USA > Massachusetts > Suffolk County > Winthrop > Town of Winthrop : Record of Deaths 1910-1912 > Part 18
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Statement of cause of death. - Naine, first, the DISEASE CAUSING DEATH (the primary affection with respect to time and causation), using always the same accepted term for the same disease. Examples: Cerebro-spinal fever (the only definite synonym is "Epidemic cerebro-spinal meningitis") ; Diphtheria (avoid use of "Croup") ; Typhoid fever (never re- port " Typhoid pneumonia ") ; Lobar pneumonia ; Broncho- pneumonia ("Pneumonia," unqualified, is indefinite) ; Tuber-
culosis of lungs, meninges, peritonaeum, etc., Carcinoma, Sar- coma, etc., of ... .. (name origin: "Cancer" is less definite; avoid use of "Tumor" for malignant neoplasms) ; Measles ; Whooping cough ; Chronic valvular heart disease; Chronic interstitial nephritis, etc. The contributory (second- ary or intercurrent) affection need not be stated unless im- portant. Example: Measles (disease causing death), 29 ds .; Broncho-pneumonia (secondary), 10 ds. Never report mere symptoms or terminal conditions, such as " Asthenia," " All- aemia " (merely symptomatic), " Atrophy," "Collapse," "Coma," "Convulsions," "Debility " ("Congenital," "Senile," etc.), "Dropsy," "Exhaustion," "Heart failure," "Haemorrhage," "Inanition," " Marasmus," "Old age," "Shock," "Uraemia," "Weakness," etc., when a definite disease can be ascertained as the cause. Always qualify all diseases resulting from childbirth or miscarriage, as " PUER- PERAL septicaemia," " PUERPERAL peritonitis," etc. State cause for which surgical operation was undertaken.
Cases for the Medical Examiners. - Under the provisions of chapter 24 of the Revised Laws deaths under the following conditions must be referred to the Medical Examiners:
1. Deaths following injury or violence, as Burns, Falls, Drowning, Gas Poisoning, Suicide, Homicide, etc.
2. Deaths supposedly caused by violence, as Criminal Abortion, Poisoning, Starvation, Suffocation, Ex- posure, etc.
3. Sudden deaths of persons not disabled by recognized disease, as A death upon the street, or one supposed to be due to Alcoholism, etc.
4. Deaths under circumstances unknown, as A person found dead, etc.
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.
The Commonwealth of Massachusetts STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH Winthrop (No. 68 Bates avenue
St. ;.
Ward)
Winthrop (City or town.) [If death occurred in a hospital or institution, give its NAME instead of street and number.]
*FULL NAME. Catherine a, Lill
[If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE 68 Bates anche Winthrop
Wife of George m.
nee Jacke
Registered No.
PERSONAL AND STATISTICAL PARTICULARS
MEDICAL CERTIFICATE OF DEATH
3 SEX
4 COLOR OR RACE
W
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
married
6 DATE OF BIRTH
(Month)
(Day)
7 AGE
49 yrs.
mos. .
ds.
8 OCCUPATION
(a) Trade, profession, or particular kind of work Housewife
(b) General nature of industry, business, or establishment in which employed (or employer).
9 BIRTHPLACE
(State or country)
West Newton Mass!
PARENTS
12 MAIDEN NAME OF MOTHER
widget Clark
13 BIRTHPLACE OF MOTHER (State or country) 2 rueand
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
John W. will
(Address)
44 rates are
18 Filed 191.
REGISTRAR
17
1 HEREBY CERTIFY that I attended deceased from
1
(Year)
July
15
,1910, to Mar. 14
1910,
If LESS than
I day .....
hrs.
that I last saw haus alive on
nov. 14
, 191.0 ,
and that death occurred, on the date stated above, at 2-10/m.
or ....... min. ?
The CAUSE OF DEATH* was as follows :
Epicheliana of arvi Utri
Uren tain-
(Duration)
yrs.
mos. ds.
Contributory
Cardiac
(SECONDARY)
(Duration)
yrs.
2
(Signed)
N.J. Porter
M.D.
...
/200 16. 1910 (Address)
* If death followed injury or violence the certificate of death must be made out by the Medical Examiner.
18 LENGTH OF RESIDENCE (FOR HOSPITALS, INSTITUTIONS, TRANSIENTS, OR RECENT RESIDENTS).
At place
of death
yrs.
mos.
In the
ds.
State . .. .. yrs.
mos.
ds.
Where was disease contracted, If not at place of death ?
Former or usual residence.
19 PLACE OF BURIAL OR REMOVAL
DATE OF BURIAL
mary Haitham mas.
,
1910
20 UNDERTAKER
mas: iune
ADDRESS East Postar
(Day)
14
1910
(Year)
16 DATE OF DEATH
non.
(Month)
mos. ! ds.
10 NAME OF
FATHER
Michael Jaffe
11 BIRTHPLACE OF FATHER (State or country) Ireland
Nov. 14, 1910
STANDARD CERTIFICATE OF DEATH.
Statement of occupation. - Precise statement of occupa- tion is very important, so that the relative healthfulness of various pursuits can be known. The question applies to each and every person, irrespective of age. For many occupations a single word or term on the first line will be sufficient, e. g., Farmer or Planter, Physician, Compositor, Architect, Loco- motive engineer, Civil engineer, Stationary fireman, etc. But in many cases, especially in industrial employments, it is necessary to know (a) the kind of work and also (b) the nature of the business or industry, and therefore an additional line is provided for the latter statement ; it should be used only when needed. As examples: (a) Spinner, (b) Cotton mill; (a) Sales- man, (b) Grocery ; (a) Foreman, (b) Automobile factory. The material worked on may form part of the second statement. Never return " Laborer," " Foreman," " Manager," "Dealer," etc., without more precise specification, as Day laborer, Farm laborer, Laborer- Coal mine, etc. Women at home, who are engaged in the duties of the household only (not paid House- keepers who receive a definite salary), may be entered as Housewife, Housework, or At home, and children, not gain- fully employed, as At school or At home. Care should be taken to report specifically the occupations of persons engaged in domestic service for wages, as Servant, Cook, Housemaid, etc. If the occupation has been changed or given up on account of the DISEASE CAUSING DEATH, state occupation at beginning of illness. If retired from business, that fact may be indicated thus: Farmer (retired, 6 yrs.). For persons who have no occupation whatever, write None.
Statement of cause of death. - Name, first, the DISEASE CAUSING DEATH (the primary affection with respect to time and causation), using always the same accepted term for the same disease. Examples: Cerebro-spinal ferer (the only definite synonym is "Epidemic cerebro-spinal meningitis ") ; Diphtheria (avoid use of " Croup") ; Typhoid fever (never re- port " Typhoid pneumonia ") ; Lobar pneumonia; Broncho- pneumonia ("Pneumonia," unqualified, is indefinite) ; Tuber-
culosis of lungs, meninges, peritonaeum, etc., Carcinoma, Sar- coma, etc., of. . (name origin: "Cancer" is less definite ; avoid use of "Tumor" for malignant neoplasms) ; Measles ; Whooping cough ; Chronic valvular heart disease; Chronic interstitial nephritis, etc. The contributory (second- ary or intercurrent) affection need not be stated unless im- portant. Example: Measles (disease causing death), 29 ds .; Broncho-pneumonia (secondary), 10 ds. Never report mere symptoms or terminal conditions, such as " Asthenia," " An- aemia " (merely symptomatic), " Atrophy," "Collapse," "Coma," "Convulsions," "Debility " ("Congenital," "Senile," etc.), "Dropsy," " Exhaustion," "Heart failure," "Haemorrhage," " Inanition," " Marasmus," " Old age," "Shock," " Uraemia," " Weakness," etc., when a definite disease can be ascertained as the cause. Always qualify all diseases resulting from childbirth or miscarriage, as "PUER- PERAL septicaemia," " PUERPERAL peritonitis," etc. State cause for which surgical operation was undertaken.
Cases for the Medical Examiners. - Under the provisions of chapter 24 of the Revised Laws deaths under the following conditions must be referred to the Medical Examiners :
1. Deaths following injury or violence, as Burns, Fulls, Drowning, Gas Poisoning, Suicide, Homicide, etc.
2. Deaths supposedly caused by violence, as Criminal . Abortion, Poisoning, Starvation, Suffocation, Ex- posure, etc.
3. Sudden deaths of persons not disabled by recognized disease, as A death upon the street, or one supposed to be due to Alcoholism, etc.
4. Deaths under circumstances unknown, as A person found dead, etc.
1
COMMONWEALTH OF MASSACHUSETTS.
RETURN OF A DEATH-1910.
CITY OF BOSTON.
FULL NAME
Florence A Crossman
Registered No.
10223
Place of Death
Boston
N. E. Deaconess Hospt.
and Residence S
Date of Death.
Nov.20
1910.
Age
54
years
11
months.
9
days.
STATISTICAL DETAILS.
SEX
COLOR
SINGLE, MARRIED, WID., DIV. M
F
Maiden Name
Pollard
ST
RAR'S
Ac. Intestinal paralysis, fol
Husband's Name
Albert P Crossman
Rockland
CITY
Birthplace
.
Name of
Isaac Pollard
Father
Birthplace
of Father
Ipswich
Contributory : ! (Duration)
Maiden Name
of Mother.
Lydia ... Stetson
Birthplace
of Mother
Rockland
Occupation
Housewife
No.v.21 1910-
......... .
SPECIAL INFORMATION from Hospitals, Institutions, Transier.ts, or Recent Residents:
In hospital 8 days
Usual Residence.
Winthrop( 5 Hillside st)
Filed
Nov.25
1910.
A true copy.
Attest : ErMSlenen
Registrar.
Place of Burial
or removal
Cambridge "Camb . Cem"
Undertaker
L Jones & Son
PHYSICIAN'S CERTIFICATE.
I HEREBY CERTIFY that I attended deceased during last illness,
1910,
from 1910, to that to the best of my knowledge and belief death occurred on the date stated above, and that the CAUSE OF DEATH was as follows:
PATRIBU
SITD Primary (Duration) FICE;
abdominal hysterectomy, for
ZBOSTONIA CONDITA AD. 1 /0.1822;
1130.
BONATA D
MASS. malignant ... disease
.....
(Signed)
G W Kaan
........ .M.D.
Informant
TISREGDEN
BOSTON
S MALNER
The Commonwealth of Massachusetts STANDARD CERTIFICATE OF DEATH
1 PLACE OF DEATH
(No. Metcalf
Shild & Dlvomfuld
BOSTON
(City or town.)
[If death occurred in a hospital or institution, give its NAME instead of street and number.]
Registered No.
PERSONAL AND STATISTICAL PARTICULARS
3 SEX
4 COLOR OR RACE
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
Jungle
6 DATE OF BIRTH
(Month)
(Day)
1 (Year)
7 AGE
If LESS than 1 day, .... hrs.
.yrs.
mos.
ds.
or ....... min. ?
8 OCCUPATION
(a)* Trade, profession, or particular kind of work.
(b) General nature of industry, business, or establishment in which employed (or employer).
9 BIRTHPLACE
(State or country)
10 NAME OF FATHER
PARENTS
12 MAIDEN NAME OF MOTHER/
13 BIRTHPLACE OF MOTHER (State or country)
Breton Highlands
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
(Address)
18 Filed. 191.
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH Aw 229 (Month)
90
191
(Day)
(Year)
17 I HEREBY CERTIFY that I attended deceased from Ihm 22, 1910, to INN 202 .191
0
-
that I last saw her alive on , 191 3mpi and that death occurred, on the date stated above, at The CAUSE OF DEATH* was as follows : madental to Birth Still born
(Duration)
yrs.
mos. ds.
Contributory
(SECONDARY)
(Duration) 31 Pulat
yrs.
mos. .
.ds.
(Signed)
IN24.
1
1910 .. (Address)
* If death followed injury or violence the certificate of death must be made out by the Medical Examiner.
18 LENGTH OF RESIDENCE (FOR HOSPITALS, INSTITUTIONS, TRANSIENTS, OR RECENT RESIDENTS).
At place
of death
.yrs.
mos.
In the
ds.
State
... yrs.
mos. .
ds ..
Where was disease contracted, If not at place of death ?
Former or usual residence.
19 PLACE OF BURIAL OR REMOVAL
DATE OF BURIAL
1915
ADDRESS
20 UNDERTAKER
(
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.
11 BIRTHPLACE OF FATHER (State or country)
6.
M.D.
,
'FULL NAME [If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE
Ward)
nov . 22, 1910
STANDARD CERTIFICATE OF DEATH.
Statement of occupation. -- Precise statement of occupa- tion is very important, so that the relative healthfulness of various pursuits can be known. The question applies to each and every person, irrespective of age. For many occupations a single word or term on the first line will be sufficient, e. g., Farmer or Planter, Physician, Compositor, Architect, Loco- motive engineer, Civil engineer, Stationary fireman, etc. But in many cases, especially in industrial employments, it is necessary to know (a) the kind of work and also (b) the nature of the business or industry, and therefore an additional line is provided for the latter statement; it should be used only when needed. As examples: (a) Spinner, (b) Cotton mill; (a) Sales- man, (b) Grocery ; (a) Foreman, (b) Automobile factory. The material worked on may form part of the second statement. Never return " Laborer," " Foreman," " Manager," " Dealer," etc., without more precise specification, as Day laborer, Farm laborer, Laborcr- Coal mine, etc. Women at home, who are engaged in the duties of the household only (not paid House- keepers who receive a definite salary), may be entered as Housewife, Housework, or At home, and children, not gain- fully employed, as At school or At home. Care should be taken to report specifically the occupations of persons engaged in domestic service for wages, as Servant, Cook, Housemaid, etc. If the occupation has been changed or given up on account of the DISEASE CAUSING DEATH, state occupation at beginning of illness. If retired from business, that fact may be indicated thus: Farmer (rctired, 6 yrs.). For persons who have no occupation whatever, write None.
Statement of cause of death. - Name, first, the DISEASE CAUSING DEATH (the primary affection with respect to time and causation), using always the same accepted term for the same disease. Examples: Cerebro-spinal fcrer (the only definite synonym is "Epidemic cerebro-spinal meningitis") ; Diphtheria (avoid use of "Croup ") ; Typhoid fever (never re- port " Typhoid pneumonia ") ; Lobar pneumonia ; Broncho- pneumonia ("Pneumonia," unqualified, is indefinite) ; Tuber-
culosis of lungs, meninges, peritonaeum, etc., Carcinoma, Sar- coma, etc., of. . (name origin: "Cancer" is less definite ; avoid use of "Tumor" for malignant neoplasms) ; Measles; Whooping cough; Chronic valvular heart disease ; Chronic interstitial nephritis, etc. The contributory (second- ary or intercurrent) affection need not be stated unless im- portant. Example: Measles (disease causing death), 29 ds .; Broncho-pneumonia (secondary), 10 ds. Never report mere symptoms or terminal conditions, such as " Asthenia," " An- aemia " (merely symptomatic), " Atrophy," "Collapse," "Coma," " Convulsions," "Debility " ("Congenital," "Senile," etc.), "Dropsy," " Exhaustion," "Heart failure," "Haemorrhage," " Inanition," " Marasmus," " Old age," "Shock," "Uraemia," "Weakness," etc., when a definite disease can be ascertained as the cause. Always qualify all diseases resulting from childbirth or miscarriage, as " PUER- PERAL septicaemia," " PUERPERAL peritonitis," etc. State cause for which surgical operation was undertaken.
Cases for the Medical Examiners. - Under the provisions of chapter 24 of the Revised Laws deaths under the following conditions must be referred to the Medical Examiners:
1. Deaths following injury or violence, as Burns, Falls, Drowning, Gas Poisoning, Suicide, Homicide, etc.
2. Deaths supposedly caused by violence, as Criminal Abortion, Poisoning, Starvation, Suffocation, Ex- posure, etc.
3. Sudden deaths of persons not disabled by recognized disease, as A death upon the street, or one supposed to be due to Alcoholism, etc.
4. Deaths under circumstances unknown, as A person found dead, etc.
'FULL NAME 3 SEX 16 DATE OF BIRTH 7 AGE 8 OCCUPATION (a) Trade, profession, or particular kind of work (b) General nature of industry, business, or establishment in which employed ( or employer). 9 BIRTHPLACE (State or country) Toulon 10 NAME OF FATHER PARENTS 13 BIRTHPLACE OF MOTHER (State or conntry) (Informant) important. See instructions on back of certificate. (Address) 15 Filed. 191 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 2.5 yrs.
The Commonwealth of Massachusetts STANDARD CERTIFICATE OF DEATH
BOSTON
(City or town.)
[If death occurred in a hospital or institution, give its NAME instead of street and number.]
PERSONAL AND STATISTICAL PARTICULARS
4 COLOR OR RACE
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
-
auq.
q', 1885
(Month)
(Day)
(Year)
If LESS than
I day,
. hrs.
3
mos.
13
ds
Or ....... min. ?
mans
Grablands
11 BIRTHPLACE OF FATHER (State or country) Boston
12 MAIDEN NAME OF MOTHER danmale J. Thuntleff
Roxbury mais.
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
REGISTRAR (
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
Nov 229
(Month)
(Day)
, 1910
(Year)
17
HEREBY CERTIFY that I attended deceased from
Av 279
1910
, to.
... 1910.
that I last saw hoz alive on
Nov 229
., 1910.,
and that death occurred, on the date stated above, at
6/m.
The CAUSE OF DEATH* was as follows :
.
(Duration)
yrs.
....
mos.
1
ds.
Contributory
(SECONDARY)
(Duration) y's
mos.
.ds.
(Signed)
331 5 mil cal
W24. 190.
( Address )
Comtrip
.,
M.D.
* If death followed injury or violence the certificate of death must be made out by the Medical Examiner.
18 LENGTH OF RESIDENCE (FOR HOSPITALS, INSTITUTIONS, TRANSIENTS, OR RECENT RESIDENTS).
At place
of death
yrs.
mos.
In the
ds.
State
... yrs.
.. mos.
ds .. .
Where was disease contracted, if not at place of death ?
Former or usual residence.
19 PLACE OF BURIAL OR REMOVAL 1
DATE OF BURIAL
1910.
.
ADDRESS,
20 UNDERTAKER C
Ward)
1
Louise bloomperle.
[If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE 155 Nordride woh Nuntroop mart.
Partidos - IL. Stanley
Registered No.
1 PLACE OF DEATH Hinitrof mais (No
Metall Idos. St. ;.
No0. 22, 1910 STANDARD CERTIFICATE OF DEATH.
Statement of occupation. - Precise statement of occupa- tion is very important, so that the relative healthfulness of various pursuits can be known. The question applies to each and every person, irrespective of age. For many occupations a single word or term ou the first line will be sufficient, e. g., Farmer or Planter, Physician, Compositor, Architect, Loco- motive engineer, Civil engineer, Stationary fireman, etc. But in many cases, especially in industrial employments, it is necessary to know (a) the kind of work and also (b) the nature of the business or industry, and therefore an additional line is provided for the latter statement ; it should be used ouly when needed. As examples: («) Spinner, (b) Cotton mill; (a) Sales- man, (b) Grocery ; (a) Foreman, (b) Automobile factory. The material worked on may form part of the second statement. Never return " Laborer," "Foreman," " Manager," "Dealer," etc., without more precise specification, as Day laborer, Farm laborer, Laborer - Coal mine, etc. Women at home, who are engaged in the duties of the household only (not paid House- keepers who receive a definite salary), may be entered as Housewife, Housework, or At home, and children, not gain- fully employed, as At school or At home. Care should be taken to report specifically the occupations of persons engaged in domestic service for wages, as Servant, Cook, Housemaid, etc. If the occupation has been changed or given up on account of the DISEASE CAUSING DEATH, state occupation at beginning of illness. If retired from business, that fact may be indicated thus: Farmer (retired, 6 yrs.). For persons who have no occupation whatever, write Nonc.
Statement of cause of death. - Name, first, the DISEASE CAUSING DEATH (the primary affection with respect to time and causation), using always the same accepted term for the same disease. Examples: Cerebro-spinal ferer (the only definite synonym is "Epidemic cerebro-spinal meningitis") ; Diphtheria (avoid use of "Croup") ; Typhoid fever (never re- port " Typhoid pneumonia ") ; Lobar pneumonia; Broncho- pneumonia (" Pneumonia," unqualified, is indefinite) ; Tuber-
culosis of lungs, meninges, peritonacum, etc., Carcinoma, Sar- coma, etc., of .. . (name origin: "Cancer" is less definite ; avoid use of "Tumor" for malignant neoplasms) ; Measles; Whooping cough; Chronic valvular heart disease; Chronic interstitial nephritis, etc. The contributory (second- ary or intercurrent) affection need not be stated unless im- portant. Example: Measles (disease causing death), 29 ds .; Broncho-pneumonia (sccondary), 10 ds. Never report mere symptoms or terminal conditions, such as " Asthenia," " An- aemia " (merely symptomatic), " Atrophy," "Collapse," "Coma," "Convulsions," "Debility " ("Congenital," "Senile," etc.), "Dropsy," " Exhaustion," "Heart failure," "Haemorrhage," " Inanition," " Marasmus," " Old age," "Shock," "Uraemia," " Weakness," etc., when a definite disease can be ascertained as the cause. Always qualify all diseases resulting from childbirth or miscarriage, as " PUER- PERAL septicaemia," " PUERPERAL peritonitis," etc. State cause for which surgical operation was undertaken.
Cases for the Medical Examiners. - Under the provisions of chapter 24 of the Revised Laws deaths under the following conditions must be referred to the Medical Examiners:
1. Deaths following injury or violence, as Burns, Falls, Drowning, Gas Poisoning, Suicide, Homicide, etc.
2. Deaths supposedly caused by violence, as Criminal Abortion, Poisoning, Starvation, Suffocation, Ex- posure, etc.
3. Sudden deaths of persons not disabled by recognized disease, as A death upon the street, or onc supposed to be due to Alcoholism, etc.
4. Deaths under circumstances unknown, as A person found dead, etc.
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.
The Commonwealth of Massachusetts
STANDARD CERTIFICATE OF DEATH
I PLACE OF DEATH
(No.
39 Hermon
St. :
Ward)
'FULL NAME.
Bridget Maria McCallion
on- Howald undow of Daniel T. M Callcon
[If married or divorced woman or widow give maiden name, also name of husband.] @RESIDENCE nul Helter It & Boston
PERSONAL AND STATISTICAL PARTICULARS
3 SEX Of fr
4 COLOR OR RACE
5 SINGLE,
MARRIED,
WIDOWED,
OR DIVORCED
(Write the word)
6 DATE OF BIRTH
(Month) (Day)
(Year)
7 AGE
65 yrs.
mos.
ds
or .min. ?
8 OCCUPATION
(a)' Trade, profession, or
particular kind of work
House wife
(b) General nature of industry, business, or establishment in which employed ( or employer).
9 BIRTHPLACE
(State or country)
Ireland
PARENTS
11 BIRTHPLACE
OF FATHER
(State or country)
Ireland
12 MAIDEN NAME
OF MOTHER
Mary Cafull
1ª BIRTHPLACE OF MOTHER (State or country) Ireland
14 THE ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
(Informant)
mrs L. M Hennessy
(Address)
210A elites It. En.
16 Filed 191.
REGISTRAR
MEDICAL CERTIFICATE OF DEATH
16 DATE OF DEATH
22"
(Month)
(Day)
,1910
(Year)
I HEREBY CERTIFY that I attended deceased from
IV~ 214
1910
to
... 1910,
If LESS than
1 day, ..
hrs.
that I last saw h M alive on
21 Nov
., 191 0 ,
and that death occurred, on the date stated above, at 2 4m.
The CAUSE OF DEATH* was as follows :
aproflex up.
(Duration)
yrs.
mos.
2
ds.
Contributory
(SECONDARY)
(Duration) mos. ds. YES Biomedical , M.D.
(Signed) .
IN 22"
1910) .... (Address).
* If death followed injury or violence the certificate of death must be made out by the Medical Examiner.
18 LENGTH OF RESIDENCE (FOR HOSPITALS, INSTITUTIONS, TRANSIENTS, OR RECENT RESIDENTS).
At place
of death
yrs.
mos.
In the
ds.
State
. . yrs.
mos. .
ds ..
Where was disease contracted, if not at place of death ?
Former or usual residence.
19 PLACE OF BURIAL OR REMOVAL
DATE OF BURIAL
Holy Cross Malden no , 24.1916
ADDRESS
.
20 UNDERTAKER
Thor y Lane
Withrofa (City or town.)
[If death occurred in a hospital or institution, give its NAME instead of street and number.]
Registered No.
10 NAME OF
FATHER
John
Non 00.22, 1910.
STANDARD CERTIFICATE OF DEATH.
Statement of occupation. - Precise statement of occupa- tion is very important, so that the relative healthfulness of various pursuits can be known. The question applies to each and every person, irrespective of age. For many occupations a single word or term on the first line will be sufficient, e. g., Farmer or Planter, Physician, Compositor, Architect, Loco- motive engineer, Civil engineer, Stationary fireman, etc. But in many cases, especially in industrial employments, it is necessary to know (a) the kind of work and also (b) the nature of the business or industry, and therefore an additional line is provided for the latter statement ; it should be used only when needed. As examples: (a) Spinner, (b) Cotton mill; (a) Sales- man, (b) Grocery ; (a) Foreman, (b) Automobile factory. The material worked on may form part of the second statement. Never return " Laborer," "Foreman," " Manager," "Dealer," etc., without more precise specification, as Day laborer, Farm laborer, Laborer - Coal mine, etc. Women at home, who aro engaged in the duties of the household only (not paid House- keepers who receive a definite salary), may be entered as Ilousewife, Housework, or At home, and children, not gain- fully employed, as At school or At home. Care should be taken to report specifically the occupations of persons engaged in domestic service for wages, as Servant, Cook, Housemaid, etc. If the occupation has been changed or given up on account of the DISEASE CAUSING DEATH, state occupation at beginning of illness. If retired from business, that fact may be indicated thus: Farmer (retired, 6 yrs.). For persons who have no occupation whatever, write None.
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