The volume, 1916–1918
Town Clerk, Winthrop · from the Internet Archive · 1314 pages · 92.8 MB
open the file ↗ · original at the source ↗
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1 PLACE OF DEATH
STANDARD CERT
(No ...fcZi
4
* FULL NAME..
[If married or divorced womaj
give maiden name, also name.o dfnsband.J
“RESIDENCE
(City or town.)
[If death occurred in
/ard) a hospital or institution,
/
give its NAME instead
of street and number.]
gistered No.
PERSONAL AND STATISTICAL PARTICULAR!
OF DEATH
3 SEX
* COLOR, OR RACE
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCE
( Write the word)
* DATE OF BIRTH
'.Jj/V C **
word)
=
(Month)
(Day)
(Year)
r AGE
7 0- / //
yrt. mo*. /. ds.
If LESS than
I day,. hr$.
or min. ?
8 OCCUPATION
(a' Trade, profession, or
part'cular kind of work
(b) General nature of industry,
business, or establishment in
which employed (or employer).
» BIRTHPLACE
(State or country)
10 NAME OF
FATHER
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ii BIRTHPLACE
OF FATHER
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11 MAIDEN NAME
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« BIRTHPLACE
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•‘THE ABOVE IS TRUE TO THE BEST OF MV KNOWLEDGE
(Informant)..
/.. I 91. ..4...
(Month/ (Day) (Year)
‘2L
I HEREBY CERTIFY that I attended deceased from
iZ/Gr. 191 v5 , to /... I9lj?_.,
that I last saw h ../*-**. alive on . . . . . .t-. -. «fr. At. , 191
and that death occurred, on the date stated/ aoove, aX.?:»}..Q..Am .
The CAUSE OF DEATH* was as follows:
L frr^fcs?.
T
(Duration) yrs. mos.
Contributory
di.
(SECOftmRr), V /
.(Duration) 2_.
-
(Signed) 1 L..-
'3'hs... .*?: , 1 9 1 /(Address)..,L/~J.(:.
M.D.
A. .........
* 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. d». State yrs. mos ds.
Where was disease contracted,
If not at place of death ?
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STANDARD CERTIFICATE OF DEATH
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1 PLACE/OFDEATH
(Noj£sL ^jLa*LJLl & uCf. ; st.;..
J
— ......
(City or vown.)
[If death occurred in
..Ward) a hospital or institution,
give its NAME instead
of street and number.]
* FU LL NAME
[If married or divorced woman or widow
give maiden name, also name of fcnsband.J
',RESIDENCE
Registered No.
PERSONAL AND STATISTICAL PARTICULARS
SEX
/
* COLOR OR RACE
“ SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
( Write the word)
__
MEDICAL CERTIFICATE OF DEATH
>« DATE OF DEATH
J
(Month)
.3
(Day)
I 9 1 .4. ..
(Year)
I.
CO
z
• DATE OF BIRTH
f AGE
•OCCUPATION
(a) Trade, profession, or
particular kind of work
if
..Af.. yrs. .^r„
lUajO Sbjt , I ?JL
(Month) (my) (Year)
/A ds.
If LESS than
I day* hrs.
or min. ?
17 I HEREBY CERTIFY that I attended ^ceased from
1 9 1 <513, to At — i ~2 , 1 9 1 A ,
that I last saw h.LV)... alive on,....>r~ri ““ 1 9 1 ...At. ,
and that death occurred, on the Wte stated above, at....(£ M. rn.
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)
A*
‘® NAME OF
FATHER
// .Jjtjfs
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*• BIRTHPLACE
OF FATHER
TT
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V ScZo-tU r, ■>
‘2 MAIDEN NAME
OF MOTHER
// <4,
/si iA^L /
■* BIRTHPLACE
OF MOTHER
(State or country)
AT LA
v AtMssC/K 1/
‘•THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)...^ £
(Addr9Ss)
_
Filed..
191...
REGISTRAR
..(Duration) yrs mos. ... AL ..d*.
Contributory..
(secondary)
(Duration)... - . . yrs mo*,.. dt.
4 -■*
(Signed)
....QrT2'...3. , I9lk„. (Address).
*if death followed injury or violence the certificate of death must he 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 yr* mot. ds..._
Where was disease contracted,
If not at place of death?.. _
Former or
usual residence ..
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STANDARD CERTIFICATE OF DEATH
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2d woman or widow
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(City or town.)
•FULL NAME..
[If married or divorced woman or widow
give maiden name, also name of husband.]
“RESIDENCE
[If death occurred in
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give its NAME instead
of street and number.]
PERSONAL AND STATISTICAL PARTICUL4
I r J ( Write the word) ^
MEDICAL CERTIFICATE OF DEATH
>• DATE OF DEATH
(Month)
(Day)
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t AGE
ay ^
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8 OCCUPATION
(a) Trade, profession, or
particular kind of work
I HEREBY CERTIFY that I attended deceased from
191-6., to.. ..ILtZ+ZZ. 3. , I9l6i..„
that I last saw h.feM* alive on AM./ah^^T.. .r£ir. , 1 9
and that death occurred, on the dat^r stated above, at.v£f?......m .
The CAUSE OF DEATH* was as follows:
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-
(Signed) /'‘nT n_/j- > . . -
. JoaasS:-.l!fe_..., I9I JL»._ (Address)..^
* If death followed injury or violence the certificate of di&th must, be made
out by the Medical Examiner. ,
l* THE ABOVE IS TRUE TO THE SU
g./ga
(Informant)
(Address)
T OF MV KNOWLEDGE
“ LENGTH OF RESIDENCE (FOR HOSPITALS, INSTITUTIONS, TRANSIENTS, OR
Recent Residents).
At place In the
of death yrs mot ,d*. State yra moj „..ds._. _
Where was disease contracted,
If not at place of death 7
Former or
usual residence
Filed..
191.
® UNDERTAKER
Registrar
Qs , /^ »/*/ Z c — Z4
DATE OF BURIAL
h , 19. L
ADDRESS
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FULL NAME
Place of Death j
and Residence (
Date of Death
COMMONWEALTH OF MASSACHUSETTS
CITY OF
RETURN OF A DEATH — 1916. BOSTON.
ALEXANDER M- GREEN Registered No. >32
B.C.H. RELIEF HOSPT.
1916. Age years months days.
Boston
J AM . 4
STATISTICAL DETAILS.
SEX.
M
COLOR.
Maiden Name
Husband's Name
Birthplace
Name of
Father
Birthplace
of Father
Maiden Name
of Mother
Birthplace
of Mother
Occupation
I nformant
Place of Burial
or removal
Undertaker
w
SINGLE, MARRIED, WID., DIV.
MAR.
BGSTON( EAST )
.VI Li. I AM GREEN
SCOTLAND
JOHANNAH LARKIN
I RELAND
TRAFFIC MGR . ( C UN ARD L
MALDEN (HOLY CROSS)
R.C.KIR3Y
PHYSICIAN’S CERTIFICATE.
I HEREBY CERTIFY that I attended deceased during last illness,
from 1 9 1 6, to 1916,
that to the best of my knowledge and belief death occurred, on the
stated above, and that the CAUSE OF DEATH was as follows:
CERE. HEMORRHAGE - 2 1-2 HRS
Contributory
(Duration)
(Signed)
ARTER 10-SCLEROSIS
S. FRASER
M.D.
I NE ) J AN . 5 1916
SPECIAL INFORMATION from Hospitals, Institutions, Transients, or Recent
Residents.
IN HOSPT. 2 HOURS
Usual Residence vV I NTHROP ( I I 7 HIGHLAND AVE)
Filed
A true copy.
Attest :
JAN. 10
1916.
Registrar.
Wl}£ (CmnmnmtiEaUb of ftesarljusdlB
PLACE OF— DEATH
STANDARD CERTIFICATE OF DEATH
.BOSTON
(City op town.)
(No ... /y.
' /
[If death occurred in
..St. ; Ward) a hospital or institution,
give its NAME instead
of street and number.]
* FU LL NAME..J)B^^ l
(If married or divorced woman or widow
give maiden name, also name of husband.]
“RESIDENCE
z.
Registered No.
PERSONAL AND STATISTICAL PARTICULARS
• SEX
>
* COLOR OR RACE
• DATE OF BIRTH
a SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
( Write the word)
(Month)
(Day)
I ft
(Year)
» AGE
‘OCCUPATION
..y.-.yre. \ moi. /
,.ds.
If LESS than
I day* hrs.
or min. 7
(a) Trade, profession, or
particular kind of work (/C
(b) General nature of industry,
business, or establishment in
which employed (or employer)...
9 BIRTHPLACE
(State or country) Hp
W NAME OF
FATHER
U BIRTHPLACE
OF FATHER
(State or country)
1* MAIDEN NAME
OF MOTHER
m u
1 X
i* BIRTHPLACE
OF MOTHER
(State or country) t-
I* THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant) X. -
(Address)
Filed..
191.
Registrar
MEDICAL CERTIFICATE OF DEATH
that I last saw h....iCSX alive on.
191.
and that death occurred, on the date stated above, at^/.(?L7ir. r
USE OF DEAT
The CAl]SE OF DEATH* was as follows:
Did a surgical operation precede death ' Date
(Duration) yrs.
d$.
Contributory..
(Secondarv)
(Signed)
, I 9 1. ..(?... (Address)
» PLACE OF BURIAL OR REMOVAL
UZ
20 UNDERTAKER
DATE OF BURIAL
ADDRESS
¥
/^esL/h'i <
I HEREBY CERTIFY that I attended deceased from
r....2y...l 191^2., to il , i9iC ,
. (Deration) . yrs mos. ... ds.
* 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..
Where was disease contracted,
If not at place of death?
Former or
usual residence...
;...t-,...U..Xf...... 191.4ft.
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(CnmntonmfaUlj of iHassarljuorllc
STANDARD CERTIFICATE OF DEATH
PLACE OF DEATH
/) (City or town.)
£1 ■ s, Ward) .
' ' n.. MAM
occurred in
nstitution,
give its NAME instead
of street and number.]
* FULL NA
[If married or divorced /oman or widow CLf, n q, V — 7 ff . A
give maiilen name, also name of husband.] (Ill JA. -C. lAt-AZA jO',
“RESIDENCE
Registered No.
I— a>
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MEDICAL CERTIFICATE OF DEATH
>» DATE OF DEATH
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MEDICAL CERTIFICATE OF DEATH
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PERSONAL AND STATISTICAL PARTICULARS
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Registrar
MEDICAL CERTIFICATE OF DEATH
1® DATE OF DEATH
ATH A
^ fir. CZrMiS..../. 1 9 1
( / (Month) (Day) (Year)
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STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH
nOflTQJN
(City or town.)
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Ward) a hospital or institution,
give its NAME instead
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'FULL NAME
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"RESIDENCE £ y-
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PERSONAL AND STATISTICAL PARTICULARS
» SEX
£
* DATE
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“THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant).
(Address)
■2 f
Filed.
191.
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
“ DATE OF DEATH
(Month)
U
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I 9 1 A
(Tear)
17 I HEREBY CERTIFY that I attended deceased from
*- *- , 191 vS , to j , 1 91. A,
that I last saw alive on„..Q£* /A
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The CAUSE OF DEATH* was as follows:
Did a surgical operation precede death? Date
..(Duration) mo*. ,d».
Contributory.
(secondary)
(Duration) .yr* mo*. .. ds.
(Signed) ^ t^*Vv M.D.
jXA*. ’ / & , 191.4.. (Address)„3 _6.A/
IN-
* If death followed injury or violence the certificate of deat
out by the Medical Examiner.
18 LENGTH OF RESIDENCE (FOR HOSPITALS, INSTITUTIONS, TRANSIENTS, OR
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©lip (Enmnumuipaltli of fUaasarljuartta
STANDARD CERTIFICATE OF DEATH
PLACE OF DEATH
\\j (No.. ip
kitUUf,
(City or town A'
[If death occurred in
St. , Ward) a hospital or institution,
give its NAME instead
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"RESIDENCE
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PERSONAL AND STATISTICAL PARTICULARS
3 SEX . | 1 COLOR OR RACE
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3 DATE OF BIRTH
/ 13$
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9 BIRTHPLACE
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10 NAME OF
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11 BIRTHPLACE
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-
12 MAIDEN NAME
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n BIRTHPLACE
OF MOTHER
(State or country)
1«THE ABOVE IS TRUE TO THE BESTLDF MY KNOWLEDGE
(Informant)
(Address)
Filed..
191.
Registrar
MEDICAL CERTIFICATE OF DEATH
i« DATE OF DEATH
%
(Month)
( So I 91. t
(Day) (Year)
17 I HEREBY CERTIFY that I have investigated the
death of the deceased.
The CAUSE OF DEATH* was as follows:
VcJt*— 1 -
L>aSx\Xo — Si cX&a_ (pLu^> If.LAj. JLuAL^
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Contributory.
(secondary)
..(Duration)
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(Signed)
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M.D.
I^J to... (Address*
(J t« / „ MEDICAL EXAMINER
* State the Disease Causing Death, or, in deaths from Violent Causes,
state (1) Means of Injury; aud (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
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15 PLACE OF BURIAL
DATE OF BURIAL
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important. See instructions on back of certificate.
I
d
1 PLACE OF DEATH
etyf (Commomtipalth nf fHaBsarljmiptta
STANDARD CERTIFICATE OF DEATH
(City or town.)
(No...
'FULL NAME
[If married or divorced wor^E or widow
give maiden name, also name of husband.]
“RESIDENCE &
(2.....^^
[If death occurred in
St.; Ward) a hospital or. institution,
give its NAME instead
of street and number.)
PERSONAL AND STATISTICAL PARTICULARS
• DATE OF BIRTH
Tf
/ TMonthV
3 SEX « COLOR OR RACE 6 SKSJl&n if *
1 ( Write the word)
(Month)
(Day)
— . I
(Year)
L<*t.. ,191 JL , .191 C.. ,
that I last saw fvdStcc/ alive on . z . / } 1 9 1 ...f,
and that death occurred, on the date stated above, a*. ..a/? m.
The CAUSE OF DEATH* was as follows :
I HEREBY CERTIFY that I attended deceased from
7 AGE
(a) Trade, profession, or
particular kind of work
If LESS th^n
I day,. hrs.
or min. ?
(b) General nature of industry^
business, or establishment iflf
which employed (or employe r)^T..."7.TL™
9 BIRTHPLACE
(State or country)
CP' sA •
10 NAME OF
FATHER
>1 BIRTHPLACE
OF FATHER
(State or country)
is maiden name
OF MOTHER
fa****?'
1» BIRTHPLACE
OF MOTHER
(State or country)
Si .
14 THE ABOVE IS TRUE TO THeTj^ST OF MT KNOWLEDGE
(Informant)
(Address)
Fil.d_
191.
Registrar
Contributory... SlsfUt*.
(Secondam) .
(Duration) yrs. mot. ds.
(Signed) CkCjL:.. m.o.
1 9 1 (Address) ^7"
* If death followed injury or violence the certificate of (fiath 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. ,d«. State yrs. mos ds.
Where was disease contracted,
If not at place of death 7
Former or
usual residence
» PLACE OF BURIAL OR REMOVAL
DATE OFJ3URIAL
I9Us
» UNDERTAKER
& /Z&
ADDRESS
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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.
(EnmmnnuiraUtj of iltassarljusjttG
STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH
• ^ (No.d , ..
5 FULL NAME
(City or to
if-
[If death occurred in
Ward) ® hospital or institution,
give its NAME instead
of street and number.]
JL
(If married or divorced woman or widow /£ > . £ / $ — '
;ive maiden name, also name of husoand.]
Registered No.
give
“RESIDENCE
I
CD
z
PERSONAL AND STATISTICAL PARTICULARS
* SEX
/
* COLOR OR RACE
• DATE OF BIRTH
6 "SINGLE, xv. . x
MARRIED,
WIDOWED.
OR DIVORCED
( Write the word)
(Month)
2./
(Day)
(Year)
r AGE
-yr*
JJU
If LESS than
I day. hrs.
or min. ?
8 OCCUPATION
(a) Trade, profession, or
particular kind of work x..
i±l..
(b) General nature of industry,
business, or establishment in
which employed (or employer)...
9 BIRTHPLACE
(State or country)
W NAME OF
FATHER
11 BIRTHPLACE
OF FATHER
(State or country)
It MAIDEN NAME
OF MOTHER
Ua
i» BIRTHPLACE
THE
Im ft
di
OF MOTHER ./) /
(State or country) j(L-^
't
“THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant). X\. jfsVL^yi/ — "
(Address)?, V - '..u/j A . , >2
uy
n
Filed.
191.
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
• •y*
I HEREBY CERTIFY that I attended deceased from
y7. i9i/„, to , \9i£.„
that I last saw h„z%L. alive on 191*?.....,
and that death occurred, on the date stated above, at xA...'.S. m .
The^CAUSE O^F DEATH* was as follows
[.(Duration) yrs. ...
. mos. ds.
C o n t r i b u to ry.
(Secondary)
.(Duration) „__^....yrs >.,^^...mo«. dt.
(Signed)
^.../(Address) £..,
M.D.
* If death followed injury or violence the certificate of death must be made
out by the Medical Examiner.
18 LENGTH OF RESIDENCE (FOR HOSPITALS, INSTITUTIONS, TRANSIENTS, OR
Recent Residents).
At place In the
of death yrs. mos. ds. State yrs mos ds.
Where was disease contracted,
if not at place of death 7
Former or
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» PLACE- OF BURIAL OR REMOVAL. .
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2 :.2r, 191.6.
20 UNDERTAKER
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Board of Health, City of Newton. The within return countersigned and approved this
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Agent.
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Sty? (ErmwumuiTaltlj of fHassarliusrtlfi
STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH
4 No U..jtt....... .
‘FULL NAME
[If married or divorced woman or widow
give maiden name, also name of husband. J
“RESIDENCE
v$>
Ward)
(City or town.)
[If death occurred in
a hospita* or institution,
gi*e its NAME instead
of street and number.]
Registered No.
PERSONAL AND STATISTICAL PARTICULARS
* SEX
°yv\
• COLOR OR RACE
\AJ
* DATE OF BIRTH
(Month)
,S.r
(Day)
... 1 f/L
(Year)
r AGE
,,d»™
If LESS than
I day. hrs.
or min. ?
•OCCUPATION
(») Trade, profession, or
particular kind of work..
(b) General nature of industry,
business, or establishment in
which employed (or employer)...
» BIRTHPLACE
(State or country)
■» NAME OF
FATHEF
•» BIRTHPLACE
OF FATHER
(State or country)
■* MAIDEN NAME
OF MOTHER
i* BIRTHPLACE
OF MOTHER
(State or country^
“
xhi
THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant).
(Address) , /^/ (ft(XA~££
Filed
191.
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
!» DATE OF DEATH
/
(Month)
.A/ 1 9 1^2.
(Day) (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:
Cbubjirir^AV
lc!n3^fcCv»|L»
..(Duration) yrs. .
..mos, df.
Contributory..
(secondary)
(Duration) yrp. ...
y/;
(Signed)
<7
1 4„.. (Address) jS..&!^„.sUL<kd^L'^;.
If death followed injury or violence the certificate of death must be made
'ut 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
DATE OF BURIAL
191.4.
ADDRESS
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„ -STANDARD CERTIFICATE OF DEATH
1 PLACE _0F^D'EAT#_.
\y/.. lS.V.l/L/:u idt. L (No....\^..fo^, St.
1 JC ■, /!■> A v
'FULL NAME
[If married or divorced woman or, widow
give maiden name, also name of husband..
sv
M v
RESIDENCE ^ jUl4sljU4j KjJ 7
/jL., iJ2& — . y
(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
» SEX
if;
• COLOR OR RACE
f/Cj
• DATE OF BIRTH
'* SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
( Write the fford)
(Month)
j&il
(Day)
JlL \Wk
(Year)
f AGE
/
yrs. / mos.
JL
£l
If LESS than
I day* hrs.
or min. ?
* 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)
1» NAME OF
FATHER^*
( yl/vu
/•
v i/'A
“ BIRTHPLACE
OF FATHER
(State or country]
La un f\AJC b
■* MAIDEN NAME
OF MOTHER
IkLOy
l z
i» BIRTHPLACE
OF MOTHER -V ,
(State or country)
“THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant) i
yy
14A
(Address)
A*
Filed.
191.
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
>« DATE OF DEATH
(Month)
J6
(Day)
ISJL.k
(Year)
17 I HEREBY CERTIFY that I attended deceased from
/\QLAa. • ) I 9 lCg_.., to.. 6 I 9 1 ..L. ,
that I last saw h.gu^ alive on 191
and that death occurred, on the date stated above, at m.
The CAUSE OF DEATH* was as follows:
(Duration) yrs mos, ....J.. dt.
Contributory.^Z^S^r^?^^..'
(secondary) j
(p«ation) .....yr mos f dt.
(Signed)
I9I.S... (Address)„..i(....^
M.D.
* If death followed injury or violence the certificate of death must be made
out by the Medical Examiner.
18 LENGTH OF RESIDENCE (FOR HOSPITALS, INSTITUTIONS, TRANSIENTS, OR
Recent residents).
At place In the
of death yrs. mos. ds. State yrs mos. dss
Where was disease contracted,
If not at place of death?
Former or
usual residence
H PLACE OF BURIAL OR REMOVAL
f f If
'V j t y f /Vi
idertakEr
. vA fp/vx a^
20 UNDERT,
DATE OF BURIAL
i9it
ADDRESS
to S- a
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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.
PLACE OF DEATH
(Enmmtmuieallh of iHaasarbusrtts
STANDARD CERTIFICATE OF DEATH
^iT (o (o
(No...|..().jQ ,
\ X J±U2- l/'JLULX
IQO A
(City or towu.)
[If death occurred in
.St. , Ward) a hospital or institution,
give its NAME instead
of street and number.]
5 FU LL NAME
[If married or divorced woman or widow
give maiden name, also name of husband.]
“RESIDENCE
Registered No.
PERSONAL AND STATISTICAL PARTICULARS
3 SEX 4 COLOR OR. RACE
8 DATE OF BIRTH
2
3 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
( Write the word)
(Month)
(Day)
, I S3*
(Year)
r AGE
^xJC t'cb
,.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)
10 NAME OF
FATHER
UDI ACC t.
11 BIRTHPLACE
OF FATHER
(State or country)
12 MAIDEN NAME
OF MOTHER
>3 BIRTHPLACE
OF MOTHER
(State or country)
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant) .
(Address)
S-'
Filed..
191.
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
48 DATE OF DEATH
(51A/v~ Zk~, 1 9 1 ..ip...
nth) (Day) (Year)
I HEREBY CERTIFY that I have investigated the
death of the deceased.
The CAUSE OF DEATH* was as follows:
.-C^AA/*£o.. ‘f
^ |vJL AyJt
(^C/nru.AAA^
,mos. ds
Contributory..
(secondary)
(Signed)
..(Duration)
mos. ds.
M.D.
*7 (Address)
lA.. \QW> 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.
i8 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
“ UNDERTAKER
DATE OF BURIAL
vLr-\...3 1 9 \&r...
DRESS
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V STANDARD CERTIFICATE OF DEATH
1 PLACS 0F^eATH 7/ A/
( n o . ..-wO
* FULL NAME
[If married or divorced woman-or'Wtdow—
itedhj
(City or town.)
[If death occurred in
Ward) a hospital or institution,
give its NAME instead
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give maiden name, algo name of husband.] .jy.
“RESIDENCE q ft
Registered No.
PERSONAL AND STATISTICAL PARTICULARS
* COLOR OR RACE
6 SINGLE,
MARRIED.
000
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•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)
CO
F
Z
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CL
2/a^i
•« NAME O
FATHE
hpi Ar~p '
h BIRTHPLACE
OP FATHER
(State or country)
12 MAIDEN NAM
MOT
Axy J
HEB *
Lou t . i-i
i» BIRTHPLACE
OF MOTHER
(State or country,
’ir-ZsnS/t///
“THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(bj%Ts<scLpc(j c^4 ;- W,.y
(Informant)
» PLACE OF BURIAL OR REMOVAL
DATE OF BURIAL
JjClaaLidtf I 9 1 fa...
MEDICAL CERTIFICATE OF DEATH
>» DATE OF DEATH
wzmgMgi tfc.. isijfe
lonth) (Day) (Year)
I HEREBY CERTIFY that I attended deceased from
I9l2?_.., to J&yiAs , 191 ,
that/ 1 last saw h H.Sju.. alive on Jfee; . isik.
and that death occurred, on the^date stated above, at wa, m.
The CAUSE OF DEATH* was as follows:
lr\jd&'
CIa£xaA( ^ u 0Q1A-*-
1
..(Duration) yrs.
C o n t r i b u to r y
(secondary)
..(Duration) yr* mot dt.
(Signed) .56202^ M.D.
-Skr.jC..., 191.0... (Adc fress)..
* If deatt
' death followed injury or violence the certificate
Out by the Medical Examiner.
or death must be made
18 LENGTH OF RESIDENCE (FOR HOSPITALS, INSTITUTIONS, TRANSIENTS, OR
Recent Residents).
At place In the
of death. yrs. mos da. State yre mot dtv..„
Where was disease contracted,
If not at place of death 7 -
Former or
usual residence
to
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FULL NAME
COMMONWEALTH OF MASSACHUSETTS
RETURN OF A DEATH-1916.
CYNTHIA MAGEE
CITY OF
BOSTON.
Registered No,
1338
p|ace of Death ) Boston
and Residence \
Date of Death jan. 31
MASS. CHAR. E.&
1916. Age
E. I NF.
65
w J years
5
months
14-
days.
STATISTICAL DETAILS.
PHYSICIAN'S CERTIFICATE.
SEX.
F
Maiden Name
Husband’s Name
Birthplace
Name of
Father
Birthplace
of Father
Maiden Name
of Mother
Birthplace
of Mother
Occupation
Informant
COLOR.
u
SINGLE, MARRIED, WID., DIV.
MAR.
WHITNEY
Wl NTHROP MAGEE
WESTMINSTER
HORACE WHITNEY
WE STM I NSTER
MARY SAWIN
WE STM I NSTER
AT HOME
I HEREBY CERTIFY that I attended deceased during last illness,
from 1 9 1 6, to 1916,
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:
DOUBLE ACoSUPP.MASTOI Dl Tl S
6 WEEKS ( OPR • J AN o 3 & 28 . I 9 I 6 )
Contributory
(Duration)
(Signed)
LOBAR PNEUMONIA - 2 DAYS
C.E. WELLS
M.D.
1916
JAN. 3^
SPECIAL INFORMATION from Hospitals, Institutions, Transients, or Recent
Residents.
Place of Burial
or removal
Undertaker
Wl NTHROP( Wl NTHROP CEM
W.C. SKAGGS
Wl NTHROP
Usual Residence
Filed
A true copy.
Attest :
Wl NTHROP
FEB. 4
1916.
Registrar.
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STANDARD CERTIFICATE OF DEATH
O . SiJ/
(City or town.)
[If death occurred in
a hospital cr institution,
give its NAME instead
of street and number.]
2 FU LL NAME..
[If married or
give maiden nr
PERSONAL AND STATISTICAL PARTICULARS
SEX
< COLOR OR RACE
‘ SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
( Write the word)
8 DATE OF BIRTH
(Month)
(Day)
(Year)
7 AGE
ds.
If LESS than
I day, hrs.
or min. ?
8 OCCUPATION
(a) Trade, profession, or
particular kind of work...
MEDICAL CERTIFICATE OF DEATH
>8 DATE OF DEATH
(Month)
.2
(Day)
., I9I.L
(Year)
I HEREBY CERTIFY that I attended deceased from
"}r.. , 1 9 1 „4_.. > to. XT 1 9$L ,
that I Hst saw h.^rTs.. alive on.. 3JL. i- ~ t i 9 1 1
and that death occurred, on the date stated above, at....^ j> m.
The CAUSE OF DEATH* was as follows : n
4 f) .
(b) General nature of industry,
business, or establishment in
which employed (or employer)...
9 BIRTHPLACE
(State or country)
10 NAME OF
FATHER
11 birthplace
OF FATHER
(State or country)
12 MAIDEN NAME
OF MOTHER
CL--"
is BIRTHPLACE
OF MOTHER
(State or country)
“THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
(Address
Filed..
191.
REGISTRAR
..(Duration) yrs, .
,.mos. ds.
Contributory..
(secondary)
* 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
20 UNDERTAKER
DATE OF BURIAL
.%*. J
191
L
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N- B.— 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 12-'15-XXM1
1 PLACE OF DEATH
Winthrop
( Jfyp (EommomueaUtj of iJtassarfjuitftta
STANDARD CERTIFICATE OF DEATH Winthrop
..(No..
52 Wave Way Ave,.
BOSTON
(City or town.)
[If death occurred in
..St. ; Ward) a hospital or institution,
give its NAME instead
of street and number.]
‘FULL NAME. All06 J.Brlgg,.
^giagi^rggjairi AUc« J.Sreyson wife, of Tyler L.-Brlggs.
give i
“RESIDENCE
52 V/ ave Way Ave, Winthrop,
Registered No.
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
female
« COLOR OR RACE
white
8 SINGLE,
MARRIEO,
WIDOWED,
or DivoRCEomarriecu
(Write the word)
* DATE OF BIRTH
Sept 15 18.66
^ Month) (Day)
I ........
(Year)
t AGE
U.9
4 20
_yrt. mot 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)...
» BIRTHPLACE
(State or country)
Port Richmond N.Y,
10 NAME OF
FATHER
Joseph Greyson
" BIRTHPLACE
OF FATHER
(State or country) England ,
« MAIDEN NAME
OF MOTHER
unknown
1» BIRTHPLACE
OF MOTHER
(State or country)
unknown
“THE ABOVE IS
(Informant)
MY KNOWLEDGE
(Address)
dl 1 *■ ^ ^
Filed.
191.
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
i« DATE OF DEATH
Feto ’4- 1916
(Month)
(Day)
191
(Year)
17
'j-
I HEREBY CERTIFY that I attended deceased from
— ^ ^ . 1916.
1 9 lit..
to
1 9 1
that I last saw i alive on...!.9j^.: , 1 9 1 .
and that death occurred, on the date stated above, .
The CAUSE OF DEATH* was as follows:
Did a surgical operation precede death? . Date
(Duration) yrs. mos. .,
..d*.
C o n t r i b u t o r y ..../.^Sfcck
(secondary) x , .
yrs mos. dr.
^ AO ->
(Signed) ...y’.. 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, Of*
Recent Residents).
At place In the
of death yrs. mos. ,ds. State yra mos. ds._
Where was disease contracted,
If not at place of death 7 -
Former or
usual residence
l» PLACE OF BURIAL OR REMOVAL
Mass • Crematory,
20 UNDERTAKER a
DATS OF BURIAL
\\u
. 1916...
ADDRESS
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STANDARD CERTIFICATE OF DEATH
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‘FULL NAME
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give maiden name, also name of hi
— . rj. *
Jr yfMJt- W
“RESIDENCE
^S%
Registered
PERSONAL AND STATISTICAL PARTICULARS
* SEX
EX s'
&•
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rub
S SINGLE, ^ X
MARRIED, ^Yyis* „ A
WIDOWED, < ‘ <f
OR DIVORCED
( U 'rite the word)
• DATE OF BIRTH
CUJ
<?•
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1
'Sty) (Year)
/
(itfy)
* AGE
— yr». X mot. .da.
If LESS than
I day, hrs.
or min. ?
a OCCUPATION
(a) Trade, profession, or
particular kind of work
(b) General nature of industry,
business, or establishment in
which employed (or emplo>er)
» BIRTHPLACE
(State or country)
w> NAME OF
FATHER
( -TV <
11 BIRTHPLACE
OF FATHER
(State or country)
P
U
IS MAIDEN NAME
OF MOTHER
13 BIRTHPLACE
OF MOTHER
(State or country)
“THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant).
Filed
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
» DATE OF DEATH
(Month)
...V
(i)ayj
191™
(Year)
I WEREBY CERTIFY that I attended deceased from
, |9|C ( X0.'JrA..,..U. 1 9 1 1=..,
that I last saw alive on T.l 4 191.4.,
and that death occurred, on the date stated above, at
.....9™...?..™[S.'f:.tlL5P.^..r.i^'.9.Q..P.r.®9.6.d(L.d.ea.th.' Act? ...Q.a.te.......
JR.... yrs. .
..(Duration) V£....yr«» mo*. ds.
Contributory
(secondary)
ipn) yrs mos.
. ds.
(Signed) .TSc. . . .., M.D.
h. I9l(f..„ (Address),,
* If death followed injury or violence the certificate ef 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 7
Former or
usual residence
» PLACE OF BURIAL OR REMOVAL
DATE OF BURIAL
T2A...L.., \9\fe_
ADDRESS
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STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH
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( N o .
‘FULL NAME.^
[If married oi
give maiden m
“RESIDENC
[If death occurred In
.St. Ward) a hosptta' or institution,
glee its NAME instead
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[If married or divorced woman or widow
give maiden name, also name of husband.]
Registered No.
PERSONAL AND STATISTICAL PARTICULARS
» SEX
* COLOR OR RACE
T
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fED.
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• DATE OF BIRTH
z
(Month)
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(Day)
(Year)
» AGE
...yr*
• Z- mo*- ■/Z*" ds.
If LESS than
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» OCCUPATION
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particular kind of work
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in
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which employed (or employer)...
9 BIRTHPLACE
(State or country)
&
iO NAME OF
FATHER^?y
Jy/zZtu
11 BIRTHPLACE
OF FATHER
(State or country) r—*
A/
IS MAIDEN NAME
OF MOTHER
n BIRTHPLACE
OF MOTHER .
(State or country)
THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
(Address)
Filed.
191.
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
'« DATE OF DEATH
Z. jfc. 191 (4
(Month) (Day) (Year)
I HEREBY CERTIFY that I attended deceased from
I9IjL, to ^ , 1 91 A,
4
191..
(at I last saw alive on. —£6:
and that death occurred, on the date stated above, afc£r Z&.m.
The CAUSE OF DEATH* was as follows :
..(Duration) yrs. ^ mos# }C....ds.
z
..(Duration]
Contributory..
(secondary)
Oration) .yrs mos. da.
(Signed) M-0'
...t&Qr. 4.'.., 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 „.d*.
Where was disease contracted,
If not at place of death 7
Former or
usual residence — —
» PLACE OF BURIAL OR REMOVAL
“ UNDERTAKER
DATE OF BURIAL
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STANDARD CERTIFICATE OF DEATH
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give its NAME instead
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[If married or divorced woman or widow
give maiden name, also name of hosband.j
-RESIDENCE L, TuV
Registered No.
PERSONAL AND STATISTICAL PARTICULARS
* SEX
* COLOR OR RACE
* DATE OF BIRTH
—
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( Write tlie word) "
...0.
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t AGE
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If LESS than
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in
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» BIRTHPLACE
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CO
V/
l» NAME OF
FATHER
6,
MEDICAL CERTIFICATE OF DEATH
>• DATE OF DEATH
(Month)
#Z..., I9lj£a...
(Day) (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.
..mos. ds.
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(secondary)
..(Duration) yrs mos. ,
•1 BIRTHPLACE
OF FATHER
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( s\/ywr
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MAIDEN NAME
OF MOTHER
/y-v ± / t ,
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OF MOTHER ^ *
(State or country)
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
‘ n n M '
(Informant).
(Address) ^ ^
B
/
Filed
191
REGISTRAR
(Signed) M.D.
191.4- (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 yrt. „ mos di..._
Where was disease contracted,
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Former or
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» PLACE OF BURIAL OR REMOVAL
KUj
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DATE OF BURIAL
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STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH
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1 wido>r
(City or town.)
[If death occurred in
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“RESIDENCE
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,.-<zS^. ZZ222?
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“THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant).
<? s?
(Address)
Filed..
191.
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
18 DATE OF DEATH
(Month)
A...... , i9i A.
(Day)
191.
(Year)
I HEREBY CERTIFY that I attended deceased from
191 X , to ,191 4..,
that I last saw h^j._„ alive on... , 1 9 1
and that death occurred, on the date stated above, at m.
The^CAUSE OF DEATH* was as follows
..(Duration) yrs.
..mos. ds.
Contributory
(secondary)
* 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 .da. State yra mos ds.
Where was disease contracted,
If not at place of death 7
Former or
usual residence
» PLACE OF BURIAL OR REMOVAL
2» UNDERTAKER
DATE OF BURIAL
i9i jl
ADDRESS
WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD.
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STANDARD CERTIFICATE OF DEATH
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[If married or divorced woman or wido1
'FULL NAM!
give maiden name, also ume of buaband.J
“RESIDENCE
Wlnifiro-t
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[If death occurred In
t Ward) a hosp'ta' °r institution,
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PERSONAL AND STATISTICAL PARTICULARS
» SEX
* COLOR OR RACE
U/
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-M7
MEDICAL CERTIFICATE OF DEATH
i» DATE OF DEATH
(Month)
£
(Day)
., 191:4
(Year)
• DATE OF BIRTH
-J.
(MTSnth)
,/JL.
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r AGE
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mos ^dTjC?...ds.
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or min. ?
17 I HEREBY CERTIFY that I attended deceased from
I9I.IL, 1 9T&_.. ,
that I last saw h....^... alive on ...AAA^.....AA. , 191.. ^
and that death occurred, on the date stated above,
The CAUSE OF DEATH* was as follows:
Ct^/*svxsd
•OCCUPATION
(a) Trade, profession, or
particular kind of work.....
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business, or establishment in
which employed (or employer)
^ JlcicLr-lsf
9 BIRTHPLACE
(State or country] /)
A A 7a£
>0 NAME OF
FATHER
duration) yrs Sc mos. ds.
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(secondary)
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11 BIRTHPLACE
OF FATHER
(State or country) S
...A (Duration) j.jm
( \^j(j
}±i. .iA. , I9I..C... (Address) kJ.J
(Signed)
(Duration) ^.yrs mos. ds.
M.D.
UP1 f j
* If death followed injury or violence the certificate of death must be made
out by the Medical Examiner.
It MAIDEN NAME
OF MOTHER
1* BIRTHPLACE
OF MOTHER
(State or country)
— i
“THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
rf. '-H
" 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. —
(Informant).,
(Address)
l» PLACE OF BURIAL OR REMOVAL
S> /
Filed..
191
REGISTRAR
a UNDERTAKER
/? ,
DATE OF BURIAL
A- U... I9lik
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STANDARD CERTIFICATE OF DEATH
PLACE OF DEATH
..(No
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(City or town.)
i
(If death occurred in
.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, also name oL huabancL-] .
“RESIDENCE u±t
Registered No.
PERSONAL AND STATISTICAL PARTICULARS
1 SEX
* COLOR JDR RACE
//^y 'Qy&Ur-
6 SINGLE, _
MARRIED, y /
WIDOWED,
OR DIVORCED ^
( Write the word)
• OATE OF BIRTH
I.
(Month)
(Day)
(Year)
f AGE
....... yrs. mos.
..ds.
If LESS than
I day,..:....hrs.
or min.
8 OCCUPATION
V A
(a) Trade, profe
particular kind
oftx.
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(b) General nature of industry,
business, or establishment in
which employed (or employer)..
9 BIRTHPLACE
(State or country)
10 NAME OF
FATHER
u BIRTHPLACE
OF FATHER w£»
(State or countrs# /
It MAIDEN NAME
“ BIRTHPLACE
OF MOTHER
ur muincir .
(State or conn try )C*
MEDICAL CERTIFICATE OF DEATH
10 DATE OF DEATH
(jfcofiiSir)
(Day)
191....,
(Year)
I HEREBY CERTIFY that I attended deceased from
A£L. I9KC„, to.C^T....g 191.4a,
that I last saw fjjfi&tx’alive o n I9l4..,
and that death occurred, on the date stated above, at. m.
The CAUSE OF DEATH* was as follows :
Did/a surgical operation precede death ? Date
/
ContrfButfcry..
(secondary)
..(Duration) yrs.
(Duration) yrs.
d s.
J
tsjTZ.ds.
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
(Informant)
Filed
: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
13 PLACE OF BURIAL OR REMOVAL
DATE OF BURIAL
ADDRESS
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1 PLACE OF DEATH, / r% ^ ^ /) /I
HtfituXTZifiT _ (No 62, AT<_^ ;
(City or town.)
5 FULL NAM
[If married o
give maiden * ‘
[If death occurred in
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(Day)
» AGE
yr«. mos. ds.
If LESS than
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or min. ?
8 OCCUPATION
(a) Trade, profession, or
particular kind of work..
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business, or establishment in
which employed (or employer)
* BIRTHPLACE
(State or country)
cJ'
10 NAME OF
FATHER
\
MEDICAL CERTIFICATE OF DEATH
18 DATE OF DEATH
%J=
(Month)
(Day)
.. 191.
(Year)
I HEREBY CERTIFY that I attended deceased from
V3 isiJL, to 2^6- /c? ,94_.„
that I last saw hiC) alive on 2^3'../...? 191™.....,
and that death occurred, on the date stated above, at/^.T^ m.
The CAUSE QF DEATH* was as follows :
..(Duration) yrs.
L
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u BIRtHRLACE
OF FATHER
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H MAIDEN NAM2“^
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OF MOTHER /&.
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(Informant).
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191.
REGISTRAR
Contributory..
(secondary)
(Duration) yrs.
mos, ds.
(Signed) 1 M.D.
1 9 l L (Address)
* ly death followed injury or violence the certificate of c)bath must he made
out by the Medical Examiner.
18 LENGTH OF RESIDENCE (FOR HOSPITALS, INSTITUTIONS. TRANSIENTS, OR
Recent Residents).
At place In the
of death. yrs mos. ,dt. State yrs mos ds.
Where v/as disease contracted,
If not at place of death 1
Former or
usual residence
i» PLACE OF BURIAL OR REMOVAL
Ao’-.T
DATE OF BURIAL
191
20 UNDERTAKER
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STANDARD CERTIFICATE OF DEATH
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BOSTON
(City or town.)
..(No. ./...SrrA
1 FULL NAME
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give maiden name, also name of husband.]
[If death occurred In
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glee its NAME instead
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PERSONAL AND STATISTICAL PARTICULARS
^ I (Write the word)
t COLOR Of( RACE I 6 SINGLE.
• DATE OF BIRTH
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(Year)
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9 BIRTHPLACE
(State or country)
10 NAME OF
FATHER
jzULq^i
H BIRTHPLACE
OF FATHER''
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1* MAIDEN NAME
OF MOTHER
1* BIRTHPLACE
OF MOTHER
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Z^7, 'i-
“THE ABOVE IS TRUE TO THE BE$? OF MV KNOWLEDGE
(Informant) C//«-JL xJ ;
(Add~4v ,<* -Z:
MEDICAL CERTIFICATE OF DEATH
»• DATE OF DEATH
(Month)
LIT. 191 la.....
(Day) (Year)
I HEREBY CERTIFY that I attended deceased from
™ 191-^., to 1 9 1 (c...,
that I last saw h„*fc»v alive on f / Z TTL, 1 9 1
and that death occurred, on the date stated above, at m.
The CAUSE OF DEATH* was as follows:
UML « IT
Did a surgical operation precede death ?
Date
..(Duration) yrs.
(Duration). yrs. mos. 1 ds.
(Signed) , M.D.
1 9 1 (Address)
* If death followed injury or violence the certificate of death must be mad<!
out by the Medical Examiner.
'* LENGTH OF RESIDENCE (FOR HOSPITALS, INSTITUTIONS, TRANSIENTS, OR
Recent Residents).
At place In the
of death. yrs. mot. .da. State yr*. mot ds..
Where was disease contracted,
If not at place of death?
Former or
usual residence.....
Filed.
191.
Registrar
19 PLACE OF/BUfflAL OR /REMOVAL/7
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20 UNDERTAKER
7
DATE OF BURIAL
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STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH
WHITER OP MASS.
..(No.
34 SIRIN' ST.
..st.
BOSTON
(City or awn.)
[If death occurred in
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give its NAME instead
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1 FULL NAME..
give maiden name, also name of husband
“RESIDENCE
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PERSONAL AND STATISTICAL PARTICULARS
SEX
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* COLOR OR RACE
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WIDOWED,
OR DIVORCED
( Write the word)
• DATE OF BIRTH
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... I
(Year)
* AGE
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If LESS than
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WENT HR OP.
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FATHER
LEWIS BRIER.
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HARBOR Kft&T H.S.
•‘THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
flnformantl
RATHER.
(Address)
34 SIREN ST.
Filed_
191.
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
>« DATE OF DEATH
I 9 I fa.,...
(Day)
(Year)
17 I HEREBY^ CERTIFYnhat I attended deceased from
...5Z^^!.:. 1 9 1 Jl. , to ,191 Cl..,
that I last saw h^ht_ alive on. 191 4.
and that death occurred, on the date stated above, at., m
The CAUSE OF DEATH* was as follows :
Did a surgical operation precede death?
Datp
(Duration) yrs.
..mos ds.
* 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
19 PUCE OF BURIAL OR REMOVAL
LALDE1T, HOLY CROSS.
20 UNDERTAKER
ADDRESS
17 BENNINGtC Oil ST.
DATE OF BURIAL
FEB. 22, 1916
., 191 —
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PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
* SEX
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kfe£
>• DATE OF DEATH
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l> PLACE OF BURIAL OR REMOVAL
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DATE OF BURIAL
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PERSONAL AND STATISTICAL PARTICULARS
* SEX
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14 THE ABOVE IS LBUE TO THE BEST OF MY KNOWLEDGE
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£
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.. 191.
Registrar
MEDICAL CERTIFICATE OF DEATH
1» DATE OF DEATH
7 ^ 7 i9i 4
(Year)
(Month)
(Day)
17 I HEREBY CERTIFY that I attended deceased from
.SL i9iiL, to , 1 9 14_„
that ! last saw h ...jsQ... alive on. 3bA JtfZ 1 9i. A,
and that death occurred, on the date stated above, .
The^CAUSE OF DEATH* was as follows:
..(Duration) yrs.
s. ....^.....d*.
Contributory..
(secondary)
(Duration) yrs mos. ds.
(Signed) M Dr
...J^dC. l9lL?.... (Address)... ^
* If death followed injury or violence the certificate of deith 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?
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usual residence
» PLACE OF BURIAL OR REMOVAL
20 UNDERTAKER
DATE OF BURIAL
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44
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important. See instructions on back of certificate.
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PERSONAL AND STATISTICAL PARTICULARS
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5 SINGLE,
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OR DIVORCED
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11 BIRTHPLACE
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“THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
...... ?&JLoJr Mr
(Address)
MEDICAL CERTIFICATE OF DEATH
i« DATE OF DEATH
M. A/l d > 3
4d±^?. ^ 191
(Month) (Day) (Year)
17 I HEREBY CERTIFY that^) attended deceased from
191.4!, 191.^,
that I last saw h8<3,.. alive on... IdA./S*/. J. , I9li>„
and that death occurred, on the date stated above, at
m.
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..(Duration) yrs. .
..mos. ds.
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(Duration) yrs.
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f 9 1 (Address) Lrec/ L/
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. mos. ds.
, M.D.
* If death followed injury or violence the certificate of death must be made
out by the Medical Examiner.
18 LENGTH OF RESIDENCE (FOR HOSPITALS, INSTITUTIONS, ^TRANSIENTS, OR
Recent Residents).
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of death..tr^C7..yrs. „../Y,.mos. ,c<^J..ds. State ;.yrs mos. ds...
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Rl IDI Al no PPMOVAI * * DATE OP RURIAL
» PLACE OF BURIAL OR REMOVAL
DATE OF BURIAL
... 191.
File^ , I 9 1 <£....
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COMMONWEALTH OF MASSACHUSETTS
FULL NAME
Place of Death
and Residence
Date of Death
CITY OF
RETURN OF A DEATH-1916. BOSTON.
CHARLES E. NOTT Registered No. *745
Boston PETER BENT BRIGHAM HOSPT.
MAR . 5 1916. Age 24 years months 28 days.
STATISTICAL DETAILS.
SEX. COLOR.
M W
Maiden Name
Husband’s Name
Birthplace
Name of
Father
Birthplace
of Father
Maiden Name
of Mother
Birthplace
of Mother
Occupation
Informant
Place of Burial
or removal
Undertaker
SINGLE, MARRIED, WID., DIV.
MAR .
COHASSET
CHARLES E. NOTT
COHASSET
MARY SMALL
COHASSET
salesman (machinist)
COHASSET (CENTRAL C'EM)
W . F . SNOW
COHASSET
PHYSICIAN’S CERTIFICATE.
I HEREBY CERTIFY that I attended deceased during last illness,
from 1916, to 1916,
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:
frac.spine(6th cervical vert)
ASSOCIATED COMPRESSION & SOFTEN
ING SPINAL CORD -SUBSEQUENT
OEDEMA LUNGS & EXHAUSTION -
MACHINERY ACCIDENT
Contributory
(Duration)
(Signed) B* MAGRATH MED. EX,
M.D.
MAR . 6
1916
SPECIAL INFORMATION from Hospitals, Institutions, Transients, or Recent
Residents.
Usual Residence WINTHR0P(2p SOMERSET AV)
Filed
A true copy.
Attest :
MAR. I I
1916.
Registrar.
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1 PLACE OF DEATH
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STANDARD CERTIFICATE OF DEATH
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(If married or divorced woman or widow
give maiden name, also name of husdand.] j9.
“RESIDENCE
BOSTON
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[If death occurred in
.Ward) a hospital or institution,
give its NAME instead
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PERSONAL AND STATISTICAL PARTICULARS
1 SEX
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8 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
( Write the word)
» DATE OF BIRTH
(Month)
(Day)
I-
(Year)
t AGE
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,.ds.
If LESS than
I day. hrs.
or, min. ?
8 OCCUPATION
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particular kind of work....
tc
th L A,
MEDICAL CERTIFICATE OF DEATH
1 QATE OF DEATH
&
(Month)
191 ,6
(Day) (Year)
(b) General nature of industry,
business, or establishment in
which employed (or employer)...
» BIRTHPLACE
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Q
10 NAME OF
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11 BIRTHPLACE
OF FATHER
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' j 11 9
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18 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
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(Addre#) Oy
—
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Filed.
., 191.
/
REGISTRAR
17 I HEREBY CERTIFY that I attended deceased from
1 9 ILL., to.. 1 9 1 JL,
that I last saw h..(aj£-_, alive on .^....^LLLLLLLL!L^....~iS.L^~-.., 1 9 1 ,
and that death occurred, on the date stated above, at :...... m.
The CAUSE OF DEATH* was as follows:
Did a surgical operation precede death? fat Date
Contributory..
(secondary)
(Duration) yrs. ,
..mas d».
(Duration) .yrs mo*. d».
c 7u.y y /7 .( - /? ' ,
(Signed) 1' tA i c/.. KLy-e^A'A OAAt/ ^ , M.D.
& I 9 \A... (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., ,d». State yrs. mos. ds..
Where was disease contracted,
If not at place of death 7
Former or
usual residence —
1» PLACE OF BURIAI* OR REMOVAL
Hit) 7mL
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20 UNDERTAKER
DATE OF BURIAL
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IS
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Registrar
MEDICAL CERTIFICATE OF DEATH
i» DATE OF DEATH
(Month)
i9i.A
(Day) (Year)
17 ^ I HEREBY CERTIFY that I attended deceased from
Z&Z...... Z.rr. 1 9i™.., to I
that I last saw h««^fer alive on 6...ZZ.. , 191^..^,
and that death occurred, on the date stated above, at
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M.D.
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* 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
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of death yrs. mos ds. State yrs mos ds..
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5
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PERSONAL AND STATISTICAL PARTICULARS
* SEX
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“THE ABOVE IS TRUE TO
(Informant)
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
1» DATE OF DEATH
&_ I9I_<L
/v (Month) (Day) (Year)
I HEREBY CERTIFY that I attended deceased from
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... M.D.
Contributory.../^.
(secondary)
(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
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At place In the
of death yrs. mos. ,d«. State yrs. mos. ds..
Where was disease contracted,
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3!!}£ (CummmuuEaltf) of lHassad?notvtto
STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH
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it THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
flnformant ^ '/-tnC*
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(Address)
Filed
191.
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
i» DATE OF DEATH
(Month)
(Day)
., 1 9 1.
(Year)
17 1 HEREBY CERTIFY that I attended deceased from
1 9 \ ft...., to....^^W^...v. g.* 1 9 1 <£..
that I last saw h'l&x^alive on. •?. i.' C.
and that death occurred, on the date stated above, at. ../..Z.GH.rn .
The CAUSE OF DEATH* was as follows:
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[Signed)
,
M.D.
y, 191 (Address),
* If death followed injury or violence the certificate of de/fh 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. moj. ds. State yre mos. ds., — ..
Where was disease contracted,
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Former or
usual residence - —
» PLACE OF BURIAL OR REMOVAL
AO*.
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MEDICAL CERTIFICATE OF DEATH
i« DATE OF DEATH
■AI*lx..c..A u
(Month) (Day)
191^
(Year)
17 I HEREBY CERTIFY that I attended deceased from
J.a 191.4.., to.... // .191 L ,
that I last saw hjca alive on <lJi /.£>. , 1 9 ,
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18 LENGTH OF RESIDENCE (FOR
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HOSPITALS, INSTITUTIONS, TRANSIENTS, OR
In the
ds. State vrs. mos ds.
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» PLACE OF BURIAL OR REMOVAL
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WRITE PLAINLY, WI1H UNFADING INK-THIS IS A PERMANENT RECORD.
ECO
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1 PLACE OF DEATH
2 FULL NAME..
(Cotmtummealtij of fHaBsartjusptts
TANDARD CERTIFICATE OF DEAJH
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give maiden name, also name of husband.]
“RESIDENCE
BOSTON
(City or town.)
[If death occurred in
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girs its NAME instead
of street and number.]
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
4 COLOR OR RACE I 6 MARRilb,
WIOOWED,
„ OR DIVORCED'
. | ( Write the >vord)
• DATE OF BIRTH
(Month)
(Day)
. I
(Year)
» AGE
,.ds.
If LESS than
I day,. hrs.
or min. ?
8 OCCUPATION
(a) Trade, profession, or
particular kind of work.....
''' . : : ’ r
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business, or establishment in
which employed (or employer)...
» BIRTHPLACE
(State or country)
r/
>» NAME OF
FATHER
11 BIRTHPLACE
OF FATHER
(State or country)
12 MAIDEN NAME
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.///&**/ '
19 BIRTHPLACE
OF MOTHER
(State or country)
“THE ABOVE IS TRUE TO THE BEST OF MV KNOWLEDGE
(Informant) ■-/ <■ ; - ' ■' - ~ '
Filed..
191.
REGISTRAR
aa
Registered No.
MEDICAL CERTIFICATE OF DEATH
i« DATE OF DEATH
(Month)
191 J*,...
(Year)
I HEREBY CERTIFY that I attended deceased from
L I9LC. to I9i4„
that 1 last saw hJbn=*»-alive on , 1 9 1
and that death occurred, on the date stated above, at...C..^.<?/|m.
The CAUSE OF DEATH* was as follows:
Q^ucY^c~^Y
Did I .a ‘.surgical ..operatipn precede death? U
Date
(Duration) yrs mos. ds.
M.D.
Contributory
(secondary)
(Duration) yrs mos.
(Signed)
191 L.. (Address)....;2...i'..6ir.
* 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
Where was disease contracted,
If not at place of death 7
Former or
usual residence
12 PLACE OF BURIAL OR REMOVAL
DATE OF BURIAL
/? /? S //^
j- r C-^
, 191
“ UNDERTAKEN
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1 PLACE OF DEATH
CHommimmfaUIj of ftasarljitapttfl
STANDARD CERTIFICATE OF DEATH
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Lynn (No. Lynn .T.ub.ex.c.ul&x- Sa.na.-v St-
!FULL NAME David Whit ft
woman or widow
name of husband.]
Winthrop, Mass.
[If death occurred in
.Ward) a hospital or institution,
give its NAME instead
of street and number.]
[If married or divorced woman or widow
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“THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
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MEDICAL CERTIFICATE OF DEATH
18 DATE OF DEATH
..March 13.^.19.16..
(Month) (Day)
191
(Year)
I HEREBY CERTIFY that I attended deceased from
Led... 5.* i9i.._.6, toMar..,. - 191...6.,
that I last saw h alive on ". 13 I9I..6.,
and that death occurred, on the date stated above, at.yiy^ ,m.
The CAUSE OF DEATH* was as follows:
pulmonary .t.ub.e.r.c.ul.o.ai.a
..(Duration) yrs. ,
..mos. ds.
Contributory..
(secondary)
..(Duration) yrs.
..mos. ds.
(Signed) P..* C... He.vl.in M.D.
Lynn
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?
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‘9 PLACE OF BURIAL OR REMOVAL
Winthrop, Mas3.
20 UNDERTAKER
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Registrar
MEDICAL CERTIFICATE OF DEATH
>« DATE OF DEATH
XI
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MEDICAL CERTIFICATE OF DEATH
>• DATE OF DEATH
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17 I HEREBY CERTIFY that I attended deceased from
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that I last saw h-tg&z- alive on , I9I.<»...„
and that death occurred, on the date stated above, at..^^2r!.!„m.
The CAUSE OF DEATH* was as follows :
(Duration) yrs mos. /L .ds.
Contributory
..(Duration) yrs moi,
(Secondary)
(Signed) M.O.
, (Address)...
* If death followed injury or violence the certificate df 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 mos. ds.._.
Where was disease contracted,
If not at place of death 7
Former or
usual residence _
» PLACE OF BURIAL OR REMOVAL
» UNDERTAKER
DATE OF BURIAL
J... 191 Jz.
ADDRESS
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STANDARD CERTIFICATE OF DEATH
;e of death
’FULL NAME..
42
;'£? /yL
(City or town.)
[If death occurred in
.St. ; 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.] fli.Jn
“RESIDENCE
Registered No.
PERSONAL AND STATISTICAL PARTICULARS
8 SEX
4 COLOR OR RACE
4 SINGLE,
MARRIED,
WIDOWED.
OR DIVORCED *7/5, n
( Write the word) ,
L X
ICED
* DATE OF BIRTH
// - "S’ — t y 1 7
(Month) (Day) (Year)
' AGE
..^..^...yr«e Zrt^...mos.
If LESS than
I day„ hrs.
or min. ?
8 OCCUPATION
(a) Trade, profession, or
particular kind of work
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in
business, or establishment
which employed (or employer)..
9 BIRTHPLACE
(State or country)
># NAME OF
FATHER
~s/
11 BIRTHPLA-
OF FATHEk
(State or country) /
XiASl -
MAIDEN NAME
OF MOTHER
/?
1* BIRTHPLACE
OF MOTHER
(State or
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country) X) 1 . 4. -
14 THE ABOVE IS TRUE TO THE BEST OF MV KNOWLEDGE
(Informant)
(Add,ess) tr* 7
Filed
191.
Registrar
MEDICAL CERTIFICATE OF DEATH
“ DATE OF DEATH
(Month)
h./..., .9I..C-
(Day) (Year)
I HEREBY CERTIFY that I attended deceased from
I9I.^To Uadhj&g/-.* 1 9 1 Jo. ,
that I last saw hJkX/ alive on.. 2tX&be~*. T^Z.r. 1 91. if..,
and that death occurred, on the date stated above, at <r/°. m.
The CAUSE OF DEATH* was as follows:
Contributory
(Duration) yrs.
CkJ&iTm
. mos. ds.
f (Duration) yrs. ,
I Jfl!.., (Address)..
ds.
M.D.
* If death followed injury or violence the certificate ft 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
19 PLACE OF BURIAL OR REMOVAL
=» UNDERTAKER .n /-
4.
DATE OF BURIAL
..cI^ZZ.JxLx- 191^..
ADDRESS
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COMMONWEALTH OF MASSACHUSETTS
CITY OF
RETURN OF A DEATH-1916. BOSTON.
FULL NAME
CATHER 1 NE
COUGHLI N
Registered
No, 35 | 3
Place of Death 1
and Residence )
Boston
1 NFANTrS
HOSP
Date of Death
MAR 27
1916. Age
years 3
months 2 7 days.
STATISTICAL DETAILS.
SEX.
F
Maiden Name
Husband’s Name
Birthplace
Name of
Father
Birthplace
of Father
Maiden Name
of Mother
Birthplace
of Mother
COLOR.
W
SINGLE, MARRIED, WID., DIV.
S I N
WINTHROP MASS
JOHN J COUGHLIN Yo%',„
EAST BOSTON MASS
FRANCES L SHEFFIELD
ESAT BOSTON MASS
I HEREBY CERTIFY that I attended deceased during last illness,
from 1 9 1 6, to 1916,
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:
RETRO-PHARYNGEAL ABSCESS
(5 DS. )
PHYSICIAN’S CERTIFICATE.
Contributory •
(Duration)
(Signed)
GEN SEPTICAEMIA
( 2DS.)
J I GROVER
M.D.
Occupation
Informant
Place of Burial
or removal
Undertaker
MAR 28 1916
SPECIAL INFORMATION from Hospitals, Institutions, Transients, or Recent
Residents.
WOODLAWN CEM, EVERETT
J F O’MALEY WINTHROP
Usual Residence WINTHROP (8 EDGEHILL RO, )
Filed MARCH 3 I '9|6-
Registrar.
Every item of information should be carefully supplied. AGE should be stated EXACTLY. PHYSICIANS should state
CAUSE OF DEATH in plain terms, so that it may be properly classified. Exact statement of OCCUPATION is very
important. See instructions on back of certificate.
dip GJommmtuipalttj nf iKaasarljus^ttB
STANDARD CERTIFICATE OF DEATH
°F
8 FULL NAM
[If married or divorced woman or widow
give maiden name, also name of husband.]
v\
..Ward)
(City or vown.)
[If death occurred in
a hospital or Institution,
give its NAME instead
of street and number.]
.RtaiOENCE^^
Registered No.
I.
00*
z
PERSONAL AND STATISTICAL PARTICULARS
1 SEX
< COLOR OR RACE
6 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
( Write the A’ord)
• DATE OF BIRTH
X
(Month)
' AGE
„ y
ds.
If LESS than
I day,. hrs.
or min. ?
8 OCCUPATION
(a) Trade, profession, or
particular kind of work /.Z.&.
(b) General nature of industry,
business, or establishment In
which employed (or employer)...
» BIRTHPLACE
(State or country]
W NAME OF
FATHER /ft /7
11 BIRTHPLACE
OF FATHER
(State or country) ^ /
19 MAIDEN NAME '
OF MOTHER _
JLL^
** BIRTHPLACE // -. . . „
(State or wintry)
“THE ABOVE IS TRUE TO THE BEST Of MY KNOWLEDGE
(Informant) 7/, t ^
(Address)
Filed ., 191.
Registrar
MEDICAL CERTIFICATE OF DEATH
i« DATE OF DEATH
(Month)
(Day)
., 191 L
(Year)
17 I HEREBY CERTIFY that I attended deceased from
f.. I9li,.., to 2w^... .191 L ,
that I last saw h..fc^.. alive on 'U* ^Jr'.... , 19 1.4„,
and that death occurred, on the dale stated above,
The CAUSE OF DEATH* was as follows:
.&C.J
...C _
LJ /
(Duration) yrs. mos. ..x'./ ds.
Contributory..
(Secondary)
.mos ds.
u r atioftl yrs
(Signed) (- v M.o.
X7T
* 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 yra mos. ds....
Where was disease contracted,
if not at place of death ?
Former or
usual residence
l» PLACE OF BURIAL OR REMOVAL
2L
to UNDERTAKER
US. Ce.
DATE OF BURIAL
191.4-.
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STANDARD CERTIFICATE OF DEATH
SA
(No.
Jl /
.St.
’FULL NAME..
[If married or divorced woman oirfyidow
give maiden name, also name of ilusband.J
“RESIDENCE
(City or town.)
[If death occurred in
..Ward) a hosp'tal or institution,
gwe its NAME instead
of street and number.]
-
Registered No.
^ m
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PERSONAL AND STATISTICAL PARTICULARS
»SEX < COLOR OR RACE * MARRIED, /
UAfO&L \ UrZZCti OR^IVORC^4^^
)/ 1 v I A ( Write the ivord)
• DATE OF BIRTH ^ - - O 9
2- A. J*A
(Month) (Day) (Year)
» AGE
.T... yr«. T.. mot. ds.
If LESS than
I day* hrs.
or min. ?
8 OCCUPATION
(a) Trade, profession, or
particular kind of work
(b) General nature of industry,
business, or establishment in
which employed (or employer)...'.
3 BIRTHPLACE
(State or country'
» BIRtA^tACE
OF FATHER
(State or country]
12 MAIDEN name-7
OF MOTHE
“ BIRTHPLACE
OF MOTHER
(State or country)
7p T
^ S-
“THE ABOVE IS TRUE TO THE BEST OF MV KNOWLEDGE
(Informant).
(Address)
Filed..
191.
Registrar
MEDICAL CERTIFICATE OF DEATH
10 DATE OF DEATH
.h*A 2:.$.. , 1 91. .4
(Month) (Day) (Year)
17 I HEREBY CERTIFY that I attended deceased from
IS-.11 - 'S' . to OyA..y..^. , I9I&..,
that I last saw hjY)... alive on , I9l.£....,
and that death occurred, on the date stated above, at
The CAUSE OF DEATH* was as follows:
..(Duration) ....vj> yrs. mos. .
..di.
Contributory..
(secondary)
(Signed)
7»
.. (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. moa. ds. State yrs. mos ds,
Where was disease contracted,
If not at place of death?
Former or
usual residence.. .
•» PLACE OF BURIAL OR REMOVAL
DATE OF BURIAL
^ 3 o
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“UNDERTAKER
•sT-yf
191.
ADDRESS
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2.
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
Male
4 COLOR OR RACE
White
3 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
( Write the word)
Single
* DATE OF BIRTH
December 28
. ,S6i
(Month) ( Day)
(Yhar)
7 AGE
If LESS than
1 day, hrs.
pl yrs. 3
mos. 2- ds.
or min. ?
mi offje (fommumuealtlj of fHasaarhusptts
STANDARD CERTIFICATE OF DEATH
PLACE OF DEATH
Newt on. Mass, t N Q. 6l Central
St.
City of Newton
(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 i
give maiden nat
"RESIDENCE
[If married or divorced woman or widow-
give maiden naine, aiso name of husband.]
Roebuck S « Cor dingle y
i or widow
' husband.]
Winthrop, Mass.
Registered No. 155
MEDICAL CERTIFICATE OF DEATH
14 DATE OF DEATH
March. 30. 1 91. 6
(Month) (Day) (Year)
8 OCCUPATION
(a) Trade, profession, or
particular kind of work.. .
Druggi st
(b) General nature of industry,
business, or establishment in
which employed (or employer)
3 BIRTHPLACE
(State or country)
(City or Town)
Boston, Mass.
13 NAME OF
FATHER
Frank Cordinglsy
Cfl
H
Z
Ui
“ BIRTHPLACE
OF FATHER
(State or country)
(City or Town)
Heckmondwlke , England
<
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13 MAIDEN NAME
OF MOTHER
Maria W. Oddy
13 BIRTHPLACE
OF MOTHER .....
(State or country) i1-'1*!'
L,^ sda , England
17 I HEREBY CERTIFY that I attended deceased from
Mar. 25. 19$ , to Mar. 30 . 1916 .
that I last saw h. im alive on Mar, 30 , :9i6 ,
and that death occurred, on the date stated above, a(> *
The CAUSE OF DEATH* was as follows :
Lobar Pneumonia
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
(Addre
Mrs. E.E.B. Johnson
qT Centra
Fifed •?
.'20.
. 7 or 8 days
(Duration) .. yrs. mbs. ds.
contributory.Myooardi ti s m. nephritis
(secondary)
(Duration).,..^ ...yrs, mos. ds.
(Signed) C, .?., Hutchinson , m.d.
Mar, 30 (Address). Auburn dal 3, Mass..
* 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
3. Me/.ton Cemetery
DATE OF BURIAL
Apr .1
191.
20 U
Cate
ADDRESS
W. Newt on. Mass
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Board of Health. City of Newton. The within return counter-signed and approved
this day of
191
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TKAx^WTfc'UJiJYLIT
Authorized by the State Board of Embalmers
Q
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County of.
Town of...
1 PLACE OF DEATH
•^.n Diesro
(Ealifarttia g»tatp Hoard of ^raltlj
BUREAU OF VITAL STATISTICS
STANDARD CERTIFICATE OF DEATH
State Index No._
Local Registered No..
or Spn Di ncrr)
City of....^....£L...tr.:LV.....y
[If death occurred In a
No - St.,— 4 (Dist.) lSSPiWMEte“nsherte
and number, and fill cut
Nos. 18a and 18b.]
2 full NAME. -
PERSONAL AND STATISTICAL PARTICULARS
-SEX
Ivba. 1 g
‘COLOR OR RACE
WMte
6 Single
Mamed O ingle
Widowed
or Divorced
(Writs the word)
<
c n
co
X
H
U
z
o
z
5
<
Uh
z
D
“ HUSBAND Or
•i’ WIFE OF
* DATE OF BIRTH
-Dec . .25 r 1316
1
(Month) (Day)
(Year)
1 AGE
If LESS th^|
I day, hrs.
.'..^ears ?L months __ days
or min?
MEDICAL CERTIFICATE OF DEATH
“ DATE OF DEATH
— 191—
(Month) (Day) (Tear)
I Hereby Certify, That I attended deceased from
— -.191-6, to„iairjJ.__^ 191.6.
that I last saw h.j-JIL alive on ei/2 ?1 i_l_ _ 1 .* 191.6.
(a) Trade, profession, or ‘ 0
particular kind of work-.— —
o’ervic
(b) General nature of industry,
business, or establishment in
which employed (or employer) .
BIRTHPLACE
(State or country)
iLfeSS
X
H
5
Z
10 NAME OF
FATHER
11 BIRTHPLACE
OF FATHER
(State or country)
^hon Doherty
'«T»t}DEN~NA~Mt~
OF MOTHER
Uia'-~no n
Ununown
BIRTHPLACE
OF MOTHER
(State or country)
3
CL
\?a mom
,8“ LENGTH OF RESIDENCE f
9 &
At Place of Death years months days
(Primay registration district)
bi
H
06
£
2
In California 'A years months .days
“THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Inform ait). _'A Q.ij?
(Address) -
Filed.
Registrar
‘and that death occurred on the date stated above a4-i_~U-_km
The Cause of Death * was as follows :
3 y o.ro.br'.l linrl Jenin-it is
. (Duration) years.
...
.months.
.days
Contributory
(Duration) years.
State whether attributed to dangerous or
insanitary conditions of employment
-months days
(Signed) Jr « ~ . Q.c; C»t. nn
-M. D.
■Qcyi
‘State the DISEASE CAUSING DEATH, or. In deaths from VIOLENT CAUSES,
state (1) MEANS OF INJURY: and (2) whether (probably) ACCIDENTAL, SUI-
CIDAL. • or HOMICIDAL.
18b SPECIAL INFORMATION for Hospitals,
Institutions, Transients or Recen
t Residents
Where was disease contracted.
if not at Diace of death?
Former or
usual residence
»» PLACE OF REMOVAL
DATE OF REMOVAL
intihor'o , i.ias's *
191...
=» UNDERTAKER , r ^ ^ ^
cc . oo lim n
ADDRESS
can Diego
( J^OOAt. REGISTRAR’S PERMIT FOR REMOVAL
N. B. — This Permit can-be signed only by the Local Registrar (Deputy or Subregistrar) of the Primary Registration District (Freeholders
Charter City, or other City or Incorporated Town, or Rural Portion of a County) in which the death occurred after the FILING and acceptance
of a COMPLETE AND CORRECT CERTIFICATE OF DEATH LEGIBLY WRITTEN IN DPR ABLE BLACK INK.
A CERTIFICATE OF DEATH having been presented to me containing the above stated particulars, and after examination the same appear
ing to be COMPLETE, CORRECT AND SATISFACTORY AS REQUIRED BY LAW (Statutes of California, 1915, Chapter 378, page 575
and Chapter 71, page 80) I have filed it with the above stated LOCAL REGISTERED NUMBER*, and on the basis thereof I HEREBY GRANT
A PERMIT to the above named undertaker for the REMOVAL of the body of said deceased person as stated above. Jn the case of death from
dangerous or communicable disease, the burial or removal must be conducted according
itate and local boards of health.
Dated .../....I.TT 191. i^t
- --Or J,-''!. A. -2^,.
TS1 • . * •A'V- Clerk.
This permit is sufficient for the removal of a body to destination as above indicated (subject to local cemetery or other regulations).
L* Local registered number may be omitted from Permit for certificate filed only with Subregistrar at place distant from county seat, but
Permit must then -6how uame of Local Registrar by whom Subregistrar was appointed and to whom certificate must be forthwith forwarded.]
ENDORSEMENT OF SEXTON OB FEBSON IN CHARGE OF PREMISES ON W&£CH INTERMENTS OR CREMATIONS ARE MADE.
Date of interment or cremation 191.
■% » (Strike out word not used)
(7
(Signature of person in charge of Cemetery, Crematorium, etc.)
Persons in charge
he undertaker
TEN (1
i
(Name of Cemetery, Crematorium, etc.)
lust return this Permit to Local Registrar of his district within ten (10) (law from above date. If no person is in charge
v-Jlie above statement, writing across the face of the Permit the words ‘ ‘ n<» uirson" in charge’' and FILE PERMIT WITH-
with Registrar in the district in which the cemetery is located.
TRANSPORTATION RULES
Adopted by the California State Board of Embalmers pursuant to Statutes
of California, 1915, Chapter 71, page 80.
Rule 1. The transportation of bodies dead of smallpox, bubonic plague,
Asiatic cholera, yellow fever, typhus fever, diphtheria (membranous croup),
scarlet fever (scarletina, scarlet rash), erysipelas, glanders, anthrax or lep-
rosy, shall not be accepted for transportation unless prepared for shipment
by being thoroughly disinfected by (a) arterial and cavity injection with an
approved disinfecting fluid containing not less than fourteen (14%) per-
cent of 40% formaldehyde solution, and that the amount of fluid injected
must not be less than one-thirteenth (1/13) of the body weight; (b) dis-
infection and stopping all orifices with absorbent cotton, and, (c) washing
the body with the disinfectant. After being disinfected as above, such
body shall be completely wrapped in a sheet securely fastened, and en-
cased in an airtight zinc, tin, copper or lead lined coffin or casket, all
joints hermetically sealed, or in a coffin or casket enclosed in a tin or
zinc lined box, all joints and seams hermetically sealed.
Rule 2. The bodies of those dead from any cause not stated in
Rule 1 may be received for transportation when encased in a sound coffin
or casket and enclosed in a strong outside wooden box. The body must
be prepared for shipment by arterial and cavity injection with an ap-
proved disinfecting fluid containing not less than 5% of 40% formalde-
hyde solution, the amount of fluid injected not to be less than one-
thirteenth (1/13) of the body weight; stopping all orifices with absorbent
cotton and washing the exterior of the body with the disinfection fluid.
RUI.B 3. No body shall be received for transportation unless having
been prepared by a licensed embalmer holding a valid license in the State
of California.
Rule 4. In the shipment of bodies dead from any contagious disease
named in Rule 1, the 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; and, before
selling passage tickets, agents shall carefully examine the transit permit
and note the name of the puaii in charge, and any other persons accom-
panying the body, and see 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 auThe text goes on. The rest is in the file.