
and that death occurred, on the date stated above, at
C^ySE OF DEATH* was as follows:
uration) yrs. 2 ..mos ds.
ii BIRTHPLACE
OF FATHER
(State or country)'-
id MAIDEN NAME 71
OF MOT
, (Duration)-.
i\^A,..kiiii, i9i..3k
(Address)..,.
* If death followed injury or violence the certificate o eath must he made
out by the Medical Examiner.
PI M TV! Q / /
HER U //
l> BIRTHPLACE
OF MOTHER
(State or country)
18 LENGTH OF RESIDENCE (FOR HOSPITALS, INSTITUTIONS, TRANSIENTS, OR
Recent Residents).
At place In the
of death. yrs. mos. _..ds, State yrs mos. ds
“THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant).
Where was disease contracted,
if not at place of death?
Former or
usual residence
I
(Address) / yif/ J , r , l , /, r
“ PLACE OF BURIAL OR REMOVAL
, / p" < y a rr 4o
Filed.
191
REOI8TRAR
31 UNDERTAKER /
DATE OF BURIAL
191
ADDRESS
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COMMONWEALTH OF MASSACHUSETTS
RETURN OF A DEATH-1913.
FULL NAME .Ca.rrie
and Residence f
Date of Death 7.7... 1913 Age.
CITY OF
BOSTON.
Registered No.
2115
Place of Death ) Boston Btoorson Hospt .
Map. 1
46
25
. months days.
STATISTICAL DETAILS.
PHYSICIAN’S CERTIFICATE.
SEX COLOR | SINGLE, MARRI ED, Wl D., DIV.
P W H
1 HEREBY CERTIFY that 1 attended deceased during last illness,
from 1913, to 1913
Maiden Name ■
Husband's Name ..*! /MS
that to the best of my knowledge and belief death occurred, on the
Hatp stated above, and that the CAUSE OF DEATH was as follows:
Six
Surgical Shock following
j / ^
| „,lL , Shelburne Palls
(Duratwft^ \ \
Operation for Ventral Hernia
\ ^fx CO!
N.m.o( Heni? B,Gro0J1 \Aj
rnrtrvx—gl] —f
tlTAA J
and Multiple Adhesions of Bowel
Birthplace
N.
Contributory: ) 2 dS .
Maiden Name -d--
of Mother “ T7
(Duration) (
Surgical Shook 2 ds.
Birthplace . .
(Signed) j0lm ATUOrean M.D.
Occupation HOUsewif©
Mar. 1 i o 1 3
SPECIAL INFORMATION from Hospitals, Institutions, Transients, or Recent
Residents.
Place of Burial EvOPett (WOOdlawn)
.. . D .. Winthrop, 69 Sargent St.
..... Brown & Rollins
Filed. Mar, 4 (913.
Registrar.
c
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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.
I
cd
(Cmttmmtujpattl) of fHassarJjaBrttB
STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH
(City or town.)
5FU LL NAME
.(No. 1
St.
[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 * /rv.
Registered No.
PERSONAL AND STATISTICAL PARTICULARS
» SEX
Jr
' COLOR OR RACE
s SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
( Write the word)
» DATE OF BIRTH
JL.
(Month)
JO \2z£.
(Day) (Year)
r AGE
_.yrs. mos. .
ad.
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)...
» BIRTHPLACE
(State or country)
‘0 NAME OF
FATHER
kJ
n BIRTHPLACE
OF FATHER
(State or country)
12 MAIDEN NAME
OF MOTHER
ifBIRTHPLAtE
OF MOTHER /VyJ y a_
(State or country) (/ r d- e tv' r
“THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
Filed.
., 191
Registrar
MEDICAL CERTIFICATE OF DEATH
“ DATE OF DEATH
..M.ai.4&. v.
dL
(Month)
(Day)
., I 9 1 3......
(Year)
17 I HEREBY CERTIFY that I attended deceased from
ld> \ b 191.5.., to ^^CsAxCvU 191.3',
that I last saw h.-M.... alive on 1 9 1 ...3,
and that death occurred, on the date stated above, at...L.i..™.tn.
The CAUSE OF DEATH* was as follows:
- —
XhL rurci/tt^ ^
S. ..s2/.Q.ds.
(Duration) yrs.
Contributory
^ ft (IAlAMA4>Vsftr.tion) .yrs. mo ff. ds.
(Signed) .Me .VvXitefev CtXt^d^r...^ M.o.
I9l3... (Addrms).
* If death followed injury or violence the certificate of deatlr 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 Ot REMOVAL
vL
50 UNDERTAKER
O' \^/
DATE OF BURIAL
Jb
... 191.^
ADDRESS
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COMMONWEALTH OF MASSACHUSETTS
CITY OF
RETURN OF A DEATH-1913. BOSTON.
FULL NAME Lydia E. Small Registered No 2319
Place of Death \ Boston Winchester Home for Aged Women
and Residence J
„ , n , liar. 6 ,90 5 12
Date of Death 1913 Age years months -days.
STATISTICAL DETAILS.
PHYSICIAN’S CERTIFICATE.
SEX COLOR SINGLE, MARRIED, WID., DIV.
F W W
1 HEREBY CERTIFY that 1 attended deceased djring last illness,
Maiden Name Il0!baJr!'
u , ,, .. Francis Small /aW4
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:
Arterio-sclerosis
D- i Boston
l Du Catkin.), -<y\'
>m ■■ 1^71 — \
J m j
Dirinpiace \"Waoi»
,, , \ NgL eoi
Name of David H.Hotart
roriiA aw 7
MTAiCk W 1
l3®- fWo,-/
Birthplace Hanson
N.
Contributory : j Catarrhal Enteritis
Sarah N. Pratt
(Duration) j
1 yr.
Birthplace Cohasset
(Signed) Heisom H.irood u 0
Occupation
.Mar. 6 19I3
SPECIAL INFORMATION from Hospitals, Institutions, Transients, or Recent
Residents.
Place of Burial NO.TmtO
Winthrop
Usual Residence
Geo.H. Gregg & Son
Undertaker Y
c, Mar. 11
Filed 1913.
(Watertown)
Registrar.
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STANDARD CERTIFICATE OF DEATH
PLACE OF DEATH
(City or townf
..(No.
!full name
[If maiTied or divorced womanCo/ widow
give maiden name, also name of husband.]
“RES! DENCE Lj ^ (J^fT .
jdstatisticmT
[If death occurred in
St. J Ward) a hospital or institution,
give its NAME instead
of street and number.]
Registered No.
PERSONAL AND
PARTICULARS
3 SEX
1 COLOR OR RACE 5 S|NGL-E.
r MARRIED,
i yf_/ V \ WIDOWED,
1/rt^lyOi^'O OR DIVORCED
( Write the word)
6 DATE OF BIRTH
(Month)
tf 7M...
(Day)
(Year)
7 AGE
(oC^ yrs.
mos. 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)...
5 BIRTHPLACE
(State or country)
A.
10 NAME OF
FATHER (J /
~yeZv.
(f)
h-
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OF FATHER
(State or country)
<
D.
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OF MOTHER
— *N
n BIRTHPLACE
OF MOTHER
(State or country)
^ — - —
—
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
(Address)
Fil.d
, 191
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
cCk £"T, i9i3.
(Month) (Day) (Year)
17 I HEREBY CERTIFY that I have investigated the
death of the deceased.
The CAUSE OF DEATH* was as follows:
Qj6kAASlJlfO '...err.
^aZCa/ViCI
. —
idk^-vyrs
s. ds.
Contributory..
(secondary)
(Duration) yrs mos. ds.
(Signed)
M.D.
I
■ l9lT ... (Address)!
/I 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. ds
Where was disease contracted,
If not at place of death 7
Former or
usual residence
>» PLACE OF BURIAL OR REMOVAL
50 UNDERTAKER .
Cc//r
DATE OF BURIAL
<5
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ADDRESS
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STANDARD CERTIFICATE OF DEATH
> (HO./...U. St.
!FU LL NAM
[If married or divorced woman or widow
give maiden name, also name of husband.]
“RESIDENCE
PERSONAL AND STATISTICAL PARTICULARS
(City or town.)
[If death occurred in
Ward) a hospital or institution,
give its NAME instead
of street and number.]
5 SINGLE,
MARRIEO,
WIDOWED,
OR DIVORCED
( Write the word)!
(Day)
tax
(Year)
? AGE
iz;„„.y<(_..yrs. mos ds.
~r
If LESS than
I day,. hrs.
or min.?
8 OCCUPATION
(a) Trade, profession, or
particular kind of work.....
r17 I HEREBY CERTIFY that I attended deceased from
191./. to.... 1 9 l ie
that I last saw huQ alive on , I9I.3L,
and that death occurred, on the date stated above, at.fj^i^Jm.
The CAUSE OF DEATH* was^as follows-:
lwx, *&Jz2=,
(b) General nature of industry,
business, or establishment in
which employed (or employer)...
9 BIRTHPLACE
(State or country)
18 THE ABOVE
(Informant) _
ir country).
IS TRUE TO
THE BEST OF MY KNOWLEDGE
(Address)
Filed.
191
Registered No.
MEDICAL CERTIFICATE OF DEATH
K DATE OF DEATH
(Mdnth)
/ o
(Day)
1 9
(Year)
..(Duration) .
I yrs b»
..ds.
Contributory..
(secondary)
. rum^,
191.3,. (Address) tsJ.
(Signed) .
* If death followed injury or violence the certificate
out by the Medical Examiner.
18 LENGTH OF RESIDENCE (FOR HOSPITALS, INSTITUTIONS, TRANSIENTS, OR
Recent Residents).
At place In the
of death....._....,yrs. mos. ,d$. State yrs. mos ds
Where was disease contracted,
If not at place of death ? ....
Former or
usual residence
-OF BURIA^ORv REMOVAL
REQI8TRAR
ATE OF BURIAL
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PERSONAL AND STATISTICAL PARTICULARS
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MEDICAL CERTIFICATE OF DEATH
10 DATE OF DEATH
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17 I HEREBY CERTIFY that I attended deceased from
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death followed injury or violence the certificate of death must be made
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18 LENGTH OF RESIDENCE (FOR HOSPITALS, INSTITUTIONS, TRANSIENTS, OR
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STANDARD CERTIFICATE OF DEATH
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MEDICAL CERTIFICATE OF DEATH
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<1 BIRTHPLACE
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13 MAIDEN NAME
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14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
Filed
Registrar
, I HEREBY CERTIFY that I attended deceased from
«■ "i-d . — , 1 9 |«J , to // 19 .
that I last saw h <4/Sr/. alive on f./ , I 9T\J... ,
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.(Duration)
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M.D.
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18 LENGTH OF RESIDENCE (FOR HOSPITALS, INSTITUTIONS, TRANSIENTS, OR
Recent Residents).
At place y 1 /Ji n the
of death .. yrs. mos. S? “v/AtV^fate yrs. mos. ds.
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If not at place of death 7
Former or
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» PLACE OF BURIAL OR REMOVAL
» UNDERTAKER
DATE OF BURIAL
/A^^c /x
ADDRESS
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.
Gtyp (Enmmmtuipaltlj nf fiaasarliusrlts
STANDARD CERTIFICATE OF DEATH
PLACE OF DEATH
m
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(Informant)
(Addr.i.)
MEDICAL CERTIFICATE OF DEATH
I® DATE OF DEATH
(Month)
(Day)
i9, 1.
(Year)
* I HEREB
M HEREBY, CERTIFY that I attended deceased from
..... I 91..*?, to
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(Signed) M.D.
( 191 3 (Address)....^^/f<^^^..^/>*^./
* 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
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MEDICAL CERTIFICATE OF DEATH
“ DATE OF DEATH
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that I last saw hiHZ™ alive on
and that death occurred, on the date stated above, atn;.7..::~;...:rrn .
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>« NAME OF
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“THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
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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.
©fjp dmmttmtutpattlj of Ifasarljusftia
49^^-
STANDARD CERTIFICATE OF DEATH
PLACE OF DEATH
t (No.
.tv an WUJ]CX«d»..
(City or town
¥
[If death occurred in
.St. J Ward) a hospital or institution,
give its NAME instead
of street and number.]
2 FULL NAME ... &&.CkA/ \ JL. J'JLfru.
[If married or divorced woman or widow Q
give maiden name, also name of husband.]
“RESIDENCE
IcT $T
5TICAL PARTnDU
Registered No.
00
z
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
4 COLOR OR RACE
Uy
3 SINGLE,
MARRIED
WIDOWE
OR DIVORCED
( Write the word)
6 DATE OF BIRTH
.../"A '
(Month) (Day) (Year)
1 AGE
4-
ds.
If LESS than
I day, hrs.
or min. ?
8 OCCUPATION
(a) Trade,
particular kind
(b) General nature of industry,
business, or establishment in
which employed (or employer)...
s BIRTHPLACE
(State or country)
>o NAME OF
FATHER
>1 BIRTHPLACE
OF FATHER
(State or country)
>» MAIDEN
OF MOTHER
\THER CV
EN NAME /
R
i» BIRTHPLACE
OF MOTHER / t — —
(Stateorrountry)^^^^-^^^^^
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
9 KAafL. O , 191.3
(Month) (Day) (Year)
(Day)
(Year)
7 I HEREBY CERTIFY that I have 1 investigated the
death of the deceased.
The CAUSE OF DEATH* was as follows:
LC/y^vula^.
Contr
(secondary)
. (Duration) vr
1U4^..WC^icLA-1L<x. CsILv-jETa. -I
(Duration) vrs. mos. ds.
..(Duration) yrs.
(Signed)
QMAr/lrr, ISlTJt (Address)
( t 5oOu medical exam I n er
mos. ds.
..., M.D.
* State the Disease Causing Death, or, in deaths from Violent Causes,
state (1) Means of Injury; and (2) whether Accidental, Suicidal or
Homicidal.
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
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 7
Former or
usual residence
>» PLACE OF BURIAL OR REMOVAL
*-c.
DATE OF BURIAL
S , 191/'
=° UNDERTAKER
Aj
ADDRESS
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Every item of information should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state
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important. See instructions on back of certificate.
(1% (Commumupattlj of fHaBaarljusftts
STANDARD CERTIFICATE OF DEATH
PLACE OF DEATH
(No.l’>..tf , , St.
1 TJkUf tupcx
'FULL NAME
K/laJLIC
(City or towny
[If married or divorced woman or widow
give maiden name, also name of husband.]
“RESIDENCE
V2-r
[If death occurred in
.Ward) a hospital or institution,
give its NAME instead
of street and number.]
3TICAL PARTICU1A
Registered No.
I
GO
Z
PERSONAL AND STATISTICAL PARTICUlARS
3 SEX
4 COLOR OR RACE
l l *7
f SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
( Write the word)
6 DATE OF BIRTH
(Month)
(Cay)
(Year)
3 AGE
yrs. mos.
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)...
0 BIRTHPLACE
(State or country)
<??.C
>0 NAME OF
FATHER
>1 BIRTHPLACE
OF FATHER ) ■
(State or country) / j
*r » / !. i
« MAIDEN NAME
OF MOTHER
(J&f CtA^ J
/J
'» BIRTHPLACE
OF MOTHER
(State or conn try)
( / J
r (
14 THE ABOVE IS TRUE TO THE BE?T OF MY KNOWLEDGE
IATL
(Informant)
(Address)
>i7"
— /■■■
/
Filed
191.
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
(Month)
(Da#)
I 9 I 3
(Year)
7 I HEREBY CERTIFY that I have investigated the
death of the deceased.
The CAUSE OF DEATH* was as follows :
^^4^rvrvr%-^0 CA-
VSsyJEfcr -
ClLWd^'
Lm i (° uration) yrs. mos. ds.
Contributory
(secondary)
(Duration) yrs mos. ds.
, M.D.
(Signed)
MEDICAL EXAM I N ER
W $ (Addres'
* State the Disease Causing Death, or, in deaths from Violent Causes,
state (1) Means of Injury; and (2) whether Accidental, Suicidal or
Homicidal.
8 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
J J, J
20 UNDERTAKER
a j/7
DATE OF BURIAL
'}...Y 191... ‘
ADDRESS
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Every item of information should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state
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important. See instructions on back of certificate.
I.
ca
z
PLACE OF DEATH
UJhc (EommomttpaUb of fHassarliusftts
STANDARD CERTIFICATE OF DEATH
(No.// Z?
-FULL NAME
[If married or divorced woman or widow
give maiden name, also name of husbajid.]
“RESIDENCE
PERSONAL AND STATISTICAL PARTICULARS
(City or town.)
[If death occurred in
a hospital or institution,
give its NAME instead
of street and number.]
3 SEX
COLOR OR RACE
7^?
77T
3 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
( Write the word)
DATE OF BIRTH
(Month)
AX - ifcfc
(Day) (Year)
r AGE
~yrs. mos.
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)...
* BIRTHPLACE
(State or country)
to NAME OF
FATHER
77'
ii BIRTHPLACE
[O OF FATHER
Hj (State or country)
LU 1
CC ;
< ! I2 MAIDEN NAME
OF MOTHER
» BIRTHPLACE -O
OF MOTHER 'S'-*
(State or country)
“THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant) .
Registered No.
MEDICAL CERTIFICATE OF DEATH
10 DATE OF DEATH
5- A
(Month)
(Day)
I 9 i .SJLf
(Year)
17 I HEREBY CERTIFY that I attended deceased from
I 9 1:3...., to. %-/ , I 9 I .IM?,
that I last saw h^sfJH^alive on 191^..,
and that death occurred, on the date stated above, at..^?/? m.
The CAUSE (J)F DEATH* was as follows :
...(Duration) yrs. mos
..ds.
Contributory..
(secondary)
(Duration) . yrs. mos. So ds.
(Signed) , M.D.
I 9 l"\i... (Address). t+rlUt.....*.
* If rieath followed injury or violence the certificate or death must be made
out by the Medical Examiner.
iS 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..
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COMMONWEALTH OF MASSACHUSETTS
RETURN OF A DEATH
(czrr ojj Towir.)
FULL NAME
Place
Death * ) —
Residence.J?.£p.,Q (5^ztr
STATISTICAL DETAILS
SEX
**.&*_,'
COLOR
SINGLE, MARRIED,
WIDOWED, OR
DIVORCED
MAIDEN NAME t /? VA’
HUSBAND’S NAME t
(Z)L/UaxXV
(X^^O /& Xfr.
BIRTHPLACE?
L ^/<X 1 —
NAME OF
FATHER
BIRTHPLACE
OF FATHER?
MAIDEN NAME
OF MOTHER
BIRTHPLACE
OF MOTHER?
OCCUPATION
INFORMANT §
PLACE OF BURIAL OR REMOVALH
/i*c*csrjts&s
UNDERTAKER
DATE OF BURIAL
190 .
ADDRESS .
PHYSICIAN'S CERTIFICATE
I HEREBY CERTIFY that I attended deceased during last
illness, fronuc^^.x*.^. 190^... to. .19/1?....,
that to the best of my knowledge and belief death occurred on the
date stated above, and that the QAUSE OF DEATH was as follows :
Primary: r..
.(duration) DAYS
Contributory:
(Signed).
. (duration) DAYS
M.D.
'TT2> wrs
Z&.^.yx/7L
190'J. . (Address) . (T.. . /i.c . .
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.
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.
Sty? (Umittmmnmtllh of iftassarfjusptts
STANDARD CERTIFICATE OF DEATH
( N o Frost Hospital St. ...
1 PLACE OF DEATH
Chelsea
£
‘full name Eliza A . Uorso
[If married or divorced woman or widow _ _ .
give maiden name, also name of husband.] iaJr.X.Z.a il.». r?..”-..r..
“RESIDENCE
CHELSEA.
(City or town.)
[If death occurred In
..Ward) a hospital or institution,
give its NAME instead
of street and number.]
155 lleasant Et . . Winthron
Registered No. 204
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
* COLOR OR RACE
White
s SINGLE,
MARRIED,
WIDOWED,
OR DIVORCElWi<30W&d
( Write the word)
MEDICAL CERTIFICATE OF DEATH
»* DATE OF DEATH
Ma rch
(Month)
,9) O
(Day) (Year)
l#
02
z
6 DATE OF BIRTH
(Month)
(Day)
, l„
(Year)
1 AGE
5.0. yrs. -..
dt.
If LESS than
I day, hrs.
or min. ?
» OCCUPATION
(a) Trade, profession, or
particular kind of work
At Home
17 I HEREBY CERTIFY that I attended deceased from
jJ&ZU to Mar. 22 191.
that I last saw hQ.r.... alive on MSX^. 2.1 , I9I..j2,
and that death occurred, on the date stated above, at “ m.
The CAUSE OF DEATH* was as follows:
Gr.§.ngr.o.ne......Q.f.....E.Q.ot
(b) General nature of industry,
business, or establishment in
which employed (or employer)^
J BIRTHPLACE
(State or country)
Rockland , Me .
1° NAME OF
FATHER
Unknown
CO
1-
z
11 BIRTHPLACE
OF FATHER
(State or country)
T?
UJ
<
Cl.
12 MAIDEN NAME
OF MOTHER
It
i* BIRTHPLACE
OF MOTHER
(State or country)
TT
Contributory..
(secondary)
_ pi
(Duration) yri.~j£.. mos.
...Gh.ro.nic. ln±.e..r.st.i.t.i.al..
..ds.
..IJ.ep.hr. ilia ..(Duration) ___2...yr$. mos.
..ds.
(Signed) . .Edward J..* Grainger m.d.
'&T.22 (Addr,„) Winthrop
* If death followed injury or violence the certificate of death roust be made
out by the Medical Examiner.
‘•THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
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 v/as disease contracted,
If not at place of death 7
Former cr
usual residence
(Informant).
Alhort. II- Unto..
(Addr...) 155 ^lc a sart^-St .
“ PLACE OF BURIAL OR REMOVAL
V/int hrop
Filed
Mar .52
191
3" x/LO .
■ UNDERTAKER Q . R . BOH nO T
REGISTRAR
DATE OF BURIAL
26
ia.r_»..2.5. .Q.r, 191 5_
ADDRESS
Y/inthrop
to
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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.
1
m
2
©Ij? (Eommmttircalttj of flassarljusrtts
STANDARD CERTIFICATE OF DEATH
(City or town.)
..St.
Ward)
[If death occurred in
a hospital or institution,
give its NAME instead
of street and number.]
‘FULL NAME
[If married or divorced wi
give maiden name, also na:
i or widow
/of husband.!
“RESIDENCE
PERSONAL AND STATISTICAL PARTICULARS
* SEX
Ui-
4 COLOR OR RACE
kj
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8 DATE OF BIRTH
•/ ^
.., \//~-
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r AGE
yrs- a ...mos. ds.
If LESS than
I day, hrs.
or min. ?
8 OCCUPATION
particular kind of work...
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business, or establishment in
which employed (or employer) ......
8 BIRTHPLACE
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■0 NAME OF
FATHER ^
(/)
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“ BIRTHPLACE
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“ maiden NAME
OF MOTHER
U BIRTHPLACE
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“THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
rmformenti -ft,. '
(Address)
Filed.,
191
REGISTRAR
Registered No.
MEDICAL CERTIFICATE OF DEATH
»• DATE OF DEATH
(Month)
I9|JL
(Day) (Year)
17 I HEREBY CERTIFY that I attended deceased from
Ldd&r: 191.)?..., to ishl,
that I last saw h.Afe-.. alive on... 191^2.,
and that death occurred, on the date stated above, at...y..rcrjR..m.
The CAUSE OF DEATH* was as follows:
* 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
Former or
usual residence
“ PLACE OF BURIAL OR REMOVAL
2?
30 UNDERTAKER
A>rt
DATE OF BURIAL
JL~JL£ I9U3
ADORESS
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CQ
COMMONWEALTH OF MASSACHUSETTS
RETURN OF A DEATH-1913.
FULL NAME Catherine Rodes Registered No....??8Q
piace_of Death ^ Boston Infanta* Hospt.
and Residence )
Date of Death 1913
CITY OF
BOSTON.
Age
1 K
months “V days.
STATISTICAL DETAILS.
PHYSICIAN’S CERTIFICATE.
SEX
P
COLOR
w
SINGLE, MARRIED, WID., DIV.
Maiden Name
Husband’s Name
Birthplace
Name of
Father
Birthplace
of Father..
Maiden Name
of Mother
Birthplace
of Mother.
Winthrop
Treant os Rodes
Greece
Helen Lla t hop oul one
Greece
I HEREBY CERTIFY that I attended deceased during last illness,
from 1913, to 1913,
that to the best of my knowledge and belief death occurred, on the
stated above, and that the CAUSE OF DEATH was as follows:
Tub .Meningi t i s
Occupation
! nformant
Place of Burial
or removal
Undertaker
St. Michael’s Cemt.
Joseph A.Langone
16 ds.
ontributory :
(Duration)
(Signed) M. □.
Mar. 24
1913.
SPECIAL INFORMATION from Hospitals, Institutions, Transients, or Recent
Residents.
Usual Residence.
Filed
Winthrop, 195 Lincoln St.
A true copy.
Attest:
liar. 27
1913.
Registrar.
FULL NAME.
Place of Death j
and Residence )
Date of Death
COMMONWEALTH OF MASSACHUSETTS
CITY OF
RETURN OF A DEATH-1913. BOSTON.
Kidd
Registered
No
3138
Boston
Boston Lying-in Hospt.
Mar, 26
913 Age years
11
months days.
STATISTICAL DETAILS.
SEX
u
COLOR
w
SINGLE, MARRIED, WID., DIV
Maiden Name
Husband’s Name
HEREBY CERTIFY that I attended deceased during last illness,.
from I 9 I 3, to 1913,
that to the best of my knowledge and belief death occurred, on the
;te stated above, and that the CAUSE OF DEATH was as follows:
Umbilical Hemorrhage
Boston
II
Birthplace
ii Mame of Harry E.Kidd \<sT
Father " Vo
Birthplace
of Father..
Maiden Name
of Mother...
Birthplace
of Mother.
Baltimore Md.
Hina Borsky
Boston
ontributory :
PHYSICIAN’ S CERTIFICATE.
1 dy.
Anaemia
6 ds.
(Signed) Somers Fraser M ,D.
Occupation
! nformant .
Place of Burial
or removal
Undertaker
Hone
I
Tewksbury
J.S.Uat orman & Sons
Mar • 26 1913
SPECIAL INFORMATION from Hospitals, Institutions, Transients, or Recent
Residents.
Usual
n .. Winthrop, 117 Revere St.
Residence
Filed
A true copy.
Attest :
Apr. 1
1913.
Registrar.
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1 PLACE OF DEATH
0 abridge..
Gttjp (Enmmflnamtlttj of ilaasarljuHPttB
STANDARD CERTIFICATE OF DEATH
.(No.. 350 Charles River Rd*. ;
Ch^lesgate Hospital,
Cambridge
(City or town.)
[If death occurred in
..Ward) a hospital or institution,
give its NAME instead
of street and number.]
’FULL NAME HELEN DOUGLAS CARR
[If married or divorced woman or widow MaCCtil iUITl .
give maiden name, also name of husband ! *
“RESIDENCE
rastyand,] .
Wintnrop, Mass,
J. Stewart Carr
Registered No.
442
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PERSONAL AND STATISTICAL PARTICULARS
3 SEX
Female
* COLOR OR RACE
s SINGLE,
MARRIED,
widowed, wo-pried
OR DIVORCED -LCU-
( Write the word)
4 DATE OF BIRTH
_...., I
(Month) (Day) (Year)
1 AGE
.4.6
_.yrs.
0
..0. ds.
If LESS than
I day,. hrs.
or min. ?
8 OCCUPATION
(a) Trade, profession, or
particular kind of work
At ho i.;e
(b) General nature of industry,
business, or establishment in
which employed (or employer)
9 BIRTHPLACE
(State or country)
Pr. Ldwrl . Island
«> NAME OF
FATHER
(ft
H
Z
LU
“ BIRTHPLACE
OF FATHER
(State or country)
Pr, Edwcl. Island
<
Q.
“ MAIDEN NAME
OF MOTHER
( Unknown )
•» BIRTHPLACE
OF MOTHER
(State or country)
Pr. Hdrr-I. Island
“THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
J . Stewart Carr , _
- Winthrop , Ma s a .
(Informant).
(Address)
Fi'«d Mar » ~2 1913.,
I—
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
“ DATE OF DEATH
Maroh 28,1913,
(Month)
(Day)
191
(Year)
I HEREBY CERTIFY that I attended deceased from
..Mar..* 21..,.19Ji3u...... to I.:ar...«.28...,.19li3 1 ,
that I last saw h.....(321’ alive on MUX...*.2.7..,.l9l3 191
1
and that death occurred, on the date stated above, at * m.
The CAUSE OF DEATH* was as follows
Myoma of-Uterus
A,
(Duration) .8. ...yrs. ...TfT..*" “..•*•***•' ds.
Operation- Ileus
. ... — — TTTTWs . ds.
Contributory..
(secondary)
(Duration) .
(signed) _.N» H, • Germain , M D
liar .28, 1913# 416 Marlboro. si
• — 191 (Addfess) bob ton
* 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.
l» PLACE OF BURIAL OR REMOVAL
V; in t hr op , Mas 3.
» UNDERTAKER
ADDRESS
A. 0, Shades, Li .itlirop .Mass .
DATE OF BURIAL
tar .30,191?,,,
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Ei}t (Comma ttutpaLlt nf fftasearljusetts
STANDARD CERTIFICATE OF DEATH
PLACE OF DEATH
..(No.....:
St.
(City or townQ
[If death occurred in
..Ward) a hospital or institution,
give its NAME instead
of street and number.]
2 FULL NAME
[If married or divorced woman or widow
give maiden name, also name of husband.]
“RESIDENCE
Registered No.
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3 SEX
ccj£*~~
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6 DATE OF BIRTH
3 SINGLE,
MARRIED
WIDOWED
OR DIVORCED
( Write the word)
(Month)
tCEC
1 wo 1
/P 7m
(Year)
(Day)
3 AGE
r. yrs.
/ mos. 11 ds.
If LESS than
I day, hrs.
. min. ?
8 OCCUPATION
(a) Trade, profession, or
particular kind of work
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business, or establishment i
which employed (or employer),
3 BIRTHPLACE
(State or country)
>0 NAME OF
FATHER
11 BIRTHPLACE
OF FATHER
(State or country)
“ MAIDEN NAME
OF MOTHER
» BIRTHPLACE
OF MOTHER ' ' ' ^
(State or country)
“THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
Vfi
(Address)
<3^
Filed
191
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
(Month)
1 9 1 ..HL.
(Lfey) (Year)
17 I HEREBY CERTIFY that I have investigated the
death of the deceased.
The CAUSE OF DEATH* was as follows:
LxAwtwrV‘>LArF*..{
/VL/WX. ^tLc 4^Av-t .
UXtb. fyfzX. ... rJL CMAsSthx^L-
..(Duration) yrs.
✓. (Duration) yrs. mos. ds.
Con/rifcijifti^i&Lw $*JLa£L~ ..rfi/KAf. &IjuZjb*~ Jfaf&f.&.Ais..]
(SEoSaotRy) J* 9
(Duration) yrs mos. ds.
(Signed) . \^***^»rvr'>C> , M.D.
Q^,Mi J9I.3... (Address) L/
2. -7 6 f ,, , 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.. ds.
Where was disease contracted,
If not at place of death 7
Former or
usual residence.
>» PLACE OF BURIAL OR REMOVAL
au
DATE OF BURIAL
» UNDERTAKER
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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.
I_
m
PLACE OF DEATH
Stye (EommoKuiealtti nf fHasaarlwsftis
STANDARD CERTIFICATE OF DEATH
(N0..../1J (p ,
f St.
’FULL NAME.,
[If married or divorced woman or widow
give maiden name, also name of h"~l — J '
“RESIDENCE
J£L
norrEA
(City or town.)
[If death occurred in
Ward) a hospital or institution,
give its NAME instead
of street and number.]
Registered No.
PERSONAL AND STATISTICAL PARTICULARS
r-
7 AGE
*2«*.
* 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)
C/5
>0 NAME OF
FATHER
11 BIRTHPLACE
OF FATHER
(State or country)
LACE f7
tER A Cr
'7 MAIDEN NAME
OF MOTHER
n BIRTHPLACE
OF MOTHER
(State or country)
“THE ABOVE IS TRUE 70 THE BEST OF MY KNOWLEDGE
(Informant)
( Address)
Filed
is
191.
REGI8TRAR
MEDICAL CERTIFICATE OF DEATH
>• DATE OF DEATH
I'Vl s&JUiJL
(Month)
3 6
(Day)
I 91 3
(Year)
17 i HEREBY CERTIFY that I attended deceased from
^VCjUl^Lu} 'O , 1 9 \SL) , to y)/tUs*t£o 3d r 191-3...,
that I last saw bf&Y'. alive on 3 0 , I 9 [3 . .,
and that death occurred, on the date stated above, at.^LxT^m".
The^CAUSE OF DEATH* was as follows j
Contributory „
(SECONDARY) 'Or-'v'V'Y' •
(Signed)
(Duration)... yrs. ... -Sr mos. .A «
<S. CP. P^UdpJ^Iu)
M.D.
191.3... (Address) All...
* If death followed injury or violence the certificate of death must be made
out by the Medical Examiner.
'J
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
l> PLACE OF BURIAL OR REMOVAL
DATE OF BURIAL
, 191
SW.KER 7L_ A
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PLACE OF DEATH
(Jflj? (Unmmxmmealtlj of l0asaad|UBflls
STANDARD CERTIFICATE OF DEATH
0 z 3,
2 FULL NAME
[If married or divorced woman or widow
give maiden name, also name of husband.]
“RESIDENCE
(City or town.)
[If death occurred in
Ward) a hospital or institution,
give its NAME instead
of street and number.]
JL 3 £-i/ cntnz&t ^ t
Registered No.
I.
ad
z
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
1 COLOR OR RACE
s SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
( Write the word)
9 DATE OF BIRTH
(Month)
v3?
(Day)
, 1 m
(Year)
7 AGE
If LESS than
I day, hrs.
8 OCCUPATION
(a) Trade, profession, or
particular kind of work
(b) General nature of industry,
business, or establishment in
which employed (or employer)...
0 BIRTHPLACE
(State or country')
I >» NAME OF
FATHER
I " BIRTHPLACE
OF FATHER
(State or country)
/V-
< >- MAIDEN NAME
0- OF MOTHER
j- j+x.
'» BIRTHPLACE . .
OF MOTHER
(State or country) r w is u' r
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant) .
)^cc t £_ *3 c~&C
(Address) Xb OSUl—
Filed
191
Registrar
MEDICAL CERTIFICATE OF DEATH
>« DATE OF DEATH
/ (M<
(Month)
(Day)
I 9 I ,/T?
(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.
ds.
Contributory..
(Secondary)
(Duration)
* If death followed injury or violence the certificate of death must be made
out by the Medical Examiner.
19 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 j
» PLACE OF BURIAL OR REMOVAL
DATE OF BURIAL
191
ADDRESS
MARGIN RESERVED EOR BINDING.
COMMONWEALTH OF MASSACHUSETTS
CITY OF
RETURN OF A DEATH-1913. BOSTON.
FULL NAME
Place of Death 1
KARL G.
Boston
MORSE
CITY HOSPT.
Registered
No 3351
and Residence j ""
Date of Death
APR. 4
1913. Age
26
5
years
>4
STATISTICAL DETAILS.
PHYSICIAN’S CERTIFICATE.
SEX COLOR SINGLE, MARRIED, WID., DIV.
M W SIN.
1 HEREBY CERTIFY that 1 attended deceased during last illness,
from 1 9 1 3, to . . 1913
Maiden Name
that to the best of my knowledge and belief death occurred, on the
_jdg,te stated above, and that the CAUSE OF DEATH was as follows:
AC. OEDEMA LUNGS. TUB. TRACHEA
DEXTER. ME. fagfa-f
(Duration) (
LARYNX - WITH STENOSIS
Jim 1
Name Of CHARLES E. MORS^V-
ftSHTA'"Sri
/ TRACHEOTOMY (l YR)
liC- X/c
Birthplace ■““““■■"Wit;. '■
N.
Contributory : )
Maiden Name NELLI E GOFF
(Duration) i
Birthplace DOVER. ME
of Mother
PHYSI Cl AN
Occupation
T. LEARY MED. EX.
(Signed) M.D.
APR. 4
1913
SPECIAL INFORMATION from Hospitals, Institutions, Transients, or Recent
Residents.
Place of Burial DEXTER«ME#
or removal
WlNTHR0P(l&7 SHORE DRIVE)
Usual Residence
HUTCHINSON & GATES
1 Undertaker
APR. 7
Filed ' 1913.
DEXTER. ME .
Registrar.
• '
. , •. ! 5 3
..
. .
'
_
'
•■7
Every (tern 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
m
z
<1% dmnmxmuipalll| of UlassarlpjHPttfl
1 PLACE OF DEATH
/
STANDARD CERTIFICATE OF DEATH
'^7^:..:. ( n o .
(City or town.)
!FU LL NAME
e
flf death occurred in
..St. ; Ward) a hospital or institution,
give its NAME instead
of street and number.]
“RESIDENCE
[If married or divorced woman or widow
give maiden name, also name^pfyhusband.]
PERSONAL AND STATISTICAL PARTICULARS
» SEX
1 COLOR OR RACE
k/
\ SINGLE_
MARRIED,
WIDOWED,
OR DIVORCED
( Write the word)
m c
6 DATE OF BIRTH
._.ZZ I fJj«
(Month) (Day) (Year)
t AGE
yrs- AL mos. .. -2...2L.ds.
If LESS thai
I day, hrs.
or min. ?
* OCCUPATION
/0""
that I last saw heifer, alive y?...:. I9I.O.-.,
and that death occurred, on me date stated above,
The CAUSE OF DEATH* was as follows:
(a) Trade, profession, o^
particular kind of work
(b) General nature of industry,
business, or establishment in
which employed (or employer)...
9 BIRTHPLACE
(State or country)
10 NAME OF
FATHER ry , -
ii BIRTHPLACE
OF FATHER -
(State or country) / s>
MAIDEN NAME
OF MOTHER
7^
j2
■&—ZA-
» BIRTHPLACE
OF MOTHER
OF MOTHER
'•THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant).
Filed.
., 191
MEDICAL CERTIFICATE OF DEATH
l* DATE OF DEATH
f (Month)
(Day) (Year)
I HEREBY CERTIFY that I attended deceased from
, I9I.J.., to /..Z._..., I9ll..i
°Cs
OL.<~
-C
Contributory..
(secondary)
laCj<f... (Duration) yrs mos. ds.
< jZ ft--, yy /TO * ■r^^.ee.r.if.
(Duration) yrs. mos. ...Z ds.
(Signed) .... r~&f. ,.c
• 191^3... (Address)
Z If death fol
followed injury or violence the certificate of death must be made
'out by the Medical Examiner.
" 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
Registrar
* UNDERTAKER
9
\2£l
DATE OF BURIAL
191.
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Ety of iMassarbuaetts
STANDARD CERTIFICATE OF DEATH
PLACE OF DEATH
A/*
(City or town.)
[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 husbandj
“RESIDENCE
egistered No.
«
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
COLOR OR RACE
CO ©
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3 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED- ^
( Write the word) "
8 DATE OF BIRTH
f ¥ , \ttA
(Month) (Day) (Year)
3 AGE
S-. l
ds.
If LESS than
I day, hrs.
or min. ?
8 OCCUPATION
(a) Trade, profession,
particular kind of work
(b) General nature
business, or
which employed
^ A.
ature of industry, v,
establishment in /Y (i
ed (or employer) y*
5 BIRTHPLACE
(State or country)
. lAJ - 1
X
>> BIRTHPLACE
OF FATHER w
(State or country) (XX t3'-4-'1 *•
-fit
>3 maiden name
OF MOTHE
'Z20SJL.
>» BIRTHPLACE
OF MOTHER
(State or country1' '
14 THE ABOVE IS TRUE TO.THE, BEST OF MY KNOWLEDGE
(Informant)
(Address)
Filed.
191
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
38 DATE OF DEATH
/lWnntl
!X/ , I9I.J .
(Month) (Day) (Year)
17 I HEREBY CERTIFY that I attended deceased from
.... hr 3 .... , I 9 I .\?. , to f.y .., I 9 I ,t_i ,
that I last saw h alive on. , 191. J,
and that death occurred, on the date stated above, at Cm .
The CAUSE OF DEATH* was as follows :
L — V — ■ 4 *■ f
>
..(Duration)
yrs.
Contributory..
(secondary)
(Duration) yrs.
(Signed) ...
i.*L 191*5 (Addre$»).J?„TC!^I.^!?r:
S&
* 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 »
30 UNDERTAKER
DAT^ OF BUrflAL
191
1
I
ADDRESS
C iy t -x * -h
Every item of information should be careThe text goes on. The rest is in the file.