The volume, 1919–1921
Town Clerk, Winthrop · from the Internet Archive · 1190 pages · 113.3 MB
open the file ↗ · original at the source ↗
I
1
\
t
■WRITE PLAINLY, WITH UNFADING INK-THIS 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.
I
ca
Z
©fj? (Sornuumturattlj oi ,u.
.a
lNDARD certificate of death
State
Registered .Sf..
ST/\ INUAKU LLKIIfU-Alt. CJU UtAIM (City ox- towii)y
1 PLACE OF
County.:
Township tfV /JMs/ or Village or
City No., At , St, Ward
(If death occurred in a hospital or institution, give its name instead of street and number)
^ s? g (if in the Army or Navy of the United States, give rank, organization, etc.)
(a) Residence. Nof. St., Ward
(Usual place of abode) . _ _ (If non-resident give city or town ami State)
Length of residence in city or town where death occurred J_ years months days. How long in U. S., if of foreign birth? years months days
2 FULL NAME <
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
4 COLOR OR RACE
5 SINGLE, HARRIED, WIDOWED. OR
(writeihe word)
5a If married, widowed, or divorced
HUSBAND of
(or) WIFE of
6 DATE OF BIRTH (month, day, and year) , /Ja
7 AGE Years
32-
Months ^
/ /
Days
JJ
If LESS than
L day, Jtrs.
or jnin.
8 OCCUPATION OF DECEASED
fa) Trade, profession, or
particular kind of work.
(b) General nature of industry,
business, or establishment ij
which employed (or emploj
(c) Name of employer
9 BIRTHPLACE (city or town)..
(State or country)
14
15
10 NAME OF FAT!
11 BIRTHPLACE O
(State or country
12 MAIDEN NAME OF MOTH
(city or town)
13 BIRTHPLACE OF MOTHER (city or town)..
Inforxna
(Address) < i •
Fiied":..:„ i9/J.
Registrar
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH (month, day, and year) £
19
A
17
1 HEREBY CERTIFY, That I attended deceased from
, i9 to... 'k*r*v. 2t. i9>^
that I last saw alive on , .
and that death occurred, on the date stated above, at
The CAUSE OF DEATH* was as follows:
.(duration) yrs mos.
S'
ds.
CONTRIBUTORY
(secondary)
IS Where was disease contracted
if not at place of death?
(duration) yrs. mos..
Did an operation precede death ? Date of..
Was there an autopsy?.... Ziktaa
What test confirmed diagnosis?..
VJi
.(Signed , f
, 19/? (Address) J% L ^ Y , .
ATH,4$r i
H.D.
* State the Disease Causing Death, ^r in deaths from Violent Causes, t
state (1) Means and Nature of Injury, and (2) whether Accidental,
Suicidal, or Homicidal. (See reverse side for additional space.)
19 PLACE OF BURIAL, CREMATION, OR REMOVAL
20 UNDERTAKER
DATE OF BURIAL
1U»^ 5 19 /?
ADDRESS
termine definitely. Examples: Accidental drowning;
Struck by railway train — accident; Revolver wound of
head — homicide; Poisoned by carbolic acid — probably
suicide. The nature of the injury, as fracture of skull,
and consequences (e. g., sepsis, tetanus) may be stated
o g O a cr®
H ji “• > — ~-
gzp'-'o
° 50 sr.p o •
? h S J 5 5
r 1 1 |.g*i
o c
*3
to 5. £S ;S
^ §-:3 “
§ -°Ip\p
„ S. e
P p c ® P
co p -j CD ~ rr
^■p p
S.pgf sp
?g p oq*S=
~s; p a.
& . ^ £ > W
; S M P
Q O CD ^ *1
i— O Cc CD
-.§§5-3 8
S 5 O 111
to £ H P-
2.- > o' a'
"tn B ^ ~ 2
® d S b -B
6 gtra PI tr
5-B «s rs=
J g l-S g
1 '■»£• =g.
a ' „P
3 Op - =
„ o'— ;0
55 ^2 tngo
c-p » » 3 3
§!? %
»?°oP3
P o, a, 5^ e S-
tg vctr fc-sr
CD ~ ^ p W O
o °S - o §
p ^ HP p
p p o
CJ o P.PL.
tr^f pQ p"
!9 g WB
3 P^ 5 ..
p P-P t -
to P p - 33 !>.
o -^P. £.5-
o -2- CTS,
3. o' d — o
g | -p ^
^ =* •
cl Wg S | to
0 1 $ 3f.<§
“IBS §>I g
. 5CS-R o
° S.?.""-S 0*3
P ^ §5 o R —,3-
S'
-i a S 2. • S. -•
3 o £.5' *8 .
S'§ ~§ oS R ~
p a.05 p
-SSS S §13 g
nJS'§ „ s*E ®
Sc-c o.g § 3 ®
Bi®? o?E^h.
tu 5 o a.
f !*•§>£. 3S§£
§ o-® 2 s-<|-n o-a
On o ffi
" p §
3 O
P C
B
» 5's.# Be
??§•-«! < to S' B-.»
lei's I* §
S-S
i n a?s
‘2 £.?g I 2.SS 5s s p
a" o-?2 .
® 3 ^e p P P
^ w. rr» »—
- CD
. 3 |
:• ~ 3
5 CT-* F« 5 *
stLg>
to,® g- ft-P £
c e
^ I h2.“1| % P
-R P
a^Sogp
CR£-
g .
“oPg'Po
J 3 e S p
s < a-g.
o 2 S ® j
cSp o ofljv
pP- 5 p?5®
“ 2 !®»ao
2-
» ® ■ 3 o
£1® tC’O ii
§ ” § 3-k*
r’B S-r -
v’O O (Tt- pj
-2-a
s ® 3 psP ® “ p
- a'c.g 51“ g^3?
~ 2,5.0® ?•
:o |g P
O? 3
H
~S 52^ sS! 0 iss s'5
“‘|‘S o'™
__ _ 2- ©■'•T*
2 5 ■ g 2 a 22." S P P.P o ;
B
£ ’"r“n 2" R
Si g-s p*“ r
§ s ® z g p ■§
^ o-q 3 ® 5. _
R"^ 5>Mn^iSpS'!::r o*S"^'
p3§S5'lS§2QBu §-g-° o_- O'
e I3 § 3 I O OJ3 S !•§ ^ 3 3^n
^ g.S-KB^”’S's | '“*3 3* 3
"f - s to o, rv*3 o O ; s,S P
0‘® !
Hr^ 1
x p R"
g|S^&-S88gs-
5.|l 3?S g-S§ 2
Ep°s02'R5p^2
Spo- eP^-.R_~<g
nP-o * Si- 2 .St S
3 p pr3 ® e g.
s-ge-o ®pT
0 3 53- §
o 3 o'- 3 ^ 3 g 9 §
"oa = 5p|S
O
2
L'C
3 g'-S’ • -a' p $ S 3°
55 S-^ S'? o
p "s'5' i ^ — o p §■ §
&K*'lf®3B!t
I:rsbi- mm
s. . —,
c p P
2- 2
'P
>s
3 p p cr£ o a-:
2 o s 2I.2 1
33-303®
5-i- =fl
p
•R ®
•5 p
o hj i-s g. R
' PS g*
®
P. <th 1 '-JSCcroi~,P -! s « u
ji os P R o 2 ® E— P-2tI?t~itI> ptS.fP-S:®'
5 a c*- P g_ to P-J3 SR» 2
2.-; m® • s-o _P P Sir o*rt 2 3 O
sr^-“ocrq po's-“gw®o3,pp,o^s
® !>tcs 8 3 «-s;i
- 2#d- e-S-S tj- R
g 3 p & IB P I
§ OP S ^ _
SB P g § ?Q®
P 9 .||;^ ® §B
P o rr, ^ u ~ 3 *-J
2.5:3-13 rl E IB.
aa^e, *• P -1®
XT . . 0 5?* *‘2* k-J ^
S.'C n
CD P
3
O •a
P-g
«r+- <*•
V-'I'S
d o
® 3 e+
O 5-a ^ Ej
^ cr- o c* C* ^ B
sr- 3 ^ O E3
. A- I CD ^ CD
^5*8=.
gg’^p
:o ase
_ay; — p-P;1! "So 2S P
§8;ao ’2--® p* O- s. 2. > B«s &3 B
p _ i-i- . . o . ®P a> - ^ • R =
-— ^ — ' c- S IT*- JT '
Bb'®5^o<h^
tr o ■p §t 0 §V*
CD S
d- P
5 rt-p # p tj3 ° B. 3
- T A2 rr> T >-t 5S*5S id ^
o-S
— orE
2Sp-^I- » -f
- ® s'^jp h;o
<7*. S
oi CD
BH1 -ii; 1 loti'll ?! mmtl fill
E 5 £5 6^6 p.S.gJ si g g g
^ B P.^-
cr £-3
o
3 g 5
W O CD
X S o O* 5 CD
CD p. O ** *_< p k-»
6 T'js S>3 o'? STi^P cd 9 co
CD CD
p3
(Tt- «;
a.S'g 'ZB “ s*§
^ c p <3 ? ?<3 S2.R
-WRITE PLAINLY, WITH UNFADING INK-THIS 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.
©If? (Enmuumujpaltl; of Massarljitsdte
STANDARD CERTIFICATE OF DEATH
BOSTON
(City or town)
State Mm.J . Registered No
PLACE OF DEATH
County
or Village
Township
City
No. , ^ St, Ward
(If death occurred in a hospital or institution, give its name instead of street and number)
FULL NAME
(a) Residence. No.
(Usual place of abode)
Length of residence in city or town where death occurred
it.}... i-Ward
. . ■>%' (If non-resident give city or town and State)
How long in D. S., if of foreign birth? years months days
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
5 SINGLE. MARRIED, WIDOWED. OR
DIVORCED {write the word)
4 COLOR OR RACE
16 DATE OF DEATH (month, day, and yeaj
That I attended deceased from
and that death occurred, on the date stated above, at
The CAUSE OF DEATH* was as follows:
8 OCCUPATION OF DECEASED
(a) Trade, profession, of . ^
particular kind of work r
(duration)
(b) General nature of industry,
business, or establishment in
which employed (or employer) .
(c) Name of employer
CONTRIBUTORY
(secondary)
.(duration)
18 Where was disease contracted
if not at place of death ?
9 BIRTHPLACE (city or town]
(State or country)
Did an operation precede death?
10 NAME OF FATHE1
Was there an autopsy?.
11 BIRTHPLACE OF FATHER (city or town)
(State or country) S
What test confirmed diagnosis?
(Signed)
12 MAIDEN NAME OF MO'
* State the Disease Causjrg Death, ofum^eaths from Violent Causes,
state (1) Weans and Nature of Injurt, and (2) whether Accidental,
Suicidal, or Homicidal. (See reverse side for additional space.)
13 BIRTHPLACE OF MOTHER (city or to
(State or country)
19 PLACE OF BURIAL, CREMATION, OR REMOVAL
DATE OF BURIAL
Informant
(Address)
20 UNDERTAKER
Filed
5a If married, widowed, or divorced
HUSBAND of /
(or) WIFE of ^
6 DATE OF BIRTH (month, day, and / y/r /<f
7 AGE Years
Months
Days
If LESS than
1 day Jirs.
or .min.
to
z
lS-XXM
§ g f'iSts 2 w
sB2i^b5sm.3 k o h
P’S ss °
P ®p o
cn ^ . P* P- p; C2
p S p <<i
“ &2 ® p-p ® g g 3
S.P3 ap.-P.Q
- T* ^ ?*• O
S.®.^-5 Q^S « 5
a p 5s- — c^-p
s 3
. EL ^ , , Th' o' 0-<P ^ fa Ej.* r^- H
fe“H2-3 o’g-f ® Sto?
tr
p
<23
-CD
0 P
1 °
O O
■ ,-. p
rt-O ® O «l O
5*e 2 BJg."
g <5 o
£ ?•»
Bp g-S n3,
2 ITs'S p
2° g\Q 5)p -r-
gL. sjr c 5 - - ~P
«-"&§•' a 3
og^„ .= 2 * O.®
2.o
■3 <<
^-p-o£V§'® &
o
• 3
'C
?6§.n
B;° - W
^ aoif » £?<2
sp S-P-5 033
P '0s a 2 ^ J0 P
o«< *8 _ |§ 3 i ^
O'* <-a “ n s ci- f- j -v" ^
i *0
o
■s ■ sobdd^&iiso^
i"o
^ o' 3
— i'Cfo 2-"-- << Pd S' a co -OR
S'S.'S 8. 2 ® ., o 322 o hs p
“ p R.?. P p, 1 o 0 § H S ;OSj
<$ 2 2,“.PWf5{3<-j S~-o'
S.H S 8. F > 5 g > ® rr B p§ -' -
“ <?-- tB* 0 SSNo2 ^
£ro ® 2 §• s"S “Cpo
cr* o
‘ S
►1 a m.q
■-^Oai2
o ^X
P ~ _
m r-
g-n>
- ^ H WCR ’d
.5 “.£p S'
-s wj p 5-3
dl =gSs
§ •= HU^ ^
o 5
_ P
, CD & P O _ -w, , o ^ a
M ST.nn^ 2o 2,P
P n trv
^ Bp
p m
^III
p-p 2
1 B
__;] O
Is
>-a ©
O ci-
fi* ~
C O
M X
l*
o
?|.go*g
S 3 3 on .
2 2!
as*
p
o « p _p ”*0 P P'S p'p'O H1" p
g‘ SS o^S- a.HtF§ p.a'2-o 2^“ S^p
“ 25'^ o S-S $ § “ &® 2 S^g
slt^lio.'.®-8 Rl-OK"
O Q
» <
•+ m
. ° A .
S. S > p ^
5*. 3 H g O
So-.wlr
a. P CP -
p
oo j p
s'S*'^ 2.0
‘ 3^'< 3
P o
^ p-P s' 4
e-ofc-l-
e-a B B g
o- o < ^ 5 s
^ ^ O $ ts « p 3
. ** co 3- — . • • .f!
CS) «-*- C’
. -i O
3
p" S ^
- H P-
2 p-;
O 53
M®
a ^ . o w w
^F-’gpg^ff
3 » c p i 3
a*-"*- g 0*3 8 i
g 2 §•< 3-
O
P
^ P-O p CO g.
»^'P2U o
3 3.mB § I
s i 2
o-^ p
CD t3
o S.2
» £3
p
^0 co 3
O P
S S a ® §..3
■ "III
p 2 g.3 2.
® <3 sjU _
r--^ ® O g
-1 s
f 2
■ ^8 ^e.-o « §
K-s P o 2 p g'
.0-0
CD
S.ftO'p'g 2 ^ 3
B p o 2 s pu 2 cr
cr
“o^SS „
m„ds5?o
£• P p* S C*>
a~au?. ■ "
<! ra 5
I p s5 HS-'g.
-j- ^ S' a ~>5 S3
rs O^ ^ a* v. 0 CD _?1 O^ s*—
^-ir-7? a ^ -O q^cd -
ro C w m sg
g hdo S S
d Fid O
“ S a
dm d 3
O 3
- E P- 1
X. : ^ g. ^ a
o “ H-^oi p 3
CP crl O . rn w
o'OqS.
*-< n C3
g l.t'p
eg S*-.^ s'- g
|§ tel 2 U51
g<^ ll5-Il g
1‘i |b l&u®
•- -V 9 e+ *? O O
^ * I c-x'Q
^-j "'o 2 P
5 3 :o ® g
2 p r-,0 2“ffl
P p O-s S
3 m 3 P g p
P 3 O o'.g p
1 H.g.US §>§
s P p -‘O R
£ ^ g
- - K3-
p p
2 >
F ?
•-.?
(5*0
ag
3- 3-
oio ^
p £ p
P
O P p-'P
P P o
<n- 3 o
■5 S p
^ O Q w N •
q p cr- u
2. 01 a £.3 £f o
I 1 "i P« l CD a
05 p S- 2 O t» P-W ^ S P
vjMP^S-O PJoScr
?.®^rto p EpM » P
a:" ®
e 3 p Jt 2 2
CR Co d*
iS P CD °5
SCR P 2 S
a S^oEFPa
p - M. Op
^p^pgus^a:
o p^ d P p-“§ o-§ 2 ®
X a-rjq o c 2 - ^ ^
w cd a* 0
J, o
r- C _
c- a i=J o
3 „ y 3 p ? co <5 2 o
“ o '"’3 pcD(1 o S' '2
3 P g o p &' ^ P S
b^® 8,^81 fig
o c a
3
o 3s P CO
S.e.B*o
« 1 a i
p i__i
cl- “
&"p Ho S 3 o s
'":§£!i*%Kg's3ir~-
s'i < = * s ~-=sag
CD
O-g -
1 ^ p-M ^ 2. 3
p P -.
0 S'
CD
r* 2 o ^ '>2m ty * &■
CD
20 s p & co
Bxr “erg
pi p ST. p 2
S-- g P.5-
p
P B
O
a odB ^ p g 3-
^22.c,"c«-"22ai2®
3^5 n 3 2"U ti. JL
o T'cr ° » n ? P
sI^IhI'^s^b-Ss" £
§ u:
55 <
CLC.
-o
a p g- 2* ^ w s- 5" p
3 » ? S pp S'5 3
b* P
2 rt-n-f ^ w^3
?SeT!2h 2, E=3 f
=>§
I bft.O w?
5, a p
^On S co
a P °
ORM R-301
L = I
r12
£ Q
<2 <±
c O
“
o co
E <
2 o
. ®
>.
- ea
> —
LU -a
I-
<
O-
1 . m
«£
< a.
2
oc
LU >-
0- -J
03
^ O
crt <
— X
C/5 lx!
»
4^ W
o o
C3 (JZ
x ~
LU ~
X -a
I— 2
I <2
X <e
Z «
— .a
o 2
< 2
o
■a ^
<s °
2 o
w ®
o
X' O
a lu
Z o
Q <
< .
® «
CL S
© d
Q. ®
« X
■ * i
“O CO o
0
.2 E
CD
X o.
L. CD
£ >•
•w o
CO p
X
o
— CO
< O
&- XI
0) £=
+- o
c «•-
— o
CO 3
|5
5 •
Q. X
c c
X
Z
10-’18. 100,000.
tityp (CommmtuipaUIj of i0assarl}usi?ti&
1 PLACE OF DEAT
County.
OFFICE OF THE SECRETARY
DIVISION OF VITAL STATISTICS
STANDARD CERTIFICATE OF DEATH
. .
City or Town j .. No ., St., Ward
(If death occurred in a hospital or institution, give its name instead of street and number)
Registered No.
2 FULL NAME
(a) Residence. No.ty U
(Usual place of abode)
Length of residence in city or town where death occnrred / *-S
(If in the Army or Navy of the United States, give rank, organization, etc.)
St., Ward.
years
months
(If non-resident give city or town and State)
days. How long in U. S., if of foreign birth ? years months days
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
4 COLOR OR RACE 1
u)
5 SINGLE, MARRIED, WIDOWED, OR
DIVORCED {write the,’ word)
5a If married, widowed, or divorce^ *
HUSBAND of ■*--
(or) WIFE ofy
—y
6 DATE OF BIRTH ... / ' 7
7 / i
( Month) (Day)
(Year)
7 AGE J^O Tears Ylonths Days
If STILLBORN, enter that fact here /
If STILLBORN, stale period of nterogestation mcs.
If LESS than
1 day, Iirs.
or min.
8 OCCUPATION OF DECEASED
(a) Trade, profession, or (V
particular kind of work. 7!....
(b) Genera! nature of industry,
business, or establishment in
which employed (or employer)
¥*-
(c) Name of employer
9 BIRTHPLACE (City)
(State or country)
-±
10 NAME OF
•R
FATHER
12 MAIDEN NAME
OF MOTHER
13 BIRTHPLACE OF
MOTHER (City).
(State or country) _™= , . .
M j
(Address) ^
15
FfledSMt tA ml.
(HVjftnth) (Day) (Year)
Registrar
MEDICAL
16 DATE OF DEATH
17
1 HEREBY
RTIFICATE OF DEATH
C£5
(Day)'
(Terfr)
RTIFY, Th;
W , 19
that I last saw h. <bT alive
I attended deceased from
G
and that death occurred, on the date stated above, at
The rl was as follows;
, 19 l J
, 19 ( J.
ds.
18 Where was disease contract'
if not at place of death?
/ -4- ^
A yrs .J mos. ...... ’ ds
ation)
Did an operation precede death?
Was there an autopsy?
What test confirmed diagnosis ?
(Signed)...
19 PLAI
IF BURIAL, CREMATION, OR REMOVAL
y:1 : V, ^
(Cemetery)
DATE OF BURIAL
(City or town)
19/ /
211 HEREBY CERTIFY that a satisfactory stan-
dard certificate of death was filed with me
BEFORE the bnrial or transit permit was issued -
20 UNDERTAKE Ft,
*T/I~ A Ja
ADDRESS
Official
position
V /
22 Date of issue of burial ,
>r transit permit
L
7
e* *i S'
® p © 1
p oq g
B ® o
S 3
o "5
o *
2. «
CO p
' D
•g ®
1 8
8s
V
2 ®
§•3
•d -
® I
B.8
S B
w ?.
■§
S D
® S'
12
3 S
i5 «
® O 3®
O «» £
•-«» . . ®
(-*■ Cfi
a sr .
® © ^
p ^ si
e+ JJ £2
2&o-
> 1 “
cr 2. ©
2*1 5
g as
? S p-
o P ^
©wo
►—©*-»
cr to
3 - P
3*. <i a
el* 2. a
F ? a
o o o
P* c g
& ® r
|« a
y s °
2 r»* P
3 S'
S-B §
ss a.
o ^ 3*
2 3* °
® c
ss
ss
CS3
pn
o
s 2
I S
s P*^
o
>■
30
2: r^»
« m
*
r §
■ n
?• m
s. o
a— c.
©
rj
r* CL
9- S 2 W
©. ^ 5
o’ 5* g
o Bio1
o “ “
o cr
5* ^
T W S
3 u> 5
r 2
® *< ©
C a B;
*< 3 o
O' ® S.
a 2. S
If!
MS
! S3.
o 3
w
2. D
& 8, I
CR o. S’
; 5 ® ®
2 8 B ®
■ 3 e o p
3 “ ^ a
-a §
w p- -
V* O
a sr.
' ©
r. p <<
© S' ?
3 00 °
2. © P
P P S3
^ a
P o o
xv d a %
o a a cr
» cr 3* ®
• - »< o to
P r4. ® C
3 tr - *0
a © << V
2 *
Iffe
CL ® *<
• *d
cr o
2. B
2. o
p
3 —
“t
c n
2
D p
**“ <
©
o a
B ®
0 *.
1 &
3 i-
r:
:§
cr d
© *a
r. «
o w
^ o
8 S s
c &
cr p
p -"
o S.
O O 1
" 2 !
a a
B S
a 3
O ® H
w «» cr
. o ©
> — -*»
« a
Ie
o
a? *
^2.
a ©*
§ g
cr 3
— w
o .
a ^
8 E
2- o
% 3
* 3
o p,
^ 3*
5* W5
•d
3*
a ? ^
nr ta
o «3 ©
£ tr B*
5 p 3
, d ©
■ cr cr.
‘I?
a o
© m
© 3
B-S
&S*
2 a
cr ©
c* $
a g
fi B
•-f ©
C D
*5 ®
p d
ae
© *o
f5
©
I"
B
m
p
a cr
8 8
u ©
O Pj
B* F
P- o
“ B
~ o
M
a
m
H
C
73
Z
o
■n
0
m
3D
H
T1
n
>
H
m
OJ
0
•n
D
rn
>
H
1
Q
r
_D
FORM R-301
E 8
< w
LU .
Q -S
p_
° o
LlI cl
s.§
S £■
©
© >
TO <f>
LU *o
Q
CC
O
n O
o £
z
Q
z
m
K
0
li.
Q
UJ
>
tt
IU
U)
UJ
k
2 o
o H
j: <
<B Q_
C/5 3
Z O
< S
o ?
LU
z
< 0.
s
cc
LU
CL
<
CO
co o
> *.
E
®
>■ n
0 ®
a |
< 2
O o O
< CO <C
X ,* =
LU LU s_
-0.0
O T3 t_
♦; « ©
<2 «:
<® '3
... «) w
S w 2
■° o
-o > =
= -E °
O ©
-=0.5
® ©
LU
a
< *%
13 TO O
.® s c
©
=> -5 ~
Q. *•“» CO
o- o
S « f5
CO r- L.
^ x
— o ©
X
I-
>
z
<
-J
Ql
LU
h;
BC
£
I.
CO
z
10-'18. 100,000.
£ « =
S £ "
o t. ®
o c
v V a
■Q _ ~
O “■
5 .5
©Ijp GJamramtui?att!j nf iSassarliuBPtta
STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH
County.
City or Town ... 2%r,
OFFICE OF THE SECRETARY
DIVISION OF VITAL STATISTICS
State Registered No.
2 FULL NAME
L "7^
No 2r... z£j2l - St, Ward
llf death occurred in a hospital or institution, give its name instead of street and number)
Co*?
(If in the Artsy or Navy of the United States, give rank, organization, etc.)
(a) Residence. No. 2'... St., Ward
(Usual place of abode) (If non-resident give city or town and State)
Length of resilience in city or town where death occurred years months days. How long in U. S., if nf foreign birth ? years months days
PERSONAL AND STATISTICAL PARTICULARS
3 SEX 4 COLOR OR RACE
2-^'Zc+t —
5a If married, widowed, or divorced
HUSBAND of
(or) WlPt^of
6 DATE OF BIRTH
( Month)
7 AGE S ^ Years ^ Months
If STILLBORN, enter that fact here
5 SINGLE, MARRIED. WIDOWED, OR
DIVORCED (write the word)
Z. ^
/ <P £ ci
(bay) (Year)"
If STILLBORN, state period of oterogestation . ...< .z^r.. .mos.
-X
/ ^Days
If LESS than
1 day hrs.
or min.
8 OCCUPATION OF DECEASED
(a) Trade, profession, or
particular kind of work
(b ) General nature of industry,
business, or establishment in
which employed (or employer)...
(c) Name of employer
9 BIRTHPLACE (City)
(State or country)
10 NAME OF 1 ' ^
FATHER J'C77SSSe^,
•w-t - /'f. ls y j
A R E NTS
11 BIRTHPLACE OF
FATHER (City) X
(State or country)
12 MAIDEN NAME ^ S <T f
OF MOTHER -^ (>^,7^.
13 BIRTHPLACE OF
MOTHER (City)....
(State or country)
14
Informant
(Address)
cf- /?
Filed \ Juf.Z
(Month) (Day) (Year)
Registrar
21 I HEREBY CERTIFY that a satisfactory stan-
dard certificate of death was filed with me
BEFORE the burial or transit permit was issued
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
17
I HEREBY CERTIFY, That I attended deceased from
hr: , 19./.?...., to. i? , 19./ /
. ■-? . 19// .
that I last saw h.Jr^
alive
and that death occurred, on the date stated above, at....y/..6*. ^4 m.
The CAUSE OF DEATH was as follows :
(duration) ^
CONTRIBUTORY
(secondary)
(duration) yrs,.
18 Where was disease contracted
if not at place of death?
Did an operation precede death?
Was there an autopsy? ....
What test confirmed diagnosis^
(Signed)
(Address)
Date
U
Date of
flVionth)
nosis
^-t^r Jrf. S.A T... ^
2 I lUi
(T)ay) (Year)
M.D.
19 PLACE OF BURIAL, CREMATION, OR REMOVAL
^
rt) r.J^IL&A<flLt<Twn)
(Cemetery)
20 UNDERTAKER
tSS£^t^£. ZfS
DATE OF BURLAL
/c^. (P
19/ Y
ADDRESS
22 Date of issue of burial
or transit permit
7^24, 'It
n. p*
% s> 2
c 5 3
p ® o
C a
o
p a
O P
O •
S. <*
to P
- P
oq
•g 3
© P
fr.®
§?
I- S
ftp*-,
g ® 2.
ct- — CS
ST
► 1 “
D- S. ®
O P 2
a ^ §
z? s S.
•d
s ®
©3
sr. €'
CO CD
•d -
3 1
B.8
j» g'
oq
w gi
•§ .w
S'B.
2 w
B 2
3. P
p *?
£- g
p <1 o-
R- 2. a
w 5. <-*-
- “ P*
© o o
3* 3 g
fS ct
O* © 2
O' * g
C‘2 Hi
e+ m O
p* S 3
;S 3
sis
S § 2
l£®e*?3H*H°°liri§’s&
;• 3 o ►. 2 S- o ® 3 S
1 - ft : 9 ?. «8-"iip.^s*rS!"§
D-a-l S 2.S ^ ? E.b
& e&(S* s |-I;P-B
-3^?s§?
“ 3* O - -
3.frS S 2 g
p>
. P> o
52 Cl- p
tr S7.
3 ?
* i; b-s?S€ i f|
SSsr&g.&Ei&.gSa
§ I $>b § I! S^&o
D w O (5 ^o p « ® ® « 7 0
s'
$ ^ S- 1 Joi! |®> II ?g £r52 o 3 &!§
E 1 f § § ® I P |^-s-s 3 |8 2a fas.? S-’i
o**cD^Qo*o5‘f3 r . _ P^ *p 3 (n r* p
5 S. *■*»£• 3 _ 3 3*^ S' t* IT tl> 12 ® ©'£?<%©* O r*- CD
^SS^gSSS
3 » s g » i fi
' >^ M ^ S' -
'CD O g *< S. -
p t ^ s 5* <3 ►_© £, 2 3
C CD^-O - © D M Q
© p- ;
3. S- B S- -a o g £ I
3- _. P- a
S' M — > C- P- cr _
® 3 g ® s, r »
B ®” § 3 o <2T E O- £ g-
!. o » s a
^3_, >-►> O - ^ O 3 < 50 ©
-^s6i®Xfg,s-!lBSsa
?-S-*g.-ig.|-B|fgg|-8.
•Ko05p°CO
“' A2yf+M®0
o- O'
p 5' 3
; 2. a- 3
■ m ^ &5 g. S_
1 i'll S f f |&3 l» E - »
I 1 1 s. &. B I & 3 t* : s 1 I 3 ! i
§Soo°53?2,||Sg.?po3
ajcoHprojjOv- opg^. - <r 3 ^
^ f*' H S 2 ^ W « £T ^ F* «> c~ 2 p
s-s'Sp^. o S. p ® . 3
OP-Wo^.pSs-1 H. HB
tr^®a'°w £*«§ g 0^2 o
§§&l?rprs§| 3
ffl rt- O D *1 • *< © f r-. C^- 3 ■
s»
=■ o
rrl
s
5
«» »p S* o- p o
O m S © ® ^
I m Li-
c 3 •p- »
g.9. C
o *p
2. o
3 55 «
B ^
o
i ^ ^ & 2 g p-
g-pSplal
go-. °P--<Po
&sf §• r 2.8
|gf
Q, »1
“g 2-1
S' B E |
o £| B. *<1 ©
p w s* * 3
Cf S’ - “ 2* w
*< c cr ° B H <
- ® e ^ _ rr 5.
®
P* «♦ 13
2 r » 2.
S 0 S
CKJ o O
P O _ D
S. o o- »
S o a ^
S
&■ ? 3
- to CO O Cfl B
. S 1
: SL “
p. (w*
© %
&r
® O 3
g P B
©
cr 5'
p © ©
g ta P
g ®
— S' 3
S'!?
§
S' § S'
ao ?
“ ”* ® a. p.
©^ *0 Q •-*,
£T. P <<
O Q
S p
o a.
■a
§
5
6 a b g.r^
io c o ^
o j 2 » § « ^
g a a — w g
“ *< o U & g >
H- o’ 51 g ® § S
^303 & ^ g
O CL
E*
• o ° o
M. 2 "•
p - H
B ^ 5'
S S'0^
E 1
B- g
£=‘ I- §
® P cr ^
s P o ^
< c P
=r ® <5.5
O P; F W
R ©’ O- o
^ p- S’ S'
s' ^ p 2
o ^ cr D
B ^ © w
® r p-a
^ c cr p
cr — •-
o «<
p
«3
B <
i
3 2
p g ©
«■ 8 § K
g" E m ^
w
o
5
ta
O
•»t
►d
g
>
o
►3
2 O
M
§
r 2 B f
!. B “ °
> P. O P
J P P OC
r-~g s-
> b a. g.
e, • ® cr 3? “
M P» - «< o »
tfl 2 M . o a
b i' ?
2 2. ®
C- c
“g'&S-
B- r » b-
O s ®
-DC
D. g- B
§ S 3
cr ©
o ®
00 *-t &•
p <<
. p s
• cr
• 52 C?
CL. O
© CD
O P
p o
S p-
p- ®
§ -
B g"
oq ““
g gr s
S 8 o
oo © *-»»
Pccr^g-
P -d to S ° y
*4- •“ s *^ R P
e. e. K g 2 3 5- o
CDWOOP-PcwPco
- - tr r - » o<ra ►—
B- 2 O c- — D o fT"’
• cr ca -• . c- ^ w
cr
S- BB S-.® ■g.a B ■ 3 3. o- p
§ g S.&g^S-
s - _;s “ 2 „ ? " s- rr ■ ?
^ E S
C+1 © v-
^ P* c- ^
*-•• O <5 p
w © ™ cr *" ,-f
5- a ® o s
s s* 5 § i; • a g,g‘e
B s> P - “
3-0 0
© *Q f? 3
“ s ® ^ s.
3* R* *p 2 ..
f ssgs«
° g* «• 8 2- ®rg-p,p
S-0’?' S » ffl 2
! I ll!a ||§ |&|?
“®D^ag®-«Br»W„
- B 5 fl n E
3 4
S X
a -0 B" B-
g O P
a "US'S 2
8 2 _ ® a. << cs
' g- B o m B =•
^Og^PngOB-
E — S’S 3-2 ra-
il ^Hvc I
<s ^ w p* ? S*©"^
o tr ® S, 3 ®
t^2 ^ CL © 55 CL
P P o... S © >-^3 ©
$?P©r*-©pg©*i
“ E a „ g B B. S. 5
**—“-■ — oo
D* 3
© o ►-•
© 3 3-
S
O © S p S. 05 *<
P^hoPoPcjPcv*
<-d Sp©o»Po&S
sl- p- o si r. s. w © cl ©
© tC t? r h> m c+ pt - • P
•a *<
5f <.
S B- 2
©
S' 5
K*
p o P p
S' p
CR O P
. ^
„Eb« p
b- <l E 8
g-e-s 3 &
P o ® o
p p
p
C3 H r- <3 . ,
p & S s .
O © © P* M
O p rt P
r^ O £■ O O
“©22
cr n " ™ r M A w rE
o s' cr 7 3 oq P cli-*p--
g- 8 s g
*■?&&:
8 5
► ^ 2. *a
SpE § BlW
S r p © o
R ^ 3- &- g s s
L g* 3 p 8- cr ^ ®
° R‘ 3- 5 s S 7*. o
PM0£'(IQ C^
oPcl©©oRo
3- d- c- o
^g-
B
P*
PL P ^ ^ ^
.pp-crs-
. P- © © ©
. 2- cr cr
s-ss
X
m
H
C
3
Z
0
T1
o
m
x
H
0
>
H
m
a>
0
T|
0
m
>
H
1
0
0
2
Z
0
z
$
m
>
r
\1
\ o
i ■*
! 2
1 >
0)
U)
>
o
X
c
(/)
:xm.
Z z
0
q:
<
2
0 <n
£ r a
_ fc ej
T3 s. jq
1 “ =
£.E °
“ n ®
£ CL O
.2 c ~
X .= o
2 3
Eli
«- 1— in
£ < .5
c_ Q a>
0 u CO
£ ° ~
<U m E
= «2
>, X fr
s- °
> <-' E
1 ■ I c
“ ® —
. ■£ >>
Q
cc
O -a
O 3 -
U O 7
cc -c X
oo Q
t»h
2 z <
£ < 2
log
2 a> o
cc >- o
Ql o
^ . c
t/3 > ®
“ rj E
— O ~
x < -2
H- x *
. Ill -4-*
o
a
x
tf) <u
>
CO
SZ T3
z 5
n
{3 »
a
<
Ll.
H
O
X LU
■a
X a>
•° «=
■o oo
sT 73 ^
r 4) D
J Z -Q
E g; >>
< P- «
c
w e n
” o
5^ X <E
ce E ~ «
> n O ©-
> O <o o
le
eo
z
CJljp (Emttmmmitaltlj nf iMassarljnartta
_ A _ A vanthrop B»8TON
STANDARD CERTIFICATE OF DEATH (city or townj
1 PLACE OF DEATH
County Suffolk state Massachusetts Registered No.
Township or Village or
City BOETO rn; No .1.8 ...Park... Aye* Jliithrop. st, Ward
(If death occurred in a hospital or institution, give its name instead of street and number)
2 FULL NAME .Y®.?.S.P.P.a.*
(a) Residence. No 1™™..™®.^ St., Ward.
(Usual place of abode) (If non-resident give city or town and State)
Length of residence in city or town where death occurred years months days. How long in U. S., if of foreign birth? years months days
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
male
4 COLOR OR RACE
white
5 SINGLE, MARRIED, WIDOWED, OR
DIVORCED ( write the word)
married*
5a If married, widowed, or divorced
husband o/ Angela L.
Cot ) WIFE of
6 DATE OF BIRTH (month, day, and year)
X & wr<f3
7 AGE Years
35
Months
Days
<7
If LESS thau
1 day, Jirs.
or jnio.
8 OCCUPATION OF DECEASED
Manufacturer
Ca) Trade, profession, or
particular kind of work
(b) General nature of industry,
business, or establishment in
which employed (or employer) ..
(c) Name of employer
Italy.
10 NAME OF I ATHeI ' ~ T'"
9 BIRTHPLACE (city or to
(State or country)
11 BIRTHPLACE OF FATHEB
(State or country)
(city_or town)
tally
12 MAIDEN NAME OF MOTHERC&nCett a COSta
13 BIRTHPLACE OF MOTHEF
(State or country)
1 (city, or Ipwn)
Italy •
14
Informant .
(Address)
..i).* ye.rfi.ona.%.
■*■12 School St .Boston.
15
ra*dj0iMJ2' 19 fj...
Registrar
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH (month, day, 3i)&Ifcar)6 1 919
19
17
4 HEREBY CERTIFY t That I attended deceased from
, 19.ZZT, u> , i9./,y
that I last saw hZZKL_ alive on 19.../
and that death occurred, on the date stated above, at /. .. IJA..P. .. . m.
The CAUSE OF DEATH51' was as follows:
J
a
CONTRIBUTORY..
(secondary)
y (duration) yrs xnos. ^7. ds.
+L a.
..(duration) yrs. mos.
18 Where was disease contracted
if not at place of death?
Did an operation precede death? Date of..
, FOR WHAT?
Was there an autopsy?.
What test confirmed dia^, T
(Signed)
I ! y, 19 ’* (Address) J V ^ ^ ^
fl.D.
♦ State the Disease /Causing Death, or in deaths from Violent Causes,
state (1) Means and Nature of Injury, and (2) whether Accidental,
Suicidal, or Homicidal. (See reverse side for additional space.)
19 PLACE OF
St.
iURIAL, CREMATION, OR REMOVAL
iichael.Boston.
DATE OF BURIAL
//^ 19
I
ft
)EI
:
n
V
AKER,
J Sn^/K 'kX^v lA Cw \. i
r\
' V . /%
ADDRESS
9 S' Sag 2
2M^.I J
P ^ - | g g ^ J2r
;-j-® 3-3
0 “ CC
:- » n h
-^g-P P 2
"•®|CQ
CTO O £.0 ®f5 5S° O-ET
^gllTS 3 §5§^ 5,2 O
s° S-F2-C i'£;° 3
' hn 0° 2.!
'w cd 2»- x ST :
a 02 2.3 p g. £
£ £ * 55 3 «
3>§&o^ §£•§>§ '"r?3i,5:s^
CO o'-"5 3
5 5 p *o
^p-o^R . .
=■=5 = 1“ a !•*
?r "°»^-
3 S-r! ll'l
. fc* .5® O •?» Cl
s o
2. 35 re
• a.p
„p ® “ o »; "tj 8 ® s 5“tf ^ ” P
p n> O -=§ -o'3 g • £ g^a.r«“! g.a‘2.8 s:?! £3J
, P 3 re ^ r
ig £ “ a-g
:<3i
.5 g S'S §.8 5-g
§^f-lr4 g:si5
§ |J! r =i «£■§ .Sfis § S.s p
ss^srs^r^^iS'r r=i.
g» :i°-| =S„ MSawisaSo-
~ . to S«“ =
$ JT^e® S'ir
§ g^ 5 “iSglo^'piPS
5-b--m.sM :
,_ ^ " Q tu
° fScTcP-o E,-*’
i sg..
w Hew c; 3* g> “ -
CL> ^ o’B 30 £.02
' s-
«► 3 S- sa^So'Bf g. ® pp 2 ofa g
?-F h g? 9*^ sf s? r ;7f
;p, » fcc"3 ■ » ^
sf® 3 3 „.B § c
o Q2r\~. ~ ^ J £.**3 o>
o kJP 3 s-S gSfr.s-
■ <n- O a je o
• I c^-Q r-+i
- 2,2.0® 2.
^ O 2 SO O
hP 3 o a B
P B s o cs |3 w
3 3 O-! 3 2.
5 3 2 $L§ so 2
3 3 O OV* re 3-
2 O 3 2 - n
g.B.’oS
3 SO -T3
£ ^ c5 o * p. — » — • — c—
— O - o>- . *=! p ^
i.s.O'o’ggas&si
3 si i:^ e-p^
3.w ® re ^O P P to CR
a 3 o 3>~ -
S“S- •=> 2 — .-^cr
° 2 Ssg®
a a - ,-
- S -p ^os
3 p e S. 2
‘‘1 2- £-
►1
©
§* (0 H
fo3-“ o<s
ass >rj~,g. 3
a oJB 5-*o
a ct-c-® are
- C.p-^
g_. wr-!!
= 3 oJ2,| ®
2 ** ~ ^
2?£2^
<n ^ fe 2
y c . o 0)
.as 3 2 2
a re a
X w /-s" w 2* 2
2 g 2 ^g.a =
2 2.3
s I "5-3
rr"i’
- O ^
O . fD
^ O
r+- c-*"
^ P
*2 0^3
a g,S*|‘i.'2-.S
frl I;? ^2 %
3^i?s B
C3 q
, V„ p C3 _
3 “ a'^tr
0.2 “ s re «?g
- ’’S-Bo g-a^’SS.n »2 3°^P
h- „ 3 «- O tLi* 3^ ft. ~ 2. „ Stai Op w
o 03 55 a 3
“ ■ 9.5 1H SSog» 5“ re
«« p e+ ,05 n
s' or. S §- ^ s
a o § re S O O-
. » w 3 ® » ‘
re 2 g 3^^
'2 g-.O^SST
pc:®-”:^3 sr.^®
— o rre o i 3c
offo'CS;,
-d 3 -s 2 ~ K
„ « 0 w _ 5 d 8’i‘S. _. _.
33Sre >x<^-0_^*p ^30
-•£ < re « 5‘S- t Ed
'g‘5V_>£>S tS®p§32 s-2
si^lirsifS rg
2 o a 5*3 S Z » s: S
S ^pSS, H- O
HJ p
<§ as'
®<<o“reo'_>areo5re'
o rereP C- S a.-; re ®
a«o oO-^gre
2 5'5tT?3c,"3§3-2»
^ g g-B-^aa “ I s e^J
cro-a o s'ET'-re VS-r, 5"'
o T to —>re re I ST- P re
r+-
ET E
a> -
r-*- —s
CD ^
-J -
- ^ -
J.® K-Cq" E!
e w-2 2^ p ^
ETS’C ^ - Stg 2
^ ? K S 2 S ^ 9
°-?§| -p 2
op §■<§ go Sf
30
m
re = 5 2.
- 5'’»o»
p v-' «. ^ 8 2 ^ 2
— C."5 s- 2 a' re 2 a
3 3 lu g 5
3H.3° ',
k»-.a,v.r=u-n35-l
E§? is 2 p '
5’c ,<: g S Og-o 5 g S?
o£’^i5r|srl:s
- 55 P r+ Q S‘
o
o
S3
2
3
o
2;
>
tr*
l PLACE OF DEATH
County -
Township
Department of Commerce
BUREAU OF THE CENSUS
or
Village
or
City (No
2 FULL NAME
STANDARD CERTIFICATE OF DEATH
/Q / V/ State of
J /n J yF(7^.,/ Registered No
, st.; - Ward)
x %_2La, . „
[If death occurred In
a hospital or Institution,
give 'ts NAME instead
of street and number.]
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
3 SEX
4 COLOR OR RACE
MCLL
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
( Write the word)
16 DATE OF DEATH
( Month )|
X
(Day) ’ (Yeai^
6 DATE OF BIRTH
.!'>< IZ , lSJA.
(Month) (Day) (Year)
7 AGE
1C
yrs.
LI
If LESS than
1 dev, hrs.
or mln. 7
8 OCCUPATION ,
(a) Tradei profession, or / /
particular kind of work 1*
C. qS.
particular
(b) General nature of Industry,
business, or establishment In
which employed (or employer) .
!7 I HEREBY CERTIFY, That I attended deceased from
//— , 191.$-, to - JL, 191-?-,
that I last saw h-Lirs. alive on , 191-?—,
and that death occurred, on the date stated above,
The CAUSE OF DEATH* was as follows:
CCt^LfS^l.O' -
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
(Address)
18 LENGTH OF RESIDENCE (For Hospitals, Institutions, Transients,
or Recent Residents)
At place jq In the , C3
of death yrs. mos.^Uy-ds, State yrs. mos. 'SLX ds.
W here was disease contracted, / A
If not at place of death ? . _
Former or /sis' C1 O
usual residence.^.'rL— ft— *— ..LL— _
19 PLACE p F BURIAL OR REMOVAL
’sC-
ll.
191^
Registrar
20 UNDERTAKER
cCVL
DATE OF BURIAL
..,191.
11—3184
© p
w P
„ *a cr
E. cr p
B *r* B
5- S- “3
S m’ D
E - ©
ra l:
s 3
1 E S {? a
2 n pr ai O
o O «. w
"5 s O I
& < *i » J.
a ® oi § S'
P r-*- O D
p p ,2 c-
F C ST ^ *i*
•• "< 8 "
fe a s
S £
^■S. Si
<1 r*o >
s&2.
• © i
o' 5
— ©
o P
: =3 ©
g. E
o i
S p -
W5 o QTQ
CP £3 j
'T' P
(P p
B
_ CP
o* J2.
3 09
& o'"®
® 5. “•
P S’
C3> o
1 p 3
Q <T>
B
. — ~ a t>
„ j<w 3 Eg
5. 5 & S 5. I
■ I. & s
Js j 5 ?&
P
■a •- E
.SB
■ *■ 3
O' S.
B =
ro o
Q« H
cr
d £
■3 &
B 2 g S' p S
& E 8 a g 3-
^ >1 T P O
o. o.
P S *d
•g _ § 3
° w'T
5 g 3
p- 8 »
^ B g1 a
C) CP Q 2
O ^ M J
0 g* £ 2,
S" ™.
p. Pf
e cc
3 -
a. »
(D 3
>1 p.
S 3 & O
9- ST 5?
»- o- g >
^ 'si 3 ^
Kt) a 5" °
g.fr? a
0 1 9- O
?S
01
^ s?
< 3 Lw
^ P
a OQ
55 I
:* P
o- o
Pi p
■ p 2
St 3
* 2- >
p
o
*-s
ft<&
® 8
> ©
» 3
0 P
*9 CT
-. s
s. 3. H p
S’ a H a
” o> p
a s u "s
o r* ® 3
s; .• *g
e- o
= B
o
r p-
hj t=:
d g-
H ^
U r-f
H P-
W -
> 2
p ^
*8 B
s. ^ o
3 -< 3
CP CP - ^
p- ^ -
p p -
m cp
™ P
: e -
e p §
re - CO
CP
. O
CP CD
CP
o o
3 P
o-
^ §- p- a.
^ Cr* ►£> 2
•* ^ tf r4
v p 5“
S 3 — . a>
p. o *-< 3
ft. 3*
s;
cr -
^So
^ p
Pj p
CD CP 0Q
>9 3 -®
I- ff '
^ ^ p
WOH'
kl CP 3-
^ CT'.
p n: r.
i. <5" f>
- £f
§ - 3
c c cr
c
M O ^
g5 P
g 93 :
CP
B- §
P P
©
s g
p
B B
P d
a ^
cr cr
? E c*
F ® P w '
- p m cr
r. w o o *®
to n
o
B ^ a 5
3 ft! 00
2 g _ ct>
JL a <o e
ST 3 9 n>
S- rt- P- 3
d O
3 o o a
CP »-r» i-r> CD
- P
^ P
a ^ >
?e
~' o
g 3 ^ n
a §. I
? I «a
g> i
CP - t-3
S*. P
to CIm
W O
CP P
o’ ^
co a
3" s
C-T 2
CP ^
H
8 w
p >
fi b
® ?s
f?*a & s
£.2o
= s r
D. ® c
® P c
g 3 a
“8*g
1 1 §.
— ^ 8°
8 -
m *
- CP ^
K 2; Q
1-3
B - p
O CP w s.
5 3";
p ^ 6
tra o
CP ^ D
j; <
: - &
2 0 2.
3^0
p ^ g
d - i°
3 - Y’ -
WRITE PLAINLY, WITH UNFADING INK -THIS IS A PERMANENT RECORD.
H
co<
zo.
o
50
— o
£0
gi
X «
13 C3
S X
•ElU
g O
■°«=
_ </)
3 <0
o-3
0> >*
UJ *-
o g.
< o
ft.
TJ ^
0) ©
1 1 5
>3+- <2
OOO
C3 ^ V
■“ » »
2 l-Q
= 4) C
O *< o
e “ o
.2
"S C 3
1h-5
.5 < ©
. in «
*Sqco
io-s
— IjJ -*->
*-3 2
2*
ujo.2
I.
CD
el'tjp (Ccmmimmpallli nf fHasBarliusrtta
STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEAT
2^^
(City or town,
[If death occurred in
,.Ward^ a hospital or institution,
gwe its NAME instead
of street and number.]
’FULL NAME
[If married or divorced womatfor widow
give maiden name, also name off husband. J
“RESIDENCE
Registered No.
PERSONAL AND STATISTICAL PARTICULARS
» SEX
‘ COLOR OR RACE
U) £ctr
‘ SINGLE
MARRIED
WIDOWED
OR DIVORCED
( Write the word)
n
* DATE OF BIRTH
t AGE
(Mofith)
(Day)
yrt. mo*.
,,ds.
1 m
(Year)
_ if LESS than
I day.^.hrs.
or min. ?
* OCCUPATION
(a) Trade, profession, or
particular kind of work.....
yi&vL*.
(b) General nature of industry,
business, or establishment in
which employed (or employer).
» BIRTHPLACE
(State or country)
UJ2
~ut£Z'
10 NAME OF
FATHER
11 BIRTHPLACE
OF FATHER
(State or country)
(3
U MAIDEN NAME
OF MOTHER /-X . D
;rS"lo^ XiW
(State or country)
■‘THE ABOVE IS TRUE TO THE BEST OF MV KNOWLEDGE
(Informant).
(Address)
Filed.
d
f
Registrar
MEDICAL CERTIFICATE OF DEATH
I HEREBY CERTI
19
that I 4wst ami' hl..^ alive
that I attended deceased from
91^.., to , 191^..
and that death occurred, on the date stated above, at,."....' m .
The CAUSE OF DEATH* was as follows:
..(Duration) ...TT...!!T:....yrs»
,.mo8. ,ds.
Contributory..
(secondary)
(Signed) ...
(Deration) yrs. mos. _....„ dt.
M.D.
. . . _
, 191*9, (Address)„£^XMdtM^
ojur
1 If death followed injury or violence the certificate of death must be made
out by the Medical Examiner.
18 LENGTH OF RESIDENCE (FOR HOSPITALS, INSTITUTIONS, TRANSIENTS, OR
Recent Residents).
At place In the
of death yrs. mos. ,ds. State yrs mos ds. _
Where was disease contracted,
If not at placed death?
Former or
usual residence
>• PLACE OF BURIAL OR REMOVAL
JL.
DATE OF BURIAL
/.
vr
® UNDERTAKER
t
address
191
—
b
•§*
U1 O'.
a 2
P
4
p-
£ ®
S. 3
g
*5
P>
CD
o-
O
t=J
"2.
£
2. ®
p
3*
? B
o 5.
Ci
g w £ o'
B s << S
So
CO
p
CL
CL
s i
^L. ^
a*
§
>■
c"
<<
rr
^ a-
?. a-
Q
p
o P
—
p:
CL
S p ^5 S’ 3
p
p
cl
oo
3
cr
o
00“.-.
5 *d
tr»
p
cr
o-
o
g. <<
,p p
p
CL
P
CD M.
>=j
3 5*
o
P
*d
p
ct
CD
(
p
a.
p
H
p-
B •
3 & p
g sr
Q £
p
B
CL
-0
-4)
b
a
<££
p
CL
CL
Vs
•-J £; L-.
1 L
B
P- P
^ 3*
3- o
O
p
a SP 9
o
a-
x, CD
P"
p
CR
- B
a-
? §
s &
^ 2'
a
5; CL
P
Q-
P-
P
P
& P
P
P
CL
3 §;
03
d
p
CL
t*r
b
p
p
CL
•a
p-
V-
. a
£ r?
O
S>
O
E. =T -a
tsi
H
O
5.
- 3
>
d
B sr
N. B.-WRITE PLAINLY, WITH UNFADING INK-THIS 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 PLACE OF DEATH
County.. Suffolk
efje (Commmutiratib of ittassarljusrtts
STANDARD CERTIFICATE OF DEATH
(City or town)
State MOSS* Registered No.
Township finthrop or Village
City
Nr°p-, I
(If death occurred in a hospital o:
- St, Ward
or institution, give its name instead of street and number)
2 FULL NAME*ILLIiiV FYNPY McLAUGHLlN
(Tf i'ii file Army dr Kavy bribe United Stales, give rank, organization, etc.)
(a) Residence. No XfLOTJUMlt 3.1*. St., Ward
(Usual place of abode) (If non-resident give city or town and State)
Length of residence in dly or town where death occorred years months days. How long in U. S., if of foreign birth ? years months days
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
3 SEX
Me 1 e
4 COLOR OR RACE
White
5 SINGLE, MARRIED, WIDOWED, OR
DIVORCED (write the word)
Married
16 DATE OF DEATH (month, day, and year)
ML
19
5a If married, widowed, or divorced
HUSBAND of _ „ , , , .
(or) wife of Nora Feeney I'elaughlin
6 DATE OF BIRTH (month, day, and year)
7 AGE
Tears
3SL
Months
Days
It LESS than
l day, hrs.
or join.
—
8 OCCUPATION OF DECEASED
Iheffeur
17
I HEREBY CERTIFY, That I attended deceased from
f. , 19/.#..., to / 0 ,19.1 3 .
that I last saw h_^M». alive on . , 19 .../...yf*
and that death occurred, on the date stated above, at £..^. Q. m.
The CAUSE OF DEATH* was as follows:
..
(a) Trade profession, or
particular kind of work
(b) General nature of industry,
business, or establishment in
which employed (or employer) ..
(c) Name of employer
.(duration) yr
CONTRIBUTORY
.(duration)
(secondary)
.J?. mos.
. ds.
Ce. i
ds.
9 BIRTHPLACE (city or town) .M9.dLtfi.QIL
(State or country)
18 Where was disease contracted
if not at place of death?..
10 NAME OF FATHER
XI BIRTHPLACE OF FATHER (city or town) .Kedi-BOn
(State or country)
12 MAIDEN NAME OF
MOTHE*ilary MoHugh
13 BIRTHPLACE OF MOTHER (city cjtfgtii&On
Did an operation precede death ? j&4/. -Date of.
Was there an autopsy?
What test confirmed diagnosis ?...„
(Signed)
Zj ,19 {? (Adless)
* State the Disease Causing Death, or in deaths from Violent Causes
state (1) Means and Nature of Injury, and (2) whether Accidental.
Suicidal, or Homicidal. (See reverse side for additional space.)
M.D.
14
Informant Mr.a..JiclB.ughlin..
IP Fremor.t St.
19 PLACE OF BURIAL, CREMATION, OR REMOVAL
Wintlirop
DATE OF BURIAL
/T2/ / ///»
15
Filed
\0pLiX--7J.-., IS fj„
Registrar
20 UNDERTAKER
<rt
ADDRESS
7-
i! !Tgo a =<5 IT s o ’S H 2
Z p £ ^ o ~ - p S' 3 o “
“ r a ' S! - ’-I E. 2 g
- - K*0
> o ~ m, ~ _ P *«
£p Op - =
^ Efg ;0
do
a E° ” p B5®
«£ << -
| 3 §
§ -P 5
- g.?.T“
0 t^ajtti § ~>k ®
2 aSc!??§o p | ° ?.“
-rt § I g 3 8 I s- ° 3 ?§s
es
ok ~ - P-
P“- to
?• S .CP
o, 'j? P
H p « _ » el «- »
P'l !"§ H§ &o3.
- p CP
a
' r>” ~ CO (j 00 C3
5 ^ 0-^3 » o to 2
sp 3 3o ■ “ H D
O,® 2 to" ® a. ° 2 P
_ - p »— 1 Q » /-+■
a ' &•§■»&§>
geg
^s-S 3 §
-• o O S-P
^§■3-
£l >
CD
O £
* n p O3^ d
■??*»$•§ ?• g
' w | 3 ® 55 8 P "2 •' g. p P „
S^p-oS^S. S'cg.l
alv^S « &2'£9-g^ O
Er^s jL o-g.^
« ~ ” P o - 3 o
J3
2 =s P- 5 3j
p S a ® a
■5?nS
o
?■ 5T/SS "'op 3
* P- p *-.CD w,®5 vT*1 p
3 2 ^?'^'rKf0 ° i-'to!^'^ E2.<<
*?• i
?!T u n s «^&§ g^p |s| g irs Jigpi
?Saifr ^ i-S-s-B-P^cr
IB
oto
ro~a|fH; g^&g-^g
a- 0'S ito^to *Tjo » m “33
2 o
9§ g
3 P
js^S S-B
r era *2-. >— • S
S-® S-grg S I
iZljg rr, 2 5? M CQ a
I S |”f! si £ I ^"=Sg fS.?'* !la®
c-“ -^u oOrarHo2M* .. o <5 § » S''” '" §5 a
a S“. a «a E ® a s « B 5^ s s^g 8-^2 - b-!N
^ 3 »0 “ w v.w v* j )_j
.- <<' p- j: o p s ?, d 5 cw
_ 2 *c WT-L^a ^ =• 2 a, p „ $
o 5 PC'3 ® _
Q- U CD o ^ 2.q
- Cprs^r,“'^Hr+-
a « » s M r”
fi-iSfigSisi.
O S-1-' S P S O “ £3 n .
O »
p
3 '^L, g~*~_
p-p^ 9?PC?
„.&S ^d3
o O'
P 2
; s « c---o
O-'O- CD
s:.H 2 g
a-o 9 ° 3
*V>
_?pg.p
z 2 ■§.£■! -80 &
^ 3- o :H
i»5l 5 tpo
2- 3 k p_ «b ft«*-2, -
S' a K’P -x
^p
a g p
|°£;pe:s 3 tj-s 5-^ p
I.S-e-o’g 2 a§ tai” S
g ^2 1.3 Ik
rao^^-o PPS33 0-0 ^ O 3 s O
^ ,.5!c§Q
J+p *a “ p p ??“
»-» rn O •— /-,
ZK- -SS 5 2 Brag'S
3 S “•
to m P g
sl a.” “
» oj s§
3&'
o
'P “C
- o ,°9
feS'g
V&n
j o s t-SH01 p p a,
b SL7 =?
•^33
. ,_. CO p
_<<: o “ • <
fco-5 ° | S ^
3 ° s e
•to r4- S O co
S P 5- £■•§ «
?rv§.l2
3<5»«2?N‘ -
.'g i 6 Pog P ta,
1 I g ?■§ 8 5*3 ■
cp^ b-
a crs'M « cd o
- - H o ^
^ 2.§
M CO C « ^3 3* I CO* 3
°-g P ll s i|J |sla:i «
^3 P £P‘?'a>p-a~n g-3^- «>“
““ o c
owgog®?^^ ® Bjj,,,*
o m 3 3 S P? 9 2 9 t+2 o'. k2
og-ffl^-Sf' P^PSPP,tr§^
b C H‘ rf ^
p 3 c cr
T* T
*g 3
2 p ^.p
» to o' g
O CD CD
gC“(jq O
CD C* d
sill
O' CP 3 _
o T'k iSb
2.B‘s<< £5“ £.■■
rv*6 2 o a s’
o 2-
3^p§5'
S 05 “ 5 -
O CD
O p-l-1 V3'P g-s
CD p
I'g.
P CQ c p CD CD M
,^0-s. B^lg* 1
f^p |s.
® o 9. S? . ^ >o E-o
Ips'C ~2 ^ m hp n
iimisi-ii
S-o
o- ?Tp 1-3 1 &-
o'g ffri
.plB "i*
CD CD g
‘ P
qq -
S- e? ©:
V- C-t- M
CD «-<
CO »"* -
O P
T
toJ ' P Q
CD"< O -
m
>•
&
-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.
l PLACE OF DEATH
Township
or
Village
Department of Commerce
BUREAU OF THE CENSUS
STANDARD CERTIFICATE OF, DEATH
City -
2 FULL NAME
State
1 j Registered No..
^ p s-py P* /7 ^ [If death occurred in
Ward) JKKS
/O' /y / /f — -i , / *■ /} of street and number.]
\ c
- (No.
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
4COLOR OR RACE
w
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
( Write the word)
a.
6 DATE OF BIRTH
(Month)
/' ia.L°.
(Day) ’ (Year)'
7 AGE
-l
— yrs
JO
Xf.
. ds.
8 OCCUPATION
(a) Trade, profession, or
particular kind of work..
(b) General nature of Industry
business, or establishment
which employed (or employe
If LESS than
1 dsv. hrs.
or min.?
9 BIRTHPLACE
(State or country)
w
H
Z
u
cc
<
CL
10 NAME OF
FATHER
OH. W.
111 jJU* m- .
11 BiR'f HPLACE
OF FATHER
(State or country)
12 MAIDEN NAME
OF MOTHER
//
13 BIRTHPLACE
OF MOTHER
(State or country)
6 •
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant) .
(Address)
15
Fi'edJ^O^..^/., 191^.
MEDICAL CERTIFICATE OF DEATH
IS DATE OF DEATH
/O
(Month)
, 191.1.
(Day) (Year)
Registrar
17
i^€Le , //
I HEREBY CERTIFY, i hat I attended deceased from
191-£-, to .19—., 19
that I last saw h alive o n 9.9. , 191 1.,
and that death occurred, on the date stated above,
The CAU$E OF DEATH* was as^follcwsL
(Duration) yrs.
1—9— ds.
Contributory.
(secondary)
. ds.
(Duration) yrs. mos.
Cf.., 191-^- (Address)
<X^7
the Disease Causing Death, or, in deaths from Violent Causes, state
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 ? t
Former or
usual residence
19 PLACE OF BURIAL OR REMOVAL
20 UNDERTAKER
DATE OF BURIAL
../y/ji-. _i9i.2.
ADDRESS
11—3184
ORM R-301
o . «
g u •
E Q c
® u. 2
.5® S
*.uj a
o i/> c
s<i
2 ® 5
>
U CO 0)
O
cc
o
o
UJ
cc
H
z
UJ
z
- <
2 o
o P
J= *c
« Q.
Cfl 3
Z O
< S
2 2
CO O
>-
X C
' S
. ®
>“ "c?
— J ■*£ O)
u. 40 >♦-
rr ^ w
5 o o
< C3 <P
X * ^
LlI LU s-
H ®
<u
3 £
* %
< <
2 £
3
X
<jj tp ®
"* '« "S
® <S ™
■° o ■“
■® >, =
= Z ®
© £ <o
S 1 1
g --
• * I
*a a o
f E i
S--- *
9- H- O
2 ™ 2
>>~ ><
- O «
3 </) _
t«- ^
g « s
i e w
o u 2
a) c
a> -m o
in
Q. .
C C
o
■E
(f) ■— .z
10-’ 18. 100,000.
1 PLACE OF DEAT
County
City or Town
2 FULL NAME
(a) Residence. No. /9
(Usual place of abode)
Length of residence in city or town where death occorred
Stye QIammomm'attb of fHassarbusrtta
STANDARD CERTIFICATE OF DEATH division of vital statistics
^ State (/'/ j Registered No.
^ St. Ward
y (If death occurred iu a hospital oivinytitutlon, give its name instead of street and number)
x.-Yl<*, Z' ’
(If in the Army or Navy of the United States, give rank, organization, etc.)
St.,
niontbs
days.
.Ward.
(If non-resident give city or town and State)
How long in U. S., if of foreign birth? years months days
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
4 COLOR OR RACE
5 SINGLE, MARRIED, WIDOWED, OR
DIVORCED (write the word)
ZZ-'V-'T
5a If married, widowed, ui ilivuiC?d
WI WIFE of
6 DATE OF BIRTH
(Alonth)
(Day)
(Year)
7 AGE ^ (? Years ^ Months
If STILLBORN, enter that fact here
-2-r^7 Days
If LESS than
1 day, hrs.
If STILLBORN, state period of uterogeslation
mos.
or min.
8 OCCUPATION OF DECEASED
(a) Trade, profession, or
particular kind of work
(b) General nature of industry,
business, or establishment in ,/ - _
which employed (or employer)
(c) Name of employer
9 BIRTHPLACE (City)
(State or country)
10 NAME OF
FATHER
11 BIRTHPLACE OF
FATHER (City)
(State or country)
12 MAIDEN NAME
OF MOTHER
22i_
13 BIRTHPLACE OF
MOTHER (City)
(State or country)
-jC-
14
Informant T'.. 1
(Address) / f £ ' rfcrz^^L.
15
-j , m
(Day) (Year
Registrar
21 I HEREBY CERTIFY that a satisfactory stan-
dard certificate of death was hied with me
BEFORE the burial or transit permit was issued
Jj£
MEDICAL CERTIFICATE OF DEATH
16
DATE OF DEATH
c [Month) (J
17
HEREBY C
tliat I last saw h £ Y alive
and that death occurred, on the
The CAUSI
I attended deceased from
19..^,
te stated abovey at *
E^OF DEATH was as follows :
ds.
(duration) T. yrs. * mos. / ds.
CONTRIBUTORY f ^ lr > (i^O^cA^
(secondary) '
s-^rrA/4tr » (duration) yrs, mos.
18 Where was disease contracted - _
if not at place of death?
Did an operation precede death? Yix? Date of
Was there an autopsy? ^
What test comfiXned diagnosis 2^ u&JL
(Signed) ^
/sec, , YV'-CUU a- *
M.D.
/T”) - —
Dale l
II (Month) C7 (Day) /
(Year)
19 PLACE OF BURIAL, CREMATION, OR REMOVAL
(Cemetery) v (City or town)
DATE OF BURIAL
'Y
19 /i
20 UNDERTAKER
ADDRESS
/Qy/ 22 Date of issue of burial / -
or transit permit /. fT.
gag-
11 a 9
P oo B
S _® o
c a
W 2*
• B Ef
5
•a
2 ®
19
2 *
STS g
s s a
I3 «
o £
o •-*> £
»-«> _^ ®
r*- CO
a tr .
® ® ^
P H;
c+ p:
fr&cr
> 1 ®
o' 2. ©
o P £
S« s
Sag
?>
® g S?
5 2 *
p - p
^ <i a
n- ^ a.
P
.. CD
•d -
» §
II
-p 5'
<*
w S
® CD
73 -
5 1
i i
*r. os
w ct- 2- C-*
“ -£’ 5 £
a o o
2 £ g
J2 c* P
O* © [“*
S3 g
& p o
b4 2, *i
■ p s
S S.s
B ° S'
i-c §
£S I
o „ tf
B tr S'
“ ® B-
50
m
s»-
-H
30
m
H
C
30
Z
0
n
0
m
7)
H
31
n
>
H
m
(/>
0
T1
□
m
>
H
X
a
0
2
2
0
z
:>
m
>
r
x
0
T1
2
>
0)
01
>
o
Q
cc
O
O
UJ
CC
U z
Z <
_ S
□
“ LU
Z 0.
CQ <
s i
<
a.
© >>
s_
cc o
CO<
Z 0,
<=>
5°
— o
£o
5 ^
h- ©
ss
X *
in -*-*
©
■Off
(/)
__ C f)
K
0
C/5
3 C3
5®
C f) >-N
Ll
X
i—
LU
og.
0
i
id
< O
L.
UJ
z
• o.
>
a> ©
DC
a
— .q
o
UJ
z
©
V)
a
5 EtS
UJ
K
j
<
u.
z
3
X
©2 ©
r O
W c*«
5
K
H
o o O
5
®
■“ • 2
CQ
Z
Era
__ J2
3 (D C
O +- o
» = «l
§«§
o Q.—
lli "S C 3
L E” 2
uJIj? (Eommmuufaltlj nf fHassarijuitftts
STANDARD CERTIFICATE OF DEATH
PLACE OF DEATH
(City or town.)
2.3
or widow
give maiden name, also nam&pf tmslwuid.] V .. I
"RESIDENCE | ^ -JLjr^ Vj. .
[If death occurred in
St Ward) a hospital or institution,
give its NAME instead
of street and number.]
'FULL NAME
[If married or divorced wo
give maiden name, also nami
Registered No.
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
4 COLOR OR RACE 5 SINGL^
WIDOWED,
OR DIVORCE
( Write the word)
6 DATE OF BIRTH
/ /. <*Xi
(Month) (Day) (/ear)
t AGE
,E< a>
LU ©
%OV)
>,co £
s. 3 °
© "2 to.
> < c
luO.E
.Lfc
yrs.
tmos. ds.
If LESS than
I day, hrs.
or min. ?
8 OCCUPATION
(a) Trade, profession, or
particular kind of work...
(b) General nature of industiy,
business, or establishment in
which employed (or employer)...
9 BIRTHPLACE
(State or country)
»3 BIRTHPLA
OF MOTHER
(State or coun
Filed
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
17 I HEREBY CERTIFY that I have investigated the
death of the deceased.
The CAUSE OF D£ATH* was as follows:
QcCuJ^.. ^ • ’/
Cty\ X J3a. ~ •
CS^dUt^ dx3£)
..(Duration) yrs. mos.
ds.
Contributory..
(secondary)
(Duration) ...yrs mos ds.
* State the Disease Causing Death, or, in deaths from Violent Causes,
state (1) Means of Injury; and (2) whether Accidental, Suicidal or
Homicidal.
* LENGTH OF RESIDENCE (FOR HOSPITALS, INSTITUTIONS, TRANSIENTS, Ofi
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...
■ /f* 7
■§ 5
3- 1
r
H ^
v- g.
I ^
o- o.
>d
3 C
O c«
P CD
3 o
o
5. t
K 6
- >-i
w O
P
^ *°z
O w
Cr*
P
3 g.
H
■g.
51
H
3 i*
a. 3
cd
d §
CO p
o , I
g S'
J> Q
►3 p
W o
CT
co p
p 3
S' 1
© n
o O
3 5 *
cr
p
<
CD
C i
o
o
u ' cr
& 2
CL p
v V.
►U o
3
tr
O
p CD
-S P"
cd p:
$ -
b<
p
*d
p.
El
CD p
£ I
« B
r r’.
3 ^
O ^3
p E>
CD
O-
El
CD
CL
CD
/-
y.
cr*
d
H
*<
9
>
CO
O*
0
6
CD
CD
X
sr
'
X
S1
CO
p
Go
*9.
3
3 5s
Go
C.
S3
P-
<5
3
O
3-
o
a. 3
rn p
d
*d
p
C*
o’
d
GO
*o p
*0 PT
3CJ
— 0
S3
P
O-
*53
£
P-
U1 •
P
p.
£ ••s
►l. ►**.
cr
'C
a s.
& °* ?
cr
<c
to
§
tq s’
H O
to
s 9
«* a
13* 2.
CD C
P
2 w
p. x
co P
a 3
t-1 5
cl cr
H £-
P
CL
cr
d
p
cl
g
c->.
<Q
Go
p
P
CL
CL 0-
H S
P
3 ^
•o P
2 2
cd
e & £
a
B
W „
^3 CT
d
p
o-
fcj
w* GO ffi GO O P
CD P* P/ Q C -'
3 2.
^ p
O CD
cr p*
El p
cr “
i p-
' - p
£: P
O
a g*
: a
H
x
cr
p
d
O
51
*g
p
o-
p
s >
o
t3
cr
*<
\ 2
> <
^ CL
H H
o
p
CL
3 cr
|
p
Go
o
WRITE PLAINLY, WITH UNFADING INK-THIS 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.
GO
z
(Sonumutvurallfi of iHassadfuattta
DEATH
1 PLACE OF DEATI
STANDARD CERTIFICATE
1 ownship \ y/
or
City
No
.State .
2 FULL NAME
t
St., Ward
(If death occurred ina hospital or institution, give its name instead of street and number)
t|j " Yjn'i nk , d ^hizatioh, etc'.'i / .
(a) Residence. No. /.S /J. Ward
(Usual place of abode)
Length of residence in city or town where death occurred
years
months
days.
_
(Ir non-resident give city or town and Shite)
How Ions in 0. S., if of foreign birth ? years months days
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
3.SEJL_
4 COLOR OR RACE
5 SINGLE, MARRIED, WIDOWED, OR
DIVORCED (write the word)
16 DATE OF DEATH (month, day, and year)
/;S
5a If married, widowed, or divorced
HUSBAND-«f
(or) WIFE
aowea, or aivorcea #
6 DATE OF BIRTH (month,
7 AGE
Tears
4 ^
Months
| CS Davs
V
1
1 ^
If LESS than
1 day Iirs.
or jnin.
17 I HEREBY CERT1FJ, That I attended deceased from
yjy... yyyy.yy. ., to....._;^^r^^rff. a~? ,\o..s y .
that I last saw h.. ^?7. — alive on AnS.. ,19./!^.
and that death occurred, on the date stated above, at
The CAUSE OF DEATH * was as follows:
8 OCCUPATION OF DECEASED
(a) Trade, profession, or
particular kind of work
(b) General nature of industry,
business, or establishment in
which employed (or employer) ..
(c) Name of employer
.(duration) yrs. mos.
ds.
9 BIRTHPLACE (city or town)....Srr^.
(State or country)
CONTRIBUTORY
(secondary)
(duration) yrs..
18 Where was disease contracted
if not at place of death? f.
ds.
10 NAME OF FATHER
11 BIRTHPLACE OF FATHER (city
(State or country)
ity Y
Did an operation precede death?.
Was there an autopsy?
..Date of...
town)..
What test confirmed diagnosis ?
12 MAIDEN NAME OF MOTHER
13 BIRTHPLACE OF MOTHER (city or town)CT
(State or country)
cY«-C.
* State tW-lHSEASK Causing Death, or in deaths from Violent Causes,
state (1) Means and Nature of Injury, and (2) whether Accidental,
Suicidal, or Homicidal. (See reverse side for additional space.)
14
Informant iZMJht,. g,
(Address)
19 PLACE OF BURIAL, CREMATION, OR REMOVAL J „ ^
Filed 19 N...
Registrar
20JUNDERTAKER
DATE OF BURIAL
Q 19//
ADDRESS
«- p * w ^3 K s*
£5 IC ^5"
3 “*
c-
o &
5-3 =<8 s\=
3 B C ^ J >r ®
2.3ZPS-0
s-5'2 02 £
® 2.
3 ?-
g. gvr
„ *=3
3 _
" 5
° §1 3 >
<?•$. !
> g- 5c ^
ii-li
'o' b 53
• o
iph^e
a -CR P
” .. i— ® 55
O'* 57
g^- ^ . r~~ e“ .
p c Kp *o >
- “ re C.co p
^ ;g P-" 2
I- 5e,"rt “|
3 C? = :
-j. r^- 3* ~ ^
^ 02°
:P o
3 >
p- O O e+ C 2 o
*• M ^30 2 M
2"^ H2 S 5 :p s- cs*g 'S’TO o _ „
3 a £ q "2 .s ? 5 §g EC.m- » p_i «/»< ej- p. 5 n 3 g5 §" ‘ so c o
“ill ?>i i i^.l " » o I s-^a-s §
^ 5.'- g » 5 » S p z ““ -
§■2
g
o^
a o
o m-CT a
-•3 3
P P z
|3C®
n”p 3= “3-5-g’|-2 m!!® p ®
K 3)^) ^ O S-- . o V c*- n ^T. K
O 3- 2. 2.5-a Q-S >
sMi||q'9*,s
• Or-’ £ O O
S IS § S^g-'S § 2 g 5-
i S-e-a/g §-*• 32 2.2.3 2
t^?.-§ ^ 2 s- ft
a < m
C* C/Jg H
,a » « S 3
— ~ - 3 P a
a jq “ 7 •
3 P w
CO |3 -.
.US
£3*2 O
ef ®_ S ~Z.
a
3 ‘C
3p
*3 a m (S'
Co *-*• ct-> rs . ' ^
P 3 | ? CC’fl
S O.
3 frS
CC <
^ ^3
H b
b<<
b ~
£ 3 _
' «>
x
~ P »
3oo
P
^ 2 ,
cr c I
a o^
CO 2
cl- 05 X
3 £f a
b 3- S
C-r-^
§• rn OT m O O ca
a.f. 3 p >1 o h S
§ S-“<gg$
o ^ b r1 cc o
S0 3.-.B § g*^ s
cu od 3 »
rg* S a 3 1
p o »-< ^ 2 w
w j*r tr B
o ^ p CO 3
a '=5 so' 3
p
?cj’3
SI H?g
Sp'c -
p £-p ~ - M
in P !-< >- V
b co
^ o
e.w ~
3 3?^
p Q.
g "£3
C2 bta
^ co a
- g ff.
2.P ^5
3
S if P>.
i o5.to.
o^g a- 2
~ I a
^ |f P 1-11
® s p s § l>5 3-
S-Si 1 ?3
® g-o>
a X3 d
,<< a — ' 3
3 o § £ 3
e-*- -J - cr* cs
3 g
p ^
”g g-3
-3 3 3
ftg “ i_|H ^ja
° "5 3q ^ P" J TO
O c+- b r^- ~j . y
&» — • o — • co rri"
g§ | a 2 ?? P
w , O ^ K ^ ►- w -r;
B g’g-po^g
m3 g-
^ 2 w CO ^
e -?->§ S ?3 T-S’cV” p
S.^g-a.ETo'l g.S'S.a 5:5°. a a?
o s- » » 5 “ o. a
- 3
-sr
O 3
2&.®5®3'i(R
D S- 2 ~ £T.
>
o-sr
r — ;
=- 5 a'i5 p
g a-^co a p"'"::2
2 3 ° a =0 01 73
§ 2 o 2 2 3 ^a
9-1. 0^13
g SX> S a‘«
•2,? ? r a E- 7
-a
g |
c-g sg
g g*s!b .
“ s n §‘06
3?i-si s.
O - l - I I
P rr ^ Co" 3 B S
MTO as - ,o
2 o- p § Q cl a
a oj^l- 2.S-?
2 S&8 ’ sag1” I
a^p § CCl^'C^.'o'g
p^3^3 3?a*
00 2 fca a" o-o S
ct^i" P 3 S
^ O a> "1 3. «
.-3 £■„>< «'■•
b o
b
- co a t 3
-q:3 2
a » ^
3 2 a o
“ • “• Cn X
-■ 3 o P g. a
p .3 §. 5 Sr 2- S-
:_33 S
7 St<5 ».
5*3
3 3
2 a
3 P
1 3
O o
2,§.Og |.
o b P O
30 i.3 ®
02 r * g
■ S g M
■sga
f.-^lsS-guplaS
-iOiSPoOPj3- a,OM
1 3 a-M g p
■■H » a tfo ppeoarcs
- s crg-co o a
&3“ ® 38M?0-
P a o5
3 >~:
a 7'
? i® o W.'
o O-
s 3. 3/® 1 3
§ P pjB 3 I®
§• ix-- 5'^S.a
3 ,^r p^>^2
-3-2
P >3
=S^ 3 P g ^
2 o ^ ~ cp 3 §
S. hs o o b b h
- ^-3 0 O-^T^
A
*g 3 3
™ p 'tp
^0 3
^ >g b<-^ a .
S P cr 5 5.2^3*
2. 31b g. 5 B O 3
I I -i b- I b *-S b
ro
m
5"$ 2 5 3-S n 3 ” < I
“ g.3 CL 3 a ^oM 2 -
o p 3 ~
a ^
ct;
^-n t-j Ur*- ; c. .
a m.* 71 b
O'*
O'B-s ^ •
p 3 p
■ a 2 << &,‘5
k ^ a ~ a*^ co Q
v"bo P
;. 5 P ^ e* O *+,JQ *J
§ a.r^-0: ^.5i
s P O ? a
?&3®Sa?S
^o-o'3 g I § 3
o- b 3 g. co a b
P p
3 3
< o vS* Si
o 3 a 01
2-mE-S
o
»v 3 O
g P ^ <2 o
®<2 g s's^l S
® § 322 ?
=r
3 M
e-*- w
OJS !?a-0
? -CoS-'i§§| g-|
o?rs2|o 5‘dS 0
— ■ 3 — g.- 3 3 g
<T t) S- 5 - £
b b 3 < b
p b ® 3
co m-3
TJ O
“ *< or o S’ .g o 34 5
Scr®S' g-o a-s 8 “
. „ cS 2. o
m a < M
^ ^ mm - “ O (Dpf
3-C-3 o 3-^T.^ P-
c T‘jq Bb b I P b
b h- • — C+- 0- ■
J* o § b £T 1
m P a ^ ■
* P (K? 3 J
■ b b b 3 ^
— a g.g'L
e.g-|§'ft*|-g.g-
— 3 - >: *— • *-> e-»-
5" a _ . ^ a -.Oj- s'^p sro^
?.ao® °2 |o
5-. O H 3-3o
.2 3 3:3 S'j» 2
iigf- -iS’g ^p 01 ®3
® 3=3 f g“<5 o ® 2
<r**
« p*i
? 30
l =3
15
o
*TJ
o
m
3»
-H
3C
>
0
a
Ss
e ^
g ■
« 2
S.S-
- 3-
b “
<r»*
•°g
a-
o
a.a f°
S P
» ® 02
~-® 3
3 C-
S*
P 5 k>3
> y.
2'ol.u
>T b J ^
P ^ p
a-p
b
Cc' b r»-
b a-
V
2- g m
a *53 33
3 li
O
=5- 3
o oc
S.3-S
co xn
2 „ a _
g S *• g
g 33 S3 31
«?^.T3 b O
3 o £-^
53 co O 3-
a 3 3
0-5.13
o'
§o.2'
3 p Ccq
a 3 s <2
Sia
§§S
U.U.C ®
3 3
S35* o ^
CO 3^ O
• • b p -t
§ M S*
O. a sr
cop
3 3 3
C P
2 JC
3 3a
2-3 p-
P c+ a
M p
3 2ft
13 ~
z
a o
O P “
.ars =
■?® o
■ a o o
8 3
■5 8.0
o- a. ->
'■faff
, — a at
S^.3
fe'o-a.
3 o p
a P
o— ^
.0.
a 3
p-3
5' a- 1
3 22 ^
3 £-
1 cp
#i'i
• ,
S3
3 Q.
g —
® CJ“
co^
cT2.3
:§ §“p
og ft
o 2
O."?
•S-f
u
•y a
1 3
JS -
p
Is
• to
e
a
s
ST
EC. 3"
® C ?
(^3 3
ftft
a a -s
0-^-1
a'EC®
P =f 3.
•— * b
1 cr o
3
> a
:5 0 3
o o
> 3 3
:• P Cu
■3 £
o ^ 5
3 £" S
b 3
b co
WRITE PLAINLY, WITH UNFADING INK-THIS 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.
I.
m
z
-'1S-XXM.
CERTIFICATE OF DEATH
dommoiuuraltlj of fUassarljusrtts
:ANOAR
1 PLACE OF DEATH
County v) llllolk
Township Iil!?.throp.
City BOSTON
BOSTON
(City or to\\j^j ^
»»•
...State Massachusetts Registered No.'
.or Village T.T. or
No.,8.8 Circuit Road st, Ward
(If death occurred in a hospital or institution, give its name instead of street and number)
2 FULL NAME
(If in the Army or Navy ol-tliB Chitted Si
(a) Residence. No. ...8.8 QiXC.U^t ROad
(Usual place of abode)
Length of residence in city or town where death occurred
Statesfgive ranTorgamzaTi on , (
a.
months
days.
.../I Ward
(If non-resident give ci.y or town and State)
How long in U. S., if of foreign birth ? years months days
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
Male
4 COLOR OR RACE
White
5 SINGLE, HARRIED, WIDOWED, OR
DIVORCED ( write the word)
Married
5a If married, widowed, or divorced
HUSBAND of
(o.) WIFE of Mary Snellincy
6 DATE OF BIRTH (month, day, and year) Nov. 11 , 1858
7 AGE
Years
62
Months
2
Days
If LESS than
1 day, his.
or jnin.
8 OCCUPATION OF DECEASED
^Seidn7&or Store..
(b) General nature of industry,
business, or establishment in
which employed (or employer) ..
(c) Name of employer
9 BIRTHPLACE (city or town) BQS t OH , — — - — .
(State or country) Mass
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH (month, day, and yi
17
I HEREBY CERTIFY,
nf , 19 .1.9..., to ...
from
that I last saw h (M4U. alive on 19..
and that death occurred, on date stated above, at m.
The CAUSE OF DEATH* was as follows:
. (duration) .yrs jnos,
CONTRIBUTORY.
(secondary)
-(duration) yrs. mos.
ds.
10
name^ father Washington Spelling
11 B
'LACE OF FATHER (city or town) ...B.QS.t.QIl.
or country) MaSS .
12 MAIDEN NAME OF MOTHER UnknOWIl
13 BIRTHPLACE OF MOTHER (city or town)
(State or country)
Bos ton
Mass .
14
Informant Mr s. Iter yJE. Sn^llM
(Address) 88 Circuit Road Winthroi
15
Filed... ££.!.? 2-1- 19/^
Registrar
* State th
18 Where was disease contracted ^
if not at place of death? uJS.
FOR WHAT?
Did an operation precede death?. $**<3 ..Date of...
Was there an autopsy? JYO
What test confirmed diagnosis? f
/<3
(Signed)-
(Address)
/Sc*.
M.D.
the Disease Causing Death, or in Heaths from Violent Causes,
state (1) Means and Nature of Injurt, and (2) whether Accidental,
Suicidal, or Homicidal. (See reverse side for additional space.)
19 PLACE OF BURIAL, CREMATION, OR REMOVAL
Wocdlawn Cemetery
20 UNDERTAKER
(}< (J.
DATE OF BURIAL
Jan. 19 iol9
ADDRESS
F. Boston
p 2 s-
3 S
at
©
a
§ * S*g g ts-g
§-< 5 s- ► 3 5 cia
' a-S.||&^P
5 „ o' - ~
Q § 3
C Egt) >
- “ re -■“ 3
* =§ ? ” §
tr- "5.
■® = «, - -3
■3 Op - -
51? -0
CO
ft-5
CD
©-
2^
•g
I ® 8-
c-o
n ^ *-•
sr‘ V. <
S p p
r». *-i
811 mi 1st i nit&fH
saM.?!i-^
fT\ !>* *-*• '
O P '
CO r*-
I S® 3
o o
cp 2, |
'* ^ S
00 g-^
^ O ^
*53 _
Oa H*
-* JT r4- r.
g ^ ^P °
^ ^ ®§3
O-p O 2 » 3
3 3 5‘ 2 ®(R s3.3 ®
* |"aJ5| ~P s3
' S' _K = =
O.®
30S'S-53K 3 ' ^ cn m 2
s -5 3 i'- § 3 2 ?§ OG-ppS
© fcL c* 5*. O >T w 5 C"* • « 5 ? n
2 s* c* 3° rv ^ o ^ P p:
^ !••• p § 53.5. » S'? n,e ® p c
~-ig;?S-3 S-'g-f «•" ® 5S-" S«
» ® !?2 o S “ K
3":
p ;
< I
o C*0 ® o <
a- o 2 a; •
‘ S® 3 <| ®
O 73 P o
n O S 31
a o 9 ?.
R o JLS
/?- | ‘ "*S'ro &o'j>
;-' 03.&„ §rq 5^a
c “ ¥
j
P ~
9 P S',,!? |
3 2.
p a I 3 CO^
a
= SK pSo.
-J> -.H M.
2 5* 05 Q 3 3 CB
51“ 1 g ° a a g
o ® p a S
cr <;S?!5
a
3 P
S'
g. ? <! 5 c ^
■'• ^_.o Oo^
^>0 P Co O
«?* »1 {
5
p a
° S:
cr
o O '
cn ©
<r»- CO rj-i
p ^sT
?R?
o--&«s <S,
"H S *-*>^5 CO
•2 § c*© a
2- 2. *2 h m 05 5
i-sas e:|.‘r
s^r.Ss^i*
2S®2»» -3
S 5 o 2 2 e-
o-g.ogqsgp'
3 cl> £ S' 3 &
>£>;? ® 3 g p » cl
Bi SS3 S-o
P5?On33
O O ►i • _ <4
p o *-s ^ p ^3
» f^s* E.?r
O - w p co o
_ *” ^ Q* 3
P m3 P
3 = S?- a
— 9* -° =-2-
-aa -
o 2 *— < ^o
D P ^ s -
p -•P'*VH -
w P a ^y>
o - ^ C-. o Jm
S'?. 2^ ?
CO- O - p
s. -i3 ws-H
3 5- - ii. ^-2
2 ^ "
— p ag
P g'gt-
» p o’Oq
soy
- ~ p 2-
8- a &<3
!'l£§ ^Slop’ll |1 P|.f
"aPolP ?fvM^
oi-^OG.<as3(iiSS3 5 „.yp g-
2 p o c» o- o a<t»rf£-3
n.iaSaPa-w v : e j£ gs R
?°pO?aOM.o!2s^S‘ £ n
ff.R.gc’-a-otSqso^ ^
o Cc p Cf <^*3 D O 2 cra^ o ^ p
g S ^5-a.p frl s.a'o I s:“ g:25
p j*j ;
o 2
3 "*
^ o a-®
> -1 c
G-3“J]
-D C ■<-
ill I
“Is
o
a o®
«S n <
p o
® -v x ?
p.c p
png
pn’3,*i^CnpteS
C.S2 2 ,rt 35® E5_a ° V>
^ p. £? ^ s ~ 3
01
a
3 2
3-p
P M
™ O
S-
ro ST-”1 p
o w
p^ 5,0
3 ^'c 5
3 o S
?.^3p,<: 2.
5PQ'Oa.g. j,
2 S
m'W S-q 8 3 ”
“ 2 Q,P g^-G-O^ Hrt„
®"p®"w"' B)p K S 3
? G-m ^5 - S
®Se o
p *5 ^ 5 p g- § ®
“ 2 J§fT?2 a,
^ S.I^p
Ci '*• <
O
~ co
^ rs CC
“3 ^3^
2“' 3 o
o>
: * p
D-'' ^6
O W © *-! ^5 S
s ?3 12
^■•3 © p <r*- S'
P 5 ^3 o **. 5*
"* ^ © p^- A © ,sj o
-I I • I i-r
o
2,§.o® «•
o s p o
:o 2 3 -
tpQ*2 1
H S >1 O § B 3
3 g o cr^ 0 a-
Oo3^I»„
3.5/° g S-c 3
P P o-S £.5?'
5^ al
■§ ?-| cr“ 25-3
I 111 z* : S-Ii
.ere
1 O s s-
. « 3 p» 5 ^ ®
sj-E.gl § o
8.?" *8 -a"
- S®& (-5*3
app n 6 St-' Q,o'!W
® 3 O M G-JQ ^ e p
,.^mO • Jf o PPSjq
~J®03T=I 3 0- 3‘ ® « O
“ -4. o 3-£C5 ® B,^£“G-
c3 S
® 3
c- a
.5 5_-i 35® 2-2.3 2
_!e?S . — o 3.ff
"3 3^3^3 VS
-1 ® S>~2'M
PO
m
o
. o M ^00
S <B M ®
gq a
P ra
< “ 3-
^ w ® ■e „
03 o 5.5
® ~ 3 G- ®
C7-3 S’ rt
O O « kx®
C*- C S «--
© c ^
» c O
£ ^ 3
1- -T5
^ & 5,
o
bi® -
©-*a 3
© o
r- o a
So®
IS'SS'
y«,gtf 5 p o . o » ^
OjP s-*3 |cr 3 2 P 5^
hjOO ©o 2 0
§ ©“-al^s-G-
~ - - o c
J ^ g 8 ^ o
I §
S 5,S“0 g.?,—>3
tJ. 33 a £.3 e* o 3
1 1 1 a 1 ® b it
g I g.5’S^ aj
S!^ en o n~ J o
O-jq O 0°- ^
SB'gtrl^pI
tzr O- p - m- ^ m
CO * ©
P
£3
OS "5
a.®
,3 §1-5
■3 S S E
^ s s o-
2 x-v^cr
3 3gc
w
p ^ © o
2. ^ ~
«?*'©©
O 5 ? O
aSTgl-
„ ^ >
a
■T3
E- w a
H'O P - S'
a 3 £'
2’p S' p 6
£ S ® q §
-Rg^'3
r*- O S
S-S:0-00-
«* ® —I
o??S^s-
3 o’?
gp «
s ?. S
.S O £
p —
® S’— -“
2 §■ » 2
O © W M
a •** *.
G.1? ^3
"jq 5,(5 07
P 0>
1 P cw
2- 5
£. ~
©* Q
H| g-
g-! S-
0 a
S B‘
<r*- <? .
t- ^ — C3 ^ j
3 o-^c S a ? w
p w ►-. c+ § ^ -j g 2- o
5- ? 3‘S a ® S 3 c t»
ffl - = -'s-‘'ji^5l*
^ O O'? —
2 3 « 01 g
O 2 3 =r
^ O 5 P w
2. a §; o
b 3 o (t 2^0 J do ®
3 erg^ r 3 ® o pS-
S.g < 2.3 <'S
g'5'^E'S «s a p - ® 2
6- |^q=S'§.?cg
M g 2.a
® o ?3'8 S Z.
^2.° k- Co" 5'S-3 K2.
^ g-grs-S^® |o
&|g-^ii £| i'll
®q p.?| ? s<< SS.?
a | ,
5 w
n' ^ -
O CP M
CP3
g-
DRM R-301
! 5
E Q
co
<2 U.
c O
1 <
2 o
©
>» •*-
• CO
©
>
LjJ ~q
. *3
Q O
oc ^
O *
o CO
) a z
; oc <
: h «
! 5p
i Is
oc
C£
• UJ >
; a. _J
<o
C/5 <
i X
1 CO LU
1 X -a
<n
cz
o o
a qz
X ~
I ^
Z a)
” .a
X "O
O 2
< i
<2 °
© "o
<y> °
cs w
o ^
_ o
CO
to
) 5 UJ
' z o
r 5 <
t < .
1 U- -a
Z a>
3 =5.
X Q.
i— 3
if)
>>
w >
Q. £
O W
a. ©
© **
1 1
5 ~ X
>2
-J ©
< O
r-* ©
0- .C
© C
o
c
- o
W 3
QC O
£ -g
I
co
■O-’IS. 100,000.
<5f}? (Cammmtttipalttf of Haaaarljuaptta
STANDARD
1 PLACE OF DEATH
County
£
City or T own
CERTIFICATE QF DEATH
State Registered No.
2 FULL NAME
OFFICE OF THE SECRETARY
DIVISION OF VITAL STATISTICS
No. .Z Z.Z St. Ward
(If death occurred in a hospital or institution, give its name instead of street and number)
(a) Residence. No. J S ^
(Usual place of abode)
Length of residence in at; or town where death occnned years months
(If in the Army or Navy of the United States, give rank, organization, etc.)
St., Ward.
(If non-resident give city or town and State)
days. How long in U. S., if of foreign birth ? years months days
3 SEX
PERSONAL AND STATISTICAL PARTICULARS
4 COLOR OR RACE
5 SINGLE, HARRIED, WIDOWED. OR
DIVORCED [icrite the word)
5a If married, widow*— hy
u 1 1 wire af
6 DATE OF BIRTH
( Month)
7 AGE ? 1 — Tears ^7
If STILLBORN, enler that fad here
If STILLBORN, state period of ulerogestation
Months
. <P - / <P
(bav) (Year)
Days
if LESS than
1 day, hrs.
8 OCCUPATION OF DECEASED
(a) Trade, profession, or
particular kind of work
<b) General nature of industry,
business, or establishment in
which employed (or employer)
(c) Name of employer
9 BIRTHPLACE (City)
(State or country)
10 NAME OF
FATHER
11 BIRTHPLACE OF
FATHER (City)
(State or country)
12 MAIDEN NAME
OF MOTHER
13 BIRTHPLACE OF
MOTHER (City)
(State or country)
14
Informant —
(Address) ^5
15
FUecf-*?,^ P
(AJenth) (Day) (Yeaf)
Registrar
MEDICAL CERTIFICATE OF DEAT
16 DATE OF DEATH
/(Month)
17
I HEREBY CERTIFY, That 1 attended deceased from
, 1 9/f .to / V" ,19 / % ,
that I last saw alive on , 19 /?,
and that death occurred, on the date seated above, at
The CAUSE OF DEATH was as follow^ :
(duration) ^ ^ ^yrs. mos. ds.
CONTRIBUTORY
. (secondary)
(duration)
18 Where was disease contracted
if not at place of death?
ds.
Did an operation precede death? Date of
Was there an autopsy ?
CJ
(Signed)
What test c^^med diagnosis?
t_ 3-u , Jfr- ^
( Montii) ( Day) (Year1
M.D.
(Address) ,
Date
19 PLACE OF BURIAL, CREMATION, OR REMOVAL
(Cemetery)
DATE OF BURIAL
/Vi
19 r ?
20 UNDERTAKER
ADDRESS
21 I HEREBY CERTIFY that a satisfactory stan-
dard certificate of death was filed with me
BEFORE the burial or transit permit was issued
5&
Official
position '/
^~22 Date
or transit
of issue of burial n ,« / /7
ansit permit v *.
ft i I
% 5'! :
& m g i
a ? o •
« a
P*
R »
P
o W
►1 o ^
* 8*
o £
o «» sr
^
w P
a <2
•a
££ © p
1-1 H
2- «« E
2. co 5
& *5' M
£* R* <,
? “ I
ft H
Fgto-
t> i -i
n* 2- ®
o P S
S"1 5
§ & 8
P s p-
> O g «•
£ ® o
•a -
® i
II
to 5'
TO
CO £
® CO
•O "
||
i I
£. 2. p*
? & S
O O o
v a p
ct P
Di © r*.
°'£&
5,
F p
. p §
§ a &
3 O K'
s-° §
ESI
2 c» £
P p- O
“ ffl P*
m
O
cn
— J
>;
C/J
-H
3»-
O
3»
<“5
EH
PO
o?
s
|. pH
— o
■n
o
pn
3»>
■—3
EC
5» w p- o. g
® P o ®
S ”3- 5. s-
S o ■
p. p <<
►T p
<=-g o £ a« •« ®
® a’’?" Eto-S
; 5 h.o ( S
F°PS. o-ojl
a§« 5- o ®
& o §■ “ S £ |
a B a&S S p
1 tr4 p co 5*
jffgB
2 rt » ...
O O co ®
B co M.
“ © B
a* <!
CL CO
Is.
W w - P C ~-
® c^f+1R g-S
R R © ® §-
n p co ® CO P ®
2: 2- «• a e ° to
W o O 6 " P
SPB.E-5'I®'
CL O
ct- P* m
g* & 2
o ffl *3 &
t» o ?• &
3- io H*
1 B CD
?' S. O
3
O t3 i « C
o W & | >
S' 2 w s> I s s
"< B <5 "I 6 . B
g- B 3 0* ® O 5,
2. o o o 0 ^ K
S S ”■
B co
O v;
l II
F« r ■
&4
CT « vr
CO p4- tj*
2 p- tr **
°-, g o hj
5 I? ^
e. ®
r *a
p p*
V. Vl «—
® c E b r 6
2,g-s« g S.2
g P 0 a. a. ?
~ £J w S’ O' F “
F M - “<2 2
a o S g B-g-W
& n, p a. a *< I
I ® IK
O' m ^
S & B
g (D Q- C
B- °* f ®
MffP
B | S' "
® F p*
&- p-
«-*- ©
O »< O
R- 2
< 8
li-i
ae
s? P cr
p. cf V-
© *-t „ *v
p g © 3.
r«- ® 8 c;
S' & <5 ^
8 S I
B ®
o- :i
" i?
>< E o
S.
w
cl
to
o
►fl
►tl
so
>
o
H
a as.?
S’i&S'
g. r 8 o.
® & g g
o S’ ® |
© p R o
p B ® P
t? 8 g F
s-8 S-8
1 1
If
M O
P g_
CO ®
I c I’ & p f
® « © © o HJ
3 e a-a sj
§■ * s. 1 5- a f
2. to s? ® tr s.
© p P- 0- o
n o o P R t3
© • S to .r
P- . 2- ^
tf ti *d m 2 ®
© ® c E B. ?°
a. ^ tr 5* m
Bo^ »ftP
© O ►-.►3*0
^ otr- p
p p. ® » p
pRg.^S
” § s» j,
O© . a ^ M» ff 2. O rr*
© Vi CD „ ft u* p. (2
b; 2*
5* ®
Cj B V*
® p o
M © © v*»
&C3-0-
sp ?g>S ?
£ Jw ” g. -
$ a « 8 I
c* o ^ o
2 o*^ P ^
H ft »
S a e*
pSM ^D«H.o£!,2eto0N
® BaCoPh.^S S^oO0*50
i g- a « & & « 3 p b g' a * §■ s g g •
?o'g 5 ®isa°apcn?'e'?D,S,i
©p-tP 7 hi mj P Pi ►* p. I I - 1MM.
• ^ ® © Sf
PU ® q p- ©
.$ ,-t»Po — P^©
bt ® S- g4 0- ® tQ
s » • ss gs » g
“5tgogp-BS.tr
o®^p
a 0**53 O'* ?2,g P
•ti ■< ®
' <rt.^O®Pp'p©
»S p (« w ® p s
.‘“©©SCjtdfl.O
► AS £2. t3 ° © © d
s*l §• S
is-ScS-rs-si
oi'3»»S'woB
I p P4 © ® o R O ®
^ P B P P
- P- © © ©
B4 R* %
5’ R* ® S
7}
m
H
C
30
Z
0
-Tl
o
m
7)
H
Tl
n
>
H
m
cn
0
■n
□
m
>
H
X
o
0
2
2
0
z
$
PI
>
r
!3
I o
MARGIN RESERVED FOR BINDING
-WRITE PLAINLY, WITH UNFADING INK-THIS 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.
Ottfe (Eomaummrattl] of iHassarljnsrtta
CERTIFICATE OF DEATH OF NON-RESIDENT
1 PLACE OF DEATH
County
City or Town. — i
Registered No.
State .^AAU., .
dyU,
M \j, J (It death occurred in a hospital or institution, give its name instead of strt
.U, Vxjo^;
Registered No
(Place of residence)
St., Ward
eet and number)
2 FULL NAME x
^ » (Ifjn the Ariuy or Nhyy of thajjnited States, give rank, organization, etc.)
(a) Residence. State __(V\<^bt^..T .City or Town No. St.
(Usual place of abode) . p. \
v. years V months ' days How long in D. S., if of foreign birth? years months
Length of residence in city or town where death oecnrred
days
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
3 SEX
4 COLOR OR RACE
5 SINGLE, MARRIED, WIDOWED, OR
IY0RCED ( write the word)
16 DATE OF DEATH (month, day, and year)
)0»A-Vd ^
1 1
5a If married, widowed, or divorced
HUSBAND of ft
6 DATE OF BIRTH (month, day, and year) — ~ —
7 AGE Years Months Days
If STILLBORN, enter that fact here
If LESS than
1 day, Jirs.
or min.
8 OCCUPATION OF DECEASED
(a) Trade, profession, or
particular kind of work.
3<k XuAAJUiT
17
I HEREBY CERTIFY, That I attended deceased from
.'jkiVMt.i. ITT..., 19.VH.--e to- -^.^V\.!.....k^V...., 19.1..^..,
that I last saw h.kkAAu... alive on ^3aa_..^Hc * 19-^t >
and that death occurred, on the date stated above, at \AAb k. _m.
The CAUSE OF DEATH* was as foUows :
•State the Disease Causing Death, or in deaths from Violent Causes,
state (1) Means and Nature of Injury, and (2) whether Accidental,
SuicipAL, or Homicidal. (See reverse side for additional space.)
cidal, or Homi<
(b) General nature of indostry.
business, or establishment in
which employed (or employer)..
(c) Name of employer
9 BIRTHPLACE (city or town)..
(State or country)
10 NAME OF FATHER
...ds.
AA /USVAA
CONTRIBUTORY
(secondary)
18 Where was disease contracted
if not at place of death ? _
yjAvsaA
. ds.
11 BIRTHPLACE OF FATHER (city or town) aA..
(State or country)
V —
12 MAIDEN NAME OF MOTHER
Did an operation precede death?.
Was there an autopsy?
What test confirm^
.Date of..
13 BIRTHPLACE OF MOTHER (city or town) V...
(State or country) n
T
(Signed) ...
/2>\,19\^ (Address)
pd diagnosis frVU
M.D.
14
Informant
(Address)
19 PLACE OF BURIAL, CREMATION, OR REMOVAL
DATE OF BURIAL
15 Filed..^.fiik. A , . 19^_
Ffled..)L:fkir. 19 1 '
•OAA. ..
de^th oecnrred
)V &M, 19^
GO
Registrar of city or town-
20 UNDERTAKER
ADDRESS
Registrar of city or town where deceased resided
§ s
C-o
- ?7* e+ O 2 W • u w
~2 - e s-g
2.9 z p > - a
^5 S ® sr. o '
o 5 _ c *r$ *"*
rSo.gS’lg.s
>
C ^ C* I!r
05
2. B "•§ p.:
<r»- ^ MC £
-/Jill
I- .
j 8® .'
c+sl”
= 1 £11
S 2 P 3 g.'S c"
E § 3 g S.PTa
^s- ava’^E.g CB 2
?g ip-l i £■•<< ° o-a
js tj>? g p
1:5.- S ®
SE$3P
^ P
S’ sj
g a p
- _ p >i
•0 5
t-> O O e*- C ® « « O P- S' <! fcl -Zm
-pg.5*?'? " £§■* & 2 of 02 B
o s2 § 3.8 § t^s 1"= « < p
• cD K SlL >-j
’ 3*2 s-a jsa
Ss, „0
d52.
; s a'
fe-Sig-o off:
» o
p .
a :
p-
a.
1 a-<
S-S.1
- e
S’"
©
er-
gs ©
P C
'C S
cr°
a e 1
P tT;
S’ SjS
C--— :
g-s.
■v _P .O
&* -=8 g
a - rt
•a ^P p g1?
Hi* r ffP
I p ITS ? GO "C^
I 3 gfe iTg O.
§;» g g 8 o a "
a a ® p
s cr. -c e
- ool
« ^2 S
P3 5. w. 0 s
a a. a ts j
^ C: P ^ T
©3*0 § -
S E° £ § a-g0”
”2/ * S’ §3
- aH-u x v =2
3 m a ® m s3
S ?TQ ® S ►’da
g h or a cr
° > o' tS CP
p SJ C-
_p o 2 g P
arc ; 3~B 2
g*-® ST =3
2. s a- - ^
a „>-4 c:
- o ^ Cl ao
££3 g-o'S
I r-5“-
p~~p cc.§
'05 to P
w —
§ s
w e
2
P o
> CD
P _
»-n^ pi
' o P
^ 5?. ^
< 5 5'
. © rvn
| 8-*-61|;
13-ce
era -tj
m ! 5*<ss S .
.§ =&: 1*3
-I o o£-;o
SB
e*
ll?^I^Qp|||.^|.r
2 ^ j2. ^ p
"E.
03 rs* O CD S* CD e+ a?
s*. © a. CD M-** CT- p?
o3OB S'.
.. ~3'o ° § a §
bp § ff 3 s2S-g2
" 3 tTd § O^P-’o'S a B g g-i 58 a
lEl^li-rl.” 1 i § r-S.8 r
3- 50 !S S5 « S
_ .. «, a a § o
5* “C © D“J® OR 2 m
o -
P. o’g
- O 2
g 2 ffi *d
3 § a g.5
® ' 1 5- p- 0 ^ a -3.
P Q _v. P ^
o o h k* 2 Q
§■^11
s -« » “ - ^
'^c,"p „ wt'T1 ®«3
Oja a^&’g’o' B S
U?pSh.&§ •sig.-g g 3
b s H&: B-i ^ B E
® s M
:a 2 |
- m— ^.g'2 p o £ ^
2 3 3® p §
!? 5-"^ i® O OR
Pa co - -
-a|| E|i!s.g s.g.8 1 ?§| p &I
s-s ii ^s.! : §5£va ?lc S'
3„ a."
S 3 -3r
ag 3g
^>1-3
2 CD 4
© • < i
s ^o.
i j° 5".
o'O^
>-i
■•£.?. ?”r b
. CD i -
g-as £.
hj . _a cj
fc3^ >i
a p 3 i-i M
3. a 3 g §■£••§ ® !
,-al £ P2 S’! o 1
— ~Z - '■
l O
S.=Q P.1
P o
S 43 d
» 3- “
-o-- gv-ag
to Sf ^
■ -23?
s 3 0
rr w -o- ^ ■_/ >—
p o- © c. cl s
r! © 2*. s *-< o >-
^ I c *-s »
& aj ^ 13
yp.; o
^2:
■ cr-
1-1 * 1.1
,.S? 2.
ri , S p
p c® P *-0.
1 a ® a*
cr „ a r.
o ? P
^STB*® pgl'5|!
2g‘2rar;>-Hjt0-,3p
^ | ^ 2.9 iSsf-ii < s
- a'p 2 S -S'— ^ 'S ■ • 50
0 s-^a p-S e
^ cr i
rS®g
2oo"°SoH§2.ii» o~o “o S-^a P-S^^ g S'^l 1. a *
!i»°S;>1o"®‘c'S'~S -a'=&3ao’cc^a-gi'"’ £o-
flapB- h.°5" oc KcP'-cggog.a^g— p g.
sja^ttiss^to ,a|^g5. TS- oaCo” B'^a E
-8|
^ P ^P
MV O'®
O a a
a o-.jq o
00 a a- a
r B'3.3
P'S:3 o = -
O 1 05 >“+» O O
&| als
n prs «
S' a ■ ^ 5 -.So- B->slp —
2a^iof3va^o«3§a0
-s §i S ffl § P’mccs S’ I S.a 5-S a
p jq 3 r c ® cc S 2 c
a cm — aa3 c^-rt- ^ -- Pas ^
a.| f g,a<3 ? a 2,?
■ p
o
»*3
o
5 »
CD
s «
S a
5RM R-301
E S
c UJ
o
LU q.
3J
5 £T
0)
£ >
•>
= |
o H
■c <
« Q.
CO 3
z o
< «
CO o
>• *.
£I
. ®
>• "S
< CO «c
x * ~
0)
# T5 ».
« <£ ®
® O
c/> U
-S^-S
" -o
— >Y
3
O
(/>
a- >
o «
^ -r
O ^ S
< ® «M
. >J
T3 W O
.2 E i
L. <0 l.
> ^
Q. <0
Q-Z o
— «
>» X
o
3 <0
2 1
CZ £
O L.
_ 8}
= 5 a-i
CD
Z
0-’18. 100,000.
Sty* (EammmuM'alth of iKassadjuactta
1 PLACE OF DEATH
County
STANDARD CERTIFICATE OF DEATH
OFFICE OF THE SECRETARY
DIVISION OF VITAL STATISTICS
City or Town
State Registered No.
No. ^ St. Ward
(If death occurred In a hospital or institution, give its name instead of street and number]
2 FULL NAME
( If in the Army or Navy of the United States, give rank, organization, etc.)
St., Ward.
(a) Residence. No. <7
( Usual place of abode) 4 _
Length of residence in city or town where death occurred
years
(If non-resident give city or town and State)
months days. How long in U. S., if of foreign birth ? years months days
PERSONAL AND STATISTICAL PARTICULARS
3 SF.X
4 COLOR OR RACE
5 SINGLE, MARRIED, WIDOWED, OR
DIVORCED (write the^rord)
5a If married, widuwett7 or tllvurced
To^WIFE of //■
6 DATE OF BIRTH
M <mt\
7 AGE Years 5*
If STILLBORN, enter that fad here
If STILLBORN, state period of uterogestation
( MOuth)
Months
/ 3
~s*
S<.
/ s> P*
(bay) (Year)
Days / e-
If LESS than
1 day, hrs.
8 OCCUPATION OF DECEASED
(a) Trade, profession, or
particular kind of work
(b) General nature of industry,
business, or establishment in
which employed (or employer)
(c) Name of employer
9 BIRTHPLACE (City)
(State or country)
10 NAME OF XJ ' .
FATHER C#
11 BIRTHPLACE OF ^
FATHER (City) X
(State or country)
r
12 MAIDEN NAME -
OF MOTHER /
13 BIRTHPLACE OF^ ^
MOTHER (Citv)
,^c \
(State or country)
14
informant
(Address) «_r*
15
Filed ,k31 ,
(Month) (Day) (Yea
Registrar
21 I HEREBY CERTIFY that a satisfactory stan-
dard certificate of death was filed with me
BEFORE the borial or transit permit was issued /
-O'
^ On.
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
Utf&L : 2JL •
(Monthly (JOSy)
car)
17
I HEREBY CERTIFY, That I attended deceased from
Ca^L* / IT ,19/.#...., to. / tT*l ,19'/ ,
that I last saw h alive on ** /- J , 19 f ,
^ // X-7
last saw h alive on
and that death occurred, on the date stated above, at
The CAUSE OF DEATH was as follows :
(duration)
ds.
CONTRIBUTORY
(secondary)
(duration)
18 Where was disease contracted
if not at place of death?
yrs mos.
ds.
Did an operation precede death? Date of
Was there an autopsy ? ^
What test confirmed diagnosis?
(Signed)
, zV/ r'
M.D.
A
/7/f
(Year)
\9 PLACE OF BURIAL, CREMATION, OR REMOVAL
(Cemetery) / & (City or town)
20 UNDERTAKER
DATE OF BURIAL
19 *?
tZ/Zs/c
ADDRESS
Sz
22 Date of issue of burial
or transit permit
ial C-
7
S» w
3 ®
C
, i
® Is-o
3 ® ® ®
O O B T.
a g 8 ~
S' S ^ o
• £ ® o s»
® 2, ** ®
I * d CO
" •> S' 5* 4
?» ►* r=
a Er&o-
2 o ®
:8&13
« s g s
. p d ^
:So£»
3.9 5 c.
d * ®
F 8 § o
:??%
.«< p j] a
. 52. d 2. pi
1 *0* 5’ £ d
© - & *?
IT O O o
g £ £ g
I . *2 d P
BO- ® *Z
O* X d
L|Sf I
1 i -? I §
t— O 1+ 05
1 °
• wPOC'
i - < 0 2
► a C - P
j Iss g.
S g 5 £
i . o tr
© a ® Jr* : ^ > o o B o 2-
- ° ~ S £ 5- S 3 1 ■o?- 2
p 7
vj 3 -j
- - J -
B = :fe’§ e.-
£«6§!S3§2“„»
•- g- o B. „ 5' ® •a •• ® S
oil ' 8 g-
O® p O > X fi. w
a 2 o 3 ® dd_®
M o § # << cr J U 5. 2. =•
’5 5Q Q O —•■
® : - ^ ^ —so,,
- ^ 50 cn J ft £3 «- Q. t
* td * S' b <♦■ Li o 5 H
ft g 0 v2 B ?= 2- o H |. *
- - -» - “ - ® - »• pi S?
t»^®0 oO>
=rdO‘B 0 P-2»
O ^ - ’O *1 to D C r?
o 2. 3-’ ^ 0 S-O)® 8
*• g- V! 2 g- § S.3. 2® 3
:G -22^©o*2S»
:.®9J9 ?s £s T
o :o2S? -S “h®
fwf -® Il^l|-?
■«2 fts.S 8 i : •
£fi
*■*:<? -2 § 1 ° B-=r:
| ^2 = g.|| S' S' § g
* r I? - - » O ® 7 » S g
m
o
s
s-
SO
m
H
C
3
Z
0
-n
0
m
x
H
■n
n
>
H
m
Ui
0
■n
□
m
>
H
I
n
0
2
2
0
z
2
m
>
r
0 -I
2 i
n
1 0
S 71
1 2
" >
(J)
ifi
>
n
1
COMMONWEALTH OF MASSACHUSETTS
CITY OF
BOSTON
FULL NAME
Place of Death
Date of Death
RETURN OF A DEATH-1919.
FRANK ALDEN Registered No. • 540
Boston PETER BENT BRIGHAM HOSPT .
JAN. 2 7 191 9, Age 57 years
months
days
STATISTICAL DETAILS.
SEX
COLOR
SINGLE, MARRIED, WID., DIV.
M
Maiden Name
Husband's Name
Birthplace
M
PHYSICIAN’S CERTIFICATE.
I HEREBY CERTIFY that I attended deceased during last illness
from 1919, to 1919,
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:
Name of
Father
Birthplace
of Father
Maiden Name
of Mother
VINEYARD HAVEN
JOHN ALDEN
Ml DDLEBORO
HEPSEY PEASE
ACUTE PERITONITIS-DAYS
(autopsy)
ributory :
(Duration)
CARCINOMA STOMACH -I MONTH
Birthplace
of Mother
Occupation
Informant
VINEYARD HAVEN
WATCHMAN
(Signed)
E .P. HOWARD
1919
M.D.
SPECIAL INFORMATION from Hospitals, Institutions, Transients, or Recent
Residents.
Place of Burial
Usual Residence
W 1 NT HR OP ( 22 HARVARD
' or removal
Wl NT HR OP
i Undertaker
C.R.BENNISON
Filed
JAN. 30
i Date of Burial
! L.
Wl NTHROP
A true copy.
Attest :
1919.
< > •• '7 f 7 ,
Registrar.
7
p •
-o
o
— o
Form R-302
u.
O c
_ OT
« LU ■£
~ (/> o
5 Q.
0) s_
-2 >
CO
to
— 2
'>, § 2
M5
u <n 9;
ee ^
a ui O
5zo
Q fi
Z z
— <
m 2
ce
X 05
O 4>
£ O <4-
< ~ O
u c <»
© CO
J c +-
-» c cs
5 ® o
_ m E
-+-u
3 « «-
- ^
► o O
C3 t*_
. * o
S“E
- -d 5
j « »
tc >■
< '« (U
0 C3
c -
< <
2 t
>-
—i
z
<
_i
q.
UI
t
cc
3:
l#
02
ui £ £
Sf 1
• 5 *
S - £
— o o
Q. co ®*
- i
3 CO x
co £ 0)
^ «- t_
— tlr
1 PLACE OF DEATH
County .Vj^,
City or Town
2 FULL NAME
(a) Residence.
(Usual place
Length of residence in city or town
©Ip dommmtuiraUIj of fHaHsarfjusptts
MEDICAL EXAMINER’S CERTIFICATE OF DEATH
. ^(ISSBEIMONDKR THE PROVISIONS OF REVISER LAWS, CHAPTER 24)
J?_
tal or institution, give its name
OFFICE OF THE SECRETARY
DIVISION OF VITAL STATISTICS
Registered No
(If in the Army or Navy of the Unite'
St., Ward.
St., Ward
street and number)
, give rank, organization, etc.)
(If non-resident give city or town and State)
How long in l), S., if of foreign birth? years months days
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
4 COLOR OR RACE
5 SIMPLE, MARRIED, WIDOWED, OR
DJYIIRCED (lerijjfthe word)
5a If married, widowed, or divorced
HUSBAND of
(or) WIFE of
6 DATE OF BIRTH .
<$2r V real
(Month)
(Day)
(-Year)
7 AGE
If STILLBORN, enter that fact here
Months
Days
8 OCCUPATION OF DECEASED
(a) Trade, profession, or
particular kind of work
(b) Geoeral nature of industry,
business, or establishment io
which employed (or employer) .
(c) Name of employer
9 BIRTHPLACE (City)
(State or country)
Filed .V ,
(Month) (Day) (Year)
Registrar
MEDICAL CERTIFICATE OF DEATH
16 DATE OF D
Ct<sL' .
I onth)
t 3M
17
I HEREBY C't RTIFY, That I have investigated the
death of the person above-named and that the CAUSE AND MANNER
thereof are as follows :
If LESS than
1 day, hrs.
or min.
(Signed)
18 Where was injury sustained
if not at place of death? ,
(See reverse side for additional space)
t
(Address)
dj
? 0 S , -Z-tfi cL UA,
Q.V-Us.
, M.D.
Medical Examiner for
Dale f ^ ( ^ t (
(Metith) (Day) ' (YearJ
'19
PLACE OF BUR^j
L, CREMATION, OR REMOVAL
20
TINDERTAtf
DATE OF BURIAL
/ a,? it 19
(Month) (Day) (Year)
ikSS
21 Burial permit
issued by
Official
position .
22 Date of
issue
EXTRACTS
FROM THE LAWS OF THE
COMMONWEALTH OF MASSACHUSETTS
GOVERNING THE
RETURN OF CERTIFICATES OF DEATH
A physician shall forthwith, after the death of a person
whom he has attended during his last illness, at the request
of an undertaker or other authorized person or of any member
of the family of the deceased, furnish for registration a stand-
ard certificate of death, stating to the best of his knowledge
and belief the name of the deceased, his supposed age, the
disease of which he died [defined so that it can be classified
under the international classification of causes of death], where
contracted, the duration of his last illness, wTken last seen alive
by the physician, and the date of his death. . . . — Revised
Laws, Chap. 29, Secs. 10 and 1, as amended by Acts of 1910,
Chap. 322.
No undertaker or other person shall bury a human body . . .
until he has received a permit from the board of health or
its agent, . . . or . . . from the clerk of the city or town in which
the person died; . . . no such permit shall be issued until
there shall have been delivered to such board, agent or
cleric, ... a satisfactory written statement containing
the facts required by law to be returned and recorded,
which . . . shall be accompanied by a satisfactory certificate
of the attending physician, if any, as required by law, or in lieu
thereof a certificate as hereinafter provided. If there is no
attending physician, or if, for sufficient reasons, his
certificate cannot be obtained early enough for the
purpose, or is insufficient, the chairman of the board
of health, if a physician, or any physician employed by
said board or by the selectmen for the purpose, shall
upon application make such certificate as is required
of the attending physician. If death is caused by vio-
lence, the medical examiner only shall make such
certificate. . . . The person to whom the permit is so given
and the physician who certifies to the cause of death shall
thereafter furnish for registration any other necessary infor-
mation which can be obtained as to the deceased, or as to the
manner or cause of the death, which the clerk or registrar
may require. — Revised Laws, Chap. 78, Sec. 38.
Medical examiners shall, in all cases, certify to the city or
town clerk or to the city registrar in the place where the
deceased died, his name and residence, if known, otherwise
a description of such person as full as may be, with the cause
and manner of his death, and shall make examination upon
the view of the dead bodies of only such persons as are sup-
posed to have come to their death by violence. — Revised
Laws, Chap. 2A, Sec. 8.
RULES OF PRACTICE
The fulfilment of the purpose of these laws calls for the
observance of the following rules of practice:
(1) Attending physicians wall certify to such deaths
only as those of persons to whom they have given bedside
care during a last illness from disease unrelated to any form
of injury.
(2) Board of Health physicians will certify to such
deaths only as those of persons who, though disabled by
recognized disease unrelated to any form of injury, have
died without recent medical attendance or whose physician
is absent from home when the certificate of death is needed.
(3) Medical Examiners wifi investigate and certify to all
deaths supposably due to injury. These include not only
deaths caused directly or indirectly by traumatism (including
resulting septicemia), and by the action of chemical (drugs
or poisons) , thermal, or electrical agents, and deaths following
abortion, but also deaths from disease resulting from injury
or infection related to occupation, the sudden deaths of
persons not disabled by recognized disease, and those of
persons found dead.
STATEMENT OF CAUSE OF DEATH
For violent oeaths state means of injury and qualify
as accidental, suicidal, or homicidal, or as probably such,
if impossible to determine definitely. Examples: Accidental
drowning; Struck by railway train — accident; Revolver wound
of head — homicide; Poisoned by carbolic acid — probably
suicide. The nature of the injury, as fracture of skull, and
consequences (e. g., sepsis, tetanus) should also be stated.
DESCRIPTION (for unknown person)
NOTICE TO UNDERTAKERS: No embalming fluid, or any substitute therefor, shall be injected into
the body of any person supposed to have come to his death by violence, until a permit in writing, signed
by the Medical Examiner, has first been obtained. — Revised Laws, Chap. 24, Sec. 20.
THIS CERTIFICATE CONSTITUTES SUCH PERMIT
WRITE PLAINLY, WITH UNFADING INK-THIS 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.
I
GO
z
JElje (Cmmmmturallh of ittassarijusctts
(City or town)
Registered No.
STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH
County y State
Township / r /a t r or Village
city ' No. .a zz,
yAM death occurred in a Hospital or i
2 FULL
(a) Residence. No. S. Ward
(Usual place of abode) (If non-resident give city or town and State)
Length of residence in city or town where death occurred years months days. How long in U. S., if of foreign birth ? years months days
^±3.. . £ Ward
fcspital or institution, give its name instead of street and number)
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
'7 f itf ^ (c
4 COLOR OR RACE
5 SINGLE, MARRIED, WIDOWED OR
DIVORCED {write the word)
5a If married, widowed, or divorced
HUSBAND of
(or) WIFE of
6 DATE OF BIRTH (month, day, and year)
' AVf
7 AGE
Tears
7J
Months
Days
If LESS than
1 day, hrs.
8 OCCUPATION OF DECEASED.
(a) Trade, profession, or
particular kind of work
f.
(b) General nature of industry,
business, or establishment in
which employed (or employer) ..
(c) Name of employer
.+ a t.../-*, « f
9 BIRTHPLACE (city or towny, r * * a Y-. * €7.yt.
(State or country)
10 NAME OF FATHE <* e 7 7t t.
11 BIRTHPLACE OF FATHER (city or town)
(State or country)
luigr or lowu).,.
f < Ql at r 7
12 MAIDEN NAME OF MOT
13 BIRTHPLACE OF MOTHER (city .or town)
Jl
(State or country)
< A
14
Informants
(Address)
~77r
1 *- 9 SA'^1 0
15
Filed L , 19 ...
Registrar
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH (month, day, and year) ( J? C
19,
A?
17
I HEREBY CERTIFY, That I attended deceased from
..Z.V. 19./,? , to JkgsSSsJLSl ., 19./ 7 ...
t /l last saw alive on , 19./? , J
and that death occurred, on the date stated above, at
The CAUSE OF DEATH* was as follows:
CONTRIBUTORY
(secondary)
(duration) ... yrs. mos.
ds.
18 Where was disease contracted
if not at place of death?
(duration)
yrs. mos.
ds.
Did an operation precede death? ^ _Date of.. /
Was there an autopsy?.. ^
What test confirmed diagnosis? ..oS> rr-.
t (Signed), .. ^h
' /, 19/4? (Address) 0/ 2.
M.D.
tjzL
/ * State the Disease Causing Deatw; or in deaths from Vioi^/nt Causes,
state (1) Means and Nature of #njury, and (2) whether Accidental,
Suicidal, or Homicidal. (See reverse side for additional space.)
19 PLACE OE BURIAL, CREMATION, OR REMVAL - DATE OF BURIAL
20 UNDERTAKER
/rrj
r e 7,1
o c.~<
*) re o <
K srsc 2
3
c n- i re
-< O S-ffl o 3
© p Q-P
~ - So ~
P4I O >« P *< rL O
sllfMl
Bs1' |J?«
o & g'QS^o
rl s 1 2 w,2 ~
§ a _ ^i3 « C.SS
- S 2.® 3 O- re
3o33«£SSi»5'
C.ii~ J 1 32 2." a
S,ag5s.-' § p C?
l|l?f "»ilg'
55
r*
V
rr
C
- § 2
-pSaSf-
S- o 5“ ^ S re CL
8 ? O 3» -
5-3. ^ o ^_^cr
= re 3 o--? re
05 w - 3 '
J* S3 i, L
O T3 5^. Cj ai
►1 p e o q
r^sr
r^oj£,l *2
*■* <d 5 _ cr* © >—
^ re §
I ®3®»~
O p >
= ?
_.. re / 2 re §• ' _
■gs. sia^|s. .
-CoS^ssl g-
CO Si. - f-v SL p j :
»a » x<« ysi o < 33 (
So-g-Sgf 3”rerj
»*■?»... -
?p & 3 e->
2 &.3-.0 «a re f
re* £ « ^
2 P o- o --2.-^3
3. c: a 5-3 5^0 3
11 1 a. 1 re re
;s! "
0*~ o £
p 3 << <"*•
»-< o © ^ o
- G- ~ G- si: 2 03
p CT“crc o o 2 - ^ 0
" 2 B-S ~3 ~p s 3 -
* 5'2.3-^S ^ “ I rec
o" Vcr S.g's-? StJ^P re
S-ff.s |
„« c 3 re ga P
»<8 3 * » •
® 2 2 3
X *3 a - .
p-a s-s C 5 ?
b p ^ ^ p o ® :
G-2 s. Gijq ® p- 5
Sa^ 1 S s ? s-s =
Seag^i: §3'
~1« =-W 5'Sp £$
p"3 -2 an® ®2 E -
■ ° 9-~c §•. => d U2?
p2 2sS = 33 5'$!
5tS‘a'-! S "S ‘—P “ &£
re •< o p',3 S 5“,E
*~t - •—
: £ 5"5 o
— ^ 1 (tv; o ^
WRITE PLAINLY, WITH UNFADING INK-THIS 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 bo properly classified. Exact statement of OCCUPATION is very important. See instructions on back
of certificate.
03
1 PLACE OF DEATH
County
Township
City
©Ijt (Commonwealth of Iflassarhusetto
STANDARD CERTIFICATE OF DEATH
State
.or Vi!
(City or town)
Registered No.,
No. fW . St., Ward
(If crcath occurred in a hospital or institution, give its name instead of street and number)
2 FULL NAME
(a) Residence. No.
(Usual place of afiod ■)
Length of residence in city or town where death occorred — years
L..^A....St.( Ward.
(If non-resident give city or town and Stats)
months days. How long in U. S., if of foreign birth? years months days
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
4 COLOR OR RACE
5 SINGLE, MARRIED, WIDOWED, OR
DIVORCED {write the word)
5a If married, widowed, or divorced
HUSBAND of
(or) WIFE of
6 DATE OF BIRTH (month, day, and year)
yuti /&. fit&f
7 AGE
Years
( P Y
Months
— . - y 4 —
Days
X
/f
If LESS than
1 day,. Jits.
or .min.
8 OCCUPATION OF DECEASED
fa) Trade, profession, or
particular kind of work
(2£
fb) General nature of industry,
business, or establishment in
which employed (or employer)
(c) Name of employer
9 BIRTHPLACE (city or to\V
(State or country)
10 NAME OF FATHER
u _ ri) J
II BIRTHPLACE OF FATHER (city or town
(State or country)
12 MAIDEN NAME OF MOTHE!
13 BIRTHPLACE OF MOTHER (city or town) .1
(State or country) V\A.<.fw& ,
Q,... . 19/^..
Registrar
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH (month, day, and year)
17
I HEREBY CERTIFY, That I attended deceased from
\ , i9\r: toJ£<A \
,i9.1 ^
that I last saw alive on V ,19.. I
and that death occurred, on the date stated above, at S^m.
The CAUSE OF DEATH* was as follows:
.jj.. (duration) ^ vrs., mos
CONTRIBUTOR
(SECONDARY^! D •
VAAAAiSiS^fduration) yrs. ios
18 Where was disease contracted
if not at place of death?
Did an operation precede death Date of ...
./vO
ds.
ds.
Was there an autopsy?,
What test confifmed diag
(Signed)
(Address)
v^VV
ng Death, or in deftths fr
r.i.D.
* State the Disease Causing Death, or in (Whths from Violent Causes,
state (1) Means and Nature of Injury, and (2) whether Accidental,
Suicidal, or Homicidal. (See reverse side for additional space.)
19 PDACE OF BURIAL, CREMATION, OR REMOVAL
A
20 UNDERTAKER
jGJLt^ry’
DATE OF BURIAL
19 * ^
L/rtlL C/I ULH
ADDRESS
E ?
3 S <5
ag-g
9’S,sS 3
- 1
s g o ^ o-j » a teg s
re < re 3 ? SO “ - » Cl> — s; re-
02! P re 3 . ;P STi® 9
5 SO “S3
° 3
- _3-o >3 §
_co S’ 2.® 3 3 3
fll-
5 -* S
r» _ o
2-ti
3
c r
. p -.
e-*- >?
= 3
s^iJ.JSog:
> 3 S © S| so P-B »
® &p ® £S g ? 3 J
1
P'.M
• 3 -
M S«i S'" *— •
p -s* | sr p
Z a 2 2 P f
*< § 3 p*?s
e§1§j?s
5 3 §.« ? | 2
3 s 3.^3 3 §
'— . c+ ^T", O
3 »5 0^2 a>
p >- *-'^
^ S Q !-l -
o £ .
'5?S
o £•§
~>© £
c* 3 ,
, XT
CD
e 2-^
c^ <5
^ p
CO
Hi
”5 QQ u< a w w r k m ^
3-2 rer£i-3 P re 3.0
'1I‘-§ §>? IT = 3 3 R
CD -
CD P SP
• CD
.K
- CD
, p Q-
- «< H- P
8 5’ n3 .a
s-2 .« p -g
“ * Ss.~0§,
■c M
3 33
5
■a.
*3 „
?». 3 ;
^ Ss 5£ 3 2- 9% 2 ^
it S_*3 re JpJSOoSSs^
P S 5 ? = ~ 3 3 saga a°
g g- a S" d a 2 a cr a S’ ~ • a
a .2 <g- a p a Ss3 - -p o> o 0 &=
*< ►sj® 3 2 „ "Cg ;o'3g’
ar. cg®nsi§ 3--CS §■“ ^
a a s-%p^§®cj ^3-=s:
S.-~ •.-3r35P..SrS.;?9 -s
O CL CD
p o
92 r< P ^ ^
s-s " *
3 5. 2 a
»*3 Dmr o jp o
»3®S'P.?3^
a- a a — <a3 &-b
-
S’l 0 0.^5
«.§-»- 8,3 3 o
pg-2_5tspo
a 3 < toa re- a
2,
3 SE3
S 3 3 5s')-
hI e”*>3
x p 3
6 “ P 72
.it*? § 1 iiiii §j |2
IS -hi kifciii’iaa *si § Ji :§ H
o ^ _ o 5
a O e+ co w
3 I sr » 5
<? 9 c £
CO
g ?
CD
S-3 k.
P ^3
o £- a
a'< O S- ® o - » -3
<iss?.rsa
p
5’2 r*
3 "> ST
s: <v
p x 3 ™
3
S?. 5*2
P rJj *-'
; '35
1 S’ 3 «-2 0-“ C I r“g
s “ : S-o 2 S e ’ §- p
0*3
S-^OO 5
1 1
~ ti CD o
rr
(i P-l ffi
' , i-h ^5 r*
O 3 3 o
•^— s »-J ►— “ ^ •
6 C-' 5 M.(? »1 M
^ o p °
1 ^|l §
“P3S* 5
k-r- o'm ? • -
. o
'*3
p a o
a.3
S p
5 -3
o a r -s
r » c
« aO 2
Z 2 ~ -
h3 ^
P
*<
■£|
Q
g,S
co._
O5
a-r- w
a
ffl 2 r-.» _ «
g 3^ - -»pr ^
p g*2 2
2 " - s: g-^P "g
£^i m O
- ^
p cr
P XTC — — w
CO Q c+ P C5 2
5* o c» o> ^
^ ^ 3 M ^
§ -EE-g-2
CD >- . CD
<39 £C2
o-p
■ o
p--'
O 13 a
"»a s
s-ri-s.* o
P e- S Q->
‘ “ .© 5J CD JT1
3
H
>g|.ScKp ;§g !?•§ ^
3 ^ =2 af
O-o
3 8 o^5-'o
3 3?a»
ts fj* a. o a,
to M P ~
R S P Z
O' CS t5 ® B ^
2 R jO 2 S- 5
SPoi^o. *3p.s-
^ CU Z 3 O
<2, = 2,2.0® -
M-rt « 2 P 2
R33 ^Og.P3
^$BcD/-v(D^CDj*
^ p P s -
^ 5!
2.^3 g
2 3 >
o - Soo’OoErr
H 2-2 3 p 1 ra.
3 ~
.<< O 5 .'5
«°S’H25^o
2 "--10 £ S,
. re 3
3 3 re
„ Pp:re
s'3 re
3-P<<
2 2P
„ w- 3 2 o
P o ^ re
ct- £T-
3 6
03
rl 2 3
-- .p. a a
i* 5
3
a o ■
1 "I
P O'* ^ jf CD /-5
K » a. o’3 2 2. 2 £2 §
3-S- . y ra c.o- 2 > =
3 3
3-
S _ eq
3 01 2 3 i-
p 3 E 3
» ?£!Ei3'?'’2 R'
2 w
3 - 3
• « 2 3 re
3 2 § «
p CD P
,0*0
- CD
S3 O
O 3
re -
3 3
o-r
re 01
P re" m << S O
cs ~3 2 'S.’1
®3Po
(-re n.tre W re ^ O
re re 1 ® n 33 - 3 3
23«rrere3-S:a‘3
-re— O.OJQt^3
3 i (MR „ ? p a
jm <«. e** a ■ .
P P £ J9 cr-P ^
•— • r/> ^ »T \
'•3 ttreO
P g a
g. 5- g- »-re
a„.?r
o
CD
_ , - -■> <J CO ^ ^ ^ re-
p^aaio^gi rf
5 s-^
• CO « CD o
l*- CL ^
^ CD ~
O 5
^3" 3-2
_T^ PA P-
2 W ® ^ P Pj
2 Sp 5*0^2.^
- 0 — p
-P ;® re
3 SO, 3
^ ..
5. o-, P
Ci '•* <
C
H79 CJ
5 S-M
e 2-r
• tre » »» 3 O
- ^ CO - P
CD - I - I
o .r
. p o
fctfS ^
2 o
O -J W-.
^ (TP 3
clS 5-
rs.8
s'^a
^ “
Co o
P’S.®
P3. ia
o ~ o
cL'Q v
3 3 3 S-,§ ^
2 O 3 re
“3
05 u ►- * -s>
2 S.s'a g s
T
d s®3
p'5o*§ 1^1
- ^ v.'^ ■-;• CD ^
'-'gsag
-- - • £L 2 «r^
2 ^ h s 'D ^
*2 O’ta re 3 re-
P g.rg.-gre,3'
a a s- 3 a o g
1 -i <9- 1 CD -i CD
>-ri > .
o p
re w. re
_ 3 p.ff || 3 1
cd >^5 <• ' y. ~y- I
O co
§-:$ 2-*rt q XTO
CD £t S. 2.^ ^ H CO
2. 3 &
CO P Q
CD p ^
p
o cr£*5
57- tw ^ Q j
o w - ^ 3
$2 o
S." 3
XT ■
<r*- CD :
5 a2.t
re 3
< a
< re
o "g. ® a a 5
o . o
- . 6*
• re- 3 ©
3gp3.
? p ^ p S
§^8 3
g g^-l _
^ B*|.g-^8a
s’ a 3 o a ^ re ^ e-
1 CD CD 1
‘5^2,^ a-i
I'sfllsIffJl
rt P ."1 *>re I-+. CO ^ 2 OT P
-
o S3
I 2.!
s
pg<<:03 ST. 3 3 22. ^o-re rere.io- a-r
re3 3 o 2 ® ?-p ?» h(2 aSre.“ 5 ^ re re'
3-On-~re“3«-rere-323re£aaS.
2re” |"„»oSs3a3, .3-3-3 re.
g ^ P g 3
*'*“8®,-.. 33
o ®
CO -7- ►
sore s
o p :
3 a'
a;
!• =3
S3 g<
3 ®. 3
“jq
'vf^p CD
6i®c3,S,|-^ m feg
P 55 ^3 « ®
CO - •
. P cr
w- <r- •-*
^8^
re a 'S ,— P “ 00 ,
2:=s?r3^a,
(Commmum’altlf of iHassarfyusctta
STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH
town)
County SMfjQjk ...State ... M 5^ ^ ^ 3. ^ i? Registered No.
;
St., Ward
(If death occurred in a hospital or institution, give its name instead of street and number)
2 FULL NAMfi,
lence.
(Usual place of abode) (If non-resident give city or town and State)
Length of residence in dty or town where death occurred years months days. How long in U. S., if of foreign birth? years months ' days
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
3 SEX
4 COLOR OR RACE
5 SINGLE, HARRIED, WIDOWED. OR
DIVORCED write the word)
5a If married, widov
HUSBAND ;
(or) WIFE if
, or divorced
6 DATE OF B
7 AGE
, Years
Months
Da vs
If LESS than
1 day, Jtrs.
16 DATE OF DELATH (month, day, and year / 19 (,<y
17
I HEREBY CERTIFY, That I attended deceased from
Swj/, ,19 .
that si1 last saw alive on - ■ «s? 8 , 19.?. ,7 .
and that death occurred, on the date seated above, at /ACC^m
The CAUSE OF DEATH* was as follows:
8 OCCUPATION OF DECEASED
(a) Trade, profession, or
particular kind of work..-.:....!....
’ V
(b) General nature of industry,
business, or establishment in
which employed (or employer) .
(c) Name of employer
.(duration) yrs.
CONTRIBUTORY
(secondary)
(duration^ yrs..
18 Where was disease contracted -
if not at Diace of death?
rO"ft"WMST?
Did an operation precede death? _J)ate of..
'At as there an autopsy 3:1'
What test confirmed diagnosis?
. * ds.
ds.
13 BIRTHPLACE OF MOTHER (citv^or town)
(State or country)
( Signed )
, 19 (Address)
* State the Disease Causing Death, or in deaths from Violent Causes,
state (1) Means and Nature op Injury, and (2) whether Accidental,
Suicidal, or Homicidal. (See reverse side for additional space.)
Informant - . .'.^L=r : Au . .
(Address)
O'
19 PLACE OF BURIAL, CREMATION, OR REMOVAL
'~Z,
AKER 71 J , - ADDRESS
DATE OF BURIAL
15
Filed,.
JJL. 19 Aj
Registrar
20 UNDERTAKER P . /
2 2 £
3 «■. © c-». (5 1-
►2
2
S- 3
CD
ifi ^
.5 25
2 co
a s o"S
t3 H 3-9
3 5 dg
£.3 - J»
2 *53
P ©
3 t£
& <81-:
O
© 5
crq
o»S,
^ s ?
e+ 5»
co p- ii
© CD **■ ^ _
; c~ >-+,
co ^’cro ►_- ^
S-S.^ 3. <g a „
“ - av®cg
•si*
£ g-C
Z 2_P
g-sJ\o
o, ~CR 2
cd _ S° 2
3- c«- M tV
P
CD 5p
P
<r»- r~ ^
g.3 S
5-3 «g F *
n 3 Hs 93 >
- ® a S.® 3
| ^1
s2i:
^SaiS-
&,so ® 2 3 3
9 CR “ ; 2.P 2
S’-® (B ~ 2.
s-- -l5'2 'p
:£"dS £
3 ~ *
uO
3 CD
$1.2
&
CD CO ^
2 cd 8
so?
2.o
p g S
p q-^
“£ 2
o - S
3 . P
3.
©v;
8 I
3-- •
~ R
8- Sag.
© ©j J
ss ..
p c+- S?
^ ^ ,
cr® I
° S.’S
a ©
5 ©
©1 S
<PV
o
. 5
H
2!
H
>
P
£ ^
' O
P > CO
co H
CD L 2
Co CD
*-*.©£»
0-3 3
— CD f*) rn
&5S3 £o*|
So^23
p a i-'p "
* rs* 3-sr
CD - ^ p CO O
« -'g -p" 3
g 8-“ OE. „ ^
.3-=^® 2
rgpg -
3 - „
L O ffl
sr.cvg
3 ' s
CO
p
CO
&. -P- ®
3 ® 2
3 0 3
^ <s>. P
©- s a>
l-ST1,© ^ CD P
5S
8 3'
S crq
J--1 ZL. <?*•
> O ^
3 ^ i 3
P ^ s
CQ 00 ~3
CO 3 '-do
>23.9 B“.
ai.? ^
p
„ ^ S. c5
CD S3-. O' SJ
P S»
P-p d£ 5
p s .
$ £ o’Oq
S Jo p 3 2 o
- CO ■» P X
CD - I I I
2.
•CR
p ^ g-
2.-3 p
a
cd
So 33 S-'
“ 2
3- to
1 - o,
:£S? ^
iCD W
” “*i
CD M O
3^ a
5:it
• 1 1
0 S £>
c « 2 jP
-s ^ s Hp
“ p
2.^ 3 CD
c^- ?3*. O
'-9M 0^-2
P >* ^*
rs CD ^ ^crq
3* S- = o c-
1 p g. ^ - •
-• p 3
§H|&6
s ^11 s
o*8 ^ as
|||g J!
^ 5: co
O'P^Xw-
CD P CD
C s*. co co
§ », O-
sr^-~v c^> *- . cd
a-o ^3 ■
3 § oj^-
3 § ^ B ®.
~Q-o §L
CO P s CD ..
CO —. S. 03 P
<<: n -• <
|g'>|VE.2 ?g g
| p*g a “•c?Q ^9
71 ^ ’ W
^ ;A m o h
» S SP ^
O
" 3 ’S'” OS 3 33
S.gS-2 Hg.° p o
o 2"-“ S O 3- S'. HI
- & &2 ^
ssi-srg
S— • OO s- 0
55 >-J «■*
© , © cr*- s-<
1 H .? 8
Cb ~ -, O
3 § £? a. = 3 p .
S © *n ^ ^
©" g cd"W p
^ d>‘d CO P‘CO c+- — t
CD ^
p ~
9 g S
B-®
3,
x eL 3
50 ?g
W< S -.CD
a® p3»
o S . S 2
i® 9
o£
-3 ^3 £
o % 3 S- 9
» K-3 3- 2
;0 ® 0 J o a3>
CD © HJ *2 0
■ip o
<0 p
O
« S.
a§
„ .31?
9 P . p § p c/J P
33 o C.P. — 2-3 3
p-sg-S
^ 2 ^ o 3p
p ^ p'^.S E-^5-
— £§
s“£^£-o
2 3 3
g n
o'?3 2 -
£;^ O 5-
ft -*>9'C5ro “ P S 0*35 Si-* o cd <
.SO?§.3^ |g.S3if®g££
1- B52 g.3.p 2
,2-p
P r£
m OS
■ 3 a-
» o
P
_ st. o .
S'pxs
-• CD 2 2 3 3 -
® 3 flC — 3 *
— .''it £> 2 ®
» ^ 2 £-3-
^ 3 co
^ ^ p —
CCco p
. w « O h- .
^§p p g “
© 3 ST. P ^
CD 2:-^ § 9--C 2
crt- c^. 2 P '^0
p P cd w ® r? _
'o H
:3^
cr»
CO >^ • o
CO. © o
CO
. CD
^-' S.S.S'O’g
3-2 3 ffl*a °
P § “ 3 8 a P.P
P O
OR &~=g.p
o o
3 S't'I
P-^
^ o &
p r- o P
C-Dh O
- -
3-^3
- P CD
o -
S 3
a 3
3 3
8 >5.72 -j
5 S® ?
© © rn
M
P- CD
P
- ^© '
2 s*
S' 3
«T
P CD
Cb
■38 1
5-
3 9 3
3 2 2
«D g p
” 2 3
3§23:
3 3. 3 33
3 P p'
3.0*
O 2 P
CD
CD o
- CD 8 3
^CD =“ CD
'-1 CD S$ CD
C 0-9, CD
”’5S.g
0
C*~ ^ vP
P CD c4
3 >>
°§. -1
CO CD
O
CD
j S3
o
2 . 3
CT CD ^3 3
- a-2 cr
-7q S P
p p
CT — • co
crq
CD
©
ire
2 3
S 9
Co -ro
2!© hrj
O f5
CD
P- 2 ‘
p 3S§ *3 5'
sr’-< g ^ ®
© Co
5‘ 3
CD p
o"p _
&^?3
a- - • re 3 _
r^- 3 2
S 3 S' 05 0 § §- w
3 v— P £T CO
r- ' C P
9^0»3®
p e © CD 3
^P-S'S'®'0 -^5?-ra ^ S“3
3 » O £'J° 3 3
■ ■ CC1 0- s a-Dd Cteag^o
£asae.^< -i _3i2 ss - 3
9^®-~ o o-o’S
^ < P '
P
<9.~
^ o
O P
*-! -
£.3
S“g
CD 3.
p IT
9 s’
o-r
CD CO
w-O
a p S S
-2 o g S 2cd*3 ^
8 9"-
5'Ha ’
a.s c
<3
© P
®to
^3^©©^+-
^3^26
3.Str§J-&s*l
T CD
CD
O
P
o 3 £.
g*
2 S'15
co cd a*
P
^9 3.
S3.3
C T CR
p CD
'g-l#
•_, o .
^
S'
SS ®
s' a.
0.2 "do
© ^ o
© g P ^ r
~g- -S.'? g^3
S O P* * ST- $
p h5!©
§•£• p 9
o g 2
2 CR 3
S !
9 !
S" aj d3 J o’5 a
• g-o P-S | “
te3 ^9 1 §
■1$ a * S S
d-to v 2.
5’? g-i^P S
o -
p- 2.
p
VIC <r*- O -s ^
2 5 3s"»2 9
3“ P’^~. 9 CQ c<s ® 50 CD CD
2o?3’3|- §-
3-&J- 5 3,2
9 2^3 5.5.0 O® 2-3 3
9“ a
- " CS a »
O 9-
->-> CD
a. -
>
o
o
COMMONWEALTH OF MASSACHUSETTS
FULL NAME
Place of Death
RETURN OF A DEATH-1919.
ELEANOR BROOKS
CITY OF
BOSTON
Registered No.
175B
Date of Death
Boston
FEB. I
CHILDRENS HOSPT .
1919, Age >
months
days.
STATISTICAL DETAILS.
PHYSICIAN’S CERTIFICATE.
SEX.
F
COLOR
SINGLE, MARRIED, WID., DIV.
W
Maiden Name
Husband's Name
Birthplace
Wl NTHROP
Name of
Father
MICHAEL BROOKS
Birthplace
of Father
IRELAND
Maiden Name
of Mother
JULIA ROGERS
Birthplace
of Mother
BOSTON
Occupation
Informant
Place of Burial
or removal
CALVARY (NEW)
Undertaker
J ,L. BURKE
Date of Burial
rb fl -o n K ■ ■ '1 f /
I HEREBY CERTIFY that I attended deceased during last illness
from 1919, to 1919,
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:
CARDIAC FAILURE DIUE TO PRESSURE
OF PUS IN PLEURAL CAVITY
3 WEEKS
(Durat
•ibutory: J 0pR<R JB RES£CTION JAN. I. I 91 9
(Signed)
FEB. 2
R.E .RAMSAY
M.D.
1919
SPECIAL INFORMATION from Hospitals, Institutions, Transients, or Recent
Residents.
Usual Residence
Filed
A true copy.
W I NTHROP ( 3 1 CROSS ST )
1919
Attest :
FEB. 5
Registrar.
l
_o
—O
(
\
-WRITE PLAINLY, WITH UNFADING INK-THIS 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.
CommomoraUl] of iHassarfjusx'tts
CERTIFICATE OF DEATH OF NON-RESIDENT
Registered No TfiV -
(Place or death)
Registered No.
(Place of residence)
Ma n jL.e Hospital St., ward
(If death occurred in a hospital or institution, give its name instead of street and number)
1 PLACE OF DEATH
County. .SnffOlk State.. 1£LM
City or Town No
(If dear
2 full name _...Cha..rle..a 7 fe.s.s.e.y.
(If in the Army or Navy of the United States, give rank, organization, etc.)
(a) Residence. State Sfe..§®..8, City or T own..?V.i.U .thrOp No. 2) LiS I* S llci 1 1 gt.
(Usual place of abode)
Length of residence in city or town where death occurred
months
days
How long in U. S., if of foreign J>irth?
months
days
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
3 SEX
Male
4 COLOR OR RACE
White
5 SINGLE. MARRIED, WIDOWED, OR
DIVORCED ( write the word)
Mo rriea
16 DATE OF DEATH (month, day, and year) J'g'k 19 19
5a If married, widowed, or divorced
HUSBAND of
(or) wife of Mary Ann
6 DATE OF BIRTH (month, day, and year)- 10 65
7 AGE Years Months Days
If LESS than
54
1 day, hrs.
if STILLBORN, enter that fact here
or min.
8 OCCUPATION OF DECEASED
(a) Trade, profession, or Co rpent e r-Bu i Id or
particular kind of work : .+... -
(b) General nature of industry,
business, or establishment in
which employed (or employer)
(c) Name of employer
17
I HEREBY CERTIFY, That I attended "frtTm
ha ve intrestigf^ed^ t£he deat h o f f ^ he
1 *Uy* <u> 19
-amd-tha* 4aath ^oeufKd; on the datr ftated *tove,“ar m .
The CAUSE OF DEATH * was as follows:
•State the Disease Causing Death, or in deaths from Violent Causes,
state (1) Means and Natube of Injury, and (2) whether Accidental,
Suicidal, or Homicidal. (See reverse side for additional space.)
Multiple fractures and probable
pulmonary embolism.
fron^aaf fold ♦
(duration) yrs mos ds.
9 BIRTHPLACE (city or town) .JL.-E-.. .£
(State or country)
CONTRIBUTORY.
(secondary)
.(duration) _
. ds.
10 NAME OF FATHER T)nr)-{ Q"|
18 Where was disease contracted XJO V7 £cli X* Ci % Gl-S S * Ti
if not at place of death? _..._
11 BIRTHPLACE OF FATHER (city or town)
(State or country) Eng la nd
Did an operation precede death?.
Was there an autopsy?
.Date of...
12 MAIDEN NAME OF MOTHER Tfa Q LG T TB T\
13 BIRTHPLACE OF MOTHER (city or
(State or country)
What test confirmed diagnosis?
(Signed) W .H .Walt GTS
M.D.
2 — {j)19 £ ^Address)
Boston
m
z
14
Informant
(Address)
Mrs.C . Vessey
2 2 lla r aha' St . , W in t 1
19 PLACE OF BURIAL, CREMATION, OR REMOVAL
rop Winthrop Gem.
DATE OF BURIAL
Bet . 6
19
19
15 mudPeh. 6, 191 9 ... ...1.
Registrar of city or town where death
Filed.
.. 19 | %.
20 UNDERTAKER
W.O .Skaggs
CX^ahRegistrar of city or town where deceased redded
ADDRESS
Y/inthrop
ssr
pi
5 .rs
® o
pi?
I
6
: <D ^
. C
3 = B >
cTff 2 » S
CD £ _
' «°
& Epr* £
,fr§~ c
S ^ o s:
§ £-•=* K
^ B g
c *5 C“3
? a S
5 «*
3 > o-g
r o ’
‘x. c-. w— i i:
S ® &
? a ^
*5 c- a
e? a- O'
_ -! Cl
sr;< g
a a
S P
S *
cc
s =*
*< 3
cr®
® o
01 _
S-gfg
o c- a.
o.-— a
Pi 8
-VP
Cj *"*» ^
^S-ts-S
§ r 3 2
~sl-= 3
“ -i '— cio JT
a 65-?®
i § 3 ® S
! | | g-Q
S-g.c 5
s c->
■-a. ?. ? r
p|g£
g 9 ° p
s |8j*S
£ J°’ £\o
Q. '•J3 C
l®-° t
•g.P **<
8 =69
? cz: *-ar =
; P 3 CL
■ T+- n
■=j CD
0 3 ^ T J5
0 E ^ - “ ►*- :
- -®Jf S.-S g !
1 £,";3
§- g.<
s sg ;^'
g 5
*-* O ft
2 8
2 p
3 cc
Cj p O O 3 ff
c -n " - 3 P o
- ffi- ^ »-j
3*-° o-o.
2. ^ <<
o "a
- CD O 00
rt£3 ac*s
■j- g o a 3 3
<9 O n • <<|S
6= n y S-^ 2 s.
S pr cr a- c
ffl - „ p a: °
_ -33 ;o -
® ® ^2 P
® §.2
2®?
Pi
Sgg
p O-
■“g a
oiSg
2 - p
3 ^ co
o- q, ®
K2 § § c
* 3 -3 a r®
- §-==.£
-i S“ 3
^K*
p 5?- ~
2«&3 5*
3 S a s
“ | 0-2
S 3
: 8-B
■,« E
gsr?
|«|‘B
O ' c+
3 3-r 3
S-2,1 §
<! 3
3 'A
P a
P 3 o
- > -
r
- 3
Co O
o’-S 3
^ s-S
£ 2 3
B-S CR
«*.
- a ^ -
"s3 ®
_ 3
. p j“. a
„ ,:g =3 3
S a~ ; 0 uu -
" Cl _3' = «.
cr-^
° | 3 5 -
s sg-; s:?
—a
co oq ^ ;
71 3 'TJo
>-:j5 a b
> S' m &•
3 3 0-
E o.
^ p c: 3
P .
'iS.oOQ
r-lS-'J ®
CD - l - * 1
< g-
S-S&
i2 s
$ O ts
3-^
>3 F
£T o -
S- 2 -
CL O
C =5 2
2 - g
P '3 §■
g’la.Sf
O s*« TO
1^11
£■ . . - .
2 "Si *•
O- a
3 O QS'
3.3 ?a
o --a
2-3-2 8
sg. P §*-•
s?l?
o2
: 0§— • Q_
P ? g“
3 2 ®
§50
■ <1 X <2* TO
5^ a 3
w. ^2 g
W =J S3 8
-h-8 | |
S 2 S-s
x a
>sr.c £:a n
1 k-5'® 0-3
S a > 03
: - ai « h
Og-P P 2
3 pig S3 “
2 5 o p o
g tost*, et.b
®-§'m &2 h
3 s- o p-_
® K g a - -2
s i| ? 1-f
'flECl
i 5 ® £ 5* S3
j®. 2 ^ p
/E? 2- = 3 P -l
c-3--;
o <
E® o 20 j n “ e
p p ",5^g 3 &§•
m 0.^2 ■§ s-|j
o ^ ® I £ o
iPSg
^ - ^rl’.l 1
“ ' =r~
rfe 3 ! »
0 rr •— -
• Off
©
S “ Ks ^
3 —’O 3^P
5 5^3
C.S C.S cri'
2 S § 3 m -
^ § P-Q
■< ^ rt
5 <To «
g-a-B 5
P 3s
^ P
S-P^P-O
i 3
?o3 -
5- e 3jJ S' ® p
0 | £2“ a 35
2 5 3
_2.0® ff.
1 ‘a S 3 O
'1 =o|3-
2 03 f ® 1
6 ^ « § p 3-
ff O O ff-
.8-SS*9"
s.®
O-ft
.O CP
ri
« S 3
-y Q
CO P ^
00 -J
5-
5 o
“•"0 *i
o
•-1 t-.
e+ M
5 a
<y -5
g. -3
3 1
2. p 3 „
-
n ^2 P 3
•--- ~y .— ff -2 O
■ g | " o 3 » £.2
3 I'o-Scg a.2»g-3 1°-®
^SS-S§3oi6&£P
S|^§org-gi|
t-y =>7"yo« 22.5s ;. 2^
-a^2-^TO=i*XC'3n3^
sC»2.3p; 3.® 5 2
"So^psE® 5*^- 3
p2-®;«s c a
S' s* ^ <3 S-i s s
»S-”fg-p ?
o- a a-.® » “
“53w,r* a ° - fcj
S^g-pg-l
2 5-0 P s;-
3 O-a” ' ‘
3- C- 3“
O-S® 3
W. 75 o « <! C
Silp.i‘2
| 5‘g-
-11^1
•3 o
?, =3
§ Z-V*
so- o
a 3 o 3
g-g 2 O/^
3 2
a a
2s Si
CT2
,C 3
"oRc?® g
CO
* C • H, P
*T3 ^ O cr- tff O ^ p
~s p^OOP^^P
>■*"! 2T- ^ C5 5 C£
O 05
CD
CD O
tft
-|2'o
^ “ O ,
-a a p 3 -
CD c^- »*
*-J P __P
TO ^ c-p
P <e ^
CTjq
CD
w ?r ou
1 « w-.
1 <§ ^ I 3 a
ll^ll;^®
§:c-o'3 n'a-o-
W-. o ^ Op
» tu
o-2o°
3 3
O ~ |
§“d ?o 3 3 o S’ft®-
2- a 31 Is 3 cr o “o
g 1 ® < 3 § «
a a S'^a-o-a- .
=3
o
CjiS'*-";® S.'a'® ®”5 ~ *“
21 S§
3 0-2
h3^p|
S w “ i
c.S-’o w y
o ST?:-®
w © —
2 .g.«3t>a
s; =*-“-• a k q o sa a .
I® £.2:1
‘gigSS ^sro 5 S
r tR s ^ - EL 2. 0- '■’■
.« 2 2 3 2.
'ng-:^e^S^ 2.S-
I'i a:3 fl 2
~ *— - j: co >ff
? S"p o s.?
PO
CT1
§
§
H
E
z
g
CO
)RM R-301
.1?
<
c Ui
I Q
<2
c O
E <
“ O
— ■ (/)
+* rr1
a>
>
UJ -a
. a
Q o
rr "C
o "
0 to
UI Z
OC <
I— O
< Du
S
DC .
UJ >~
Q. _i
< o
V) <
— X
c<2 ui
E -o
(_ 0)
1 —
I ™
X <e
z *
— -a
O ^
3J
“ »
0 LU
z a
D <
< .
b- TJ
Z ®
=> =5.
1 CL
2 O
V
5 ir
>■' a
</) 43
•+-> W
o o
cn qz
X 43
ui t:
®
■O
£ ®
£ o
cj ra
O ■“
-§
03 ^
o w
a) ^
fj
E £
Z O
C3 W
■C £
*"* x
o o
— 03
< o
El
X •
GO
V18. 100,000.
a> =
+- o
CL £
to
e =
1 PLACE OF DEATH
County.
City or Town
2 FULL NAME
(a) Residence. No. ' /
(Usual place of abode)/
Length of residence in city or town where death occurred
OFFICE OF THE SECRETARY
DIVISION OF VITAL STATISTICS
dtje (EmnmmutiraUlt of fHassarijusptts
STANDARD CERTIFICATE OF DEATH
- NokJ/..../, Ward
(If death occurred in a hospital or institution, give its name instead of street and number)
Registered No.
years
months
days.
.(If in the Army or Navy of the United States, give rank, organization, etc.)
St_ Ward _
(If non-resident give city or town and State)
How long in U. S., if of foreign birth ? years months days
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
4 COLOR OR RACE
5a If married, widowed, or -divorced
HUSBAND of
(or) WIFE of
6 DATE OF BIRTH
5 SINGLE, MARRIED, WIDOWED, OR
DIVORCED ( write the word)
( Month)
Months
7 AGE 5 J Y ears
If STILLBORN, enler that fact here
If STILLBORN, slate period of uterogestation mos.
8 OCCUPATION OF DECEASED,
(a) Trade, profession, or
particular kind of work
(b) General nature of industry,
business, or establishment in
which employed (or employer)
(c) Name of employer
(Day)
/ 7 Days
5« iroi
(Year)
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH 3 ^ fjf f‘
(Month) (Day) (Year)
r
I HEREBY CERTIFY, That I attended deceased from
f ,19/4^', to f=t£^, £
that I last saw h alive on f?
and that death occurred, on the date stated above, at ^
iM /o M
TV6nth) (Day) (Year)
Filed
21 I HEREBY CERTIFY that a satisfactory stan-
dard certificate of death was filed with me
BEFORE (he burial or transit permit was issued '
S a g- g «
£ p ® 2. < o
p Od g ® a a
S ® O O B -t
g a e h s
? „ S' £ 5 g>
B t: w ^ o
«g*oi
g ® © ►* g-
O ~ tt »
<n S' S' <i
6 p g ® 2.
* P ^ ^
a 2 . o ®
3. § ► 4 g
“ o- j- ®
o _ o B p
H.p a
SSo«:g
3. P g g,
•B =• S 1 ?
|sg-SS
s-^giS
-5 t? s
■ B* « O 2
g s' c g
•a - s; «’• g,
g &S a-
ilsf I
1 F 8 3
ag s 1
M 2* O ►-•<*■
®5po*r
•O ' § 3 ®
?.B S' P
Ss'“£«
H o o _ S'
i?Bg&
w
«P® - O : 2. 2 — ~ 3 :2
a = = J 3 o F ? ft » a B p 3.
S &«* 1 =§ g | 3 ” | I
s 2 o. S v; E _*'|Bq=.6i,ss
M *B P g 3 2
I? o 9 -5 p 5 -
* ’* a s.
,~x ®
•?g
p
© Cf P 5
i =11
0.^63*
— O ”»
S' 3
p
> ?
o g
2. ^
•a
3.
0 2 cr. ©
s' g s g 2
® S",,'1b25SS;'’«
3 ?|lr:-S-l|C® ?I'f|
1 1 g-y'-?oa f *t?l 1 1
!' O' sr s I 3.
; I; t)» ® 5 ®
| « U ® 1 q |
c a &■ o ® p g
| c a = U a
& 3 3. << a 2 7
B> o ° „ C. ® O
O 3 O* a*
cl a. p © © © a
' p. 5 E* 3 a ®
5‘ J 2. 2. 3 3_ g.
5* . c ° ®* o' P*
e- Er | ^ - b i
o
p
4
p
Cfl
C
g
Pi
©
s
p
pr
5* *« i— i • y ©
- g ws
s; ? 3 2o>°lS“§o
I- • -PJ 2. £ | § e 8 I
np ; 5 s J r. ® g. g »»
-rt s ^r-“^§ ?s°
» g © 8 W ^ ^ s
- . •L-_r/3 - r» 2 « P
> G
•d
c
w
» X
D r
P ID
~ a
- p
: © g- g
o. &
I'? I
1 § B
d g o w
o 3 © a*
u p © p
0 «< c a
| ?u
1 g.p s
§ S' J*
° a <
* a o- «
p- e-a b
P V* r-
a- d »S
? g s.®
2 “ 5 o
r1 w 3
s» ? O
< a.s
R g*|
5 H-O
v- v-
6 ^ £
rr
? 3
© S
O O
CL 3^
g *
*i C ©
B ?.
3 2
■4
s-'i
5» ■* „
C ~T U3
~ c
' tJ ‘i
o g. §
O H. O
o o
a o
* w ^
&5 o S-
: ?b
s
a BJ °
* g.t5
^ 5 p
^ a c-
? “ 2
2 2 ? o 5 6
~ 5 ►-*» 3' fl
to 2
? §
c ©
n ©
1 1
*• »
2 4
T ^
3 c. ir
g. "o cr 5
a w a c
S* Co 2 o’
t“S 3
nj'p
2 3 § 3
4
3 ? « 3 O
.. 3 •< _
e. ■ ^ o-
2 c ^ t.
3 '— ' © O
p a
. p »
< ■ s
b- to-.
O Q
p ^ r
£ o ©
° 3
3 -
c- .
° ^ O ^ n ^ !
E B s. 2. 2
S.! * |b^
4 •< 3 ■ ^ C :
6 5 w o o
t B- 2 ■: a g.
pr B - 2 S?
p 5‘ to ? •o a
2 1 s: 3 s p
p 5 2?
» 2. 2 * S c
O P’S g ® ©
TO £*■
a 2 a- a- O
' K ?
| J-
S 2 & “ 6- 2: &
C 5 *3. ‘ w* a 3
ST 3 • H O 3
2 ^ w-i? y © -
s 10a” d tr
o to<e 2 P- ©
2. g •a B Mo o
09 2 a* x P a
«. I, I o I B I
- s S>:
© © ^ :
© a 0
^ ^ ^
-®° § — o " 5- >
3 I g ■§. ? E i
«• 3 < 3 ^ a* 5
?»'5 2,?no
05 S- 2
«S 73
2 © H
* G* H
m § 2
2 a- g
« £ 5
m o' O
2 © M
3 w 2
CD «> Pi
a a a
o p -
cr £ g.
5 p p
3 8- S'
3 2.
B- B. I
C-
B o'
1-if
2 m r
P- © -
*-• 1
p 2 -
■g ^
g ^ « o
2. ? i i1
f§!?:
» a ® °
o "5 O) y
^33 ©* 5*
^ 8
8 &
S- 0
<-*- o
S' c
*1 CO
2- e?*
S- o
<■ ?
° 1
S' 1
M
2 2 p s; 2. o.
3
© ©
cr a
►—• x> ;
H: 2.
CL ci-’
32s3!.
| 3 S' to t §
| S 8 s-s. g.
o F 3 | o O
IT S-* ^ sf "
D- 5 a
© 3 ^
cr a-
. <<
,3 2
o' a so & I
o' 0
B g
tr" 1
TO r» a*
? £.3
5S
S. © g. a
5 j g. p
0 © ©
P Cr* «-►
O ©
<M- 1 •
cr a - 1
S- 1 i
1 ?|
? £. &
£ ■3. S'
© a a
s 1 s |
O C“ ~i p
2. £-■ X ©*
5* © cr B
’X* w ©
Z5 ?E
2 © s: - •
I? § s
f 9 s § ° 3
j. » | 3 o
SSglf?
co w «-. © a
“ £ HH O 31 2
o ^ ® 1 «i 2
"1 “ C - CD CD
Ml d k *0
3 X ^ m- ©
a° » 3 S'2
g s- 3 2: ® 3'
? g g 0 4 »
3 3 ~ £ 2.
o' o
B* B'
E. ®
0 at
a S'
w B.
® s
a 3
E §
« «
S *B
n g.
eg-
CD P
i 5‘
X* *d d* cl p o *a o
o©p©©^o^-v 2
w w a ^ c — p ' ^ P-
So a 5^ a cl h1 _ ©
P o m. 2 p* C?
a o = 2. <<
S: o w o ^
g & B o. S’ ^
o
m
x
H
X)
>
n
■H
U)
DRM R-301
c i «
0 £ ®
= t »
gw •
1 ° c
.O h ffl
ir *•
c o t
o- Lu
O (/>
6 <
" o
>> -2
Q ©
cc -c
O "
0 CO
LJ Z
oc <
I- O
Z »
< 0-
S
oc .
LJ >-
CL -I
«£
if) <
“ X
GO LU
1 “O
h- 9
<D
« -S
4-* C3
O O
W Cf=
x ~
LU ~
0)
“O £
I «
CO
to °
cs 2
o ■“
-§
2. s
o w
tm
Q. 0>
• £
ll
S £
>N ■*-
X
o v
*- o
c
— o
CO 3
Q.*
co
c c
Z
0-T8. 300,000.
©Ij* (EnmmximtttaUIf of fSasoarljuartta
1 PLACE OF DEATH
County »Uff0lk
City or Town Winthrop
2 FULL NAME George "ilMen M’jrp^y
STANDARD CERTIFICATE OF DEATH
State *®~S» Registered No
OFFICE OF THE SECRETARY
DIVISION OF VITAL STATISTICS
No 49 .Sagamore Av. ...... „.st, Ward
(If death occurred in a hospital or institution, give its name instead of street and number)
(.) Residence. JhJ? St,
(If in the Army or Navy of the United States, give rank, organization, etc.)
Ward.
( Usual place of abode)
Length of residence in at; or towo where death occurred
years
mouths
days.
(If non-resident give city or town and State)
How long inU. S., if of foreign birth? years months days
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
Male
4 COLOR OR RACE
▼hite
5 SINGLE, HARRIED, WIDOWED, OR
DIVORCED (write the word)
Married
5a If married, widowed, or divorced
HUSBAND of T. , , „ , -
(or) wife of Bello Hollaran
6 DATE OF BIRTH 'July ,4
TPPf>
(Month) (Hay)
(Year)
7 AGE 33 Years f Months J Days
If STILLBORN, enter that fact here
If STILLBORN, state period of oterogestadoa mcs.
If LESS than
1 day, hrs.
or min.
8 OCCUPATION OF DECEASED
(a) Trade, profession, or P.vaT 1 + ifolt
particular kind of work 1
(b) Genera! nature of industry,
business, or establishment in
which employed (or employer)
(c) Name of employer Cudahy Packing Co.
9 BIRTHPLACE (City) ...
(State or country)
Malden
Mas * .
10 NAME OF _ . . ,
father Tinotny
a )
11 BIRTHPLACE OF
FATHER (City)
z
UJ
cc
(State or country)
Ireland
12 MAIDEN NAME
<
OF MOTHER
Ellen ^ahey
13 BIRTHPLACE OF
MOTHER (City)
(State or country)
Ireland
14
Informant J.?.?.
Address) 4** Sagamore Ave*
15
riled fyjn. 10. J.f/f..
(Month) (Day) (Ye
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH „
7s
(Day)
(Ten
at)
17
I HEREBY CERTIFY* That I attended deceased from
AC ,19/7 . to
that I last saw h .... alive on s/ , \9/y ,
^//m.
and that death occurred, on the date stated above, at
The CAUSE OF DEATH was as follows:
(duration) . yrs.
CONTRIBUTORY
(secondary)
(duration)
18 Where was disease contracted ^
ds.
ds.
if not at place of death?
Did an operation precede death?
Was there an autopsy ? ...
What test confirmed diagnosis ?
(Signed \
Date of
Z O-tJ
Date
(Address)
( Month)
rf
,L
. M.D.
19 PLACE OF BURIAL, CREMATION, OR REMOVAL
Holy Cr os s Malden
(Cemetery)
DATE OF BURIAL
21 I HEREBY CERTIFY that a satisfactory stan-
dard certificate of death was filed with me
BEFORE the burial or transit permit was issued
S p *
p « 3
3 ® o
3 n
a <5
O '
2. °o
to P
- 3
•g 1
® 9
a?
ej to
5* S
. § a
® o P
a "• s
0- ? “!
? ® i
c* £2
ST g: «r
O ®
t> ^ 3
a“ 2. o
3. w ®
5 & a
?sl
a p ►?
3: S n
c - P
* e-
3. ®
® 3
£ ?>■ 2. cl
£T. -cj 5' a S
w a ’ m c"
' 3" o 2
s g&g
o- ® *T.
?« a
*o -
“ I
B s
? 5'
£3
p o
Z ~t
w £J,
■o "
Hi
* 1
rf P
II
» g 4
a * E
8 ?&
30
cn
■c
m
<=>
C/i
3»
90
<T1
pn
3*3
& 5*3
a Q
8. £
rj w S' c. g o W
gSsH'S'gS
g. a q S' ° & s g
»■“ O o ° S.
gO-nCSo. tap-
° g 1 I i
afs If
c» p P .
* cr
£ h 0
5T P 3
3 o
tr p
^ ® £ °
2 & & w
® r* p 2.
® O w ^
TO O O
0 O I P
p. o C- ec
N O ® J-*
® C P *
^“O c* ?
a p w g
-* ?p
p t
w •
®
P © ®
3 CA P
^ C 55
- S. 5
It g* ®
8 2^
0 ^ & p
o CL C. to
* Rg&
8 fjC
C o
a> p
e* *!'
O ©
*
1 1
- ®
B *
* g*
g- 8 _
8. ® <<
• *a
tr o
“ B
o tr ^
3 “ W
? I
C P
TO L(f • r-|
W CO M
B H *
^ cr c:
P 8
2- 0 D
c 5’ 3
rv 2 ®
cr p, co
w w c
a B EL
CL o
2- *H-
I f
=-B
8-t
3 ®
O p
CL £T.
8 <?
o w
o
•a p
3.
o
g ° &
B ® “ S’
a- 3 > £
S' o S o
O 3 tt <
P. “ ® -•
P 3
■ § 2,
■ l n
Si
m c+
. r* b*
- rr* ^
< c
O CL
B ®*
CL
^ M
C- r‘
Bi
D 2 a
O- ^
c 3:
^ 8
3 O a 2 tr-'O
05 H% P Cu © << |
O P
- P CC
^ 6 CL
PO®
D CL P
CL p, p-
D- £ ®
^ss
— ”* w
_ 8
C- 3
o
8 I
a. Sr.
ft
O CL TO
3 ^ B' c
II” a
S- B p- o
8 -.
TO *<
P ^
5* o
? 0>
&&
o << o
§ tr
5 § g
fc 1
o g 8
B g* 5
*< cl o
• ® B
0 3
1 &
CL g*
g.|
S cr
!3
d
t*
w
8 w
a
0 O
£ «
S *3
■v M
1 >
g G
»M
0 o
E. W
CL £.
e cr
g “
“i o
2- 0
c- £
o
0
COMMONWEALTH OF MASSACHUSETTS
RETURN OF A DEATH-1919.
CITY OF
BOSTON
FULL NAME
Place of Death
PAUL DAY
Registered No.
I 957
Date of Death
Boston
feb.6
C I TY HOSPT .
1919, Age
years
8
months
25
d.ys
STATISTICAL DETAILS.
PHYSICIAN’S CERTIFICATE.
SEX
M
COLOR
SINGLE, MARRIED, WID., DIV
W
Maiden Name
Husband’s Name
Birthplace
BOSTON
Name of
Father
Birthplace
of Father
Maiden Name
of Mother
Birthplace
of Mother
Occupation
Informant
LOUIS S . DAY
CAMDEN. ME .
MARTHA LIND
SWEDEN
SCHOOLBOY
I HEREBY CERTIFY that I attended deceased during last illness
from 1919, to 1919,
that to the best of my knowledge and belief death occurred, on the
stated above, and that the CAUSE OF DEATH was as follows:
BRONCHO -PNEUMONIA -DAYS
ributory :
(Duration)
POTTS DISEASE SPINE -MONTHS
(Signed)
WM.B .YOUNG
M.D.
1919
SPECIAL INFORMATION from Hospitals, Institutions, Transients, or Recent
Residents.
Place of Burial
or removal
Undertaker
Date of Burial
MT .HOPE
J.S. WATERMAN cc SONS
Usual Residence
Filed
A true copy.
'VfLhA ^.'9
W I NTHROP
FEB. 1C
1919
Registrar.
i
vv
RM R-301
c i ®
0 £ ®
V t »
1 O ■£
,2 u. »
c O *-
■sS
s <
2 o
U CO
<U tX
> •»
UJ “O
Q O
nr -C
o M
0 CO
uj Z
cc <
I- O
Z 55
*£
< 0.
s
QC .
UJ >-
CL _J
<5
</> <
— X
cn uj
1 -a
»- £
I «
X <e
Z „
“* J3
X T3
<1
00 »
O uj
Z O
o <
< .
lA- "O
z ®
I a.
t 3
5 >«
—I o
Z m
< o
jr1 a>
o- J3
tl
OC o
CO
o o
CO
x W
LU T
QJ
0=
S 8
O ■“
■S' ©
® »
Q. 5
o w
L
Q. o
0) £
si
E *
■H Cf>
Z o
CO co
j= i
X
o V
Z
’18. 100,000.
GJammumtiealtlj of fHassarljuartta
STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH
County
yx
is
OFFICE OF THE SECRETARY
DIVISION OF VITAL STATISTICS
County _ \. . l!* State Registered No.
City or Town ' // S /s' S /('l ^0 No. '*1#^ St. Ward
(If death occurred iu a hospital or institution, give its name instead of street and number)
2 FULL NAME
(a) Residence. No.
(Usual place of abode)
Length of residence in city or town where death occurred
(If in the Army or Navy of the United States, give rank, organization, etc.)
St., Ward
(If non-resident give city or town and State)
days. How long in U. S., if of foreign birth ? V. years ^ months )C days
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
4 COLOR OR RACE
7^1
5 SINGLE. MARRIED, WIDOWED, OR
DIVORCED ( write the word)
5a If married, widowed,
or divorced
HUSBAND of
(or) WIFE of
*
**
- —
6 DATE OF BIRTH
( Month)
(Day)
(Year)
7 AGE j> s / Years
^ Months
! v
i w
i
Days
If LESS than
If STILLBORN, enter that fact here
1 day, hrs.
If STILLBORN, state period of uterogestation
mos.
or min.
8 OCCUPATION OF DECEASED
(a) Trade, profession, or .j— ^
particular kind of work
<b) General nature of industry,
business, or establishment in
which employed (or employer)
‘~y-‘
(c) Name of employer
/'Yf ? f/C.
9 BIRTHPLACE (City)
(State or country)
10 NAME OF
FATHER /A*-****. /(. Cs
(/)
|-
11 BIRTHPLACE OF
FATHER (City)
~^s(j -
z
(State or country)
DC
12 MAIDEN NAME
<
OF MOTHER
0.
13 BIRTHPLACE OF
MOTHER (City)
(State or country)
14
Informant ^
(Address)
2
15
FUed \&MT, 10 An
(Month) (Day) (Year)
Registrar
21 I HEREBY CERTIFY that a satisfactory stan-
dard certificate of death was hied with me
BEFORE the burial or transit permit was issued
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
(Month)
z
(Da
(Day)
(Yeaf)
17
l
HEREBY CERTIFY, That I attended deceased from
-....// ,19/^ ,to 'he^. 7 ,19/7..,
that I last saw h i--n. - . alive on > 19 / °j ,
and that death occurred, on the date stated above, at //. m.
The CAUSE OF DEATH was as follows:
(duration) yrs. mos. ^ ds.
CONTRIBUTORY
(Secondary) y7 ' *
(duration)
yrs mos.
ds.
18 Where was
if not at
as disease contracted y
place of death? I /C<rx-t a/la*' kV.Urrd * —
■i Date of
Did an operation precede death?
Was there an autopsy ? /? &
What test confirmed diagnosis?
(Signed)
(Address)
Dale
( Month)
■JtL
l ,.d<
!»). ,y o %
- 11
( Year)
M.D.
19 PLACE OF BURIAL, CREMATION, OR REMOVAL
(Cemetery)
(City or town)
DATE OF BURIAL
• /
19/^
20 UNDERTAKER
ADDRESS
^22 Dale of issue
transit permit
of burial
/ /
c* H h"
ȣ I
» w B
0 ® o
S a
? H *
a < O
'0=2. Z
U & o . - 3 O j» a
® o
- *-*>
S2. ^
w P
- 0
« 3
c. v
© ©
P _
e+ d*
a a
3
s- -
§ «
{;, p ct
Cd a*
> 1 ®
?5’|
31* S
rf&g
D 2 a
Q* H *< p ► '
© P * „ - • N
o> 2 - : > ®
E. § i = 5 "
• e g p I
•d ;
a ,
®.-j
a “
C - 9>
^ ci.
St. *d w
os ©
p
OS
*a -
3 B
5. P
s° p
oq
t? g-
O O O
CJ* C 3
get P
p* © !T.
cr * g
e* *2. S,
C+ M O
(j* S M
.r P a
~ e> S
B 5
p »1
° g c*
P 2 o
a-p §
ss a
2 c E
P p* o
“ ® P1
^a~a9 2.-2,<i "-«?
- CSS3-S c Ofl J?
§ 2 g | 5 a~ S
- c : 2- t,
g 3 g g.^ 2. §§o3B3S|S-go
°»8£f£EriB5.2.S-oj*tfE;oo.
°’<cgl8g’2.?»-l3BSir£-c-&
go.’P(RMP;030"„“n * “ "
C »s» an ig
s. g << ? §
® S te? s: I
o
® _ g. 6 E. 3 s « •• » o £ c
e & '» 5 p. 2 n d. ? p » • & B
I. 8 i 6 3 SiSs-o^S
E S 1' I 5 ? '
o eft 3 :
© *e p
5* 2 p - , 5 S h ^ cr o ^
2 £ *2 - - .. © ,2 *_ © • 'Q
dp© ► - *d
P • .. Ji * *< H- *0 C D ©
§• ® ':gd^ BfSS'ls S'»
"•“ 5 »S • - S O S'ES'B.-'
= sa " s-=l«8 IS’*
§ &2.S* 3
© © O' o O, o
; 8- s O' 5 E 8
t-i 2 ® 2, p v
g. £ £ g S »• 2. »*;
jiil !.“ i.i i! Hi? g
- ^ & P 5’Oo§
- kS P * ■*- ►r-g D ' w » •o d ©iP
tag f 5’ o “ s o o a- c S. 3 8 » 3 ?
S ! 1 2 • B g ? ?« » ?
?r* m H P -i P S- 03
np'iut— .coT ^s ^rnr^^
© - pP£ o © O ^'Q ° ® m C
^ < ,^P P'5 Q-D^ ~ ”_© .
? ® »s» S 3”. S'erl
eoOa O-J-. ^g-toa ^
« -B ' • 5S; »«{S.S
g Sg Sfe-s a f |ff l o-gs.
2 S » s. S-ss-^oge.®
3 « ° ? E S'? g g?S.a.S5
p- ® P- 3 2
3 3
•O p*
B- a. 5- 3 2. 5. B
•d
2
B®djoa|.|i-|:
a K o . „ e tj
ib.| 1 ►! i a
® i° § B. & p. 3 a
2 :S £4 I S' a
^ ? w
D- 5 S’
s e, - . go - go
* > ^ - © p
d 5*2 h'io?'? § a
W P. P p .® o g ® s
^ -. p
Cfi s
P- 2
??
p- 3
■2-r-S.-
*=s
^3-0
i 1
" a. 1:1 ^3
^ ® a s
© o • w
H* 1 _ O ^ **J r*
© R ST © C ~ © ^- O -wq
pL.^.’^P-g-PpM. 5
t? a p'5'^P-o-rt-Lwn-
" “ a® §-|«g'gS,|s- _o- so
isIsIv'lHsil?-
M»nQ©3?;^m2M
°a^2?p^”n''W
S ^ f r_
S- b S- i S,
a 3“
o1 B |
M cr cn
P- !
: ® o-
os J5
5
0 w
© m S-
< ® ©
0
^ P
2 2-o
P. a S’ K»
2 *0
&-3
P o
w B
03 W
5? ^ ^
r w
o P - O’
£• ®' o
C3 CD H
M © ©
P- ^ *3
e 5- 2
:2?8S-^ |S ^
o1 g 3
p- 1 i-zr o11
. , p g.
r.aE'S |g
p 3
g off!
■dnaS2?CTffi?S-B.2«
d o £ »■ n * • ;■ .
o f+ ® L “ d.- . d P
p 8 S. 0 o- .
s 5- It ^ vi r- t= S. © *<J
'0,8 0^
° © 3 - rf - —
3 H P M. d" CO CO
w OI C H O P p^
2P*^Co
P°&3. ao-®E
Oa a 2 i- ^ o ®
a- a ” l sj ® m
p £• cr ?3 P b
o* 2 o d dr 5
a* a a 2- 5 g p
p‘l^& p.^5 ®
o- S’ -° « s 3
^ S % 2 B g
3 o* S- « « % e
g «*• » 2. § ® S'
o o cn W sr •— 5
CK} O O P a 5
g.gg.g&|a
• c g. ■ K D. S
01 1 g-g-S s ®
■ “2^5
® ^.S1
- ^ k. &
® a- a- ^ S' S o'
(f<C?gp'g
3 I&I ® | B
B 2 & 2. 2 ® 1
a" ^ a g
o a o' P
B K 2- «
a & - H
g s 3 B
8 8 I P»
® rt- P* O Tfl
P © ffl ©
P n P ® S
P- r- 2 ° S
^ o. ® 5 3
g" a ® § |
B P
^ P o* &
cr ^
o a.
p © S
0- s
*< ^
O- JT.
© C*»
*< ol ©
ft- Wfi
p* p (ra
B
o Es
p <<
B*?
B 5' o
2 a.®
B; P- C
S'S.ZZ
® ®
s c
O Pi
„ ^ S
g.
S' g.
© a.
g §
P D-a
; M D*
«<
Q L1,
' g c E
. 2- p ^
p P
a e
2- E-
P v;
P* P-
s a b o.g's-
CO ©
;b o *d ^ o' :
5, p (3* V. * 5
2 ®
° 3
Es as ?? s
S g. §• S' ® 3 B .
p nP’E'&B. c2 r-
“g • sr|.|
H " * SO 03 ^ ^ r/3 o H i- H
__K©B S ~ ^ E. *-* PT <-
5«,p(':»(Lt?-.!s5SoS®:»? ^
® M ®$’Pi'©® 2 d' 2 ® O* n W* 3
2 sS S?g» ff2S5? > 3 8 ® 2. «
^ r* ® o R
p & « << P" g "*
& % w ® ® St K
“aSo1^-
re 2 ® £• ° S o' ° ® “
S°.SoEf£'&0‘BP
b:|E?-cp 5'g-S.g
tr5'2SB^EaftS
■ 5* Bt 5" o
Z- % p -i
© © 5 h tr*
. 2 S * ~ -
0* R ®
>
£ ™ o 5 tJ
® S' 3- a S
p® Es s.a o.
O O
v> © © rf- o ,d
E 2. n ?#?■»,
2 © p o- &. o
5 ^ p st. *0 2 5
D-p-^P-p O © 5- 5
S' K* c* K
g- p?'^3®S’‘Jg'<-’'®-.2S5a-('
p o a^m’d 5'2.Wk. »-®5. ><2 C
6 a®a-ao“PSC.^PCL-ge.-
^[,f.v:®ooooagrop«2.
S' SS-3E2. 3-2®®pfl°.P-SR&.
W )S ^
, pf c <<
CD *1
3.1
2.
v v>
® §• 3 b. a|®*p3£
!!Hli!i5it«^ ...
^o-B^®o’EaS'oa'r.30'p^®i'’R
P © . <pPHw»8®cr50rf.pp©'>^*P'
S-3®^ g onEac-B
2&»56'SS??^
p- — g-p o © ►:• p
D>% hh,
© CL >-*> P Op O
p ►-• CL. *+* u> H
S- s. ? e s —
g ® s -B
'SRa°a:p&^.
g B o' P J B B 5 -O p
If Sil llH-al-B l?=s-l
ii-O pj x *-a© ^ <
m © O p P ^
»<S-CL«®g^p-
S.3oS.a2s°
> 9. 8 E * ?■ J 0
2 p
3 -
7. J
m
H
C
73
Z
0
o
t-n
>•
0
0
2
2
0
Z
$
o
m
3]
H
rn
>
r
-t
x
T1
n
>
H
m
U)
0
■n
□
m
>
H
I
2
>
03
03
>
n
i
c
0)
m
H
H
03
m
x
H
73
>
0
•H
cn
-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. Soe instructions on back of certificate.
County
Township
lPLAQf: OF DEATH
V4 < 't- Y XL
Department op Commerce
BUREAU OF THE CENSUS
Village y—
or 70- f ^ r-/ <
City.
yi
(No.
STANDARD CERTIFICATE OF DEATH
Stato of
CvY / y/f? ft 4 * Registered No.
-y# J f /' ft // /. [If death occurred in
Y Jr-t / {4 ^ a a a hospital or Institution
, ,Z Ward) name inutmu
2 FULL NAME
vj.
At**- ApYl -T <,< ^
give ’ts NAME instead
of street and number.J
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
A COLOR OR RACE
5 SINGLE, /
MARRIED,
WIDOWED,
OR DIVORCED
( Write the word)
6 DATE OF BIRTH
(ft ..A- 1..P.. T~
(Month) (Day) ’ (Year)
7 AGE
3ZL
yrs.
.z.
//
. ds.
If LESS than
1 dry, hrs.
or min. ?
8 OCCUPATION
(a) Trade, profession, or j~
particular kind of work ftft.x
(b) General nature of Industry, - , , r~> y
business, or establishment In cY - , ) r ft 4 (4
which employed (or employer)
9 BIRTHPLACE
(State or country)
A
10 NAME OF
FATHER
PARENTS
11 BIRTHPLACE
OF FATHER
(State or country)
12 MAIDEN NAME
OF MOTHER
13 BIRTHPLACE
OF MOTHER
(State or country)
77 TX A u t ^
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant) t — - Y ^ ^ if
(Address)
15
Filed
■ l M~ ^ , 1Q1°[ <LcSLoJL^>
Registrar
17
I HEREBY CERTIFY, That I attended deceased from
.(7ft.Aji.7ft , 191.4., to , 191-4,
that I last saw h-CidA. alive on .44— — (ft. , 191.4.,
and that death occurred, on the date stated above, at^-4— ?Zm.
The CAUSE OF DEATH* was as follows:
<-~7 c< 4
C2 Y-L jftft-ftfjJ-?i(lc- — —4. ---- ftcTA-
,<L C CaA7
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
r
(Month)
191..Y
(Day) (Year)
Contributory.
(secondary)
(Duration) yrs
(Duration) yrs. mos. .... ds.
^ /3 ^ <^tt. D
191-^- (Address)^^y^Z^— ■ A*
* State the Disease Causing Death, or, in deaths from Violent Causes, state
(1) Means of Injuby ; 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. A. ds. State yrs. mos. ds.
V/here was disease contracted, /n
If not at place of death 7
Former cr
usuaj residence.—^
19 PLACE
4
-ACE OF BURIAL REMOVAL,
Aft? v vA
20 UNDERTAKER
LftAz
. DATE OF/BURI AL
191
ADDRESS
-A//.ftZ^
ft
11—3184
s •a<s s * ^ 3
. I S 5 = Z § 5- £
a c ” o S-!To S
. g C O O H
- rr* 3 CR p O "i
® c.?^ p i
► »— (R £ ® 2Lo a
“* ^ P
c* P
p p
O
o as
s J
eo
. ? "3
cr- B ? 5? o
re tz g r- '-’
? s. a i>
!T ft as 5’ S*
o’ 2 hi re re
* | 3 °* £-
w P 0 S? P
c ~
£.o- 3 ov S:ci» m g>
■ ?cs sr 3- S' S Ch g 2
CQ
p: a>
COMMONWEALTH OF MASSACHUSETTS
FULL NAME
Place of Death
Date of Death
RETURN OF A DEATH-1919.
STANLEY S .R I GG Registered No.
Boston MASS .HOMEO.HOSPT .
FEE « I 0 1919, Age 1 3 years I
CITY OF
BOSTON
months
2 082
I I
days
STATISTICAL DETAILS.
PHYSICIAN'S CERTIFICATE.
SEX.
COLOR
SINGLE, MARRIED, WID., DIV.
M
W
Maiden Name
Husband’s Name
Birthplace
Name of
Father
Birthplace
of Father
FORT WARREN
iSAAC H.RIGG
BELMONT .ILL.
Maiden Name
of Mother
ETHEL CRUMMERS
Birthplace
of Mother
GREENBAY.WI S.
Occupation
AT SCHOOL
Informant
Place of Burial
or removal
malden(forestdale)
Undertaker
W.C .SKAGGS
Date of Burial
Wl NT HR OP
I HEREBY CERTIFY that I attended deceased during last illness
from 1919, to 1919,
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:
SCARLET FEVER -35 DAYS
LEFT MASTOIDECTOMY JAN. 31.1919
ributory: j GENERAL SEPTICAEMIA
tion) )
(Signed) S. A. CLEMENT M.D.
FEB. 10 ,919
SPECIAL INFORMATION from Hospitals, Institutions, Transients, or Recent
Residents.
I \J HOSPT .12 DAYS
Usual Residence W|NTHROP(59 LEWIS AVE )
1919
Filed
A true copy
FEB. I 3
Registrar
WRITE PLAINLY, WITH UNFADING INK-THIS 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.
I>
co
z
8-XXM
(CmmtumutpaUfj of £J3assari}Hsrtta
STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH
County j Suffolk
BOSTON
(City or town)
State Mossochusctts ....Registered No.
or Village ^ ./ or
No 'T St, Ward
(If de:itk occurred in a hospital or institution, (give its name instead of street and number)
2 FULL NAME
(If in the
(a) Residence. No. /
(Usual place of a'hode)
Length of residence in city or town where death occurred
months
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
4 COLOR OR RACE
S SINGLE, MARRIED, WIDOWED, OR
DIVORCED (write the word)
5a IE married, widowed, or divorced
HUSBAND of
(or) WIFE of
6 DATE OF BIRTH (month, day, and year)
7 AGE Years
J3
Months
3
Days
If LESS (ban
1 day, hrs.
or join.
8 OCCUPATION OF DECEASED
(a) Trade, profession, or
particular kind of work
(h) General nature of industry,
business, or establishment in
which employed (or employer) ..
(c) Name of employer
9 BIRTHPLACE (city or town)
(State or country)
10 NAME OF FATHER
11 BIRTHPLACE OF FATHER (city or town),
(State or country)
12 MAIDEN NAME OF MOTHER
13 BIRTHPLACE OF MOTHER (city or town)
(State or country)
VVefc.y
St., Ward
(If non-resident give city or town and State)
How long in U. S„ if of foreign birth? years months days
MEDICAL CERTIFICATE OpA.DE AT H
16 DATE OF DEATH (month, day, and year) \~f Jj II 19 i
17 WHEREBY CERTIFY, Than
JO , 19^ .too.
that I last saw h. alive on , \pt. .
and that death occurred, on the date stated above, at .../ ZL m.
The CAUSE OjF DEATH v was as follow^T^
4L
19.J
.(duration) yrs..
s. J '
ds
CONTRIBUTORY
(secondary)
..(duration) yrs. mos.
ds
14
Informant .
(Address)
15 \'b,
Registrar
18 Where was disease contracted
if not at place of death?
Did an operation precede death
Was there an autopsy?.
What test confirmed diagnosis ?
* State the Disease/Causing Death, or in dratar s frfmf VIOLENT Causes,
state (1) Means and Nature of Injury, and (2) whether Accidental,
Suicidal, or Homicidal. (See reverse side for additional space.)
19 PLACE OF BURIAL, CREMATION, OR REMOVAL
20 UNDERTAKER /
i/tr <0? f*'
DATE OF BURIAL
3-/1/ 19/^
ADDRESS
<
2 2 s*
*§:§
8§*|
7.
2 H-
•2 a^S
5 a a,
2 ? »
o P -
X ra-
xraB .ra,
o o J
• a
OS
a
" e*3
Co P'S
a a
•tt
cr*
Cc£- o 2
^ CO -
-*2 Sr
« g a 5
<s K.q Z
s- 3 2 w
a -
O' o O
t~ n >5
o b cro
T3 H 3-P
o 58
►
c*
3. = -K p -
~ “ « 5; 2 3
i- "^=1.
3 CP ’ =*5
__ ^ e— ^
' S «2§ O
ap®2gS
O'M ;5 .y o
5 .. o - o
e*-* ^ iJj 2
CO „ >— i
~ CO C*^) Tf\
223 2.0^
£ R O O P 3
o o i • 52
p n >-i — p “
2 fCp* c-Sf
P ~ ~ p m O
o "p 5®i
p h3 5.
5 - ; O m ra
d 3 =£
srs =•§ ~
. p
w- 'J-
ra p
O ■
S'® -
3 2,> 3
&2/- g
5 JOB
<§&'’ ^
• S p
3
3£
R g-' So' ^
5 2 o p
8 £53
a. ^35 “
o
p
co p
CD ~ *r
cn
g
5s ^.J © *o
~
2 S-'*-
£ 3 p
3 c~ •
§0
?r*
co
? GO*
Cc I
P
§•$2
H ft 1
3 j
o a-"
3 P 5
£ co
' 5 ®
>
„ o
^ o
a -1
i . H
^CD S3 £
o ^ 2
"* g » §
<! p p 2
o $ p -
co
ft rv m
P ©
n <n
sr g-
•3
<r~ *2
a °
S’ 3"P O ra P O
SP3~P.-P®-P>
-•(P'O CLP
p a. - - ^ stg^ O
&§ o S| S
0^,2 ™ - S“£ n
O^g a-g^£2
M ® 3- r
c -i §
O-^
g -“! ^ b^b n B
3 S'l ^-.'J:S'P p 2
- „ 2 -a" • g. 3 P a
ig|j9Ig!g
• ra • o — -
” EJ> ®
ft3.tcw Sr«2
?jS3?s
2.^'g'® 3.2
EPO o C.C x.
f; p — > 5* o 2
p 5= — > E5-
-O o =-
— ■ Cl P
cn o-
Q-o'rC
&o'^
w P H
|o^$gS-^'<os-pg'p
g o g • > 3 jj g: 2 p e-g.
* g " t? H Z- ^ o
_ , p o
5-3 .PS? ^ “
-- w
O g ~
B-®
„ p $3
O r^- P
» C- -
ts 2
^p.g O s^p^ ®.
5 “ P g 5 gi"'
” § “
2r o (
7
cr3 i
°
QD ^ 3
§- — - 7)
“ CD
? g 2:^.^ g. 2^p4
tc >
P pra
S’&S
cl-F«s ■
o ij
s
a «a
o 2
o
— >
?r
n s-E
§IP
>
5 s
^ CO 5 ^
2 S ’-So
g qg p p-
B p7 ^
co Q 3 3^ -
P H-P
M P 3 '-y >
o - w S. o L
q ^ cr ST
d £p o
Wy g
M ||
p
p d
J vj
O ^3 P
O '-O
3 3 =B- =?
EL “ P
P s ~
“op q'Oq
MnOJ
w a p' P 2 u
CD
i
3
s < o-g
“ 2 tSmPo E-"
2. CO CO P ^
g£‘:«3 8f 5
S. o fc~ >i a-
a o s
8 1 N “
n P 3- £:‘3 tu
~~ P O ^ .
? ^ V S-CQ 2
o 73
S.'S
p p
age
“■ C! g P
p g v- p.
£.2 T) H_
o s yp ^ s p
i.S'o.S a?. S^g?
“^S-2 o§
•^2 2,1-PS
- ° g a
-Opgp ;o »3
- 3 2 p e^o 2 P
S> S P PS 3
.-^3o w _
§ p a'S 3 §■§ g
a p-“- a S
5- l^S-l
• ® §‘^.8-
p*
_ O
3
5 s-3 e-g cr-10 c » ""a 5
5 § S S ^ g p'® • gj S'
o^^P-Opcn^. o ^
o^?h a ^opEa^g-
I!i®alt4'“&£§
^ ~».s-o-s salas
Jl OjP P o S ™ ® ^.^nro
3 P r* B O ce
^ rn ra * ra
B Qffl -.
'S P ^ P
£.S? =■
S“5 ^
r- sa 5
O c» 5*
-■» p 3 S
3 o
P3 »
C^p °>
S^p
3 p
“ • p 2
p 3 2 "» &• 2 o
P S B 3 a c o
-Hilii
- p << 3 C ^ P
p p
. CO
o p
3 3-' a ® r.3
^p 2
' a _.
§p
iT-1 O &
a - ^
o-g. 2 o
o " p a
*»j'
0&5»
a ^ ®"
a 2-0
a a a
a s P-
S ^ O'
ra — • • a ' 2
CO co CO J"-
p °;..w^T:i
P c+ r“ a "*
CD
8 ^ ^
_ *o
E5 P
7= ^
5'
s !
| ;
P- . c+- *-* • ^ j^'
£»•„ ®s*
8 >a,TO.,-J
^ dJ tr- m
P.P
r»-*a
a o
r li
a a p o-qO p 3 O- co a a _
3 3-;3rrc^p^|S
*- ?< Ti ^ O. ►—x.*-! -o g.
— o 3
sr.M «
o^2
p co
cl ^
^ o
O P
*-! '-
s! cj P p o 2 2 E® &. o qg
3 ra ra- x a x. Clm a p
1 ra.^e mp S' o p P S m
r+ 2: * 3 C'-’W «i O
o a^l^-tqS ®
Q k*n ^
si-
p
3 a-p
ra J? p.P
5 “'O
ra P
t3*» ap.
a
2“ra dO
Cx <-* w ra-f
- - L~, ' r - ra ra ra ra ra — --
- i 3
as ^rag-C § P 2 „ » «•
2 ' o g ra .-3 g crq p P a
— ^2.2_S2^3-i-s5
:® tj
p
O '~‘-
2. § tr
, o p CT>,
i a M
O X o
a p a
S' c
§g
ifrllisl
2 g. a- a P.£t-+,a
ra. •=•■ a ra. a P'0 P
i i w, i CO CO
- ^ pr
' a § CD 2 53 ^
ra- P o g-CLra--§
>a ra ra P P“ o£
® S S,'’. K'l O’ O P
% a r:g S-5 cc:
^ O CO
g* o co ►
ss0;
o ^ a
£s.^"
^ co
^ p § 5
p B
® p
cr-T
CO U)
>r°
$£.
° p
- S’
o c c
Cfl ft , .
sj* c -i a _i
o “ - a 3
Sg o
3.- ®
. - • si < O
CO V' " co
3 CO
o-c *3
s.s ^ s.q a&K-g 5-i
S"B'rarap =5 <g ® P P O !
rs CD Q PZ ^ 3770 CO *-»- ►
ra— r/3 S ~- 3 -a ra^- <
g-g. p 5-^'i
. 2 Sr 53 - § —
ra- „.o ra.&j- g-jT|p p;<
3?ra§.SO®S®g;
^ s
trr- CO •
<Hra 3
° p, p“t
'7?2,a?
3-cl~o.
r^- CO ^ "*s ^ —
O ■ ® O ? X® S.2 3 2
p O-rjQ o o 2 - s 2
“ P R-P Mg ra- ra n 2.0
<0l&2la8S^ ”
r^s.g'g’-l ^p
b-
P CO
ta --
0^ o i>co
of p r*-
S-S- p *
" I M S
ft> CD CD
S' — P
3 cq
P o
S-ra
a H
g^* K'S.gcV
■ R-C ra. a
CO
^prp-p g. 5 ? ^ ~p o
limiBlal!
:eT8^ ® E<3 ? g*^ S’ 2
>
d
O
COMMONWEALTH OF MASSACHUSETTS
FULL NAME
CITY OF
RETURN OF A DEATH-1919. BOSTON
DOUGLAS H. FULLERTON Registered No> 2236
Place of Death
Date of Death
Boston
FEB. 13
257 EVERETT ST.
1919, Age
51
years
months
days
STATISTICAL DETAILS.
PHYSICIAN’S CERTIFICATE.
SEX.
M
COLOR
Maiden Name
Husband's Name
Birthplace
Name of
Father
Birthplace
of Father
1 kid
W
SINGLE, MARRIED, WID., DIV.
DIV .
I HEREBY CERTIFY that I attended deceased during last illness
from 1919, to 1919,
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:
WINDSOR .N.F.
ASHEL FULLERTON
LOBAR PNEUMONIA
ributory; (
tior>) )
I NF LUENZA -~2 DAYS
Maiden Name
of Mother
Birthplace
of Mother
(Signed)
E .E. BOWEN
M.D.
Occupation
F IS HERMAN
1919
Informant
SPECIAL INFORMATION from Hospitals, Institutions, Transients,
Residents.
or Recent
Place of Burial
or removal
W 1 NT HR 0 P ( W 1 NT H R OP OEM)
Usual Residence
Wl NTFROP( SNAKE ISLAND)
Undertaker
Date of Burial
F.A.MAGRATH
Filed
A true copy.
Attest :
1919.
1ZUZ!
Registrar.
£
—
_9
.
• ' * « »
; :
N. B.-WRITE PLAINLY, WITH UNFADING INK-THIS 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.
©ommmunpaUIt of fHassarliuarflfl
STANDARD CERTIFICATE OF DEATH (City or town)
1 PLACE OF DEATH
County X' O I* C © State i’.i.&.R.k?. # Registered No.
Township Wcatboro - or Hospital or
City
Mary V.Pi^er
2 full name 5-5 broe&erset Av© • - - Winthrop Mass »
(a) Residence. No St., Ward
(Usual place of abode) “ *“ *" (If non-resident give city or town and State)
Length of residence in city or town where death occurred gears months days. How long in D. S., if of foreign birth ? gears months days
No St., Ward
(If death occurred in a hospital or institution, give its name instead of street and number)
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
Pub. . ± 7
3 female 4<™m$RRACE \*t
R1ED, WIDOWED, OR
rite the word)
16 DATE OF DEATH (month, day, and year)
19
17
Sa If married, widowed, or divorced
HUSBAND of
(or; WIFE of
mm mm mm
1865
6 DAI E mjBIRTH (month, day, and year)
I HEREBY CERTIFY, That I attended deceased from
May. ...8 iA.4 , to Fab* 1.7 , i3.9
that I last saw k
er
alive
Feb. 17
.19
19
T5
7 AGE
Years
Months
8 OCCUPATION OF DECEASED
(a) Trade, profession, or
particular kind of work—
Days
Housewife
If LESS than
1 dag hrs.
or min.
p, $
and that death occurred, on the date stated above, at m.
The CAUSE OF DEATH * was as follows:
(b) General nature of industrg, _ .
business, or establishment io,T , . _ _
which emploged (or employer)nS,V©X>bl XT
(c) Name of employer
Chronic Myocarditis
Chroni(®*~I«tei»sM t
cowW-lcftiB
ISECONDARYj
.ass a.
.(duration) yrs mos. ds.
9 BIRTHPLACE (citpbrOoifikE B .Bar tl© 1 1
(State or country) KottlnghaP-
18 Where was disease contracted
if not at place of death?
10 NAME OF FATHER
N.H.
no
Did an operation precede death? Date of..
no
Was there an autopsy 7...„
11 BIRTHPLACES f,AT«£R),(city ‘Vd-l-ley-
(State or country) ...
I'-ottinghai
12 MAIDEN NAME OF MOTHER .
What test coriflittggl
(Signed). Weetboro Maes.
.» FWfrur laia
r:.D.
13 BIRTHPLACE^
(State or country) ^ RfhWTVa ?/»
* State the Disease Causing Death, or in deaths from Violent Causes,
6tate (1A_Mkans and Vatuke yp Ln-jurv, and (2) whether Accidental,
Suicidal, QicHoi?3^X^a!71eeitet<?f reside for additional space.)
DA^TiF BURlA°-
©stboro19
14
Informant
(AddrSobelC 1919
19 PLACE OF BURIAL, CREMATION, OR REMOVAL
L.P.Conant
15 Filed . 19 I ?.
Q^UJr Registrar
20 UNDERTAKER
ADDRESS
um
fp'l W1
2 H§ S' o s
2 ® 9.8. Es -r' b »
2 § §" I" §■’ o " a
®-« 8 a-*^
- _ no ..
— eS-?5 p
w.s a"" a-. 3 §
ft. ' 2 £• a St 5
3
so
,|JS
III p ^3 ®a?3 S 8'g.1
S3 » §£ ®-S I I 2.0 |s* ~ g = 3
-*5\p§? -g-~53 § g.* p H|J:o§
■ 3 £ I- 'hT' sg ^§! § 2
2. 3*0 -JO1 -O * '-g a o c-? o j-
-(®_O'»2--:'raQ-O®53O0
? a> O- W 3 » O ^ 2 - p O n e*- 1/
i o 2 ? 2 = a-S® 3 3-n 3 “&3
GG^P S-^2 O 5-§
£0 d o o> PO CO 3-5T P-D-P CO 5.40 o
g.« B-.®--p 52. 2 2 ? a n-c U — 8
“‘g =2|S
5? g =--05 B.
_o =-£-2
c* s -"a - a
gc^ - - co
fO. '"I -
o-a
A §
3*0 O 2:0 ® 2.0
p p ~>coo 8 &§-
I#'', « an 2 <! n ® v
5® 8 ==« 3C °
■ 02
ff® P-aH-S S-SL
ay n 5 » a .*o
3V1.2
— T*3 S-^ ~
o®2®2®e'o
2-§?^
»• £.9 q .r. g-®
3-2o ® £ E
3 O ag B s-.^ ° r* Hp I-5 „ a
“O^S^SS-2 2po •a]'-'"’ P
3^3-3- gf&a®-
*-* - op . _.aas
= « 3 S 8 |»8 8 B g »
~ZH5l Ws ^o-S.g
p 3
5 o
s
,j= *a
x JL a
p 5f t?
3^* " ** " O ft *? C ®
S'B'ii* s3-§g<
3 « §•-- o' 0--0 3
E7!
rr
isg.
o'-^o r. s- g, i-o g. *».- g a <3 a
^ _ t g'S^"' 2 *.£® I* 6 5 3 g-o
■ §• I * S'S--® S ” . S .S? EE -
V a® O 6
a 2 O =
oi o*--® a S
“ o sa’g s*
§ “ &
I 2
a e
co
. P era Er-^r
S-® SgrS 1 g
Zj? g.O | 3 “
2 0-5° ^ § Wg
5 rT^ ^ v. • 5?
s S g-^-
- 3 p .
E,5a
a 5*a a ra “ p
S.e’g.S &?.
« s; 2 a -
o
D- _
(B Q £• 2 ^ O
» < o O'* J5 S.">g.fl
r?i^g » S.VtJ 2
o 3 cr--’ 5 3 J: 3
-I rip
o ^ O V _
o *a
5 - .
a s
e-^2o^ cro
03oB.^0<0-0O o;-s:o 3
§ 3-^a — e £
. »J-srr i« h ..
ls.“S-r.!ji-i|||
j M Cti
S O O'- Sr
O 3 o w g
►-! — /-S a
a-
1 o
rF
^ °5 5 g- 2 o 2
3 3'2
» g-g-cOs;’ SSa 8 Q^5-'o
-B. s»,g:p,a^3.3 >•§
5: ua rt- p "o -
sr. .22 »“ 2 >a® Po £
a = — P item B s a
5 -W ^ w ►- .. , >4-1 VJ
ht"% =g§-“^
5 a s>5 4 -d.
3-- = 0 2 ® _p - ; 5S o O
o -
_v JS?2i»
SL co 5 S 0 B ►€
q c*. ___ y ►>
CO- O- »>■ »_3
P ^ <pPg
p
s.a 3 g yog-g
2 a g?-“ g-E§ a-E-f
p 3
- P
o -• <
*.^2.
-E3 60*5 « IS'2'
w 30 §"c
2 <4- m * S2. 0 TJi
s p 3- S*g ®
s* 3 o g-§ -
rrv?.4 2
= - O P
P6P -
2,3.0* &
5 «■ p o
-"S33
- . 3S-1I&
1 IM 8 l-S |
§• 5o- gvj.p-8
«a - 'Z'*
H ^ O P
g 3 3
?2»
«a K a
,-“ 3 3
v § o'1 i-o '“' p g S E §"3
^ ^ “ O aq - 3 O- 3- o g. ffi s 2
O CO
8 <5:“ ||*ti:8 ^.8 2.3
•<r»- Q
O a> - 5 a
%Jpg
So-g 3
S-n 8
g 5-0
^ SI 30 3
g H
o-og 8 .
gm(lri*3 00jit=;g 2 ps‘^1,5'
5'p o ? ? S-rS-oa? t^® cS-oo^®
OoS^oS'
O c*. a ^ 3 _
.. 3 stSi^
£' 1 1 1 ®'i~^ i.s ^ E'!-
g^g'S-iVSL'S.’S 2 *3
" g o ^.3"S^Si ® §"o §l'^'3
§ ^^oU^g'g'-g. -S.«
« S’s® S; ^"®
®^Ig3®|-^p9
— r
i° g s *« a o
*? o ^ —
^ rr o ?j- a
P 0-0 K- C- P
1—- rs ?>). J3 ET^ O *5
Stag's
. P S r-
«? J5 £ a*
^ p fD . ^ ^
g(R 3 2 ^
9 a 3 >S; ^
C5
flslIfiR&lf'lii
^ 3 3.^ a— 01 31
3-0-3 o CO'O- ii
O 7 CT5 p>®
^p § *5-s.- e«S 3
b’s®,.®. 823^-.
-73s^CL 3?p- PBS
• tp >• S- pro°~ -0-7^.
S2.o-«gP§»|^rg3
- — O- <r*- i
c^- <r*- ^ mj
. r*- ^ 3.:
>2'-g o p ,
C/2 “ - >—
2 a3 ^
•a ^ ^ ^
2 ® »•§
CO 3 c* o P
(5 > O ^ I
*5j
2 o
S M
o 3
> 3
£,°-3 3^"<
sr-, ^
3 * I f
e'“ cJSjo ?
j.&3 o O- c
o 3 P __r,
g.o ~srs
StP-"1 > ’ C
- cn /**\ *■
- C/3 5
csco
^ 2.3 g
Bel 3 o'|1
g &<P 9
WRITE PLAINLY, WITH UNFADING INK -THIS IS A PERMANENT RECORD.
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.
©omutxmmi’alth nf fHassarljusrtta
STANDARD CERTIFICATE OF DEATH
(City or town.)
(If married or divorced woman or widow
give maiden name, also name of husband.]
rr ' ' '
[If death occurred in
St. ; Ward) a hospital or institution,
give i ts NAME instead
of street and number.]
“RESIDENCE
Registered No.
PERSONAL AND STATISTICAL PARTICULARS
* SEX
/t'
< COLOR OR RACE
3 SINGLE,
MARRIED, / // /
WIDOWED,
OR DIVORCED
( Write the word)
• DATE OF BIRTH
x/ /p^y . , i
(Year)
(Month)
(Day)
r AGE
„..yr*. mos. \P. ds.
£
If LESS than
1 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
ACE /
10 NAME OF
FATHER
n BIRTHPLACE
OF FATHER
(State or country)
H MAIDEN NAME
OF MOTHER
» BIRTHPLACE
OF MOTHER
(State or country)
/ '
“THE ABOVE IS TRUE TO THE BEST OF MV KNOWLEDGE
(Informant) ..
(Address)
A. ^
Tr ' 7
n;. / -v/ v
Filed..
191
Registrar
MEDICAL CERTIFICATE OF DEATH
“ DATE OF DEATH
s~\
(Month)
.%r..Q. I 9 1
(Day) (Year)
1 HEREBY CERTIFY that I attended deceased from
jhd^2..L.y. , I9lj£.„ to.„ X Q , 191^.,
that I last saw h.j alive on.. H . 191.^..,
and that death occurred, on the date stated above, at...^!.. .^m .
The CAUSE OF DEATH* was as follows:
uration) yrs. mos,
. .X... ds.
(Signed) ,-nnC; rT?....
, 1 9 1 (Address)...,_....l...a....^:... J.....
* 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
20 UNDERTAKER
C.O.
DATE OF BURIAL
I 9 1 y.
ADDRESS
S ° «s. 2.
^ ^ s*
K ^ JS- P
in c.
e+ t-r «4-
5- £== P-
p P a
w »
O P.
^ °
^ p. 03
S. C2
s H 2.
S* 2 e *<
*o p
^ P
o: o
oo *-«
•» • w
a S
3 i-i fc
SI
OO -O
CP
® ®
2. < 3
d 2.
a. 3
g w - «
5 g I •
O C 0 z
H
o *
§ H »
Z ” 2
-* e‘ 3
3=
sr
t-<
a
cr
c
Ci
o
x*
C. 3 0 t=l
P o «
S: (L is
3 «, z
a. 1 o
« 3 §
5 cr *
co p g
5 ®
0 *s
b
B-
s
M. 50
3
p-
p
O
I. b
P. o
pi cr-
- -
P- -*
1
P
S3
>-
o
to
p 5' si
n ~ ?r
2 *0
o £■.
g m
gi a a
Co
cd
P-
o
p
•o p- g
sa|
03 P
o *-*» *b
P g p
OQ O
M*
CT>
p
<<
- s
'i w
u.
P
c*-
•1
*<
— "Z-. r-
CD #P- C5
x* ^ s-
c
CO
CD*
CO
*0
CD
O
>“1
o'
•-*
3
1 Co
§ *s
s 3*
3
CD
P
P
2
P h CD
P- P 2*
0*
s
5
CD
P
CD
3
p
•d
p
►1
3
^-s CD
C- ^
c+-
p*
^ P Co
^ c" E
O P !5*
0
3
2 *5
r *:
i &
p
H
tr
5- O -
3
o
3
o O
< o
%• B 3
o P p
'C S-
3 cr g*
O {U <<
m. o
p*
o
e
p p p
o p- P
O o 0
2 a
<? 8 °
p-
o
P^
2
O'
b
2-
2
cr
p
p
p-
t. ^
0
p
p-
p
p-
p-
I
a
CD
b 2
3 5
O ~
p 3
p- p
cd
p
c+
P
2 0
W
p
2- o
cp o
2 o
02
p
p-
p-
* •S
o
>•
Co 7-.
P
<r*-
P-
n- ►?>
cr
p
CR
5 B
O
p
p
p-
p. p
e+
P4
w
>*
a
f3 si
o
5. c 0 cT
p
>•
P- C5
P
0
1
p
cr
*<
p. o
p- si
t?j
s
B
P
Pi
O
P
P-
P
5 W
: d &
H
P
3
S
—
p
p
: p
= > &
2- R-
f"T^ Co
S
: 3
!>-
■a
cr
Go
&
0b
tt!
c
a
a
2. o a
3
p Q-
d
p
p-
w
p
p
a-
o
*0
p4
<<
p
cr
p
s
2
d p-
g. p- *d
k* o —
d
d
H
W
CD
D
O
P
(R
P
6
e+-
CD
P
6
2
*-*>
P-
0
Pi
3.
p
(R
O
P
2
*-!
CD
r*-
P
2
*d
'j.
CD
CD
-
-
-
•
P
P-
IM R-301
c i <u
0 c «
= b «
1 2 .
E Q c
<2^-2
.E°S
«. u a
O </5 P
6 <
'Z.& *
S- C5 CO
2 O
Q o
cc ^
o ®
O «0
LU Z
DC <
I- O
z 35
< 0.
s
cc .
LU >-
CL _l
<s
CO <
— X
CO LU
X “O
. a,
CT3
tf) £
^ CO
o o
cc qz
LU t!
a>
OJ
CC W
o
o w
O
r I
^ o
cc w
^ X
O 0)
E "
u CO
O C
4- O
c *•£
— o
CC 3
CL £
00
z
18. 100,000.
Stye (Emnmmunealtl? of JHassarijUBrttfl
STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH
County
City or Town
2%
OFFICE OF THE SECRETARY
DIVISION OF VITAL STATISTICS
Registered No.
2 FULL NAME
( :/7~Z^_
(a) Residence. No. S
(Usual place of abode)
Length of residence in city or town where death occurred
No. .^.. ,...e St. Ward
(If depth-occurred in a hospital or institution, give its name instead of street and number)
-
( If in the Army or Navy of the United States, give rank, organization, etc.)
St., Ward
years
(If non-resident give city or town and State)
days. How long in U. S„ if of foreign birth? years months days
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
4 COLOR OR RACE
5 SINGLE, MARRIED, WIDOWED, OR
DIVORCED (write the word)
5a If married, widowed, or divorced
HUSBAND of
6 DATE OF BIRTH
A'S r c
- jFW - ^
2_lf
( M until)
7 AGE .'ijrj Years ^ Montlis ^
If STILLBORN) enter that fad here
If STILLBORN, stale period of ulerogestation
fDav)
Days
2L
( Year)
If LESS (ban
1 day, brs.
8 OCCUPATION OF DECEASED
(a) Trade, profession, or
particular kind of work
(b) General nature of industry,
business, or establishment in
which employed (or employer)
(c) Name of employer
9 BIRTHPLACE (City) 1 ^ (/ / ^
(State or country)
10 NAME OF
FATHER
'JUI
11 BIRTHPLACE OF AAf
F4THFR M itv) U r O
£AAjr
FATHER ( City) •/ *
(State or country)
12 MAIDEN NAME
OF MOTHER
13 BIRTHPLACE OF
MOTHER (City)
(State or country)
/V
14
Informant ^
(Address)
15
FiledT'nJ^
(Montlr) (Day) (Year)
Registrar
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
(Months
(Day)
tpef
(Year)
17
HEREBY CERTIFY, That I attended deceased from
r ...t- .it/fr.
S-l .x*r?.
that I last saw h t^Mzalive on
and that death occurred, on the date stated above, at
The CAUSE OF DEATH was as follows :
/j cx-£*cl^-> -t~&
CONTRIBUTORY
(secondary) ^
K
Date of
l^e-o
yrs.. mos.
mos. ds.
ds.
18 Where was disease contracted
if not at place of death?
Did an operation precede death?
Was there an autopsy ?
What test confirmed diagnosis?
(Signed)
(Address) f ^ 1
D.
( Month)
19 PLACE OF BURIAL, CREMATION, OR RE1
st-/
(Cemetery) (City or town)
20 UNDERTAKER
DATE OF BURIAL
^ 19
, si? ■ a S t
21 I HEREBY CERTIFY that a satisfactory stan-
dard certificate of death was filed with me
BEFORE the burial or transit permit was issued
'is
22 Date of issue of burial
or transit permit
a u*
P ®
« 0
? o
3
B ?
s I
2 w
® ®
O M
S 3
05 *<
® o
®
® ®
' B
*3
o _
p <5
p. p
c+ w
s* s
«. W
St •d*
to Q
p _ c:
£15
. ° ®
cr P- ®
o P £
a*> 5
o o- g
Pje-
o P **»
® W O
►— ® *1
►r w
P - P
a
a
*p -
» 1
B S
p 5'
(2.
M 2i
•§ -
§ l
9 -•
o o o
p* C g
*2 d P
p* ® IT.
D* « H
efg. 5
«g?
F B
m
p B
2 «■ p
3 o 2
i-8 §
E* g 3
° n- 5!
B tr o
“ ® B1
o
3» O
5 <T5
(“5
s-
O
«n
o
m
X
m
H
C
3)
0
■n
0
m
x
H
■n
n
>
H
m
(/)
0
T1
D
m
>
H
1
0
0
2
2
0
z
$
m
>
r
H
1
0
■n
2
>
0)
W)
>
0
1
WRITE PLAINLY, WITH UNFADING INK-THIS IS A PERMANENT RECORD.
J= O
“V
<£<
z 0_
o
50
— o
C0O
£ 0
«♦-*
. c
>- 0>
Fii
S3
x •
LJ ■*-»
o "S
-®<£
2 8
3 <SJ
o o
LJ t-
O S.
< O
L.
• o.
"O
0) o
— -Q
£>, •
men
= --F
a-r
g
<3 C_
» 00
4> ^
■° * «
3 1) C
O o
(fi C co
CȤ
O Q. ;
'ra c 3
E_i
* r X <0
|h =
.E < a>
LJ «
oQ*
pU- ■
50 c
“iu|
E
uO.E
CO
(Eommmmrcaltlj of iHaBBarljusetts
PLACE OF DEATH
..(No..
2 FULL NAME !
[If married or divorced woman or widow
give maiden name, also name of husband.] ..
“RESIDENCE
STANDARD CERTIFICATE OF DEATH
0^7 i2jUkA
\u..\ Qu\jn^\y\
to, SSI,
IiamSCu,
(City or town jl
[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
MARRIED,
WIDOWED,
OR DIVORCED
( Write the word)
DATE OF BIRTH
(Month)
(Day)
1 s-iu-
(Year/
7 AGE
yrs.
mos. ds.
If LESS than
I day, hrs.
or min. ?
8 OCCUPATION
(a) Trade, profession, or
particular kind of work
Jklt i....!:..
(b) General nature of industry,
business, or establishment in
which employed (or employer) ^f..L
9 BIRTHPLACE
(State or country)
10 NAME OF _
}.
l
V
u BIRTHPLACE
OF FATHER
(State or country) f s *
IJX Z+K
.Vc-
12 MAIDEN NAME
OF MOTHER
Ma/:<Z£ /J'
y / '< t
'3 BIRTHPLACE
OF MOTHER
(State or country) y
/
11 THE ABOVE IS T»UE JO THE BEST OF MY KNOWLEDGE
, . P
(Informant)
(Address)
- T
Fi ledi r[^.. jJLSC., 1 9 1 T-..
Registrar
MEDICAL CERTIFICATE OF DEATH
DATE OF DEATH
"TaXk
(Month)
(Day)
19
(Ye.
%
17 I HEREBY CERTIFY that I have investigated the
death of the deceased.
The CAUSE OF DEATH# was as follows:
. flLrC?.
CL\A. ..* ..
i/tA* a.
^
(seAndary) I fl ^
/ ^..(Duration)
(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, OH
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
4J-
UM I C
ritr
=0 UNDERTAKER
DATE QJf BURIAL
1
91.
ADDRESS
H 2
2 8
p. tr-<
ei
•a
P- p
a h §
o £- a
“ *
p
o ^
*3
p
w sr.
3 §■
| E?
3
a
o
a
p
<
CD
a
o
o
<3.
a
2.
S’
a o a
° 3- *a
8 « f
< CD CD
*— CD CL
8 §> *
-*» p W
8 ~ ^
a
p
p
Do
& &
a-
a
1 S'
Ci p
o a
p ©
H p"
cd p:
cn a-
p- H
o 2
a P
r
Cr*
%
t-<
o
<D «
t ©
c
»-J _
a„ 3-
g a
£*> ©
p
3 a
4 8
E- 3
>.
*9.
53
3
p z.
cl
a
O a
S’ S P E
o p 2. §-
1 *0
3 r
53
2 ?
a 53
a a.
p *L
a
a- cd
p 3
w *a
O o
•g: <<
- 3
2 r
a* p
a ^
W 8
o
a-
o
2 2.
c. w
O rt‘
a £
Mas.
o | g.
3 2 cd
S- 9
oo
f
4
C-D
N>
^6
a
a
—
p
q
3
ns
53
a-
M
a
a-
a-
p
a
a
<<
U
Q a’
Q-
vf
53 <<
a- q
a
vj
Co
53 O
Co
4
a-
ca
tr*
•c 5 a
to
O
w
a b
P CD
< **
5 5°
a. |
CD I
P
«?+• a
a
a
§
g
S'
?
Co
w 5- a.
^ a o-
5 3
£o 3*
a- a-
£. CD
C/J
CD
1. f
P 5
P ,q
“ a
5 £.
a 5
d <<
w M
a SL
» ? P i
rr1 m
P
a
a
- W
O
£
U
CD
a
o
•a
a
*<
!» *2
CL n »-•
? B
- I
£; 5=5
P 5
2. o
3 -
*-» CD
-WRITE PLAINLY, WITH UNFADING INK-THIS 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.
Stye CCommannipaUl] of fSaEsatfjuseHa
CERTIFICATE OF DEATH OF NON-RESIDENT
1 PLACE OF DEATH ✓ Registered No.
County - -..-State... " v
City or Town
2 FULL NAME
. /fa . - . j (Place of death)
Registered No.
\ j / j (Place of residence)
St. .Ward
If^ death occurred in a hospital or institution, give its NAMauustead of street and number)
/L, (If the 4^
• Cit-o nr T nurn
(a) Residence. State City or Town..”"!?
(Usual place of abode) t f ,
Leagth of residence in city or town where death occurred years ' month; X Q days How long inyfl. S., if of foreign birth?
Nay of the United States, give rank, organization, etc.)
fcs.. No St.
months
days
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH (month, day, and year) 2. 3 19 If
3 SEX
4 COLOR OR RACE
5 SINGLE, MARRIED, WIDOWED, OR
DIVORCED ( write the word)
. . DIVORCED (write the won!
WMLl
17
5a If married, widowed, or divorced
HUSBAND of V 4
(or)W1FEof
6 DATE OF BIRTH (month, day, and year)
zkaTa
7 AGE f Tears Months
Days
If LESS than
1 day, hrs.
If STILLBORN, enter that fad here
or min.
1 HEREBY CERTIFY, Tl^.1 * ttended deceased from
, 19./^. . / f ,
Jt. ^!.Jf 19
that I last saw
alive on..
8 OCCUPATION OF DECEASED .
(a) Trade, profession, or
particolar kind of work—
(b) General nature of industry,
business, or establishment io
which employed (or employer)
(e) Name of employer
nd that death occurred, on the date stated above, af?..... -ITS.
'he CAUSE OF DEATH* was as follows:
•State the Disease Causing Death, or in deaths from Violent Causes,
tate (1) Means and Natuee or Injury, and (2) whether Accidental,
iUicidal, or Homicidal. (See reverse side for additional space.)
9 BIRTHPLACE (city or town).
(State or country)
(duration) yrs mos.
. ds.
CONTRIBUTORY.
(secondary)
10 NAME OF FATHE!
11 BIRTHPLACE OF FATH
(State or country)
(duration).
„ds.
12 MAIDEN NAME OF MOTHER
(city or t™™) .-i ■ -
18 Where was disease contracted
if not at place of death?..
Did an operation precede death?.
Was there an autopsy?
What test confirmed
. Date of „
13 BIRTHPLACE OF MOTHER (city or town)
(State or country)
st confirmed diagnosis?
. (Signed
/Z.4. 19 /f (Address)
M.D.
14
Informant
(Address)
, _ .
2*a£jA. (P/sa&S
T~ * O' Registrar of city or towo where death occ
19 PLACE OF BURIAL, CREMATION. OR REMOVAL
y'-oC.A C 19 //
20 UNDERTAKER 7 ADDRESS
DATE OF BURIAL
OQ
z
IS
Filed.
Filed^'-.^X.;.. 19
occurred
Registrar of dty or towo where deceased resided
P 2 g-
S-g.E.
g S* I
,c-«aa sn g- sg-a Kg § 8 Ja
? 2 3 &g-p ® frs.g 5 3 g i 3 3^-e 3
s 2 3
5 s:
© ,jj 5:
© © ©‘
p « S;
§ 5-a.
GO
© ©
_- © V
5 = - >
ft £.5 z
S*3 3 3C
© g _
<r„ c s
s-© -
afsS
&g.- C
s sr c k
a 2.*» k
<= << p _
j ^ ' 5 s
■l.^t
O tP
, a>S^
■s*. © • .
c: 3 S
^ 2:
x
a —
ft O
w.
cc ji*
y.‘tH.
- P
ft<<
••
&?.S g
§ S-
■ >
©
- - * 42
ft £- sr- a* 5
— -v ft S3* a B
2 5 z
S’ 8 >
s > ftg
sr. ” o ‘ ^
2
*2%; -O
, si* *% sp2-
3 ® S' £ -° s p o
cS'r-W =&-.§
a >(5gi:. ; f; <<
2 g - =E5? ^sr
p g^cLKg _
sp S"5"c g 3 3
i = ? 2 2 o< -5
&§
0-«5in ”« s S' 3
S”
G.O
5 s.
. o®
®. CPS
G -
-! i--<! p
Bi*f
:-s’q
pi 2-1 O
!S o 3 *-4
ST. © 3
•2 .,« p
H r.
:g o §5
c? “•s '£'£.2 ~£ 2
al«31?a?S5
— - >r
5
c
1 C. =r c s-d
•* CC << y.
■— ^ _ ® © *■*
fj^IlP
i? a I'O t.5 ® p s
‘no^ojosos--^ :
p s.rro 2 saS.-1 « o <g f
-° 2 3irfeni- 1
& «
5 S*»!
© ^ £*.
* p 5 ,
'"1 w n «*». w . _. '*■ w zz. x
o*i-” S, ?|»&2So5
?. _ c5 S' OJ 8 P.B S-3
■ i
'• ?§;»
6§.:
p
p ■
^ C © ft X W r- ■
-^?,2 3.g « g.
255? Ci2 5-
2 3.3 6 g.
Jg?3§
cs'~'~?i’§'2 s~s*'5 -'<~’S-2 s ^ ■< s> ~t a i a ® <;
s r: I; P., * iis.g
. . 51- ® O
3 5 H 'i ^ C* ©
B.g.1 a 3 3g g.g.e
r* ^ o' a ^2-g! 2 s-
?PXS'21’
ii4
l-£^l 5
w >- • ■»
§s<|
“ ■ a • * <
o s-g^,£.o ts
a © 3 i-^-< a *»4
o? b. . 3?
2 a
*» g w a s- -
1 02*
zr.^>
ff.sa
G ?; O
c^SP^ O
: v; u-;
. „ o .- Mg».
n H g g * ST.
» a ft o
§
*-i © 2
^3
■ - CO ^
« P O
- - ~
p C
'i® I
° S.’S
r+i — ._
n o
e*- 2L -
a jg5
e-' p
c
a-
rf ” g p v; S
“ p g-g-cOv
' 2
£|
o 2
2-n p
3 ® S
c-2 B :g;>
s- r. o -S'! cr sr co
i 1 s a 5 - ^ =
^-Scr p r» fttS's*
o' 2 o
M ^P
Q .
§ g-r.a’5 5 wr
p
X O
>2 :
O*?- ft-p
C T4' X
.Hi l
2 ^ *
a i qS
>^ — 3 £.
i x P i= ©
tt -i
<-d ft ^ •
-sg §:<
rc $* s? *n
.. ft O u r-
?■ 2. B •< a ,2 «
. ^ O cf — is
^ GrP ^ i
S S g --X 5® K"
2 S < P :
5 S *< t-H’G ■§ ‘C .
OS’^IT'P^© P
— © a 'T- P‘ ^ r4~.
5 S g-9 2o 2" Gn
l § 80 2 o §
- 2, g.Cico ff.
S' » ^ >--^, G 2 c S
SjG g9 3 GOg-s^c
5- | g 1 os s’ ® 3.-
-C^©.$Pc-!
^ r? d “©o ^ ^ ^
c. § ST.§ rri® § 5 © P
§ 3 s 3 5 «■! ? «1^~. 3
&3 g“l £-5 ov
^So&gPs-r *■
§ § I - S a-’2 3
a-G*" 5-"„ S S 2 i. o *
■a-. 3
rr
3 ©d3 S-S.
.2,® B g
■ 2 g-3 ajS” 3
•KsIlNe-isr
_ -k Ui .
= « £'..*«5 «
C»i .
Cl©
,c 5
c->
Sl’SelfaasM
im^ipiggFi
B S-? V a s“ sT ’T - i
;•§ 8 | 3
;Ss.|i
’ "’i.
■a g §■• ■
rt' Q (
►-s ©
2 3 *5 8 c"
c 2 *».x h
s S’ 5' g2S a a- »
a s
o
P-§ ^G-
p P 5 era S-g
ers’® 2.2 = ^
G S.kk.?P-2 G
” 5* „.S5 2.
p.^i'SS ~
?a 3
1 i-IJs-’^o
?• T s» a, i g <■>
2 C
P ft*-
S 8 ? * GO®
3 a 2 ^ G a -C
-k < Q G
'oS?^E~2’
Hrt*a!t5ffE
•-< n*r»s © c ^ - S2,ft©
a ft!R 2
co g q- G
O *7 CR *^» ©
3^p| |-ST I
© X ^ § o ^ ©
^ ^k-3 k -*
c 5^ p* © ^
’,r* P ©
O ©)w
a 0&5®
M= 1 si
HJ O ^ — k
© 2 o' c- ©
"fl
2 a S. 2
^CO&
s>s.! :§
ie|l«
I ®5-~ a
•-i 2.a 2
0 0^3
G^lgg
t>2. ~ o
f j » C-
p P *g a o
3 c S'! &-
£ 3 ®i 3 •
G G 3
r> Pg9>
i k/»
-S'^|a^S®3
^ ^ uj c J .
= §’2.^5 S.e*{
^ ft,
©ST.©
»■ § ^s-
. „ g-&j- B'^s, a^2,
g-gkEli?;^^
P x n . P- kT;
'”er *,..§^
c-*- ^ j--
© ^ O P ,
CO
>
g
§S-
©
|
p al
© ©
© ~
’p
00
<^G :
2.'
5
ra
g
P
00
o O-
Cc^
JS
"* ©
p g*
X .
tea
g
giS*'
® a '
B
z
>k
^ n
K-i C3
S3
O
i
'
H
X
•e
3
5 iS
if
•3
c
Cc
gi
3.
p.
S3
H- * ©-
£t?'
a
►<
CC
s-S*
-*
1
Is
© C-
P- ©
.8 • -g
■oiz
g-S =
•c .E °
® _ra c
= 0.0
.2 c ~
♦; .5 o
2 3
Eli
^ U (/)
<2 < .5
-E £ •
c*_ Q O)
oLw
E°*-'
.£ LlI E
•- a> 2
>,=> o
<u 5 o.
> w C
u • •-
■ « ^
S " S
81-2
£5g
^ C/5 f-
z z <
sj < s
<«3
S CO O
CC > o
a I ”
=- 0. O
< t :
^ "O w
~ « X
5 -S U
w ■? -o
Z ® a;
q ^ £
<2 2
Lu 3 n
1£ «
iu t
£ 2
-•d a
>■ Q) C
J — -Q
Z Q. .
< g-»5
j S c n
« o
111 — —> ’-5
h 5 5 fe
E £ - o
> o o C-
> O <o ©
l#
00
2
XXM
511}p (dommotucpaUI? nf iHassartjusrtta
achusetts
STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH
County /SUffOll^ State
Township
City. BOSTON
BOSTON
(City or to wn)
Registered No.
...or Village
No , ..J'/'c St., Ward
(If death occurred in a hospital or institution, give its name instead of street and number)
2 FULL NAME...m.n|.ff|(r.;-v-y.j^^
(a) Residence. No.«
(Usual place of abode
Length of residence in city or town where death occurred
anrTiftTOrrjxtcvr
St., Ward.
years
(If non-resident give city or town and State)
Bow loog in 0. S., if of foreign birth ? years months days
PERSONAL AND STATISTICAL PARTICULARS
5 SINGLE, MARRIED, WIDOWED, OR
DIV0RCEU (write the word)
3 SEX 4 COLOR OR RACE 5 SINGLE, MARRIED, WIDOWED, OR
DIVORCEU (write the word)
5a If married, widowed, or divorced ^ /
m ten a Mn
5a If married, widowed, or divorced
HUSBAND of
(or) WIFE of
6 DATE OF BIRTH (month, day, and year)
7 AGE Years
Months
/*
Days
- P-
If LESS than
1 day, hrs.
8 OCCUPATION OF DECEASED
(a) Trade, profession, or
particolar kind of work
(b) General nature of industry,
business, or establishment in
which employed (or employer)
(c) Name of employer
10 NAME OF FATHER
THER (city^ear town)
II BIRTHPLACE OF FATHER (city>
(State or country)
(cty^ town)
12 MAIDEN NAME OF MOTHER'
13 BIRTHPLACE OF MOTHER (city
(State or country)
14
Informant
(Address)
&£. (22l
15
Filed
X.^..:ASr, i9i %.
Registrar
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH (month, day, and year)
: 1 19 ._
17
I ^HEREBY CERTIFY, That I attended deceased from
J-%. 19./..?... . to ,19j#...
that I last saw h . iMl alive on , 19 Jr.%.
and that death occurred, on the date stated above, at / a m.
The CAUSE OF DEATH* was as follows:
J-
(duration) yrs. mos ds.
CONTRIBUTORY
(secondary)
(duration) yrs.
18 'Where was disease contracted
if not at place of death?
jratioi
.£
ds.
fOTwh/ST?
Did an operation precede death? _Date of.
Was there an autopsy ?.„
| What test confirmed diagnosis? T
i...^Likv.
: /
m.d.
ate the Disease Causing Death, or ill deatHs from Violent Causes,
state (1) Means and Nature of iNJutyr, and (2) whether Accidental,
Suicidal, or Homicidal. (See revergfe side for additional space.)
19 PLACE OF BURIAL, CREMATION, OR REMOVAL
20 UNDE
DATE OF BURIAL
fY // ^
19
ADDRESS
p &= o g o g
3|s?S>,5^2
p-?> §
-s. « MR , -
o e tcS • l >
^woss -c'S- ch'ti'^qs.S &S? S
§1 k §■8.1 nils.?! &&STS.S
S 3 5 S 1 | w. a
| p|,. o 03 B-|
3
p p
V%< ~
ST <d
'n o ^ c SE ^
s-S o
_;p-p _ _
i'p-&3 g n
p». o 5 ^ p o
p ^
. g ® o
S' p >•
^^gig-S o
3 8 §1? 3*
B g § k1 ° 3 a .
K'Ss'a ,«P *3.®
gg.S3Ha
-?#|'6;l|s
~atun
P O
£Bo ^
B d ^
cd - — ' K
P ~ _
o P
3°
(D O
3 O
*+ n
a|
_ p
_..CD CD
cd 33„ d
n 8 d* cd » 2.5s ^ 2 ^ ® 2
S S' S ^ P e ? 2 ¥ *< S' P d 3 2 § 3.2
|0»
<= a <
p.2
cd &
c-*- Ui hrf
o'g
p ^
33 2.^ CD O _
itfcir
cT s p g =S
« fc-* P 0^5 o g
OS'P'^E.O o" 3
‘ - 2 i"*T S ^
— o s (-►
EL2 3 2
-i -d 3
3«= g-s
_3 - • CD ^
O ca P
3 <5 •
P-^.-a
CD -* J3J CD O 1-1
w-g-g
<c s
2 g 3 ~
3 p-3 «
ZT>
2. *5
cd
p p o
•1 a «/>
o'o'l.S
s
ge^
§- S- S' p-33 2 •
o'® 3.® 5 ® S »
m-o
O
5 P
-.f |.g S-8 g g^g ?”
I!s!\i“s.!?;a3
o'*
s p
s
_ p ft-H; P S P-
• o- 1 -SL^ ^ ST 3 «'
;,« 2« ® . o 2 p
cd 2 o . P P to
a s P-. < p b» to
O-”- jl. O O ffl ^ H
O npo 3 Cl ®
- t=J
~ CD C)W
p-a;d g.o 'c
B- g" 5 f> p B
CD O
p 2- 5.^ d P-
o PP P-ST
CD - *. p w 2
•05 so p
o ^
• S.^
p
<» ^ CD **' CD
^ P-O g M &
n-b o ^
O V P'2 3
s- ETP
Cr-P C-
o ^
O ■
» &.M " so
h— ja w h1 2: ^9 JO ? ^ ^
a 3.1 3 ! **§ ^
is! § Ir|"4|l h|u;i i-! • % s-^s^ ts,»; ^ 3^
Z.tuZ^s § S-8 o § 2
2 ® p o-p
oi (d ^a,P tD
c-ttf O ?»• CO 52
5- a. 3 >5 g
o
*t5W
O Co cn
^ cr w
^2 o P s;
5 S o Ci-C."1
_ou §1&^5P
§"3 »tJ°g.cSo' “ a-o'g g
3.sgi.3fe-ygg®g,B®
P D- CD O M w P ^ w
3 M “ ^
p °
3 g g.3 a
S'-0 *»
3
1
s'i p p m B s
B sr.2
i ** a.
o
O P
Co
s- &3-a-g z gf 3.
O- ro
•-! ~ ^ 3 ^ ^ o'h^
I ||;S gS > S s,5tRThe text goes on. The rest is in the file.